All about the Prostate

Transcription

1 MEN S HEALTH Dr Nick Pendleton January 16 th 2018 All about the Prostate 1

2 What does it do? Functions of the Prostate 1. Secretes Prostatic Fluid slightly alkaline fluid, 30% of volume of seminal fluid, neutralises acidity of vaginal tract and prolongs life and motility of sperm 2. Smooth Muscle contractions - help expel semen during ejaculation 2

3 Prostate Specific Antigen What is PSA? It is a component of Prostatic Fluid produced exclusively by epithelial cells of the prostate (both benign and malignant) It is a protease enzyme It breaks down proteins forming in the seminal fluid It makes seminal fluid more liquid 3

4 PSA can be detected in the blood Example PSA Cut-off Values (please use local lab reference ranges) Age (years) The normal range is age-dependent PSA Cut-off nanogram/ml or higher is abnormal nanogram/ml or higher nanogram/ml or higher 70 or older 5.0 nanogram/ml or higher There are no age-specific reference limits for men older than 80 years of age Does PSA rise after DRE? We will discuss PSA test counselling later but this is a common question! From a Consultant Urologist: DRE does increase PSA slightly but not to a clinically significant level. I just do the DRE and then order the PSA. I never worry about this! Mr A. Noon MB ChB (Hons) MD FRCSEd (Urol) 4

5 So what can go wrong with the Prostate gland? Symptoms of normal/benign prostatic growth (BPH) Prostate Cancer Prostatitis BENIGN PROSTATIC HYPERPLASIA (BPH) 5

6 Symptoms of BPH Decreased flow Hesitancy / Stop-start / Straining Urgency / Frequency / Nocturia Small volumes Difficulty fully emptying Urinary incontinence / Terminal dribble Urinary Tract Infection Acute Urinary Retention 6

7 Grouping Symptoms of BPH (LUTS) Storage (irritative) Urgency / Frequency / Nocturia Urinary incontinence Voiding (Obstructive) Hesitancy / Stop-start / Straining Decreased flow, Terminal dribble Difficulty fully emptying Post Micturition Symptoms Sensation of incomplete emptying and post-micturition dribble International Prostate Symptom Score (IPSS) Classifies symptoms into mild, moderate and severe and assesses impact on life Grade 7 individual symptoms 0 5 and add up scores Mild = 0-7, Mod = 8 19, Severe = Link to PDF: flets/ipss.pdf 7

8 Diagnosis Careful history taking IPSS score Abdo and Digital Rectal Examination Urine test for infection PSA counselling +/- PSA test Other bloods? Urinary Frequency-Volume chart URINARY FREQUENCY-VOLUME CHART A urinary frequency volume chart is used to help distinguish and diagnose: Frequency: high frequency with normal 24-hour volume suggests that the bladder capacity is diminished (the male bladder normally holds ml urine comfortably) Polyuria: passing more urine than usual (up to 3 L of urine in 24 hours is normal) Nocturia: waking at night to urinate Nocturnal polyuria: passing, at night, more than 35% of the 24-hour urine production 8

9 Advice for BPH Mild Symptoms Drinking less alcohol, caffeine and fizzy drinks Limiting intake of artificial sweeteners Exercising regularly Drinking less in the evening Medications for BPH If IPSS is 8 or more offer ALPHA BLOCKER medication: Tamsulosin Alfuzosin Doxazosin Terazosin Review at 4-6w and then every 6-12m 9

10 Medications for BPH If the prostate is enlarged and symptoms could progress rapidly ie. Older man, lower flow, higher IPSS scores Use 5-Alpha Reductase Inhibitor eg. Finasteride or Dutasteride Review at 3-6m and then 6-12m Combining Medications Can use Alpha-blocker and 5-Alpha reductase inhibitor together in men with mod-severe voiding symptoms and enlarged prostate Can use an Anticholinergic on top of Alphablocker if mixed picture of storage and voiding symptoms do not improve with Alpha-blocker alone eg. Immediate release Oxybutynin But see further info here: 10

11 What next? If treatment fails to adequately relieve symptoms: Consider offering referral to a urologist for assessment and further management. Secondary care options include catheterisation and Prostate Surgery Secondary Care Treatments Urethral catheterisation: intermittent, indwelling urethral, or indwelling suprapubic Prostate surgical options include: Transurethral resection of the prostate (TURP) Transurethral vaporisation of the prostate (TUVP) Holmium laser enucleation of the prostate (HoLEP) Transurethral incision of the prostate (TUIP) Open prostatectomy Choice of surgery depends on: size of the prostate, availability of specialised equipment and skills, the man's health, and preferences Most operations are performed through the urethra, but open surgery is used for larger prostates (weighing more than 80 g). 11

12 PROSTATE CANCER Prostate Cancer 2014 ONS Data 12

13 Prostate Cancer Incidence 2014 ONS Data Is an Adenocarcinoma Prostate Cancer It develops in the peripheral zone of the prostate Risk factors: Obesity, Age and Family History No particular gene and often there is no FH Post mortem studies have shown prostate cancer in up to 80% of over 70s who have died from other causes It metastasises to particularly to bone and lymph nodes 13

14 BPH and Prostate Cancer? The risk of prostate cancer is no greater for men with an enlarged prostate than it is for men without an enlarged prostate Prostate Cancer can present like BPH By Cancer Research UK - Original from CRUK, CC BY-SA 4.0, 14

15 Prostate Cancer vs BPH Early Prostate Cancer often has no symptoms The symptoms can be like BPH It could present with back pain The symptoms tend to evolve more rapidly than BPH Potential Diagnosis made by: Symptoms, DRE and PSA How sensitive is DRE on its own? Not very PSA Counselling is very important PSA Counselling What are the main points? As a result of altered prostate architecture in prostate cancer, more PSA leaks out increasing serum PSA However, blood PSA is an inaccurate marker for prostate cancer, because cancer can be present without increased PSA levels, and there are many other causes of increased PSA levels (for example, benign prostatic enlargement, prostatitis, and urinary tract infection) 15

16 PSA Counselling Benefits of PSA testing, including: Early detection PSA testing may lead to prostate cancer being detected before symptoms develop Early treatment detecting prostate cancer early before symptoms develop may extend life, or facilitate a complete cure PSA Counselling Limitations and risks of PSA testing, including: False-negative PSA tests about 15% of men with a negative PSA test may have prostate cancer, and 2% will have high-grade cancer. However, it is not known what proportion of these cancers become clinically evident False-positive PSA tests about 75% of men with a positive PSA test have a negative prostate biopsy 16

17 PSA Counselling (Risks) Unnecessary investigation a false positive PSA test may lead to invasive investigations, such as prostate biopsy, and there may be adverse effects (for example bleeding, or infection) Unnecessary treatment a positive PSA test may lead to the identification and treatment of prostate cancers which would not have become clinically evident during the man s lifetime Adverse effects of treatment are common and serious and include urinary incontinence and sexual dysfunction Decision Aids for Patients PHE: /uploads/attachment_data/file/509191/patient_in fo_sheet.pdf NHS Right Care: ty%22:[%22patient%20decision%20aids%22]},{%2 2srn%22:[%22NHS%20RightCare%22]}]&ps=50 SWOP: 17

18 When to refer 2WW Referral if: DRE abnormal :hard, nodular prostate suggestive of cancer Or PSA levels above the age specific reference ranges What will the Urologist do? Offer Prostatic Biopsy (TRUS) TransRectal UltraSound guided cores of prostatic tissue If histology shows tumour it is graded with the Gleason Score TRUS misses 45% of tumours Additional Imaging 18

19 Risk stratification Table 1. Risk stratification for men with localized prostate cancer according to prostate-specific antigen (PSA) level, Gleason score, and TNM clinical stage. Risk of progression PSA level Gleason score Clinical stage Low risk < 10 nanogram/ml and 6 and T1 T2a Intermediate risk nanogram/ml or 7 or T2b High risk* > 20 nanogram/ml or 8 10 or T2c * This also includes locally advanced prostate cancer Source: [NICE, 2014 ] Treatment options for Prostate Cancer Depends on stratified risk Watchful Waiting (in Primary Care) or Active Monitoring (DRE, PSA and biopsies) or Surgery or Radiotherapy (variations depending on if Low, Intermediate or High Risk +/- HORMONAL TREATMENTS eg Zoladex 19

20 10 Year Survival after Prostate Cancer Detection The ProtecT Trial (Hamdy et al) Compared Active Monitoring with Surgery and with Radiotherapy Results: No difference in deaths from Prostate Cancer between approaches No difference in all-cause mortality More disease progression and metastasis in the Active Monitoring Group Prostate Cancer (C61): Age-Standardised Ten-Year Net Survival, England and Wales 20

21 The 5-year survival rate in the United States is 99%. "SEER Stat Fact Sheets: Prostate Cancer. NCI. Archived from the original on 6 July Retrieved 18 June Prostatitis 21

22 Andy Tomkins, 32 Works in a local supermarket Infrequent attender at the surgery Fit and active, goes to gym and plays football Emergency appointment Last 24 hours has had severe lower abdo and back pain also felt around testicles, penis and anus Dysuria, frequency, hesitancy and stop-start urination, pain on opening bowels Feels generally unwell with fever symptoms NICE CKS ACUTE: CHRONIC:

23 Small Group Task HARNESSING DIGITAL TECHNOLOGY AND SOCIAL MEDIA IN PRIMARY CARE RULES OF ENGAGEMENT WITH SOCIAL MEDIA FOR HEALTH PROFESSIONALS AND EMPLOYED STAFF Consultation Skills Video Erectile Dysfunction 23

24 Upcoming Sessions 20th February 2018: GPs and the Coroner (Dr Laura Barnfield) 6th March 2018: Asthma (Michaela Bowden) 24