A 78-year-old man develops prostate cancer and is also found to have metastases. He would like to have definitive treatment.
Which of the following is not an appropriate treatment?
Correct Answer D:
Patients with a locally advanced tumor or metastases may benefit from androgen deprivation by castration, either surgically with bilateral orchiectomy or medically with luteinizing hormone-releasing hormone (LHRH) agonists, such as leuprolide.
Radical prostatectomy (removal of prostate with adnexal structures and regional lymph nodes) is probably best for patients < 70 with a tumor confined to the prostate.
Most patients, regardless of age, prefer definitive therapy. Watchful waiting (choice D) may be appropriate for asymptomatic patients > 70 with localized prostate cancer, but it would be inappropriate in this symptomatic patient who definitely wants to try everything that can be done to treat his condition.
A 70-year-old man complains of increasing urinary frequency and dribbling. On physical examination, a digital rectal exam reveals a normal-sized prostate. The prostate specific antigen level is elevated at 14 ng/mL. Ultrasonography reveals a small hypoechoic area on the prostate measuring 5 x 9 mm.
Which of the following is the most appropriate next step?
Correct Answer B:
Measurement of serum levels of prostate-specific antigen (PSA) can be used to screen for prostate cancer. However, this substance can also be elevated in prostate hypertrophy. A transrectal ultrasound can identify lesions not palpable on rectal examination, and the area can be biopsied under ultrasound guidance.
In the treatment of benign prostate hyperplasia (BPH), which of the following is true?
In BPH, the prostate gland cells increase in number and eventually narrow the urethra that they surround.
This can lead to urinary problems such as frequency, hesitancy and retention. A digital rectal exam will show an enlarged prostate. A PSA level, urinalysis and prostate ultrasound are commonly obtained. Two main types of drugs are used to treat this.
Alpha adrenergic receptor antagonists (alfuzosin, terazosin) block receptors in the bladder neck and prostate to relax the smooth muscle, resulting in improvement in urine flow rate and reduction in symptoms of BPH.
The androgen DHT causes prostatic enlargement. 5 alpha reductase inhibitors (finasteride and dutasteride) inhibit conversion of testosterone to DHT, causing serum DHT levels to decrease. This reduces prostatic size and improves urinary symptoms.
A 75-year-old man with a history of nocturia has not micturated for the last 10 hours, and is complaining of severe lower abdominal pain.
The most likely cause is:
Correct Answer A:
Benign prostatic hyperplasia is nonmalignant adenomatous overgrowth of the periurethral prostate gland. Symptoms are those of bladder outlet obstruction, urinary frequency, urgency, nocturia, hesitancy, incomplete emptying, terminal dribbling, overflow incontinence, or complete urinary retention. Diagnosis is based on digital rectal examination, cystoscopy or transrectal ultrasonography.
During a comprehensive health evaluation a 65-year-old black male reports mild, very tolerable symptoms of benign prostatic hyperplasia. He has never smoked, and his medical history is otherwise unremarkable. Objective findings include an enlarged prostate that is firm and nontender, with no nodules. A urinalysis is normal and his prostate-specific antigen level is 1.8 ng/mL.
Based on current evidence, which one of the following treatment options is most appropriate at this time?
Watchful waiting with annual follow-up (choice A) is appropriate for men with mild benign prostatic hyperplasia (BPH). Prostate-specific antigen (PSA) levels correlate with prostate volume, which may affect the treatment of choice, if indicated. PSA levels > 2.0 ng/mL for men in their 60s correlate with a prostatic volume > 40 mL. This patient’s PSA falls below this level.
→ A recent high-quality, randomized, controlled trial found no benefit from saw palmetto (choice B) with regard to symptom relief or urinary flow after 1 year of therapy. The current guidelines do not recommend the use of phytotherapy for BPH.
→ Alpha-blockers (choice C) provide symptomatic relief in men whose disease has progressed to the point that they have moderate to severe BPH symptoms.
→ In men with a prostatic volume > 40 mL, 5 alpha-reductase inhibitors (choice D) should be considered for treatment.
→ Surgical consultation (choice E) is appropriate when medical therapy fails or the patient develops refractory urinary retention, persistent hematuria, or bladder stones.
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