? Storage (irritative) symptoms:
? Urgency
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? Urinary frequency? Nocturia
? Urinary incontinence
? Voiding (obstructive) symptoms
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? Hesitancy, poor stream, terminal dribbling
Causes of LUTS
? Obstructive
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? BPH
? Prostate/bladder/rectal cancer
? Bladder neck/urethral strictures
? Antimuscarinic drugs
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? Autonomic neuropathy/neurogenic bladderCauses of LUTS
? Irritative
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? BPH
? Bladder/prostate cancer
? Infection
? Bladder stones
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? Neurological? Dementia
? Diabetes
? Stroke
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Assessment? History ? type of LUTS, duration of Sx, how
bothersome are they?
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? Examination ? abdomen (distended bladder),
external genitalia, DRE
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? International Prostate Symptom Score:? Used to assess severity of symptoms
? Score of 0-5 for seven symptoms (total 35):
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? 0-7 ? mildly symptomatic? 8-19 ? moderately symptomatic
? 20-35 ? severely symptomatic
Management
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? Urine dip +/- culture
? U&E
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? Chronic retention? Recurrent UTI
? Hx of renal stones
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? PSA
? Urinary frequency-volume chart
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? Ask patient to note down when they drink fluid/pass waterand to comment on type of fluid
? Allows to differentiate between frequency of urine,
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polyuria and nocturia
? Obstructive symptoms
? Lifestyle changes.
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? Alpha blocker: e.g tamsulosin? 5 ? reductase inhibitors
? Irritative symptoms
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? Exclude/manage treatable causes? Urine containment devices
? Supervised bladder retraining
? Anticholinergics e.g oxybutinin
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Benign Prostatic Hyperplasia
? Generalised disease of the
--- Content provided by FirstRanker.com ---
prostate due to hormonal
derangement which leads to
--- Content provided by FirstRanker.com ---
enlargement of the gland(increase in the number of
epithelial cells and stromal
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tissue)to cause compression
of the urethra leading to
--- Content provided by FirstRanker.com ---
symptoms3/24/2022
9
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Etiology
? Cause not completely understood
? Reawakening of the urogenital sinus to proliferate
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? Change in hormonal milieu with alterations in thetestosterone/estrogen balance
? Induction of prostatic growth factors
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? Increased stem cells/decreased stromal cell death? Accumulation of dihydroxytestosterone, stimulation by estrogen
and prostatic growth hormone actions
--- Content provided by FirstRanker.com ---
BPH facts
? Occurs in 50% of men over 50 and in 80% of men
--- Content provided by FirstRanker.com ---
over 80 have BPH? BPH progresses differently in every individual
? Many men with BPH may have mild symptoms and
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may never need treatment? BPH does not predispose to the development of
prostate cancer
--- Content provided by FirstRanker.com ---
11
Benign Prostatic Hyperplasia
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12--- Content provided by FirstRanker.com ---
BPH Pathophysiology
Normal
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BPH
BLADDER
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Hypertrophieddetrusor muscle
PROSTATE
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URETHRA
Obstructed
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urinary flowPathophysiology
? Slow and insidious changes over time
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? Complex interactions between prostatic urethral resistance,intravesical pressure, detrussor functionality, neurologic
integrity, and general physical health.
--- Content provided by FirstRanker.com ---
? Initial hypertrophydetrussor decompensation poortonediverticula formationincreasing urine
volumehydronephrosisupper tract dysfunction
Complications
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? Urinary retention
? UTI
? Sepsis secondary to UTI
? Residual urine
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? Calculi? Renal failure
? Hematuria
? Hernias, hemorroids, bowel habit change
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3/24/202215
Clinical manifestations
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? Voiding symptoms
? decrease in the urinary stream
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? Straining? Dribbling at the end of urination
? Intermittency
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? Hesitancy
? Pain or burning during urination
--- Content provided by FirstRanker.com ---
? Feeling of incomplete bladder emptying--- Content provided by FirstRanker.com ---
3/24/202216
Clinical manifestations
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? Irritative symptomsurinary frequency
urgency
dysuria
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bladder painnocturia
incontinence
symptoms associated with infection
--- Content provided by FirstRanker.com ---
3/24/202217
Benign Prostatic Hyperplasia
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? Leading to "symptom bother" and
worsened QOL
Other Relevant History
--- Content provided by FirstRanker.com ---
? GU History (STD, trauma, surgery)
? Other disorders (eg. neurologic, diabetes)
? Medications (anti-cholinergics)
? Functional Status
--- Content provided by FirstRanker.com ---
Diagnostic Tests
? Prostate specific antigen
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? History & Examination(PSA)
? Abdominal/GU exam
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?? Transrectal ultrasound ?
Focused neuro exam
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? Digital rectal exam (DRE)
biopsy
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? Validated symptom? Uroflometry
questionnaire.
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? Postvoid residual
? Urinalysis
? Urine culture
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? BUN, Cr3/24/2022
20
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Optional E DRE
valuations3/24/2022
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21
and
? Urine cytology in patients with:
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D
? Predominance of irritative voiding symptoms.
? Smoking history
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i ? Flow rate and post-void residual
a
--- Content provided by FirstRanker.com ---
? Not necessary before medical therapy but should beg
considered in those undergoing invasive therapy or those
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with neurologic conditions
n ? Upper tract evaluation if hematuria, increased creatinine
--- Content provided by FirstRanker.com ---
o ? Cystoscopystic Te
st
s
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Differential Diagnosis? Urethral stricture
? Bladder neck contracture
? Carcinoma of the prostate
--- Content provided by FirstRanker.com ---
? Carcinoma of the bladder? Bladder calculi
? Urinary tract infection and prostatitis
? Neurogenic bladder
--- Content provided by FirstRanker.com ---
Treatment IndicationsAbsolute vs Relative
? Severe obstruction
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? Moderate symptoms
? Urinary retention
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of prostatism? Signs of upper tract
? Recurrent UTI's
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dilatation and renal
? Hematuria
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insufficiency? Quality of life issues
Therapy
--- Content provided by FirstRanker.com ---
? Watchful waiting and behavioral modification? Medical Management
? Alpha blockers
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? 5-alpha reductase inhibitors
? Combination therapy
--- Content provided by FirstRanker.com ---
? Surgical Management? Office based therapy
? OR based therapy
--- Content provided by FirstRanker.com ---
? Urethral stents
Carcinoma Prostate
--- Content provided by FirstRanker.com ---
Epidemiology? Risk factors
? Increasing age
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? Family history? African-American
? Dietary factors.
--- Content provided by FirstRanker.com ---
? Nutritional factors have protective effect against prostate cancer
? Reduced fat intake
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? Soy protein? Lycopene
? Vitamin E
--- Content provided by FirstRanker.com ---
? Selenium
? Race
--- Content provided by FirstRanker.com ---
? Incidence doubled in African Americans compared to white Americans.? Genetics
? Common among relatives with early-onset prostate cancer
--- Content provided by FirstRanker.com ---
? Susceptibility locus (early onset prostate cancer)
? Chromosome 1, band Q24
--- Content provided by FirstRanker.com ---
? An abnormality at this locus occurs in less than 10% of prostate cancerpatients.
Pathophysiology
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? Adenocarcinoma
? 95% of prostate cancers
--- Content provided by FirstRanker.com ---
? Developing in the acini of prostatic ducts? Rare histopathologic types of prostate carcinoma
? Occur in approximately 5% of patients
--- Content provided by FirstRanker.com ---
? Include
? Smal cel carcinoma
--- Content provided by FirstRanker.com ---
? Mucinous carcinoma? Endometrioid cancer (prostatic ductal carcinoma)
? Transitional cel cancer
--- Content provided by FirstRanker.com ---
? Squamous cel carcinoma
? Basal cel carcinoma
--- Content provided by FirstRanker.com ---
? Adenoid cystic carcinoma (basaloid)? Signet-ring cel carcinoma
? Neuroendocrine cancer
--- Content provided by FirstRanker.com ---
Pathophysiology
? Peripheral zone (PZ)
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? 70% of cancers
? Transitional zone (TZ)
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? 20%? Some claim
? TZ prostate cancers are relatively nonaggressive
? PZ cancers are more aggressive
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? Tend to invade the periprostatic tissues.
Clinical Manifestations
--- Content provided by FirstRanker.com ---
? Early state (organ confined)? Asymptomatic
? Locally advanced
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? Obstructive voiding symptoms
? Hesitancy
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? Intermittent urinary stream? Decreased force of stream
? May have growth into the urethra or bladder neck
--- Content provided by FirstRanker.com ---
? Hematuria
? Hematospermia
--- Content provided by FirstRanker.com ---
? Advanced (spread to the regional pelvic lymph nodes)? Edema of the lower extremities
? Pelvic and perineal discomfort
--- Content provided by FirstRanker.com ---
Clinical Manifestations? Metastasis
? Most commonly to bone (frequently asymptomatic)
--- Content provided by FirstRanker.com ---
? Can cause severe and unremitting pain
? Bone metastasis
--- Content provided by FirstRanker.com ---
? Can result in pathologic fractures or? Spinal cord compression
? Visceral metastases (rare)
? Can develop pulmonary, hepatic, pleural, peritoneal, and
--- Content provided by FirstRanker.com ---
central nervous system metastases late in the natural
history or after hormonal therapies fail.
--- Content provided by FirstRanker.com ---
Detection and Diagnosis? PSA level
? Helpful in asymptomatic patients
--- Content provided by FirstRanker.com ---
? > 60% of patients with prostate cancer are asymptomatic
? Diagnosis is made solely because of an elevated screening PSA level
? A palpable nodule on digital rectal examination
--- Content provided by FirstRanker.com ---
? Next most common clinical presentation
? Prompts biopsy
? Much less commonly, patients are symptomatic
--- Content provided by FirstRanker.com ---
? Advanced disease
? Obstructive voiding symptoms
? Pelvic or perineal discomfort
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? Lower extremity edema? Symptomatic bone lesions.
Detection and Diagnosis
? Digital rectal examination
--- Content provided by FirstRanker.com ---
? Low sensitivity and specificity for diagnosis
? Biopsy of a nodule or area of induration
? Reveals cancer 50% of the time
--- Content provided by FirstRanker.com ---
? Suggests? Prostate biopsy
? Should be undertaken in all men with palpable nodules.
--- Content provided by FirstRanker.com ---
Detection and Diagnosis
? Transrectal ultrasound with biopsies
--- Content provided by FirstRanker.com ---
? Indicated when? The PSA level is elevated
? The percent-free PSA is less than 25%, or
--- Content provided by FirstRanker.com ---
? An abnormality is noted on digital rectal examination
? Type of biopsy
--- Content provided by FirstRanker.com ---
? Sextant biopsies (base, midgland, and apex on eachside)
? Generally obtained
--- Content provided by FirstRanker.com ---
? Seminal vesicles are biopsied in high-risk patients
Detection and Diagnosis
? A bone scan
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? Warranted only
? PSA level greater than 10ng/mL
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? Computed Tomography or magneticresonance imaging
? Abdominal and pelvic CT or MRI is usually
--- Content provided by FirstRanker.com ---
unrevealing in patients with a PSA level less than
20ng/mL. .
--- Content provided by FirstRanker.com ---
Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprintProstate Cancer
Prognosis
--- Content provided by FirstRanker.com ---
? Prognosis correlates with histologic grade andextent (stage) of disease
? Adenocarcinoma
--- Content provided by FirstRanker.com ---
? > 95% of prostate cancers
? Multifocality is common
--- Content provided by FirstRanker.com ---
? Grading? Ranges from 1 to 5
? Gleason score
--- Content provided by FirstRanker.com ---
? Definition
? Sum of the two most common histologic patterns seen on each tissue specimen
--- Content provided by FirstRanker.com ---
? Ranges? From 2 (1 + 1)
? To 10 (5 + 5)
--- Content provided by FirstRanker.com ---
? Category
? Wel -differentiated (Gleason scores 2, 3, or 4)
--- Content provided by FirstRanker.com ---
? Intermediate differentiation (Gleason scores 5, 6, or 7)? Poorly differentiated (Gleason scores 8, 9, or 10).
Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint
--- Content provided by FirstRanker.com ---
Prostate CancerStaging
?
--- Content provided by FirstRanker.com ---
Stage T1
?
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Nodal metastases? Nonpalpable prostate cancer
? Can be microscopic and can be detected only by
--- Content provided by FirstRanker.com ---
? Detected only on pathologic examination
biopsy or lymphadenectomy, or they can be
--- Content provided by FirstRanker.com ---
?Incidental y noted after
visible on imaging studies
--- Content provided by FirstRanker.com ---
? Transurethral resection for benign hypertrophy
?
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Distant metastases(T1a and T1b) or
? On biopsy obtained because of an elevated PSA
--- Content provided by FirstRanker.com ---
? Predominantly to bone
(T1c-the most common clinical stage at
--- Content provided by FirstRanker.com ---
? Occasional visceral metastases occur.diagnosis)
?
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Stage T2
? Palpable tumor
--- Content provided by FirstRanker.com ---
? Appears to be confined to the prostatic gland (T2aif one lobe, T2b if two lobes)
?
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Stage T3
? Tumor with extension through the prostatic
--- Content provided by FirstRanker.com ---
capsule (T2a if focal, T2b if seminal vesicles areinvolved)
?
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Stage T4
? Invasion of adjacent structures
--- Content provided by FirstRanker.com ---
?Bladder neck
?
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External urinary sphincter
?
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The rectum?
The levator muscles
--- Content provided by FirstRanker.com ---
?
The pelvic sidewal
--- Content provided by FirstRanker.com ---
Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprintTreatment
? PRINCIPLES OF THERAPY
--- Content provided by FirstRanker.com ---
? May include
? Watchful waiting
? Androgen deprivation
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? External beam radiotherapy? Retropubic or perineal radical prostatectomy
? with or without postoperative radiotherapy to the prostate margins
--- Content provided by FirstRanker.com ---
and pelvis? Brachytherapy (either permanent or temporary radioactive seed
implants)
--- Content provided by FirstRanker.com ---
? with or without external beam radiotherapy to the prostate margins
and pelvis.
? Surgery
--- Content provided by FirstRanker.com ---
? Traditional
? Robotic
? Radiation
--- Content provided by FirstRanker.com ---
? Brachytherapy
? External beam
? Cryotherapy
--- Content provided by FirstRanker.com ---
? Androgen Deprivation? Watchful waiting
Treatment ? Hormone resistant
--- Content provided by FirstRanker.com ---
? HORMONE-RESISTANT PROSTATE CANCER? Climbing PSA
? First manifestation of resistance to androgen deprivation
--- Content provided by FirstRanker.com ---
? In the setting of anorchid levels of testosterone
? Therapy
--- Content provided by FirstRanker.com ---
? Discontinuation of antiandrogen therapy (flutamide, bicalutamide, nilutamide) whilecontinuing with LHRH agonists
? Results in a PSA decline
--- Content provided by FirstRanker.com ---
? Can be associated with symptomatic improvement
? Can persist for 4 to 24 months or more
--- Content provided by FirstRanker.com ---
? Secondary hormonal manipulations? Ketoconazole or
? Estrogens
--- Content provided by FirstRanker.com ---
? Chemotherapeutic regimens
? Mitoxantrone plus corticosteroids or
--- Content provided by FirstRanker.com ---
? Estramustine plus a taxane? Monitoring
? Serial PSA levels (best)
--- Content provided by FirstRanker.com ---
? A decline of 50% or more is probably clinically significant
? PALLIATIVE CARE
? Bone pain
--- Content provided by FirstRanker.com ---
? Advanced prostate cancer
? Analgesics
--- Content provided by FirstRanker.com ---
? Glucocorticoids? Anti-inflammatory agents
? Can al eviate bone pain
--- Content provided by FirstRanker.com ---
? Widespread bony metastases not easily controlled with
analgesics or local radiation
--- Content provided by FirstRanker.com ---
? Strontium-89 and samarium-153? Selectively concentrated in bone metastases
? Al eviate pain in 70% or more of treated patients.
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