Transcript Benign Prostatic Hyperplasia

Men’s Health
Dr Jonny Harper
Dr Krusha Patel
GP registrars
11th October 2007
Benign Prostatic Hyperplasia
What is it?
• Clinically:
– Lower Urinary Tract Symptoms (LUTS),
‘prostatism’
• Histologically:
– Proliferation of glandular epithelium, stroma,
and smooth muscle
• No direct correlation between the two
Why is it?
• Cause not known, but factors implicated:
– Aging
– Long-term exposure to testosterone
How common is it?
• Prevalence increases with age:
– Histological BPH
• 60% of 60 year olds1
• 90% of 85 year olds1
– LUTS
• 30% overall prevalence (aged >40)2
1) American Urological Association 2003
2) Speakman et al, 2004
LUTS
• Obstructive
– Hesitancy
– Slow, intermittent, weak stream
– Straining
– Terminal dribbling
– Sensation of incomplete emptying
– Double voiding
– Overflow incontinence
– Acute retention
LUTS
• Irritative (filling)
– Nocturia
– Daytime frequency
– Urgency
– Urge incontinence
IPSS
• International Prostate Symptom Score3
– Based on AUASI3
– Useful to grade extent of symptoms
• Score <8 – mild
• Score 8-20 – moderate
• Score >20 – severe
– Not diagnostic tool
3) Barry et al, 1992
IPSS
(insert ipss)
On examination
• Abdominal examination
– Palpable bladder in acute/chronic retention
• Digital Rectal Examination
– Smooth enlarged prostate
Investigations
• Urinalysis
– Nitrite = infection?
– Blood = bladder malignancy?
– Glucose = diabetes?
• Urine culture
• U&Es
– Creatinine/K+, chronic retention → CKD
Investigations
• USS, Urodynamics, cystoscopy
– Not routine
– For severe sx/surgical candidates
– Usually secondary care
• Prostate Specific Antigen (PSA)…
When to PSA?
• PSA rises with:
– BPH (25%) (↑ratio free/total PSA)
– Prostate cancer (80%)
– UTI
– Prostatitis
– DRE, ejaculation, bicycling
• No consensus on whether to test men with
LUTS
When to PSA?
• Why not to test?
– ²/3 pts with high PSA do not have prostate ca
• Unnecessary TRUS+biopsy
– 20% prostate ca have normal PSA
– BPH does not ↑risk prostate Ca
– LUTS caused by prostate ca indicates advanced
(incurable) disease
– Detection of early prostate ca may not improve
morbidity or mortality
• Treatments have significant adverse effects
– PSA should not replace DRE for prostate volume
assessment
When to PSA?
• Why test?
– Raised PSA in BPH indicates ↑risk of progression,
worsening sx 4,5
• Useful when assessing for Rx
– Reassure pt if normal
– Early detection of cancer, if treated - potentially less
morbidity associated with advanced disease
– NICE guidance 2005…
4) Speakman et al, 2004
5) Maderbacher et al, 2004
Suspected cancer referral
NICE guidance
1.
Hard irregular prostate
•
Check PSA and refer
2. Normal prostate but raised/rising age-specific PSA
3. LUTS and high PSA
•
5α-reductase inhibitors ↓PSA by 50%, so double lab PSA
Age 50-59
PSA 3.0ng/ml
60-69
4.0
70-79
5.0
When to PSA?
• Case by case basis
• Pre-test counselling:
– False-positives → unnecessary TRUS+biopsy
– False-negatives → false reassurance
• Irritative >obstructive sx more likely in
prostate ca
• Consider, in combination with DRE, for
asymptomatic pts with strong family hx
Management of BPH
• Assess severity of sx
– IPSS but also sexual sx (erectile and
ejaculatory)
• Ask about aggravating factors
– antimuscarinic, diuretic drugs
– caffeine, alcohol
– constipation
Management of BPH6
• Minimal LUTS and low risk of progression*
– Avoid caffeine and alcohol
– Relax during voiding
– Double voiding
– Breathing exercises for urgency (‘holding on’)
6) British Association of Urological Surgeons (BAUS) 2004
* Larger prostate/raised PSA increases risk of progression of BPH
Management of BPH6
• Minimal LUTS, risk of progression
– Lifestyle advice PLUS 5α-reductase inhibitor
• Bothersome LUTS, low risk of progression
– Lifestyle advice PLUS α-blocker
• Bothersome LUTS and risk of progression
– Lifestyle advice PLUS α-blocker AND/OR 5αreductase inhibitor
• Failure of medical Rx
– TURP
When to refer
• NICE guideline Suspected cancer (2005)
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Prostate, as above
Painless macroscopic haematuria (any age)
Persistent UTI >40yr old
Microscopic haematuria >50 yr old
• NICE Referral Advice Urinary outflow
symptoms (2001) - ?defunkt
• AUR, ARF – immediate referral
• Sx failed to respond to Rx in primary care
Complications
• Acute urinary retention
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Annual incidence 0.6%7, 0.7%8, 0.22%9
May be presenting sx of BPH
Often precipitated by drugs, UTI, surgery
Risk increases with:
• Age, LUTS severity, prostate size
– Prognosis – 50% fail first TWOC10
• UTI – 0.1%7
• Chronic retention → hydronephrosis → renal failure – rare
7) MTOPS trial, McConnell et al, 2003
8) Jacobsen et al, 1997
9) Verhamme et al, 2005
10) Tan & Foo, 2003
Localised Prostate Cancer
Treatment
• Conservative Management:
- Watch and wait (acceptable if estimate <10y
survival, histology of tumour non-aggressive)
• Active Management:
- External beam radiotherapy
- Brachytherapy
- Radical prostatectomy (60% erectile
dysfunction, incontinence)
Early treatment of localised
Prostate Ca improve mortality?
• BMJ review 2006
- Conservative/active management
compared, only radical prostatectomy has
RCT evidence of benefit
- NEJM 2005, RCT, average age 65y:
10y
follow-up:
Prostate Ca deaths
Metastatic deaths
Overall deaths
Watchful
waiting
14%
44%
30%
Radical
prostatectomy
8.6%
19.2%
24%
Advanced Prostate Cancer
Treatment
• LHRH analogue – sc injection eg. Zoladex
ie. chemical orchidectomy, ↓ testosterone
• Anti-androgen eg. Cyproterone acetate,
before/3w after LHRH prevent initial LH
‘flare’ which could increase tumour activity
• Surgical orchidectomy
• Bony metastases – hormone therapy
(above), DXT, chemotherapy,
corticosteroids, bisphosphonates
Scrotal Lumps/Swelling
• History:
- Age
- Symptoms – lump, swelling, pain,
dysuria, penile discharge, sexual active,
fever. Duration of symptoms.
• Examination:
- Offer chaperone, record in notes
- Abdomen including for hernia, scrotum
3 Point Scrotal Examination
• 1) Can you get above the swelling? If not:
- Inguinoscrotal hernia
- Saphena varix
- Varicocele
- Hydrocele of cord
2) Can the testis and epididymis be
identified separately?
3 Point Scrotal Examination
• 3) Is it cystic or solid?
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Separate + Cystic = epididymal cyst
Separate + Solid = epididymitis
Testicular + Cystic = hydrocele
Testicular + Solid = orchitis, tumour, granuloma,
gumma, testicular torsion
Varicocele
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Varicosities of pampiniporm plexus
L>R (NB. Renal carcinoma)
Heavy/dragging sensation
OE: Standing, ‘bag of worms’
Treatment:
- None
- Scrotal support
- Symptoms/subfertility - surgery
Epididymal Cyst
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Usually age>40y
Lie above/behind testis, non-tender
Transilluminate
Clear/milky fluid(spermatocele)
Treatment:
- None
- Aspirate or excision if large/symptomatic
Epididymo-orchitis
• Cause: Chlamydia, gonorrhea, E.Coli, mumps,
TB (NB. Testicular torsion)
• OE : Painful, red, scrotal swelling, +/- fever
• Treatment:
- Analgesia eg. NSAID
- Rest, Scrotal support
- Antibiotics eg. Ciprofloxacin 500mg bd 14-28d
- STI – Antibiotics/Refer GUM
- Abscess – Refer for drainage
Hydrocele
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Fluid collection, tunica vaginalis
Primary/Idiopathic: slow onset, adult >40y
Secondary: inflammation/tumour testis
Treatment:
- Excision
- Aspiration
- Of underlying condition
Testicular Torsion
• Any age, >10-20y, ↑undescended testis
• Hx – duration symptoms, sudden onset
pain 1 testis/abdomen, nausea
• OE: testis tender, swollen, high/transverse
lie
• REFER - SURGICAL EMERGENCY <6hrs
• Treatment: exploration +/- orchidectomy +
bilateral orchidopexy
Testicular Torsion
Testicular Tumours Classification
• Commonest malignancy young men,
↑ undescended testis (x30)
• Germ cell 90%:
- Teratoma – age 20-30y
- Seminoma – age 30-40y
• Others 10%:
- Benign Leydig/Sertoli cell tumour
- Lymphoma – age 60-70y
Testicular Tumours –
Symptoms/Signs
• Hx – 80% painless lump or swelling
• Other – Metastases – lymph/blood:
- Neck lump – L supraclavicular node
- Abdominal pain/mass
- Chest symptoms
Referral Supected Testicular
Tumour
• NICE 2005 – Referral guidelines for suspected
cancer
• 2 week rule
• Swelling or mass in body of testis
• Treatment after staging:
- Seminoma – Excision/DXT
- Teratoma – Excision/chemotherapy
• 70% survival (> for early disease)
Conditions of the Penis
• Balanitis – adults:
- poor hygiene, faecal bacteria, antibiotics
- DM, candida, topical anti-fungal
• Phimosis – foreskin will not retract, circumcision
• Paraphimosis – foreskin will not reduce, LA jelly
for reduction, refer, circumcision
• Priapism – persistent painful erection, climb
stairs, ice packs, refer for aspiration of corpora
Penile Fracture
-
Uncommon
Mechanism – usually erect,
often intercourse
Pathology – corpus cavernosa
+/- urethral rupture (10-58%)
OE: ‘aubergine sign’
REFER: Urological emergency
Ix – USS/MRI, urethrogram
Surgery: full tear/urethral injury
Partial tear heal by fibrosis
Complication – curvature,
erectile dysfunction
Peyronies Disease
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- Age 40-60y
- ? Aetiology – intercourse, recurrent trauma
- Associated with Dupuytren’s contracture
- Fibrosis corpora cavernosa
- Pain, curvature on erection
- Spontaneous resolution rate high
- Surgery if >1y
BXO
(Balanitis Xerotica Obliterans/Lichen Sclerosis)
o
o
o
o
o
o
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- Thickened foreskin
- Depigmentation
- Unknown cause
- Risk phimosis
- 5% malignant change
- Steroid cream
- Circumcision
Carcinoma of the Penis
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Age 60-80y
Rare in uncircumcised
Aetiology – Poor hygiene, smegma, herpes
Histology – SCC 90%
OE: Firm, ulcerated painless lesion, inguinal LN
NICE 2005 Urgent Referral Suspected Cancer:
- Ulceration/mass glans penis/prepuce
- Not mass in corpora cavernosa (Peyronies)
Erectile Dysfunction – Aetiology
• Any age - 52% Age 40-70
• 90% too embarrassed to seek help
• Organic (80%):
- Vascular – hypertension, PAD
- Endocrine – DM, hypogonadism, ↑ prolactin
- Neuro – Pelvic/spinal surgery/injury, MS
- Drugs – side-effects
- Lifestyle – smoking, alcohol, drug abuse
• Psychogenic – performance anxiety, depression
Erectile Dysfunction - History
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What situations, how long a problem?
Early morning erections
Relationship
Depression/Anxiety
Alcohol, smoking, drugs
PMH
DH
Erectile Dysfunction - History
Onset
Loss of erection
Early morning
erections?
Wants
intercourse?
Age
Psychogenic
Organic
Sudden
Inconsistent
Yes
Gradual
Consistent
No
Relationship
problems
Usually <60y
Normal libido
Usually >60y
Erectile Dysfunction –
Examination/Investigation
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Genitals small, hair absent
Peripheral pulses
BP
Urinalysis – glucose
Bloods – testosterone +/- prolactin +/Endocrinologist referral
Erectile Dysfunction Management
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Lifestyle advice – ↓ smoking, alcohol
Psychosexual counselling
Oral/local drug treatments
Mechanical devices
NHS treatment (endorse FP10 ‘SLS’):
- severe pelvic injury, radical pelvic surgery or
prostatectomy, prostate Ca, renal failure, spinal
cord injury, MS, spina bifida, PD, polio, DM
Erectile Dysfunction – Drug
Treatment
• PO Phosphodiesterase 5 inhibitors eg.Sildanefil (Viagra):
- 70% effective
- 30-60 min before intercourse
- avoid excess food/alcohol
- CI: Unstable angina, recent MI/CVA, nitrate
• PO Apomorphine:
- 20min before intercourse
• Intraurethral/cavernosal alprostadil:
- 40% effective, SE: priapism, penile pain
• Combination 92-100% success (sildenafil/alprostodil)
Erectile Dysfunction –
Mechanical Devices
• Useful for drug non-responders
• Vacuum Devices:
- 80% effective
• Penile prosthesis:
- rigid/inflatable
- SE - infection
Any Questions?