UROLOGY- PROSTATE Flashcards by Maddie YEAR 3 & 4

Outline the age-adjusted upper limits for PSA/

50-59 - 3 ng/ml
60-69 - 4 ng/ml
>70 - 5 ng/ml

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What can raise PSA?

BPH
Prostatitis
UTI
Ejaculation, prostate stimulation, anal sex
Vigorous exercise
Urinary retention
Instrumentation of urinary tract

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What supplies venous draining of the bladder?

Vesicoureterine plexus into the internal iliac vein

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What type of drug is bicalutamide? What’s it used for

An androgen receptor blocker
Used to treat prostate cancer

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What type of drug is goserelin? What’s it used for?

GnRH agonist - prostate cancer

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Whats the function of the prostate?

Produces 20-30% of the volume of seminal fluid which nourishes and protects the sperm (its alkaline so helps sperm survive acidic vagina whilst also providing nutrients)

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What phenotype is BPH most likely to affect?

Older man of Afro-American origin

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How does BPH present?

Urinary frequency
Urinary urgency
Hesitancy
Dysuria
Dribbling
Incomplete bladder emptying feeling - causes Nocturia
Push/strain to overcome obstruction

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What examination should you do for bpH?

Abdominal
Digital rectal examination

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What investigations should be done for BPH?

Urine dipstick microscopy and culture
U&E, creatinine, FBC. LFTs
PSA
Imaging

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How do you manage BPH?

If symptoms are minimal - watchful waiting
Medications - alpha 1 antagonist and 5 alpha reductase inhibitors
Surgery - TURP, open prostatectomy,

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What are the complications of BPH?

Urinary retention
Recurrent UTI
Hydronephrosis and renal failure
Bladder calculi
Bladder hypertrophy
Haematuria

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Whats the function of prostate specific antigen?

This enzyme participates in the dissolution of the seminal fluid coagulum and plays an important role in fertility

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What are the androgens and where are they produced?

Testosterone produced by testcicles
Dihydrotestpsterone produced in prostate by 5 alpha reductase (converts testosterone to this)

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Whats the main difference between testosterone and dihydrotestosterone?

Dihydrotestosterone is 10 times more potent than testosterone as it can bind to androgen receptors for longer

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Why does BPH increase with age?

After the age of 30, men produce about 1% less testosterone per year
But.. 5 alpha reductase activity increases = increase in dihydrotestosterone
Normal prostate cells respond to this by living longer and multiplying

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Why does BPH cause bladder hypertrophy?

Nodules tend to form in the periurethral zone of the prostate
This can compress the prostatic urethra and make it difficult for urine to pass
Urine builds up in the bladder causing it to dilate
Smooth muscle walls contract harder which eventually leads to bladder hypertrophy

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Whats the pathology of BPH?

Increase in 5 alpha reductase activity with age increases dihydrotestosterone
These act on epithelial cell androgen receptors and cause inhibition of normal cell death and hyperplasia
Nodules form in transition zone of prostate, narrowing the urethral canal

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What are the risk factors for BPH?

Increased age
FHx
Heart disease and diabetes
Beta blocker use
Obesity - increase intra-abdominal pressure which raises intravesicle pressure

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Why don’t we screen for prostate cancer in the UK?

PSA testing only has a sensitivity of 21% and specific yet of 91%
Early detection doesn’t correlate with clinically beneficial outcome
Men with abnormal PSA will have a prostate biopsy which has complications
Overdiagnosis leads to unnecessary treatment which can be harmful
False positives cause unnecessary anxiety

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Which area of the prostate do most prostate cancers arise?

Peripheral zone

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How common is prostate cancer?

Commonest cancer in men
Lifetime risk of 1/6

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What age is most common for prostate cancer?

75-84

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How long does it take for serum PSA to reduce back to its original value after rising?

4-8 weeks

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What are the risk factors for prostate cancer?

Old age Obesity Family history Ethnic origin of black afrocarribeans High fat/low fibre diet

Whats the most common prostate cancer?

98% are prostate adenocarcinoma

What mutations are associated with prostate cancer?

HOXB13 BRCA1 and BRCA 2

Outline the course of prostate adenocarcinoma?

At first the tumour cells rely on androgens to multiply but eventually these cells mutate and keep multiplying without androgens It’s a relatively slow growing cancer

How is prostate cancer graded?

Gleason scoring system

How is diagnosis of prostate cancer made?

Finding a raised PSA Abnormal feeling prostate gland on digital rectal exam Symptoms - slow flow, hesitancy, frequency, urgency, haematuria, weight loss, lethargy, bone pain, fractures, pelvic lymphadenopathy Multiparametric MRI Transrectal ultrasound-guided Prostate biopsy Bone scans to look for metastasis

Whats an abnormal serum PSA level?

>3ng/mL Between 3-10 can be BPH, prostatitis or cancer Typically over 10 suggests malignant disease

Where do prostate cancers typically metastasise to?

Bones and lymph nodes

What’s considered a low risk prostate cancer?

PSA <10 and Gleason <6 and T1/T2

Whats considered medium risk prostate cancer?

PSA 10-20 Gleason 7 T2

Whats considered high risk prostate cancer?

PSA >20 Gleason >8 T3/T4

How do we treat low risk prostate cancer?

Active surveillance

How do we treat medium risk prostate cancer?

Radical prostatectomy Radical radiotherapy

How do we manage metastatic prostate cancer?

Bilateral scrotal orchidectomy - surgery Medicines - anti-androgens, LHRH analogues, oestrogens Treatment is non-curative

How do you manage castration-resistant prostate cancer?

Systemic chemotherapy Palliative care

Whats the median survival for castration-resistant prostate cancer?

18-24 months

How does synthetic GnRH agonists work in treating prostate cancer?

paradoxically result in lower LH levels longer term by causing overstimulation, resulting in disruption of endogenous hormonal feedback systems. The testosterone level will therefore rise initially for around 2-3 weeks before falling to castration leves

Whats the main difference between GnRH agonists and antagonists?

Agonists cause the initially rise in testosterone levels whilst antagonists avoid this flare phenomenon

What separates the rectum from the prostate?

Denonvilliers fascia

Whats the arterial supply to the prostate?

Inferior vesicular artery from prostatovesical artery

What type of drug is bicalutamide?

An androgen receptor blocker

Whats the most commonly used GnRH agonist?

Goserelin

Whats the primary lymphatic drainage of the prostate?

Internal iliac nodes

Approximately what percentage of patients with a raised PSA level (relative to their age) do not have prostate cancer?

75%

What is the first line investigation for prostate cancer? How are the results reported?

Multiparametric MRI of the prostate The results are reported on a Likert scale, scored as: 1 – very low suspicion 2 – low suspicion 3 – equivocal 4 – probable cancer 5 – definite cancer

What is the IPSS/

International Prostate symptom score A tool for classifying the severity of LUTS and assessing the impact on the QOL Score 20-35 - severely symptomatic 8-19 - moderately 0-7 - mildly

Whats the moa of alpha-1 antagonists such as tamsulosin?

Tamsulosin selectively blocks alpha receptors in the prostate, leading to the relaxation of smooth muscles in the bladder, neck, and prostate, thus improving urine flow and reducing symptoms of benign prostatic hypertrophy (BPH).

What are the adverse effects of alpha-1- antagonists?

dizziness, postural hypotension, dry mouth, depression

Whats the moa of 5-alpha-reductase inhibitors such as finasteride?

block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH It may cause a reduction in prostate volume and so may slow disease progression

How long might it take 5-alpha reductase inhibitors to work?

Up to 6 months

When are 5-alpha reductase inhibitors indicated in BPH?

indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression

What are the adverse effects of 5 alpha reductase inhibitors?

ED Reduced libido Ejaculation problems Gynaecomastia

When should you use a combination therapy of alpha-1 antagonist and 5 alpha-reductase inhibitor?

bothersome moderate-to-severe voiding symptoms and prostatic enlargement'

How should you manage BPH when there is a mixture of storage and voiding symptoms

Alpha blocker If symptoms persist an antimuscarinic can be used e.g tolterodine or darifenacin

What is TURP syndrome?

Transurethral resection of the prostate (TURP) syndrome occurs when irrigation fluid enters the systemic circulation. The triad of features are: 1. Hyponatraemia: dilutional 2. Fluid overload 3. Glycine toxicity Management involves fluid restriction and the treatment of the complications associated with the hyponatraemia.

What are patients at increased risk of following radiotherapy for prostate cancer?

Bladder, colon and rectal cancer