Prostate

Management of prostatitis?

3-4 weeks of fluoroquinolone (ciplofloxacin/ofloxacin) treatment or TURP if prostate abscess Retention treated with suprapubic catheterization Category 3 notoriously difficult to treat - may get response wt a-blocker, non-prostatic massage, warm baths, avoiding caffeine, alcohol, spicy food Category 4: no need for treatment

Incidence of prostate cancer in the West

40% males born in West will develop it, 10% diagnosed, 3% die

Categories of prostatitis

Category 1: acute infection of prostate (E.coli, pseudomonas, Klebsiella) Category 2: chronic infection of prostate (same organisms) Category 3: chronic pelvic pain syndrome (without infection but with or without inflammation) Category 4: asymptomatic inflammatory prostatitis (incidental finding) after TURP/prostate biopsy

Management of BPH

Conservative: Avoid caffeinated and sugary drinks and evening fluids Medical: - alpha-blocker ie. tamsulosin or alfuzosin (relax prostatic smooth muscle via blockade of a-adrenoreceptors > reduce dynamic component) -5a-reductase inhibitor e.g. finasteride or dutasteride (prevents peripheral activation of testosterone in prostate) Surgical: Transurethral resection of the prostate (TURP); laser vaporisation or enucleation (best outcomes, fewer complications but technically more challenging so less widely used)

Pathophysiology of BPH

Exact mechanism unknown Androgens play a role. Unlike other androgen-dependent organs, prostate converts testosterone to dihydrotestosterone (DTH) using 5a-reductase. DTH = more potent and accounts for 90% of androgen in tissue. Also prostate, unlike other tissues, retains ability to respond to testosterone so levels DTH remain high through life.

Investigations for BPH

FBC: anaemia in renal failure U&Es; MSU (UTI?); urinary flow-rate and post-void residual volume (for chronic retention); PSA depending of PR exam findings > for cancer although sometimes slightly raised in BPH too; urodynamic investigation

Complications of TURP

Haemorrhage, sexual dysfunction, retrograde ejaculation, and urethral stricture. TURP syndrome But most widely used procedure and excellent outcomes generally

Risk factors for prostate cancer

Increases with age, autopsy studies show present in 70% men over 75 Ethnicity: black African/Caribbean twice as likely compared to Caucasian men Family history of prostate cancer Genetic predisposition: BRACA 1 or BRACA 2 Less significant = modifiable rfs: obesity, DM, smoking

Risk factors for BPH

Increasing age - approx 40% men over 50 have it; 90% men over 80 Family history Afro-Caribbean ethnicity Obesity Most common cause of bladder outlet obstruction and LUTS

Clinical features of prostate cancer

Localised disease: LUTS e.g. weak urinary stream, increased frequency, urgency Advanced local disease: Haematuria, dysuria, incontinence, haematospermia, suprapubic pain, loin pain, rectal tenesmus Metastatic disease: Bone pain, pathological fracture, spinal cord compression, acute renal failure from ureteric obstruction, lethargy, anorexia, unexplained weight loss O/E: PR exam: essential as most arise prostate adenocarcinomas arise from posterior peripheral zone: asymmetrical, nodular, fixed irregular mass

Treatment options for prostate cancer

Localised disease: - active surveilance: PSA monitoring and treat if increase or cancer upgraded on repeat biopsy - Radiotherapy: external beam or brachytherapy (125Iodine seed implantation) - Surgery: laparoscopic, robotic or open radical prostatectomy Advanced/metastatic disease: - Medical: Chemo: docetaxel, cabazitaxel Hormonal manipulation with LHRH agonist (goserelin, triptorelin, leuprorelin); GnRH-receptor antagonists (e.g. degarelix); testosterone antagonist (flutamide, bicalutamide) - Surgery: castration/orchidectomy - Radiotherapy: treat painful mets

Prostatitis common in which age group? Other risk factors

Most common urological problem in under 50s Acute bacterial prostatitis: Indwelling catheters Phimosis or urethral stricture Recent surgery, including cystoscopy or transrectal prostate biopsy Immunocompromised In addition, for chronic prostatitis: Intraprostatic ductal reflux Neuroendocrine dysfunction Dysfunctional bladder

Histological diagnosis of benign prostatic hyperplasia

Non-cancerous hyperplasia of glandular epithelial and stromal tissue of the prostate leading to increase in its size

Investigations for prostate cancer?

PSA (can monitor course of disease) FBC, U&E, Ca2+, LFT Transrectal USS (TRUS) -guided biopsy for Gleason grading MRI for ?lymph node involvement ?mets Nuclear medicine bine scan ?mets

Clinical features of acute bacterial prostatitis

Pelvic, urethral, perineal or rectal pain, frequency, urgency Systemic infection (including pyrexia), perineal or suprapubic pain O/e: very tender and boggy prostate on PR Chronic prostatitis: Pelvic pain/discomfort for at least 3 months, wt LUTS, perineum most common site of pain but can also occur in suprapubic region, lower back, rectum

Differential diagnosis for BPH

Prostate cancer: LUTS but asymmetrical craggy/nodular prostate and raised PSA UTI: dysuria + loin/suprapubic pain, pyrexia, positive dip nitrite/leucs Overactive bladder: LUTS but bladder USS shows low post-void residual volume Bladder cancer: haematuria predominant feature

What is PSA and when can it be raised?

Serum protein produced by both malignant and normal healthy cells in the prostate gland. PSA can be elevated secondary to prostate cancer. Can become artificially raised with several other conditions, including BPH, prostatitis, vigorous exercise, ejaculation, and recent DRE, reducing its specificity. Not part of national screening but men given option to have test routinely with good counselling prior though

Clinical features of BPH

Symptoms: LUTS e.g. voiding symptoms (hesitancy, weak stream, terminal dribbling, or incomplete empyting) or storage symptoms (urinary frequency, nocturia, nocturnal enuresis, or urge incontinence) Less common = haematuria and haematospermia O/e: PR exam essential to distinguish BPH from prostate cancer > firm, smooth, symmetrical prostate is a reassuring sign (a more rounded prostate of greater than two finger widths may indicate enlargement) International Prostate Symptom Score (IPSS) questionare

Investigations for prostatitis

Urine culture - guides abx therapy STI screen Routine bloods: FBC, CRP and U&Es. Note: PSA will be elevated but not routinely done Transrectal prostatic USS or CT imaging if prostate abscess suspected

Bit more about chemotherapy in prostate cancer

Usually only indicated in patients with metastatic prostate cancer. Some examples: docetaxel (recommended in men with testosterone-resistant cancer) cabazitaxel (used with prednisolone, recommended for treating relapsed prostate cancer which has progressed after using docetaxel chemotherapy).

Complications of BPH?

acute urinary retention, overflow incontinence, acute renal failure, bladder stones, recurrent UTI , haematuria

What is TURP syndrome?

rare but potentially life-threatening complication of TURP. TURP using monopolar energy requires use of hypoosmolar irrigation during the procedure which can result in significant fluid overload and hyponatremia as the fluid enters the circulation through the exposed venous beds. Patients with TURP syndrome present with confusion, nausea, agitation, or visual changes and needs urgent management by addressing the fluid overload and carefully reducing the level of hyponatremia. Fortunately, TURP syndrome is increasingly rare due to the use of bipolar energy which uses isotonic irrigation fluids.