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Flashcards in Prostate Deck (32):
1

Prostate cancer presentation

rarely symptomatic
PSA & DRE detection
large/extensive - obs
metastasize to bones: back pain

2

BPH symptoms

obs: hesitancy, decreased force of stream, incomplete voiding, straining, post void dribbling
- can be dynamic or mechanical
irritative: frequency, urgency, nocturia
- response of bladder to increased resistance - detrusor hyperplasia & hypertrophy, collagen deposition

3

Prostatitis Sx

dysuria
frequency
urgency
fever
chills
malaise
perineal/back/rectal pain

4

DDx of prostatic nodules

Malignancy ~25%
BPH (most common)
calculus (very common)
Infarction
cyst
tuberculous/chronic granulomatous
previous TURP-biopsy scar

5

Screening for prostate cancer

early asymptomatic, detected by PSA
DRE - usually detect more advanced (>T2)

6

PSA screening guideline

Not recommended unless risk factors present, or monitoring rise after age >50
Risk factors: African-Am, fam Hx (1st degree), age ( >55 normal, >50 risk), previous abnormal biopsy
Prostate CA can also present with low PSA
elevated in infection, BPH, inflammation, manipulation of prostate - need to wait 2 weeks after DRE

7

PSA level

worry when >4
>10 high risk for cancer
velocity rise >0.75/yr

8

BPH assessment

US for bladder, kidney assessment
PE for prostate
catheterization

9

Congenital abnormality assessment

UPJ, posterior urethral valves
US first line for children

10

Anuria with rising creatinine assessment

differentiate btw surgical vs medical renal failure
surgical: obs of both kidneys, bladder obs due to BPH, bladder cancer, urethral stricture
US and catheritization

11

Sepsis, UT obs assessment

catheterization
cultures , electrolytes, creatinine
US for hydronephrosis
drainage via retrograde stent or pc nephrostomy

12

Terazosin/Doxasozin

fast alpha1 blocker (selective)
SE: dizziness, fatigue, rhinorrhea, ED

13

Tamsulosin, alfuzosin, silodosin

alpha1 subtype A selective
less SEs than other alpha blockers
retrograde ejaculation (Tamsulosin), orthostatic hypotension

14

alpha blocker for BPH

All similar in efficacy
SEs; CV problems, dizziness, ejaculatory

safe in elderly
need to titrate with anti-HTN meds
subtype A selective meds do not require titration

interaction with PDE5is - mild hypotension, not a concern with selective blockers

long-term use: prostate continues to grow, most grow resistant

15

5-alpha reductase inhibitors

Blocks prostate growth fueled by DHT
blocks testosterone --> DHT
slower onset of action than alpha blockers

Dutasteride - blocks both
Finasteride - blocks type II - reduce incidence of AUR in surgery in men with large prostate

Prostate CA risk: 25% reduction in dx of low risk cancers
high risk cancers detected more readily

16

Combination therapy for BPH

alpha blockers + 5-alpha reductase inhibitors
reduce risk of AUR
decrease cumulative incidence of BPH
reduce BPH-related surgery (mostly finasteride)
may also combine with anticholinergics, PDE5is

Indications: men with BPH AND:
- LUTS
- elevated prostate volume (>30cc)
- elevated PSA (>1.4)
- moderate-severe bother

17

PDE5i

relax smooth muscle
decrease symptoms, no effect on flow
SEs: erections

18

Anticholinergics - BPH

relax bladder muscle (helpful after removing obs)
decrease symptoms, no effect on flow

19

Minimally invasive surgery for BPH

botox, alcohol injections
photodynamic surgery (reduce blood supply)
microwave heat
radiowave ablation

20

TURP

GOLD STANDARD
3-6 weeks of recovery - hematuria, painful urination

Early risks: retrograde ejaculation (70%)
transfusion for hematuria (10%)
injury - rare
prolonged retention (10%)
infection, incontinence rare
prolonged hematuria
obs
loss of erection

Late risks:
10-15% will need TURP again in 10-15 yrs

21

Open prostatectomy

Indications:
urinary retention refractory to treatment
recurrent UTI
renal compromise
hematuria
bladder stones

22

Dx of prostate cancer

abnormal PSA/DRE --> biopsy
indications: suspicious DRE, abnormal PSA (>4 or increasing >0.75/y)
10 core sampling
Gleason score & grading (2-6 low, 7 intermediate, 8-10 high risk)

trans-rectal US not specific/sensitive enough (CA often mutlifocal & heterogenous) - use in guide for biopsy, estimate size for BPH

23

Staging of prostate cancer

PSA
Bone scan - only high risk/bone pain
CT - only high risk

high risk: PSA > 20, Gleason score 8-10, T3

24

TNM for prostate ca

T1 a/b - TURP only, c - biopsy
T2: palpable on DRE and confined to gland
T3: palpable beyond prostate
T4: well beyond prostate

25

Tx for prostate cancer

Goal: active surveillance Gleason 2-6 , low risk, Stage up to T2a

Surgery: radical prostatectomy
radiotherapy
watchful waiting
hormonal therapy

26

Radical prostatectomy

Retropubic: minimal post-op morbidity, no spinal/epidural required
Perineal: obese, other contraindications, higher rates of adverse outcomes

27

Complications of surgery

Intraoperative - bleeding, dmg to obturator, rectal injury, dmg to ureters and seminal

Postoperative - incontinence, ED - want to spare Neurovascular bundles of Walsh (2 spared - 50-60% erections, 1 spared - 20%)

28

Radiation therapy for prostate CA

localized
Internal: brachytherapy - radiation source into prostate (low risk)

External: IMRT and proton beams - high risk patients, beams of radiation aimed at tumour location, effects on adjacent tissues (effect on bladder and rectum)

29

Active surveillance for prostate CA

localized cancer, low risk
periodic DRE and PSA measurements, repeat biopsies

30

Hormonal therapy for prostate CA

Standard in localized advanced and metastatic
adjuvant with radiation possible
after failure of radiotherapy

Bilateral orchiectomy
GnRH analogues - initial surge in testosterone but downregulation of GnRH receptors on pituitary surface, reduction in LH, reduction in testosterone
GnRH antagonists - block GnRH receptor on pituitary - no testosterone flare
Progestational/estrogenic agonists - severe side effect profile (CV, thrombosis, feminization)
Anti-androgens: competitive inhibition of androgen receptor, not used as monotherapy, combine wiht GnRH analogue to prevent flare

31

Castration resistance

prostate develops ability to grow even without testosterone

32

Chemotherapy for prostate CA

Docetaxel (taxel)
standard therapy used in hormone resistant tumours that are metastatic