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Interactive Cases in Urology

  • Prostate Cancer 1 - The Case of Mr. Powers’ Prostatic Nodule
    The effervescent Mr. Powers is found by his primary care provider to have a prostatic nodule. You are expected to direct the evaluation, education, and management of this condition.
  • LEARNING OBJECTIVES for The Case of Mr. Powers’ Prostatic Nodule
    1. Describe the physiologic role of the prostate – “what does the prostate do?”
    2. List the signs & symptoms of prostate cancer
    3. Describe when a patient with a prostatic nodule should be referred to a urologist
    4. Describe the natural history and the common patterns of progression of prostate cancer
    5. List the major components in the staging of prostate cancer
    6. List and briefly describe the options for treatment of localized prostate cancer
    7. Describe how surgery and radiation therapy can impact continence and erectile function
  • Mr. Powers' Visit to his Primary Care Provider - 1
    Mr. Powers is a 64-year old Caucasian male who comes into the office of his primary care physician with the following request: "How's my wedding tackle doing?". His past medical history is notable only for hypertension and gallstones. The examination reveals a 1 cm hard nodule palpated on the right side of his prostate. His PSA was checked 2 months ago and was found to be 1.6ng/ml. What is the most appropriate next step? (Please select the single best answer.)

     a.  To repeat the digital rectal examination in 6 months
     b.  To repeat the digital rectal examination in 1 month
     c.  To refer to a urologist for consideration of a prostate needle biopsy
     d.  To send a urinalysis and urine culture
     e.  To repeat the PSA test
  • Mr. Powers' Visit to his Primary Care Provider - 2
    The doctor reports the presence of the prostatic nodule to Mr. Powers and suggests that he see a urologist for consideration of a prostate needle biopsy. Mr. Powers looks horrified and states "you want me to let them do what?!" Once the doctor explains the procedure and reassures him, Mr. Powers asks, "what does that prostate actually do?" The doctor explains that the physiological role of the prostate is.... (Please choose the single best answer.)

     a.  to stimulate capacitation of sperm
     b.  to secrete seminal fluid that helps liquefy the ejaculate
     c.  to initiate the flagellar activity of the sperm
     d.  to store sperm prior to ejaculation
     e.  to help maintain an erection
  • Mr. Powers' Visit to his Primary Care Provider - 3
    Mr. Powers tells the doctor that he cannot have prostate cancer because he feels just "fine" and has "great Mojo." What are the usual presenting symptoms of prostate cancer in the United States? (Please choose the single best answer.)

     a.  Reduced force of his urinary stream
     b.  Urinary retention
     c.  Hematuria
     d.  Pain on urination
     e.  No symptoms at all
  • Mr. Powers' Visit to the Urologist - 1
    Mr. Powers meets the urologist who repeats the prostate examination and concurs that there is a 1.0 cm nodule contained within the right side of his prostate. She recommends that he undergo a trans-rectal ultrasound-guided prostate needle biopsy to determine if the nodule contains prostate cancer. Three days later, the prostate needle biopsy is performed under trans-rectal ultrasound (TRUS) guidance. The pathology results show that he has moderately-differentiated prostate cancer in 2 of the 3 biopsy cores from the right side of the prostate. The question now facing the urologist is whether the cancer is localized in the prostate or has already spread. The major component(s) of the staging of prostate cancer include: (Please check all answers that apply.)

     a.  Prostate-specific antigen (PSA) level
     b.  Cystoscopy
     c.  Findings on digital rectal examination (DRE)
     d.  Pathology results of the biopsy specimen
     e.  Chest radiography
  • Mr. Powers' Visit to the Urologist - 2
    If Mr. Powers' cancer had in fact begun to spread from the prostate, to which organs would you expect the cancer to spread?

     a.  To the bladder, then to the obturator lymph nodes
     b.  To the inguinal lymph nodes, then to the pelvic bones
     c.  To the bladder, then to the long bones in the legs
     d.  To the rectum, then to the peri-rectal lymph nodes
     e.  To the pelvic lymph nodes, then to the spine
  • Mr. Powers' Visit to the Urologist - 3
    The urologist explains to Mr. Powers that (1) his low PSA of 1.6ng/dl, (2) his small localized nodule on prostate exam, and (3) the moderately-differentiated cancer on the biopsies together strongly suggest that his prostate cancer has not spread and is still confined to the prostate. What are appropriate treatment options for localized prostate cancer? (Please check all answers which apply.)

     a.  external beam radiotherapy
     b.  brachytherapy (interstitial seed placement)
     c.  transurethral resection of the prostate (TURP)
     d.  radical prostatectomy
     e.  watchful waiting
  • Mr. Powers' Visit to the Urologist - 4
    Always feeling the need to be prepared, Mr. Powers asks, "So, Doc, could any of these treatments cause problems? And how long until I can get back into my shaggin' wagon?" He learns that there is currently a great deal of controversy in this area. While radiation oncologists and urologists may disagree about the relative rates of complications, two major categories of complication are found with any of the therapies mentioned above: (Please select the single best answer.)

     a.  Loss of libido and urinary incontinence
     b.  Fecal incontinence and ureteral strictures
     c.  Loss of libido and fecal incontinence
     d.  Erectile dysfunction and loss of libido
     e.  Urinary incontinence and erectile dysfunction
  • Mr. Powers’ Visit to the Urologist - 5
    Mr. Powers is shocked, just shocked, to learn that all of the therapies for localized prostate cancer have the potential to decrease his potency. “I must keep the Mojo going.” He talks to his friends about these options and their possible complications. He also talks again with his urologist to express his concerns and discuss how best to proceed. Given his young age, his relative lack of co-morbidities, and his desire to "get that evil cancer out of my body,” Mr. Powers decides to undergo a radical prostatectomy.

    The operation goes well and Mr. Powers has an uneventful recovery. He is pleased to learn that the pathology report indicates that all of cancer was removed. His PSA level is checked 6 weeks after the surgery and is undetectable, consistent with complete excision of the prostate and the tumor. Mr. Powers does, though, report having occasional leakage of urine with coughing or straining. When asked about sexual function, he says, “Oh, yeah, Baby, I’m still shaggin’, although I must admit, I ain’t standin’ at attention quite the way I did before the operation.” He resorts to the use of the Swedish vacuum pump to help out.

    Overall, he is pleased with his decision to undergo radical prostatectomy. The urinary leakage is minor and easily controlled with a thin pad. And luckily enough, his erections are getting better and better all the time...

    To be continued...
  • Take-Home Messages - from Prostate Cancer 1 - The Case of Mr. Powers’ Prostatic Nodule
    1. All prostate nodules should be referred to a urologist for consideration of a prostate needle biopsy.
    2. In the United States, prostate cancer is now usually detected prior to the development of any symptoms from the disease.
    3. Prostate cancer often disseminates in a step-wise fashion, moving from the prostate to the pelvic lymph nodes, and then to the spine and pelvic bones.
    4. The three common components for staging prostate cancer are prostate-specific antigen (PSA) level, findings on digital rectal examination (DRE), and the pathology results from the prostate biopsy.
    5. Treatment options for localized prostate cancer are radical prostatectomy, external beam radiation, brachytherapy, and watchful waiting.
    6. Transurethral resection of the prostate (TURP) is NOT a cancer operation.
    7. Due to the anatomy of the structures around the prostate, urinary incontinence and erectile dysfunction are potential complications from both radical prostatectomy and radiation therapy (both external beam and brachytherapy).
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