Benign prostatic hypertrophy and prostate cancer: Clinical sciences

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Introduction 0:00–0:51

Benign prostatic hyperplasia or BPH refers to non malignant enlargement of the prostate gland caused by prostatic cell proliferation.
BPH is the leading cause of lower urinary tract symptoms in biologically male adults, especially after the age of 30. On the other hand, prostate cancer is a common malignancy that usually affects biologically male patients between 64 and 75 years of age.
While BPH and prostate cancer both present with urinary symptoms and are differentiated based on clinical and imaging findings.
BPH does not increase the risk of prostate cancer when a patient presents with a chief concern, suggesting BPH or prostate cancer first perform a focused history and physical examination when it comes to BPH, affected individuals typically report difficulty urinating a weak urine stream and occasionally nocturia or urinary incontinence.

H&P 0:51–1:55

Digital rectal examination or DRE often reveals a firm, symmetrically enlarged prostate. With these findings, you should suspect BPH.
Here is your first clinical pearl. Keep in mind that DRE can only detect prostatic hypertrophy once the prostate volume reaches 50 mL or more.
Whenever a patient presents with lower urinary tract symptoms, remember to perform a neurologic examination by assessing motor and sensory function of the pelvic region and lower extremities to rule out other causes.
Now, once you suspect BPH, order a urinalysis to rule out other urinary tract pathology such as infection and consider ordering a prostate specific antigen or psa level.

BPH 1:55–3:23

Here's a clinical pearl. While PSA testing has a limited ability to accurately predict urinary retention or prostate size in patients with BPH results might be useful when determining treatment, using shared decision making, be sure to discuss the risks and benefits of PSA testing with your patient.
Ok. In addition to lab testing, consider ordering a post void residual or PVR scan.
This test measures the amount of urine remaining in the bladder after voiding to look for evidence of urinary retention.
Additionally, order a transrectal ultrasound which can assess prostate size more accurately than a dre. If your patient has no co existing urinary tract pathology, the urinalysis will be negative for bacteria, protein blood white blood cells and glucose.
However, psa levels might be elevated and PVR might indicate mild to moderate urinary retention. Transrectal ultrasound typically reveals an enlarged prostate which confirms BPH.
Next. To determine an appropriate treatment plan.

Assess Symptom Severity - IPSS 3:23–4:23

You'll need to assess your patient's symptom severity to do this. Have your patient use the international prostate symptom score or IPSS, a self administered validated metric that predicts the severity of urinary retention.
This metric was previously called the American Urological Association. Symptom index.
Vi pss questionnaire assesses the frequency of seven specific BPH symptoms including incomplete bladder emptying, urinary frequency, hesitancy and urgency, weakness of the urinary stream, straining with urination and nocturia.
IPSS also assesses a patient's quality of life to determine symptom severity. The score ranges from 0 to 35 with higher scores predicting a greater severity of urinary retention.
Now, if the IPSS score is less than eight diagnose mild BPH. Here, treatment primarily consists of behavioral and lifestyle modifications to alleviate symptoms.

Mild BPH 4:23–5:00

For example, your patient can reduce urinary frequency and nocturia by limiting fluid intake before bedtime or travel and by reducing consumption of caffeine and alcohol.
Since both have a diuretic effect, finally, be sure to recommend regular physical activity, pelvic floor, muscle training and weight loss.
If indicated. On the other hand, if the IPSS score is between eight and 19, your patient has moderate BPH.

Moderate BPH 5:00–7:40

In this case, treatment includes behavioral and lifestyle modifications combined with pharmacologic therapy for symptom reduction.
First line medications for BPH include alpha blockers like tamsulosin and phosphodiesterase five or PDE five inhibitors like Tadalafil.
Both medications relax the bladder and prostate muscles which improves urine flow. Now, if these medications do not improve symptoms, consider starting a five alpha reductase inhibitor like finasteride or an anticholinergic like Solifenacin.
Alternatively, you could start combination therapy which could consist of an alpha blocker with any of the other medications or a PDE five inhibitor combined with a five alpha reductase inhibitor.
Keep in mind that five alpha reductase inhibitors are more effective for patients with moderate to severe symptoms and an enlarged prostate.
For this reason, you should only combine an alpha blocker with a five alpha reductase inhibitor if your patient is symptomatic and has a prostate volume greater than 30 mL on a transrectal ultrasound, a palpably enlarged prostate on digital rectal exam or a psa of 1.5 nanograms per milliliter or more time for a clinical pearl PDE five inhibitors like Tadalafil are often used to treat erectile dysfunction.
But since they can also effectively treat BPH, consider using them as a first line treatment for patients with both erectile dysfunction and BPH.
Here's a high heeled fact, patients who undergo cataract surgery while taking alpha blockers like tamsulosin are at increased risk of intraoperative floppy iris syndrome or ifis this complication occurs when the iris becomes flaccid and prolapses through the incision site during cataract surgery, which increases the risk of serious complications like retinal detachment before starting an alpha blocker.
Find out if your patient requires cataract surgery and if they do wait until after surgery to start the alpha blocker using shared decision making with the patient and their ophthalmologist.
Finally, if the IPSS score is 20 or greater diagnose severe BPH, just like patients with moderate BPH, those with severe BPH should begin behavioral and lifestyle modifications combined with pharmacologic therapy.

Severe BPH 7:40–8:11

Additionally, some individuals may benefit from surgical intervention such as prostatectomy or transurethral resection of the prostate, also known as turp all right now that we've discussed BPH.

Suspect Prostate Cancer 8:11–10:00

Let's move on to prostate cancer. Affected individuals often experience difficulty urinating but some also report weight loss, night sweats or a family history of prostate cancer.
Other patients are asymptomatic but are found to have persistently elevated psa levels. Physical exam may reveal prostate nodules or asymmetry with these findings.
You should suspect prostate cancer. Here's a high yield fact, patients are at an increased risk for prostate cancer if they have a BRCA one or BRCA two, germline mutation, a first degree relative who died of prostate cancer.
A first degree relative who was diagnosed before 60 years of age or a family history of Lynch syndrome. A genetic condition associated with multiple malignancies including colorectal ovarian and prostate cancer.
Let's follow that up with the clinical pearl psa testing and digital rectal examination should not be used to routinely screen for prostate cancer since routine screening has not been shown to decrease mortality and false positive results can lead to unnecessary biopsy and treatment.
Instead for patients ages 55 to 69 use shared decision making to weigh the risks and benefits of screening and offer screening to those who requested it.
Additionally, you can use validated online screening tools to identify patients with a higher risk for prostate cancer who may benefit from further screening.
Now, once you suspect prostate cancer order a PSA level as a baseline to compare with post treatment levels, also obtain a multiparametric MRI or MP MRI of the prostate to detect any clinically significant prostate lesions and to help guide the biopsy, then obtain a transrectal ultrasound, guided prostate biopsy.

Prostate Cancer 10:00–11:03

With pathology results typically show a PSA that is elevated and MPMRI demonstrates a prostatic lesion suspicious for cancer pathology will confirm a clinically significant malignancy such as adenocarcinoma with these findings diagnose prostate cancer.
Here's another clinical pearl. If your patient's life expectancy is greater than 10 years, consider ordering a biopsy if psa levels are elevated or if you detect a palpable prostate abnormality.
Now, once you diagnose prostate cancer, obtain oncology and urology consultations to determine a treatment plan which may include surveillance radiation therapy or prostatectomy.

Prostate Cancer - Treatment 11:03–11:18

All right, as a quick recap BPH is typically identified through clinical findings, psa levels and imaging patients with mild, moderate and severe PPH should begin behavioral and lifestyle changes for symptom reduction.

Review 11:18–12:22

While those with moderate and severe BPH also benefit from pharmacologic therapy. First line medications include alpha blockers and PDE five inhibitors.
While second line options include five alpha reductase inhibitors, anticholinergics or combination therapy. Patients with severe BPH may also require surgical intervention.
On the other hand, if signs and symptoms suggest prostate cancer obtain psa levels. MP MRI and a prostate biopsy.
Once you diagnose prostate cancer, obtain oncology and urology. Consultations for surveillance radiation therapy or prostatectomy as indicated