PROSTATE CANCERAND

BENIGN PROSTETIC HYPERTROPHY

ORHAN HAKLI, NP

ANATOMY OF THE PROSTATE GLAND

ANATOMY OF THE PROSTATE GLAND

The gland is located posterior to the pubic symphysis, superior to the perineal membrane, inferior to the bladder, and anterior to the rectum.

A normal prostate gland is approximately 20 g in volume, 3 cm in length, 4 cm wide, and 2 cm in depth.

As men get older, size of the prostate gland varies due to secondary to benign prostatic hyperplasia

FUNCTIONS OF THE PROSTATE GLAND

The main function of the prostate gland is to secrete an alkaline fluid that makes up approximately 70% of the seminal volume.

The secretions produce lubrication and nutrition for the sperm.

Prostatic secretions also contains seminal plasmin that is an antibiotic that prevents UTIs in males.

The muscular tissue provides the force to push these secretions into the prostetic urethra.

BENIGN PROSTATIC HYPERTROPHY(BPH)

BPH is a noncancerous enlargement of the prostate gland.

It is considered a normal part of the aging process in men and is hormonally dependent on testosterone and dihydrotestosterone (DHT) production.

An estimated 50% of men demonstrate BPH by age 60 years. This number increases to 90% by age 85 years (Deters& Costabile,2013).

As many as 14 million men in the United States have symptoms of BPH (Deters et al. 2003).

The prevalence of BPH in white and African-American men is similar. However, BPH tends to be more severe and progressive in African-American men, possibly because of the higher testosterone levels (Deters et al. 2003).

BENIGN PROSTATIC HYPERTROPHY-PATHOPHYSIOLOGY-

Prostate gland makes its first growth around puberty and reaches to the average size of 20g

The gland again undergoes a second growth spurt during the fifth decade. This growth is characterized by localized proliferation in the periureteral region.

BPH is characterized as a hyperplastic process. The hyperplasia results in enlargement of the prostate that may restrict the flow of urine from the bladder, resulting in clinical manifestations of BPH.

The prostate enlarges with age in a hormonally dependent manner.

Males who are unable to make testosterone do not develop BPH.

Urinary frequency - The need to urinate frequently during the day or night (nocturia), usually voiding only small amounts of urine with each episode

Urinary urgency - The sudden, urgent need to urinate, owing to the sensation of imminent loss of urine without control

Hesitancy - Difficulty initiating the urinary stream; interrupted, weak stream

Incomplete bladder emptying - The feeling of persistent residual urine, regardless of the frequency of urination

Straining - The need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully evacuate the bladder

Decreased force of stream - The subjective loss of force of the urinary stream over time

Dribbling - The loss of small amounts of urine due to a poor urinary stream

BENIGN PROSTATIC HYPERTROPHY-PRESENTATION-

Urinary frequency - The need to urinate frequently during the day or night (nocturia), usually voiding only small amounts of urine with each episode

Urinary urgency - The sudden, urgent need to urinate, owing to the sensation of imminent loss of urine without control

Hesitancy - Difficulty initiating the urinary stream; interrupted, weak stream

Incomplete bladder emptying - The feeling of persistent residual urine, regardless of the frequency of urination

Straining - The need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully evacuate the bladder

Decreased force of stream - The subjective loss of force of the urinary stream over time

Dribbling - The loss of small amounts of urine due to a poor urinary stream

BENIGN PROSTATIC HYPERTROPHY-PRESENTATION-

Bladder CA Stones Trauma Neurogenic Bladder

Urethral Strictures UTI Cystitis Prostatitis

BENIGN PROSTATIC HYPERTROPHY-DIFFERENTIAL DX-

Hx DRE

To see size and condition of the gland UA

Look for ; blood, leukocytes, bacteria, protein, or glucose. Urine Culture

To exclude infectious causes Prostate- Spesific Antigen (PSA)

To r/o CA (note: people with large prostates may have slightly elevated PSA)

BMP with BUN and CRE to r/o renal insufficiency.

Ultrasound of abdominal, renal, transrectal To determine bladder and prostate size and the degree and any

presence of renal involvement Cystoscopy

To determine the size, location and degree of obstruction

Urine Flow study to check any reduction in urine flow

BENIGN PROSTATIC HYPERTROPHY-DIAGNOSTIC WORKUP-

WATCHFUL WAITING Patients with mild to moderate symptoms Pts not bothered by the symptoms Pts not experiencing complications of BPH

re-examine the pt annually, see the size and condition of the gland

Utransurethral Resection of the Prostate (TURP)

Pharmacological approach(Rx) To reduce morbidity and prevent complications alpha-adrenergic blockers,

Phenoxybenzamine (Dibenzyline) Prazosin (Minipress) Alfuzosin (UroXatral) Terazosin (Hytrin) Tamsulosin (Flomax) Doxazosin (Cardura, Cardura XL)

5-alpha-reductase inhibitors They inhibit the conversion of testosterone to DHT, causing DHT levels to drop and

helps with decreaseing prostate size Finasteride (Proscar) Dutasteride (Avodart)

BENIGN PROSTATIC HYPERTROPHY-TREATMENT-

Prostate cancer is the most common noncutaneous cancer in men in the United States.

An estimated 1 in 6 white men and 1 in 5 African American men will be diagnosed with prostate cancer in their lifetime, with the likelihood increasing with age (Chodak & Krupski, 2013).

 It is the second most common cause of cancer death in males 

Currently, with PSA screening, most prostate cancers are diagnosed at an asymptomatic stage

RISK FACTORS Advancing age(65 and up, rare in younger than

40) African- American race Family Hx of Prostate CA

PROSTATE CANCER

The most common type is adenocarcinoma Develops in the acinar glands that is located in the

posterior peripheral zone of the prostate Tumors can develop in one or both lobes of the prostate

and can spread in the prostate gland

PROSTATE CANCER-PATHOPHISIOLOGY-

EARLY STAGES The majority of patients with prostate cancers, are

asymptomatic. Diagnosis in such cases is based on abnormalities in a

screening prostate-specific antigen (PSA) level or findings on digital rectal examination (DRE).

Also can be incidental when tissue is removed after TURP for BPH

LATER STAGES urinary complaints or retention back pain Hematuria Weight loss and loss of appetite Anemia Bone pain Lower extremity pain and edema due to obstruction of

venous and lymphatic system

PROSTATE CANCER-PRESENTATION-

A firm nodule on rectal exam; induration; or a stony , asymmetric prostate should make health care provider suspicious for prostate CA

In early stages, PE tends to be normal that is why it is recommended to do DRE routinely on ; patients 50 and over 45 years old and over African American male 40 and over with pts who have family hx

PROSTATE CANCER-PE-

-DIFFERENTIAL DX- BPH/Bladder Outlet Obstruction UTI Prostatic abscess Prostatitis (bacterial/nonbacterial) Prostate Calculi

PSA WITH DRE Most sensitive diagnostic tool

AGE Normal PSA range in mcg/L 40-49 0-2.5. 50-59 0-3.5 60-69 0-4.5 70-79 0-6.5

REFER PT TO A UROLOGIST WHEN A SUSPICIOUS FINDING IS FOUND ON DRE OR PSA IS ELEVATED

PROSTATE CANCER-DIAGNOSTIC WORKUP-

Make your decisions based on; Stage Prognostic features of the tumor Pt’s age/medical condition/preferences

Standard treatments for clinically localized prostate cancer 

Watchful waiting Cryotherapy Radical prostatectomy

For stage A and B long term survival rate 80% to 90%

Radiation therapy For stage A and B long term survival rate 80% to 90%

Hormone therapy For symptomatic pts with advanced disease Hormone therapy for prostate cancer is also known as androgen deprivation

therapy (ADT). It may consist of surgical castration (orchiectomy) or medical castration. Agents used for medical castration include luteinizing hormone–releasing hormone (LHRH) analogues or antagonists, antiandrogens, and other androgen suppressants.

Consider pain management and palliative care for more advanced cases

PROSTATE CANCER-TREATMENT-

REFRENCES Buttaro, T.M. , Trybulsky, J., Bailey,P.P. ,Cook, J.S. (2008). Primary Care

a Collaborative Practice. Philadelphia, PA: Elsevier. Chodak, G.W., Krupski, T.L. (2013).

http://emedicine.medscape.com/article/1967731-overview. Retrieved from www.medscape.com: http://emedicine.medscape.com

Deters, L., Costabile, R.A., . (2013). http://emedicine.medscape.com/article/1967731-overview. Retrieved from www.medscape.com: http://emedicine.medscape.com/article/1967731-overview

Martini, F., Timmons, M.,Tallitsch, R. (2003). Human Anatomy. New Jersey: Prentice Hall.