Clinical Approach To Diseases Of The Prostate Flashcards
Benign prostatic hyperplasia (BPH)
SUPER common in elderly males (90%) get this by 70
Usually presents with the following symptoms
- weak stream/straining
- nocturia
- urinary frequency and urgency
- weak streams
History needs to include
- onset
- duration
- Severity
- recent trauma or neurological issues/damage
Often use the American urological association symptom index to determine grade clincial in tandem with rectal exam
- also assess neurological exam to rule out neurogenic bladder
BPH diagnostics
Always need a serum prostate specific antigen (PSA ) and urinalysis
Can also get a post void residual volume and frequency volume chart
DONT USE:
- ultrasound
- endoscopy of lower urinary tract
- pressure flow studies
Treatment for BPH
Always start with lifestyle
- losing weight
- decrease evening fluid intake
- avoid alcohol, caffeine and highly seasoned foods
Medications
- alpha blockers (tamsulosin and “zosin”)
- 5-alpha reductase inhibitors (“asterides”)
- anticholinergic
Surgery (only if really bad)
- photoselective vaproization of prostate
- transuretheral incision of the prostate
Prostatitis
Infection of the prostate
- affects 10-14% of men in the United States a year
4 subsets
1) acute
2) chronic
3) asymptomatic
- 1-3 shows >10 WBC per HBF
4) chronic pelvic pain
- doesnt show elevated WBC<10 per HPF
Risk factors
- BPH = highest risk
- epididymitis
- orchitis
- urethritis
- UTI
- high risk sexual behavior and history of STDs
- catheterization and cystoscopy
Common pathogens
- E. Coli #1
- pseudomonas
- klebsiella
- enterococcus
- proteus
- serratia
DDX of prostitis
Acute cystitis
BPH
Urinary stones
Bladder cancer
Prostatic abscess
Enterovesical fistula
Foreign body in urinary tract
Acute bacterial prostatitis stuff
PE must include:
- abdominal exam
- genital exam
- digital rectal examination
- CVA tenderness (rule out secondary pyelonephritis)
DONT get a PSA
Always get midstream urinalysis to confirm
Also measure postvoid residual urine volumes if you think there might be an obstruction as well
Patient will be very ill appearing and show >10 WBCs per HBF on urine dipstick
Treatment = levofloxacin for 4-6 weeks
- if compounding STI = add ceftriaxone usually
Chronic bacterial prostitis
Similar exam stuff as acute neeed to be done
patient is NOT ill appearing But still elevated WBCs in dipstick
- no fever
Always get a urinalysis midstream, pre-post prostatic massage test and post residual volume test to make sure no chronic damage
Often has history of recurrent UTIs, urethritis or epididymitis with the same bacterial strain
- also can show testicular pain, perineal and lower back pain and penile pain
Chronic prostitis/pelvic pain syndrome
Is pelvic pain and lower urinary tract symptoms for more than 3 months
- oftne also shows equal dysfunction
However there is no elevation of WBCs and usually no bacteria found
Prostate cancer
3rd most common cause of cancer death in US men
- 1/7 men in a lifetime will be diagnosed with this
- most cases are localized and easily corrected
- high chances in black men
Always do a Screening test on men 55-69 yrs and old if you have clinical suspicion since often times once symptoms start it is poor prognosis
- don’t screen men above the age of 70
- always always get a PSA first when evaluating
Risk factors:
- older age
- African American
- family history of prostate cancer
Complications to prostate cancer treatment
Urinary incontinence
Erectile dysfunction
Chemotherapy ADRs
Four main factors to stratify risk of prostate cancer progression and recurrence
1) clinical stage
2) pathological grade
3) PSA assay/level
4) comorbidities and life expectancy
the only way to diagnose definitively is prostate biopsy
What types of tests are used as surveillance for patients with confirmed prostate cancer
1) digital rectal examination = at least once a year
2) prostate biopsy = 6-12 months of diagnosis and then every 2-5 years after that
3) prostate-specific antigen assay every 3-6 months
Curative treatments for prostate cancer
1) radical prostatectomy
- less risk for metastatic
- always produces infertility, scarring and urinary incontinence
2) EBRT
- avoids surgical risk and has more precision as time goes on
- still does present with he same risks (lower chance) than conventional surgery. Also adds risks for GI disturbances (diarrhea, blood stool, rectal pain, etc.)
3) Brachytherpy
- only used for patients with low risk prostate cancer but is the least risk for ADRs of all surgical options
Target PSA levels for patients after successful prostate cancer treatment
If using radiation = <1.0 ng/mL
- usually decreases to this level within 6 months-2 years
Prostatectomy = <0.03 ng/mL within 2 months after surgery
- requires subspecality referral if levels increase
Androgen deprivation therapy = <0.05-0.1 ng/mL within 6-8 weeks of initiation
- need to have oncologist monitor if this is the treatment modality
