85 y/o with back pain and constipation x 7 days
Patient will present as → a 65-year-old man who presents to the office with slowly progressive trouble urinating. He is still able to urinate but claims that his, "stream is weak." On physical exam, external genitalia have no notable abnormalities. On digital rectal exam, you note several rock-hard nodules on the patient's prostate.
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May present with urinary retention, decrease in urine stream strength, or back pain (metastatic disease)
- Urinary retention is more likely a sign of BPH
- Digital rectal exam: hard, nodular, enlarged and asymmetrical prostate
- PSA > 4 warrants further workup
- PSA > 10 suggestive of cancer
Risk factor:
- Risk factors include old age (most men > 80 have a focus of prostate cancer) and family history
PSA > 4 get an ultrasound with needle biopsy
PSA > 10 get a bone scan to r/o METS
Screening (lots of debate here)
- All men 50 years old
- 40 years old if first-degree family history or African American patient
The NCCN issued revised guidelines on prostate cancer screening
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- The NCCN recommends performing a baseline history (including family history, medications, and any history of prostate screening and disease) and physical examination.
- The clinician should then discuss the risks and benefits of a baseline PSA test with the patient, and consider a baseline DRE to identify high-risk cancers associated with a seemingly normal PSA.
- In patients with a normal DRE result, the NCCN recommends baseline PSA testing at age 45-49 years, with retesting at age 50 years in patients with a level below 0.7 ng/mL and annual or biannual retesting in those with a level of 1.0 ng/mL or higher.
- For patients aged 50-70 years with a normal DRE and a PSA below 3 ng/mL, the NCCN recommends retesting every 1-2 years.
- NCCN panel members were divided on the question of PSA thresholds that would prompt prostate biopsy: 2.5 ng/mL has been used, whereas 3 ng/mL is evidence-based and reduces the risk for overdetection; however, some panel members recommended considering the PSA level in the context of other risk factors rather than using a specific PSA cutoff.
- In selected cases, risk calculators could be used to stratify risk.
Radical Prostatectomy - Complication is Erectile Dysfunction!
- With Mets will need androgen deprivation therapy (leuprolide) if no meds then castration
- Monitor PSA should be less < 0.1
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Prostate cancer is the most common cancer among men, and typically occurs in men over the age of 65. It can initially present with symptoms similar to those seen in BPH, like dysuria, dribbling, urgency, hesitancy, and hematuria. Prostate cancer can metastasize, and often does so to bone, and a common site is the lumbosacral vertebrae. Patients can display fatigue and lower back pain. There are diagnostic tests if there is a clinical suspicion of malignancy, such as PSA, PAP, and digital rectal exam. The only definitive diagnostic test is via ultrasound-guided needle biopsy.
Prostate cancer assessment | Play Video + Quiz |
Leuprolide | Play Video + Quiz |
Question 1 |
Periodic rectal exams Hint: Many prostate carcinomas are contained within the gland, making it difficult to assess progression with a digital examination alone. | |
Transrectal ultrasonography Hint: Ultrasonography is used largely for staging disease, not monitoring disease progression. | |
Measurements of serum acid phosphatase Hint: Serum acid phosphatase is more predictive of metastatic disease than PSA measurement, but its use has largely been replaced by PSA. | |
Measurements of prostate-specific antigen |
Question 2 |
Squamous cell carcinoma found in the peripheral zone Hint: Squamous cell carcinomas constitute less than 1% of all prostate carcinomas | |
Squamous cell carcinoma found in the central zone Hint: 15%-20% arise in the central zone | |
Acinar adenocarcinoma found in the peripheral zone | |
Sarcoma found in the transitional zone Hint: 10%-15% arise in the transitional zone |
Question 3 |
1 | |
2 | |
3 | |
5 |

Question 4 |
Routine prostate-specific antigen (PSA) testing in men older than 75 years | |
Repeat PSA testing every 1-2 years in men aged 50-70 years with normal digital rectal examination (DRE) findings and PSA level below 3 ng/mL | |
Annual retesting in patients with a PSA level 0.5-0.7 | |
Prostate biopsy at a PSA level of 2 ng/mL |
Question 5 |
MRI and CT | |
Ultrasonography and CT | |
MRI and ultrasonography | |
PET and ultrasonography |
Question 6 |
External-beam radiation therapy | |
Robotic prostatectomy | |
Total androgen deprivation | |
Watchful waiting |
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