Snapshot A 65-year-old man presents to the office with slowly progressive trouble urinating. He is still able to urinate but claims that his, "stream is weak." On physical exam external genitalia have no notable abnormalities. On digital rectal exam you note several rock hard nodules on the patient's prostate. Introduction Most common cancer in men and second leading cause of cancer death Risk factors include old age (most men > 80 have a focus of prostate cancer) and family history Presentation Often asymptomatic May present with urinary retention, decrease in urine stream strenth, or back pain (metastatic disease) urinary retention is more likely a sign of BPH Digital rectal exam may show palpable nodule on prostate Evaluation Diagnosis suggested by clinical findings or elevated PSA (mild elevations may be seen with BPH) Diagnoses confirmed with transrectal ultrasound guided biopsy Bone scan and CXR for staging Staging based on Gleasin histologic system Routine evaluation/screening for prostate cancer not clearly recommended Differential BPH, prostatitis, urethral stricture, and neurogenic bladder Treatment Appropiate treatment is controversial because many cases are latent and do not progess while some metatasize Some patients choose close follow up with PSA, digital exams, and imaging cancer may remain asymptomatic Radical prostatectomy, even with nerve sparing, may result in incontinence and impotence Radiation is used in some centers Follow PSA in all patients following treatment Treat metastatic disease with androgen ablation (GnRH agonists + orchiectomy/flutamide) and chemotherapy Prognosis, Prevention, and Complications Metastasis is often perineural or to bone