Prostate Neoplasms | Medical Science Optional Notes for UPSC PDF Download

Acute retention of urine

Male

• Bladder outlet obstruction, most commonly caused by:
  a. Benign prostatic hyperplasia (BPH)
  b. Bladder neck stenosis
  c. Bladder neck hypertrophy
  d. Prostate cancer
  e. Urethral strictures
  f. Functional obstruction due to neuropathy, including:
  i. Diabetes mellitus
  ii. Parkinson's disease
  iii. Tabes dorsalis
  iv. Cervical spondylosis
• Other causes of male bladder outlet obstruction include:
  a. Urethral stricture
  b. Acute urethritis or prostatitis
  c. Phimosis
• Factors common to both genders causing bladder outlet obstruction:
  a. Blood clot
  b. Urethral calculus
  c. Rupture of the urethra
  d. Neurogenic causes (injury or disease of the spinal cord)
  e. Smooth muscle cell dysfunction associated with aging
  f. Faecal impaction
  g. Anal pain (after haemorrhoidectomy)

Female

• Causes of bladder outlet obstruction in females:
  a. Retroverted gravid uterus
  b. Bladder neck obstruction (rare)
• Factors affecting both genders related to bladder outlet obstruction:
  a. Intensive postoperative analgesic treatment
  b. Drug-induced causes, including anticholinergics, antihistaminics, antihypertensives, antipsychotics, antidepressants, NSAIDs, and benzodiazepines
  c. Spinal anesthesia

Potential neurological causes should be excluded by checking reflexes in the lower limbs and perianal sensation.

Investigations

• Diagnostic procedures for urinary issues include:
  a. Urine analysis using dipstick for blood, glucose, and protein, along with cytological examination.
  b. Urine culture to identify infections.
  c. Measurement of serum creatinine, electrolytes, and hemoglobin.
  d. Urinary flow rate and residual volume assessment through ultrasound (USG). A flow rate of <10 mL/s for a voided volume >200 mL warrants treatment.
• Pressure flow studies involve simulating bladder filling and emptying while measuring pressure. A bladder pressure increase of less than 15 cmH20 is expected, without phasic pressure increases. Normal voiding pressure should not exceed 60 cmH20 in men and about 40 cmH20 in women, with a flow rate between 20 mL/s and 25 mL/s.
• Prostate-specific antigen (PSA) measurement is recommended for men where an early prostate cancer diagnosis may impact treatment decisions (e.g., those under 70 or with a positive family history). If PSA exceeds 2.5-4 ng/mL, consider transrectal ultrasound scanning (TRUS) and transrectal biopsies (12 biopsies from six areas).
• PSA levels in men with metastatic prostate cancer typically rise to >30 ng/mL and decrease after successful androgen ablation. Locally confined prostate cancer usually shows serum PSA levels <10-15 ng/mL.

BPH-Presentation

Lower Urinary Tract Symptoms (LUTS)

Voiding Symptoms:

• Hesitancy, particularly exacerbated when the bladder is very full.
• Poor flow during urination, not improved by straining.
• Intermittent stream, characterized by starts and stops.
• Dribbling, which may occur after urination.
• Sensation of inadequate bladder emptying.
• Episodes of near retention, where the ability to void is compromised.

Storage Symptoms:

• Increased frequency of urination.
• Nocturia, the need to urinate during the night.
• Urgency, a sudden compelling need to urinate.
• Urge incontinence, involuntary leakage associated with a strong urge to urinate.
• Nocturnal incontinence (enuresis), involuntary urination during the night.

Bladder outflow obstruction can result in Acute or Chronic Retention, leading to complications such as infection and the formation of stones.

Investigations

• Evaluation of the upper urinary tract is necessary if there's infection or hematuria. This involves using ultrasound (USG) or intravenous pyelography (IVP).
• Cystourethroscopy is performed to rule out conditions like urethral stricture, bladder carcinoma, and non-opaque vesical calculus.
• Prostatic enlargement can be estimated through transrectal ultrasound.

Management of BPH

Conservative Management (Watchful Waiting - Behavior Modifications):

• Recommended as the primary treatment for mildly symptomatic Benign Prostatic Hyperplasia (BPH) and as supplementary therapy for those requiring medical intervention.
• Behavioral modifications include limiting fluid intake before bedtime, reducing caffeine and alcohol consumption, and ensuring thorough bladder emptying.

Management of BPH - Conservative and Medical Therapy:

• Conservative management involves watchful waiting for mild BPH or uncomplicated moderate BPH with minimal symptoms.
• Medical therapy, either monotherapy or a combination of two drugs, is indicated for mild BPH or moderate BPH causing minimal discomfort.
  a. Alpha-blockers (e.g., tamsulosin, doxazosin) relax bladder neck and prostatic urethra muscles, improving urinary outflow.
  b. 5-alpha-reductase inhibitors (e.g., finasteride, dutasteride) reduce prostatic growth and enhance apoptosis, improving Lower Urinary Tract Symptoms (LUTS).
  c. Parasympatholytics/anticholinergics (e.g., oxybutynin) are for irritative symptoms without elevated post-void residuals.
  d. Phosphodiesterase type 5 inhibitors (e.g., tadalafil) are for patients with mild/moderate BPH symptoms and erectile dysfunction.

Indications for Surgery (Prostatectomy):

• Acute retention (25%)
• Chronic retention with renal impairment (15%)
• Complications of Bladder Outlet Obstruction (BOO) like stones, infection, and diverticulum
• Hemorrhage
• Elective surgery for severe symptoms, including increasing difficulty in micturition, frequent urination, delayed start, poor stream, low maximum flow rate (<10 mL/s), and increased residual urine volume (100-250 mL).
  • Transurethral Resection of the Prostate (TURP) is the gold standard.

Surgery Options Based on Prostate Size:

• Small prostates with obstructive symptoms or those at high surgical risk: Transurethral Incision of the Prostate (TUIP).
• Very large prostates (>75g): Holmium Laser Enucleation of the Prostate (HOLEP) or open prostatectomy.

Complications of TURP:

• Hemorrhage
• Bladder or prostatic capsule perforation
• Sepsis
• Incontinence due to external sphincter damage
• Retrograde ejaculation (>50%) and impotence
• Urethral strictures
• Bladder neck contracture
• Low incidence of death (0.2-0.3%)
• Water intoxication risks (congestive heart failure, hyponatremia, hemolysis) have decreased with the use of bipolar TURP with normal saline irrigant.

Management of Prostatic carcinoma

Investigations for Prostate Cancer

• Digital Rectal Examination
• Prostate-Specific Antigen (PSA) test
• Alkaline Phosphatase and Bone scan (for bone metastasis)
• Liver Function Tests (LFT)
• TRUS-guided Prostatic Biopsy: 12 samples are taken from various areas of the prostate for histological analysis.
  • Gleason Scoring: This system classifies histological patterns based on glandular de-differentiation and its relation to stroma. Two histological areas are scored between 1 and 5, with the scores combined to generate an overall Gleason score ranging from 2 to 10. This score, along with cancer volume, correlates with the likelihood of spread and prognosis.

Staging

• Imaging through MRI/TRUS.
• TNM Staging:
  • T1: Incidentally found tumors
    a. T1a: Involves <5% of the resected specimen
    b. T1b: Involves >5% of the resected specimen
    c. T1c: Impalpable tumors discovered during PSA investigation
• T2: Suspicious nodule found on rectal examination, confined within the prostatic capsule
  a. T2a: Involves a single lobe
  b. T2b: Involves both lobes
• Early prostatic cancer includes T1 and T2.
• T3: Extends through the capsule, involves seminal vesicles
• T4: Fixed tumor invading the rectum or pelvic side wall

The treatment plan considers the patient's age, life expectancy, medical condition, and preferences. Imaging results, PSA levels, and Gleason score are crucial factors when evaluating treatment options.

Management of Prostatic carcinoma

• Active Surveillance: Low-risk prostate cancer, characterized by low PSA levels and small Gleason 6 disease foci, can be managed through active surveillance. This involves regular digital rectal examinations (DRE), PSA measurements every 3 to 6 months, and repeated prostate biopsies. This approach allows some individuals to avoid the potential side effects of aggressive treatment.
• Radical Prostatectomy: Complete removal of the entire prostate gland, encompassing the prostatic capsule, seminal vesicles, and vas deferens. It might include pelvic lymphadenectomy if necessary. Potential complications include bladder irritation leading to urinary frequency and urgency, rectal irritation causing diarrhea, and erectile dysfunction in approximately 30% of cases.
• External Beam Radiotherapy (EBRT): Administered daily for 4 to 6 weeks. Side effects may involve bladder and rectal irritation, potentially leading to urinary and bowel symptoms.
• Brachytherapy: Utilizing iodine-125 and palladium-103. This method results in reduced complications and lower morbidity compared to some other treatments.
• Androgen Deprivation Therapy (ADT): Involves various approaches to reduce testosterone levels.
  • Orchidectomy: Bilateral orchidectomy eliminates a major source of testosterone production.
  • Medical Castration: Achieved through different medications:
    • LHRH agonists via monthly, 3-monthly, or 6-monthly depot injections.
    • Cyproterone acetate.
    • Antiandrogens like Flutamide, Bicalutamide, Enzalutamide.
    • LHRH antagonist known as Degarelix.
    • Abiraterone, which blocks testosterone production from one of its precursors.
    • Taxane chemotherapy might be considered as well.

Prostate Neoplasms-Repeats

Q1: A 55-year-old male presents with acute urinary retention .List the differential diagnosis. What steps would you take to relieve him of his condition? How would you investigate this patient to reach at the diagnosis? (2015)

Q2: A 75-year-old male presented with acute retention of urine with hematuria. On per rectal examination, hard nodular prostatic enlargement is present. (2017)
(i) Discuss the diagnosis and its investigation.
(ii) Outline the management of the above-mentioned condition. 

Q3: What are the various causes of retention of urine? Describe the management of a case of retention of urine due to stage II benign hypertrophy of prostate. (1994)

Q4: Write short notes on Non-surgical management of BPH (Benign Prostatic Hyperplasia). (2001)

Q5: What are the clinical features and plan of assessment of a patient of benign prostatic hypertrophy? Discuss its medical management and indications for surgery. (2007)

Q6: List the causes of hematuria. Briefly discuss the management of carcinoma of the prostate. (2015)

Q7: Discuss the hormonal management of a 70-ycar-old man with carcinoma prostate. (2010) 

Q8: Write short notes on Management of Cancer of Prostrate. (2002)