3 - Prostate Conditions Flashcards
Prostate anatomy
7-8
Acute bacterial prostatitis is MC?
Gram-neg rods
- e. Coli
- pseudomonas
Acute bacterial prostatitis caused by?
Typically ascending infection from urethra and reflux of infected urine into prostatic ducts
Presentation of acute bacterial prostatits?
Abrupt onset of:
- perineal, sacral or suprapubic pain
- fever
- irritative voiding
Prostate swells
- obstruction/urine retention
PE for prostatitis?
High fever
Warm/inflammed/tender prostate
- gentle DRE
Acute bacterial prostatitis pts do not get?
Prostatic massage
- risk of septicemia
Labs for acute bacterial prostatitis?
UA
- pyruria
- bacteriuria
- hematuria
CBC
- leukocytosis
Urine culture
- agent
Acute bacterial prostatitis tx?
Abx (culture sensitivity)
Hospitalization if:
- septicemic
- comorbid
- bad patient
Broad spectrum abx (ampicillin + aminoglycoside)
MC abx for acute bacterial prostatitis?
IV
- fluoroquinolone + aminoglycoside
PO
- fluroquinolone
- septra
4-6 weeks of therapy
If urinary retention developes (acute bacterial prostatitis)
Urethral catheter is contraindicated
- septicemia
Percutaneous suprapubic tube is indicated
Post tx acute bacterial prostatitis pts need?
F/o culture
Chronic bacterial prostatitis comes from?
Same route as acute
May or may not have hx of acute
Presentation of chronic bacterial prostatitis
- irritative voiding
- low back pain
- perineal pain
- hx of UTI
PE for chronic bacterial prostatitis?
Unremarkable (afebrile)
Prostate can be:
- normal
- boggy,
- indurated
- palpable prostatic calculi
Labs for chronic bacterial prostatitis?
UA and culture
- likely normal
Prostatic secretions
- H leukocytes
- culture
CBC
- leukocytosis
Unlike acute, chronic bacterial prostatitis needs?
Prostatic massage
- get the secretions
Pics on slide 20
chronic bacterial prostatitis tx?
Difficult to attain therapeutic abx levels
Abx
- septra
- fluoroquinolone
- other (dont care, slide 21)
Symptoms
- NSAID
- sitz baths
chronic bacterial prostatitis prognosis?
Difficult to cure
Recurrent disease
Infected prostate stone may develope
chronic bacterial prostatitis may need? (tx)
Suppressive abx to control symptoms and recurrent UTI
MC prostatitis?
Chronic nonbacterial prostatitis
Chronic nonbacterial prostatitis is?
Prostate inflammation
- w/o infection
Ukn cause
Chronic nonbacterial prostatitis clinical presentation?
Similar to chronic
- no h/o UTI
Labs for Chronic nonbacterial prostatitis?
H leukocytes on expressed secretions
- inflammation not infection
Neg cultures
Chronic nonbacterial prostatitis tx?
Trial of abx against atypicals
- erythromycin
NSIADS
Sitz baths
Chronic nonbacterial prostatitis sequela?
None, its annoying but not a big deal
Prostatodynia is?
Non-inflammatory d/o
Young/middle aged males
Causing voiding dysfunction and pelvic floor musculature dysfunction
With Prostatodynia?
Prostate is normal
Prostatodynia presentation?
Same ssx as chronic prostatitis
No h/o UTI
NO fever
Poss hesitancy and flow interruption
Labs and PE for Prostatodynia?
Unremarkable/normal
Prostatodynia tx?
Alpha blocker - bladder neck and urethral spasms Diazepam - pelivc floor dysfunction Sitz baths - symptomatic relief
Prostatodynia that is unresponsive to empiric tx?
Urodynamic testing
- r/o dysfunctional voiding
High speed prostate chart?
Slide 29
BPH pathogenesis?
Not understood
- maybe endocrine
- maybe multifactorial
factors for developing BPH?
- Dihydrotestosterone (DHT)
- Age
Pathology for BPH?
5-alpha-reductase converts testosterone to DHT -> promotes prostate cell proliferation -> BPH
Hyperplatic process
- high cell #
Nodular growth pattern
- variable stroma or epithelium
BPH occurs in the?
Transition zone
- pic on 34
BPH causes?
Hyperplasia
- mechanical obstruction of urethra
- bladder outlet resistance
Big Prostate size on DRE
With BPH size?
Doesnt matter
- but seriously it correlates poorly w symptoms
BPH symptoms
Obstructive
- hesitancy
- Low force/caliber of stream
- incomplete emptying
- double voiding
- straining to urinate
- postvoid dribbling
Irritative
- urgency
- freq
- nocturia
most important tool for BPH eval?
AUA (americal urological association) symptoms index
- self-administered questionnaire
- ID pts who need hterapy
7 questions to quantify severity of obstuctive irritative complaints
Pic on 40
BPH hx questions?
Prostate ca
UTI
Neurogenic bladder
Urethral stricture
BPH PE
DRE
- prostate size and consistency
- smooth, firm, elastic enlargement of prostate
Abdominal exam
- bladder distention
If prostate is indurated?
Further w/o to r/o cancer
- PSA
- TRUS (transrectal ultrasound)
- biopsy
BPH labs?
UA - exclude
- hematuria
- infection
Serum PSA
Seum BUN/creat
- r/o obstructive uropathy (postrenal azotemia)
Optional
- urodynamic
- PVR (post void residual)
BPH imaging/
Renal US/CT if: - concomitant UT disease - BPH complications — hematuria — UTI — CKD — H/O stones
BPH ddx?
Obstructive conditions
UTI
Bladder ca
Neurogenic bladder
Mild symptoms (AUA 0-7) tx?
Watchful waiting
- risk is uncertain
- progression is not inevitable
- f/u interval not defined
Moderate to severe BPH sx tx?
Options
- watchful waiting
- surgery
- med therapy
Absolute surgical indications
- refractory urine retention
- large bladder diverticula
- BPH sequellae
BPH sequelae?
- recurrent UTI
- recurrent/persistent gross hematuria
- bladder stones
- CKD
Pharmacotherapy for BPH?
Alpha blockers
- prazosin
- doxazosin
- terazosin
Alpha-1a blockers - receptor-specific and fewer s/e than alapha blockers
- tamsulosin
- alfuzosin
5-a-reductase inhibitors
- finasteride
- dutasteride
PDE-5 inhibitors
- tadalafil (pts w BPH and ED)
Phytotherapy
How do 5-a-reductase inhibitors work?
Block conversion of test - DHT
Improves symptoms
Combo therapy for BPH?
Alpha-blocker + 5-a-reductase inhibitor
Dozxazosin + finasteride
Wha tis phytotherapy?
Plants/extracts for medical purposes
- saw palmetto berry
- phygeum africanum bark
- pollen extract
- echinacea purpurea root
- hypoxis rooperi root
No good trials to prove efficacy
Minimally invasive therapy for BPH?
TULIP: transurethral laser-induced prostatectomy
TUNA: transurethral needle ablation of the prostate
Transurethral electrovaporization of the prostate
Microwave hyperthermia
Implant to open prostatic urethra
Conventional surgery for BPH?
TURP - transurethral resection of the prostate
- can be endoscopic (95%)
- 1-2 days in hospital
TUIP - Transurethral incision of the prostate
- open simple prostatectomy (when prostate is too large to remove endoscopically)
Other options for BPH tx?
Botox injection
- off label
Prostate cancer stages?
Slide 61
Stage I - stage IV
Prostate cancer usually has? (Symptoms)
Asymptomatic
- if symptomatic - wt loss, bone pain etc
Prostatic induration on DRE
PSA elevation
prostate cancer factoids
MC non-cutaneous cancer detected in US
2nd leading cause on cancer related death
Risk factors for prostate cancer?
Age
AA
Fam hx
High fat intake
Prostate ca ssx?
Early - asymptomatic
Late/metastatic - symptoms
- lumbar spine pain (red flag)
Obstructive/irritative symptoms
PSA numbers?
Normal <4ng/mL
Confined to prostate <10ng/mL
Advanced >40ng/mL
But… no level absolutely excludes or diagnoses ca
PSA testing cannot?
Determine tx decisions
- refer for US/biopsy
Other labs for prostate cancer?
Urinary retention
- H BUN
- H creatinine
Skeletal metastases
- H alk phos
- Hypercalcemia
If your pt has an abnormal DRE or PSA they are getting?
TRUS guided biopsy
- transrectal ultrasound
Definitive diagnosis
Imaging for prostate cancer?
MRI
- prostatic lesions and regional lymph nodes
Radionuclide bone scan
- detect skeletal metastasis
Indications for radionuclide bone scan
- advanced local lesion
- symptoms of metastases
- high grade disease
- H PSA (>20ng/mL)
Tx for prostate ca
Controversial
- survival benefit of tx is not conclusive
Most pts w expected survival in excess of 10 yrs should be considered for tx
- otherwise active surveillance
Prostate cancer treatment options?
Radical prostatectomy
- seminal vesicles, prostate, and ampulle of vas removed (stage T1 and T2)
Brachyotherapy
- perm/temp radioactive stuff in prostate
Cryosurgery
- freeze/destroy tissue
Androgen deprivation
- hormonal therapy
Prostate cancer prognosis?
CAPRA nomogram
- big complicated paper thing to calculate slides 76-78
Prostate cancer prevention
Antioxidants - lycopene Cruciferous veggies - broccoli Vitamin D Omega 3 fa
So eat veggies and fruit if you want your dick to work in the old folks home
L BMI Dont smoke High fiber/low fat diet Green tea L ETOH
Prostate ca screening?
Begin at age 50 for:
- average risk whites
Begin at 45 for:
- blacks
- fam hx
- BRACA 1
Stop screening when life expectance is <10 yrs
PSA and age/?
PSA gradually increases w age
Slides i skipped
82-86 its more screening bs
Prostate cancer screening tests?
PSA velocity
- serial PSA
- PSA change >0.75ng/mL per yr is cancer
PSA density (free PSA/total PSA)
- free PSA >25% - ca unlikely
- Free PSA<10% - 50% chance of ca
I bought some shoes from a drug dealer, i’m not sure what he laced them with but…
I’ve been tripping all day
