1. By Dr Mahya Mirfattahi GPST1 HDR Wednesday 17th February 2010
Prostate Problems
By Dr Mahya Mirfattahi
GPST1
HDR Wednesday 17th February 2010

2. Lower urinary tract symptoms
Obstructive
Poor stream, hesistancy, terminal dribbling, pis-en-deux (incomplete bladder empyting), overflow incontinence
Irritative
Frequency, nocturia, urgency, dysuria

3. Case 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?

4. Aims of history Assess symptoms & severity
Assess impact on quality of life
Identify other causes of LUTS
Identify complications
Identify co-morbidities that may complicate treatment

5. 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

6. 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?

7. 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

8. DD continued Bladder storage disorders Neurological conditions
Overactive bladder syndrome, underactive detrusor
Neurological conditions
MS, Parkinson’s, CVA
Conditions causing polyuria
Diabetes, congestive cardiac failure

9. 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

10. 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

11. Prostate

12. 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

13. Treatment of BPH Aims of treatment are Relieve symptoms
Improve quality of life
Attempt to prevent progression of disease & development of complications

14. 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?

15. 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 pre-existing cardiovascular co-morbidity or co-medication

16. 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

17. 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

18. 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

19. Combination therapy
For those patients with increased risk of disease progression & symptomatic
Increased side effects

20. 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

21. 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

22. 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

23. When to refer in BPH? Based on NICE guidelines Urgent if UCR Soon
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

24. 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

25. What’s your DD? UTI Acute prostatitis Urethritis Cystitis
Pyelonephritis
Acute epididymo-orchitis
Local invasion from prostate, bladder or rectal cancer

26. 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

27. Treatment of Acute Prostatitis
Start antibiotics immediately (whilst waiting MSU results)
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

28. 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

29. 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

30. 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

31. 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

32. What will you do next? Physical examination
Exclude other diagnosis
DRE: diffusely tender prostate
Urine culture
Consider PSA – more on this later
Prostatic massage not recommended in primary care

33. 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

34. 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 months-years
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

35. 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

36. Case 4 – 68 yr old, male 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

37. 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

38. 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

39. PSA testing counselling
There is no prostate screening programme in the UK
Men can request a PSA test
= good website with pt info leaflet

40. 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

41. Things to tell patients (2)
What is the PSA test?
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 non-aggressive tumours
May detect early stage of cancer when treatments could be beneficial

42. 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

43. 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

44. 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)

45. Problems with PSA screening
A good screening test should fulfil Wilson-Jungner 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

46. 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

47. 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.

48. Threshold PSA levels Age PSA referral value (ng/ml) 50–59 ≥ 3.0
Age-related referral values for total PSA levels recommended by the Prostate Cancer Risk Management Programme
Age PSA referral value (ng/ml)
50–59 ≥ 3.0
60–69 ≥ 4.0
70 and over > 5.0

49. 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

50. Treatment options Watchful waiting Low risk patients
Monitoring with annual PSA/rectal examination
Increase in PSA or size of nodule triggers active treatment

51. Treatment options (2) Active surveillance Radical prostatectomy
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

52. 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

53. 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

54. Treatment options (5) Bony metastases
1st line LHRH or bilateral orchidectomy
If hormone refractory
MDT: palliative care as needed
Chemotherapy
Corticosteroids
Spinal MRI
Bisphosphonates

55. 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)

56. Any questions?
Thanks for listening!

57. References & Useful resources
BMJ Learning modules: Benign Prostatic Hyperplasia, Prostate cancer risk management. Accessed via
Clinical Knowledge Summaries on BPH, acute & chronic prostatitis. Accessed via
GP notebook. Accessed via
Oxford Handbook of General Practice 2nd Edition
Department of Health. Prostate cancer risk management programme: PSA Testing in Asymptomatic Men. Accessed via
Prostate Cancer. InnovAiT, Vol 1, No. 9, pp , 2008
GP Update Handbook (login access courtesy of Joanna Blyth) via
Patient UK – leaflets for patients
Management of prostatitis. BASHH 2008 guidelines. Accessed via
UK prostate link
Prostate cancer charity
Prostate cancer support association