URO - Prostate Conditions Flashcards
Prostatitis
Pathophysiology
Clinical Features
Investigations
Management
1.) Pathophysiology
- ascending urethral infection or direct/lymphatic (from rectum) or haematogenous spread via sepsis
- usually E.coli, STIs are a rare cause
- R.F: indwelling catheter, immunocompromised, recent surgery, phimosis, urethral stricture
2.) Clinical Features
- LUTS, perineal/suprapubic pain, urethral discharge
- features of systemic infection e.g. pyrexia
- prostate is tender and boggy, lymphadenopathy
- chronic: pain >3months + LUTS
3.) Investigations
- urinalysis and urine culture
- routine bloods, STI screen
- TRUS (transrectal prostatic US) or CT: if the initial therapy fails or looking for underlying causes
- PSA can only be measured one month after prostatitis
4.) Management
- PO ciprofloxacin, analgesia
- alpha-blockers (tamsulosin) or 5aRi (finasteride) for chronic prostatitis
Benign Prostatic Hyperplasia
Pathophysiology
Clinical Features
Investigations
Complications
1.) Pathophysiology - non-cancerous hyperplasia of glandular-epithelial and stromal tissue of the prostate
- prostate: testosterone –> dihydrotestosterone using 5a-reductase. DHT is very potent and remains high
- R.F: age, obesity, FH, afro-Caribbean
2.) Clinical Features
- LUTS (most common), haematuria, haematospermia
- DRE: >2 finger widths, firm, smooth, symmetrical
- should complete IPSS questionnaire
3.) Investigations
- urinary frequency and volume chart
- urinalysis, post-void bladder scan, PSA
- renal tract USS to calculate the volume of prostate
- urodynamic studies
4.) Complications
- most common cause of bladder outlet obstruction
- high-pressure urinary retention –> AKI
- recurrent UTIs, significant haematuria
Management of BPH
General
Medical
Surgical
Complications of TURP
1.) General
- BPH w/ no clinical features only needs reassurance
- symptom diary, medication review, ↓bad fluid intake
- IPSS can be used to measure a patient’s response to treatment
2.) Medical - only if symptomatic
- tamsulosin (a-blocker): relax prostatic smooth muscle, side effects: postural hypo…, retrograde ejaculation
- finasteride (5a-RI): ↓prostatic volume, can take up to 6 months to perceive a symptomatic benefit
- tolterodine (anti-muscarinic): used only when mixed storage and voiding sx do not respond to tamsulosin
3.) Surgical Management - TURP is the main one
- endoscopic removal of obstructive prostate tissue,
- complications: bleeding, retrograde ejaculation
- TURP syndrome (rare): hyperosmolar irrigation w/ glycine leads to significant fluid overload, hyponatraemia, hyper-ammonia, and visual disturbances
4.) Complications of TURP
- TURP syndrome: dilutional hyponatraemia, fluid overload, glycine toxicity
- Urethral stricture/UTI
- Retrograde ejaculation
- Perforation of the prostate
Prostate Cancer
Pathophysiology
Clinical Features
PSA Testing
Initial Investigations
1.) Pathophysiology
- the majority are adenocarcinomas (95%), arise from the peripheral zone (75%), and are often multifocal
- acinar adenocarcinoma: originates in glandular cells lining the prostate gland (most common)
- ductal adenocarcinoma: originates in cells that line the ducts of the prostate gland (metastasise faster)
- risk factors: ↑age, obesity, afro-Caribbean, FH, BRCA2/1 gene,
3.) Clinical Features
- localised prostate cancer is often asymptomatic as it’s often in the periphery so doesn’t cause obstructive sx
- LUTS, dysuria, haematuria, haematospermia,
- incontinence, pelvic/suprapubic pain, rectal tenesmus
- lethargy, weight loss, ↓appetite, bone pain (mets)
- DRE: asymmetry, nodularity, fixed irregular mass, with loss of median sulcus
4.) PSA Testing - PSA is an enzyme produced by normal and malignant prostate epithelial cells
- normal level: <3 (50-59yrs), <4 (60-69), <5 (70+)
- has poor sensitivity and specificity as it can also be raised in: BPH, prostatitis, UTI, ejaculation, vigorous exercise, retention, urinary tract instrumentation
- PSA test should be delayed: >1mth after UTI tx, >48hrs after ejaculation, >48hrs after vigorous exercise
4.) Initial Investigations - suspected cancer is based on symptoms, abnormal DRE, ↑PSA, FH + other risk factors
- 1°multiparametric MRI - Likert score of 3+/5 suggests ↑risk of prostate cancer so a biopsy is required
- 2°TRUS biopsy: invasive procedure w/ complications inc pain, fever, sepsis, bleeding/haematuria
- biopsy produces a Gleason score
Management of Prostate Cancer
Staging of Prostate Cancer
Low Risk Disease
Intermediate/High Risk Disease
Metastatic Disease
Castrate-Resistant Disease
1.) Staging of Prostate Cancer - risk stratification is based on the PSA, Gleason score, and the tumour size
- Gleason score: 2-10, 2 grades on a scale of 1-5, most dominant grade written first (4+3 is worse than 3+4)
- imaging: staging CT (CT-CAP) and PET scan for intermediate or high risk disease
- T1/T2: localised prostate cancer
- T3/T4: locally advanced prostate cancer
2.) Low-Risk Disease - PSA<10, Gleason <6, T1-T2a
- active surveillance: assessing for progression with 3mthly PSA, 6-12mthly DRE, re-biopsy 1-3 yr intervals, radical treatments if evidence of disease progression
- watchful waiting: sx guided, the intent is not curative (reserved for older patients with ↓life expectancy)
3.) Intermediate/High Risk Disease: intermediate (PSA 10-20, G7, T2b), high (PSA >20, G8-10, T2c+)
- open/lap/robotic radical prostatectomy: side effects inc erectile dysfunction, stress incontinence
- external-beam radiotherapy and brachytherapy can be curative for localised prostate cancer
- intermediate can have surveillance or treatment
4.) Metastatic Disease - anti-androgen hormone ther…
- synthetic GnRH agonist (goserelin) or antagonists
- bicalutamide: non-steroidal, block androgen receptor
- abiraterone: androgen synthesis inhibitor
- bilateral orchidectomy: rapidly ↓testosterone levels
- chemotherapy: docetaxel, cabazitaxel (if relapsed)
5.) Castrate-Resistant - hormone-relapsed disease
- further chemotherapy, corticosteroids
