Prostate Problems

1. ProstateProblems Dr Imran Cheema ST3 19/10/2010

2. 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.

3. Lower Urinary Tract Symptoms (LUTS) • Obstructive • Poor stream, Hesitancy, Terminal Dribbling, Incomplete Bladder Emptying, Overflow Incontinence • Irritative • Frequency, Nocturia, • Urgency, Dysuria

4. 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?

5. 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.

6. 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.

7. 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?

9. 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.

10. Differential Diagnosis • Bladder Storage Disorders: • Overactive Bladder Syndrome, Underactive Detrusor. • Neurological Conditions: • MS, Parkinson’s, CVA • Conditions causing Polyuria: • Diabetes, Congestive Cardiac Failure.

11. 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

12. 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.

13. PROSTATE

14. 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

15. Treatment of BPH • Aims of treatment are: • Relieve symptoms. • Improve quality of life. • Attempt to prevent progression of disease & development of complications.

16. 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?

17. Medical Therapy • Alpha antagonists = 1stline. • 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.

18. 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 = 1stline. • Alfuzosin.

19. 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.

20. 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.

21. Combination Therapy • For those patients with increased risk of disease progression & symptomatic. • Increased side effects.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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

31. 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.

32. 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.

33. Prostate Cancer

34. 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.

35. 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).

36. PSA Screening • A good screening test should fulfil Wilson-JungnerCriteria (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.

37. 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.

38. 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.

39. Threshold PSA levels • Age-related referral values for total PSA levels recommended by the Prostate Cancer Risk Management Programme. • AgePSA referral value (ng/ml). • 50–59 ≥ 3.0 • 60–69 ≥ 4.0 • 70 and over > 5.0

40. 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.

41. Case 3 continued

42. Treatment Options • Watchful waiting: • Low risk patients. • Monitoring with annual PSA/rectal examination. • Increase in PSA or size of nodule triggers active treatment.

43. 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.

44. 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.

45. 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.

46. Treatment Options • Bony metastases: • 1st line LHRH or bilateral orchidectomy. • If hormone refractory. • MDT: palliative care as needed. • Chemotherapy. • Corticosteroids. • Spinal MRI. • Bisphosphonates.

47. 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).

48. 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.

49. What’s your DD? • UTI. • Acute prostatitis. • Urethritis. • Cystitis. • Pyelonephritis. • Acute epididymo-orchitis. • Local invasion from prostate, bladder or rectal cancer.

50. 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.