Tutorial: BPH and Prostate Cancer

Question 1

This session relates to the following TILOs:

Answer 1

• 1-BRS1-URO-3: Genitourinary disorders: Summarise the pathology and pathophysiology of genitourinary disorders.
• 1-BRS2-URO-4: Genitourinary disorders: Describe the clinical features and treatment options of genitourinary disorders.

Question 2

Task 1:

Q1. What is your differential diagnosis?

Q2. Which diagnostic tests should he be referred for?

Answer 2

1)

hesitancy=difficulty starting urinary flow

• Benign prostatic enlargement (slight prostatic enlargement (as greater than 25g)
• BPE

BPH—benign prostatic hyperplasia, a term that should be used exclusively to describe the histologic changes characteristic of BPH. BPE—benign prostatic enlargement, a term describing increased size of the gland usually secondary to BPH.

• Bladder output obstruction
• Slight raised PSA so could have some degree of prostate cancer but PSA is prostate specific not cancer specific so could just be because his prostate is enlarged

2)

• Flow rate and post-void residual (essentially get a man with full bladder to wee in turnstile device to measure how strong the urine comes out of bladder ie flow rate and on this basis can determine if he has enough force in urine or if there is a blockage making it weaker and post-void residual is urine left in bladder after urinating, should be negligible but may be high if there is obstruction)
• Bladder diary
• Raised PSA for age group and negative urine dip so should undergo a multi-parametric MRI scan-better to characterise prostate cancer. Gives us an idea whether PSA is raised due to underlying malignancy, and also gives an image of prostate
• Could argue for a trans-perineal prostate biopsy

(not urodynamic studies as first line, since this is more invasive and sophisticated version of flow rate and post-void residual. Catheter put in urethra and rectum, important in scenarios like neurogenic bladder.)

Question 3

Task 2:

Q3. What can you infer from these results?

Q4. What treatment and management plan should be followed?

Note: Gleasons score-2 taken as very variable and then you add the scores together to get a combined score.

Answer 3

3) Gleason score is 6-well differentiated. Since gleason score is 3+3, this is likely to be prostate cancer rather than benign prostate hyperplasia,

4)

• No surgery
• Active surveillance with PSA testing
• Lifestyle changes via bladder diary ie less caffeine
• Possibly give an alpha-adrenergic blocker as this will relax the prostate
• (Smooth-muscle tension in the prostate stroma, urethra, and bladder neck is thought to be a significant component of LUTS secondary to BPH. The smooth-muscle tension is mediated by alpha-1-adrenergic receptors; therefore, alpha-adrenergic receptor–blocking agents should theoretically decrease resistance along the bladder neck, prostate, and urethra by relaxing the smooth muscle, thus allowing easier passage of urine.)

Question 4

Task 3

Q5. What is your inference from analysing these results?

Q6. What treatment plan should be followed?

Answer 4

5)

Gleason score has increased to 7 which suggests the cells are only moderately differentiated and so the prognosis has worsened

PSA has increased from 5 to 8 which indicates prostate cancer

Since 4 comes first it shows 4 is more common than 3

6)

Radical prostatectomy or radiotherapy and then monitoring PSA for relapse

Question 5

Task 4

The patient decides on a radical prostatectomy and following surgery develops both erectile dysfunction and urinary incontinence.

Q7. What is the mechanisms of these post operative complications and how should they be treated?

Q8. What post operative follow up should the patient undergo?

Answer 5

7)

Urinary incontinence is removal of proximal urethral sphincter and shorten in length and also damage to cavernous nerves affect this

If there is urinary incontinence can give pelvic floor exercises as training to strengthen, change in lifestyle-weight loss, less coffee, tea, alcohol etc. Or can replace external urethral sphincter in extreme cases.

ED caused simply by damage to cavernous nerves-Phosphodiesterase-5 (PDE5) inhibitors such as sildenafil (Viagra), prostaglandin injections into penis-vasodilator allows penis to engorge more blood to get an erection, penile prosthesis

8)

-Regular PSA to check for relapse (should be negligible like 0.01, once reaches 0.2 this is a relapse and he will require hormone therapy)

Question 6

Summary

Answer 6

1. The management paradigm for suspected prostate cancer has shifted towards imaging prior to biopsy testing. This is because historically random biopsies of the prostate were associated with an under detection of high grade (clinically significant) prostate cancer and over detection of low grade (clinically insignificant) prostate cancer (1). Several large RCT’s have shown that the use of risk assessment with multiparametric MRI before biopsy and MRI targeted biopsy is superior to the previous gold standard of transrectal ultrasonography-guided prostate biopsies (2).
2. Post-mortem study data has reported that 80% of 80 years olds will have some degree of prostate cancer. A huge proportion of men will die with prostate cancer rather than from it. The main treatment options for prostate cancer include radiotherapy and radical prostatectomy and these have significant potential for side effects including erectile dysfunction and urinary incontinence. Therefore, in some cases of low-grade prostate cancer a policy of surveillance is advisable as the potential complications of treatment may be more damaging than the cancer itself. Active surveillance protocols vary depending on institution but in general most patients will require quarterly PSA and DRE and annual MRI coupled with prostate biopsies.
3. The prostate contains the proximal sphincteric unit, which controls some degree of urinary continence. Prostatectomy removes the proximal urethral sphincter and there is a risk of inadvertent damage to the cavernous nerve to the prostate (which provides neural innervation to the bladder and urethra) resulting in bladder function being affected (3). Moreover, urethral length changes during the operation which can also affect continence (3). The main treatment for this type of incontinence is building the pelvic floor muscles through exercises but should this fail there is an option for an artificial urinary sphincter device. Erectile dysfunction is a result of damage to the cavernousal nerves. Treatments involve PDE5 inhibitors, prostaglandin E1 injections and penile prosthesis devices.
4. Following prostatectomy, the PSA should be undetectable or <0.01 ng/ml. Patients should undergo PSA testing 6 monthly and a biochemical relapse is defined as a PSA >0.2ng/ml.