DISEASES OF THE PROSTATE GLAND

The common diseases of the prostate gland are benign enlargement, carci-noma and prostatitis. Prostate-specific antigen (PSA) is a glycoprotein that is expressed by normal and neoplastic prostate tissue and secreted into the bloodstream. Serum concentrations can be increased in any of these condi-tions and also after perineal trauma and mechanical manipulation of the prostate (cystoscopy, prostate biopsy or surgery). Serum PSA concentration >4.0 ng/mL is abnormal and can be due to benign disease or cancer. However, prostate cancer is present in 50% of men with a serum PSA >10 ng/mL.

Benign enlargement of the prostate gland

Benign prostatic enlargement (hypertrophy, BPH) is common particularly after the age of 60 years. There is hyperplasia of both glandular and connective tissue elements of the gland. The aetiology is not known.

Clinical features

Frequency of micturition, nocturia, delay in initiation of micturition and post-void dribbling are common symptoms. Acute urinary retention or retention with overflow incontinence also occurs. An enlarged smooth prostate may be felt on rectal examination.

Investigations

Serum electrolytes and renal ultrasonography are performed to exclude renal damage resulting from obstruction. Prostate cancer may present with similar symptoms. Serum PSA may be elevated in benign disease but an elevated value is usually an indication for specialist referral and prostate biopsy.

Management

Patients with mild symptoms are managed by ‘watchful waiting'. Selective α1-adrenoceptor antagonists, such as tamsulosin, relax smooth muscle in the bladder neck and prostate producing an increase in urinary flow rate and an improvement in obstructive symptoms. The 5α-reductase inhibitor finasteride blocks conversion of testosterone to dihydrotestosterone (the androgen responsible for prostatic growth) and is an alternative to a-antagonists, particularly in men with a significantly enlarged prostate. Patients with acute retention of urine or retention with overflow require urethral catheterization or, if this is not possible, suprapubic catheter drain-age. Further management is then with prostatectomy or a permanent catheter.

Prostatic carcinoma

Prostatic adenocarcinoma is common, accounting for 7% of all cancers in men. Malignant change within the prostate is increasingly common with increasing age, being present in 80% of men aged 80 and over. In most cases these malignant foci remain dormant.

Clinical features

In developed countries many patients now present as a result of screening for prostate cancer by measurement of serum PSA although this is not widely recommended (see later). Presentation is also with symptoms of bladder outtlow obstruction identical to those of benign prostatic hypertrophy. Occa-sionally, presenting symptoms are due to metastases, particularly to bone. In some cases malignancy is unsuspected until histological investigation is carried out on the resected specimen after prostatectomy. Rectal examination may reveal a hard irregular gland.

Investigation

The diagnosis is made using transrectal ultrasound of the prostate, elevated serum PSA (see above) and transrectal prostate biopsy. If metastases are present serum PSA is usually markedly elevated (>16 ng/mL). Endorectal coil MRI is used to locally stage the tumour.

Management

Microscopic tumour is sometimes managed by watchful waiting. Treatment of disease confined to the gland is radical prostatectomy or radiotherapy, both resulting in 80-90% 5-year survival. The treatment of metastatic disease depends on removing androgenic drive to the tumour. This is achieved by bilateral orchidectomy, synthetic luteinizing hormone-releasing hormone analogues, e.g. goserelin, or antiandrogens, e.g. cyproterone acetate.

Screening

Screening for prostate cancer by annual measurement of serum PSA and digital rectal examination reduces the mortality from prostate cancer but the benefit is small and there is the potential for overdiagnosis and treatment-related complications. Most major medical organizations world-wide do not recommend screening for prostate cancer.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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