Download Prostate Health and the PSA in Primary Care

Primary Care Winter Conference
Friday, February 22, 2013
Prostate Health and the PSA in Primary Care
Ron Jendry, M.D.
Associate Professor of Medicine
University of Colorado, Denver, School of Medicine
Faculty, St. Anthony Family Medicine Residency Colorado
Patient: Frank B
80 y/o man immigrant
from Hungary
C/O urinary frequency
and nocturia,
seemingly worse
lately
Language barrier; his
wife Julia is more
understandable
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
He c/o “…my
peanuts…” and “I
have problem with my
peanuts…”
He has to urinate 5 – 6
times nightly.
Something sounds
“irritated”.
Friday, February 22, 2013
?
??
His present medications:
Celebrex, 200mg/day for lumbar degenerative
disc disease
Oxycodone/APAP, 5/500, very occasionally for
the same
ASA 81mg/day
Prilosec 20mg/day for GERD
Clonazepam 0.5mg/HS for nocturnal myoclonus
Flomax 0.4mg/day for BPH
OTC Saw Palmetto for BPH
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Social HX
Born and raised in Hungary
Drafted into the German army late in the war
and captured by the Russian army
Escaped and fled to the American lines, met
Julia at a refugee camp
Emigrated to the USA to be with his son, Lake
Tahoe and then Evergreen (1993)
Non-smoker (since 1976)
Likes a little cognac, 1 or 2 , twice a week
Caretakers at a ranch, very strong and
physically active!
Past HX:
No surgeries!
GERD , originally OK with H2’s, then
PPI’s, EGD on 3/18/00 mild inflammation
Colonoscopy on 4/4/00: mild diverticulae
and hemmorhoids
Nocturnal myoclonus for about 5 years
Long Hx of intermittent LBP, MRI 9/1/01
showed no stenosis, degenerative
changes
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
URINARY HX:
1ST Sx’s reported 12/21/93, increased
frequency, nocturia, slight urgency,
decreased stream, no discharge, no fever,
but c/o:
Exam recorded as “normal feeling
prostate”, but she has a 3 cm finger:
U/A, dip & micro were WNL
PSA was 1.4
International Prostate Sx Score was 14 =
moderate Sx’s
Let’s talk about symptoms.
1-Storage Symptoms
Urgency
Daytime Frequency
Nocturia
Urge Incontinence
2- Voiding Symptoms
Slow stream
Intermittency
Hesitancy
Straining to void
Terminal dribble
Dysuria
The International Prostate Symptom Score
looks at a combination of these symptoms.
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Her DX:
“…probable prostatitis given Sx’s…wonder
about BPH…”
Treated with Cipro 500mg BID x 2 weeks
Somewhat improved: “…my
“
Still c/o mild frequency and nocturia
Came back, 3/6/95 c/o post voiding
irritation, and “…
…”, frequency
and nocturia.
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Our PA’s Dx and Rx:
“…probable prostatitis, again wonder
about underlying BPH…”
Treated with Floxin 400mg BID x 10 days
Returned on 3/17/95, not any better;
reacted to Floxin, it made him feel:
“…really weird…”.
Hx stated: “ …lots of signs and Sx’s of
BPH”.
His complaint: “
!”
These seem to be:
Frequency, nocturia,
which are storage
sx’s
And…urgency,
decreased stream
and some kind of
discomfort, which are
voiding sx’s.
So, here are the questions:
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
How can the U/A look in BPH?
Can be totally normal
Do a MICRO, not just
a dipstick
Up to 4 WBC/HPF.
>4, consider infection
0 – 3 RBC/HPF; if >3
– 5, needs referral for
cystoscopy!
This slide, I’d culture,
treat, and follow.
So, the 2 tests that
should be done in the
setting of BPH are
serum creatinine and
a U/A (micro!)
>4 WBC/HPF, think
about
prostatitis/cystitis
>3-5RBC/HPF, refer
for cystoscopy to r/o
bladder ca!
Amateur Urologist
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Don’t forget the physical exam:
DRE as a screening test for rectal ca
or prostate ca is an “I” rating.
However, it is very important part of
the examination of a symptomatic
man! If patients aren’t having a PSA
performed, it may be more important to do this exam!
Before getting to treatment, we
have to learn another new
language!
We say BPH (Hyperplasia), which is actually a histologic
diagnosis, but we usually mean BPE (enlargement);
these terms are practically interchangeable.
This causes BOO (bladder outlet obstruction)
The symptoms, predominantly voiding sx’s, of BPH
present as LUTS (lower urinary tract sx’s)
OAB (overactive bladder) refers to urinary urgency with
or without incontinence.
Although typically associated with storage sx’s, rather
than voiding sx’s, OAB often accounts for sx’s in men
who are thought to have BOO, but who fail to respond to
therapy!
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
BPH: TREATMENT OPTIONS
Do nothing! 30 – 50% of patients will have a
spontaneous decrease in Sx’s over 6 months,
especially in mild cases.
Prescribe medications: For moderate to
severe Sx’s. Use the rating questionnaire.
Microwave Thermotherapy: for moderate –
severe Sx’s, unresponsive to medications, can’t
or doesn’t want surgery, or a risk of upper tract
injury present
Surgery
2 components of bladder outlet
obstruction in BPH:
A dynamic or
physiologic
component, related to
tension of prostatic
smooth muscle
A fixed, anatomic
component, related to
the bulk of the
enlarged organ
impinging upon the
urethra
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Medications for BPH
Alpha-adrenergic antagonists
Act on dynamic component
More effective for short-term
treatment
No evidence that they reduce
the need for surgery
Combine for Htn Tx!
Terazosin, doxazosin,
alfuzosin, tamsulosin, silodosin
They work rather quickly!
5-alpha-reductase inhibitors
Act on anatomic component
Potential for long-term
reduction in prostate volume
Can reduce the need for
surgery
Finasteride, dutasteride
Most adverse sexual sideeffects are chiefly in the 1st
year!
Takes awhile for effects
Combination may be
superior to either alone!
Other Therapies:
Herbals: Saw Palmetto; plant derived betasitosterol; Cernilton (rye grass pollen); African
Plum Bark (pygeum Africanum). There is no
compelling evidence yet.
Phosphodiesterase-5 Inhibitors: some reduction
in prostate symptom scores reported (combined
with tamsulosin, especially?)
Anticholinergics, especially with irritative LUTS
(and better when combined with tamsulosin ?)
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Surgery for BPH may be indicated:
Refractory urinary retention and failed at
least one attempt at catheter removal
Recurrent UTI’s due to BPH
Recurrent gross hematuria due to BPH
Renal insufficiency due to BPH
Bladder stones due to BPH
PROSTATITIS
Acute Bacterial: Chronic Bacterial:
Sudden onset of
fever, chills, low back,
perineal, or
suprapubic discomfort
Dysuria, frequency,
urgency, or retention
Gram Stain & Culture!
2 week minimum,
likely 4 – 6 week
antibiotic treatment!
More subtle and less
severe but similar
Sx’s
Relapsing UTI’s
May have
hematospermia or
painful ejaculation
Culture and long
course of
“penetrating” Abx’s
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
NON-BACTERIAL PROSTATITIS
Probably the most common
Inflammatory
Chlamydia or Ureaplasma urealyticum?
Same Sx’s as chronic
Don’t see >4 WBC’s or >3 RBC’s/HPF;
nothing grows on culture
Most of us treat like Chronic Bacterial
Prostatitis. Why?
Maurice Ainedoleur
39 y/o salesman, negative past
hx, other than occasional
heartburn, for which he takes
OTC ranitidine a few times a
month.
1 – 2 month h/o vague, dull,
achy, pain between the rectum
and scrotum.
Occ lower abdominal pain
No fever, frequency, dysuria,
urgency, or discharge.
Single, no current sexual
partner, no sex recently, no h/o
STDs or high risk behaviors
Get your Gizmos ready!
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
PROSTATODYNIA
Young to middle aged guys with vague
discomfort Sx’s
Male version of Chronic Pelvic Pain?
Spasm?
May respond to alpha-blockers
His new diagnosis is: “Category 3
Prostatitis”
NIH Classification of
Prostatitis:
CATEGORY 1: identical to acute prostatitis
CATEGORY 2: identical to traditional chronic
bacterial prostatitis
CATEGORY 3: the presence of GU pain in the
absence of urogenic bacteria by culture
1-3A: inflammatory (+ p/massage WBC’s)
2-3B: non-inflammatory (why a massage?)
CATEGORY 4: asymptomatic inflammatory
prostatitis (+WBCs or bacteria in the absence of
typical chronic pelvic pain…again, why????)
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Prostate Massage
Be VERY gentle!
If you suspect ACUTE prostatitis, and/or the
prostate is very tender, DON’T!
I was taught when differentiating between BPH
and chronic prostatitis, a gentle prostatic
massage before a microscopic U/A may be
helpful. (looking for WBCs and bacteria)
There is NO evidence that it is helpful in treating
prostatitis.
And…
There’s no evidence of
the usefulness of
getting a U/A before
and after a prostate
massage.
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
In older men, the diagnosis of Chronic Prostatitis is
very difficult to make clinically, because
symptoms are almost indistinguishable from
those of Prostatic Hyperplasia!
So, back to Frank B
He was treated with
Flomax and Saw
Palmetto:
Still having Sx’s, he
was treated with
antibiotics for 6 weeks
Still having
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
It really seemed that he had an urgent, almost
uncomfortable component to his symptoms. You decide to:
1.
2.
3.
4.
Use a longer course
of antibiotics
Add a drug like
tolteradine (Detrol)
Add a drug like
finasteride (Proscar)
Refer to urology
When to refer patients with LUTS:
Men < 50 y/o
Abnormal prostate exam
Hematuria w/o infection
Failure to respond to
initial Tx for BOO
Men who desire surgery
Men with incontinence
Men with severe sx’s
These lucky dogs can do an ultrasound
to measure post-void residual
volume!
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Prostate Cancer Screening
The most commonly
diagnosed visceral ca
in the USA!
2009: new Dx192,000 and 27,000
deaths!
16 % lifetime risk
Lifetime risk of dying
from this = 2.9%
Finger in Rectum
More:
5 y survival in localized
(confined) ca = 100%!
Regional spread = 100%
Distant mets = 31.9%
Thus, a screening
program that could
identify asymptomatic
men with aggressive
localized tumors might be
expected to substantially
reduce prostate ca
morbidity, including
urinary obstruction and
painful metastases, and
mortality!
Future urologist, J. Horner
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
The Ultimate Gray Zone!
A summary from UTD literature review, May, 2010
Although screening for prostate ca with
PSA can reduce mortality, the absolute
risk reduction is small.
Given limitations in design and reporting of
randomized trials, there remain important
concerns about whether the benefits of
screening outweigh the potential harms to
quality of life, including the substantial
risks for overdiagnosis and treatment
complications.
Prostate CA Factoids
The rates of prostate ca are declining
since the 90’s!
Deaths are also decreasing!
It takes 1410 men screened, and 48
treated, to save 1 life from prostate
cancer! (ERSPC Trial)
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
The 2 Major Studies
PLCO and ERSPC
USPSTF gives a “D” rating to perform
PSA’s as a screening test!
The PLCO trial is what mainly influenced
this recommendation. (Prostate, Lung,
Colorectal, Ovarian Ca)
The results from the ERSPC (Europian
Randomized Study of Screening for
Prostate Cancer) indicate some prostate
Ca mortality benefit, no overall mortality
benefit
“A Tale of Two Trials”
Both are good trials, with large numbers and
dedicated, reliable patients.
ERSPC 11 year follow-up results demonstrate a
man’s risk of dying from prostate cancer, using
PSA screening, is reduced by 29%! (NEJM,
3/15/2012)
In the PLCO trial, 44% of men had already had a
PSA before being “randomized” into control and
study groups!
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
The American Cancer Society’s
statement:
“Information should be provided to all men
about what is known and what is uncertain
about the benefits, limitations, and harms
of early detection and treatment of
prostate cancer so that they can make an
informed decision about testing.”
Meta-analysis of trials of decision aids to
provide this information appear to result in
fewer men deciding to have PSA’s.
PSA, other thoughts
The great majority of cancers found are low
grade (Gleason 6 or less).
Is the real issue what happens after the biopsy?
Watchful waiting is often a very appropriate
option, not used as often as it probably should
be!
Maybe, when discussing Tx options, we should
change the language, using a term less terrifying
than “Cancer”? (e.g. neoplasm of uncertain
potential).
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
PSA: The Medical/Legal
Conundrum
The Merenstein case (the
resident was exonerated, but
the residency program was
liable for $1 million!)
JAMA article, 2004, entitled
“Winners and Losers”
The plaintiff’s lawyer put
“Evidence Based Medicine” on
trial and won!
Is it safest to simply perform
PSA’s routinely, without timeconsuming discussions that
might lead to decisions that
can ultimately increase the risk
of a malpractice lawsuit?
Dr. Kildare failed to recommend
a PSA!
PSA, the Gray Zone
A great article: The Journal of Law, medicine,
and Ethics, summer 2008, entitled: “Reactions of
Potential Jurors to a Hypothetical Malpractice
Suit Alleging Failure to Perform a PSA Test”
Summary: jurors in this small group of one urban
demographic were less likely to support liability if
informed consent was well documented, and
especially if an educational video was shown to
patients considering a PSA test.
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Other Tidbits
Legally, how does the USPSTF’s
statement affect the practitioner?
What will weigh more in a jury case, the
“state of the art” locally practiced or a
USPSTF recommendation?
Will insurers(and/or Medicare)pay for PSA
testing?
The Vet
55 y/o special forces Veteran
An electrician, a little HTN and
dyslipidemia
Neg Fam Hx
Last Physical 2 y/ago, PSA
was 2.0
This time, PSA = 6.2
Bx: Gleason 6
Had Radiation Seeds
5 years later, PSA < 0.1, has
some ED, relieved by “Vitamin
V”, and is pretty happy (always
a bit grumpy!)
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Retired FBI
58 y/o retired FBI, government
contractor
A very little HTN, in fabulous
shape!
Father has Prostate CA, a and
w in late 80’s
PSA on exam = 4.6, DRE wnl
Bx: Gleason 6
Robotic Prostatectomy
Not incontinent but impotent
Has to inject self for sex
Not very Happy, but diseasefree x 5 years
The Cowboy
A 53 y/o physicist, actually was
a Rocket Scientist!
Quit that to teach HS Physics
and run a working ranch in
Pine, Colorado
I met him many years ago
when his Dad was dying from
prostate ca.
On exam, PSA 5.0; we
repeated it 6 months later, 4.8
Bx: Gleason 6
“Watchful Waiting”, 4 y later,
PSA in low 4’s; repeat Bx,
negative for CA!
He’s sexually active and happy
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
The Family Doctor
60 y/o used to practice “up
there”, now FM Faculty
No PSA
Happy (though Grumpy), and
not worried much…at least
about prostate ca
Sexually…none of your
business!!!!
So, who made the right choice?
A Reasonable
Recommendation
Have and document a discussion about
the advantages and disadvantages of PSA
screening.
Get a 1st PSA at age 40.
If that PSA < 1.0, screen q 5 years.
If that PSA is between 1.0 and 2.0, screen
q yearly
If that PSA > 2.0, refer to urology.
Ronald Jendry, MD
Prostate Health and PSA
Primary Care Winter Conference
Friday, February 22, 2013
Also:
Be more aggressive if + Family Hx and
with African/Americans
With 1st timers (< age 70), have that
discussion!
Stop PSA’s if life expectancy < 10 years
and if > 70 y/o!
Promise (insist!) to stay involved with your
patient if cancer is found for decision
making, choices, etc.!!!!!
Finally, what is wrong with my
Correct Answer Indicator?
One too many fingers!
Ronald Jendry, MD
Prostate Health and PSA