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Prostate Problems

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Prostate Problems By Dr Mahya Mirfattahi GPST1 HDR Wednesday 17th February 2010 Lower urinary tract symptoms Obstructive Poor stream, hesistancy, terminal dribbling ... – PowerPoint PPT presentation

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Title: Prostate Problems


1
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 1 - 60 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
  • Overactive bladder syndrome, underactive detrusor
  • Neurological conditions
  • MS, Parkinsons, 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 gt70yrs, IPSS gt7, Prostate volume gt30mls, PSA
    level gt1.4ng/ml, QMax lt12ml/s, Post void RV
    gt100mls

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
  • 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
Whats 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 lt70yr RR 2
  • Two 1st degree relatives (one of them) lt65 RR 4
  • Three or more relatives RR 7-10
  • Risk factors
  • Increasing age (85 diagnosed gt65yrs)
  • 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
  • www.cancerscreening.nhs.uk 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 lt50yrs
  • 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-related referral values for total PSA levels
    recommended by the Prostate Cancer Risk
    Management Programme
  • Age PSA referral value (ng/ml)
  • 5059 3.0
  • 6069 4.0
  • 70 and over gt 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
  • Low or intermediate risk, localised prostate
    cancer
  • PSA surveillance at least one re-biopsy
  • Treatment of choice if estimated life expectancy
    of lt10yrs
  • 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 www.learning.bmj.com
  • Clinical Knowledge Summaries on BPH, acute
    chronic prostatitis. Accessed via www.cks.nhs.uk
  • GP notebook. Accessed via www.gpnotebook.co.uk
  • Oxford Handbook of General Practice 2nd Edition
  • Department of Health. Prostate cancer risk
    management programme PSA Testing in Asymptomatic
    Men. Accessed via www.cancerscreening.nhs.uk
  • Prostate Cancer. InnovAiT, Vol 1, No. 9, pp.
    642-650, 2008
  • GP Update Handbook (login access courtesy of
    Joanna Blyth) via www.gp-handbook.co.uk
  • Patient UK leaflets for patients
    www.patient.co.uk
  • Management of prostatitis. BASHH 2008 guidelines.
    Accessed via www.bashh.org
  • UK prostate link www.prostate-link.org.uk
  • Prostate cancer charity www.prostate-cancer.org.uk
  • Prostate cancer support association
    www.prostatecancersupport.co.uk
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