Clinical features

The patient may be asymptomatic, the carcinoma being an incidental finding at autopsy. This is a common finding in patients with localised prostate cancer (confined within the capsule) and locally advanced prostate cancer (1)

In symptomatic disease, presentation may be due to the primary disease, secondary spread, or from general effects of malignancy.

Features of the primary disease may include:

• urethral - causes bladder outlet obstruction (60% of cases)
  • patients may have a combination of both voiding symptoms (poor flow, hesitancy) and storage symptoms (frequency, urgency)
  • urinary retention - if there is complete obstruction (2)
• haematuria, haematospermia
• pain - back, perineal or testicular
• constipation
• ureteric obstruction - anuria, uraemia
• stress urinary incontinence - due to local invasion into the sphincter (2)

Features of metastatic disease:

• bone - pain, fracture, hypercalcaemia, acute neurological deficit in the lower limbs
• lung - usually, an incidental finding
• liver - pain, jaundice, or an incidental finding
• brain - fits
• pelvic lymph nodes - swollen legs from iliac vein occlusion, penile and scrotal oedema

In addition patients may present with general effects of malignancy such as fatigue, lethargy, weight loss, anaemia, anorexia, arthropathy (especially the lower limb) (2).

On rectal examination, the prostate may show asymmetrical, nodular enlargement. It may feel characteristically stony hard and irregular with obliteration of the median sulcus. However, the gland may appear normal or smoothly enlarged as in benign hypertrophy.

Note:

• the number of latent prostate carcinoma (cancer that is present in the prostate gland but never detected or diagnosed during a patient’s life) is greater than the clinically detected disease (2)
• around 70%-80% of prostate tumours begin in the peripheral zone (away from the urethra) hence when patients presents with lower urinary tract symptoms the cancer may have reached an advanced and incurable stage (1)

Reference:

• (1) Prostate Cancer Risk Management Programme Information for primary care; PSA testing in asymptomatic men. Evidence document. NHS Cancer Screening Programmes, 2010
• (2) How to treat. Prostate cancer - part 1. Australian Doctor 2010
• (3) National Cancer Institute 2011. Genetics of Prostate Cancer. Introduction