Prostate
- Appropriately identify patients requiring prostate cancer screening.
- 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.
- In patients with prostate cancer, actively search out the psychological impact of the diagnosis and treatment modality.
- In patients with prostate cancer, considering a specific treatment option (e.g., surgery, radiotherapy, chemotherapy, hormonal treatment, no treatment):
- Advise about the risks and benefits of treatment.
- Monitor patients for complications following treatment
- In patients with prostate cancer, actively ask about symptoms of local recurrence or distant spread.
- Given a suspicion of benign prostatic hypertrophy, diagnose it using appropriate history, physical examination, and investigations.
- In patients presenting with specific or non-specific urinary symptoms:
- Identify the possibility of prostatitis.
- Interpret investigations (e.g., urinalysis, urine culture and-sensitivity testing, Digital Rectal Exam, swab testing, reverse transcription-polymerase chain reaction assay) appropriately.
General Overview
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
- 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
BPH
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)
- Voiding - predominant in bladder outlet obstruction (BOO) secondary to BPH
- Rule out nocturnal polyuria (signficant if 2+ voids at night)
- Medical history, surgery, trauma
- Medication, drugs
- Lower Urinary Tract Symptoms (LUTS) and severity
- 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
- Lifestyle and watchful waiting
- 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)
- eg. Tamsulosin (Flomax) CR 0.4mg PO daily (avoid in sulfa allergy)
- 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
- eg. Dutasteride (Avodart) 0.5mg PO daily , or Finasteride (Proscar)
- 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
- For smaller prostates, Alpha-blockers alone (relax smooth muscle, onset 3-5 days)
- 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)
- PSA<10 low risk (routine), PSA 10-20 (semiurgent referral), PSA>20 high risk (urgent)
Prostatitis
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
- Acute Bacterial Prostatitis
- 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
- Consider Urine culture at 7 days (if still positive, consider change in management)
- 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
- Urinary (storage/voiding symptoms)
- Refer to urologist if does not improve significantly with initial treatment
- Target UPOINTS
- Acute/Chronic Bacterial
References:
- Prostate Cancer
- BPH
- CUA 2012. http://www.canjurol.com/html/free-articles/V19I5S1F-03-DrKapoor.pdf
- CUA 2010. https://www.cua.org/themes/web/assets/files/guidelines/en/guidelines_for_the_management_of_benign_prostatic.pdf
- AUA 2010. http://www.auanet.org/guidelines/benign-prostatic-hyperplasia-(2010-reviewed-and-validity-confirmed-2014)
- Prostatitis