1. health and fitness
2. disease
3. cancer

Prostate Problems
By Dr Mahya Mirfattahi
GPST1
HDR Wednesday 17th February 2010
Lower urinary tract symptoms
• Obstructive
– Poor stream, hesistancy, terminal dribbling,
pis-en-deux (incomplete bladder empyting),
overflow incontinence
• Irritative
– Frequency, nocturia, urgency, dysuria
Case 1 - 60 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 history
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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 things 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
DD continued
• 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
– QMax & post void residual volume
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 – He returns 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 – the options
• 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 preexisting cardiovascular co-morbidity or co-medication
Alpha antagonist continued
• Side effects
– Cardiovascular – postural hypotension, dizziness, headaches
– GU – failure of ejactulation
– 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
continued
• 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 – 70 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
What is your 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
When to refer in BPH?
• Based on NICE guidelines
• Urgent if
– Acute or chronic urinary retention
– Renal failure
– Any suspicion of neurological dysfunction
• UCR
– Haematuria – see next presentation
– Suspected malignant prostate
• Soon
– Recurrent UTI
• Routine
– Unclear diagnosis
– No improvement on initial medical therapy
Case 3 – 50 yr old male
• Presents with dysuria, frequency &
urgency symptoms
• Feverish
• Low back pain
• Suprapubic pain
• Perineal pain
• Painful to open bowels
• PMH: Type 2 Diabetes, Angina
What’s your DD?
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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)
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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 continued
• 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
– Immunocompromised or diabetic
• Consider referral when recovered –investigation
to exclude structural abnormality
Case 3 continued
• 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
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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 monthsyears
• 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
– Quinolone 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
Case 4 – 68 yr old, male
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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
How will you approach this
request?
• 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 (2)
• What is the PSA test?
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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 nonaggressive tumours
May detect early stage of cancer when treatments
could be beneficial
Things to tell patients (3)
• 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
Things to tell patients (4)
• 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 practicalities
• 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)
Problems with PSA screening
• A good screening test should fulfil WilsonJungner 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
Problems with 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 4 continued
• PSA = 4.5 ng/ml
• DRE – hard craggy prostate
• What will you do?
– UCR 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
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Age
PSA referral value (ng/ml)
50–59 ≥ 3.0
60–69 ≥ 4.0
70 and over > 5.0
Case 4 continued
• 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
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 (2)
• 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: importence, incontinence
Treatment Options (3)
• 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 (4)
• 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 (5)
• Bony metastases
– 1st line LHRH or bilateral orchidectomy
– If hormone refractory
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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)
Any questions?
Thanks for listening!
References & Useful resources
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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.gphandbook.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