Download MBBS Urology Presentations 7 Disorders Of Prostate Lecture Notes

DISORDERS OF PROSTATE

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Outline

? Introduction

? BPH

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? Prostate cancer

? Prostatitis
v Acute bacterial

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v prostatitis

Chronic bacterial

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prostatitis

v Chronic pelvic pain (CPP)

(inflammatory/non-inflammatory)

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syndrome

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Prostate Overview

What is the Prostate?1

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? Walnut sized gland at base

of male bladder

? Surrounds the urethra

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? Produces fluid that transports

sperm during ejaculation

? Prostate grows to its normal

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adult size in a man's early

20s; it begins to grow again

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during the mid-40s


? the normal prostate measures between 3-4cm at its

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widest portion; it is 4-6cm in length & 2-3cm in

thickness.

? Weight 17-25 gm

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? In the early 1970's McNeal proposed a concept of

zonal anatomy.

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? According to this concept, the glandular portion of the

prostate is composed of a large peripheral & a Small

central zone, which together constitute about 95% of

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the gland.

Benign Prostate Hyperplasia

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Incidence & Epidemiology

? I

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The term BPH is a misnomer because the actual

change is a hyperplasia & not hypertrophy.

? TIhe initiation of BPH may not be environmental

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or genetically influenced.

? It I is also suggested that the prevalence of BPH

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increases with age in al male populations.

Etiology

? Two factors are necessary for BPH

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1)Endocrine control(DHT)
2) Aging

Relative role of testosterone estrogen, DHT

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is complex

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Normal vs. Enlarged Prostate

? As the prostate enlarges,

pressure can be put on the

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urethra causing urinary

problems (LUTS)1

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? Prostate size does not

correlate with degree of

obstruction or severity of

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symptoms.3

Normal Prostate

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Enlarged Prostate

Pathophysiology Of Symptoms

Symptoms of BPH:

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1) obstructive

?

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decrease in force & caliber of the stream: due to urethral

compression is one of the early & constant features of BPH.

Hesitancy: occurs because the detrusor takes a longer time to

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generate the initial increased pressure to overcome the urethral

resistance.

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?

lntermittency: occurs because the detrusor is unable to sustain the

increased pressure until the end of voiding.

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?

Terminal dribbling of urine & incomplete sense of bladder

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emptying


Pathophysiology Of Symptoms

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2) Irritative symptoms:

? Frequency:

-Incomplete emptying during each void results in shorter

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intervals between voids.

-The presence of enlarged prostate provokes the bladder to

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trigger a voiding response more frequently than in normal

individuals, especially if the prostate is growing intravesically.

? Nocturia: normal cortical inhibitors are lessened and also because

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the normal urethral and sphincteric tone is reduced during sleep.

? urgency & dysuria: uncommon.

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Pathophysiology Of Symptoms

?

Sy Istemic symptoms related to the UT:

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- Vesicoureteral reflux

- Dilatation & hydronephrosis

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- Renal failure & symptoms of uremia

? Symptoms unrelated to the UT:

- hernias, hemorrhoids and vesical calculus

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- change in the caliber of bowl movements

? Symptoms related to complications:

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- cystitis

- pyelonephritis

- bladder calculi

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- micro or gross hematuria.


Signs of BPH

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? If the disease is advanced & has resulted in renal failure.

Signs of renal failure include elevated BP, rapid puse &

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respiration, uremic fetor, pericarditis & pallor of nail beds.

? Abdominal examination may reveal palpable kidney or

flank tenderness if there is hydronephrosis or pyelonephritis.

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? A distended bladder may be noted on palpation or

percussion.

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? DRE: Enlarged prostate. Median sulcus always present

How is an Enlarged Prostate Diagnosed?12

? Medical History

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? Physical Exam*

Prostate Exam

? Digital rectal exam (DRE)

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Urinary Output Testing

? Peak urinary flow (Qmax) testing
? Post-void urine volume testing

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? Self Evaluation of Symptoms

American Urological Association Symptom Index (AUA-SI)
International Prostate Symptom Score (IPSS)

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Quality of Life (QoL) Questions
Bladder Impact Index (BII)

*Additional testing is optional and may be done at physician's discretion and/or depending on patient symptoms

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Laboratory Findings

? Urinalysis & microscopic examination: to R O

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infection

?or tshe

er presence

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um U/E

&of

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c hemat

reatin u

i ri

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n a.

e: to provide baseline

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information

on

? renal

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Uro fflunct

ow i

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mon

etr &

y: met

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At abol

a vol iuc st

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me at

us.

of 125-150ml,

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normal

individuals have average flow rates of 12ml/sec & peak

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flow close to 20ml/sec.

? Residual Urine: estimated by U S or catheterizations.

Volumes >150 ml are considered significant since they

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constitute approximately one-third of normal bladder
volume.

IMAGING

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? Ultrasound KUB-
Document :
?size of prostate
?Post void residual urine

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?Hydronephrosis


Treatment

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? Because BPH is not invariably progressive, the timing

of intervention is variable

? Absolute indications for treatment include severe obstructive

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symptoms & renal insufficiency.

? Relative indications - moderate symptoms of

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prostatism, recurrent UTI,vesical calculus and

hematuria.

? Until recently, surgery was the mainstay of therapy for

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BPH. In the last decade or so , there has been a

tremendous resurgence of interest in non surgical therapies.

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Treatment Options Overview

WATCHFUL WAITING/

MINIMALLY INVASIVE

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INVASIVE

MEDICAL THERAPIES

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SURGERY

SURGERY

Alpha Blockers

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Microwave Therapy

(TUMT)

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Open Prostatectomy

5 Alpha-Reductase

Laser

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Inhibitors

TURP

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(Monopolar, Bipolar,

Button)

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Treatment Options

Watchful Waiting/Medical Therapies

? Characteristics12

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Best for men with mild symptoms
Consists of yearly exams and no active intervention
No surgery
No drugs

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May involve lifestyle modification such as adjusting diet, evening fluid intake,

medication use and exercise patterns

? Side Effects

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Symptoms may worsen or remain unchanged without lifestyle modification1

Medical Treatment

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? Obstruction secondary to BPH occurs because

of 2 factors:

a.Dynamic component: a result of contraction

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of smooth muscles of the prostate

& prostatic urethra mediated mostly by adrenergic

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receptors.

b.Mechanical component: related to the

presence of a mass which compresses& narrows

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the urethral lumen.


Alpha adrenergic agonist

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? Ideally suited for the treatment of the

without impairing detrusor contractility

dynamic component of BOO because they

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can selectively reduce resistance along

the bladder outlet

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?Example:

-Tamsulosin 0.4mg OD, Silodosin 8 mg

-Alfuzosin XL 10mg OD, Terazosin

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-Doxazosin4mgTID

alpha- reductase inhibitor 5

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? Agents that selectively blockade androgens at

the prostate cellular level are termed anti-

androgens.

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?

the prostate normally requires conversion of testosterone

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to dihydrotestosterone by the enzyme 5 alpha-reductase.

?

In long term clinical trials, proscar has been

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shown to decrease prostatic size & improve urine

flow rates & symptoms of BPH.

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? Dutasteride and finasteride


MINIMALLY INVASIVE

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SURGERY(Conventional)
? TURP
? TUIP
? Laser Prostatectomy
? TUNA(Trans urethral needle ablation of

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prostate)

Conventional Surgical Therapy

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TURP

The principles of TURP are to remove the obstructing

adenomatous portion of the prostate via the urethra.

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?Overall morbidity: 18%.

?Current mortality: 0.2%.

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One preventable complication is TUR syndrome

? Immediate complications: failure to void, post op

.

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haemorrhage, clot retention, & UTI.

? Late complications: impotence, incontinence, uretheral

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.

stricture and retrograde ejaculation

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Instrument

inserted through

riesectoscope

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to remove the

prostate gland

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Before

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Af ter

TURP LOOP

TUIP

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Laser Prostatectomy

Treatment Options

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Invasive Surgery

Open Prostatectomy
Involves surgical removal of the inner portion of the prostate via a suprapubic or retropubic

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incision in the lower abdominal area.
Characteristics12

Side Effects12

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? Typically is performed on patients with ?

A

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ssociat

ed

wit

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h

a

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longer

hospit

al

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larger prostate volumes (>80 - 100 mL)

stay

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? Effective for men with:

? Risk of blood loss, transfusion

? Very enlarged prostate glands

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significantly greater than with

? Bladder diverticula (pockets)

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transurethral procedures

? Stones

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Open prostatectomy

? Open prostatectomy can be done either Tranvesical, perineal

or Retropupic prostatectomy.

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? In recent years the suprapubic & retropubic approaches for

BPH have been limited to approximately 10% of patients.

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? Indications for suprapubic prostatectomy are a gland size

greater than 100g, cystolithotomy or diverticulum excision.

? Most post op complications are similar to TURP, however,

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wound infection & thromboembolism are additional

complications.

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Prostate cancer

Prostate Cancer

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Statistics

? Most common non-cutaneous

malignancy in men in North America

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? 2nd most common cause of cancer-

related deaths in men

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? 1 in 7 men will be diagnosed
? Lifetime risk of being diagnosed with

prostate cancer is 18% but risk of dying

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of prostate cancer is only 3%


Prostate Cancer

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Risk Factors

? Established

? Potential

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? Advancing age

? High dietary fat

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? Presence of

? Obesity

androgens

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? Inherited mutations

? Family history

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(BRCA1 or BRCA2

(1st degree

genes)

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relative)

? Vitamin D or E

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? African ancestry

deficiency

? Selenium

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deficiency?

Prostate Cancer:

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Presentation

? Early stages usually asymptomatic

? Most cases detected by serum PSA screening

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? Palpable nodule or firmness on DRE

? Advanced stages

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? Urinary retention/renal failure

? Bone pain

? Anemia

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? Weight loss, fatigue

? Spinal cord compression

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Disease Screening

? Goal

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? To identify the presence of disease at a

stage when treatment can be given that

will cure it

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? Use a combination of DRE and PSA

Digital Rectal Examination

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? DRE (digital rectal exam) has a 50% positive

predictive value

? DRE alone is not a good screening tool

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? BUT it is an important part of screening


What is PSA (Prostate Specific Antigen)?

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? A Serine protease

(enzyme) found in the

prostate

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? Secreted by prostate

epithelial cells

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? Found in ejaculate
? As diagnostic tool for:

? Screening
? Staging

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? Prognostic indicator
? Surveillance

Prostate Cancer:

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Screening with PSA

? No clear cut-point between normal and abnormal

PSA levels. Even PSA cut-off of 1.1 ng/ml misses

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up to 15% of prostate cancer (The Cancer Prevention

Trial ? 2003)

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? Positive predictive value for PSA > 4ng/ml = 30%

(i.e. About 1 in 3 men with elevated PSA have

prostate cancer detected at time of biopsy

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? PPV increases to 45-60% for PSA > 10ng/ml
? Nearly 75% of cancers detected in the grey zone

(PSA 4-10) are organ confined; potentially curable.

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? <50% of prostate cancers organ confined if PSA

>10

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Free/Total PSA Ratio:

A Way to Improve Specificity

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? Prostate cancer maybe

associated with more

protein-bound PSA

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BPH

(less free PSA) than in

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BPH

? F/T ratio is lower in

Prostate Ca

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patients with prostate

cancer

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? Can improve test

specificity

? Useful when total PSA

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in 4-10 ng/ml range

Prostate Cancer:

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Diagnosis

? Indications for transrectal ultrasound (TRUS)

guided biopsy

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? Palpable nodule on DRE
? Elevated serum PSA

? Biopsy involves 10-18 needle cores taken

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mostly from the peripheral zone of the

prostate

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Imaging

2) CT:

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used only when extensive L.N. disease is suspected and it is

based only on the size of the nodes thus false

+ve and -ve are common.

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3) MRI:

not useful because of the cost and the overlap in the

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appearance of benign & malignant processes, but its more

accurate than TRUS for staging extracapsular extension and

seminal vesicle involvement.

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4) Bone scanning:

- most common way to assess systemic metastasis.

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- False +ve rate is less than 2?/o .

- Diagnosis is confirmed by plain radiographs, thin section CT or

MRI and bone biopsy

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Prostate Cancer:

Pathology

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? Adenocarcinoma
? Gleason "grade" is from 1-

5 based on glandular

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architecture

? Gleason score is the total

primary grade (1-5) +

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secondary grade (1-5) = 2-

10

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? 4-6/10=well-differentiated
? 7/10=moderately

differentiated

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? >8/10=poorly differentiated

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Prostate Cancer:

Staging

? Can spread to adjacent organs (seminal

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vesicles, bladder), lymph nodes, bone

? Most bone mets are osteoblastic
? Prior to initiating treatment consider

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? Bone scan (PSA>10, Gleason Score >7)
? CT scan pelvis/abdomen (PSA >10, Gleason

Score >7))

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? These tests are typically not required in

asymptomatic men with low risk prostate

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cancer

1. The size and extent of the primary Tumor (T category)

? T1 - The tumor is not detectable with a digital rectal exam (DRE) or imaging but is

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found in prostate tissue from a biopsy or surgical treatment.

- T1a - Cancer is found in 5% or less of the removal tissue.

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- T1b - Cancer is found in more than 5% of the removed tissue.

- T1c - Tumors are found by needle biopsy done for a high PSA.

? T2 - The tumor is detectable with a DRE or imaging but is confined to the prostate.

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- T2a - Cancer is in no more than one half of one side of the prostate.

- T2b - Cancer is in more than half of one side of the prostate.

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- T2c - Cancer is in both sides of the prostate.

? T3 - Cancer has grown outside the prostate and may have grown into the seminal

vesicles.

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- T3a - Cancer has spread outside the prostate but not to the seminal vesicles.

- T3b - Cancer has spread to the seminal vesicles.

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? T4 - Cancer has grown into other nearby tissues, such as the urethral sphincter,

rectum, bladder or wall of the pelvis

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Whether the cancer has spread to nearby lymph Nodes (N Category)

? NX - The lymph nodes have not been assessed for cancer.
? N0 - There is no cancer in nearby lymph nodes.
? N1 - Cancer has spread to nearby lymph nodes.

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The absence or presence of cancer outside the prostate, or Metastasis (M

Category)

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? MX - It is unknown if cancer has spread to distant sites.
? M0 - The cancer has not spread to distant sites.
? M1 - Cancer has spread to distant sites.

- M1a - Cancer has spread to distant lymph nodes.

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- M1b - Cancer has spread to bones.

- M1c - Cancer has spread to distant organs

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Prostate Cancer

Treatment

? Considerations

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? Patient's age
? Co-morbid health

conditions

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? Tumor stage
? Tumor grade (Gleason

score)

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? Often a patient choice
? Surgery and

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Early Stage Prostate Cancer


Treatment

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? Early stage Cancer

1. Radical Prostatectomy
2. External Beam Radiotherapy
3. Radioactive Seeds (Brachytherapy)

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4. Active Surveil ance
5. Observation ? Watchful Waiting

Prostate Cancer Treatment:

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1. Radical Prostatectomy

? Radical Prostatectomy

? Complete surgical removal of entire prostate,

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seminal vesicles

? Considered a good treatment for men <70

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years of age with clinically organ confined

cancer who are healthy

? Open or laparoscopic/robotic approaches

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Prostate Cancer Treatment:

1. Radical Prostatectomy

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Prostate Cancer Treatment:

Radiotherapy

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? Radiotherapy Options

? External Beam

? Brachytherapy (seed implant)

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? Concept of maximizing dose to the tumor and

minimizing collateral damage

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? Curative options for patients at high risk for

morbidity from radical prostatectomy

? Age, medical co-morbidities

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? Patient preference

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Prostate Cancer Treatment:

2. External Beam Radiotherapy

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Prostate Cancer Treatment:

3. Brachytherapy

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Prostate Cancer Treatment:

4. Active Surveil ance

? Observing low grade tumors in men <70 yrs and

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>10 yr life expectancy

? Delay definitive treatment until it is necessary and

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cancer is stil curable

? Goal is to delay potential treatment-related

morbidity

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? Monitor DRE, PSA, and periodic repeat biopsy
? Ideal candidate:

? PSA < 10

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? Normal DRE
? Gleason <7 (low grade)
? Only 1-3 / 12 biopsy cores positive

Prostate Cancer. Treatment:

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5. Watchful Waiting

? Observing low grade tumors in men >70

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yrs or <10 yrs life expectancy

? Institute hormonal therapy when patient

becomes symptomatic

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? No curative intent


Advanced or Metastatic Prostate

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Cancer
? Not curable disease
? Goals shift to disease control
? Development of cancer cells unresponsive

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to androgen deprivation

? Typically occurs slowly over time, although

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it can occur rapidly

Advanced Prostate Cancer:

Treatment

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? Androgen Deprivation

(Hormonal Rx)

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? Orchidectomy

? LHRH analogues

? Antiandrogens

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? Supportive therapies

? Analgesics

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? Steroids

? Bisphosphonates/Vitamin D/Calcium

for bone health

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? Chemotherapy

? Taxotere, Docetaxel

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? Last line of treatment


Prostate Cancer

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Prognosis

? Depends upon grade, stage and treatment
? Early stage/well-differentiated Ca treated

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by radical prostatectomy:

? 85% + 10 year survival

? Metastatic disease

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? <10% 5 year survival

PROSTATITIS

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Definition

? Infection &/ or inflammation of the prostate

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Epidemiology

? Overall prevalance in men is 5
? higher risk age 20 ? 50 & >70

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Pathogenesis

? Tissue around prostatic acini become

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infiltrated by inflamatory cells.

? Organisms:

? G-ve (E.coli, pseudomonas, klebsiella , serratia,

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Enterobacter aerogenes.)

? G+ve 5-10 %
(staph aureus, saprophyticus, streptococcus

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faecalis)

? Aetiology ?

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Risk factors

? UTI
? Acute epididymitis.
? Urethral catheters.

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? Transurethral surgery
? Intraprostatic duct

reflux

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? Phimosis
? Prostatic stones


Segmented urine cultures

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? Localize bacteria to specific part of the

urinary tract.

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? first voided 10ml ---------- urethritis &

prostatitis VB1

? Midstream urine -------------cystitis VB2

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? Prostatic massage
? 10 ml post massage---------- prostatitis

VB3

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? EPS ------------------------------ prostatitis

Classification

? Class 1: acute

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? Class 3: chronic

bacterial prostatitis

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pelvic pain syndrome

? 3a inflammatory non-

? Class 2: chronic

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bacterial : wbc in EPS,

bacterial prostatitis.

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VB3 or semen.

? 3b non-inflammatory :

no wbc in Eps , vb3 or

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semen.

? Class 4:

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Asymptomatic

inflammatory

prostatitis

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Evaluation

? Class 1: acute bacterial prostatitis

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? E.coli common
? Associated with LUT infection.

Class 1

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? Acute onset fever.

? Signs:

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? Chil s

? Systemic toxicity

? Nausea &vomiting

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? Suprapubic

? Perineal & sp pain

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tenderness.

? Irritative urinary

? Palpable bladder with

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symptoms (

UR

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frequency, urgency,

? Tender DRE

dysuria)

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? Obstructive

(hesitancy, strangury,

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UR, intermittency)


Class 1

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? Systemically well

? Systemically unwell

? Oral quinolone

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? I.V antibiotic

ciprofloxacin 500 BID

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? Aminoglycoside+3rd

? 2-4 weeks

generation

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cephalosporins

? Pain relief

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Class 1

? Prostatic abscess

oPersistant symptoms:

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oFever while on antibiotic.

oTRUS ? PAIN

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oTransurethral management


Class2

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? Previous history of recurrent UTI
? Chronic episodes of pain & voiding

dysfunction

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? DRE: tender, enlarged & boggy prostate

Class 3

? Chronic pelvic pain

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? ED

syndrome

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? Symptoms can recur

? Both types present

over time

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with:

? Affect patient's quality

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? >3 months localized

of life

pain.

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(perineal, suprapubic,

penile , groin or ext.

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genitalia)

Pain with ejaculation.

LUTS

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Class 4

? Incidental histological Dx in prostate

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specimens.

Evaluation

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? Hx
? NIH- CPI questionnaire:
? Pain ( location, severity, frequency)
? Voiding (obstructive , irritative symptoms)
? Impact on quality of life.

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Evaluation

? Segmented urine culture & EPS

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? Cultures ?ve
? high Leucocyte count >10/ HPF
? Favor Dx inflammatory chronic pelvic pain

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syndrome

Treatment

? Alpha- blockers: improve urinary flow,&

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reduce intraprostatic ductal reflux

? Anti inflammatory drugs NSAID
? 5 alph reductase inhibitors :improve

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intraprostatic ductal reflux.

? Microwave heat therapy

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Non- inflammatory chronic pelvic

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pain syndrome
? Treatment:

? Drugs: analgesia ( tricyclic antidepressent,

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anti inflammatory, muscle relaxants, 5- alpha

reductase inhibitors

? Biofeedback.

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? psychological

Thank You