Conditions of the Prostate Flashcards
prostate - anatomy
*fibroglandular tissue comprised of 3 zones:
1. peripheral zone
2. transitional zone
3. central zone
prostate - physiology review
*secretes prostatic fluid and prostate specific antigen (PSA)
*contracts during ejaculation to expel semen and prevent retrograde flow into the bladder
benign prostatic hyperplasia (BPH) - epidemiology
*men > 45 years old
*affects > 50% of men after age 60
benign prostatic hyperplasia (BPH) - overview
*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
benign prostatic hyperplasia (BPH) - key symptoms
1. weak urinary stream
2. increased urinary frequency
3. urinary urgency
*other: nocturia, dysuria, urinary hesitancy, dribbling, or intermittency, sensation of incomplete bladder emptying
benign prostatic hyperplasia (BPH) - pathophysiology
*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
benign prostatic hyperplasia (BPH) - physical exam
*digital rectal exam: non-tender, smooth, elastic, and firm enlarged prostate
benign prostatic hyperplasia (BPH) - complications
*urinary retention
*bladder diverticula
*recurrent UTIs
*hydronephrosis
benign prostatic hyperplasia (BPH) - classic vignette
“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.”
benign prostatic hyperplasia (BPH) - treatment: smooth muscle relaxation
*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
benign prostatic hyperplasia (BPH) - treatment: reduction of prostate size
*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
prostate adenocarcinoma - overview
*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
prostate adenocarcinoma - epidemiology & risk factors
*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
prostate adenocarcinoma - cancer screening
*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
prostate adenocarcinoma - diagnosis
*diagnosis requires prostatic biopsy
*buzz words for biopsy findings: invasive glandular pattern with prominent nucleoli
prostate adenocarcinoma - cancer grading
*Gleason scoring system: assess differentiation and aggressiveness
*higher score = more undifferentiated cells with minimal gland formation = poor prognosis
prostate adenocarcinoma - metastasis
- 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 - lymph nodes: pelvic and para-aortic lymph nodes
prostate adenocarcinoma - treatment
*treatment tailored based on whether disease is localized or advanced
1. prostatectomy (local)
2. androgen deprivation therapy (GnRH analogues)
prostate adenocarcinoma - classic vignette
“A 65yo male presents with very mild urinary symptoms with some low back pain. On digital rectal exam, there is a nodular, asymmetric prostate.”
acute prostatitis - overview
*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
acute prostatitis - common pathogens in young, sexually active males
- gonorrhea: gram negative diplococci, oxidase positive, intracellular
- chlamydia: “elementary” and “reticulate” body; obligate intracellular
note - E. coli is also a problem
acute prostatitis - common pathogens in older men
- E. coli: gram negative rod, lactose fermenting, indole positive, facultative anaerobe
- Pseudomonas: gram negative rod, obligate aerobe, non-lactose fermenting, oxidase positive
acute prostatitis - treatment
*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
acute prostatitis - classic vignette
“40yo male presents with dysuria, fever, perineal pain, and urinary frequency. Digital rectal exam reveals a tender, boggy prostate.”
