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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
Q

BPH medical therapy

A

α-Blockers
5α-reductase inhibitors
Phosphodiesterase-5 inhibitor
Combination Therapy= α-blocker + 5α-reductase inhibitors

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26
Q

α-Blockers MOA

A

: Relax the smooth muscle in the bladder neck and prostate gland
reducing bladder outlet obstruction and increasing peak urinary flow rates

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27
Q

side effects of α-Blockers

A

Orthostatic hypotension, dizziness, fatigue, retrograde ejaculation, rhinitis and HA
Usually given at night

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28
Q

α-1a Blockers

A

Receptors are localized to the prostate and bladder neck; therefore fewer systemic side effects
No dosage titration required
Ex. Tamsulosin (Flomax), Silodosin (Rapalfo)

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29
Q

5α-reductase inhibitors MOA

A

Blocks the conversion of testosterone to dihydrotestosterone

Decreases prostate size, increases urine flow rates and improves symptoms

30
Q

2 side effects of 5α-reductase inhibitors

A

decreased libido and erectile dysfunction

31
Q

Phosphodiesterase-5 inhibitor

A

Enhances smooth muscle relaxation in the prostate, bladder, and urethra.
Not used as first line treatment

32
Q

Phosphodiesterase-5 inhibitor approved to treat what?

A

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
Q

Combination Therapy= α-blocker + 5α-reductase inhibitors

A

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
Q

Transurethral resection of the prostate (TURP)

BPH- Conventional Surgical Therapy

A

Endoscopic prostatectomy
Under a spinal anaesthetic
1-2 day hospital stay

35
Q

Transurethral incision of the prostate (TUIP)

BPH- Conventional Surgical Therapy

A

Used in men w/ mod to severe symptoms and small prostates w/ posterior commissure hyperplasia or an elevated bladder neck.

36
Q

Open simple prostatectomy

BPH- Conventional Surgical Therapy

A

Performed when the prostate is too large to remove endoscopically

37
Q

what are 4 BPH- Minimally Invasive Surgery

A

Laser Therapy
Ablation of prostate gland
Transurethral needle ablation of the prostate (TUNA)
Transurethral electrovaporization of the prostate
Hyperthermia

38
Q

what is Transurethral needle ablation of the prostate (TUNA)

A

Similar patient improvement to TURP

Radiofrequencies are used to heat the tissuecoagulative necrosis

39
Q

Etiology of Acute Bacterial Prostatitis

A

Caused by gram negative rods (E.coli and Pseudomonas species), less commonly gram positive organisms

40
Q

pathophys of acute bacterial prostatitis

A

Ascent of bacteria up the urethra

Reflux of infected urine into the prostatic ducts

41
Q

symptoms of acute bacterial prostatitis

A

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
Q

What is found on physical exam of acute bacterial prostatitis

A

Fever
Warm and tender prostate (gentle exam since vigorous manipulations may result in septicemia)
Prostate described as feeling “boggy”
Prostate massage is contraindicated

43
Q

labs found in acute bacterial prostatitis

A

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
Q

Uncomplicated (age <35 years, risk of STD) treatment of acute bacterial prostatitis

A

Treat as an STD and cover for both Chlamydia and Gonorrhea

Ceftriaxone 250mg IM x 1 or Cefixime 400mg po X1, plus Doxycycline

45
Q

Uncomplicated (age >35 years, low risk of STD) treatment of acute bacterial prostatitis

A

Fluoroquinolone (Cipro 500mg bid x 14 days or Levofloxacin or TMP-SMX
Some recommend up to 4 weeks of treatment

46
Q

When to hospitalize a patient with acute bacterial prostatitis

A

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
Q

prognosis for acute bacterial prostatitis

A

Rarely develop secondary chronic bacterial prostatitis if not properly treated

48
Q

Etiology of chronic bacterial prostatitis

A

May evolve from acute bacterial prostatitis
Many cases have no hx of acute infection
Gram negative rods are most common

49
Q

Symptoms of chronic bacterial prostatitis

A

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
Q

Physical exam for chronic bacterial prostatitis

A

Unremarkable
Afebrile
Prostate may feel normal, boggy or indurated

51
Q

Labs for chronic bacterial prostatitis

A

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
Q

Treatment for chronic bacterial prostatitis

A 
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
Q

Prognosis for chronic bacterial prostatitis

A

Difficult to cure
Typically results in recurrent urinary tract infections:
Can be controlled w/ suppressive antibiotic therapy

54
Q

Etiology for nonbacterial prostatitis

A

Unknown, therefore a diagnosis of exclusion

Most common of all the prostatitis syndromes

55
Q

Clinical presentation for nonbacterial prostatitis

A

Identical to chronic bacterial prostatitis, except there is no hx of urinary tract infections

56
Q

Labs for nonbacterial prostatitis

A

All cultures are negative

There may be increased numbers of leukocytes in expressed prostatic secretions (indicates inflammation, not infection)

57
Q

Treatment for nonbacterial prostatitis

A

Does not respond to antibiotics
NSAIDS or sitz baths for symptomatic relief
Dietary restrictions only if certain foods/beverages make symptoms worse

58
Q

prognosis for nonbacterial prostatitis

A

No serious sequelae

Recurrent symptoms are common

59
Q

What is prostatodynia

A

Noninflammatory d/o that affects young and middle-aged men
Voiding dysfunction
Pelvic floor musculature dysfunction

60
Q

Symptoms of prostatodynia

A

Same as in chronic nonbacterial prostatitis
No hx of UTIs
Hesitancy, interruption of flow and may describe a lifelong hx of voiding difficulty

61
Q

Labs for prostatodynia

A

U/A normal
Expressed prostatic secretions- normal number of leukocytes (no inflammation)
Urodynamic testing: May show voiding and pelvic floor muscle dysfunction

62
Q

Treatment for prostatodynia

A

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
Q

What is Erectile Dysfunction (ED)

A

Inability to attain or maintain an erection for sexual performance

64
Q

Erectile Dysfunction (ED) risk factors

A 
DM, obestiy, BPH, HTN, low HDL levels, cardiovascular disease
Smoking
Spinal cord injury
Hx of radiation or surgery of prostate
Medications
65
Q

Erectile Dysfunction (ED) 3 mechanisms pathophys

A
  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
Q

Erectile Dysfunction (ED) Physical exam

A

Evaluate for signs of HTN, evidence of thyroid, hepatic, hematologic, CV, renal and neurologic dx

67
Q

labs for Erectile Dysfunction (ED)

A

CBC, serum chemistries, lipid profiles
Serum prolactin level
PSA
Testosterone level

68
Q

Erectile Dysfunction (ED) treatment

A

Lifestyle changes: weight loss, exercise, smoking cessation, decrease alcohol, refrain from recreational drug use
Penile devices
Psychological therapy/Sex therapy
Surgery

69
Q

Erectile Dysfunction (ED) medications

A

Oral Phosphodiesterase type 5 inhibitors (PDE-5)
Injection therapies
Testosterone therapy

70
Q

Vasculogenic- ED

A

Most common organic cause
Disturbance of blood flow to and from the penis
Atherosclerosis, traumatic arterial disease, structural alterations

71
Q

PDE-5 Inhibitors for ED treatment

A

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
Q

Surgery for ED treatment

A

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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