Asim Pasha

 Common condition seen in older men  Risk factors  1-age:  Around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms.   Around 80% of 80-year-old men have evidence of BPH  2-ethnicity: black > white > Asian

 Family history and genetic factors.  Diet is possibly a risk factor.  Exposure to the metal cadmium

 lower urinary tract symptoms (LUTS)  voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying  storage symptoms (irritative) urgency, frequency, urgency, incontinence and nocturia  post-micturition: dribbling  complications: urinary tract infection, retention, obstructive uropathy

 >70 yrs with LUTS  IPSS >7 i.e. moderate or severe LUTS  Flow rate<12ml/s  Prostrate volume >30cc  Post void residual volume > 100mls

LUTS->assessment->PSA high ->refer  exam/urine RE concern  PSA haematuria  U&E high  palpable bladder  recurrent uti  abn. Cytology  severe symp. LUTS->assessment-> bothersome->no-> RF prog  exam/urine symp.  yes LS + 5ARI  PSA ->yes->RF prog  ->yes->LS 5 ARI/AB3-6m  ->no ->LS AB6-12w

 watchful waiting  medication:  alpha-1 antagonists, 5 alpha-reductase inhibitors.  The use of combination therapy was supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial  surgery: transurethral resection of prostate (TURP)

 Alpha-1 antagonists e.g. tamsulosin, alfuzosin  decrease smooth muscle tone (prostate and bladder)  considered first-line, improve symptoms in around 70% of men  adverse effects: dizziness, postural hypotension, dry mouth, depression

 5 alpha-reductase inhibitors e.g. finasteride  block the conversion of testosterone to dihydrotestosterone (DHT)  Reduction in prostate volume - may slow disease progression.  Symptoms may not improve for 6 months.   May decrease PSA concentrations by up to 50%  adverse effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

 Prostate cancer is the second most common cancer in adult males in the UK  The most common malignant condition in men over 65 years.  Risk factors  increasing age  Afro-Caribbean ethnicity

 bladder outlet obstruction: hesitancy, urinary retention  haematuria, haematospermia  pain: back, perineal or testicular  digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus

 important tumour marker but much controversy still exists regarding its usefulness as a screening tool  Age-adjusted upper limits for PSA were recommended by the PCRMP*:  Age PSA level (ng/ml)  years- 3.0  years- 4.0  > 70 years- 5.0

 PSA levels may be raised by:  benign prostatic hyperplasia (BPH)  prostatitis and UTI (NICE recommend to postpone the PSA test for at least 1 month after treatment)  ejaculation (ideally not in the previous 48 hours)  vigorous exercise (ideally not in the previous 48 hours)  urinary retention  instrumentation of the urinary tract  whether digital rectal examination

 Localised prostate cancer (T1/T2) Treatment depends on life expectancy and patient choice.  Options include:  conservative: active monitoring & watchful waiting  radical prostatectomy  radiotherapy: external beam and brachytherapy

 Localised advanced prostate cancer (T3/T4) Options include:  hormonal therapy  radical prostatectomy  radiotherapy: external beam and brachytherapy

 Metastatic prostate cancer disease - hormonal therapy Synthetic GnRH agonist  e.g. Goserelin (Zoladex)  cover initially with anti-androgen to prevent rise in testosterone  Anti-androgen  cyproterone acetate prevents DHT binding from intracytoplasmic protein complexes  Orchidectomy

 Gleason score  grading system is based on the glandular architecture seen on histology following hollow needle biopsy  The most prevalent and the second most prevalent pattern seen are added to obtain a Gleason score.  The Gleason grade ranges from 1 to 5 meaning the Gleason score ranges from 2 to 10 (i.e. two values added) The higher the Gleason score the worse the prognosis

 The Prostate Cancer Charity  Helpline: Web: Provides support and information for patients and their families.  Prostate Action  Tel: Web: A national charity dealing with all prostate diseases, including prostate cancer.  Macmillan Cancer Support  Tel: Web: Provides information and support to anyone affected by cancer.  Cancer Research UK  Web: provides facts about cancer including treatment choices.  The NHS Prostate Cancer Risk Management Programme  Web: Provides information as to why there is no organised screening programme for prostate cancer but an informed choice programme instead.  Other support groups  See for a list of support groups for cancer patients.

Are you ready?- This is the beginning…..