Prostate

Question 1

If patient with BPH develops BPE (benign prostatic enlargement), what could develop?

Answer 1

BPE often leads to benign prostatic obstruction (BPO) and bladder outlet obstruction (BOO), which in turn often give lower urinary tract symptoms (LUTS).

Question 2

Name some symptoms which can occure in lower urinary tract symptoms (LUTS)?

Answer 2

LUTS can be subdivided into symptoms of:

• Urinary storage (eg, urgency, frequency, nocturia, etc),
• Urinary voiding (eg, straining to void, urinary
  intermittency, dysuria, hesitancy, etc)
• Post-voiding symptoms (eg, sensation of incomplete
  bladder emptying, post-void urinary dribbling, etc).

Question 3

Is BPH a risk factor for prostate cancer?

Answer 3

BPH is not a risk factor for prostate cancer.

Why:

Question 4

What are possible complications of BPH?

Answer 4

Urinary retention, which increase the risk for UTI, stones, renal damage and bladder diverticuli.

Question 5

How do you define polyuria?

Answer 5

24-hour urine volume that exceeds 3 liters per day (or 40 mL per kg)

Question 6

How do you define oliguria?

Answer 6

24h urine <500 ml

Question 7

How do you define anuria?

Answer 7

24h urine <100 ml

Question 8

If a patient with BPH have a post-void residual volume of 200 mL, would you be concerned?

Answer 8

In gernal, no!

Normal men have less than 12 mL of residual urine, but most urologists are not concerned unless the PVR volume is greater than 250 mL.

Question 9

Do you need prostate imaging to diagnose BPH?

Answer 9

No. This is only needed if:

• It is indicated only when the treatment choice of
  LUTS/BPH is dependent on total prostate volume, as
  in the use of 5ARIs, or in the choice of certain surgical
  techniques
• This is done when there is suspected prostate cancer,
  such as elevated PSA levels, abnormal rectal digital
  examination.

Question 10

What is often the first line pharmacological treatment of BPH?

Answer 10

Alpha-1-adrenergic antagonists.

Question 11

Why is it important to slow increase the dose in Alpha-1-adrenergic antagonists?

Answer 11

Reduce orthostatic effects

Question 12

When should patient take alpha-1-adrenergic antagonists?

Answer 12

Once daily at bed time.

Question 13

When can patient start to feel improvment with alpha-1-adrenergic antagonists?

Answer 13

Can take up to 4-6 weeks

Question 14

Name alpha-1-adrenergic antagonists, and which of them are uroselective alpha-1-adrenergic antagonists?

Answer 14

Systemic effects (Higer risk of orthostatic effects )

• Terazosin
• Doxazosin,

Uroselective:

• Tamsulosin
• Alfuzosin
• Silodosin

Question 15

If patient use PDE-5 inhibitors (sildenafil or vardenafil), what type of alpha-1-adrenergic antagonists is best to use?

Answer 15

Uroselective ones (Tamsulosin, alfuzosin or silodosin)

• This is because the systemic ones and PDE-5 intreact
  with each other and increase risk of hypotension.

Question 16

What are common side effects of alpha-1-adrenergic antagonists?

Answer 16

Headache, dizziness, and nasal congestion

Question 17

If patient take Tamsulosin or silodosin, what could be an important side effect to tell these patient if they want to have children?

Answer 17

Ejaculatory dysfunction

Question 18

What is the mechanism of action of alpha-1-adrenergic antagonists in BPH patients?

Answer 18

Relaxation of the smooth muscle of the bladder neck and the urethra → decreased resistance to urinary outflow → symptomatic improvement

Question 19

Which hormone have a potent prostatic growth factor? And which drug could prevent this?

Answer 19

Dihydrotestosterone (DHT).

Drug: 5-alpha reductase inbhitiors, stop the conversion of testo to DHT.

Question 20

How long does it generally take before 5-alpha-reducatase inhibitors have effect on the BPH symptoms?

Answer 20

Treatment for 6 to 12 months is generally needed before prostate size is sufficiently reduced to improve symptoms

Question 21

Name 5-alpha-reducatase inhibitors and dose for each.

Answer 21

Finasteride - 5mg daily

Dutasteride - 0.5 mg daily

Question 22

Do you need to titration for 5-alpha-reducatase inhibitors ?

Answer 22

No you do not.

Question 23

When could Phosphodiesterase-5 inhibitors be a good alternative for BPH?

Answer 23

It is reasonable to consider treatment with PDE-5 inhibitors in patients who have erectile dysfunction and mild or moderate symptoms (IPSS <20) of BPH

Question 24

When can anticholinergic agents be a good choice in BPH?

Answer 24

Anticholinergic agents are an alternative monotherapy for patients with predominately irritative symptoms (frequency, urgency, and incontinence) related to overactive bladder and without elevated postvoid residuals.

Question 25

What is normal weight of prostate?

Answer 25

The mean weight of the normal prostate in adult males is about 11 grams, usually ranging between 7 and 16 grams.

Question 26

What can we also call BPH?

Answer 26

Prostate adenoma

Question 27

What complications can occure in monopolar TURP?

Answer 27

Postprostatectomy or TUR syndrome refers to symptoms related to hyponatremia as a result of systemic absorption of hypotonic irrigating fluid used in some transurethral prostate resection procedures

Question 28

What sexual dysfunction can be seen after prostate surgery?

Answer 28

Ejaculatory dysfunction - Typically retrograde ejaculation into the bladder.

Question 29

What is the most common cancer in males?

Answer 29

Melanoma, then followed by prostate cancer

Question 30

How is the 5-year survival rate in patient that have localized or with regional spread compared with those who develop metastasis?

Answer 30

Localized or with regional spread = 100% 5 year survival Metastasis=31% 5 year survival Advanced disease = Palative care.

Question 31

At what age is it recomended to start screening for prostate cancer? And when should it be considered to start screening more early?

Answer 31

Age 50 is often a good start point to start screening Screening at age 40 should be done in patient that have: - BRCA 1 and 2 gene or other known genetic cancer genes. - Black population - Family history of prostate cancer

Question 32

What happens with the PSA levels when a prostate enlarge?

Answer 32

PSA reflects the amount of glandular epithelium, which in turn reflects prostate size. Thus, as prostate size increases with increasing age, the PSA concentration also rises.

Question 33

What is the historically level of PSA which is conisdered abnormal? And why is it historically?

Answer 33

Historically a level above above 4 ng/mL was considered abnormal. This is not true anymore because we know that there different levels of ´´normal´´ PSA levels in different ages, which mean that PSA levels are age-dependant. Also, PSA increase normally around 3.2% each year in a healthy 60 years old man.

Question 34

How often should PSA screening be done?

Answer 34

Some recomend anually and some recomend every second year.

Question 35

At what age PSA screening is usually stop?

Answer 35

Age 70 to 75 or patient that have a life-expectancy of <10 years.

Question 36

At what level of PSA you should refer to urologist?

Answer 36

PSA ≥4.0 ng/mL - If PSA levels is between 4-7 then we can do a new test in 6-8 weeks. - If the levels is >7ng/mL then we refer directly. - Some will refer directly if the levels are ≥4.0 ng/mL. Any raise in PSA of patient is on 5-alpha reductase inhibitor. Because these drugs can lower PSA levels more than 50%. Even if the levels is <4.0 ng/mL If for some reason we are doing digital rectal examination (Not recomended as a screening) and we fine irregular surface, nodular surface, asymetric surface we have to refer to urologist, even if PSA levels are low.

Question 37

What are the different zones of the prostate and where does BPH most often develop and where does prostate cancer most often develop?

Answer 37

There are 3 main zones. - Peripheral – Approximately 70 percent of the prostate gland. Main site for prostate cancer development - Central – The central zone comprises 25 percent of the volume of the normal prostate with an increased proportion in men with benign prostatic hyperplasia. - Transition – The transition zone comprises 5 percent of the normal volume of the prostate and is the site of benign prostatic hyperplasia. The majority of prostate cancers originate in the peripheral zone, whereas only 5 and 10 percent originate from the central and transition zones, respectively.

Question 38

Which type of biopsy approch is the most common one

Answer 38

Transrectal ultrasound (TRUS) Ultrasound via ultrasound probe is gently inserted into the rectum and then core biopsy needle is inserted along side the probe.

Question 39

Should patient undergoing prostate biopsy receive A/B prophylaxis?

Answer 39

Yes, it is recomended, to prevent bacteruia and bactermia. One dose of oral fluroquinolones.

Question 40

What are the typical symptoms of prostate cancer?

Answer 40

In gernal almost all patient that are diagnosed with prostate cancer are asymptomatic. Most patient at diagnosis of prostate cancer have localized prostate cancer (70%) and this give no urinary tract symptoms, if there would be symptoms, such as hematruia it is most likley due to other urinary tract problems. Symptoms that develop are on most cases due tp metastasis, which is around 6% at diagnosis of prostate cancer. Most typical symptom is bone pain, due to bone is the first site of metastatis in many cases. Other symptoms of metastasis is weight loss, fatigue, anemia, hematuria, incontience and more.

Question 41

What is the most common site of metastasis in prostate cancer?

Answer 41

Bones

Question 42

Is PSA cancer specific?

Answer 42

No it is not. Important to remember that it can be seen in several benign conditions, such as BPH, after TURP, after prostatis and more.

Question 43

If patient comes in with lower urinary tract symptoms (LUTS), what would you say if patient think they have prostate cancer?

Answer 43

That almost always prostate cancer do not give these types of symptoms, and are more or less always due to benign conditions, such as BPH and UTI and more..

Question 44

How many biospy shoud be taken in suspected prostate cancer?

Answer 44

Around 12

Question 45

How do you grade the prostate biopsy in suspected cancer?

Answer 45

The prostate biopsy is then graded with Gleason grading and score system. Gleason grade: 1-5 - Gleason grade takes the two most predominat differentiation seen on biopsy and add them together, eg - Grade 3 and 4 is predominantly seen. 4+3=7 Gleason score: 2-10 - Example above = Gleason score 7

Question 46

Which surgical approch is most often done in BPH?

Answer 46

Transurethral techniques where most often transurethral resection of the prostate (TURP) is done.

Question 47

What is indication for BPH surgery?

Answer 47

Severe LUTS symptoms, where there is or risk of develop complications which could lead to hydronephrosis or renal insufficiency, recurrent UTI and urinary retention.