BPH, Urinary tract disorders, and prostate ca Flashcards
1
Q
______ tissue comprises 30% of the prostate.
A
glandular
2
Q
______ comprises 70% of the prostate.
A
stroma, it supports the glandular tissue
3
Q
What is the smallest structure in the glandular component?
A
Acini
4
Q
Proliferation of the Acini is what condition?
A
BPH
5
Q
What influences BPH?
A
-testosterone decrease, estrogen and adipose increase deposition
6
Q
Proliferation of what 2 cell types leads to BPH?
A
epithelial and stroll
7
Q
Proliferation of what = cancer?
A
basement membrane
8
Q
Peripheral zone info:
A
- majority of prostatic glandular tissue (70%)
- Origin of 70% or prostate adenocarcinomas
9
Q
Epidemiology of BPH:
A
- *normal part of aging
- Present in 50% of men by age 60 and 90% by 80
- More progressive and more sever in blacks, but prevalence rates are similar
10
Q
Pathophys of BPH:
A
Testosterone -> 5 reductase -> DHT: binds to nuclear receptors in the prostate leading to hyperplasia
A1- adrenergic receptors in:
-Muscle of stroma
-Capsule of Prostate
-Bladder neck responds causing smooth muscle contraction and contribute by worsening urinary symptoms (LUTS)
11
Q
Prostate areas involved in BPH:
A
Transition and periurethral zones:
- epithelium proliferation (divides forms nodular cells
- Acini proliferation (“sitting in the sauce”)
- Smooth muscle proliferation
- Stromal support changes
12
Q
What does growth of the transitional zone cause?
A
urethral obstruction
13
Q
LUTS=
A
- Lower Urinary Tract Symptoms
- Symptoms are classified as voiding (obstructive) or Storage (irritative)
14
Q
What are the obstructive urinary symptoms?
A
- weak stream
- hesitancy
- incomplete emptying
- double voiding
15
Q
what are the irritative urinary symptoms?
A
- urgency
- frequency
- nocturia
16
Q
Urinary incontinence:
A
- paradoxical or overflow incontinence
- urge-related
- Hx or uti
- symptoms exacerbated by cold meds
17
Q
American Urological Association’s BPH symptom score:
A
- how often have you had a sensation of not emptying your bladder completely after you finish urinating?
- how often have you had to urinate again less than two hours after you finished urinating?
- How often have you stopped and started again several times when you urinated?
- how often have you found it difficult to urinate?
- How often have you had a weak stream?
- how often do you have to push or strain to begin urinating?
- How many times did you most typically get up to urinate form the time you went to bed at night until the time you got up in the morning?
18
Q
Normal BPH work-up:
A
- scent of urine
- soiling of undergarments
- DRE
- UA
- BMP
- Baseline PSA
19
Q
Specialty BPH work-up:
A
- Bladder sonogram with measurement of post-void urinary residue (PVR)
- Measurement of urine flow rate/ pattern (Uroflow)
- Transrectal ultrasound
- Cystoscopy (determine best surgical approach, if indicated)
- Upper tract imaging (renal sono or ct if s/s of stones, CKD, hematuria)
20
Q
How do medications of BPH work?
A
- either they open up the gland by relaxing smooth muscle
- or they shrink the gland
- or antimuscarinics
- or combo
21
Q
Meds that open of the gland in BPH tx:
A
- Non-selective alpha-blockers: doxazosin (Cardura), terazosin (Hytrin)
- Selective alpha-blockers: tamsulosin (Flomax, now available as a generic), silodosin (Rapaflo)
22
Q
Meds that shrink the gland in BPH:
A
5-alpha reductase inhibitors: finasteride, dutasteride
23
Q
Antimuscarinics:
A
Oxybutynin
24
Q
How Finasteride shrinks the prostate:
A
Finasteride inhibits the enzyme 5alphareductase (5ARI)
Thus, testo in the prostate not converted to DHT
Prostate shrinks over time
25
indications for surgical tx of BPH:
- symptoms refectory to meds
- urinary retention
- pt can't tolerate meds
- pt prefers surgery
- recurrent UTI attributable to BPH
- Impaired renal function attributed to BPH
26
Confounders of BPH:
```
UTI
Prostatitis
Neurologic disease (CVA/TIA, Parkinson’s, MS)
Dietary indiscretion (caffeine, alcohol, etc.)
Diabetes (polyuria)
Timing of diuretics
OSA (“Does he snore?”)
Advanced cancer of the prostate (rare)
```
27
Prostate Ca epidemiology:
Most common non-skin cancer in men in the U.S.
2nd leading cause of cancer death in men in the U.S.
241,000 new cases annually
28,100 deaths in 2012
Survival – excellent if detected early
28
Prostate cancer screening types:
- PSA
| - DRE
29
PSA-
“prostate specific antigen”
- Enzyme that liquefies ejaculate-sperm swim free
- May have a role in reproduction*
- Sensitivity 21% for any cancer (threshold of 4.0 ng/mL), 50% for high-grade cancer
30
DRE-
digital rectal exam
- Should be smooth, symmetric, no nodules/induration
- Sensitivity 59%, specificity 94%
31
Annual prostate screening:
PSA + DRE
- Tries to answer the question: “Does he need a biopsy??”
- Men < age 50 only if positive family history in 1st degree relative or African American (then age 40)
- “Normal” PSA range: 0.0-4.0
- If positive family history, many lower biopsy threshold to 2.5
32
PSA limitations:
- Non-specific: elevated in benign conditions (BPH, prostatitis), trauma, instrumentation, ejaculation (48 hours)
- DRE has minimal effect on -PSA value (increases 0.26-0.4 ng/mL)
- Altered by 5ARI (finasteride/dutasteride, lower PSA value)
Further refinements:
- Serial measurements
- PSA free percentage (lower = higher risk of cancer)
- Age and race-specific reference ranges
- Take time to retrieve/compare past values!
33
DRE limitations:
-only 85% of cancers arise peripherally (palpable)
34
PSA interpretation:
Know that there are age- and ethnicity-related norms for PSA that range from 1-6.5. Don’t memorize the table.
35
Presentation of Prostate Ca:
-Prostate screening – elevated PSA, nodular prostate, etc.
-Urinary symptoms are rare, usually only when advanced
-Constitutional symptoms:
Weight loss, night sweats
-Bony metastatic symptoms
36
Working up prostate ca:
- prostate needle biopsy (PNB)
- Patient awake
- Topical and injected local anesthetic
- Low but significant risk of prostatitis
- Predictable self-limited bleeding (urine, stool, semen)
- Transrectal ultrasound (TRUS) guidance
37
Prostate Needle Biopsy (PNB):
Sextant sample:
- Right apex, mid, base
- Left apex, mid, base
Variable number of cores depending on size of gland, results of past biopsy, etc.
38
Prostate Cancer grading/ scoring:
Know that Gleason scoring exists and that low numbers are better (indicate low-grade, low-stage tumors)
score= 1-10
39
Staging work-up of prostate ca includes:
Chest X-ray
Comprehensive labs – CBC, LFT’s (alk phos)
Bone scan if PSA >20 ng/mL
CT of pelvis if high risk
40
Tx options of prostate ca:
```
Radical retropubic* prostatectomy (RRP)
Radiotherapy
Brachytherapy “seed” implant
External beam (3-D conformal, IMRT)
Androgen suppressive therapy (AST)
Active Surveillance
```
41
Selection prostate ca tx:
Is the patient treatable at all?
Which modality is likely to give best result?
What does your patient value most?** (incontinence, erectile function, etc.)
42
* Quality of life is determined by....
the person living the life
43
Brachytherapy is best for what?
- localized, contained ca
44
what is brachytherapy?
Brachytherapy seeds are radiated and implanted in prostate They remain in prostate even after radiation has degraded about 60 days.
45
Dyuria:
-pain/burning with urination
46
Hematuria:
-blood in urine
47
urgency:
sudden, strong urge to pass urine
48
frequency:
-complaint of voiding too often
49
UTI:
UTI
| you should probably know this by now
50
Recurrent UTI:
recurrent infection, generally with different organisms or same organism but different susceptibilities
51
Asymptomatic bacteriuria:
-bacteria in urine, w/o significant host response/ symptoms
52
UTI etiology:
- begins with inoculation of the urinary tract (usually from fecal reservoir)
- E. coli (80% of acute cystitis)
- Staph species, Klebsiella, Proteus
53
UTI epidemiology:
50-60% of women have reported having an UTI
54
UTI presentation:
- variable
- Local urinary symptoms – dysuria, SP pressure, frequency, urgency, cloudy/malodorous urine
- Systemic symptoms – fever, malaise, flank pain
55
UTI work up:
- Good history
- Good exam with vitals, check for CVAT, +/- genital exam
- UA +/- culture
56
UA:
Evaluation of mid-stream urine (“clean catch”)
Male: retract foreskin if present, cleanse glans
Female: cleanse perimeatus, separate labia
Begin voiding, sweep under to collect mid-stream
57
Gross exam:
Color – food (beets), infection, medications, blood
Clarity/turbidity – infection, post-prandial, phosphaturia
-Pyridium turns urine orange and can make dipstick unreliable
58
What does dipstick analysis look at?
- Specific gravity
- pH
- Blood
- protein
- glucose
- ketones
- nitrate
- Leukocytes
59
specific gravity:
-hydration status
60
pH:
ranges from 5.0-8.0
>7.5 can be indicative of urea-splitting organisms (Proteus)
<6.0, think uric acid stones
61
blood:
ranges from none to 3+ (large)
Sensitivity is >90%; specificity is lower
False positives: menses, highly-concentrated urine, exercise
Should be confirmed with microscopic analysis
62
Protein:
ranges from none to 4+
63
Glucose:
always abnormal if positive
| Renal threshold corresponds to serum glucose of ~180 mg/dL
64
Ketones:
-sign or hunger or DM
65
Nitrite:
negative or positive
| If positive, likely infection (specificity of ~90%, lower sensitivity)
66
Leukocytes:
ranges from none to 3+ (large); presence of WBC in urine
| Often positive with infection, can also be positive with contamination
67
What does microscopic UA look at?
- RBCs
- WBCs
- Epithelial cells
- Casts
- Crystals
- Bacteria
68
Bacteria in UA:
5 bacteria/hpf reflects 100,000 cfu/mL
| Any bacteria found in male sample should be cultured
69
technique in urine culture:
-freshly voided/catheterizations
70
Who needs urine culture?
```
All men
Women
Recent antibiotic treatment
Early recurrence
DM
Pregnancy or recent pregnancy
Suspect surgical or other anatomic complexity
Symptoms > 7 days
```
71
Some RFs or UTI's (anatomy, behaviors, environment)
Anatomy - female v. male urethra; VUR; incomplete bladder emptying from functional obstruction (neurogenic bladder, diabetic bladder) or anatomic obstruction (BPH, stricture, meatal stenosis), phimosis, kidney/bladder stones
Behaviors - sexual activity, spermicidal use, ?post-coital voiding, ?wiping technique, ?condoms, ?baths instead of showers
Environment - increased host exposure to pathogen
Repeated introduction of contaminated FB (intermittent catheter)
Colonization of chronic FB (indwelling catheter, pessary)
Overgrowth of pathogens due to alteration of host native flora (post-menopausal female)
72
Tx of UTIs
ANTIBIOTICS APPROPRIATE TO THE INFECTION- AND IT’S USUALLY E COLI, but don’t hesitate to culture!
73
UTI prophylaxis:
Reasonable to attempt if infection is recurrent in otherwise straightforward female patient
Usual duration of six months; 50% recur 3 months after stopping
```
First-line:
TMP/SMX SS qHS
TMP 100mg qHS
Nitrofurantoin non-monohydrate 100mg qHS
Second-line: (if allergic, or if recurrent despite first-line agent)
Ciprofloxacin 125mg qHS
Cephalexin 250mg qHS
```
Non-antimicrobial strategies:
Cranberry or lingonberry juice, 20 -30% effective
Vaginal estrogen, 30% effective
Probiotics
74
What percent of open system catheterized pts are bacteriuria by 4 days?
95%
75
Catheter-associated UTI:
Catheters are a problem due inevitable colonization of the bag or tubing, with subsequent extraluminal migration (66%) or intraluminal migration (33%) into the bladder
Open system: 95% of patients are bacteriuric by 4 days
Closed system: rate as low as 5% per day of catheterization, but as high as 50% at 7 days
76
Prolonged catheterization >6 days relative risk?
5.1-6.8
77
Pyelonephritis:
infection of renal parenchyma and collecting system (upper UTI)
78
Pyelonephritis Etiology:
E. coli most common
Also Proteus, Pseudomonas, and Klebsiella
Ascending spread most common, rare hematogenous spread
79
Predisposing factors of Pyeloneophritis:
Obstruction, renal calculi, DM, immunosuppression, congenital anomalies, prolonged catheter, pregnancy
80
Clinical presentation of pyelonephritis:
Fever, chills, malaise, flank +/-radiation (upper tract sxs)
Dysuria, urgency, frequency (lower tract sxs)
N/V
CVAT on affected side is hallmark PE finding
81
Pyelonephritis work up:
UA, urine culture, blood culture, CBC, chem-8
| Renal sonogram to exclude obstruction, especially if history of stones
82
Tx of Pyelonephritis:
IV antibiotics, hydration, blood glucose monitoring, etc.
Low threshold for hospital admission, especially in at-risk individuals (elderly, DM, immunocompromised, pregnant, potentially non-compliant patients)
If urinary tract obstruction, should be decompressed via placement of percutaneous tube or ureteral stent
83
Urinary lithiasis:
calculi within the urinary tract, anywhere from renal calyces to the urinary bladder
84
Urinanary lithiasis Etiology:
chemistry!! (pH, urine concentration/supersaturation)
Ca-stones – hypercalciuria, hyperoxaluria (gastric bypass patient), hypocitraturia (important stone inhibitor), low urine volume
HyperPTH, dietary indiscretion (sodium, oxalate, animal protein), medullary sponge kidney
Uric acid stones – acidic urine (pH < 5.5), elevated serum uric acid
Gout, chronic diarrhea (bicarb loss), DM/metabolic syndrome (low urine pH), dietary indiscretion (animal protein)
Struvite stones – chronic upper tract infection, urease positive organisms (Proteus, Klebsiella); can develop into “staghorn calculi”
Cystine stones – autosomal recessive disorder (leads to cystinuria)
Mucinex stones/HIV drug stones
85
Predisposing factors of urinary lithiasis:
```
Environmental factors (chronic foreign body, factory worker)
Functional abnormalities (high-pressure neurogenic bladder)
Anatomic abnormalities (horseshoe kidney, congenital UPJ obstruction, stenosed infundibulum)
```
86
Epidemiology of Urinary Lithiasis:
- 12% of men and 5% of women will have at least 1 symptomatic stone by age 70
- appears to be increases in US especially SE US
87
Types of calculi:
80% ca- containing (ca oxalate, ca phosphate or mixed)
- 15-20 infection stones
- 5-10 uric acid stones
- 1-5 cystine stones
88
Presentation of 1st time urinary lithiasis:
-renal colic (waxing and waning)
-Location- specific (pain, urinary symptoms
Kidney – often asymptomatic
Proximal ureter – flank pain (sharp, intermittent, severe)
Distal ureter – groin/inguinal pain, can radiate to ipsilateral testicle/labium
UVJ – urinary hesitancy, urgency
Bladder – frequently asymptomatic
```
Other complaints:
Hematuria
Nausea, vomiting
Symptoms of associated illness:
-UTI symptoms, fever, etc.
```
89
Urinary lithiasis work-up:
UA and culture:
- Hematuria (absence does not exclude stone)
- pH <5.5 suggests uric acid stone
- pH >8 suggests infection (struvite) stone
Chem-8:
-assess renal function (creatinine)
CBC:
-if pt appears ill/ febrile
Imaging:
- CT abd and pelvis w/o contrast is nearly 100% sensitive
90
3 tight spots ;) to look for ureteral calculi:
- Ureteropelvic junction (UPJ)
- Iliac vessels / pelvic brim
- UreteroVESICAL junction (UVJ)
91
Likelihood of stones passing:
- 90% in distal ureter and <4 mm will pass spontaneously
- 50% 4-5.9 will pass without surgery
- 20% >6 mm will pass w/o surgery
92
Urinary lithiasis conservative tx:
- a-blocker (flomax), not fad approved for stones but widely used. Contra indicated in infection
- 40-65% more likely to pass stone w/ flomax on board
- strain all urine in anticipation of stone passage
- pain control- narcotics, NSAIDs
- Urology referral if illness, renal failure, unyielding pain n/v
93
Indications for kidney stone surgery:
- Ureteral stone too large to pass
- Persistent/severe pain
- Recurrent urinary tract infection
- High risk non-compliance with expectant management
- Staghorn calculi
94
kidney stone procedures:
ESWL (extracorporeal shock wave lithotripsy)
Ureteroscopy + laser lithotripsy
Percutaneous nephrolithotripsy
Open stone surgery (rare)
95
if stone is retrieved what should you lo0ok at?
composition
96
when do you do metabolic work up on someone who has had a kidney stone?
- recurrent stone formers
- Blood work- serum uric ac id, calcium, magnesium, phosphorus, PTH
- 24 hour UA
97
general recommendations for someone who's had a kidney stone:
- increased hydration, decreased dietary sodium/ oxalate/ animal protein
- no need to avoid dietary calcium. pursue normal calcium diet
98
ESWL
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