Eduovisual
Renal & Urinary
Prostate cancer: staging and treatment overview
— Most common non-cutaneous cancer in US men; ~1 in 8 lifetime risk
— Second leading cause of cancer death in men (after lung)
— Median age at diagnosis ~67; rare before age 40 except in high-risk groups
— Black men: 1.6× incidence, 2× mortality vs. White men; earlier onset, more aggressive disease
— Family history (1st-degree relative): doubles risk; BRCA2 carriers have aggressive phenotype
— >95% adenocarcinoma arising in peripheral zone (palpable on DRE)
— Androgen-driven growth → rationale for ADT
— Bone is dominant metastatic site (osteoblastic lesions, axial skeleton)
— Asymptomatic in localized disease — most cases found via PSA screening
— LUTS (hesitancy, weak stream, nocturia) — usually BPH, but coexists
— Hematuria, hematospermia, new erectile dysfunction
— Bone pain, pathologic fracture, cord compression → suspect metastatic disease
— Unexplained weight loss, fatigue, anemia in older man
— USPSTF 2018: Age 55–69 → individualized shared decision-making (Grade C); ≥70 → do not screen (Grade D)
— AUA/ACS: Offer baseline PSA at 40–45 for high-risk (Black, BRCA, FHx), 50 for average risk
— Stop screening when life expectancy <10–15 years
Step 3 management: Document shared decision-making conversation in chart before ordering PSA in a 55–69-year-old — covering overdiagnosis, biopsy risks, and treatment morbidity (incontinence, ED). This is the single most testable ambulatory-care behavior on this topic.
Board pearl: A man with new-onset low back pain, weight loss, and elevated alk phos but normal calcium → order PSA before chasing other malignancies; osteoblastic mets are classic.
— Elevated PSA on routine labs; patient feels well
— DRE may be normal (peripheral zone tumor not yet palpable) or reveal a nodule
— Workup driven by PSA kinetics, not symptoms
— Obstructive: hesitancy, weak stream, incomplete emptying, post-void dribbling
— Irritative: frequency, urgency, nocturia, dysuria
— Key distinction: LUTS alone are far more likely BPH than cancer — but coexistence is common, and PSA + DRE still indicated to exclude malignancy in appropriate age group
— Hematuria, hematospermia
— Erectile dysfunction from neurovascular bundle involvement
— Perineal or pelvic pain, obstructive uropathy → hydronephrosis, AKI
— Bone pain — lumbar spine, pelvis, ribs; worse at night, not relieved by rest
— Spinal cord compression — saddle anesthesia, lower extremity weakness, urinary retention → oncologic emergency
— Pathologic fracture, anemia of chronic disease, pancytopenia from marrow replacement
— Lower extremity edema from pelvic nodal obstruction
— PSA history (trend matters more than absolute value)
— Prior prostate biopsies, 5-α-reductase inhibitor use (artificially halves PSA — double the value)
— Family history: prostate, breast, ovarian, pancreatic (BRCA), Lynch syndrome
— Race/ethnicity, life expectancy estimate, comorbidities
— Sexual function and continence baseline — drives treatment counseling
— Anticoagulation, prior pelvic radiation, inflammatory bowel disease (affects RT candidacy)
Board pearl: Patient on finasteride/dutasteride with PSA of 2.5 → true PSA is ~5.0. Failure to adjust is a common stem trap.
Step 3 management: When a 70-year-old presents with new back pain and any history of LUTS, order PSA, CBC, alk phos, and lumbar imaging concurrently — don't sequentially work up "musculoskeletal back pain."
— Normal prostate: smooth, rubbery, symmetric, ~20 g (walnut-sized), well-defined median sulcus
— BPH: symmetric enlargement, smooth, non-tender, preserved sulcus
— Prostatitis: boggy, exquisitely tender, warm; do NOT massage acute prostatitis (bacteremia risk)
— Cancer: hard, nodular, asymmetric, irregular contour; obliterated median sulcus in advanced disease; fixation to surrounding tissue suggests extracapsular extension
— Sensitivity of DRE alone is poor (~50%); abnormal DRE warrants biopsy regardless of PSA
— T1: not palpable (incidental, e.g., on TURP)
— T2a: ≤½ of one lobe; T2b: >½ of one lobe; T2c: both lobes
— T3: extracapsular extension or seminal vesicle involvement (fixed nodule, induration beyond capsule)
— T4: fixed to adjacent structures (bladder neck, rectum, pelvic wall)
— Bony tenderness on spine percussion → vertebral mets
— Focal neuro deficit, hyperreflexia, sensory level, urinary retention → cord compression
— Supraclavicular (Virchow) or inguinal lymphadenopathy
— Lower extremity edema (unilateral > bilateral) from pelvic nodes
— Hepatomegaly (uncommon, late)
— Cachexia, pallor (marrow infiltration anemia)
— Generally stable; instability suggests urosepsis post-biopsy or massive GI bleed from rectal invasion
— Bradycardia + hypotension + flaccid paralysis = neurogenic shock from cord compression
Key distinction: A hard, nodular prostate is cancer until proven otherwise; a uniformly enlarged, smooth, rubbery prostate is BPH. PSA does not override DRE — abnormal DRE alone justifies urology referral and biopsy.
Board pearl: Post-DRE PSA is unreliable for 1 week — don't draw PSA right after the exam; if both ordered, draw PSA first, then perform DRE.
— No absolute "normal"; risk increases continuously
— Traditional threshold: >4.0 ng/mL prompts further evaluation; >3.0 in younger/high-risk men
— Age-specific ranges: 40s <2.5, 50s <3.5, 60s <4.5, 70s <6.5
— PSA density (PSA/prostate volume): >0.15 increases cancer suspicion
— PSA velocity: >0.75 ng/mL/year concerning
— % free PSA: <10% suggests cancer; >25% favors benign
— Causes of falsely elevated PSA: prostatitis, recent ejaculation (48 h), DRE within a week, recent catheterization, cycling, UTI
— Causes of falsely low PSA: 5-α-reductase inhibitors (multiply by 2), obesity (hemodilution)
— Repeat PSA in 6–8 weeks after treating any UTI/prostatitis
— Rule out other elevators before triggering biopsy cascade
— 4Kscore, PHI (Prostate Health Index), PCA3 urine, SelectMDx — refine biopsy decision and reduce unnecessary procedures
— Used to triage; not stand-alone diagnostic
— PI-RADS 1–2: low suspicion → can often defer biopsy
— PI-RADS 3: equivocal — consider biopsy with biomarker assist
— PI-RADS 4–5: high suspicion → MRI-targeted fusion biopsy
— Recommended before first biopsy per AUA 2023 — improves clinically significant cancer detection, reduces low-grade overdiagnosis
— CBC (anemia from marrow mets), BMP (obstructive uropathy), alk phos and LFTs (bone/liver mets), testosterone (baseline before ADT)
Step 3 management: PSA 5.2 in a 60-year-old → don't biopsy immediately. Repeat PSA after 6 weeks, rule out prostatitis, then obtain mpMRI; biopsy guided by PI-RADS score. This sequence prevents overdiagnosis and is the modern ambulatory standard.
Board pearl: Recent ejaculation can elevate PSA — instruct 48-hour abstinence before draw.
— Transrectal ultrasound (TRUS)-guided systematic 12-core biopsy, increasingly transperineal (lower infection risk)
— MRI-targeted fusion biopsy at PI-RADS ≥3 lesions, combined with systematic cores
— Pre-procedure: hold anticoagulants per protocol, fluoroquinolone or rectal swab–guided prophylaxis (rising fluoroquinolone resistance)
— Complications: hematuria, hematospermia (weeks), urinary retention, sepsis (1–3%) — fever post-biopsy is urosepsis until proven otherwise
— Gleason adds primary + secondary patterns (e.g., 3+4=7)
— ISUP Grade Groups 1–5:
— GG1 = Gleason 6 (3+3): low-grade, often indolent
— GG2 = 3+4=7: favorable intermediate
— GG3 = 4+3=7: unfavorable intermediate
— GG4 = Gleason 8: high-grade
— GG5 = Gleason 9–10: very high-grade
— Low risk (PSA <10, GG1, cT1–T2a): no imaging required
— Intermediate risk: consider bone scan + CT/MRI pelvis if unfavorable features
— High risk (PSA >20, GG4–5, or cT3+): bone scan + CT abdomen/pelvis (or MRI), or preferably PSMA-PET/CT (more sensitive than conventional imaging — now standard for high-risk and biochemical recurrence)
— Bone mets: osteoblastic, axial skeleton; bone scan shows hot spots
— Recommended for metastatic, high/very-high-risk localized, intraductal histology, or strong FHx
— Test for BRCA1/2, ATM, CHEK2, MMR genes — guides PARP inhibitor eligibility and family counseling
CCS pearl: In a high-risk new diagnosis on a CCS case, order PSMA-PET/CT, germline genetic testing, and urology + radiation oncology consults on day 1 — multidisciplinary discussion is the expected pathway and earns points for advancing care efficiently.
Key distinction: Gleason 3+4 (GG2) vs 4+3 (GG3) — same total of 7 but very different prognosis; the dominant (first) pattern drives behavior.
— Very low: PSA <10, GG1, cT1c, <3 cores positive, <50% any core, PSA density <0.15
— Low: PSA <10, GG1, cT1–T2a
— Favorable intermediate: GG1 with PSA 10–20 OR GG2 with PSA <10 and cT2b–c
— Unfavorable intermediate: GG3, or multiple intermediate factors
— High: PSA >20, OR GG4–5, OR cT3a
— Very high: cT3b–T4, or primary Gleason 5, or >4 cores GG4–5
— Very low / low risk, LE >10 yrs → Active surveillance preferred
— Favorable intermediate, LE >10 yrs → AS (selected), radical prostatectomy, or RT
— Unfavorable intermediate → RP or RT + short-course ADT (4–6 mo)
— High/very high risk → RP with pelvic lymphadenectomy, OR RT + long-course ADT (18–36 mo) ± abiraterone/docetaxel for very high risk
— Node-positive → RT + long ADT (preferred) or RP + adjuvant therapy
— Metastatic (M1) → ADT + treatment intensification (see chunk 7–8)
— PSA every 6 mo, DRE every 12 mo
— Confirmatory mpMRI + biopsy at 1 year, then biopsy every 2–5 years
— Trigger for treatment: grade progression (GG ≥2 with adverse features), volume progression, patient anxiety
— For LE <10 yrs or significant comorbidity
— Symptom-directed therapy only, no curative intent
Step 3 management: A 72-year-old with CHF, GG1 prostate cancer, PSA 6 → recommend watchful waiting, not active surveillance, because life expectancy <10 years means curative intervention won't improve survival but will cause morbidity.
Board pearl: Overtreatment of low-risk prostate cancer is a USPSTF-cited harm — recognizing AS as standard of care for GG1 is the single most testable management pivot on this topic.
— GnRH agonists (leuprolide, goserelin): initial testosterone flare → co-administer antiandrogen (bicalutamide) for 2–4 weeks to prevent tumor flare/cord compression in metastatic disease
— GnRH antagonists (degarelix injection, relugolix oral): no flare, faster castration; relugolix preferred if cardiovascular disease (lower MACE signal)
— Bilateral orchiectomy: definitive, cheapest, immediate castration — still an option
— Bicalutamide, flutamide, nilutamide — used short-term for flare prevention; monotherapy inferior
— Abiraterone + prednisone (CYP17 inhibitor — blocks adrenal/intratumoral androgen synthesis)
— Enzalutamide, apalutamide, darolutamide (AR antagonists)
— Indications: metastatic hormone-sensitive (mHSPC) in combination with ADT (doublet); nonmetastatic CRPC with rising PSA; metastatic CRPC
— Triplet therapy (ADT + docetaxel + darolutamide/abiraterone) — for high-volume mHSPC
— Docetaxel — added to ADT in high-volume mHSPC and in mCRPC
— Cabazitaxel — second-line after docetaxel failure
— PARP inhibitors (olaparib, rucaparib) — for BRCA/HRR-mutated mCRPC
— Sipuleucel-T — autologous immunotherapy for asymptomatic mCRPC
— Radium-223 — α-emitter for symptomatic bone-predominant mCRPC, no visceral mets
— Lutetium-177 PSMA — radioligand for PSMA+ mCRPC post-ARPI and docetaxel
— Pembrolizumab if MSI-high/dMMR
Step 3 management: Newly diagnosed metastatic prostate cancer → never use ADT alone. Standard is ADT + ARPI (doublet) or ADT + docetaxel + ARPI (triplet for high-volume). ADT monotherapy is now substandard care.
Board pearl: Start bicalutamide before the first leuprolide dose in a patient with bone mets — prevents testosterone flare and catastrophic cord compression.
— Robot-assisted laparoscopic most common in US
— Removes prostate + seminal vesicles ± pelvic lymph node dissection (PLND) for intermediate/high risk
— Best for younger men, longer life expectancy, high-volume localized disease
— Adverse effects: erectile dysfunction (50–70%), urinary incontinence (5–20% long-term), anastomotic stricture, lymphocele
— Post-op PSA should be undetectable (<0.1) within 6–8 weeks; persistent or rising = biochemical recurrence
— IMRT or stereotactic body RT (SBRT) — 5–8 weeks (or 5 fractions)
— Equivalent oncologic outcomes to RP in localized disease
— Adverse effects: proctitis, cystitis, ED (delayed onset), secondary malignancies (bladder, rectal — long latency), urethral stricture
— Combined with short ADT (4–6 mo) for unfavorable intermediate, long ADT (18–36 mo) for high/very-high risk
— Low-dose-rate (LDR) permanent seed implants — for low/favorable-intermediate risk
— High-dose-rate (HDR) temporary — often boost combined with EBRT for higher risk
— Avoid in large prostates (>60 g), severe LUTS, prior TURP
— Post-RP rising PSA → salvage RT to prostate bed ± ADT
— Post-RT rising PSA + positive biopsy → salvage RP (high morbidity), cryotherapy, or systemic therapy
— External beam RT for painful bone mets
— TURP for obstructive symptoms
— Bilateral ureteral stents/nephrostomies for malignant obstruction
— Spinal cord compression: dexamethasone immediately, neurosurgery/RT consult emergently
CCS pearl: For new spinal cord compression from prostate mets, sequence is: IV dexamethasone → MRI whole spine → neurosurgery and radiation oncology consults → start ADT with antiandrogen cover. Delaying steroids costs points and function.
Key distinction: RP and RT have equivalent survival in localized disease — selection is driven by patient preference, comorbidities, and side-effect profile, not oncologic superiority.
— Decisions hinge on estimated life expectancy, not chronologic age
— Use validated tools (Lee Index, ePrognosis) — comorbidity burden trumps birthdate
— LE <10 yrs: avoid screening, favor watchful waiting even for high-risk localized disease
— LE 10–15 yrs with high-risk disease: still consider definitive therapy
— Geriatric assessment (G8 screening tool) before chemotherapy or aggressive ADT
— Hot flashes, fatigue, sarcopenia, falls
— Bone loss → DEXA at baseline; supplement calcium 1200 mg + vitamin D 800–1000 IU; bisphosphonate or denosumab if osteoporosis or high fracture risk
— Metabolic syndrome: weight gain, insulin resistance, dyslipidemia — monitor A1c and lipids annually
— Cardiovascular: ADT increases MACE, especially in pre-existing CVD; relugolix (GnRH antagonist) has lower cardiac event signal than leuprolide
— Cognitive changes, depression — screen routinely
— QT prolongation with abiraterone, apalutamide — baseline ECG, avoid concurrent QT-prolonging meds
— Most ADT agents do not require renal dose adjustment
— Cabazitaxel: caution if CrCl <30
— Contrast considerations for staging CT — use MRI/PSMA-PET if eGFR <30
— Obstructive uropathy from local progression → check Cr, post-void residual; decompress with stents/PCN
— Abiraterone: hepatotoxicity — check LFTs every 2 wks × 3 mo then monthly; hold if ALT/AST >5× ULN
— Enzalutamide: dose-adjust in severe hepatic impairment
— Avoid hepatotoxic combinations; review herbals/supplements
Step 3 management: Before starting abiraterone, obtain baseline LFTs, K+, BP; schedule biweekly LFTs for 3 months. Abiraterone causes mineralocorticoid excess (HTN, hypokalemia, edema) — co-prescribe prednisone 5 mg BID to suppress ACTH-driven mineralocorticoid synthesis.
Board pearl: Falls and hip fractures in a man on long-term leuprolide → check DEXA; ADT-induced osteoporosis is preventable with bone-targeted therapy.
— Higher incidence, earlier onset, more aggressive biology, worse mortality — partly biologic, partly access disparities
— Earlier screening discussions starting at age 40–45
— Higher rates of upgrading on prostatectomy vs. biopsy — active surveillance criteria may need to be stricter
— Ensure equitable access to mpMRI, PSMA-PET, and genetic testing — health-systems equity question often appears on boards
— BRCA2 → more aggressive, earlier onset, higher metastatic risk
— Screen earlier (age 40); lower PSA threshold for biopsy
— Eligible for PARP inhibitor therapy in mCRPC (olaparib, rucaparib, talazoparib)
— Cascade testing for at-risk relatives — ethical duty to inform
— Pembrolizumab for MSI-high mCRPC — durable responses
— Higher risk of multiple malignancies — coordinated cancer surveillance
— Prostate is not removed in gender-affirming surgery — cancer risk persists
— Estrogen does not eliminate risk; PSA may be artificially low
— Counsel about ongoing screening based on shared decision-making
— Use age-appropriate screening intervals; lower PSA cutoffs in this population
— BRCA2 carrier diagnosis → refer female relatives for breast/ovarian surveillance
— Family planning conversations for younger probands
— Prostate adenocarcinoma essentially does not occur in children — embryonal rhabdomyosarcoma of GU tract is the pediatric mimic (different management entirely)
— Sexual rehab: PDE5 inhibitors early post-RP for penile rehabilitation
— Pelvic floor PT for incontinence
— Hot flash management: venlafaxine, gabapentin
— Fertility: discuss sperm banking before ADT/RT/RP if reproductive plans
Key distinction: A Black man at age 45 with FHx of prostate cancer should be offered baseline PSA even though USPSTF starts shared decision-making at 55 — high-risk groups get earlier consideration per AUA.
Board pearl: Always ask about family history of breast, ovarian, pancreatic cancer in prostate cancer patients — triggers germline BRCA testing.
— Spinal cord compression — oncologic emergency; back pain → neuro deficit → paraplegia within hours; treat with dexamethasone + emergent RT/surgery
— Pathologic fractures — vertebral, femur; consider prophylactic stabilization for impending fracture (Mirels score)
— Bilateral hydronephrosis / obstructive AKI — from local invasion or nodal compression; decompress urgently
— DIC — uncommon but classic association with prostate adenocarcinoma; bleeding + thrombosis simultaneously, elevated D-dimer, low fibrinogen
— Bone marrow infiltration — leukoerythroblastic smear, pancytopenia
— Bladder outlet obstruction, hematuria, recurrent UTI
— Cancer-associated VTE
— Post-prostatectomy: ED, stress incontinence, anastomotic stricture, bladder neck contracture, lymphocele, rectal injury (rare), positive surgical margins
— Post-RT: radiation proctitis (rectal bleeding), cystitis, urethral stricture, ED (delayed 1–2 yrs), secondary cancers (bladder, rectal), pelvic insufficiency fractures
— ADT: hot flashes, sarcopenia, osteoporosis, gynecomastia, anemia, fatigue, depression, MACE, metabolic syndrome, diabetes
— Abiraterone: HTN, hypokalemia, edema, hepatotoxicity, adrenal insufficiency on abrupt withdrawal
— Enzalutamide: fatigue, falls, seizures (caution in seizure history), HTN
— Apalutamide: rash, hypothyroidism, falls, fractures
— Docetaxel: neutropenia, neuropathy, nail changes, fluid retention, hypersensitivity
— Radium-223: cytopenias
— Hematuria, hematospermia (weeks), AUR, urosepsis — fever post-biopsy is sepsis until ruled out; admit, blood/urine cultures, empiric broad-spectrum (cover resistant E. coli — carbapenem if local resistance high)
Step 3 management: Man on enzalutamide presenting with new generalized seizure — discontinue enzalutamide, rule out brain mets and metabolic causes, switch ARPI class.
CCS pearl: Suspected cord compression — give IV dexamethasone 10 mg load → 4 mg q6h before MRI confirmation. Don't wait for imaging to start steroids.
— Suspected spinal cord compression → admit, IV dex, emergent MRI whole spine, neurosurgery + radiation oncology consult
— Symptomatic hypercalcemia (less common than in other malignancies but possible) → IV fluids, calcitonin, bisphosphonate/denosumab
— Acute urinary retention with obstructive AKI → bladder catheter or suprapubic; nephrostomy/stents if upper tract obstruction
— Post-biopsy sepsis → admit, blood/urine cultures, broad-spectrum antibiotics covering resistant gram-negatives; ICU if hemodynamic instability
— Pathologic fracture or impending fracture → orthopedic surgery consult, weight-bearing precautions
— DIC with bleeding → cryoprecipitate, FFP, platelets; treat underlying cancer
— Severe ADT side effects: symptomatic anemia, severe hyponatremia
— Septic shock from post-biopsy bacteremia
— Spinal cord compression with respiratory compromise (high cervical)
— Febrile neutropenia after docetaxel (ANC <500, fever ≥38.3) — empiric cefepime, admit; ICU if septic
— Urology: any new abnormal DRE, persistently elevated PSA, biopsy planning, obstruction
— Radiation oncology: definitive RT planning, palliative bone RT, cord compression
— Medical oncology: metastatic disease, CRPC, systemic therapy decisions
— Palliative care: symptomatic metastatic disease, advance care planning — early integration improves outcomes
— Genetic counseling: metastatic, high-risk, intraductal histology, FHx
— Orthopedics: impending pathologic fracture (Mirels ≥9)
— Interventional radiology: nephrostomy, pain procedures
— Cardiology: pre-ADT in CVD; QTc monitoring on ARPIs
— Rising PSA on AS → repeat biopsy/MRI
— Post-RP PSA rising above 0.2 confirmed → salvage workup
— PSA doubling time <10 mo after definitive therapy → high-risk biochemical recurrence
Step 3 management: A man post-biopsy at home develops fever, rigors, hypotension → direct admission, blood/urine cultures, carbapenem empirically (high prevalence of FQ-resistant E. coli post-biopsy), urology + ID consult.
CCS pearl: In CCS metastatic prostate cancer cases, schedule palliative care consultation early — it counts as appropriate longitudinal care.
— Symmetric, smooth, rubbery enlargement on DRE
— LUTS without systemic symptoms; PSA may be modestly elevated proportional to gland volume
— Treat with α-blockers (tamsulosin), 5-α-reductase inhibitors (finasteride — halves PSA), TURP for refractory
— Key distinction: BPH PSA elevation tracks with gland size; cancer PSA rises out of proportion or in nodular gland
— Fever, perineal/pelvic pain, dysuria, exquisitely tender boggy prostate on DRE
— Markedly elevated PSA (often >10–20) — don't biopsy; treat first, recheck PSA in 6–8 weeks
— Fluoroquinolone or TMP-SMX × 4–6 weeks (longer for chronic)
— Avoid prostatic massage in acute phase — bacteremia risk
— Recurrent UTIs same organism; localization via Meares-Stamey 4-glass test
— Prolonged antibiotics (ciprofloxacin 4–6 weeks)
— No infection; pain >3 mo; α-blockers, pelvic floor PT, multimodal
— Mimics cancer on DRE and elevates PSA; biopsy distinguishes
— Fluctuant area on DRE, persistent fever despite antibiotics; transrectal US or CT; drain
— Hematuria, irritative LUTS; cystoscopy + cytology; PSA normal
— Smoking risk factor
— LUTS without prostate enlargement; uroflowmetry, retrograde urethrogram
— Precursor/equivocal biopsy findings
— ASAP → repeat biopsy within 3–6 months
— HGPIN → repeat only if multifocal or other risk features
Board pearl: PSA of 22 in a febrile man with perineal pain and a tender boggy prostate → acute prostatitis, not cancer. Treat with antibiotics, repeat PSA at 6–8 weeks; don't rush to biopsy.
Key distinction: A nodular, painless, hard prostate = cancer workup; a tender, boggy, hot prostate = prostatitis. DRE consistency is the discriminator.
— Multiple myeloma — lytic lesions, hypercalcemia, anemia, renal failure, M-spike on SPEP; bone scan often negative (lytic doesn't take up tracer well) — skeletal survey or whole-body MRI/PET
— Lung cancer mets — smoking history, pulmonary symptoms; CT chest
— Renal cell carcinoma mets — hematuria, flank pain, paraneoplastic syndromes
— Primary bone tumor (rare in elderly)
— Osteoporotic compression fracture — no malignancy markers; DEXA
— Vertebral osteomyelitis/discitis — fever, elevated ESR/CRP, IV drug use or bacteremia history; MRI with contrast
— Bone source (prostate mets, Paget disease, fractures) — confirm with GGT (normal) and bone-specific alk phos
— Hepatic source (cholestasis, infiltrative liver disease) — elevated GGT
— Paget disease — elevated alk phos, normal PSA, characteristic radiographic appearance (cotton-wool skull, bone enlargement)
— Neurogenic bladder (diabetes, MS, cord lesion)
— Medication-induced (anticholinergics, opioids)
— Detrusor overactivity
— Urethral stricture
— Urothelial carcinoma of bladder/upper tract
— Stones
— Glomerular disease (RBC casts, dysmorphic RBCs, proteinuria)
— Anticoagulation-unmasked lesion — still requires workup
— Vasculogenic (CV disease — ED is a marker)
— Psychogenic, hormonal (low testosterone), neurogenic, medication-induced (SSRIs, β-blockers)
— BPH, prostatitis, urinary retention, recent ejaculation, DRE, catheterization, cycling
Step 3 management: Older man with back pain, anemia, hypercalcemia, AKI, normal PSA → think myeloma, not prostate. Order SPEP/UPEP, serum free light chains, skeletal survey — don't anchor on prostate cancer just because of age.
Board pearl: Bone scan positive = osteoblastic (prostate, breast); bone scan negative with lytic lesions = myeloma or RCC. Match imaging to suspected biology.
— Post-RP: PSA every 3 months × 1 year, every 6 months × 2 years, then annually
— PSA should be undetectable (<0.1); rising PSA >0.2 confirmed twice = biochemical recurrence → workup (PSMA-PET) and consider salvage RT ± ADT
— Post-RT: PSA every 3–6 months; nadir typically reached 18–24 months
— Phoenix definition of biochemical recurrence after RT: PSA rise of ≥2 ng/mL above nadir
— PSA q6 mo, DRE q12 mo, mpMRI + biopsy at 1 yr and then q2–5 yrs based on findings
— Trigger to treat: GG progression, significant volume increase, PI-RADS upgrade, patient choice
— Bone health: DEXA at baseline and every 1–2 years; calcium 1200 mg + vitamin D 800–1000 IU daily; denosumab 60 mg SC q6mo or zoledronic acid for osteoporosis or high FRAX risk
— For bone metastases (different dosing): denosumab 120 mg SC q4wks or zoledronic acid q4wks — reduces skeletal-related events
— Monitor calcium with denosumab/bisphosphonates — avoid hypocalcemia, supplement first
— Dental evaluation before initiating bone-targeted therapy → osteonecrosis of jaw prevention
— Cardiovascular: optimize BP, lipids, diabetes; statin per ASCVD; consider relugolix if high CV risk
— Metabolic: annual A1c, fasting lipids, weight, exercise counseling
— Hot flashes: venlafaxine, gabapentin, low-dose progestins
— Annual mood/depression screening
— Resistance training to combat sarcopenia
— Up-to-date colorectal cancer screening (overlapping age cohort)
— Vaccinations: influenza annually, pneumococcal, RSV, shingles, COVID-19, Tdap
— Smoking cessation, alcohol moderation
— Diet: Mediterranean pattern; no specific evidence for lycopene/selenium/vitamin E (SELECT trial showed harm with vitamin E)
Step 3 management: Starting long-term ADT → on day 1 also order DEXA, baseline lipid panel, A1c, calcium/vitamin D, dental referral, exercise counseling, and document baseline weight and BP. This package is the survivorship bundle Step 3 expects you to assemble.
Board pearl: Vitamin E supplementation increased prostate cancer risk in SELECT — counsel against it.
— Active surveillance: PSA q6mo, DRE q12mo, mpMRI/biopsy per protocol
— Post-curative therapy: PSA q3mo year 1, q6mo years 2–3, annually thereafter for ≥10 years
— On ADT: PSA + testosterone q3mo (confirm castrate testosterone <50 ng/dL); LFTs, BMP, lipids periodically
— On abiraterone: LFTs q2wk × 3 mo then monthly; BP, K+ each visit
— On enzalutamide: BP, falls/seizure history each visit
— On bone-targeted therapy: calcium, creatinine, dental status
— Routine imaging not needed if PSA stable and patient asymptomatic
— New bone pain, neurologic symptoms, or PSA rise → imaging (PSMA-PET preferred for biochemical recurrence)
— For mCRPC on therapy: CT and bone scan q3–6 mo to assess response
— Sexual function: realistic expectations after RP/RT; PDE5 inhibitors, vacuum devices, intracavernosal injections, penile prosthesis if refractory; couples counseling
— Continence: pelvic floor exercises (Kegels) starting pre-op; most regain continence by 12 months post-RP; surgical sling or artificial urinary sphincter for persistent stress incontinence
— Bowel symptoms post-RT: report rectal bleeding (could be radiation proctitis or new colorectal cancer — don't dismiss)
— Hot flashes, fatigue: lifestyle and pharmacologic options
— Fertility preservation before therapy if reproductive plans
— Pelvic floor PT pre- and post-prostatectomy
— Penile rehabilitation programs (early PDE5i)
— Cancer rehab/exercise programs improve fatigue, QoL, and possibly cancer outcomes
— Cognitive and mood support during ADT
— After surgery: clear written instructions on catheter care, drain output, signs of infection, follow-up appointment booked
— Medication reconciliation at every transition — especially when transitioning between urology, radiation oncology, medical oncology
— PCP retains role in survivorship: cardiovascular prevention, bone health, vaccinations, age-appropriate screening
CCS pearl: On every CCS prostate cancer encounter, order PSA, schedule next follow-up, and address one survivorship domain (bone, sexual, continence, mood, CV risk) — broadens the case beyond pure oncology.
Board pearl: Persistent post-RP PSA (never undetectable) suggests residual disease, not biochemical recurrence — different prognosis and management.
— Screening must be a documented conversation, not reflexive lab ordering
— Discuss: lifetime risk, overdiagnosis (~20–50% of screen-detected low-grade cancers may never harm), biopsy risks, treatment morbidity (ED, incontinence), and unclear mortality benefit
— Respect patient autonomy if patient declines screening or biopsy after informed discussion
— Document the discussion — medicolegal protection and quality measure
— RP and RT have equivalent oncologic outcomes for localized disease — disclosure of alternatives (including active surveillance) is legally required
— Disclose sexual, urinary, and bowel side effects in plain language
— Surgeon-specific outcomes (volume, complication rates) increasingly part of informed consent expectations
— Capacity assessment in older patients with cognitive impairment — involve surrogate per state law if incapacitated
— BRCA result has implications for blood relatives — discuss duty to share with family; clinician should not directly contact relatives (privacy) but should encourage proband disclosure
— Document genetic counseling referral
— GINA protects against health insurance/employment discrimination but not life/disability/long-term care insurance — disclose this
— Post-biopsy patients need clear return precautions for fever (urosepsis) — written instructions reduce delayed presentations
— After prostatectomy, ensure catheter care education and follow-up before discharge
— Medication reconciliation when transferring between specialists — abiraterone requires prednisone co-administration (omission is a sentinel event)
— Reconcile 5-α-reductase inhibitor use — failure to recognize doubles PSA interpretation error
— Black men and uninsured patients have worse outcomes — clinicians should actively address access barriers (referral assistance, patient navigators, financial counseling)
— Metastatic CRPC has finite prognosis — discuss goals of care, code status, palliative care early
— Hospice referral when life expectancy <6 months and disease-directed therapy no longer beneficial
Step 3 management: Document shared decision-making for PSA screening in any 55–69-year-old man's chart — this is both a quality measure and a malpractice shield. Reflexively ordering PSA without discussion is the safety/ethics pitfall most likely tested.
Board pearl: Forgetting to co-prescribe prednisone with abiraterone → adrenal crisis risk; this is a never event in oncology pharmacy.
— Adenocarcinoma in peripheral zone (DRE-accessible); BPH in transition zone
— Bone mets are osteoblastic — elevated alk phos, normal-to-elevated calcium
— Most common metastatic site: bone (axial skeleton, especially lumbar spine)
— Spread: local → seminal vesicles → pelvic nodes → bone/distant
— Finasteride/dutasteride halves PSA — double measured value
— DRE may transiently raise PSA — draw PSA first
— Ejaculation, cycling, catheterization, prostatitis → false elevations
— PSA velocity >0.75/yr, PSA density >0.15 → concerning
— Free PSA <10% → favors cancer
— BRCA2 → most aggressive; PARP inhibitor eligibility
— HOXB13 mutation → familial prostate cancer
— Lynch syndrome → MSI-high → pembrolizumab
— Leuprolide → testosterone flare (use bicalutamide cover)
— Abiraterone → HTN, hypokalemia, hepatotoxicity (give with prednisone)
— Enzalutamide → seizures, falls
— Apalutamide → rash, hypothyroidism
— Docetaxel → neuropathy, neutropenia
— Radium-223 → cytopenias; avoid with visceral mets
— Denosumab → hypocalcemia, ONJ
— PSMA-PET/CT — most sensitive for biochemical recurrence and high-risk staging
— Bone scan: hot spots, axial skeleton; misses purely lytic disease
— mpMRI PI-RADS 4–5 → targeted biopsy
— Older man, back pain, elevated alk phos with normal calcium → prostate mets, check PSA
— Post-biopsy fever + rigors → urosepsis, broad-spectrum antibiotics (carbapenem if FQ resistance)
— Bone pain + DIC → metastatic prostate cancer
— Anemia + leukoerythroblastic smear in older man → bone marrow infiltration
— Saddle anesthesia + urinary retention in known prostate cancer → cord compression — steroids now
— Man on finasteride with PSA 3 → true PSA ~6 → workup
— GG1, LE >10 yrs → active surveillance
— LE <10 yrs → watchful waiting
— Localized high-risk → RT + long ADT, or RP + PLND
— mHSPC → ADT + ARPI doublet; high-volume → triplet with docetaxel
— mCRPC BRCA+ → PARP inhibitor
— mCRPC symptomatic bone-only → radium-223
— PSMA+ mCRPC post-progression → Lu-177 PSMA
Board pearl: "Osteoblastic bone lesions + elevated PSA" is one of medicine's most reliable triplet pattern recognitions — commit it to memory.
— 58-year-old man asks about PSA screening at routine visit
— Best answer: discuss benefits and harms with shared decision-making before ordering PSA
— Trap: ordering PSA without discussion, or refusing to discuss
— PSA 5.8 in 62-year-old with mild LUTS, recent ejaculation 24 h ago
— Best step: repeat PSA in 6–8 weeks after counseling on abstinence
— Trap: immediate biopsy
— Patient on dutasteride 2 years; PSA "stable at 2.8"
— Recognize true PSA ~5.6 → workup indicated
— Trap: false reassurance
— 68-year-old, GG1 (Gleason 3+3), PSA 6, 1 of 12 cores positive, life expectancy >15 years
— Best: active surveillance with PSA q6mo, mpMRI, repeat biopsy at 1 year
— Trap: prostatectomy or RT for low-risk disease
— Bone mets, PSA 220, GG5; about to start leuprolide
— Co-prescribe bicalutamide to prevent flare
— Trap: leuprolide alone → risk of cord compression flare
— Known prostate cancer with new back pain, leg weakness, urinary retention
— Best first step: IV dexamethasone then emergent MRI whole spine, neurosurgery + RT consult
— Trap: imaging first without steroids
— Patient 36 h post-biopsy with fever 39°C, rigors, BP 88/50
— Admit, cultures, empiric carbapenem (FQ-resistant E. coli)
— Trap: oral fluoroquinolone outpatient
— PSA undetectable for 2 years, now 0.4 on two readings
— Next step: PSMA-PET/CT, then salvage RT to prostate bed ± ADT
— Trap: observation alone
— New abiraterone start
— Add prednisone, monitor LFTs/K+/BP; dental clearance if also starting bone agent
— Trap: forgetting prednisone
— 78-year-old, severe CHF, GG2 prostate cancer
— Best: watchful waiting (LE <10 yrs)
— Trap: aggressive curative therapy
— Bleeding + thrombosis + low fibrinogen + elevated D-dimer + bone mets
— Recognize prostate cancer–associated DIC; treat malignancy
Board pearl: The most common correct answer in Step 3 prostate cancer stems is "engage in shared decision-making" or "active surveillance" — choose less aggressive answers more often than instinct suggests.
Prostate cancer management hinges on matching risk stratification (PSA, ISUP grade group, clinical stage, life expectancy) to a tiered framework — active surveillance for low-risk indolent disease, definitive RP or RT ± ADT for localized intermediate-to-high-risk disease, and ADT plus ARPI (or triplet therapy) for metastatic disease — anchored by shared decision-making, survivorship care, and disparity-aware longitudinal follow-up.
Board pearl: When in doubt on a Step 3 prostate cancer item, the best answer usually involves either shared decision-making, active surveillance, or multidisciplinary referral — the exam rewards thoughtful restraint and longitudinal thinking over aggressive intervention.