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Prostatism

Prostatism. Asim Pasha. Benign prostatic hyperplasia. 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.

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Prostatism

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  1. Prostatism Asim Pasha

  2. Benign prostatic hyperplasia • 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

  3. Prostate cancer- few more to remember • Family history and genetic factors. • Diet is possibly a risk factor. • Exposure to the metal cadmium

  4. Benign prostatic hyperplasiaPresentation • 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

  5. BPH/LUTS progression-risk factors • >70 yrs with LUTS • IPSS >7 i.e. moderate or severe LUTS • Flow rate<12ml/s • Prostrate volume >30cc • Post void residual volume > 100mls

  6. British association of urology 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

  7. Benign prostatic hyperplasiaManagement • 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)

  8. Benign prostatic hyperplasia • 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

  9. Benign prostatic hyperplasia • 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

  10. Prostate cancer • 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

  11. Prostate cancer-Presentation • 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

  12. Prostate cancer-PSA • 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*: • AgePSA level (ng/ml) • 50-59 years- 3.0 • 60-69 years- 4.0 • > 70 years- 5.0

  13. Prostate cancer • 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

  14. Prostate cancer-management • 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

  15. Prostate cancer-managenent • Localised advanced prostate cancer (T3/T4)Options include: • hormonal therapy • radical prostatectomy • radiotherapy: external beam and brachytherapy

  16. Prostate cancer-management • Metastatic prostate cancer disease - hormonal therapySynthetic 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

  17. Prostate cancer-Prognosis • 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

  18. Prostate cancer-Further help and information • The Prostate Cancer Charity • Helpline: 0845 300 8383 Web: www.prostate-cancer.org.ukProvides support and information for patients and their families. • Prostate Action • Tel: 020 8788 7720 Web: www.prostateaction.org.ukA national charity dealing with all prostate diseases, including prostate cancer. • Macmillan Cancer Support • Tel: 0808 800 1234 Web: www.macmillan.org.ukProvides information and support to anyone affected by cancer. • Cancer Research UK • Web: www.cancerhelp.org.uk provides facts about cancer including treatment choices. • The NHS Prostate Cancer Risk Management Programme • Web: www.cancerscreening.nhs.uk/prostate/index.htmlProvides information as to why there is no organised screening programme for prostate cancer but an informed choice programme instead. • Other support groups • See www.patient.co.uk/selfhelp.asp for a list of support groups for cancer patients.

  19. Prostate related senarios. Are you ready?- This is the beginning…..

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