Rrian Peterenn, 4S yr technician presents having tranble with “my water works” Take 2 histary Introduction and rapport A HOPC ~ what has been happening ? (difficulty passing urine) A how long has it been like this for ? (couple of months) A ~ how often ? (most of the time) - do you have difficulty initiating urine stream ? How long does it take ? (20 min) - difficulty arise suddenly or gradually ? (gradually) ~ have you noticed it is getting better or worse ? (slightly worse) ~ do you have to get up during the night ? (yes, 3-4 times) ~ anything make it better ? (warm bath, trickling water) + anything make it worse ? (alcohol) ~ Poor stream (stops and starts) ~ Emir volumes (yes and fequents) + suffer any dribbling after going to the toilet ? (yes, indicates obstruction) A = suddenurge ta empty yeur bladder (yes; desire comes in an instant) n ~ have you ever not been able to go when you really needed ? cowl + Liuual jo usine ur Givin tip of penis (nu, but assuc with rupun ed submucosal prusuatic veins)... ~ noticed any change in urine colour and offensive smell ? (no) A - suffer from any pain when passing urine (UTI, urethsitis; no) i ~ have any difficulty with control (overflow incontinence may arise; no) wlll ~ had a fever recently or pain in side of trunk + discharge (how much, often. colour. smell. itch, mucous. hlond - na) i ~ had any back pain or pain in your joint (mets - no) evel + any problems controlling your bowels, problems getting/maintaining an erection Low a => have you ever had you prostate checked ? ramuly Mx: insigntcant Social: married, x2 children, plenty of friends Drug: antidepressants, anti-Parkinsonian. et Smokes: none ETOH: x1 beer/night Allergies: none What is your list of differential diagnoses and likely cause => benign prostatic hypertrophy “prosits -UTI - urethral stricture/tumour (7 Renal calculi, neurogenic bladder) What on examination may suggest benign prostatic hypertrophy ? => PR: enlarged prostate and rubbery surface Asymmerical, median groove palpable mobile mux ~ palpable bladder (percussion dull to indicate fullness)‘What investigations are available to assist with reaching a diagnosis ? ~ prostatic specific antigen (25h >10-Liniay: ‘retest in 3/12) ~ transanal ultrasound (size, shape) + prostatic needle biopsy.(US pate) ~ prostatic urethroscopy : - urinalysis and culture (rule out UTI, prostatitis) ~ Tea Aimcilon (USES, aeasininey ~ xctay of spine/shoulder (gsteosclerotic; cotton wool appearance) ~ bone scan (if symptomatic and PSA > 20) ~ ALK phos, ESR, FBE_ ‘What features on examination may he present to suggest prostatic cancer as the cause? => PR: irregular surface, with asymmetrical structure ~ Joss of median groove with lateral extension of gland ~ rock hard consistency, fixed mucosa => tender lower spine/shoulder Where does prostatic cancer spread to ? * * local: Tectum, bladder neck, ureters (change in bowel habit, incontinence, impotence) .../1 distal: pelvic lvmph nades (abturator => para-aortic), bane (chronic pain, nee fractures) wll ‘How do you stage prostate cancer (adenocarcinoma)? Glassen seoke. => regtal examination, PSA, CT scanning for local spread and lymph node involvement A= microscopic and detected on TURP histology. PR: normal seed B - palpable but asymptomatic. PR: nodular asymmetrical surface sell C- prostate is large and rock hard with local symptoms. Palpable beyond prostate ...../] D-metastasised to lymphnodes bone te N => 75% patients present stage C&D (symptomatic). where prognosis is poor What management is available for prostate cancer ? => each patient should be considered individually 1. TURP with obstruction (beware local invasion resection may = incontinence)... 2. Prostatectomy (Stage A/B only and young patients; SE - incontinence, impotence) 3. Local XRT (A/B/C/pathological fractures, useful in patients >b5yr; SE -proctitis, stricture)..../1 4, hormonal manipulation {reduce testosterone and growth: late stage D only. but avoid ‘Patient ammualty active) - luteinising hormone releasing hormone (LHRH, depot injection) ~ anticandroaen drugs e.g cyproterone acetate, flutamide 5. Symptomatic relief analgesia, XRT (average survival time from presentation of mets. is 2yrs) Attempt cure (young- surg, >65- XRT) Symptomatic relief only = PSA <20 +PSA>20 ~ local spread only ~ distal spread ‘=> Autopsy: 90% of men over the age of 90yrs have microscopic cancer in prostate ~ RF: vasectomy, Fx, testosterone, black (low in Asians), environment ~ PSA may be raised in prostate cancer, prostatitis, UTIs, however only ¢ cancer >10-15ng/ml, and PSA must be se-tested in 3/12 later.