Prostate Basics for the Physician Assistant Exam
The Physician Assistant Exam will expect you to know the basic problem areas for the prostate. The three basic prostate problems you should be familiar are benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer.
Benign prostatic hyperplasia (BPH)
Benign prostate hyperplasia (BPH) occurs because the prostate gets so big it can block urinary flow by squashing the urethra. You see this condition in older men. Signs and symptoms include the following:
Difficulty initiating urinary flow
Nocturia (getting up several times a night to use the facilities)
Straining to go and leakage after voiding (the dreaded dribble)
Complete bladder retention if the blockage is severe enough
The treatment of benign prostatic hyperplasia varies, depending on symptom severity:
Medical treatment can include alpha blockers like terazosin (Hytrin), tamsulosin (Flomax), and finasteride (Proscar), which inhibit the enzyme 5-alpha reductase.
If the symptoms are severe, then urological intervention is needed, including a transurethral resection of the prostate (TURP).
Kidney obstruction secondary to benign prostatic hyperplasia is the most common cause of kidney failure in older men.
Prostatitis, or inflammation of the prostate gland, can present with a wide range of symptoms. Know whether you’re dealing with acute or chronic prostatitis:
Acute prostatitis: Acute prostatitis is usually caused by a bacterial process, most notably Gram-negative rods. A man with acute prostatitis presents with shaking chills, high fevers, back pain/perineal pain, and dysuria/urinary urgency. Laboratory abnormalities include significant pyuria. You would not perform a prostatic massage. Give antibiotics quickly after obtaining a urine culture.
Chronic prostatitis: Chronic prostatitis can be bacterial or nonbacterial. The nonbacterial form is thought to be a more inflammatory type of condition. This chronic form can also present with urinary urgency and/or dysuria, but it’s less likely to have the toxic presentation of the acute condition. Chronic recurrent prostatitis that does not get better may require surgical intervention.
Prostate cancer is a common form of cancer among older men, and you usually see it in men older than 40. The most common presentation consists of difficulty voiding. Suspect the condition if you see an elevated prostate-specific antigen (PSA) blood test. On digital rectal examination (DRE), the prostate may be big or asymmetric. The medical practitioner may or may not feel a nodule.
The gold standard of treatment for prostate cancer is prostatic biopsy, which can produce important histologic information, including the Gleason score. The Gleason score, which gives you a sense of the severity of the prostate cancer, is somewhat subjective. The pathologist evaluates the biopsied tissue and assigns a primary grade for the most affected tissue area and then gives a secondary grade for the next most affected area.
The grades go from Gleason Pattern 1 to Gleason Pattern 5. The first pattern means that the cancerous tissue is pretty normal, and Pattern 5 means that the prostate glandular tissue itself is difficult to identify. This is not good.
The primary and secondary grades are added up to give a Gleason score, which can range from 2 to 10. Generally, the higher the Gleason score, the more aggressive the cancer is. Higher grades require consideration of more invasive treatment than do the lower grades.
In addition to getting the Gleason score, staging prostate cancer is important. Staging can include CT scans of the chest, abdomen, and pelvis as well as a bone scan. Prostate cancer commonly metastasizes to bone; on lab work, one big tip-off to this is an elevated alkaline phosphatase.
The treatments for prostate cancer can vary. They can include external beam radiation treatments or brachytherapy seed implants. Hormonal therapy can also be done generally in widely metastatic disease. Surgical options include removal of both testes and prostatectomy.