Are diseases that affect urinary system including urinary incontinence, urolithiasis, benign prostatic hyperplasia, prostate cancer.
21.5.1 Prostatitis
It is an infection of the prostate caused by urinary or STI pathogens.
Diagnostic Criteria
- perineal, sacral or suprapubic pain
- dysuria and frequency
- varying degrees of obstructive symptoms which may lead to urinary retention
- sometimes fever
Investigations
- Urine analysis
- Urine culture
Pharmacological Treatment
Acute bacterial prostatitis
In men < 35 years or if there are features of associated urethritis (STI regimen):
D: Cefixime 400mg (PO) as a single dose
Followed by:
A: Doxycycline 100 mg (PO) 12 hourly for 7 days
In men > 35 years or if there is associated cystitis:
A: Ciprofloxacin 500 mg (PO) 12 hourly for 14 days
Referral to Urologist if
- No response to treatment
- Urinary retention
- High fever
- Chronic/relapsing prostatitis
21.5.2 Benign prostatic hyperplasia (BPH)
Benign prostatic hyperplasia is a noncancerous (benign) growth of the prostate gland.
Management of BPH depends on severity of symptoms according to International Prostate Symptom Score (IPSS)
Diagnostic Criteria
- weak, intermittent stream and urinary hesitancy
- Irritative (frequency, nocturia and urgency) voiding symptoms.
- Digital Rectal Examination reveals a uniform enlargement of the prostate.
- Urinary retention with a distended bladder may be present in the absence of severe symptoms, therefore it is important to palpate for an enlarged bladder during examination.
- Pelvic or transrectal USS confirms the prostate enlargement
- Prostatic specific antigen levels are within normal range
Non-Pharmacological Treatment
- Patients with mild symptoms should be put under watchful waiting (change of life style and regular follow up)
- Patients with severe symptoms should undergo surgery, transurethral resection of the prostate for prostate weighing up to 75 gms and those weighing more than 75gms should undergo open prostatectomy
- For patients presenting with urinary retention, insert a urethral catheter as a temporary measure while patient is transferred to hospital
- Remove drugs that prevent urinary outflow e.g. tricyclics and neuroleptics.
Pharmacological Treatment
Patients with moderate symptoms according to IPSS should be put under medical therapy unless opt for surgery.
Medical treatment of BPH includes alpha adrenergic blocker or 5 alpha reductase inhibitor or a combination of both
Adrenergic Alpha Blockers:
D: Tamsulosin (PO) 0.4 mg once daily
OR
S: Alfuzosin (PO) 10mg once daily
5-alpha Reductase Inhibitors
S: Finasteride (PO) 5mg once daily
OR
S: Dutasteride (PO) 0.5mg once daily.
Referral
All patients with BPH and associated commplications like recurrent UTI, Haematuria, renal insufficiency, hernia and urinary stones need surgery and should be referred to centres where specialized care can be offered.
21.5.3 Prostate cancer
Usually occurs in men over 50 years and is most often asymptomatic. Systemic symptoms, i.e. weight loss, bone pain, etc. occurs in 20% of patients. Obstructive voiding symptoms and urinary retention are uncommon.
Diagnostic Criteria
- The prostate gland is hard and may be nodular on digital rectal examination and/or PSA elevation
- Verification of prostate cancer is by prostate core biopsy
- As the axial skeleton is the most common site of metastases, patients may present with back pain or pathological fractures.
- Lymph node metastases can lead to lower limb lymphoedema.
- Serum prostate specific antigen (PSA) is generally elevated and may be markedly so in metastatic disease.
- Non-pharmacological treatment
- Wathful waiting- low risk patients with short life expectancy
- Active surveillance-lowest risk of cancer progression and more than 10 years life expectancy
- Radical prostatectomy- patients with localized cancer and life expectancy more than 10 years
- Surgical Androgen deprivation therapy (bilateral orchidectomy) for advanced prostate cancer
Pharmacological Treatment
Medical androgen Deprivation Therapy is offered in patients with advanced disease, PSA levels more than 50 ng/ml, poorly differentiated tumour and in those who cannot receive any form of local treatment.
Luitenising hormone releasing hormone (LHRH) Agonists
S: inj Goserelin 3.6 mg subcutaneous every weeks or 10.8mg every 12 weeks
OR
S: Bicalutamide (PO) 50–150mg once daily
Castrate resistant prostate cancer
S: Docetaxel 75mg/m2 every 3 weeks
Referral
All patients with suspected cancer (For more detail refer to the Malignant diseases section)
