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LUTS BPH Carcinoma Prostate PowerPoint Presentation

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Description : This medical presentation on cancer titled "LUTS, BPH, Carcinoma Prostate" tells you about LUTS, Benign Prostatic Hyperplasia (BPH) and Carcinoma Prostate.

Tags : Cancer, LUTS, BPH, Carcinoma Prostate, Benign Prostatic Hyperplasia, Carcinoma Prostate,

Published on : Apr 28, 2021 | Views : 2785 | Downloads : 7

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Slide 1-

LUTS, BPH, Carcinoma Prostate Dr Amit Gupta Associate Professor Dept. of Surgery
Slide 2-

LUTS: definition Storage (irritative) symptoms: Urgency Urinary frequency Nocturia Urinary incontinence Voiding (obstructive) symptoms Hesitancy, poor stream, terminal dribbling
Slide 3-

Causes of LUTS Obstructive BPH Prostate/bladder/rectal cancer Bladder neck/urethral strictures Antimuscarinic drugs Autonomic neuropathy/neurogenic bladder
Slide 4-

Causes of LUTS Irritative BPH Bladder/prostate cancer Infection Bladder stones Neurological Dementia Diabetes Stroke
Slide 5-

Assessment History – type of LUTS, duration of Sx, how bothersome are they? Examination – abdomen (distended bladder), external genitalia, DRE International Prostate Symptom Score: Used to assess severity of symptoms Score of 0-5 for seven symptoms (total 35): 0-7 – mildly symptomatic 8-19 – moderately symptomatic 20-35 – severely symptomatic
Slide 6-

Management Urine dip +/- culture U&E Chronic retention Recurrent UTI Hx of renal stones PSA Urinary frequency-volume chart Ask patient to note down when they drink fluid/pass water and to comment on type of fluid Allows to differentiate between frequency of urine, polyuria and nocturia
Slide 7-

Obstructive symptoms Lifestyle changes. Alpha blocker: e.g tamsulosin 5α – reductase inhibitors Irritative symptoms Exclude/manage treatable causes Urine containment devices Supervised bladder retraining Anticholinergics e.g oxybutinin
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Benign Prostatic Hyperplasia
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4/29/2021 9 Generalised disease of the prostate due to hormonal derangement which leads to enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms
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Etiology Cause not completely understood Reawakening of the urogenital sinus to proliferate Change in hormonal milieu with alterations in the testosterone/estrogen balance Induction of prostatic growth factors Increased stem cells/decreased stromal cell death Accumulation of dihydroxytestosterone, stimulation by estrogen and prostatic growth hormone actions
Slide 11-

11 BPH facts Occurs in 50% of men over 50 and in 80% of men over 80 have BPH BPH progresses differently in every individual Many men with BPH may have mild symptoms and may never need treatment BPH does not predispose to the development of prostate cancer
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12 Benign Prostatic Hyperplasia
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BPH Pathophysiology Normal BPH Hypertrophied detrusor muscle Obstructed urinary flow PROSTATE BLADDER URETHRA
Slide 14-

Pathophysiology Slow and insidious changes over time Complex interactions between prostatic urethral resistance, intravesical pressure, detrussor functionality, neurologic integrity, and general physical health. Initial hypertrophydetrussor decompensation poor tonediverticula formationincreasing urine volumehydronephrosisupper tract dysfunction
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4/29/2021 15 Complications Urinary retention UTI Sepsis secondary to UTI Residual urine Calculi Renal failure Hematuria Hernias, hemorroids, bowel habit change
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4/29/2021 16 Clinical manifestations Voiding symptoms decrease in the urinary stream Straining Dribbling at the end of urination Intermittency Hesitancy Pain or burning during urination Feeling of incomplete bladder emptying
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4/29/2021 17 Clinical manifestations Irritative symptoms urinary frequency urgency dysuria bladder pain nocturia incontinence symptoms associated with infection
Slide 18-

Benign Prostatic Hyperplasia Leading to “symptom bother” and worsened QOL
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Other Relevant History GU History (STD, trauma, surgery) Other disorders (eg. neurologic, diabetes) Medications (anti-cholinergics) Functional Status
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4/29/2021 20 Diagnostic Tests History & Examination Abdominal/GU exam Focused neuro exam Digital rectal exam (DRE) Validated symptom questionnaire. Urinalysis Urine culture BUN, Cr Prostate specific antigen (PSA) Transrectal ultrasound – biopsy Uroflometry Postvoid residual
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4/29/2021 21 DRE
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Optional Evaluations and Diagnostic Tests Urine cytology in patients with: Predominance of irritative voiding symptoms. Smoking history Flow rate and post-void residual Not necessary before medical therapy but should be considered in those undergoing invasive therapy or those with neurologic conditions Upper tract evaluation if hematuria, increased creatinine Cystoscopy
Slide 23-

Differential Diagnosis Urethral stricture Bladder neck contracture Carcinoma of the prostate Carcinoma of the bladder Bladder calculi Urinary tract infection and prostatitis Neurogenic bladder
Slide 24-

Treatment Indications Absolute vs Relative Severe obstruction Urinary retention Signs of upper tract dilatation and renal insufficiency Moderate symptoms of prostatism Recurrent UTI’s Hematuria Quality of life issues
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Therapy Watchful waiting and behavioral modification Medical Management Alpha blockers 5-alpha reductase inhibitors Combination therapy Surgical Management Office based therapy OR based therapy Urethral stents
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Carcinoma Prostate
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Epidemiology Risk factors Increasing age Family history African-American Dietary factors. Nutritional factors have protective effect against prostate cancer Reduced fat intake Soy protein Lycopene Vitamin E Selenium Race Incidence doubled in African Americans compared to white Americans. Genetics Common among relatives with early-onset prostate cancer Susceptibility locus (early onset prostate cancer) Chromosome 1, band Q24 An abnormality at this locus occurs in less than 10% of prostate cancer patients.
Slide 28-

Pathophysiology Adenocarcinoma 95% of prostate cancers Developing in the acini of prostatic ducts Rare histopathologic types of prostate carcinoma Occur in approximately 5% of patients Include Small cell carcinoma Mucinous carcinoma Endometrioid cancer (prostatic ductal carcinoma) Transitional cell cancer Squamous cell carcinoma Basal cell carcinoma Adenoid cystic carcinoma (basaloid) Signet-ring cell carcinoma Neuroendocrine cancer
Slide 29-

Pathophysiology Peripheral zone (PZ) 70% of cancers Transitional zone (TZ) 20% Some claim TZ prostate cancers are relatively nonaggressive PZ cancers are more aggressive Tend to invade the periprostatic tissues.
Slide 30-

Clinical Manifestations Early state (organ confined) Asymptomatic Locally advanced Obstructive voiding symptoms Hesitancy Intermittent urinary stream Decreased force of stream May have growth into the urethra or bladder neck Hematuria Hematospermia Advanced (spread to the regional pelvic lymph nodes) Edema of the lower extremities Pelvic and perineal discomfort
Slide 31-

Clinical Manifestations Metastasis Most commonly to bone (frequently asymptomatic) Can cause severe and unremitting pain Bone metastasis Can result in pathologic fractures or Spinal cord compression Visceral metastases (rare) Can develop pulmonary, hepatic, pleural, peritoneal, and central nervous system metastases late in the natural history or after hormonal therapies fail.
Slide 32-

Detection and Diagnosis PSA level Helpful in asymptomatic patients > 60% of patients with prostate cancer are asymptomatic Diagnosis is made solely because of an elevated screening PSA level A palpable nodule on digital rectal examination Next most common clinical presentation Prompts biopsy Much less commonly, patients are symptomatic Advanced disease Obstructive voiding symptoms Pelvic or perineal discomfort Lower extremity edema Symptomatic bone lesions.
Slide 33-

Detection and Diagnosis Digital rectal examination Low sensitivity and specificity for diagnosis Biopsy of a nodule or area of induration Reveals cancer 50% of the time Suggests Prostate biopsy Should be undertaken in all men with palpable nodules.
Slide 34-

Detection and Diagnosis Transrectal ultrasound with biopsies Indicated when The PSA level is elevated The percent-free PSA is less than 25%, or An abnormality is noted on digital rectal examination Type of biopsy Sextant biopsies (base, midgland, and apex on each side) Generally obtained Seminal vesicles are biopsied in high-risk patients
Slide 35-

Detection and Diagnosis A bone scan Warranted only PSA level greater than 10ng/mL Computed Tomography or magnetic resonance imaging Abdominal and pelvic CT or MRI is usually unrevealing in patients with a PSA level less than 20ng/mL. . Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint
Slide 36-

Prostate Cancer Prognosis Prognosis correlates with histologic grade and extent (stage) of disease Adenocarcinoma > 95% of prostate cancers Multifocality is common Grading Ranges from 1 to 5 Gleason score Definition Sum of the two most common histologic patterns seen on each tissue specimen Ranges From 2 (1 + 1) To 10 (5 + 5) Category Well-differentiated (Gleason scores 2, 3, or 4) Intermediate differentiation (Gleason scores 5, 6, or 7) Poorly differentiated (Gleason scores 8, 9, or 10). Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint
Slide 37-

Prostate Cancer Staging Stage T1 Nonpalpable prostate cancer Detected only on pathologic examination Incidentally noted after Transurethral resection for benign hypertrophy (T1a and T1b) or On biopsy obtained because of an elevated PSA (T1c-the most common clinical stage at diagnosis) Stage T2 Palpable tumor Appears to be confined to the prostatic gland (T2a if one lobe, T2b if two lobes) Stage T3 Tumor with extension through the prostatic capsule (T2a if focal, T2b if seminal vesicles are involved) Stage T4 Invasion of adjacent structures Bladder neck External urinary sphincter The rectum The levator muscles The pelvic sidewal Nodal metastases Can be microscopic and can be detected only by biopsy or lymphadenectomy, or they can be visible on imaging studies Distant metastases Predominantly to bone Occasional visceral metastases occur. Small, E., Cecil Textbook of Medicine, Prostate Cancer, 2004, WB Saunders, an Elsevier imprint
Slide 38-

Treatment PRINCIPLES OF THERAPY May include Watchful waiting Androgen deprivation External beam radiotherapy Retropubic or perineal radical prostatectomy with or without postoperative radiotherapy to the prostate margins and pelvis Brachytherapy (either permanent or temporary radioactive seed implants) with or without external beam radiotherapy to the prostate margins and pelvis.
Slide 39-

Surgery Traditional Robotic Radiation Brachytherapy External beam Cryotherapy Androgen Deprivation Watchful waiting
Slide 40-

Treatment – Hormone resistant HORMONE-RESISTANT PROSTATE CANCER Climbing PSA First manifestation of resistance to androgen deprivation In the setting of anorchid levels of testosterone Therapy Discontinuation of antiandrogen therapy (flutamide, bicalutamide, nilutamide) while continuing with LHRH agonists Results in a PSA decline Can be associated with symptomatic improvement Can persist for 4 to 24 months or more Secondary hormonal manipulations Ketoconazole or Estrogens Chemotherapeutic regimens Mitoxantrone plus corticosteroids or Estramustine plus a taxane Monitoring Serial PSA levels (best) A decline of 50% or more is probably clinically significant
Slide 41-

PALLIATIVE CARE Bone pain Advanced prostate cancer Analgesics Glucocorticoids Anti-inflammatory agents Can alleviate bone pain Widespread bony metastases not easily controlled with analgesics or local radiation Strontium-89 and samarium-153 Selectively concentrated in bone metastases Alleviate pain in 70% or more of treated patients.