EXAMINER QUESTIONS Four minutes has passed
o List differentials and what is the most likely Which investigations would you like to do and why?
What are your management options if this patient was shown to have prostate cancer?
How would you manage this patient?
HISTORY
Don McClean 68 years old
Lives at home with wife
She is well Pensioner PC
Trouble with waterworks and back pain HxPc
Difficulty passing urine for the last year or so Takes 20 minutes for him to be able to pass urine
o Stopping/starting stream o Passes small volumes
o Feels as though the void was incomplete o Dribbling
Has the sudden urge to empty his bladder Happens nearly all the time
Gradual onset, getting worse
Has to get up to use the bathroom during the night (3-4 times)
Nothing seems to make it better or worse, but has tried running the tap and using warm water to ‘get things going’
No blood in urine
No offensive smell of urine No pain No overflow incontinence No fever No loin pain No discharge No change in bowels
Still able to get an erection Back pain
o Started a few weeks ago o Lower back
o 7/10
o No radiation to legs
o Constant pain
o Nothing makes it better o Worse at night – difficulty
Has never had his prostate checked MHx
Nil allergies UTIs
o A few over the last few years Kidney stones
o Once, 10 years ago Otherwise well
No medications
Doesn’t like going to the dr FHx
Grandfather died of prostate cancer at 75 No other Hx
SHx
Non smoker
Drinks 1 beer/night 2 children – both well DIFFERENTIALS Prostate cancer o Most likely BPH Prostatitis
o No blood, no pain, less likely Renal colic UTI/pyelonephritis Urethral stricture/tumour INVESTIGATIONS PSA Ultrasound
o Size, shape of prostate PR
o Smooth – BPH
o Rough, stony hard – malignancy
Trans-rectal biopsy
Vertebral XRAY/bone scan o Mets
Cystoscopy
Urinalysis and culture o Rule out UTI Renal function If suspecting calculi
o Abdo XRAY
MANAGEMENT AND TREATMENT
The patient most likely to benefit from radical prostatectomy is one with a relatively long life expectancy (>10 years)
Who have a low PSA
Moderately differentiated tumour
Interstitial Radiotherapy:
Patient group most likely to benefit are those with high life expectancy and low volume, low grade disease
No Initial Treatment:
Those who have a preference for no intervention, long life expectancy, low volume disease, moderately differentiated disease
TURP:
A vasectoscope is inserted through the urethra and sections of the prostate are removed in order to increase the opening of the urethra
Complications can include:
o Incontinence
Permanent dilation of the urethra Effects on external sphincter
o Infection o Bleeding o Retrograde ejaculation BRACHYTHERAPY
In patients with METASTATIC DISEASE, the aim of treatment is to control
symptoms and to retard the disease progression. Most cancers are androgen- dependent, at least initially, and hormonal manipulation is the mainstay of treatment of advanced disease. Local radiotherapy is frequently effective for treating painful metastases.
HORMONAL THERAPY
There are three main treatment options:
REMOVAL OF BOTH TESTES BY SUBCAPSULAR ORCHIDECTOMY
o Quick and simple procedure that removes around 95% of the testosterone synthesised (the rest is from the adrenals), producing an immediate fall in plasma testosterone
MONTHLY INJECTIONS OF DEPOT LHRH AGONISTS
o Need to be administered at intervals ranging from 4-12 weeks
o Therapy causes initial stimulation of LH from the pituitary, which turns up testosterone secretion for up to 2 weeks, which is followed by inhibition of LH release by competitively blocking the receptors
o Many patients experience a ‘flare’ in symptoms in the first 2 weeks, aggravating bone pain or spinal compression
o For this reason, the first dose is usually covered by anti-androgen therapy ANTI-ANDROGEN DRUGS SUCH AS CYPROTERONE ACETATE OR FLUTAMIDE
o These block the binding of dihydrotestoerone to its receptor at a cellular level 5-ALPHA-REDUCTASE INHIBITORS Examples Include: Dutasteride Finasteride Mode of Action
They inhibit 5-alpha-reductase, which is the enzyme that converts testosterone into dihydrotestosterone, which is an androgen that stimulates prostatic growth decreased prostatic enlargement
Indications
BPH
Contraindications
Adverse Effects
Common
o Impotence, decreased libido, ejaculation disorder
Uncommon
o Breast tenderness or enlargement
Rare o Allergic reaction ALPHA-ADRENDERGIC BLOCKERS Examples: Alfusozin Mode of Action
These block alpha1 receptors smooth muscle relaxation in the bladder neck and prostate decreased resistance to urinary flow symptom relief in BPH/obstruction Indications Symptom relief in BPH Contraindications Hepatic impairment Adverse Effects
This is a new drug so adverse events are relatively unknown GNRH ANALOGUES Examples Include: Goserelin Leuopolide Mode of Action
Stimulates production of testosterone in a continuous manner (non-pulsatile) increased LH production feedback to pituitary gland down-regulation of GnRH receptor down regulation of testosterone production eventual cessation of hypothalamus-pituitatry-gonad axis
Indications
Prostate cancer (specifically Goserelin) Endometriosis Uterine fibroids Breast cancer Contraindications Pregnancy Breastfeeding
Unexplained vaginal bleeding Polycystic ovarian disease Pituitary Adenoma
Adverse Effects
o Transient changes in BP, hot flushes, sweats, sexual dysfunction, reduced libido
Uncommon
o Bronchospasm, rash Rare
o Depression, hypersensitivity reactions ANDROGEN-AGONIST
Examples
Bicalutamide Mode of Action
Competitively inhibits the binding of androgens (eg, testosterone) to androgen- receptors
Indications
Metastatic prostate cancer with GnRH agonist
o This prevents the initial surge of testosterone from the GnRH agonist prostatic growth prior to receptor downregulation
Prevention of GnRH-agonist associated initial tumour flare Locally advanced prostate cancer
Contraindications
Consider dose reduction in hepatic impairment Adverse Effects
Common
o Dizziness, dyspnoea, constipation, dry skin, rash, weakness Rare
o Thrombocytopaenia, CVS disorders (angina, heart failure, arrhythmias, ECG changes), pneumonitis, pulmonary fibrosis
MANAGEMENT OF THIS PATIENT
Await results and gleason score, staging, PSA Low risk: o T1 or T2a o Gleason score </= 6 o PSA </= 10ng/mL High Risk o T3 o Gleason score 8-10 o PSA >20
Intermediate – in between these values Low risk:
o Active surveillance
o Radical prostatectomy if young and healthy If high risk:
o Radical prostatectomy if young and healthy o RadiotherapY