1. BPH, Testicular Cancer and Prostate Cancer Patrick Carter MPAS, PA-C Clinical Medicine I March 4, 2011
2. Objectives For each of the following diseases describe the etiology, epidemiology, pathophysiology, risk factors, signs and symptoms, diagnostic work-up, and treatment: Urethral, penile and scrotal injuries Benign prostatic hyperplasia (BPH) Testicular cancer Prostate cancer Compare and contrast the pathophysiology, clinical presentation, diagnostic work-up and treatment of BPH and prostate cancer
4. Phimosis Inability to retract the foreskin Physiologic at birth In 90% of uncircumcised males the foreskin becomes retractable by the age of 3 years May become pathologic from inflammation and scarring at the tip of the foreskin Treatment Corticosteroid cream to the foreskin three times daily for 1 month After age 10, circumcision is recommended
6. Paraphimosis Foreskin is retracted behind the coronal sulcus and cannot be pulled back over the glans Leads to painful venous stasis in the retracted foreskin results, with edema leading to severe pain Treatment Lubrication of the foreskin and glans and then compressing the glans and simultaneously placing distal traction on the foreskin In rare cases, emergency circumcision under general anesthesia is necessary
8. Penile Fracture Traumatic rupture of the corpus cavernosum, occurs when the tunica albuginea is torn Usually associated with sexual activity Patient may hear a snapping sound and experience localized pain, detumescence, and a slowly progressive penile hematoma
11. Penile Fracture Treatment Nonsurgical – bed rest and ice packs for 24 to 48 hours followed by local heat and a pressure dressing Surgical (most common) – hematoma is evacuated, torn tunica albuginea is sutured, and a pressure dressing is applied Prognosis – 10% will experience a permanent deformity, suboptimal coitus, or impaired erections, especially if managed nonoperatively
12. Peyronie’s Disease Acute phase – pain and inflammation as the plaque is forming Medical therapy with p-aminobenzoic acid, vitamin E, colchicines, or tamoxifen may be modestly successful Chronic phase – pain subsides and the plaque is stable Surgical correction if the curvature interferes with sexual intercourse
14. Testicular Cancer Essentials of diagnosis Most common neoplasm in men aged 20–35 Typical presentation as a patient-identified painless nodule Orchiectomy necessary for diagnosis
15. Testicular Cancer General Considerations Rare (2–3 new cases per 100,000 males in the United States each year) 90–95% of all primary testicular tumors are germ cell tumors Slightly more common on the right than on the left, bilateral in 1–2%
16. Testicular Cancer General Considerations Cause unknown, but increased risk with a history of unilateral or bilateral cryptorchism Risk of malignancy is highest for an intra-abdominal testis (1:20) and 1:80 for an inguinal testis Orchiopexy does not alter the risk in the cryptorchid testis; it does help examination and tumor detection 5–10% of testicular tumors occur in the contralateral, normally descended testis
17. Testicular Cancer Signs and symptoms Most common symptom is painless enlargement of the testis Sensation of heaviness Acute testicular pain from intratesticular hemorrhage in ~10% Symptoms relating to metastatic disease in 10% Asymptomatic at presentation in 10%
18. Testicular Cancer Physical examination findings Testicular mass or diffuse enlargement of the testis most common Secondary hydroceles in 5–10% Supraclavicular adenopathy Retroperitoneal mass Gynecomastia in 5% of germ cell tumors
19. Testicular Cancer Differential Diagnosis Epidermoid cyst Laboratory Tests Serum human chorionic gonadotropin, alpha-fetoprotein, and lactate dehydrogenase Liver function tests
21. Testicular Cancer Imaging Studies Scrotal ultrasound CT scan of abdomen and pelvis Surgical treatment Radical orchiectomy by inguinal exploration with early vascular control of the spermatic cord structures Scrotal approaches and open testicular biopsies should be avoided
23. Testicular Cancer Seminomas Stage I and IIa seminomas treated by radical orchiectomy and retroperitoneal irradiation have 5-year disease-free survival rates of 92 - 98% Stage IIb and III seminomas are treated with primary chemotherapy Among stage III patients, 95% will attain a complete response following orchiectomy and chemotherapy
24. Testicular Cancer Nonseminomas Up to 75% of stage A nonseminomas are cured by orchiectomy alone Modified retroperitoneal lymph node dissections have been designed to preserve the sympathetic innervation required for ejaculation
25. Testicular Cancer Prognosis Patients with bulky retroperitoneal or disseminated disease treated with primary chemotherapy followed by surgery have a 5-year disease-free survival rate of 55–80%
37. Benign Prostatic Hyperplasia Essentials of diagnosis Obstructive or irritative voiding symptoms May have enlarged prostate on rectal examination Absence of urinary tract infection, neurologic disorder, urethral stricture disease, prostatic or bladder malignancy
38. Benign Prostatic Hyperplasia Definition = smooth, firm, elastic enlargement of the prostate Etiology Multifactorial Endocrine: dihydrotestosterone (DHT) Aging
39. Benign Prostatic Hyperplasia Epidemiology The most common benign tumor in men Incidence increases with age Prevalence ~20% in men aged 41–50 ~50% in men aged 51–60 > 90% in men aged 80 and older Symptoms are also age related: at age 55, ~25% of men report obstructive voiding symptoms
40. Benign Prostatic Hyperplasia Obstructive symptoms Hesitancy Decreased force and caliber of stream Sensation of incomplete bladder emptying Double voiding (urinating a second time within 2 hours) Straining to urinate Postvoid dribbling
41. Benign Prostatic Hyperplasia Irritative symptoms Urgency Frequency Nocturia American Urological Association symptom index
43. Benign Prostatic Hyperplasia Diagnosis Physical examination DRE to note size and consistency Focused neurologic examination Examine lower abdomen for a distended bladder Renal insufficiency from BPH If possibility of cancer, do serum prostate-specific antigen (PSA), transrectal ultrasound, and biopsy
45. Elevated Serum PSA Prostate carcinoma Glandular hyperplasia associated with BPH Acute bacterial prostatitis and prostate abscess (transitory) Prostatic infarction (transitory) Manipulation of prostate (transitory)
46. Benign Prostatic Hyperplasia Medications Alpha-blockers Prazosin Terazosin 5 alpha-reductase inhibitors Finasteride Dutasteride Saw palmetto is of no benefit Combination therapy
47. Benign Prostatic Hyperplasia Indications for surgery Refractory urinary retention (failing at least one attempt at catheter removal) Large bladder diverticula Recurrent urinary tract infection Recurrent gross hematuria Bladder stones Renal insufficiency
48. Benign Prostatic Hyperplasia Types of surgery Transurethral resection of the prostate (TURP) Postoperative complications Retrograde ejaculation (75%) Impotence (5–10%) Urinary incontinence (< 1%)
49. Benign Prostatic Hyperplasia Types of surgery Transurethral incision of the prostate (TUIP) Removes the zone of the prostate around the urethra leaving the peripheral portion of the prostate and prostate capsule Lower rate of retrograde ejaculation reported (25%) Open simple prostatectomy when Prostate is too big to remove endoscopically (> 100 g) Bladder stone is present
50. Benign Prostatic Hyperplasia Minimally invasive approaches TULIP (transurethral laser-induced prostatectomy) under transrectal ultrasound guidance Advantages of laser surgery include Outpatient surgery Minimal blood loss Ability to treat patients while they are receiving anticoagulation therapy
51. Benign Prostatic Hyperplasia Minimally invasive approaches TULIP Disadvantages of laser surgery include Lack of tissue for pathologic examination Longer postoperative catheterization time More frequent irritative voiding complaints Expense of laser fibers and generators Transurethral needle ablation of the prostate (TUNA)
52. Benign Prostatic Hyperplasia Other options Watchful waiting: only for patients with mild symptoms (AUA scores 0–7) With watchful waiting, ~10% progress to urinary retention, and half demonstrate marked improvement or resolution of symptoms Follow-Up Follow AUA Symptom Index for BPH
54. Prostate Cancer Essentials of Diagnosis Prostatic induration on digital rectal examination (DRE) or elevated level of serum prostate-specific antigen (PSA) Most often asymptomatic Rarely, systemic symptoms (weight loss, bone pain)
55. Prostate Cancer General Considerations Most common cancer in American men Second leading cause of cancer-related death in men About 234,500 new cases of prostate cancer, about 27,350 deaths in 2006 At autopsy, > 40% of men aged > 50 years have prostate carcinoma, most often occult
56. Prostate Cancer Incidence increases with age Risk factors Black race Family history of prostate cancer History of high dietary fat intake Majority of prostate cancers are adenocarcinomas
57. Prostate Cancer Signs and symptoms Focal nodules or areas of induration on DRE Obstructive voiding symptoms Lymph node metastases Lower extremity lymphedema Back pain or pathologic fractures Rarely, signs of urinary retention or neurologic symptoms as a result of epidural metastases and cord compression
59. Prostate Cancer Laboratory tests Elevations in serum PSA (normal < 4 ng/mL) PSA correlates with the volume of both benign and malignant prostate tissue 18–30% of men with PSA 4.1–10.0 ng/mL have prostate cancer Elevations in serum BUN or creatinine in patients with urinary retention or ureteral obstruction Elevations in alkaline phosphatase or hypercalcemia in patients with bony metastases
60. Prostate Cancer Imaging Studies Transrectal ultrasound (TRUS) MRI of the prostate CT imaging to detect regional lymphatic and intra-abdominal metastases Radionuclide bone scan for PSA level > 20 ng/mL
61. Prostate Cancer Diagnostic procedures TRUS-guided biopsy from the apex, mid portion, and base of the prostate Fine-needle aspiration biopsies should be considered in patients at increased risk for bleeding
62. Prostate Cancer Medications Adrenal (adrenal insufficiency, nausea, rash, ataxia) Ketoconazole Aminoglutethimide Corticosteroids (prednisone) for gastrointestinal bleeding or fluid retention
63. Prostate Cancer Medications Pituitary, hypothalamus (gynecomastia, hot flushes, thromboembolic disease, erectile dysfunction) Estrogens Luteinizing hormone-releasing hormone (LHRH) agonists Antiandrogens (flutamide) Chemotherapy with Docetaxel
64. Prostate Cancer Therapeutic procedures Surveillance For minimal capsular penetration, standard irradiation or surgery For locally extensive cancers, combination therapy (androgen deprivation combined with surgery or irradiation) For metastatic disease, androgen deprivation
65. Prostate Cancer Therapeutic procedures Radical prostatectomy For stages T1 and T2 prostatic cancers, local recurrence is uncommon after radical prostatectomy Adjuvant therapy (radiation for patients with positive surgical margins or androgen deprivation for lymph node metastases) Radiation therapy External beam radiotherapy Transperineal implantation of radioisotopes
66. Prostate Cancer Screening for prostate cancer Screening tests currently available include DRE, serum PSA, TRUS Detection rates with DRE are low, varying from 1.5% to 7.0% TRUS has low specificity (and therefore high biopsy rate) Elevation of PSA is not specific for cancer, occurs in BPH
67. Prostate Cancer Age-specific reference ranges for PSA increase specificity For men aged 40–49 years, range is < 2.5 ng/mL For men 50–59, < 3.5 ng/mL For men 60–69, < 4.5 ng/mL For men 70–79, < 6.5 ng/mL Lower Ranges for Black Males
68. Prostate Cancer PSA testing Annually in men with a normal DRE and a PSA > 2.5 ng/mL Biennially in men with a normal DRE and serum PSA < 2.5 ng/mL
