Prostate cancer and PSA testing

  • Prostate is a small walnut sized organ present in men and is the part of male reproductive organ. It helps in the male fertility. Normal prostate size varies from 15-20 gm.
  • Prostate cancer is the most common cancer in men after skin cancer.
  • PSA (Prostate specific antigen) is the blood test which is specific for the prostate.
  • Though PSA is organ specific, it is not disease specific.
  • PSA is raised in many conditions such as prostatitis (prostate infection), prostate cancer, prostate abscess, BPH (benign prostate hypertrophy), acute retention of urine, urine infection, hematuria, prostate surgery etc.
  • Normal PSA value range from 0-4 ng/ml for an average sized prostate and its upper range value corresponds to the advanced patient age.
  • PSA is used for screening of prostate cancer as it is raised in these patients.
  • Raised PSA need thorough evaluation to rule out any other cause of elevation of PSA other than prostate cancer. These tests include DRE (digital rectal examination), urine routine/culture.
  • Absence of urinary infection or in an asymptomatic men with no prior urologic surgery, raised PSA suggests the possibility of harbouring prostate cancer and need further workup for same. These tests include mpMRI (Multiparametric MRI) prostate if PSA is more than 4 ng/ml and less than 10 ng/ml.
  • Any patients with raised PSA and having prostate which is hard on DRE or harbouring nodule, need prostate biopsy directly. Also, patient with PSA more than 10 ng/ml or more than 4 ng/ml and MRI showing high suspicion for prostate cancer need biopsy of prostate.
  • Free PSA (fPSA) is often useful for patients having PSA in range between 4-10 ng/ml. This blood test tells about the risk of prostate cancer in such patients.
  • Final diagnosis is with prostate biopsy in men having raised PSA and is done by the TRUS (Transrectal Ultrasound) under local anaesthesia.

Male infertility

  • Nearly one in six couple unable to conceive after one year of marriage.
  • Male infertility contributes nearly 40% part in the couple’s infertility.
  • Initial evaluation consists of detailed history, physical examination for testes, vas deferens, varicocele.
  • A simple semen analysis gives information for future direction of investigation and management.
  • Management of infertility may include simple smoking cessation, healthy lifestyle, hormone therapy, varicocele surgery, need for IUI, IVF or ICSI.
  • Many couples with male infertility as a cause, can still have their own child with one of other method of assisted reproductive techniques such as IVF and TESA/TESE with ICSI.

Urinary tract infection (UTI)

  • A urinary tract infection (UTI) is an infection in any part of the urinary system — kidneys, ureters, bladder and urethra.
  • Most commonly it involves the bladder and urethra.
  • Kidney infections are more serious.
  • Women are affected more commonly than men. These infections are typically treated with antibiotics along with other surgical intervention if required.

Symptoms

  • Burning micturition
  • Frequent urination
  • Lower abdominal pain
  • Passing cloudy foul smelling urine
  • Persistent urge to pass urine
  • Passing blood in urine

UTI types

Organ involvedSymptoms
Kidney (acute pyelonephritis/renal abscess/pyonephrosis/emphysematous pyelonephritis)Flank pain on involved side
Fever with chills
Nausea
Vomiting
Tenderness on palpation
Bladder (cystitis)Lower abdominal pain
Frequent small volume urination
Burning micturition
Blood in urine
Prostate (Prostatitis/abscess)Fever with chills
Burning micturition
Pus in urine
Urethra (Urethritis)Pus discharge
Burning micturition

Causes of UTI

  • Main portal of microbial entry causing UTI is through the urethra.
  • Kidney infections sometimes occur secondary to bloodstream infections.
  • Women are more prone to infections due to close proximity of urethra to anus and short urethra length.

Risk factors leading to UTI

  • Chronic indwelling catheter
  • Poorly controlled diabetes mellitus
  • Women gender
  • Urinary tract abnormality
  • Any recent urological surgery
  • Stone disease

Prevention

  • Daily fluid intake of 2.5-3.0 litre.
  • Drinking cranberry juice prevents UTI.
  • After passing urine or bowel movement, women should clean from front to back.
  • Empty the bladder after intercourse.
  • Person developing infection after sexual intercourse should use barrier method.

Diagnosis

  • Urine routine test
  • Urine culture and sensitivity test- this test tells us which bacteria is causing the infection and which medicine will be most appropriate for that bacterial infection.
  • Imaging test in form of Ultrasound/CT scan as per need.
  • Cystoscopy – in case of recurrent UTI of lower tract (bladder, urethra), to look for the source of infection. 

Treatment

  • Antibiotics are mainstay of treatment for urinary tract infections.
  • Simple uncomplicated infections such as urethritis, cystitis are usually treated with oral antibiotics such as fosfomycin, cephalexin trimethoprim/sulfamethoxazole etc. Other supportive medicines for burning and frequent urination are often prescribed.
  • For complicated infections such as acute pyelonephritis, renal abscess, emphysematous pyelonephritis, hospitalisation intravenous antibiotics are often required. 
  • Surgical intervention such as pus drainage with pigtail, DJ stent placement in kidneys etc may be required. 

Recurrent infections

  • Low dose long term oral antibiotic may be required.
  • Single dose oral antibiotic after sexual intercourse, if your infections seems to related to sexual activity.
  • Vaginal estrogens in postmenopausal women.

Varicocele – common entity of male infertility

What is a varicocele?

Varicocele is the abnormal dilatation of testicular veins which become tortuous and enlarged. This condition is mostly present on the left side.  

How does varicocele develop?

Testis blood return through testicular vein requires a valve mechanism to prevent the backflow of blood. The incompetence of this valvular mechanism leads to the development of varicocele. It is seen commonly on the left side due to anatomical variation. Isolated right side varicocele may represent an underlying right kidney tumor.  

What are the symptoms of varicocele?

Varicocele can be asymptomatic or present with

  1. Dull aching/dragging pain or discomfort in groin and scrotum
  2. Scrotal enlargement
  3. Small testis same side

Is having varicocele worrisome?

Varicocele is present in up to 15% of adult men. Not all have symptoms due to their presence. People can have dull aching or dragging pain in the scrotum. Varicocele is the common cause of infertility.  Varicocele can affect testis size and semen parameters. Up to 30-40% of patients with primary infertility (never having normal fertility) and 60-70%  with secondary infertility (having prior normal fertility) are diagnosed to have varicocele as the cause of infertility. Long-standing varicocele can also affect testosterone production.

How to diagnose this condition?

Diagnosis is generally made examining scrotal contents with the patient in standing position. Ultrasound doppler may be required to look for testis atrophy and early-stage varicoceles. Isolated right-sided varicocele warrant doing an ultrasound of the kidney.

How can I prevent varicocele?

Since the cause of varicocele is largely determined by familial and genetic factors, no preventive measures are beneficial.

Is there any severity grade of varicocele?

Varicocele is graded into 3 grades as the enlargement of veins increases.  

Grade 1 – palpable only on Valsalva maneuver (taking a deep breath and holding it while bearing down) or diagnosed on ultrasound

Grade 2 – palpable on clinical examination

Grade 3 – visible veins are seen in the skin of the scrotum

Which patients need treatment?

Not all patients require treatment.  They need treatment if having

  1. Persistent pain
  2. Infertility with abnormal semen parameters
  3. Small-sized testis 
  4. Infertile patient planning for assisted reproductive techniques

How varicocele causes infertility?

Normal sperm production from testes requires 2-3 degrees less temperature. Varicocele increases intra-scrotal temperature due to the pooling of blood.  The most common semen abnormalities seen are oligospermia (decrease sperm count) and asthenospermia (decrease sperm motility).   

What are the treatment options for varicocele?

  1. Conservative measures like tight scrotal or a jockstrap may alleviate pain in some patients with low-grade varicocele.
  2. Microsurgical varicocelectomy  – This is the most common surgical procedure employed. In this daycare procedure with the patient under spinal anesthesia, a small incision (2-3 cm) is made in the lower groin region to get access to the cord of testis which harbors the enlarged tortuous testicular veins and is then carefully ligated individually under microscopic magnification.  
  3. Laparoscopic ligation – In this surgery, the enlarged testicular vein is approached through the abdomen with the patient in general anesthesia.
  4. Embolization – In this non-surgical procedure, the enlarged vein is blocked with small metal coils. The procedure is conducted by passing a small catheter through the groin or the neck. This avoids any surgical incision but the risk of varicocele recurrence is high.

What are the risks of surgery?

Risks with varicocele surgery are its recurrence and hydrocele  (fluid collection in the scrotum) formation. Both these risks are lowest with microsurgical varicocelectomy surgery.

What to expect after surgery? If surgery is done for abnormal semen parameters, 60-80% of patients find improvement in their semen analysis. In infertile patients, nearly 40-50 % can impregnate a woman successfully in one year.

Prostate cancer

INTRODUCTION

  • Prostate is a small walnut-shaped gland in males situated below the bladder in front of the rectum.
  • Prostate cancer is the most common cancer among men (after skin cancer).
  • Prostate cancer is the cancer in prostate gland.
  • Many prostate cancer grow slowly and remain confined to prostate gland, however, few prostate cancer grows rapidly and present in advanced state. Treatment depends upon the stage of prostate cancer.

SYMPTOMS

  • Weak urinary stream

• Difficulty in passing urine

  • Frequent urination
  • Blood in urine
  • Blood in semen
  • Bony pains
  • Loss of weight and appetite
  • Erectile dysfunction

Risk factors

•Older age- Prostate cancer is more common after 50 years of age.

•Familial factors – more common in a person whose relative such as father or brother has prostate cancer.

•Race – black race has more incidence of prostate cancer compared to white race.

•Genetic factors – rarely, few genetic FACTORS lead to development of prostate cancer.

•Obesity- obese people are more prone to development of prostate cancer.

Screening

•Most urologist encourage men after 50 years to undergo screening for prostate cancer which include DRE (digital rectal examination) and serum PSA (prostate specific antigen) measurement.

diagnosis

•DRE – prostate gland is felt through rectum and checked for any nodule or hardness of gland which is suspicious for cancer.

•Serum PSA – normal value in average sized prostate vary from 0-3 ng/ml. Increased PSA level suggests possibility of prostate cancer.

•MRI prostate – in suspicious cases with PSA 4-10 ng/ml, multiparametric MRI prostate is advisable. it tell the doctor about the estimated risk of prostate cancer in that patient.

•TRUS biopsy – final diagnosis of prostate cancer is made on prostate biopsy. systematic 12 core prostate biopsy is taken by ultrasound guidance. Severity of disease is also assessed by Gleason scoring on biopsy.

CANCER STAGING

•Staging of prostate cancer is done after checking the level of serum PSA, findings on DRE and biopsy report.

•Staging of prostate cancer is done by PSMA PET scan or CT scan/MRI scan abdomen with bone scan. •After staging tests, patients are segregated into localised, locally advanced or metastatic prostate cancer.

TREATMENT

Treatment of prostate cancer depends upon various factors such as stage of disease, level of serum PSA, overall health of patient, life expectancy of patient.

Deferred treatment – very low risk cancers with minimal risk of spread may be kept on surveillance. Similarly, treatment may be avoided in patients with low life expectancy.

Surgery – surgical removal of prostate (robotic surgery- RARP/lap surgery) is done in patients with localised disease. Sometimes it is done in locally advanced prostate cancer in combination with other treatments. •Radiation therapy – radiation therapy involves use of high energy to kill the prostate cancer cells. It is achieved by radiations from external source (ebrt) or from internal source after placing radioactive source in the prostate gland (brachytherapy). 

Hormone deprivation therapy – this therapy is useful in advanced and metastatic stage to decrease the testosterone level in blood. Testosterone hormone helps in growth of prostate cancer. Many injections such as lhrh antagonist and agonist are available which helps in reduction of testosterone hormone level. This can also be achieved by bilateral orchiectomy (testes removal).

Chemotherapy – chemotherapy such as docetaxel/cabazitaxel is used in patients with metastatic prostate cancer.

Bone health – bisphosphonate injections are used to prevent osteoporosis associated with the metastatic prostate cancer.