1 Appropriately identify patients requiring prostate cancer screening.
Canadian Task force 2014: (Endorsed by CCFP)
- <55yo or >70yo, no screening for prostate ca with PSA (strong recommendation, low-quality)
- 55-69 yo – no screening for prostate ca with PSA (weak recommendation, moderate-quality evidence)
Canadian Cancer Society 2014:
- Discuss with asymptomatic men >50yo with an estimated life expectancy >10yr,
- Screen if pt are well informed about the risks of over-dx, over-Tx, consider PSA for early dx of prostate ca, and wished to be screened
Canadian urology Association 2011
- Average risk: Offer PSA at age 50 with life expectancy ≥ 10yr
- Increased risk: Offer at age 40
- Offer to age 40-49 for baseline PSA
Risks of PSA testing:
- False negative & positive results
- Biopsy: pain & rare infection, bleeding
- Distress & anxiety
- Overdiagnosis (dx not otherwise have become clincially apparent) & Tx (radiation, Sx, urinary problems & incontinence, sexual dysfunction, bowel problems)
Benefits of PSA testing:
- Early detection can save lives – screen 293, dx 12 w/ prostate ca to prevent 1 death over 14yr period
- Early detection & Tx can avert future prostate ca – related problems
Causes of ↑ PSA:
- BPH, prostatitis, prostatic ischemia/infarction, prostate bx/sx, prostatic massage, XRT
- acute urinary retention, AKI, urethral catheterization, cystoscopy, TRUS
- Strenuous exercise, perineal trauma, ejaculation, coronary bypass graft
2 In a patient suitable for prostate cancer screening, use and interpret tests (e.g., prostate-specific antigen testing, digital rectal examination [DRE], ultrasonography) in an individualized/sequential manner to identify potential cases.
- DRE:
- Included as part of initial screening
- Suspicious findings: Abnormal feeling, irregular nodularity, focal lesion, discrete change in texture/fullness/symmetry, diffuse dense induration
- Ref to urologist if abn regardless of the PSA value
- PSA (glycogen produced by epithelial cells; <4 = normal)
- Serum PSA = free (15%) and bound (85%) PSA
- PSA velocity / density / free:total PSA ratio – increase sensitivity and specificity
3 In patients with prostate cancer, actively search out the psychological impact of the diagnosis and treatment modality.
Ix:
- DRE, PSA
- TRUS-guided needle biopsy
- bone scan – may be omitted in untreated CaP with PSA <10
- CT to assess metastases
Dx:
- TNM staging
- Low risk – PSA <10, Gleason score <7, stage T1-2
- Moderate Risk – PSA 10-20, gleason 7, T2
- High Risk – PSA >20, gleason 8-10, T3/4
4 In patients with prostate cancer, considering a specific treatment option (e.g., surgery, radiotherapy, chemotherapy, hormonal treatment, no treatment):
a) Advise about the risks and benefits of treatment.
b) Monitor patients for complications following treatment.
Tx:
- T1/T2 (localized, low risk): \
- consider active surveillance vs definitive Tx (RP,l brachytherapy, EBRT – no difference in cure rate)
- watchful waiting + palliative Tx if older pt
- T1/T2 (intermediate / high-risk)
- Definitive Tx over active surveillance
- T3/T4
- EBRT + androgen deprivation therapy or RP + adjuvant EBRT
- N / M >0
- Req hormonal Tx – consider combined androgen blockade / palliative RXT for mets
- bilateral orchiectomy – remove 90% of Testosterone
- GnRH agonists: Leuprolide, goserelin
- Estrogen: DES
- Antiandrogens – bicalutamide
- Local irradiation of painful secondaries vs half-body irradiation
- Hormone-refractory prostate ca:
- Chemo – docetaxel etc
Modality | Pt considered | Limitations |
Watchful waiting | Short life expectancy <5-10yr – receive non-curative hormonal Tx if dz preogresses | Dz progression |
Active SurveillanceSerial PSA /DRE/biopsies | Low grade dz, good f/u, still considering more curative Tx if dz progresses | Dz progression; decrease in QOL with serial testings; risks associated with Bx; no optimal monitoring schedule defined |
Brachytherapy | Low volume, low PSA <10, low grade | ED (50%), long term effectiveness not well-established |
EBRT | Locally advanced dz, older pt | Radiation proctitis, ED, rectal cancer risk |
RP | Young pt (<75), high-risk dz | Incontinence, ED |
5 In patients with prostate cancer, actively ask about symptoms of local recurrence or distant spread.
Prostate Ca
- Asymptomatic usually, commonly detected by DRE, elevated PSA, incidental finding on TURP
- DRE: hard irregular noduole / diffuse dense induration involving one or both lobes
- PSA
- Locally advanced dz: storage / voiding symptoms, ED
- Metastatic dz: bony mets to axial skeleton > visceral mets (liver, lung, adrenal), leg pain & edema with nodal mets obstructing lymphatic and venous drainage
Method of spread
- local invasion
- lymphatic spread to regional nodes: obturator > iliac > presacral/para-aortic
- Hematogenous dissemination occurs early
6 Given a suspicion of benign prostatic hypertrophy, diagnose it using appropriate history, physical examination, and investigations.
BPH
- periurethral hyperplasia of stroma & epithelium in prostatic transition zone
- Unknown etiology:
- DHT required (from Testosterone by 5-a reductase); ?impaired apoptosis, estrogen, Growth factors?
- age-related, common(50% of 50yo & 80% of 80yo) – 25% men require Tx
Hx: Assess LUTS & QOL
- (outlet obstruction & compensatory changes)
- voiding symptoms: hesitancy, straining, weak/interrupted stream, incomplete bladder emptying
- Storage symptoms: urgency, frequency, nocturia, urgency incontinence
- due to detrusor overactivity / decreased compliance
- AUA prostate symptom Score <8 mild, 8-19 moderate, 20-35 severe – FUNWISE – each ./5
- Frequency, Urgency, Nocturia, Weak stream, Intermittency, Straining, Emptying – incomplete feeling
O/E:
- DRE – smooth, rubery, symmetrically enlarged prostate
C/I:
- Retention, hydronephrosis, overflow incontinence
- infection, bladder stones, gross hematuria
Ix:
- U/A – r/o UTI
- Cr / renal U/S to assess for hydronephrosis
- PSA to r/o malignancy
- cystoscopy prior to Sx Tx, Biopsy if suspicious for malignancy
- Optional – uroflowmetry to measure flow rate, PVR (post-void residual)
Tx:
- Lifestyle modification – evening fluid restriction, planned voiding
- Med:
- a-adrenergic antagonists (reduce stromal smooth mm)
- 5-a reductase inhibitor (block T –> DHT, reduce prostate size)
- Combination is synergistic
- Anti-cholinergic ( for storage LUTS w/o elevated PVR)
- Sx:
- TURP, Laser ablation, TUIP, open prostatectomy
- If pt can’t tolerate Sx or wish to avoid Sx – Prostatic stent, TUNA, Microwave therapy
7 In patients presenting with specific or non-specific urinary symptoms:
a) Identify the possibility of prostatitis.
b) Interpret investigations (e.g., urinalysis, urine culture-and-sensitivity testing, Digital Rectal Exam, swab testing, reverse transcription-polymerase chain reaction assay) appropriately.
Prostatitis / prostatodynia
- Most common urologic dx in men <50yo; 2-12%
3 types of prostatitis
1) Acute bacterial prostatitis
- Ascending urethral infection with KEEPS – 80% E Coli, Most occur in the peripheral zone
- Assoicated with outlet obstruction, recent cystoscopy, prostatic biopsy
- Hx: Acute onset f/c, malaise, rectal, lower back, perineal pain, LUTS
- PEx: abd, external genitalia, perineum, prostate
- Ix: U/A, CBC, C&S, transrectal u/s if not resolving (?abscess)
- Tx: Supportive, po/IV abx
- Ciprofloxacin 500mg po bid x 2-4 weeks
- 3rd gen cephalosporin IV x 4 weeks
- Consider catheter if severe obstructive LUTS / retention
- I&D of bascess if present
2) Chronic bacterial Prostatitis
- Recurent exacerbations of acute prostatitis-like S/Sx; recurrent UTI with same organism
- Hx: pelvic pain, storage LUTS, ejaculatory pain, post-ejaculatory pain
- PEx: As per acute prostatitis + pelvic floor; urine C&S: 4-glass test
- VB1 (voided bladder): initial (urethra); VB2: midstream (bladder); VB3: post-massage/DR
- EPS (expressed prostatic secretions) – not usually done
- Tx: Abx, consider addition of an a-blocker
- Ciprofloxacin 500mg po bid 4-6 week
3) Chronic pelvic pain syndrome (CPPS)
- Inflammatory (3a) vs non-inflammatory (3b)
- intraprostatic reflux of urine ± urethral hypertonia
- multifactorial: immunological, neuropathic, neuroendocrine, psychosocial
- Hx: pelvic pain, storage LUTS, ejaculatory pain, post-ejaculatory pain
- PEx: As per chronic prostatitis; consider psychological assessment
- Tx: Supportive measure,
- Trial of Abx therapy if newly dx;
- multi-modal Tx strategy: a-blocker, anti-inflammatories, phytotherapy
KEEPs: Klebsiella, E. Coli, Enterococci, Proteus / Pseudomonas, S. saprophyticus
References:
- TN 2014
- Candian Task force 2014
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