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PROSTATE PROBLEMS
Dr Imran CheemaST3
19/10/2010
Objectives
Lower Urinary Tract Symptoms. History taking & use of IPSS. Differential diagnosis of LUTS. Examination and Investigation. Management of BPH. PSA request and counselling. Prostate cancer. Prostatitis and its Management.
Lower Urinary Tract Symptoms (LUTS)
Obstructive Poor stream, Hesitancy,
Terminal Dribbling, Incomplete Bladder Emptying, Overflow Incontinence
Irritative Frequency, Nocturia, Urgency, Dysuria
Case 1 - 62 yr old male
Describes difficulty starting and stopping
when urinating with a poor stream.
Compelled to void again soon after going.
Getting up during night average 3x.
PMH – Hypertension.
What else would you like to know?
Aims of Proper History
Assess symptoms & severity.
Assess impact on quality of life.
Identify other causes of LUTS.
Identify complications.
Identify co-morbidities that may
complicate treatment.
Case 1: Exploring Further
6/12 Hx gradual worsening symptoms.
Worries when out & about – always
looking for toilet.
No dysuria or haematuria.
No Hx of incontinence.
Thinks is part of ageing!
DH – Amlodipine 5mg.
IPSS (International Prostate Symptom Score)
Objective measurement to grade
symptoms.
Useful to quantify severity, help to
choose appropriate treatment &
monitoring response.
Mild = 0-7, Moderate = 8-19, Severe 20-
35.
Only 20% of GPs use this.
Should we be using it more often?
Differential Diagnosis for LUTS
Causes of Outflow Obstruction: BPH, Urethral Stricture, Severe Phimosis,
Idiopathic Bladder Outlet Obstruction,
Bladder Neck or Sphincter Dyssynergia.
Inflammatory Conditions: UTI, Bladder Stone, Prostatitis,
Interstitial Cystitis.
Neoplastic: Bladder or Prostate Cancer.
Differential Diagnosis
Bladder Storage Disorders:
Overactive Bladder Syndrome,
Underactive Detrusor.
Neurological Conditions:
MS, Parkinson’s, CVA
Conditions causing Polyuria:
Diabetes, Congestive Cardiac Failure.
Case 1 - Examination What would you like to do?
DRE – anal tone, size of prostate & abnormalities (hard, nodular, irregular, or fixed = carcinoma vs. smooth & regular)
Focused neurological examination.
Abdominal examination. Distended palpable bladder or other causes
e.g. abdominal/pelvic mass
Case 1 – Investigations PSA – more on this later! Urinalysis:
Exclude UTI, Haematuria, Glucose. Renal function tests:
All patients presenting with LUTS. If renal impairment needs Renal USS
to check for hydronephrosis. Flow rate studies:
Can be helpful to confirm diagnosis, objectively measure severity, monitor response to treatment.
PROSTATE
Case 1 - Management You diagnose mild BPH with no
complications, what treatment option(s) will you discuss?
Watchful Waiting: As not severely troubled by symptoms. Advise reducing fluid intake particularly
caffeine & alcoholic drinks.
Review medications e.g. diuretics Preventing constipation Advise to return if symptoms deteriorate
Treatment of BPH
Aims of treatment are:
Relieve symptoms.
Improve quality of life.
Attempt to prevent progression of disease
& development of complications.
Case 1 – 3/12 later
Symptoms worsened.
Embarrassing episodes of urge
incontinence.
Worries about leaving the house.
Wants to try medical therapy now.
He has heard of using saw palmetto &
wants to know if this is ok to try.
What can we offer him?
Medical Therapy Alpha antagonists = 1st line. Work by relaxing smooth muscle in
prostate & reduces urinary outflow resistance.
Benefits: Act rapidly usually 48hrs, symptomatic relief
immediately noticeable. 70% respond to treatment, expected in 3/52.
Evidence: Many RCT & systematic review – similar
efficacy between drugs & formulations. Choice dependant on tolerability & those with
pre-existing cardiovascular co-morbidity or co-medication.
Alpha Antagonist Side effects:
Cardiovascular – postural hypotension, dizziness, headaches.
GU – failure of ejaculation. CNS – somnolence, dizziness.
Compliance better with newer once daily sustained release e.g. Flomax MR, Xatral XL.
No effect on prostate volume.
Recommendations: Suitable for moderate-severe LUTS, low risk of disease
progression. Tamsulosin has best cardiovascular side effect profile =
1st line. Alfuzosin.
5-Alpha Reductase Inhibitors
Reduces production of dihydrotestosterone & arrests prostatic hyperplasia.
Two licensed for use in UK. Finasteride (Proscar) Dutasteride (Avodart)
Similar clinical efficacy & safety profile. Warn patients that shrinkage takes time – 6/12
& no noticeable symptom improvement for this period.
Side effects: ED, loss of libido, ejaculatory disorders, gynaecomastia,
breast tenderness. Recent drug alert issue – link to male breast
cancer.
5-Alpha Reductase Inhibitors
Recommendations: Suitable for moderate-severe LUTS &
obviously enlarged prostate & those more likely to have progressive disease.
NB – reduces PSA levels by half – need to adjust when interpreting results for suspected prostate cancer.
Risk factors for disease progression Age >70yrs, IPSS >7, Prostate volume
>30mls, PSA level >1.4ng/ml, QMax <12ml/s, Post void RV >100mls.
Combination Therapy
For those patients with increased risk of
disease progression & symptomatic.
Increased side effects.
Alternative Therapies
Remember the saw palmetto: Is a plant extract. Others: Pumpkin seeds, stinging nettle root,
cactus flower extracts, South African star grass, African plum tree.
Currently NOT recommended (be aware of Oxford Handbook of GP).
Advise patient: Although some evidence in studies shows
benefits LUTS, it has not undergone same scrutiny for efficacy, purity or safety.
Case 2 – 74 yr old male
Presents with painful inability to pass urine.
Has tried several times to go without success since last night.
No Hx of voiding difficulties.
No back pain/sciatica.
Has been constipated last few days.
PMH – Osteoarthritis.
Diagnosis & Management?
He has a palpable bladder.
DRE – large prostate, normal perineal
sensation & anal tone.
Acute urinary retention.
This is urological emergency.
Admit for catheterisation.
Referral in BPH? Based on NICE guidelines.
Urgent if: Acute or chronic urinary retention. Renal failure. Any suspicion of neurological dysfunction. Haematuria – see next presentation. Suspected malignant prostate.
Soon: Recurrent UTI.
Routine: Unclear diagnosis. No improvement on initial medical therapy.
Case 3 – 66 yr old, male
Presents with wife requesting PSA test.
No symptoms.
Concerns as advancing age.
Has friends in USA of similar age that are
screened for prostate cancer annually.
Asking if similar NHS screening programme.
PMH: Hypertension, low back pain.
What to Do Next?
Back to basics – history & examination.
Ask about LUTS, sexual dysfunction, ICE(!)
Red flags:
Weight loss, bone pain, haematuria.
DRE:
Hard, irregular prostate, loss of
sulcus, palpable seminal vesicle.
ICE is Helpful He is concerned about prostate cancer. Because there is a family Hx. Assessing risk:
If one 1st degree relative <70yr: RR 2. Two 1st degree relatives (one of them) <65: RR
4. Three or more relatives: RR 7-10.
Risk factors: Increasing age (85% diagnosed >65yrs). Ethnicity: highest rates in black ethnic group
(lowest Chinese). Diet: Evidence that high in dairy products & red
meat linked to increased risk.
PSA testing Counselling
There is no prostate screening
programme in the UK.
Men can request a PSA test.
www.cancerscreening.nhs.uk = good
website with pt info leaflet.
Things to tell patients What is prostate cancer?
Gland lies beneath bladder Each yr 22,000 men are
diagnosed with prostate cancer
Rare in men <50yrs Average age of diagnosis is
75yrs Slow growing cancers are
more common than fast growing ones –no way of telling between two
May not cause symptoms or shorten life
Things to tell patients What is the PSA test?
Blood test. Many causes of raised levels. 2/3 of men with raised PSA do NOT have
cancer. May lead to unnecessary anxiety and further
investigations when no cancer is present. Can provide reassurance if normal. May miss diagnosis too (false reassurance). Does not distinguish between aggressive and
non-aggressive tumours. May detect early stage of cancer when
treatments could be beneficial.
Things to tell patients
If raised, examine to check prostate or repeat test in few months.
If referral to specialist:
Prostate biopsy (TRUS). Complications: uncomfortable, bleeding &
infection. 2 out of 3 men who have prostate biopsy will
not have prostate cancer. However, biopsies can miss some cancers.
Prostate Cancer
Things to tell patients
Treatment options:
Depends on classification (localised to
prostate, locally advanced, metastatic).
No strong evidence to suggest treatment
of localised cancer reduces mortality.
Main treatments have significant side
effects & no certainty that treatments will
be successful.
PSA Test
Before PSA men should not have:
Active UTI (wait 1/12).
DRE (in previous week).
Recent ejaculation (previous 48hrs).
Vigorous exercise (previous 48hrs).
Prostate biopsy (previous 6/12).
PSA Screening
A good screening test should fulfil Wilson-
Jungner Criteria (1968, WHO).
The only criterion met = prostate cancer
is important health problem.
No good understanding of natural history
of condition, no acceptable level of
sensitivity or specificity of test, no clear
demonstrable benefit of early treatment.
PSA Screening
No means to detect which ‘early’ cancers become more widespread.
More men would be found with prostate cancer than would die or have symptoms from it.
Not clear if early treatment enhances life expectancy.
No strong evidence that PSA testing reduces mortality from prostate cancer.
Case 3 : Prostate Cancer
PSA = 4.5 ng/ml. DRE – hard craggy prostate. What will you do?
2WW referral: DRE: hard irregular prostate typical of prostate
cancer. Include PSA result with referral. DRE: normal prostate, but rising/raised age-specific
PSA with or without LUTS. Symptoms & high PSA levels. Asymptomatic men with borderline age-specific PSA
rpt test after 1-3 mo. If still rising refer.
Threshold PSA levels
Age-related referral values for total PSA levels recommended by the Prostate Cancer Risk Management Programme.
Age PSA referral value (ng/ml).
50–59 ≥ 3.0 60–69 ≥ 4.0 70 and over > 5.0
Case 3 : Prostate CA
His Gleason score = 7
What does this mean?
Moderate chance of cancer spreading
Gleason score characterises prostate
cancers on basis of histological findings.
Used with T part of TNM staging to
stratify risk of risk of progression.
Case 3 continued
Treatment Options
Watchful waiting:
Low risk patients.
Monitoring with annual PSA/rectal
examination.
Increase in PSA or size of nodule triggers
active treatment.
Treatment Options
Active surveillance: Low or intermediate risk, localised prostate
cancer. PSA surveillance & at least one re-biopsy. Treatment of choice if estimated life
expectancy of <10yrs. Radical prostatectomy:
Intermediate & high risk. Potential for cure, but up to 40% have
evidence of incomplete tumour removal. Complications: impotence, incontinence.
Treatment Options
Radical radiotherapy & external beam radiotherapy:
Aims to achieve cure, but persistent cancer found in 30% on biopsy.
Short term side effects: bladder & bowel related (dysuria, urgency, frequency, diarrhoea).
Long term side effects: impotence, incontinence, diarrhoea & bowel problems, occasional rectal bleeding.
Treatment Options
Brachytherapy. Hormone therapy:
In conjunction with radiotherapy or following surgery.
LHRH analogues e.g. Goserelin: given by subcutaneous injection every 4-12 wks. Side effects: Impotence, hot flushes, gynaecomastia,
local bruising, infection around injection site. When starting LH initially increases causing ‘flare’ –
counteracted by prescribing anti-androgens e.g. flutamide for few days prior to administering LHRH & for first 3/52.
Anti-androgens can be used as monotherapy.
Treatment Options
Bony metastases:
1st line LHRH or bilateral orchidectomy.
If hormone refractory.
MDT: palliative care as needed.
Chemotherapy.
Corticosteroids.
Spinal MRI.
Bisphosphonates.
Support & Monitoring
All patients should be offered phosphodiesterase type inhibitors e.g. sildenafil for impotence.
5 yrly flexible sigmoidoscopy to look for bowel cancers following radiotherapy.
Hot flushes can be helped with short blasts of progesterones (2wks).
PSA should be checked annually in primary care once pt stable for at least 2yrs (discharged from hospital).
Case 4 – 52 yr old male
Presents with Dysuria, Frequency & Urgency symptoms.
Feverish. Low back pain. Supra-pubic pain. Perineal pain. Painful to open bowels. PMH: Type 2 Diabetes, Angina.
What’s your DD?
UTI. Acute prostatitis. Urethritis. Cystitis. Pyelonephritis. Acute epididymo-orchitis. Local invasion from prostate, bladder or
rectal cancer.
Clinical Assessment
Temp 37.8 Abdomen – soft, tender suprapubic, no
loin tenderness. Urine dipstick +ve leucocytes & nitrites. DRE – Tender prostate. You diagnose acute prostatitis & discuss
with urology for urgent referral.
Treatment of Acute Prostatitis
Start antibiotics immediately (whilst waiting MSU results): Ciprofloxacin 500mg BD. Ofloxacin 200mg BD. Treat for 28 days (prevent chronic prostatitis). If neither above tolerated, trimethoprim
200mg BD for 28 days. Quinolones or trimethoprim effective in
most of likely pathogens & high concentrations in prostate.
If unable to take oral Abx or severely ill – admit.
Treatment Treat pain:
Paracetamol +/- ibuprofen = 1st line. If severe offer codeine. If defecation painful offer stool softener –
recommended: lactulose or docusate. Advise to seek medical advice if
deteriorates. Reassess in 24-48hrs:
Review culture results & ensure appropriate Abx.
Refer to urology if not responding adequately to treatment, consider prostate abscess.
Acute Prostatitis
Potentially serious bacterial infection of prostate.
Urinary pathogens = culprits commonly: Gram –ve organisms e.g. E.coli, proteus sp,
klebsiella, pseudomonas. Enterococci.
Accompanied by UTI, occasionally epididymitis or urethritis.
Not sexually transmitted. Can follow urethral instrumentation,
trauma, bladder outflow obstruction, dissemination of infection from elsewhere.
Referral Admit:
If acute urinary retention, will need suprapubic catheterisation.
Deteriorating symptoms despite appropriate Abx, need to exclude prostatic abscess (transrectal USS or CT).
Urgent: If pre-existing urological condition e.g. BPH, or
indwelling catheter. Immuno-compromised or diabetic.
Consider referral when recovered –investigation to exclude structural abnormality.
Case 4 : Prostatitis
6/12 later he returns with continuing pain in perineum.
Also complains of painful ejaculation affecting relationship.
Still getting some LUTS – mainly frequency, urgency and poor stream.
General aches in pelvis – fluctuates, deep, and sometimes in lower back.
Tired, getting him down.
What will you do next?
Physical examination.
Exclude other diagnosis.
DRE: diffusely tender prostate.
Urine culture.
Consider PSA – more on this later.
Prostatic massage not recommended in
primary care.
Diagnosis = Chronic Prostatitis
Characterised by at least 3/12 of pain in perineum or pelvic floor.
Often with LUTS. Dysuria, frequency, hesitancy & urgency.
And sexual dysfunction. ED, painful ejaculation, post-coital pelvic
discomfort. Can be divided into 2 types.
Chronic bacterial = 10% Chronic pelvic pain syndrome = 90%
Management in primary care not dependent on classification.
Management of Chronic Prostatitis
Assess severity of pain, urinary symptoms & impact on quality of life.
Reassurance not cancer & not STI. Trend is for symptoms to improve over
months-years. If defecation painful: offer stool softener. Consider trial of paracetamol +/- ibuprofen for
1/12. If Hx of UTI (or episode of acute prostatitis) in
last 12 mo consider single course of antibiotic. Quinolones for 28 days, or trimethoprim where not
tolerated.
Referral
Refer cases to urology.
Can start Abx whilst awaiting review.
Urologist may consider trial of alpha
blocker for 3/12.
Consider chronic pain specialist referral.
ANY QUESTIONS?
References & Useful Resources BMJ Learning modules: Benign Prostatic Hyperplasia, Prostate
cancer risk management. Accessed via www.learning.bmj.com Clinical Knowledge Summaries on BPH, acute & chronic prostatitis.
Accessed via www.cks.nhs.uk GP notebook. Accessed via www.gpnotebook.co.uk Oxford Handbook of General Practice 2nd Edition Department of Health. Prostate cancer risk management
programme: PSA Testing in Asymptomatic Men. Accessed via www.cancerscreening.nhs.uk
Prostate Cancer. InnovAiT, Vol 1, No. 9, pp. 642-650, 2008 GP Update Handbook (login access courtesy of Joanna Blyth) via
www.gp-handbook.co.uk Patient UK – leaflets for patients www.patient.co.uk Management of prostatitis. BASHH 2008 guidelines. Accessed via
www.bashh.org UK prostate link www.prostate-link.org.uk Prostate cancer charity www.prostate-cancer.org.uk Prostate cancer support association
www.prostatecancersupport.co.uk