Urology Flashcards
What is PSA?
What are normal PSA levels?
Enzyme produced by the prostate to liquify semen
Normal levels vary by age: 50s - 3 60s - 4 70s - 5 80s - 6
What does raised PSA indicate?
Marker for prostate cancer
Also raised in BPH
Other causes of raised PSA
BMI <25
Black Africans
Taller men
Recent ejaculation (avoid for 24h prior to measurement)
Recent rectal examination (usually insignificant)
Prostatitis
UTI (PSA levels may not return to baseline for some months after a UTI)
Granulomatous inflammation of prostate
Vigorous exercise in the past 48hrs
Prostate cancer epidemiology
1/3 men develop prostate cancer
Causes problems in 1/10
Lifetime risk of dying is 2-3/100
Histology of prostate cancer
Adenocarcinomas arise from epithelial cells lining the acini/ducts of prostate gland in peripheral zone of the prostate
Prostatic intraepithelial neoplasia:
Carcinoma in situ
Pre-cancerous and non-invasive
Progression common but not inevitable
Presentation of prostate cancer
Latent prostate cancer:
Asymptomatic
Slow-growing
Symptomatic prostate cancer: Symptoms usually related to metastatic disease Pelvic/back pain Pathological fractures Anaemia from bone mets LUTS
Risk factors for prostate cancer
Age Ethnicity (Afro-Caribbean) Family history Lynch syndrome BRCA mutations
Investigations for prostate cancer
PSA, DRE, MRU, bone scan for metastasis
TRUS:
Transrectal US-guided biopsy of prostate
Prophylactic antibiotics:
Ciprofloxacin
Saturation/template/trans-perineal biopsy
Classification of prostate cancer
Gleason 1-6
Tumour given 2x scores (3-5):
Pattern of predominant grade
Pattern of highest grade area
3-5 - Pattern 1 is benign, pattern 2 can’t be diagnosed on biopsy as need more tissue than is typically taken
6 - Indolent, good prognosis
7 - Intermediate prognosis
8 - Aggressive, worse prognosis
Treatment of prostate cancer
Depends on grade and stage
Low risk (Gleason 6, stage T1/2):
Active surveillance
Defer treatment to maximise QoL
Gleason 3+3=6:
Only small proportion of 12 core biopsies contain cancer
Investigate at regular intervals e.g. 3 monthly review & PSA
Yearly biopsy
Locally advanced (Gleason 7-10, stage T2/3): Radical prostatectomy Radical radiotherapy external beam or brachytherapy
Advanced/metastatic:
Androgen deprivation therapy - LHRH agonists/antagonists or castration, abiaterone
Chemotherapy
Define benign prostatic hypertrophy
Increased number of cells (both glandular and stromal)
Not increase in size of cells
Signs and symptoms of benign prostatic hypertrophy
LUTs
Acute urinary retention
Renal dysfunction
Storage:
Frequency, urgency, UTI, renal dysfunction
Voiding:
Slow stream, splitting or spraying, intermittency, hesitancy, straining, terminal dribbling, post-micturition dribble, feeling of incomplete emptying
Complications of benign prostatic hypertrophy
Intractable UTIs Haematuria UTI Stones Retention Overflow incontinence Obstructive renal failure Hydronephrosis Renal insufficiency/failure Acidosis Progressive bladder outflow obstruction Detrusor muscle hypertrophy Decompensation and failure
Investigations in benign prostatic hypertrophy
History Exam DRE Urinalysis Bloods (creatinine) PSA Voiding diary TRUS + biopsy USS CT KUB Cystoscopy to exclude bladder cancer
Management of benign prostatic hypertrophy
Lifestyle:
Avoid caffeine, alcohol, relax when voiding, bladder training
Drugs:
Alpha-blockers, 5a-reductase, anti-cholinergics
Surgery:
Transurethral resection of prostate (TURP), HOLEP (new laser technique), transurethral incision of prostate, retropubic prostatectomy, transurethral laser induced prostatectomy (TULIP)
