Prostate Abnormality
Prostate Abnormality: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
❑ Benign prostatic hypertrophy
❑ Acute bacterial prostatitis
❑ Chronic prostatitis
❑ Adenocarcinoma
❑ Prostatic calculus
❑ Prostatic abscess
Diagnostic Approach
History helps in risk stratification: Men with a first degree relative with prostate cancer have a 2 to 3 fold increased incidence of prostate cancer. With 2 first degree relatives, this increases 5 to 8 fold.
The normal prostate is heart-shaped with a median raphe and a mass of 20 to 25 g. Carefully examine the posterior surfaces of the lateral lobes because this is where most prostate cancer originates. In screening for prostate cancer, digital rectal examination (DRE) looking for nodules, induration, or asymmetry may help to calibrate PSA values in the “gray zone” of 4 to 10. For example, a large gland may offer an explanation for a mildly elevated PSA, but a small gland or one with induration or asymmetry should heighten suspicion of prostate cancer. The positive predictive value for prostate cancer of an abnormal finding on DRE is 15% to 30%, increasing odds 1.5- to 2-fold. Because of low sensitivity, the value of a negative DRE to rule out prostate cancer is low. Men with an abnormality on DRE and a PSA ,4 still have a probability of prostate cancer of 12%, so biopsy is usually recommended. Examination followed by biopsy of any prostate nodule is the appropriate tactic because the clinical examination alone is not accurate enough in distinguishing benign causes from adenocarcinoma.
New suspicious findings on DRE in a patient with an initial negative baseline helps to select for aggressive tumors. Cancer found based on the first DRE has a 5 year prostate cancer mortality of 3% and 10 year mortality of 14%. Cancer found on a subsequent DRE has mortalities of 19% and 43% respectively.
Clinical Findings
Benign prostatic hypertrophy In BPH the prostate is diffusely enlarged and firm (consistency of the tip of the nose). The gland may be slightly asymmetric, but architectural landmarks are maintained. There may be local induration from fibrous tissue. Obstructive symptoms usually begin early, characterized by decrease in caliber and force of stream and by hesitancy.
Acute bacterial prostatitis Dysuria, urgency, frequency, fever, and a dull ache in the perineum are the main symptoms. The gland is boggy and tender to palpation.
Chronic prostatitis It is characterized by mild persistent urethritis, with early morning mucoid secretions in the urethra and with a moderately tender to nontender gland.
Adenocarcinoma A palpable hard nodule, flat induration, or obliteration of the raphe or lateral sulcus are suspicious findings. A deep adenocarcinoma may not be palpable.
Prostatic calculus A calculus produces a palpable nodule, which feels like a large grain of sand. There may be digital crepitation. A calculus may be hard to distinguish from adenocarcinoma on examination.
Prostatic abscess An abscess presents as a soft, hot, and exquisitely tender mass of the anterior rectal wall.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Medical Books Excerpts
- Prostatitis
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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» Next page: Benign prostatic hyperplasia (Handbook of Diseases)
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