Prostate Conditions

Acute prostatitis

This is acute inflammation of the prostate, which usually occurs in infection

Causes:

– STIs e.g. Chlamydia trachomatis + Neisseria Gonorrhoeae (sexually active)

– E. Coli in older adults

Symptoms:

UTI, retention with pain and haematospermia

– Dysuria with fever and chills

Tests:

DRE gives tender prostate and secretions reveal bacteria

Management:

Antibiotics e.g. levofloxacin (Quinolone) or Trimethoprim

Benign prostatic hyperplasia (BPH)

This refers to hyperplasia of prostate which naturally occurs with age and is common

– It does not give increased risk for cancer, as it is the central zone which enlarges, not peripheral layer

– Testosterone Is converted to DHT by 5-a-reductase –> binds androgen receptors causing growth

 

Symptoms:

– Voiding –> weak flow, hesitancy, terminal dribbling

– Storage –> Increased urgency, Frequency

– Microscopic haematuria

– Impaired bladder emptying gives increased risk of bladder diverticula + UTI

 

Management:

– Lifestyle changes –> avoid caffeine and alcohol + train bladder to control urgency

– a1 antagonists (Terazosin) –> relaxes smooth muscle and also lowers blood pressure

– 5a reductase inhibitors (Finasteride) –> blocks conversion of testosterone to DHT to reduce size

– If unresolving, then surgery – Transurethral resection of the prostate (TURP)

Prostate Cancer

This is a malignant proliferation of the prostate glands, that arises from the posterior zone of the prostate

– This means that it does not give the urinary symptoms very early on unlike BPH

– It is the most common cancer in men and 2nd most common cause of cancer deaths.

– It often spreads to lumbar spine and pelvis, giving bone metastases which increase alkaline phosphatase, PSA and prostatic acid phosphatase and gives hypercalcemia

 

Risk factors:

Age (80% in men > 80)

Family history

– Race (high in blacks)

– Diet high in unsaturated fat

 

Symptoms:

Can be asymptomatic until cancer has progressed

– Urinary symptoms – nocturia, hesitancy, poor stream, dribbling and microscopic haematuria

– Weight loss and bone pain –> due to metastases

 

Diagnosis:

– Prostate serum antigen –> a serum PSA >10ng/mL suggests cancer

– Decreased % free-PSA suggests cancer, and the cancer makes bound PSA

– DRE –> gives hard, irregular prostate (non-tender)

– 1st line imaging is MRI –> can be followed by transrectal US and biopsy to confirm carcinoma

– Staging done by MRI –> if back pain is present, need a spine MRI to check for metastases

 

Grading:

This is done using the Gleason grading system, based on architecture – higher score is worse

– A score (1-5) is given for two separate areas on biopsy, based on how abnormal the cells appear.

 

Management:

– Definitive treatment is surgical removal (Radical prostatectomy)

– Anti-testosterone therapy Flutamide (androgen receptor antagonist) and continuous GnRH analogs shut down pituitary gonadotrophs e.g. Leuprolide