80. Prostate (4%)

Question 1

En présence d’un cancer de la prostate, informez-vous des symptômes de quoi ?

Answer 1

d’une récidive locale ou d’envahissement métastatique.

Question 2

Describe screening PSA

Answer 2

• No screening recommended for all ages as per Canadian Task Force
• Discuss PSA if > 10 years life expectancy
• After discussing : start at 50, 45 if high risk

Question 3

Describe PSA values

Answer 3

Think 10-20
* PSA < 10 lo risk, routine
* PSA 10-20 semi-urgent (urgent if abnormal prostat)
* PSA >20 high risk urgent, refer urology for prostate bx

Question 4

Name risk factors : BPH

Answer 4

• Age
• obesity
• diabetes
• family history

Question 5

Name Complications : BPH (5)

Answer 5

• UTI
• bladder stone
• urinary retention
• hydronephrosis
• renal failure

Question 6

Name : DDx Urinary Retention (8)

Answer 6

• BPH
• Prostate CA
• Urethral stricture
• Urethral diverticulum (women)
• Medication
• Infection
• Trauma
• Neurological (Spinal cord injury)

Question 7

Describe voiding sx (5)

Answer 7

• predominant in bladder outlet obstruction (BOO) secondary to BPH
• Hesitancy
• Weak Stream
• Intermittence
• Straining

Question 8

Describe Storage sx (5)

Answer 8

• r/o overactive bladder (OAB)
• Urgency
• Frequency
• Urgency Incontinence
• Nocturia

Question 9

Describe Postmicturition sx (2)

Answer 9

Dribbling, Incomplete Emptying

Question 10

Describe : Management of nocturnal polyuria (3)

Answer 10

• 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

Question 11

Describe : Management of BPO

Answer 11

Follow IPSS, DRE, PSA (if on 5-ARIs) as response to treatment

Question 12

Describe investigations for prostate sx (3)

Answer 12

• Urinalysis +/- culture (r/o infection)
• PSA
• PVR if considering anticholinergics (eg. storage symptoms suggesting OAB)

Question 13

Name score to follow prostate symptoms

Answer 13

International Prostate Symptom Score (IPSS)

Question 14

Describe scoring : International Prostate Symptom Score (IPSS)

Answer 14

• 0 to 7 points: Mild symptoms
• 8 to 19 points: Moderate symptoms
• 20 to 35 points: Severe symptoms

Question 15

Describe management BPO sx if MILD (Symptom score <8, or if not bothered by symptoms) (7)

Answer 15

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

Question 16

Describe management BPO sx if MOD-SEVERE (Symptom score <8, or if not bothered by symptoms) (5)

Answer 16

• For smaller prostates, Alpha-blockers alone = Tamsulosin (Flomax) (avoid in sulfa allergy)
• For larger prostates (eg. DRE>25mL or PSA>1.5 ng/dL), combination therapy more effective with **Inhibiteurs de la 5-alpha réductase ** = Finasteride (Proscar)
• After 6-9 months of combination therapy, consider stopping alpha blocker
• Consider addition of PDE-5 inhibitors for LUT symptoms, eg. Tadalafil (Cialis)
• Consider addition of anticholinergics (eg. Tolterodine, Oxybutynin, Mirabegron) especially if component of OAB (storage symptoms), caution if PVR >250mL

Question 17

Describe : Tamsulosin (Flomax) (5)

Answer 17

• Alpha-blockers
• Rrelax smooth muscle
• Onset 3-5 days
• Avoid in sulfa allergy
• Side effects: Orthostatic hypotension, retrograde ejaculation (ejaculation failure)

Question 18

Describe : Finasteride (Proscar) (4)

Answer 18

• 5-alpha reductase inhibitors
• Inhibit conversion of testosterone to DHT
• Onset 4-6 months
• Side effects: Decreased libido, erectile dysfunction

Question 19

When to refer for prostate sx ?

Answer 19

• 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)

Question 20

When to suspect prostate cancer ?

Answer 20

• PSA<10 low risk (routine), PSA 10-20 (semiurgent referral), PSA>20 high risk (urgent)
• Upgrade urgency if DRE abnormal (firm or irregular)

Question 21

Describe : Acute Bacterial Prostatitis

Answer 21

Tender prostate

Question 22

Name common bug : Prostitis

Answer 22

E.coli

Question 23

Describe : Chronic Bacterial Prostatitis

Answer 23

Intermittent UTIs with same bacteria

Question 24

Describe : Chronic Prostatitis / Chronic Pelvic Pain Syndrome

Answer 24

• Inflammatory Chronic Prostatitis
• Non-inflammatory Chronic Prostatitis

Question 25

Describe : Asymptomatic Inflammatory Prostatitis

Answer 25

Leukocytosis

Question 26

Name sx : Prostatitis (5)

Answer 26

* Fevers, chills * Dysuria * Pelvic or perineal pain * Cloudy urine * Obstructive symptoms

Question 27

Describe physical exam : Prostitis (4)

Answer 27

* Prostate warm * Firm * Edematous * Exquisitely tender (avoid massaging)

Question 28

Describe investigations : Prostitis (3)

Answer 28

* Urinalysis * Urine culture and-sensitivity testing, * Gono/chlam urethral/rectal PCR and culture

Question 29

Describe tx : Acute/Chronic Bacterial Prostitis (4)

Answer 29

* **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**

Question 30

Describe tx : Non-infectious Prostitis

Answer 30

Target UPOINTS * Urinary (storage/voiding symptoms) = Tamsulosin 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

Question 31

Nommez des classes pharmacologiques utiles dans le traitement des symptômes prostatiques HPB (7)

Answer 31

* Alpha bloquants (Flomax) * Inhibiteurs 5-alpha reductase (Proscar) * Combo des deux * Antimuscariniques * Agonistes beta3 (mirabegron) * Inhibiteurs 5-alpha reductase longue action (tadalafil) * Desmopressine

Question 32

Avant de partir, M. Thibodeau vous demande une ordonnance pour un médicament couramment utilisé pour traiter la dysfonction érectile. Depuis le décès de son épouse, il s'intéresse moins aux relations et sa nouvelle amie pense qu'un médicament pourrait l'aider. Qu'allez-vous lui suggérer?

Answer 32

* 1. Psychothérapie / éliminer autre cause psychogénique de perte de libido * 2. Rechercher autre cause organique de perte de libido