The Prostate Flashcards
10-30% of men >70 have symptomatic BPH. How does it present?
What are it’s complications?
Obstruction (prostatism) and irritation
Prostatism:
- Intermittent urinary stream, Dribbling of urine
- Incomplete emptying -> straining to void -> double micturition => Recurrent UTIs
- Hesitancy
- Reduced sexual performance
Irritative: (due to detrusor muscle hyperactivity => urge incontinence)
- Urinary frequency, urgency, dysuria, nucturia
- Haematuria
Complications:
- Recurrent UTIs
- Haematuria
- Bladder stones
- Overflow incontinence
- Outflow obstruction
Give 3 Risk factors for Prostate cancer/BPH?
1) Age (85% diagnosed >65)
2) Genetic
3) Dietary (reduced intake of food, increased intake of fat and calcium (animal meat and spinach)
4) Ethnicity
A 74 year old presents with urinary issues. What would you like to elicit in a hx?
Obstructive Sx => Dribbling, straining, incomplete emptying, double micturition, hesitancy
Irritation sx: Frequency, urgency, dysuria, nocturia, coffee, tea, alcohol
Pattern of voiding and volume: intermittent stream, large (overflow) or small volume (urge)
Reduced sexual performance
Haematuria
Pain (Socrates)
Polydipsia
Neurological sx (incontinence)
Sexual performance
+ Extra for cancer
1) B-symptoms
2) Bone pain
3) Fractures
4) Erectile dysfunction
You offer a patient the IPSS form (international prostate symptom score). What is included in it?
How would you interpret the results?
Questionnaire assesses for
1) Incomplete emptying
2) Double voiding
3) Intermittent stream
4) Urgency
5) dribbling
6) Straining
7) Nocturia
Each is scored from 1-5 based on frequency of occurrence
The total score is interpreted as follows:
0-7 = mild
8-19 = moderate
20+ = severe
What examinations would you perform? Give 4 possible exam findings for prostate hyperplasia/cancer
Abdominal exam: Distended bladder, palpable kidneys! (was always done in clinic). Why? Hydronephrosis
DRE: Anal tone, size + shape and consistency of prostate
What should a normal prostate feel like on DRE?
Smooth, rubbery, chestnut size
A 74 year old male presents for their routine blood check. They have suffered from recurrent UTIs and hence indicating the need for a PSA. You suspect a prostate pathology. What is your general workup including investigations but not management
Hx, abdominal, and DR Exams
Investigations
1) Bloods: Renal function (ACR + eGFR), urea, creatinine, serum PSA
2) MSU: Dipstick (blood, glucose) + M, C+S
3) US measurement of post-void residual
PSA has a poor sensitivity and specificity. It is routinely measured in men with urological symptoms. Give 3 pathological and 3 non-pathological causes of raised PSA
Prostatic pathology
1) Prostate Ca
2) BPH
3) Acute/chronic prostatitis
Non-pathological:
4) Prostate instrumentation (incl. biopsy, catheter)
5) DRE
6) old age
7) exercise
8) Acute urinary retention
9) Ejaculation
A patient was given the IPSS and had a score of 22. What wouldnyou need to ask before taking a PSA to ensure it is accurate? How will you perform a PSA test?
Ask patient if they have:
1) Ejaculated within the last 24 hours
2) Vigorous exercise within 48 hours
3) UTI within 1 month
4) Prostate biopsy within 6 weeks
Take blood for PSA before DRE
Based on a patient’s PSA, when will you refer?
Remember old age alone can raise PSA without there actually being any risk
50-59 -> PSA >3
60-69 -> PSA >4
70+ -> PSA >5
A 65 year old patient had a PSA of >4. After referring to secondary care, what investigations may they perform?
TRUS - Trans-rectal US
Biopsy for Gleason score
These 2 are often done together
What type of biopsy is used for the gleason score/diagnosis?
TRUS-guided Core Biopsy
What is the conservative management of BPH including when it is indicated?
1) Watchful waiting for Mild-moderate symptoms with no complications and no impact on QoL -
Conservative management:
a) Bladder physiotherapy -> Bladder training with biofeedback
b) Reduce fluid intake at night
c) Reduce caffeine, tea, fizzy drinks
d) Prevention of constipation (increased fibre, less lifting, smaller meals)
When is Drug therapy indicated for the management of BPH in primary care? What is the medical management of BPH
Drug Therapy -> For those with mild-moderate symptoms that is affecting QoL:
a) alpha Adenoceptor agonist -> Prazosin, Doxazosin (risk of postural hypotension)
b) 5 apha reductase inhibitor -> Finasteride, Dutasteride
c) Combination -> Synergistic effect
What are the indications for referral to the urologist for suspected BPH?
Referral to urologist if:
1) Severe Symptoms
2) PSA above threshold for referral
50-59 -> PSA >3
60-69 -> PSA >4
70+ -> PSA >5
3) Complications
- Recurrent UTIs
- Haematuria
- Bladder stones
- Overflow incontinence
- Outflow obstruction
4) Nodular or firm prostate on DRE
How is BPH managed in primary care?
QoL and complications are the most important factors to consider.
1) Watchful waiting for Mild-moderate symptoms with no complications and no impact on QoL -
Conservative management:
a) Bladder physiotherapy -> Bladder training with biofeedback
b) Reduce fluid intake at night
c) Reduce caffeine, tea, fizzy drinks
d) Prevention of constipation (increased fibre, less lifting, smaller meals)
2) Drug Therapy -> For those with mild-moderate symptoms that is affecting QoL:
a) alpha Adenoceptor agonist -> Prazosin, Doxazosin (risk of postural hypotension)
b) 5 apha reductase inhibitor -> Finasteride, Dutasteride
c) Combination -> Synergistic effect
3) Referral to urologist if:
- Severe Symptoms
- PSA above threshold for referral
- Complications
- Nodular or firm prostate on DRE
What is bacterial prostatitis?
How does it present?
What examination findings are consistent with it?
How is it managed?
Give 3 complications
Bacterial prostatitis is the inflammation of the prostate gland as a result of a bacterial infection
suspect it in any male presenting with UTI symptoms +/- arthralgia or lower back, rectal, perineal, penile, or rectal pain
Confirm this with a DRE showing a swollen, tender prostate
Management involves Giving analesia for the pain and Ciprofloxacin/Ofloxacin for 4/52!!
Complications are
1) Chronic prostatitis
2) Prostate abscess
3) Urinary retention
How is prostate cancer classified
T1 - Cancer not palpable
T2 - Confined to the prostate gland (clinically localized)
T3 - Breached capsule of prostate (Locally advanced)
T4 - Spread to other organs (metastatic)
In autopsies, evidence of prostate cancer is high (75% over 75) but very few are clinically evident and the cause of mortality (similar to thyroid cancer). What are the different ways of screening for prostate cancer?
PSA
DRE
TRUS
Biopsy
What is the most common metastasis of prostate cancer
Bone and LN
As most cancers in that area: Lung and liver too
What are the complications of prostate cancer?
1) Bone => Bone pain, pathological fractures and !!spinal cord compression!!
2) Erectile dysfunction
3) Site specific metastasis e.g. haemoptysis from lung metastasis
+ those of BPH
4- Recurrent UTIs
5- Haematuria
6- Bladder stones
7- Overflow incontinence
8- Outflow obstruction
Early cancer is asymptomatic and typically an incidental finding from raised PSA or DRE showing an enlarged irregular, nodular mass. What is the presentation of non-metastatic disease?
How about metastatic disease?
Non-metastatic => symptoms are from size of prostate => pressure
1) Prostatism (IPSS)
2) Urinary retention
3) Haematuria
4) Peripheral oedema (pressure on inferior vena cava in lower back leading to blood pooling)
5) Ureteric obstruction
6) B-symptoms (its still a cancer)
Metastatic disease symptoms are those of non-metastatic disease + complications of prostate cancer. Below are the complications of prostate cancer
1) Bone => Bone pain, pathological fractures and !!spinal cord compression!!
2) Erectile dysfunction
3) Site specific metastasise.g. haemoptysis from lung metastasis
+ those of BPH
4- Recurrent UTIs
5- Haematuria
6- Bladder stones
7- Overflow incontinence
8- Outflow obstruction
A patient has been diagnosed with prostatic carcinoma after an incidental finding of raised PSA and a large, irregular prostate on exam. It is a local disease of Stage II. The patient is otherwise asymptomatic. How would you manage the patient, outlining treatment options available to the patient.
Treatment is controversial as watchful waiting with active monitoring has shown to have the same effectivity as surgery and radiotherapy (in terms of 10yr survival) but with less side effects
1) Watchful waiting + active monitoring with PSA and DRE
2) Minimally invasive cryotherapy, microwave therapy
3) Radical prostatectomy
4) Brachytherapy (proven better than radio in this case)
Note: Hormone therapy may be offered but has shown no evidence of improving survival
What are the major risks of radical prostatectomy?
50% have impotence
25% have incontinence
A patient has been diagnosed with Prostate cancer. They originally presented with severe symptoms of prostatism achieving a score of 22 on the IPSS. How would you manage this patient?
Assume the patient is experiencing bone pain. A bone scan reveals bony metastasis. How would that change your management?
Hormone therapy is the mainstay tx of prostate cancer giving an 80% reduction in bone pain and PSA as well as complications (e.g. spinal compression and fractures) if started at diagnosis.
Medical: LHRH (Goserelin) or GnRH (decapeptyl) analogues administered via SC injection every 1-3 months
Surgical: Radical prostatectomy or castration (very rare)
In the case of bony metastasis, it is hormone therapy + Brachytherapy/radiotherapy + Corticosteroids!
Hormone therapy appears to be ineffective in a patient diagnosed with stage III prostate cancer. What is your next step?
Refer for MDT
What is the mechanism of action of LHRH and GnRH analogues in the treatment of symptomatic pancreatic disease?
What are the side effects?
MOA: Inhibits testosterone production (reaches levels of a castrated man within 2 months)
SE: Impotence, hot flushes, gynaecomastia, bruising
What is used for the histological grading of a prostatic biopsy?
How is it evaluated?
After a Core biopsy is obtained (to preserve architecture), cells are graded from 1-5 (higher grade = less differentiated = least similar to prostate). The 2 most prevalent patterns are observed and added up with the more prevalent one being first. Evaluated as such:
Gleason1 - 6 (low risk)
Gleason2 - 3+4 (low intermediate)
Gleason3 - 4+3 (high intermediate)
Gleason4 - 8 (high risk)
Gleason5 - 9-10 (very high risk)
What is the Cambridge prognostic group score?
It is all of the scores combined to make a prognostic score for prostatic cancer
It involves PSA, Gleason, and TNM staging
