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Clinical Case #4

Clinical Case #4. Casey Darrah, Nate Franley, Paul Rogero and Julie Johnson. So, Mr. X… what brings you in?. Caucasian male, age 66 Complaining of generalized lower back pain Started 2 months ago Pain is “dull” and has not changed in intensity Recent minor weight loss- 10# in 2 months.

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Clinical Case #4

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  1. Clinical Case #4 Casey Darrah, Nate Franley, Paul Rogero and Julie Johnson

  2. So, Mr. X… what brings you in? • Caucasian male, age 66 • Complaining of generalized lower back pain • Started 2 months ago • Pain is “dull” and has not changed in intensity • Recent minor weight loss- 10# in 2 months

  3. Let’s get you on the scale. • BP 135/80 • Pulse 75bpm, regular • Temperature of 98.4oF • Resp of 19 • Height 5’9”, weight of 225

  4. Deeper into the history. • No injury or trauma in history • Coughing in morning that produces yellow sputum • Smokes 2-3 cigars/day for 10 years • Nocturia • No medications

  5. The exams. • Lungs show expiratory rhonchi diminished on coughing • Cardiovascular, GU, musculoskeletal and neurological exams are normal • Abdominal/rectal • Irregular mass anteriorly and in midline • Nodule is not painful

  6. Okay, so now what? • What’s unusual with his exam? • BMI of 33.2 • Expiratory rhonchi • Yellow sputum • Hard, irregular nodule on digital rectal exam

  7. Another question… • What should you be able to see on a rectal exam in a male? How about a female? • Rectum, bladder, coccyx, sacrum, ischioanal fossa and anal musculature in both sexes, particularly the internal and external sphincters • In men the prostate, seminal vesicles, bulbourethral glands and the bulb of the penis • Can palpate the uterus and ovaries in women

  8. So what do you think? • What’s the problem?

  9. Nocturia? • Many possible causes • Prostate cancer • Benign Prostate Hyperplasia • Detrusor muscle weakness in older men • ADH levels • Higher during the day • Drop at night

  10. Why does his back hurt?

  11. The prostate • % of seminal volume? • Alkaline or acid? • Empties into what? • What is the structure? • What components of semen?

  12. The prostate Produces about 30% of the seminal volume Alkaline to neutralize acids in the reproductive tract Empties into the prostatic urethra Midline structure with 5 lobes Fibrinolysin, calcium, phosphate, citrate

  13. How is the prostate fed? • What arteries feed the prostate? • Internal pudendal and middle rectal aa. • What veins drain the prostate? • Internal iliac fed by the prostatic venous plexus draining into the vesicular vv.

  14. What’s the lymphatic drainage of the prostate? • Internal iliac nodes, running along with the internal iliac vein

  15. What nerves feed the prostate? • The prostate gets dual innervation • Sympathetic from T12-L2 • Parasympathetic from pelvic splanchnic nerves S2-4

  16. Obviously, masses aren’t normal. • What is this mass? • Prostate cancer or Benign Prostate Hyperplasia?

  17. Normal Prostate Changes At birth, the prostate is about the size of a pea. It grows only slightly until puberty, when it begins to enlarge rapidly Attains normal adult size and shape, about that of a walnut, when a man reaches his early 20s. The gland generally remains stable until about the mid-forties, when, in most men, the prostate begins to enlarge again through a process of cell multiplication.

  18. Benign Prostatic Hyperplasia (BPH) In up to half of men in their 40s, the prostate begins to enlarge through a process of cell multiplication called benign prostatic hyperplasia (BPH). Enlarging inner portion of the prostate puts pressure on the urethra, which can potentially cause urinary problems. About 80% of men eventually develop enlarged prostates, but only some experience significant symptoms. BPH is a normal condition and is not life-threatening.

  19. Which one is it, cancer or BPH? • Irregular nodules are characteristic, but not definitive for cancer • BPH has the nodule smooth and regular on a digital rectal exam • Develop in different parts of the prostate: • BPH occurs in the inner zone of the prostate • Cancer tends to develop in the outer area. • A 10-year study found no higher risk for prostate cancer in men with BPH.

  20. Risk factors • What might cause prostate cancer? • Obesity (?) • Age • Race (African-Americans high risk) • Family history • Diet • Vasectomy (?) • Nationality (North American, Australian, NW Europe)

  21. How to diagnose prostate cancer • Prostate biopsy (definitive) • Prostate-Specific Antigen assay • PSA over 4 is a 10% chance of cancer • PSA of 10 is a 50% chance • Risk goes up as PSA rises

  22. Stages of prostate cancer • Use bone scans, CT or MRI • Stage I- no spread outside prostate, found on a transurethral resection but NOT found on a rectal exam • Stage II- same as I, found on a DRE • Stage III- spread to seminal vesicles, but not lymph nodes • Stage IV- • Cancer has spread to pelvic wall or rectum OR • Cancer has spread to lymph nodes or has metastasized

  23. Symptoms occur in later stages: Later Stage Urinary Symptoms Late Stage General Symptoms Weak urinary stream Inability to urinate Blood in the urine Interruption of urinary stream (stopping and starting) Frequent urination (especially at night) Pain or burning during urination Chronic pain, most often in spine, & sometimes in pelvis , lower back, hips, or bones of upper legs May be accompanied by significant weight loss

  24. Metastasis? • Prostate cancer can metastasize through the venous system via the prostatic plexus • Most common metastases are to the lumbar spine (90%) to compress the spine, then to lungs in 50%, and in 25% to the liver • Lumbar spine is affected 3x more than cervical spine

  25. Can metastasis explain the back pain and sputum? • Back pain • Possible spread to the lumbar spine • Compressing the spinal nerves • Sputum • Possible spread to the lungs

  26. How to treat this? • MRI/CT to grade the cancer and investigate possible metastasis • Surgery • Prostate removal • Removal of the testes (Why?) • Chemotherapy • Drug therapies • Anti-testosterone drugs • LH-releasing antagonists • Synthetic estrogen

  27. Survival rates • Compared to men of the same demographic without prostate cancer • 5 years- ~100% • 10 years- 93% • 15 years- 77%

  28. Citations • Moore, K.L., & Dalley, A.F. Clinically Oriented Anatomy. 5th ed. Philadelphia: Lippincott, 2006. pp. 406-409. • “Digital Rectal Examination” http://www.med.nyu.edu/healthwise/article.html?hwid=hw4404 • “Prostate Cancer” http://0-www.mdconsult.com.carlson.utoledo.edu/das/patient/body/86541057-3/666880165/10041/9397.html • “Prostate Cancer” http://documents.cancer.org/117.00/117.00.pdf • Fuchsjäger, M., Shukla-Dave, A., Akin, O., Baretnz, J., & Hricak, H.. (2008). Prostate Cancer Imaging. Acta Radiologica, 49(1), 107-120. • Baxby, K., (2001). Prostatic symptoms- Essential simple investigations were not mentioned. British Medical Journal, 323(7315), 750. • “Neurologic Complications of Prostate Cancer” http://www.aafp.org/afp/20020501/1834.html

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