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Clinical Medicine II > BPH, prostate infections, Prostate/bladder/testicular CA and Incontinence > Flashcards

BPH, prostate infections, Prostate/bladder/testicular CA and Incontinence Flashcards

1
Q

what is needed to develop BPH

A

a functioning testicle

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2
Q

is BPH age related and is it understood

A

yes

BPH is not fully understood but appears to be multifactorial and under the control of the endocrine system

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3
Q

what is the frequency of BPH in the male community

A

20% age 41-50 yr and 80% age >80 yr have BPH

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4
Q

What types of tissue compose the prostate

A

stromal and epithelial tissue make up the prostate

* these tissues can give rise to BPH

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5
Q

Where does prostate cancer originate

A

prostate cancer: from peripheral zone of the prostate

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6
Q

where does BPH originate

A

in the periurethral and transition zones

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7
Q

what types of voiding sx are associated with BPH and what are examples of these

A

both obstructive and irritative voiding sx
*obstructive: decreased force and caliber of stream, intermittent stream and urinary hesitancy (caution with allergy meds)

*Irritative sx: frequency, urgency, nocturia (and dysuria?)

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8
Q

DRE may reveal what in BPH and what may be more indicative of malignancy over BPH

A

DRE may show uniform or focal enlargement of the prostate

  • focal may represent malignancy rather than BPH (need further eval)
  • sx rather than size dictate tx
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9
Q

If focal enlargement of the prostate is found upon DRE, what might you fear

A

fear malignancy… further eval is indicated (prostate ultrasound and tissue biopsy

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10
Q

what dictates prostate tx

A

sx not size of prostate

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11
Q

What lab findings should be performed when assessing BPH

A

BUN/Cr: assess kidney function
UA: r/o infection and hematuria
PSA: cancer detection

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12
Q

when should PSA testing be offered to pt?

A

asymptomatic M > 40 yr with life expectancy of at least 10 yr
*debate on checking PSA in men > 75 yr

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13
Q

When should imaging be performed in BPH pt

A

*imaging not necessary in pt with mild or moderate sx UNLESS hematuria present or Upper urinary tract disease suspected

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14
Q

What is uroflowmetry and what is used for

A

a uroflow eval may be useful in assessing BPH

*total volume must >150mL of urine for this test to be considered reliable

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15
Q

What measurement should be used to help guide BPH tx and a pt’s response to tx

A

POST VOID residual urine measurement

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16
Q

what is cystourethroscopy and when is it used

A

invasive procedure

use cystourethroscopy when BPH dx is uncertain

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17
Q

what are some ddx when considering BPH

A

disorders that cause bladder outlet obstruction:

  • urethral stricture
  • bladder neck contractures
  • bladder calculi
  • cancers of the bladder or prostate
  • UTI and neurologic disease
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18
Q

Besides med tx, how can you treat BPH

A

avoid caffeine, cold/allergy meds (this act like cholinergic thus antagonize “rest and digest”.. they cause vasoconstriction rather than relaxing/voiding)

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19
Q

What is the mainstay med tx for BPH

A

Alpha blockers! bc inhibit vasoconstriction and relax wall of prostate

  1. Cardura or Hytin
  2. Flomax (30 min after meal)
  3. Uroaxtral (w/ meal)
  4. Rapaflo (w/ meal)
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20
Q

what type of meds are cardura, hytin, flomax, uroaxtral, and rapaflo?? what should you let patients know about these meds?

A

alpha blockers commonly used to treat BPH.. relax wall of prostate and inhibit vasoconstriction

*SE: stuffy nose, dizziness, retrograde ejactuation
(these meds oppose sympathomimetics such as allergy/cold meds such as sudafed)

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21
Q

Besides alpha blockers, what other times of meds may be helpful for BPH

A

Type II 5-alpha reductase inhibitors: Proscar, Avodart

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22
Q

What are the SE of the BPH meds Proscar and Avodart. What class of meds are these?

A

Proscar and avodart are type II 5-alpha reductase inhibitors (prevent testosterone to DHT conversion)

SE: low libido, breast tenderness,hair growth
*can take up to 9 months to work thus not for acute tx of urinary retention

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23
Q

What surgical options are available for BPH, which option is the gold standard and what are pros/cons for each?

A
  1. TURP:Transurethral resection of the prostate, aka “roto rooter” is GOLD Standard for BPH tx
    pros = high likelihood of objective and subjective sx improvement
    cons: complications such as incontinence and retrograde ejaculation
  2. Green light laser
    Pro: less bleeding
    Con: don’t get tissue for pathology
  3. TUNA: transurethral Needle Ablation
    cons: takes 6 wks to see benefit
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24
Q

What is gold standard surg tx for BPH

A

transurethral resection of the prostate (TURP)

*complications: retrograde ejaculation, incontinence

25
Q

What are pros/cons of green light laser surg tx for BPH

A

pro: less bleeding
con: no tissue for pathology

26
Q

How is TUNA (transurethral Needle Ablation) surg tx for BPH performed

A

TUNA = Place interstitial radiofrequency (RF) needles through the urethra and into the lateral lobes of the prostate, causing heat-induced coagulation necrosis. A coagulation defect is created
*takes 2 wk to see benefit

27
Q

what is the prognosis for BPH

A

excellent depending on severity and tx; w/ appropriate tx, BPH patients have normal life

28
Q

In primary care, how should you approach BPH pts

A

they CAN be treated in primary care

  • if urinary retention, send to urology for further eval
  • hospital f/u for urinary retention; make sure on alpha blocker
29
Q

What types of prostatitis are there (4 different)

A
  1. acute bacterial prostatitis
  2. chronic bacterial prostatitis
  3. chronic prostatitis w/o infection
  4. symptomatic inflammatory prostatitis
30
Q

what are s/sx associated with prostatits

A

*dysuria, urgency, frequency, weak stream
*perineal pain
*suprapubic pain
*testicle/scrotal pain
*ED
*fever, chills (if acute bacterial)
(pt may have any or all of these sx)

31
Q

pt presents with ED, testicular pain, dysuria, weak stream, suprapubic and perineal pain, fever and chills… what could this potentially be

A

acute bacterial prostatitis

32
Q

What is Acute Bacterial Prostatitis and what causes it

A

Acute bacterial prostatitis = infection of prostate *often caused by the same bacteria that cause bladder infections (E. coli, Klebsiella, Proteus

  • can be acquired as an STD (chlamydia, GC)
  • infection can spread to prostate through blood stream
33
Q

What are some risk factors for Acute Bacterial Porstatitis

A

anything that sllows bacterial colonization or infection of the prostate with potentially pathogenic bacteria:

  1. phimosis
  2. Unprotected penetrative anal rectal intercourse
  3. UTI
  4. Acute epididymitis
  5. Indwelling urethral catheters and condom catheter drainage
  6. Transurethral surgery
34
Q

how should you treat acute prostatitis

A
  • if STD: Ceftriaxone (Rocephin) 250 mg IM + Doxycycline 100 mg BID x 10 d
    • the ceph for GC and tetracycline for chlamydia
  • Cipro 500 mg BID or Levaquin 500 mg qd
  • may need a blocker to assist with urination
  • supportive care
35
Q

What is chronic bacterial prostatitis and what sx are associated

A

Chronic bacterial prostatitis: uncommon illness with ongoing bacterial infection in the prostate.
*generally no sz, occasionally low grade fever/infection

36
Q

What is chronic prostatitis w/o infection. Sx?

A

aka CHRONIC PELVIC PAIN SYNDROME = condition of recurrent pelvic, testicle or rectal pain w/o evidence of bladder infection
*sx: painful urination or ejaculation, ED

37
Q

what is the etiology of chronic prostatitis w/o infection and what sx are present

A

Cause/etiology of chronic prostatitis w/o infection are NOT UNDERSTOOD
sx: recurrent pelvic, testicle or rectal pain w/o evidence of bladder infection

38
Q

what tx recommendations are there for prostatitis beyond meds

A 
sit in warm tub of water
avoid bladder irritants (ie anything acidic or spicy)
avoid sitting
timed voiding
NSAIDS
frequent ejaculation
39
Q

What is the prevalence of prostate cancer in men

A

MOST COMMON CANCER detected in MALES

*incidence does not match prevalence as ~40% of men at autopsy have prostate cancer

40
Q

what PE, lab findings, s/sx might you find in a man with prostate cancer

A
  • DRE: focal nodules or induration (usually asymp)
  • 20% have wt loss or bone pain
  • PSA elevation (may need bone scan - main sz is mets to sacral or low back.. complain of low back pain)
41
Q

What are tx options for prostate cancer

A

watchful waiting
Radical prostatectomy, radiation
possibly androgen deprivation (bc androgens stimulate prostate growth)

42
Q

what is urinary incontinence and how is it classified?

A

urine leaks involuntarily.. classified as

  1. Urge incontinence
  2. Total Incontinence
  3. Stress Incontinence
  4. Overflow Incontinence
43
Q

What is urge incontinence

A

URGE = uncontrolled loss of urine preceded by strong unexpected urge to void (ie pregnant women , neuro abnormalities, or men with bph)

44
Q

what is total incontinence

A

TOTAL = pt loses all urine all the time (stroke pt or pt with nerve loss)

45
Q

What is stress incontinence

A

STRESS = loss of urine associated with increased intra-abdominal pressure (cough, sneeze or exercise)
*no leaking in supine position; cause = weakness in musculature of the pelvic floor (multiparous women, pelvic surg pt)

46
Q

What is overflow incontinence

A

results from chronically distended bladder additional urine; intravesical pressure > outlet pressure = pt dribbles

47
Q

What is the most important in evaluation urinary incontinence?

A

HISTORY! this is the most important step
PE is important to exclude Neuro abnormalities (urge), distended bladder (overflow) and rectal exam (stress/total - ie due to decreased rectal tone)

48
Q

What dx studies are important in a workup for a pt with incontinence

A
  • UA and cultures: exclude UTI
  • Post void US or cath: determine if Residual Urine
  • cystoscopy to eval bladder anatomy

*pt with severe incontinence may require further urodynamic studies

49
Q

how do you treat a pt with URGE incontinence

A

URGE type: may respond to antimuscarinics aka cholinergics

  • Vesicare, Detrol, Sanctura
  • caution with narrow angle glaucoma and in men
  • tell pt to avoid dietary irritants to bladder
  • SE: dry mouth, constipation
50
Q

How do you treat a pt with stress incontinence

A

STRESS type: usually surg tx; try kegel exercises

51
Q

What is the outlook like for pt with incontinence

A

depends on type and severity

52
Q

What are important things to be aware of regarding bladder cancer

A

Bladder cancer is 2nd most common Urologic CA

  • M:W = 7:1
  • risk factors: SMOKING, exposures to DYES and SOLVENTS (account for 75% newly dx cases)
53
Q

What are typical clinical findings associated with Bladder cancer

A
  • HEMATURIA (gross or micro, chronic or intermittent) is presenting sz in 85-90% of pt with bladder cancer
  • Freq/urgency in small % pt due to size/location of cancer
  • hepatomegaly or supraclavicular LAD if mets
  • LE LAD due to locally advanced cancers
54
Q

What are dx findings consistent with bladder CA

A

UA: gross or micro hematuria
*Anemia: due to chronic blood loss or mets to bone marrow

Urine Cytology: useful in detecting cancer at time of initial presentation

CT urogram: checks upper tracts ie Bladder cancer

Cystoscopy and TURP: for dx and staging of cancer

55
Q

DDx bladder cancer.. hematuria

A

bc hematuria is most common sign of cancer…

stones, hematological disorders, infection or trauma

56
Q

how do you treat bladder cancer

A

Intravesical chemo, surg, radiotherapy, gen chemo, or combination of any of these

57
Q

what is the prognosis for pt with bladder cancer

A

depends on tx and extent of cancer

58
Q

How should we approach hematuria in the primary care setting?

A

Blood in urine = NOT NORMAL (even if pt on coumadin)

  • workup with CT urogram to check kidney function and urine cytology
  • refer to urology for cystoscopy

Clinical Medicine II (8 decks)

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