The routine check-up

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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Problem 21 The routine check-up

A 65-old-man presents for a routine prostate check. He is otherwise healthy and takes no regular medication. There is no family history of prostate cancer. He has mild lower urinary tract symptoms (LUTS) with slightly reduced flow and mild hesitancy. He looks fit and abdominal examination is unremarkable. On digital rectal examination (DRE) the prostate gland feels enlarged with areas of induration on the right side. Perineal sensation and gross lower limb motor function are intact.

Q.1

What is the significance of his symptoms and physical findings?

It is explained to the patient that while he almost certainly has benign prostate hyperplasia some investigations should be considered. The pros and cons of screening are explained to the patient.

Q.2

What investigations would be appropriate and why?

His PSA is 8.1 ng/mL (normal <4.5 ng/mL) and the serum haematological and biochemical estimations within normal limits. His renal tract ultrasound showed a moderately enlarged prostate and trabeculations within the bladder consistent with chronic outflow obstruction.

Q.3

What is the significance of the results and examination findings and what should be done next?

The patient is advised to undergo a transrectal ultrasound guided (TRUS) biopsy of the prostate. This confirms the presence of a small focus of Gleason 3+3 = 6 prostate cancer in the right apex, one of the eight areas biopsied.

Q.4

What are the management options and issues?

Q.5

What is the rational for active surveillance?

The patient is reviewed at 3-monthly intervals with repeat PSA and DRE. After 12 months of active surveillance a further TRUS biopsy is performed and shows Gleason 3+3 = 6 prostate cancer. This time four of the eight areas biopsied show involvement with prostate cancer.

Q.6

What staging tests should be arranged?

A whole body bone scan is performed and is negative.

Q.7

What are treatment options and their side-effects?

Following consultations with the urologist, radiation oncologist and a prostate cancer support nurse, the patient decides to proceed with radical prostatectomy via the robotic approach. Twelve months post surgery, he remains well and his PSA remains undetectable. He is continent and able to achieve erection with the use of phosphodiesterase inhibitors.

Answers

A.1 Benign prostate hyperplasia is a common process in ageing males and accounts for most of the lower urinary tract symptoms in these patients. Incidence of prostate cancer also increases with age but it is unlikely the cause of this patient’s lower urinary tract symptoms. Early-stage prostate cancer rarely causes any symptoms and is usually picked up via screening.

Risk factors for prostate cancer include increasing age, family history, long-term exposure to high levels of testosterone as well as a diet high in saturated fat and animal protein. Having one first-degree relative with prostate cancer doubles the risk of developing prostate cancer; having two or more first-degree relatives increases the risk of prostate cancer by as much as fivefold.

A.2 Investigations should include:

• Serum prostate specific antigen (PSA).

• Midstream urine (MSU) – exclude any urinary tract infection.

• Serum biochemistry – to assess baseline renal function given his mild lower urinary tract symptoms (LUTS).

• Renal tract ultrasound – to assess for signs of urinary outflow obstruction.

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