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Problems with the prostate

01 September 2008

Mr F, a 67-year-old retired headmaster, consulted his GP, Dr G, complaining of urinary hesitancy, a poor urinary stream and nocturia. He was otherwise well, with no history of any significant illness, and took no regular medication. He was referred to Mr U, consultant urologist, and was subsequently seen in his outpatient clinic.

On rectal examination, his prostate was enlarged and firm. There were no other notable physical findings. Blood tests were taken for urea and electrolytes, and a prostate specific antigen (PSA) estimation, and further investigation arranged by way of uroflowmetry with a postmicturition residual measurement. His PSA was elevated at 50 ng/ml, and his maximal flow rate was 7.5 ml per second. His post-micturition residual volume was 120 ml. Mr F was offered transurethral resection of his prostate, which was carried out six weeks later. The operation itself was uneventful, and he passed urine successfully on removal of his urethral catheter. The histopathologist, Dr J, reported the histology of the resected prostatic tissue as benign prostatic hyperplasia.

Three months later, Mr F was seen for review at Mr U’s clinic. He was passing urine with a strong flow and his nocturia had resolved. He was reassured regarding his benign histology and discharged. His PSA was not repeated. Three years later, Mr F consulted Dr G, complaining of severe low back pain and fatigue. A full blood count and plain x-rays of his lumbar spine and pelvis were arranged. His haemoglobin was measured at 7.5 g/l, and his x-rays demonstrated multiple sclerotic areas, suggestive of metastatic malignancy, possibly of prostatic origin. His PSA was subsequently measured at 3000 ng/ml, and urgent review arranged with Mr U.

On rectal examination, Mr F was found to have a hard, craggy prostate. A clinical diagnosis of metastatic carcinoma of the prostate was made, and he was commenced on treatment with hormonal manipulation. A bone scan was subsequently performed, and showed the presence of widespread “hotspots” consistent  with skeletal metastases. Despite aggressive treatment, Mr F died 12 months later. Mr F’s family made a claim against both Dr J and Mr U.

Expert opinion

An expert histopathologist reviewed the slides and found that Dr J had missed a small focus of adenocarcinoma of the prostate. Despite the negative histology report, an expert urologist was also critical of the level of follow up provided to Mr F, particularly in view of his elevated PSA. The claim was settled for a moderate sum.

Learning points

  • With such a high PSA, the urologist should have had a high index of suspicion that this was malignant. However, he was falsely reassured by the report of the histopathologist. If the reports of a test do not accord with your suspected diagnosis, consider a repeat or a review.
  • Follow local guidelines for raised PSA levels. It is important that there are robust systems in place to provide the appropriate follow up. Again, safety netting with the patient is important, so that they also know what symptoms and signs may be a cause for re-consulting.
  • In summary, all investigations and findings need to be balanced against each other. A clinical diagnosis and an elevated PSA in an elderly male should have prompted better follow up.

Further reading

  • NICE Clinical Guideline – Referral Guidelines for Suspected
  • NICE Clinical Guideline – Prostate Cancer Diagnosis and