Prostate

1. Appropriately identify patients requiring prostate cancer screening.
2. In a patient suitable for prostate cancer screening, use and interpret tests (e.g., prostate-specific antigen testing, digital rectal examination [DRE], ultrasonography) in an individualized/sequential manner to identify potential cases.
3. In patients with prostate cancer, actively search out the psychological impact of the diagnosis and treatment modality.
4. In patients with prostate cancer, considering a specific treatment option (e.g., surgery, radiotherapy, chemotherapy, hormonal treatment, no treatment):
   1. Advise about the risks and benefits of treatment.
   2. Monitor patients for complications following treatment
5. In patients with prostate cancer, actively ask about symptoms of local recurrence or distant spread.
6. Given a suspicion of benign prostatic hypertrophy, diagnose it using appropriate history, physical examination, and investigations.
7. In patients presenting with specific or non-specific urinary symptoms:
   1. Identify the possibility of prostatitis.
   2. Interpret investigations (e.g., urinalysis, urine culture and-sensitivity testing, Digital Rectal Exam, swab testing, reverse transcription-polymerase chain reaction assay) appropriately.

General Overview

• No screening recommended for all ages as per Canadian Task Force
  • Urological associations suggest discussing risks and benefits of PSA screening with patients >50yo (or >40yo if fam hx or african american) with >15y life expectancy
    • Can consider PSA screening if patient concerned about prostate cancer, high risk factors, good health status, and patient not concerned about risks of urinary incontinence and sexual dysfunction
    • Use prostate cancer risk calculator with PSA

BPH

• Risk factors
  • Age, obesity, diabetes, family history
• Complications
  • UTI, bladder stone, urinary retention, hydronephrosis, renal failure
• DDx Urinary Retention
  • BPH
  • Prostate CA
  • Urethral stricture
  • Urethral diverticulum (women)
  • Medication
  • Infection
  • Trauma
  • Neurological (Spinal cord injury)
• History
  • Lower Urinary Tract Symptoms (LUTS) and severity
    • Voiding - predominant in bladder outlet obstruction (BOO) secondary to BPH
      • Hesitancy, Weak Stream, Intermittence, Straining
    • Storage - r/o overactive bladder (OAB)
      • Urgency, Frequency, Urgency Incontinence, Nocturia
    • Postmicturition
      • Dribbling, Incomplete Emptying
    • Consider using International Prostate Symptom Score (IPSS)
  • Rule out nocturnal polyuria (signficant if 2+ voids at night)
  • Medical history, surgery, trauma
  • Medication, drugs
• Physical exam
  • Suprapubic abdominal tenderness
  • Neuro (motor/sensory of perineum and lower limbs)
  • DRE
    • Tenderness or "bogginess" suggests infection
    • Nodularity suggests cancer
• Investigations
  • Urinalysis +/- culture (r/o infection)
  • PSA
  • PVR if considering anticholinergics (eg. storage symptoms suggesting OAB)
• Management of nocturnal polyuria
  • Voiding/Frequency chart 2-3 days
  • If urine output ≥3L
    • Decreased intake, aim for urine output 1L
  • If nocturnal urine output >33% nocturnal polyuria diagnosed
    • Consider Desmopressin
• Management of BPO
  • Follow IPSS, DRE, PSA (if on 5-ARIs) as response to treatment
  • Mild (Symptom score <8, or if not bothered by symptoms)
    • Lifestyle and watchful waiting
      • Fluid restriction particularly prior to bedtime
      • Avoidance of alcohol, caffeine, spicy foods
      • Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants)
      • Timed or organized voiding (bladder retraining)
      • Pelvic floor exercises
      • Avoidance or treatment of constipation
      • Phytotherapy/herbal medicine (Saw Palmetto) has very weak evidence, although minimal side effects
  • Moderate-Severe (SS≥8)
    • For smaller prostates, Alpha-blockers alone (relax smooth muscle, onset 3-5 days)
      • eg. Tamsulosin (Flomax) CR 0.4mg PO daily (avoid in sulfa allergy)
        • Side effects: Orthostatic hypotension, retrograde ejaculation (ejaculation failure)
    • For larger prostates (eg. DRE>25mL or PSA>1.5 ng/dL), combination therapy more effective with 5-alpha reductase inhibitors (onhibit conversion of testosterone to DHT, onset 4-6 months)
      • eg. Dutasteride (Avodart) 0.5mg PO daily , or Finasteride (Proscar)
        • Side effects: Decreased libido, erectile dysfunction
      • After 6-9 months of combination therapy, consider stopping alpha blocker
    • Consider addition of PDE-5 inhibitors for LUT symptoms, eg. Tadalafil (Cialis) 5mg PO daily
    • Consider addition of anticholinergics (eg. Tolterodine, Oxybutynin, Mirabegron) especially if component of OAB (storage symptoms), caution if PVR >250mL
  • Referral
    • Failure of symptom control despite combination therapy, for possible Surgery (TURP)
    • Complications: Hematuria, recurrent UTIs, urinary retention, renal failure
    • Suspect prostate cancer (DRE/elevation in PSA)
      • PSA<10 low risk (routine), PSA 10-20 (semiurgent referral), PSA>20 high risk (urgent)
        • Upgrade urgency if DRE abnormal (firm or irregular)

Prostatitis

• General Overview
  • Acute Bacterial Prostatitis
    • Tender prostate
  • Chronic Bacterial Prostatitis
    • Intermittent UTIs with same bacteria
  • Chronic Prostatitis / Chronic Pelvic Pain Syndrome
    • Inflammatory Chronic Prostatitis
    • Non-inflammatory Chronic Prostatitis
  • Asymptomatic Inflammatory Prostatitis
    • Leukocytosis
• Symptoms
  • Fevers, chills, dysuria, pelvic or perineal pain, and cloudy urine, obstructive symptoms
• Risk
  • Indwelling catheter, urogenital instrumentation, prostate biopsy, HIV/immunosuppression, STI risk factors, BPH
• Etiology
  • Enterobacteriaceae (typically Escherichia coli or Proteus species).
  • STIs (Neisseria gonorrhoeae and Chlamydia trachomatis) in sexually active men, may have concurrent urethritis or epididymitis.
• Physical Exam
  • Prostate warm, firm, edematous, and exquisitely tender (avoid massaging)
• Investigation
  • Urinalysis, urine culture and-sensitivity testing, gono/chlam urethral/rectal PCR and culture
• Treatment
  • Acute/Chronic Bacterial
    • Septra DS 1 tab q12h x 6 weeks (or 12 weeks for chronic) or Ciprofloxacin 500mg PO q12h x 6 weeks (for both acute and chronic)
    • Urine culture to target therapy
      • Consider Urine culture at 7 days (if still positive, consider change in management)
        • Rule out prostatic abscess in immunosuppressed or poor response to therapy
  • Non-infectious
    • Target UPOINTS
      • Urinary (storage/voiding symptoms)
        • Tamsulosin 0.4mg PO daily (a-blocker), antimuscarinics
      • Psychosocial
        • CBT, counselling, antidepressants, anxiolytics
      • Organ specific (prostate tenderness, hematospermia)
        • Quercetin, pollen extract
      • Infection (positive cultures in prostate sample, previous UTI)
        • Fluoroquinolone x 6 weeks
      • Neurologic / Pain
        • Acetaminophen, NSAIDs
        • Gabapentinoids, TCA, acupuncture
      • Tenderness (pelvic floor spasm, trigger points)
        • Physiotherapy (pelvic floor relaxation), exercise, heat therapy
      • Sexual dysfunction
        • PDE-5 inhibitors
    • Refer to urologist if does not improve significantly with initial treatment