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Clin Med- Renal/GU > Diseases of the Prostate > Flashcards

Diseases of the Prostate Flashcards

1
Q

Lower urinary tract epidemiology

A

Effects 15-60% of men >40y

Patient impact: increased risk of falls, decreased QOL, depression, impaired ADL’s

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2
Q

Barriers to TX of Male GU Conditions

A

Poor provider/patient communication
Lack of knowledge (provider)
Embarrassment by the provider and patient

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3
Q

Etiology of Lower Urinary Tract symtpoms

A 
Dysfunction of the bladder
Dysfunction of the prostate
Neurologic Disease
Medical Conditions
Medications
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4
Q

normal function of the bladder

A

Stores 300-500ml of urine

Empties to completion after a gentle urge

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5
Q

abnormal function of the bladder

A

(failure to store)
Voiding small amounts frequently
Uncontrollable urge (urgency) to empty
Incomplete emptying

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6
Q

What is the prostate gland?

A

Largest accessory gland of the male reproductive system
Firm, walnut shaped gland
Located at the base of the neck of the bladder
Urethra passes directly through the prostate
Contains small ducts that open into the prostatic portion of the urethra
Produces fluids that aid in reproduction

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7
Q

normal function of the prostate gland

A

Secretes prostatic fluid that is a thin, milky substance w/ an alkaline pH
Helps sperm survive in the acid environment of the female reproductive tract
Helps mobilize sperm after ejaculation

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8
Q

What is the overactive bladder syndrome

A

Syndrome including urinary urgency w/ or w/o incontinence, urinary frequency and nocturia

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9
Q

Benign Prostatic Hyperplasia (BPH)

A

Asymptomatic microscopic detection of prostatic hyperplasia, the benign proliferation of the prostate stroma and epithelium

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10
Q

Storage- Bladder Use

A 
Urgency
Frequency
Nocturia
Urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence
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11
Q

Voiding- Prostate use

A 
Hesitancy
Poor flow/weak stream
Intermittency
Straining to void
Terminal dribbling
Prolonged urination
Urinary retention
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12
Q

Good flow, normal volume

A

consider other medical conditions

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13
Q

Voiding small amounts

A

think bladder

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14
Q

weak flow =

A

think prostate problem

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15
Q

Eval of LUTs

A

Detailed PE
Heart, lungs, abdomen, genitals, prostate and neuro
Laboratory Tests
U/A to r/o infection/hematuria, PSA

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16
Q

Prostate Conditions (acute and chronic causes of LUTS symptoms) (5)

A 
BPH
Acute Bacterial Prostatitis
Nonbacterial Prostatitis
Chronic Prostatitis
Prostatodynia
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17
Q

3 main treatment approaches for OAB treatment

A 
Pharmacologic therapy (eg, anticholinergic/antimuscarinic agents)
Behavioral therapy (eg, bladder training, biofeedback, pelvic floor muscle therapy, and pelvic floor electrical stimulation)
Surgical therapy
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18
Q

Pharmacological agents used for OAB treatment

A

Oxybutinin (Ditropan, Ditropan XL)
Fesoterodine (Toviaz)
Tolterodine (Detrol, Detrol LA)
Solifenacin

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19
Q

BPH

A

Most common benign tumor in men
? genetic component
Incidence increases with age, reaching 90% by the eighth decade of life

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20
Q

Pathophys for BPH

A

Characterized by proliferation of the prostate. Dihydrotestosterone (DHT) is the major hormone responsible for proliferation.
BPH produces nodules that compress the prostatic urethra

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21
Q

Signs/ Symptoms for BPH

A

Obstructive symptoms +/- irritative symptoms
Chronic obstruction predisposes to recurrent UTIs (d/t residual urine in the bladder)
Acute urinary obstruction may occur

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22
Q

Labs for BPH

A

U/A to exclude infection and hematuria: normal
?Serum Prostate Specific Antigen (PSA)
Normally used when screening for Prostate Cancer in combo w/ DRE

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23
Q

Imaging used for BPH

A

CT or renal ultrasound only if there is presence of other urinary tract disease or complications from BPH (hematuria, UTI, CKD, or hx of stone disease)
Cystoscopy only if considering surgery to help determine what approach to use

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24
Q

Treatment for BPH

A

Based on severity of disease
Options include watchful waiting, medical therapy, conventional surgical therapy and minimally invasive surgery
Watchful Waiting
Reserved for patients w/ mild disease

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25
BPH medical therapy
α-Blockers 5α-reductase inhibitors Phosphodiesterase-5 inhibitor Combination Therapy= α-blocker + 5α-reductase inhibitors
26
α-Blockers MOA
: Relax the smooth muscle in the bladder neck and prostate gland reducing bladder outlet obstruction and increasing peak urinary flow rates
27
side effects of α-Blockers
Orthostatic hypotension, dizziness, fatigue, retrograde ejaculation, rhinitis and HA Usually given at night
28
α-1a Blockers
Receptors are localized to the prostate and bladder neck; therefore fewer systemic side effects No dosage titration required Ex. Tamsulosin (Flomax), Silodosin (Rapalfo)
29
5α-reductase inhibitors MOA
Blocks the conversion of testosterone to dihydrotestosterone | Decreases prostate size, increases urine flow rates and improves symptoms
30
2 side effects of 5α-reductase inhibitors
decreased libido and erectile dysfunction
31
Phosphodiesterase-5 inhibitor
Enhances smooth muscle relaxation in the prostate, bladder, and urethra. Not used as first line treatment
32
Phosphodiesterase-5 inhibitor approved to treat what?
Approved to treat signs/symptoms of BPH as well as in men w/ both urinary symptoms and erectile dysfunction (ED) Ex. Tadalafil (Cialis), Sildanefil (Viagra) and Vardenafil
33
Combination Therapy= α-blocker + 5α-reductase inhibitors
have been shown to reduce the risk of progression of dz and reduce the long term risk of acute urinary retention and need for invasive surgery **Increased side effects w/ combo therapy as well as increased cost to the patient
34
Transurethral resection of the prostate (TURP) | BPH- Conventional Surgical Therapy
Endoscopic prostatectomy Under a spinal anaesthetic 1-2 day hospital stay
35
Transurethral incision of the prostate (TUIP) | BPH- Conventional Surgical Therapy
Used in men w/ mod to severe symptoms and small prostates w/ posterior commissure hyperplasia or an elevated bladder neck.
36
Open simple prostatectomy | BPH- Conventional Surgical Therapy
Performed when the prostate is too large to remove endoscopically
37
what are 4 BPH- Minimally Invasive Surgery
Laser Therapy Ablation of prostate gland Transurethral needle ablation of the prostate (TUNA) Transurethral electrovaporization of the prostate Hyperthermia
38
what is Transurethral needle ablation of the prostate (TUNA)
Similar patient improvement to TURP | Radiofrequencies are used to heat the tissuecoagulative necrosis
39
Etiology of Acute Bacterial Prostatitis
Caused by gram negative rods (E.coli and Pseudomonas species), less commonly gram positive organisms
40
pathophys of acute bacterial prostatitis
Ascent of bacteria up the urethra | Reflux of infected urine into the prostatic ducts
41
symptoms of acute bacterial prostatitis
Perineal, sacral or suprapubic pain Fever Irritative voiding complaints (urgency, frequency, nocturia) common Obstruction symptoms may develop as the acutely inflamed prostate swells urinary retention
42
What is found on physical exam of acute bacterial prostatitis
Fever Warm and tender prostate (gentle exam since vigorous manipulations may result in septicemia) Prostate described as feeling “boggy” Prostate massage is contraindicated
43
labs found in acute bacterial prostatitis
CBC will reveal leukocytosis w/ a left shift U/A: pyuria, bacteriuria and +/- hematuria GC/Chl probe if at risk for STD Urine culture will be positive
44
Uncomplicated (age <35 years, risk of STD) treatment of acute bacterial prostatitis
Treat as an STD and cover for both Chlamydia and Gonorrhea | Ceftriaxone 250mg IM x 1 or Cefixime 400mg po X1, plus Doxycycline
45
Uncomplicated (age >35 years, low risk of STD) treatment of acute bacterial prostatitis
Fluoroquinolone (Cipro 500mg bid x 14 days or Levofloxacin or TMP-SMX Some recommend up to 4 weeks of treatment
46
When to hospitalize a patient with acute bacterial prostatitis
if septic or urinary retention is present Parenteral antibiotics (ampicillin and aminoglycosides) till sensitivity is back, then tailor to culture results Urethral catheterization or instrumentation is contraindicated (retention)
47
prognosis for acute bacterial prostatitis
Rarely develop secondary chronic bacterial prostatitis if not properly treated
48
Etiology of chronic bacterial prostatitis
May evolve from acute bacterial prostatitis Many cases have no hx of acute infection Gram negative rods are most common
49
Symptoms of chronic bacterial prostatitis
Variable Some are asymptomatic Most have some degree of irritative voiding symptoms Low back pain Perineal and suprapubic discomfort Dysuria Many patients report a hx of recurrent UTIs w/ asymptomatic periods in between
50
Physical exam for chronic bacterial prostatitis
Unremarkable Afebrile Prostate may feel normal, boggy or indurated
51
Labs for chronic bacterial prostatitis
U/A is normal Expressed prostate secretions reveal increased leukocytes (not diagnostic, just indicates inflammation) Positive culture of prostate secretions or the post prostatic massage urine specimen is diagnostic
52
Treatment for chronic bacterial prostatitis
``` Antibiotics (duration of 6-12 weeks) Trimethoprim-sulfamethoxazole 160/800mg po bid Ciprofloxacin 250-500mg po bid Ofloxacin 200-400mg po bid Symptomatic Tx NSAIDS and hot sitz baths ```
53
Prognosis for chronic bacterial prostatitis
Difficult to cure Typically results in recurrent urinary tract infections: Can be controlled w/ suppressive antibiotic therapy
54
Etiology for nonbacterial prostatitis
Unknown, therefore a diagnosis of exclusion | Most common of all the prostatitis syndromes
55
Clinical presentation for nonbacterial prostatitis
Identical to chronic bacterial prostatitis, except there is no hx of urinary tract infections
56
Labs for nonbacterial prostatitis
All cultures are negative | There may be increased numbers of leukocytes in expressed prostatic secretions (indicates inflammation, not infection)
57
Treatment for nonbacterial prostatitis
Does not respond to antibiotics NSAIDS or sitz baths for symptomatic relief Dietary restrictions only if certain foods/beverages make symptoms worse
58
prognosis for nonbacterial prostatitis
No serious sequelae | Recurrent symptoms are common
59
What is prostatodynia
Noninflammatory d/o that affects young and middle-aged men Voiding dysfunction Pelvic floor musculature dysfunction
60
Symptoms of prostatodynia
Same as in chronic nonbacterial prostatitis No hx of UTIs Hesitancy, interruption of flow and may describe a lifelong hx of voiding difficulty
61
Labs for prostatodynia
U/A normal Expressed prostatic secretions- normal number of leukocytes (no inflammation) Urodynamic testing: May show voiding and pelvic floor muscle dysfunction
62
Treatment for prostatodynia
Alpha-blocking agents to control bladder neck and urethral spasms Ex. Terazosin, Doxazosin Biofeedback techniques- to help w/ pelvic floor muscle dysfunction Symptomatic relief- Sitz baths
63
What is Erectile Dysfunction (ED)
Inability to attain or maintain an erection for sexual performance
64
Erectile Dysfunction (ED) risk factors
``` DM, obestiy, BPH, HTN, low HDL levels, cardiovascular disease Smoking Spinal cord injury Hx of radiation or surgery of prostate Medications ```
65
Erectile Dysfunction (ED) 3 mechanisms pathophys
1. Failure to initiate Psychogenic, endocrinologic or neurogenic 2. Failure to fill arteriogenic 3. Failure to store adequate blood volume w/in the lacunar network
66
Erectile Dysfunction (ED) Physical exam
Evaluate for signs of HTN, evidence of thyroid, hepatic, hematologic, CV, renal and neurologic dx
67
labs for Erectile Dysfunction (ED)
CBC, serum chemistries, lipid profiles Serum prolactin level PSA Testosterone level
68
Erectile Dysfunction (ED) treatment
Lifestyle changes: weight loss, exercise, smoking cessation, decrease alcohol, refrain from recreational drug use Penile devices Psychological therapy/Sex therapy Surgery
69
Erectile Dysfunction (ED) medications
Oral Phosphodiesterase type 5 inhibitors (PDE-5) Injection therapies Testosterone therapy
70
Vasculogenic- ED
Most common organic cause Disturbance of blood flow to and from the penis Atherosclerosis, traumatic arterial disease, structural alterations
71
PDE-5 Inhibitors for ED treatment
Effective for tx of psychogenic, diabetic, vasculogenic, post-radical prostatectomy and spinal cord injuries Enhance erections after sexual stimulation Onset is 60-120 minutes Contraindicated in men receiving nitrate tx (shock d/t hypotension), CHF and cardiomyopathies (risk of vascular collapse) Ex. Tadalafil (Cialis-longer half life), Sildenafil (Viagra) and Vardenafil
72
Surgery for ED treatment
Implantation of a prosthesis Used as a last resort Invasive, potential complications, expensive High rate of success and partner satisfaction

Clin Med- Renal/GU (7 decks)

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