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Prostate disease

Benign prostatic hypertrophy

Demographics

Pathology

Enlargement of transitional zone.

Symptoms

ObstructiveIrritative
Poor stream
Straining
Hesitancy
Terminal dribbling
Retention
Frequency
Urgency
Nocturia
Urge incontinence
Obstructive symptoms are relieved by TURP, but irritative symptoms only relieved in 1/3.

Natural history

55% progress
30% stable
15% improve

Investigations

  1. Urine: urinalysis
  2. Blood: U&E, PSA
  3. Peak flow rate (<12 ml/sec)
  4. Residual vol US
  5. Consider urodynamics
  6. Consider transrectal US if ↑PSA
PSA lower limits: 40's 2.5, 50's 3.5, 60's 4.5, 70's 6.5.
4–10 20% risk, >10 60% risk.
Alternatively: free:total PSA ratio. ↓ → Ca.

Treatment

Watchful waiting
α-blockers, 5α-reductase inhibitors, saw palmetto.
Surgery: bladder neck incision, TURP.

Prostatic carcinoma

Diagnosis

Transrectal biopsy (sextant). Prophylactic antibiotics.

Staging

T1: Confined to prostate
T2: Palpable
T3: Outside prostate
T4: Fixed

Grading

Gleason grade 1–5. Gleason score = add grade from two areas.
2, 3 benign
4–7 treat
8–10 treat. Poor prognosis

Prostate specific antigen

<40 → no metastases
>40 → metastases
Also do scintigram pelvis, lumbar spine.

Treatment

T1, T2: radical prostatectomy, radical radiotherapy
T3, T4: hormones, radiotherapy
Metastases: (50% at presentation) hormones, orchidectomy, LHRH analogues, oestrogens.