Answer to Question 1
||Voiding / Obstructive
||Hesitant flow/ Weak stream
Regardless, the GP should perform urinalysis to exclude microscopic haematuria (which might indicate bladder/upper RT pathology/UTI/stones) and to check for hypertensive proteinuria. The most important test however would be to check the patient’s PSA levels, which will help to identify whether the issue is related to the prostate.
Answer to Question 2
The elevated PSA highlights that the pathology is related to the prostate e.g. BPH, prostatitis, malignancy. However, the low free PSA and the normocytic anaemia is an indicator that the diagnosis is concerning for a malignancy. Furthermore, the CKS guidelines indicate that a free PSA > 3.0 ng/ml in patients from 50–69 must be investigated as a potential malignancy. The patient should be referred on a 2WW to urology.
Answer to Question 3
The gold standard investigation in secondary care is a multiparametric pelvic MRI to assess the cancer itself but also lymph node, tissue and potential bladder wall involvement. This is often followed up with a trans perineal/transrectal ultrasound which takes guided ‘core’ biopsies of the sample (this approach is only possible as most cancers begin in the peripheral zone of the gland, which is closest to the intestines). A further CT of the abdomen and pelvis will help to stage the malignancy and highlight any extra–perineal disease
Answer to Question 4
This is a Sagittal T1 (CSF is dark, cord difficult to see) MRI of the spine. The L5 vertebrae has an extensive sclerotic lesion (in a T1 spinal MRI, sclerotic lesions are dark). This is a classic finding of vertebral metastasis arising from a prostate adenocarcinoma, leading to secondary cauda equina and bilateral lower limb LMN and sensory neurological symptoms.
Image 1:Case courtesy of Dr Angel Donato,<a
href=”https://radiopaedia.org/”>Radiopaedia.org</a>.From the case <a