Early Detection

The presenting signs and symptoms of a prostate cancer vary as a function of its site of origin in the gland, and its extent of involvement. The majority of cancers arise in the peripheral zone and do not produce symptoms in the early stages of development. Those that arise in the transitional zone, or that enlarge and encroach on the urethra, may produce hesitancy, a decrease in the force of urinary stream, intermittency and post-void leakage. Obstruction may decrease the compliance of the detrusor muscle, resulting in bladder instability. This in turn can cause symptoms of urinary frequency, nocturia, urgency and urgency incontinence. However, all these symptoms may occur for other reasons, and there is no diagnostic symptoms or voiding pattern that can positively characterise prostate cancer.

In the past, most men with clinically significant prostate cancer presented with symptoms that indicated advanced disease with metastatic progression, including weight loss, bone pain and lethargy. However, with improved public awareness and screening techniques, prostate cancer is being diagnosed in the earlier stages of development, often in men who are free of symptoms or asymptomatic.

Localised prostate cancer

Localised disease refers to prostate cancer that is confined within the capsule of the prostate with no evidence of spread (T1 – T2). Often it is not associated with any specific symptoms that the patient may identify as a cause for concern e.g. urinary frequency, urgency or hesitancy (Table 2.1). The tumour is often too small to be palpable on rectal examination and may only be suspected on PSA testing. Confirmation is usually by transrectal ultrasound scan and guided needle biopsy. Sometimes, it may only be diagnosed following histological examination of prostate ‘chips’ removed during transurethral resection of the prostate (TURP), for bladder outflow obstruction, presumed to be caused by benign prostatic hypertrophy (BPH).

Locally advanced prostate cancer

Locally advanced disease refers to prostate cancer that is no longer confined to the prostate and has started to invade nearby organs such as the seminal vesicles, but where there is no evidence of distant spread (T3 – T4).
Patients with locally advanced prostate cancer can present with a variety of symptoms but may occasionally be asymptomatic (Table 2.1). Patients may also be investigated for prostate cancer as a result of an elevated prostate specific antigen (PSA) level.

Localised disease
Locally advanced disease
Dysuria
All symptoms of localised disease
Frequency
Haematuria
Hesitancy
Incontinence
Impotence
Loin pain or lack of urination resulting from ureter obstruction
Sensation of incomplete emptying
Pain in the perineum or pubic area
Urge incontinence
Symptoms of kidney failure
Urgency
Urinary tract infection
Weak urine stream

Table 2.1 Presenting symptoms generally noted with localised and locally advanced disease (symptoms may not necessarily be restricted to localised or advanced disease).

Locally advanced prostate cancer can present with symptoms of bladder outflow obstruction (frequency, hesitancy or poor flow when urinating), although this presentation can also be due to concomitant benign disease, benign prostatic hyperplasia (BPH).

Other symptoms of locally invasive prostate cancer can include:
  • blood in the urine (haematuria) and difficult or painful urination (dysuria) as a result of direct invasion of the cancer into the prostatic urethra, and urinary incontinence resulting from invasion of the urethral sphincter
  • an inability to maintain an erection (erectile dysfunction) may present if the tumour has extended beyond the prostatic capsule and is affecting the adjacent neurovascular bundles.
  • constipation or rectal bleeding may occur as locally advanced disease impinges on the distal rectum (less frequent).
Metastatic prostate cancer

Metastatic disease refers to prostate cancer which has spread well outside the prostate and local tissues and involves multiple lymph nodes (N+) and other sites such as the bone (M+)

Frequently observed symptoms of metastatic prostate cancer are shown in Table 2.2. The main presenting symptom of metastatic disease is pain resulting from bony metastases, particularly in the pelvis and lower spine; sudden onset, low back pain can be an important diagnostic feature of metastatic prostate cancer.

Metastasis in the lymph nodes causes lymph node enlargement. The lymph nodes local to the prostate in the pelvic area and lower back are usually the first to be affected, with more distant sites becoming involved as the disease advances. Systemic metastases may produce a number of general symptoms such as lethargy, weight loss and wasting (called cachexia) and, occasionally, haemorrhage.

Distant metastases
Widespread metastases
Bone pain or sciatica
Lethargy
Paralysis in the legs secondary to spinal cord compression
Weight loss and wasting (cachexia)
Lymph node enlargement Cutaneous and bowel haemorrhage (unusual)
Loin pain or loss of urination due to ureteric obstruction by the lymph nodes


Table 2.2 Presenting symptoms of metastatic prostate cancer.

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