Download Case 2 - Ipswich-Year2-Med-PBL-Gp-2

"My urine flow is poor”
• Shane is 65-years old and complains of a 4 to
5-month history of progressive difficulty
voiding.
• He finds it difficult to start urinating and when
he does go he has the feels as though he
hasn't emptied his bladder completely.
• Consequently, after voiding he often feels as
though he needs to urinate again. He denies
any burning, urgency or urethral discharge.
WHAT IS THE LIKELY DDX?
• DxT: poor urine flow + straining to void +
frequency = BOO
• Bladder outlet obstruction
• Prostate cancer
• BPH
• Prostatitis
• Prostatic stones
Q2 WHAT ISSUES IN THE HISTORY OF A
PATIENT PRESENTING WITH LUTS
WOULD YOU SEEK TO SUPPORT A
PARTICULAR DIAGNOSIS?
• Is there a history of some weeks or months of bladder irritability (urinary
frequency, nocturia)? Exclude urinary tract infection if the history is short
or if dysuria is a major feature. Remember that acute urinary tract
infection may be the first sign of prostate cancer
• Is there a history of difficulty stopping or starting urination, and is the
strength of the urine stream deteriorating? These are cardinal symptoms
of prostatic enlargement and may not necessarily indicate prostate cancer
• Is there any bone pain? Prostate cancer often spreads to the bones early,
and bone pain may be the first symptom. The pain is usually localized,
constant, and severe, and it may be worse with movement
• Is there any pain on ejaculation or blood in the ejaculate? These
symptoms do not necessarily indicate any disease, but they may indicate
prostatitis as well as prostate cancer
• Is the patient feeling generally unwell or tired, or has there been any
weight loss, anorexia, thirst, memory disturbance, or confusion—perhaps
noted by family or friends? These nonspecific features indicate possible
systemic disease from cancer dissemination, renal failure, or
hypercalcemia
• Is there any lower limb numbness or weakness, difficulty walking,
or problems with emptying the bowels or bladder? These features
all suggest possible spinal cord problems and warrant rapid,
complete investigation
Family history
• Has anyone in your family ever had any prostate trouble? Firstdegree relatives are of particular interest
• Has anyone in your family undergone prostate surgery? Determine
if this was for cancer or for BPH
• Does anyone in your family have regular injections for his prostate?
Likely to be goserelin
Q3 WHAT RISK FACTORS ARE THOUGHT
TO BE IMPORTANT IN THE
DEVELOPMENT OF CARCINOMA OF THE
PROSTATE?
• Advanced age
• Family history
– The presence of BRCA1 or BRCA2 mutations increases the risk of
developing prostate cancer
• African-American ethnicity
• High dietary saturated fat intake, especially α-linolenic acid (found
in red meat and butter), may be a risk factor and is crudely
estimated to account for 10% to 15% of geographic differences in
incidence. In contrast, genistein, an isoflavone found in soy, is
believed to be protective (it inhibits 5α-reductase)
– Low vegetable diet
• Vasectomy has been proposed as a risk factor, but a large analysis
found no relationship, and the American Urological Association
states that vasectomy is not associated with increased risk
Q4 WHAT CLINICAL EXAMINATION
WOULD YOU PERFORM AND WHY?
• Digital rectal examination (DRE) may reveal a
nodule (50% are not carcinoma). Locally
advanced cancer typically reveals a hard,
nodular and irregular gland.
• Plus the usual….
All about PSA
(not Pharmaceutical Society of
Australia)
What is PSA?
What is PSA?
• Prostate Specific Antigen (PSA) is a glycoprotein
actually not there to help screen for prostate
pathology but to act physiologically in
the ejaculate to liquefy the semen allowing sperm to
break free from their seminal coagulum prison and
swim freely; is likely to be instrumental in dissolving
the cervical mucous via its proteolytic qualities,
allowing the entry of sperm.
• PSA leaks into serum normally, and is present in the
circulation of healthy men. Various prostate
pathology will increase PSA eg. Prostatitis, BPH,
Prostate CA etc. So PSA serum levels are used as a
screening test.
What are some of the factors that can
affect PSA levels?
What are some of the factors that can affect PSA levels?
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PSA has not diurnal variation. Normal healthy males’ PSA levels don’t change.
Ejaculation increases PSA levels, but they return to normal within 24 hours
Some say riding pushbikes and motorbikes increases PSA too, but evidence
remains inconclusive.
Some drugs like cyclophosphamide and others can increase PSA too.
DRE gives no significant change in PSA. BUT a vigorous prostate massage can
produce a short-term 2-fold increase….Nothing sus.
Cystoscopy, urethral catheterization, and TRUS do not tend to elevate the PSA
level.
Prostate needle biopsy increases PSA by a median of 7.9 ng/mL (6.5 times baseline
value) within 5 minutes following the biopsy, this persists for 24 hours.
Urinary retention increases PSA levels, but when relieved, they decrease 50% in
24-48 hours.
Acute prostatitis produces large increases in PSA, but the return to baseline
depends on resolution of the infection, which may take 6-8 weeks or longer. PSA
levels have been used to determine the duration of antimicrobial therapy in men
with acute bacterial prostatitis.
PSA half-life is 2.2-3.2 days. After a biopsy, 2 to 4 weeks may need to elapse before
the PSA returns to its original level.
What investigations would be most
helpful and why?
What investigations would be most
helpful and why?
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DRE of course - Although PSA testing detects more cancers than DRE, a
combination of the 2 methods is better: DRE detects more cancers at the PSA
cutoff of 4.0 ng/mL, but this may not occur if the cutoff is lowered to 3.0 ng/mL.
In men with prostate cancer whose PSA level was less than 4 ng/mL, normal DRE
findings were present in 4-9%, while DRE findings were positive in 10-20%. When
the PSA level was greater than 4 ng/mL, negative DRE results were found in 1232% of patients, while positive DRE results were present in 42-72% of patients.
• TRUS Biopsy
• Cancer markers in general…
Alkaline phosphatase
• Other Prostate cancer markers…
Human glandular kallikrein–2
Prostate-specific membrane antigen
Cell cycle inhibitor p27
Serum insulinlike growth factor
Few issues in medicine are as controversial as screening for
prostate cancer. Briefly discuss why this is the case.
Few issues in medicine are as controversial as screening for prostate cancer.
Briefly discuss why this is the case.
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PSA testing it has a Positive predictive value of about 35% when the cutoff is about
3ng/mL (but we normally have cutoff at 4ng/mL
PSA testing with a cutoff of 4 ng/mL has a sensitivity of 67.5-80%  implies that
20-30% of cancers are missed when only the PSA level is obtained. The sensitivity
can be improved by lowering the cutoff or by monitoring PSA values so that a rise
in PSA level of more than 20-25% per year or an increase of 0.75 ng/mL in a year
would trigger performance of a biopsy regardless of the PSA value.
The specificity of PSA at levels greater than 4 ng/mL is 60-70%. Specificity can be
improved by using age-adjusted values,
Men with low readings might still harbor dangerous cancers (gleason stage 5 might
not produce PSA anymore), while those with high readings might be completely
healthy.
PSA, while normally at a steady serum concentration, can be affected by a lot of
things (see above)
Studies have shown that screening does not reduce the death rate in men 55 and
over.
NNT = 48 That’s 47 men who, in all likelihood, can no longer function sexually or
stay out of the bathroom for long because the PSA test was justification for a
urologist to jab it.
More suited to monitor remission of prostate cancer etc
If screening is to be carried out which patients
might be targeted and why?
If screening is to be carried out which patients might be targeted and why?
• Don’t screen for prostate cancer in men aged
75 years or older – they will die WITH CA
rather than FROM it
Screening when male and:
• 40yrs + family Hx of prostate CA or proven
BRCA1/2 etc
• 50yrs + No family Hx
• recent onset of LUTS