PROSTATE PROBLEMS

Dr Imran CheemaST3

19/10/2010

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.

Lower Urinary Tract Symptoms (LUTS)

Obstructive Poor stream, Hesitancy,

Terminal Dribbling, Incomplete Bladder Emptying, Overflow Incontinence

Irritative Frequency, Nocturia, Urgency, Dysuria

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?

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.

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.

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?

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.

Differential Diagnosis Bladder Storage Disorders:

Overactive Bladder Syndrome, Underactive Detrusor.

Neurological Conditions: MS, Parkinson’s, CVA

Conditions causing Polyuria: Diabetes, Congestive Cardiac Failure.

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

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.

PROSTATE

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

Treatment of BPH

Aims of treatment are: Relieve symptoms. Improve quality of life. Attempt to prevent progression of disease

& development of complications.

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?

Medical Therapy Alpha antagonists = 1st line. 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.

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 = 1st line.

Alfuzosin.

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.

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.

Combination Therapy

For those patients with increased risk of disease progression & symptomatic.

Increased side effects.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

Prostate Cancer

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.

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).

PSA Screening A good screening test should fulfil Wilson-

Jungner Criteria (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.

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.

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.

Threshold PSA levels Age-related referral values for total PSA levels

recommended by the Prostate Cancer Risk Management Programme.

Age PSA referral value (ng/ml).

50–59 ≥ 3.0 60–69 ≥ 4.0 70 and over > 5.0

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.

Case 3 continued

Treatment Options

Watchful waiting: Low risk patients. Monitoring with annual PSA/rectal

examination. Increase in PSA or size of nodule triggers

active treatment.

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.

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.

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.

Treatment Options Bony metastases:

1st line LHRH or bilateral orchidectomy. If hormone refractory.

MDT: palliative care as needed. Chemotherapy. Corticosteroids. Spinal MRI.

Bisphosphonates.

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).

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.

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

rectal cancer.

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.

Treatment of Acute Prostatitis Start antibiotics immediately (whilst

waiting MSU results): Ciprofloxacin 500mg BD. Ofloxacin 200mg BD. Treat for 28 days (prevent chronic prostatitis). If neither above tolerated, trimethoprim

200mg BD for 28 days. Quinolones or trimethoprim effective in

most of likely pathogens & high concentrations in prostate.

If unable to take oral Abx or severely ill – admit.

Treatment Treat pain:

Paracetamol +/- ibuprofen = 1st line. If severe offer codeine. If defecation painful offer stool softener –

recommended: lactulose or docusate. Advise to seek medical advice if

deteriorates. Reassess in 24-48hrs:

Review culture results & ensure appropriate Abx.

Refer to urology if not responding adequately to treatment, consider prostate abscess.

Acute Prostatitis Potentially serious bacterial infection of

prostate. Urinary pathogens = culprits commonly:

Gram –ve organisms e.g. E.coli, proteus sp, klebsiella, pseudomonas.

Enterococci. Accompanied by UTI, occasionally

epididymitis or urethritis. Not sexually transmitted. Can follow urethral instrumentation, trauma,

bladder outflow obstruction, dissemination of infection from elsewhere.

Referral Admit:

If acute urinary retention, will need suprapubic catheterisation.

Deteriorating symptoms despite appropriate Abx, need to exclude prostatic abscess (transrectal USS or CT).

Urgent: If pre-existing urological condition e.g. BPH, or

indwelling catheter. Immuno-compromised or diabetic.

Consider referral when recovered –investigation to exclude structural abnormality.

Case 4 : Prostatitis 6/12 later he returns with continuing pain

in perineum. Also complains of painful ejaculation

affecting relationship. Still getting some LUTS – mainly

frequency, urgency and poor stream. General aches in pelvis – fluctuates,

deep, and sometimes in lower back. Tired, getting him down.

What will you do next? Physical examination.

Exclude other diagnosis. DRE: diffusely tender prostate. Urine culture. Consider PSA – more on this later. Prostatic massage not recommended in

primary care.

Diagnosis = Chronic Prostatitis Characterised by at least 3/12 of pain in

perineum or pelvic floor. Often with LUTS.

Dysuria, frequency, hesitancy & urgency. And sexual dysfunction.

ED, painful ejaculation, post-coital pelvic discomfort.

Can be divided into 2 types. Chronic bacterial = 10% Chronic pelvic pain syndrome = 90%

Management in primary care not dependent on classification.

Management of Chronic Prostatitis

Assess severity of pain, urinary symptoms & impact on quality of life.

Reassurance not cancer & not STI. Trend is for symptoms to improve over

months-years. If defecation painful: offer stool softener. Consider trial of paracetamol +/- ibuprofen for

1/12. If Hx of UTI (or episode of acute prostatitis) in

last 12 mo consider single course of antibiotic. Quinolones for 28 days, or trimethoprim where not

tolerated.

Referral

Refer cases to urology. Can start Abx whilst awaiting review. Urologist may consider trial of alpha

blocker for 3/12. Consider chronic pain specialist referral.

ANY QUESTIONS?

References & Useful Resources BMJ Learning modules: Benign Prostatic Hyperplasia, Prostate cancer

risk management. Accessed via www.learning.bmj.com Clinical Knowledge Summaries on BPH, acute & chronic prostatitis.

Accessed via www.cks.nhs.uk GP notebook. Accessed via www.gpnotebook.co.uk Oxford Handbook of General Practice 2nd Edition Department of Health. Prostate cancer risk management programme:

PSA Testing in Asymptomatic Men. Accessed via www.cancerscreening.nhs.uk

Prostate Cancer. InnovAiT, Vol 1, No. 9, pp. 642-650, 2008 GP Update Handbook (login access courtesy of Joanna Blyth) via

www.gp-handbook.co.uk Patient UK – leaflets for patients www.patient.co.uk Management of prostatitis. BASHH 2008 guidelines. Accessed via

www.bashh.org UK prostate link www.prostate-link.org.uk Prostate cancer charity www.prostate-cancer.org.uk Prostate cancer support association www.prostatecancersupport.co.uk