Prostate – CTF 2014

1 Appropriately identify patients requiring prostate cancer screening.

Canadian Task force 2014: (Endorsed by CCFP)
  1. <55yo or >70yo, no screening for prostate ca with PSA (strong recommendation, low-quality)
  2. 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:
  1. False negative & positive results
  2. Biopsy: pain & rare infection, bleeding
  3. Distress & anxiety
  4. Overdiagnosis (dx not otherwise have become clincially apparent) & Tx (radiation, Sx, urinary problems & incontinence, sexual dysfunction, bowel problems)
Benefits of PSA testing:
  1. Early detection can save lives – screen 293, dx 12 w/ prostate ca to prevent 1 death over 14yr period
  2. 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.

  1. 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
  2. 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:

  1. 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
  2. T1/T2 (intermediate / high-risk)
    • Definitive Tx over active surveillance
  3. T3/T4
    • EBRT + androgen deprivation therapy or RP + adjuvant EBRT
  4. 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:
  1. Lifestyle modification – evening fluid restriction, planned voiding
  2. 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)
  3. 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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Posted in 77 Prostate, 99 Priority Topics, FM 99 priority topics, Urol

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