1. Carcinoma of Bladder & Prostate BPH

2. Urinary Tract

3. Bladder Outflow Obstruction (BOO)
A blockage at the base of the bladder that reduces or prevents the flow of urine into the urethra
Most commonly caused by BPH or prostate cancer

4. Other causes Primary bladder neck obstruction
young to middle aged men (rare in women) with bladder neck dysfunction
Poorly understood
Urethral stricture
Catheterisation
Previous transurethral surgery
STIs e.g. gonorrhoea and syphilis
Bladder calculi

5. Lower urinary tract symptoms
Obstructive
Irritative
Poor stream
Frequency
Hesitancy
Urgency
Intermittent flow
Nocturia
Incomplete emptying
Terminal dribbling
Irritative sx may be secondary to BPH or intravesical pathology eg bladder cancer, uti and stones

6. Normal Prostate
4x3x2 cm 15g Exocrine gland Produces fluid portion of semen Role in controlling urine outflow
Prostate normally 4x3x2 weighs ~ 15g

7. Zones of the Prostate

8. BPH History Symptoms as previously described Affect on QoL?
Examination
Abdomen (retention) PR
= enlargement of the prostate with age

9. Investigations Urine dipstick and MC+S Bloods: U+E, PSA
Urine flow test
US of urinary tract
Cystoscopy for urethral stricture/bladder calculus
Urodynamics for complex cases

10. Management
Conservative
Medical
Surgical

11. Medical Surgical α1 adrenoceptor blockers e.g. tamsulosin
5 α reductase inhibitors e.g. Finasteride
TURP
Surgical

12. Complications of TURP General and specific
Early: septic shock, bleeding, transurethral syndrome
Late: secondary haemorrhage, strictures, impotence, recurrent prostatic regrowth, recurrent symptoms, retrograde ejaculation (65-85%)

13. Prostate Cancer
More common in men than women Most common male cancer (26% male cancer diagnoses in UK) Lifetime risk 1 in 9 for men in the UK Subclinical prostate cancer common in men over 50 Main risk factor increasing age- however ~25% of cases diagnosed in men <65

14. Presentation
Symptoms as described previously or reflect local invasion/distant mets
Role for screening?
Examination
Investigate as previously + Biopsy
Further imaging

15. Stages T0: no primary tumour identifiable
T1: tumour identified incidentally at TURP or with raised PSA
T2: palpable tumour without extracapsular extension
T3: spread beyond capsule; mobile tumour
T4: fixed or locally invasive tumour

16. Gleason 10 Score for histological grading
Prostate carcinomas often heterogenous and Gleason= sum of two most prominent grades
2= most well differentiated (best prognosis)
10= most poorly differentiated (worst prognosis)
Gleeson 10

17. Prognosis Gleason 4 or less: 10 year risk of local progression 25%
Gleason 5-7: 10 year risk of local progression 50%
Gleason > 7: 10 year risk of local progression 75%

18. Management

20. Medical
Gosrelin (Zoladex) (LHRH agonist)
Flutamide (antiandrogens)

21. Prostate Cancer Screening
Prostate cancer screening did not significantly decrease prostate cancer-specific mortality.
Only one study reported a 21% significant reduction of prostate cancer-specific mortality in a pre-specified subgroup of men aged 55 to 69 years.
There was no significant reduction in prostate cancer-specific and overall mortality.
Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and over-treatment are common and are associated with treatment-related harms.
Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue. Therefore, men who have a life expectancy of less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial.
No studies have examined the independent role of screening by digital rectal examination (DRE).
From a Cochrane review of prostate cancer screening by PSA

22. Carcinomas of Bladder 98% Transitional Cell Carcinoma
(remainder squamous cell carcinomas and adenocarcinomas)

23. Risk Factors Male > Female (3:1) Smokers > Non Smokers (4:1)
Rubber and dye industries- 10 to 25 year delay
Schistosomiasis

24. Presenting Symptoms Painless haematuria Recurrent UTIs
Diagnosis on cystoscopy

25. Staging Ta: confined to mucosa T1: invading lamina propria
T2: muscle involved
T3: perivesical fat involved
T4: invasion into adjacent organs/pelvic side wall
Grade I to III

26. Superficial Bladder Cancer
Ta or T1
~80% of cases
15% will progress to invasive cancers over 10 years
Treat by cystoscopy and endoscopic resection or diathermy
Adjuvant intravesical chemotherapy (e.g. mitocin)

27. Invasive Bladder Cancer
Radical cystectomy
Formation of ileal conduit or creation of a neobladder out of small bowel

28. Haematuria Local vs Generalised?
Local: infections, stones, trauma or tumours
Renal diseases e.g. glomerulonephritis
General (rarer): bleeding disorders, leukaemias, heamoglobinopathies and sickle cell disease

30. Microscopic vs Frank
Painful vs Painless
Beginning of otherwise clear stream vs throughout the stream
History of risk factors

31. Investigations MSU: dipstick, MC+S, cytology for TCC
Bloods: FBC (anaemia) U&E (renal function)
Radiology: US of renal tract, CT, KUB, CTIVU
Cystoscopy