Prostate Cancer Clinical Presentation

Updated: Sep 14, 2018
  • Author: Gerald W Chodak, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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History

Currently, the majority of prostate cancers are identified in patients who are asymptomatic. Diagnosis in such cases is based on abnormalities in a screening prostate-specific antigen (PSA) level or findings on digital rectal examination (DRE). In addition, prostate cancer can be an incidental pathologic finding when tissue is removed during transurethral resection to manage obstructive symptoms from benign prostatic hyperplasia.

Symptoms of local disease

In the pre-PSA era, patients with prostate cancer commonly presented with symptoms that included urinary complaints or retention, back pain, and hematuria. Currently, with PSA screening, most prostate cancers are diagnosed at an asymptomatic stage. When symptoms do occur, diseases other than prostate cancer may be the cause. For example, urinary frequency, urinary urgency, and decreased urine stream often result from benign prostatic hyperplasia.

Symptoms of advanced disease

Advanced prostate cancer results from any combination of lymphatic, hematogenous, or contiguous local spread. Skeletal manifestations are especially common, because prostate cancer has a strong predilection for metastasizing to bone.

Manifestations of metastatic and advanced prostate cancer may include the following:

  • Weight loss and loss of appetite

  • Bone pain, with or without pathologic fracture

  • Neurologic deficits from spinal cord compression

  • Lower extremity pain and edema due to obstruction of venous and lymphatic tributaries by nodal metastasis

Uremic symptoms can occur from ureteral obstruction caused by local prostate growth or retroperitoneal adenopathy secondary to nodal metastasis.

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Physical Examination

Physical examination alone cannot reliably differentiate benign prostatic disease from cancer. Consequently, a biopsy is warranted to establish a diagnosis. Unfortunately, false-negative results often occur, so multiple biopsies may be needed before prostate cancer is detected.

If cancer is suspected, determining whether the disease is localized or extends outside the capsule is important for planning treatment. Obliteration of the lateral sulcus or involvement of the seminal vesical often indicates locally advanced disease.

Findings in patients with advanced disease may include the following:

  • Cancer cachexia

  • Bony tenderness

  • Lower-extremity lymphedema or deep venous thrombosis

  • Adenopathy

  • Overdistended bladder due to outlet obstruction

Neurologic examination, including determination of external anal sphincter tone, should be performed to help detect possible spinal cord compression. Findings such as paresthesias or wasting are uncommon, however.

Digital rectal examination

The DRE is examiner-dependent, and serial examinations over time are best. A nodule is suspicious for malignancy and warrants evaluation. In addition, findings such as asymmetry, difference in texture, and bogginess are important clues and should be considered in conjunction with the PSA level. Change in texture over time also suggests the need for a biopsy.

Cysts or stones cannot be accurately differentiated from cancer based on DRE findings alone. Therefore, maintain a high index of suspicion for noncancerous disorders if the DRE results are abnormal.

If cancer is detected, the DRE findings form the basis of clinical staging of the primary tumor (ie, tumor [T] stage in the tumor-node-metastases [TNM] staging system). In current practice, most patients diagnosed with prostate cancer have normal DRE results but abnormal PSA readings.

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