Conditions of the Prostate

Question 1

prostate - anatomy

Answer 1

*fibroglandular tissue comprised of 3 zones:
1. peripheral zone
2. transitional zone
3. central zone

Question 2

prostate - physiology review

Answer 2

*secretes prostatic fluid and prostate specific antigen (PSA)
*contracts during ejaculation to expel semen and prevent retrograde flow into the bladder

Question 3

benign prostatic hyperplasia (BPH) - epidemiology

Answer 3

*men > 45 years old
*affects > 50% of men after age 60

Question 4

benign prostatic hyperplasia (BPH) - overview

Answer 4

*benign nodular hyperplasia of the stromal and epithelial cells of the prostate that results in lower urinary tract symptoms (LUTS)
*most often involves the transition zone (surrounds prostatic urethra)
*progresses very slowly

Question 5

benign prostatic hyperplasia (BPH) - key symptoms

Answer 5

1. weak urinary stream
2. increased urinary frequency
3. urinary urgency
*other: nocturia, dysuria, urinary hesitancy, dribbling, or intermittency, sensation of incomplete bladder emptying

Question 6

benign prostatic hyperplasia (BPH) - pathophysiology

Answer 6

*androgen-mediated proliferation through dihydrotestosterone (DHT); failure of venous spermatic drainage
*BPH → urethral compression → bladder outlet obstruction (BOO) → increased bladder smooth muscle tone, decreased compliance

Question 7

benign prostatic hyperplasia (BPH) - physical exam

Answer 7

*digital rectal exam: non-tender, smooth, elastic, and firm enlarged prostate

Question 8

benign prostatic hyperplasia (BPH) - complications

Answer 8

*urinary retention
*bladder diverticula
*recurrent UTIs
*hydronephrosis

Question 9

benign prostatic hyperplasia (BPH) - classic vignette

Answer 9

“A 65yo male presents with progressively worsening urinary frequency, nocturia, and difficulty initiating urination over the past year. On digital rectal exam, the prostate is symmetrically enlarged and non-tender.”

Question 10

benign prostatic hyperplasia (BPH) - treatment: smooth muscle relaxation

Answer 10

*alpha-1 blockers: terazosin, tamsulosin
-RELAX smooth muscle around bladder neck and prostate
-improve lower urinary tract symptoms of BPH
-ADEs: orthostatic hypotension and reflex tachycardia

Question 11

benign prostatic hyperplasia (BPH) - treatment: reduction of prostate size

Answer 11

*5alpha reductase inhibitors: finasteride, dutaseride
*INHIBITS CONVERSION OF TESTOSTERONE TO DHT
*decreases prostate volume, reduces risk of urinary retention
*ADEs - sexual dysfunction: ED, low libido, ejaculatory issues

Question 12

prostate adenocarcinoma - overview

Answer 12

*unregulated cellular growth commonly in the peripheral zone and posterior lobe of the prostate
*silent beast - asymptomatic in 68% of cases
*digital rectal exam findings: asymmetric, hard, and nodular prostate

Question 13

prostate adenocarcinoma - epidemiology & risk factors

Answer 13

*most common cancer in men (2nd leading cause of cancer death)
*disproportionately higher rates in Black men
*risk factors: increased age, obesity, smoking, FAMILY HISTORY

Question 14

prostate adenocarcinoma - cancer screening

Answer 14

*prostate specific antigen (PSA): made by epithelial cells of prostate gland; exists as both protein bound and unbound (higher bound = more worrisome because the cancer usually releases the bound form)
*PSA can be elevated in several conditions involving prostate, including BPH
*PSA > 10, concerning (50% chance of prostate cancer); PSA < 2.5 normal; in between, DRE may be helpful
*digital rectal exam (DRE) has no real clinical utility on its own

note - screening is all about shared decision making & weighing prevention of prostate cancer death against the known potential harms associated with screening and treatment

Question 15

prostate adenocarcinoma - diagnosis

Answer 15

*diagnosis requires prostatic biopsy
*buzz words for biopsy findings: invasive glandular pattern with prominent nucleoli

Question 16

prostate adenocarcinoma - cancer grading

Answer 16

*Gleason scoring system: assess differentiation and aggressiveness
*higher score = more undifferentiated cells with minimal gland formation = poor prognosis

Question 17

prostate adenocarcinoma - metastasis

Answer 17

1. BONE mets: osteoBLASTIC lesions in spine, pelvis, ribs
   -can see increased serum alkaline phosphatase
   -“sclerotic lesions” (bright white)
   -Batson venous plexus, which connects pelvic veins to the vertebral venous plexus, facilitating bone metastases
2. lymph nodes: pelvic and para-aortic lymph nodes

Question 18

prostate adenocarcinoma - treatment

Answer 18

*treatment tailored based on whether disease is localized or advanced
1. prostatectomy (local)
2. androgen deprivation therapy (GnRH analogues)

Question 19

prostate adenocarcinoma - classic vignette

Answer 19

“A 65yo male presents with very mild urinary symptoms with some low back pain. On digital rectal exam, there is a nodular, asymmetric prostate.”

Question 20

acute prostatitis - overview

Answer 20

*acute inflammation of the prostate, most often due to infection with uropathogens
*usually presents as a sever UTI, with fever, chills, urinary burning, frequency, rectal pain
*digital rectal exam shows tender, boggy prostate
*ascending infection from urethra; most common in ALL groups = E. coli

Question 21

acute prostatitis - common pathogens in young, sexually active males

Answer 21

1. gonorrhea: gram negative diplococci, oxidase positive, intracellular
2. chlamydia: “elementary” and “reticulate” body; obligate intracellular

note - E. coli is also a problem

Question 22

acute prostatitis - common pathogens in older men

Answer 22

1. E. coli: gram negative rod, lactose fermenting, indole positive, facultative anaerobe
2. Pseudomonas: gram negative rod, obligate aerobe, non-lactose fermenting, oxidase positive

Question 23

acute prostatitis - treatment

Answer 23

*prompt recognition and empiric antibiotic initiation
*first line antibiotics = trimethoprim sulfamethoxazole or fluoroquinolone
*MUST CONSIDER ADDING (if young and sexually active):
-ceftriaxone for gonorrhea
-doxycyline for chlamydia

Question 24

acute prostatitis - classic vignette

Answer 24

“40yo male presents with dysuria, fever, perineal pain, and urinary frequency. Digital rectal exam reveals a tender, boggy prostate.”