🔑 Key Learning

  • BPH = benign enlargement of the transitional zone → LUTS (voiding + storage).
  • Prostate cancer = adenocarcinoma from the peripheral zone
  • DRE and PSA help differentiate.
  • Management:
    • Finasteride for volume
    • Tamsulosin for flow

Benign Prostatic Hyperplasia (BPH)

👀 Clinical Features

  • Voiding: SHIT = poor Stream, Hesitancy, Intermittency, Terminal dribble
  • Storage: frequency, nocturia, urgency, incontinence

✋ Examination

  • Smooth, symmetrical enlargement on DRE
  • Irregular or craggy → think malignancy

🧪 Investigations

  • PSA (can be mildly raised in BPH)
  • IPSS score:
    • 0–7: mild
    • 8–19: moderate
    • 20–35: severe
  • Imaging (e.g. MRI) if diagnostic uncertainty or haematuria

💊 Management

  • Voiding symptoms → 1st line: alpha-blocker (tamsulosin, alfuzosin)
  • Persistent symptoms despite alpha-blocker → Consider anticholinergic (e.g. oxybutynin)
  • Enlarged prostate → 1st line: 5-alpha-reductase inhibitor (finasteride, dutasteride)
    • Inhibit conversion of testosterone to DHT - reduces prostate volume  
    • NICE defines 'enlarged' referencing - estimated prostate > 30g / PSA > 1.4ng/ml 
  • Surgical: TURP if refractory to medical therapy

Prostate Cancer

📊 Background

  • Most common cancer in men
  • Acinar adenocarcinoma = most common subtype (peripheral zone)
  • Ductal adenocarcinoma = more aggressive
  • RFs: age, African-Caribbean ethnicity, FHx

👀 Clinical Features

  • Voiding LUTS: SHIT symptoms
  • Haematuria, dysuria
  • Back/bone pain → consider mets
  • Lethargy
  • Erectile dysfunction - always check PSA

✋ Examination

  • Nodular, irregular, craggy or asymmetrical prostate on DRE
    • DRE sensitivity for prostate cancer = 'very poor' in the absence of a raised PSA
    • A gland that feels normal does not exclude a tumour.

🧪 Investigations

  • PSA
  • 1st line imaging: MRI prostate
  • Biopsy: TRUS or transperineal
  • Staging: CT TAP ± PET

🔁 2WW referral

  • Refer using suspected cancer pathway (2WW) if prostate feels malignant on DRE.
  • Consider referring patients with possible symptoms of prostate cancer using a suspected cancer pathway if their PSA is above the threshold for their age in below table 3. 
Age (years) PSA Threshold (ng/mL)
< 40 Use clinical judgement
40–49 > 2.5
50–59 > 3.5
60–69 > 4.5
70–79 > 6.5
> 79 > 20, or > 7.5 with symptoms of metastatic disease (e.g. bone pain, fatigue, weight loss)

💊 Management

Local disease

  • Low-risk: active surveillance (PSA, MRI, biopsy)
  • Intermediate/high-risk:
    • Radical prostatectomy
    • Radiotherapy ± brachytherapy
    • SEs: ED, incontinence

Metastatic disease

  • Androgen deprivation therapy (ADT)
    • Bicalutamide (anti-androgen)
    • Goserelin (GnRH analogue)
  • Chemotherapy if hormone refractory

📝 Exam Clues & Clinchers

  • Smooth prostate + LUTS + mild PSA rise → BPH
  • Nodular prostate + LUTS + PSA significantly raised → cancer until proven otherwise
  • Back pain + LUTS + high PSA → mets

🔗 Useful Links and References

NICE guideline 131. Prostate cancer: diagnosis and management