Clinical Presentation

Prostate carcinoma with all its significant prevalence is also quite heterogeneous in its clinical forms. Prostate cancer rarely causes symptoms early in its course, since the malignancy arises in most patients posteriorly, in the peripheral portion of the gland, away from the prostatic urethra. Actually, once symptoms are noticed, it usually implies locally advanced or even metastatic disease. As the prostate carcinoma involves the urethra or bladder neck, obstructive voiding symptoms general develop. These symptoms include hesitancy, slowing of the urinary stream and intermittent flow. Irritative voiding symptoms, including frequency, nocturia, urgency and urge-related incontinence, also may occur. These symptoms are not significantly different than those symptoms associated with progressive benign prostatic hyperplasia, although they usually occur with a more rapid onset in the prostate cancer patients, with the duration of symptoms measured in months as opposed to years. As the tumor continues its local progression, patients may notice either hematospermia or decreased ejacu-latory volume secondary to ejaculatory duct obstruction. Erectile dysfunction as a consequence of extension beyond the capsule of the prostate by the malignant process and involvement of the neurovascular bundle(s) with local tumor progression may occur. In later stages of locally advanced prostate cancer, even the corpora cavernosa may be directly involved.

Signs of metastatic prostate cancer are most often related to bony pain as a result of tumor involvement within the axial or appendicular skeleton. Anemia may result if sufficient bone marrow stores are replaced by the carcinoma. Genital and lower extremity edemas are related to the invasion and subsequent obstruction of the local lymphatics as well as compression of the iliac veins by lymph node enlargement. With advanced disease, any organ or system may be involved. In rare cases, isolated metastatic lesions to various organs including the central nervous system may be the first clinical manifestation of prostate cancer. Yet, the percentage of patients with symptomatic prostate cancer diagnosed because of these symptoms has declined proportionally to the vast majority of patients in the USA now being diagnosed based upon PSA screening.5

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