1. Case Presentation
Dr. Muhammad Humayun Kabir
MBBS, FCPS, MRCS(Edin)
BSMMU, Dhaka, Bangladesh

2. Particulars of patient
● Name: Mohiuddin Ahmed
● Age: 67 years
● Sex: Male
● Occupation: Retired service holder
● Address: Dhaka
● Date of admission: 09.15.15
● Date of discharge:

3. Presentation
Urinary frequency, urgency, occasional
dribbling of urine and nocturia 06 months
back.

4. HISTORY OF PRESENT ILLNESS
According to the statement of the patient, he was reasonably
alright about 06 months back. Then he developed lower urinary
symptoms in the form of urinary frequency, poor urine flow,
occasional dribbling of urine and nocturia. He also complained
of difficulty in initiating voiding and a sense of incomplete
evacuation. He had a feeling of epigastric and lower abdominal
discomfort. His symptoms were worsening rapidly.

5. With this complaints, he consulted a private hospital in Dhaka
where he was investigated and was advised to admit in
BSMMU. On 04.02.15, pt got admitted in the department of
Hepatology, BSMMU. On the next day (05.02.15), he was
catheterized, was further evaluated and treated conservatively.
On 14.02.15 a referral was sent to department of Urology,
BSMMU.

7. He does not give any history of:
• Bleeding during micturition
• Passage of any stone during micturition
• Cough, haemoptysis, chest pain, bone pain or
dyspnoea.
• fever with chills and rigor
• Traumatic injury to the spine

8. He is normotensive, non diabetic and non asthmatic.
Family history: Married, having 3 children, all are in good
health.
Personal history: Non-smoker
History of allergy: No known history of allergy to any drug or
food.
Systemic enquiry reveals no other abnormality.

9. General Physical Examination
● Appearance: normal looking
● Behaviour: Co-operative
● Anaemia: absent
● Jaundice: absent
● Pulse:80 bpm
● BP:120/70 mm of Hg
● Respiration: 18 breaths/min
● Oedema: absent
● Dehydration: absent
● JVP: not raised
● Lymph nodes: not enlarged
● Heart: S1S2 normal, no added sound

10. Abdominal and
genitourinary examination
Inspection:
● Patient is catheterized using a 16 Fr bichannel Foley catheter
connected with a closed collecting bag containing about 200 ml
straw coloured urine.
● Abdomen is normal in shape with centrally placed inverted
umbilicus
● No visible lump, engorged vein or any scar mark
Palpation:
● No palpable lump, no tenderness.
● Liver, spleen and kidneys are not palpable
● Renal angle: non-tender
● Urinary bladder: not palpable
● Testes and both epididimis: normal

11. Percussion:
● No ascites
Auscultation:
● Bowel sound present
DRE:
● Perianal sensation- intact, anal tone – normal
● Prostate is moderately enlarged, hard in consistency,
irregular surface with few hard nodules involving both
the lobes, overlying mucosa is free, median sulcus is
obliterated.

12. Lower limb neurological and other systemic
examination revealed no abnormality.

13. Investigations available at the time of referral were:
Date
28.01.15
05.02.15 ( After
catheterization)
07.02.15 14.02.15
S. Creatinine
(mg/dl)
6.33 5.3 2.6 1.0

24. 07.02.15
●S. PSA: 43.2 ng/ml
●CA 19-9: 11.6 U/ml ( normal upto 35 U/ml)
●CEA : 2.93 ng/ml (Normal upto 5.0- non smoker, 10 - smoker)

26. ●Patient underwent TRUS guided prostate biopsy in the
department of urology, BSMMU (after antibiotic prophylaxis
and bowel preparation ) on 28.02.15 as OPD basis and tissue
sent for histopathology.
●His postoperative period was uneventful. He was catheterized
again and advised to consult with HPR report.

30. ●Patient was counseled regarding the disease process and treatment options. He chose bilateral
orchidectomy rather than Injecting gosereline monthly/ 3 monthly.
●On 09.03.15: Tab Flutamide 250 mg tds started.
●Bilateral orchidectomy was done under LA at Minor Operation theatre. Antibiotics and appropriate
analgesics were prescribed.
●Serum PSA and S. testosterone were advised after the operation.

31. Investigations
Date
28.01.15 05.02.185 07.02.75 14.02.15
14.03.15
(Bil.
orchidectomy
done)
09.05.15
S. Creatinine
(mg/dl)
6.33 5.3 2.6 1.0 0.83
S. PSA
(ng/ml)
43.2 55.12 0.09
S.
Testosterone
(ng/dl)
92.60 <0.20

32. ●Patients catheter was removed one week after three orchidectomy after 2 days of intermittent
clamping of catheter but patient failed to void. Pt was again catheterized.
●Two attempts of TWC were failed within last one month.

33. USG of KUB region (09.05.15)

34. USG of KUB region (09.05.15)

35. USG of KUB region (09.05.15)
Comment:
●Bilateral HDUN
●Cystitis
●Intravesical protrusion of median lobe of the prostate.
●Prostate volume 20 cc

36. Operation note
●Date: 11.05.15
●Name of operation: TURP
●Indication: Metastatic carcinoma of the prostate (post orchidectomy status) with refractory urinary
retention.
●Anesthesia: SAB
● Findings:
●Postoperative period:

37. Follow up and future management:

38. Hormone Therapy for Prostate Cancer
●It had been known for at least a century that prostatic epithelium undergoes atrophy after
castration

39. Figure: Hormonal interventions and endocrine axis in prostate cancer.
●Figure 109–1. Hormonal interventions and endocrine axis in prostate cancer.

42. MECHANISMS OF ANDROGEN AXIS BLOCKADE
Four therapeutic approaches for androgen axis blockade in current clinical use:
1) ablation of androgen sources,
2) inhibiting androgen synthesis,
3) antiandrogens, and
4) inhibition of LH-RH and/or LH release.
Ablation of Androgen Sources
Bilateral orchiectomy quickly reduces circulating testosterone levels to less than 50 ng/dL. Within 24
hours of surgical castration, testosterone levels are reduced by greater than 90%.

43. Inhibition of LH-RH: LH-RH Agonists
●The LH-RH agonists exploit the desensitization of LH-RH receptors in the anterior pituitary after
chronic exposure to LH-RH, thereby shutting down the production of LH and, ultimately,
testosterone.
●The initial exposure to more potent agonists of LH-RH results in a flare of LH and testosterone
levels. This ‘flare up phenomenon’ can result in a severe, life threatening exacerbation of
symptoms.
●The flare, associated with up to a 10-fold increase in LH, may last for 10 to 20days.
●Coadministration of an antiandrogen functionally blocks the increased levels of testosterone.
●Although it had been argued that the administration of the antiandrogen should precede the
administration of the LH-RH agonist by a week, others have found no differences in PSA levels
with the simultaneous administration of both agents.

44. RESPONSE TO ANDROGEN BLOCKADE
●After the initiation of ADT the vast majority of prostate cancer patients will show some evidence of
clinical response: the magnitude and rapidity of that response remain the best predictors of its
durability.
●An incomplete or sluggish response is evidence of a significant androgen-refractory population.
●Patients who had more than an 80% drop of PSA within 1 month of initiating ADT had a
significantly longer disease-free progression rate.
●A rise in PSA level, which is evidence of the emergence of castration resistant disease, preceded
bone metastatic progression by several months, with a mean lead time of 7.3 months.

45. GENERAL COMPLICATIONS OF ANDROGEN ABLATION
1. Osteoporosis
●The longer a man remains on ADT, the greater the risk of fracture.
Treatment of osteoporosis:
● Smoking cessation, weight-bearing exercise, and vitamin D and calcium supplementation
(1200 to 1500 mg/day and 400 IU/day, respectively)
● Oral alendronate
● bisphosphonate zoledronic acid
2. Hot Flashes
● Not life threatening but are most common side effects of androgen ablation, affecting
between 50% and 80% of patients.
● Described as a subjective feeling of warmth in the upper torso and head followed by
objective perspiration.
● Treatment of hot flashes should be reserved for those who find them bothersome
● progestational agent megestrol acetate (20 mg, twice per day)

46. 3. Erectile Dysfunction and Loss of Libido
●Loss of sexual functioning is not inevitable, up to 20% of men on ADT able to maintain some
sexual activity.
●Treatment for loss of libido is extremely.
●Medical treatments, such as oral phosphodiesterase type 5 inhibitors, or local treatments,
such as intracavernosal injections of alprostadil, can be effective in selected patients but may
not be used over the long term.
4. Changes in Body Habitus
●A loss of muscle mass and increase in percent fat body mass are common in men undergoing
ADT

47. 5. Diabetes and Metabolic Syndrome
6. Gynecomastia
7. Anemia:
●Normochromic, normocytic, and very common:
●Treatment: recombinant human erythropoietin.

48. Combined Androgen Blockade