Diseases Of The Prostate

Question 1

Gonorrhea

Answer 1

2nd most common infection STD in the US (chlymida is #1)

Humans are only natural reservoir

Is an gram (-) diplococci organism that lives in mucosa of infected patients.

• induces Purulent exudate
• use pili to adhere

can ascend into epididymis or prostate or testicles

Symptoms males:

• dysuria
• urinalysis frequency
• mucopurulent exudate discharge

Symptoms females

• dysuria
• lower pelvic pain
• vaginal discharge
• increased risk for infertility and ectopic pregnancy

Treatment = IM ceftriaxone

• often give doxycycline PO for 10 -14 days to treat potential chlamydia infection (if you cant rule it out or it is)
• if disseminated = IV ceftriaxone plus azithromycin

Uses three strategies to alter its antigenic composition

• 1) saialyated LPS (tries to mimic human oligosaccahrides
  2) undergoes phase variation to express alternative sets of surface molecules at any given time
  3) homologous recombination of pillin gene to prevent antibodies against pilli

Question 2

Neonatal gonorrhea

Answer 2

Can be transmitted if infected mother gives live birth through vagina

Causes ophthalmia neonatorum which is a Purulent infection of the eyes and can cause blindness if not treated

Question 3

Diagnosis fo gonorrhea outside of symtpoms

Answer 3

Culture = chocolate agar

• takes longer
• helps determines antibiotic sensitivity however

Nucleic acid based tests

• rapid and more sensitive
• no data on anti optic sensitivity

Question 4

What organisms can be nongonococcal STDs?

Answer 4

Chlamydia
- most common period

Mycoplasma genitalium

Trichmonoas vaginialis

Question 5

Chlamydia trachomatis

Answer 5

Small gram (-) cocci that is the most common cause of STD in the US 
- are obligate intracellular pathogens (cant make ATP) 

Has tow forms

• elementary body = infectious extracellular
• reticulate body = metabolically active intracellularly

Almost the exact same symptoms of gonorrhea

May show pharyngitis, conjunctivitis, PID, proctitis

Also can cause atypical pneumonia sometimes if pneumoniae subtype.

Can also be neonatal
- newborns = 15% atypical pneumonia And 50% chlymidal conjunctivitis

If patients who are HLA-B27 get this = reactive arthritis will occur

Diagnosis

• DONT gram stain or use culture plates
• MUST use PCR or nucleic acif amplification on voided urine (can also add giemsa or fluorescent antibody smears)

Treatment = azithromycin PO one dose or doxycycline for 7-10 days PO
- add ceftriaxone if you cant rule out gonorrhea infection

Question 6

3 categories of prostatitis

Answer 6

1) acute bacterial prostatitis
- 2-5% of cases
- presents with sudden onset fever, chills, dysuria, perineal pain and bladder outlet obstruction
- if suspected = NEVER do digital rectal exam (pushing it can cause bacteremia)

2) chronic bacterial prostatitis
- 2-5% of cases
- usually caused by recurrent UTI’s
- gradual lower back pain, dysuria, perineal and suprapubic dyscomfort

3) chronic pelvic pain syndrome
- 90-95%
- can be inflammatory or non inflammatory based on presence of leukocytes
- characteristic of chronic pain in the perineum and suprapubic region as well as penis. Is associated with pain with ejactulation also
- diagnosis is always of exclusion and treatment is empirical therapies

Diagnosis is not typically done with biopsy for risk of sepsis increases
- exception is granulomatosis prostatitis since you gotta rule out cancer for this

1/2 treatment = antibiotics for UTI bugs (usually TMP-SMX)

Question 7

What is the most common cause of granulomatous prostatitis

Answer 7

Bacilli Calmette-Guerin (BCG) instillation

- used for treatment of bladder cancers and is a attenuated TB strain

Question 8

Benign prostatic hyperplasia (BPH)

Answer 8

Common cause of prostate enlargement
- almost always occurs in the inner transition zone

Usually presents in men over 40yrs old and 90% of men have this by 80s
- very high yield cause of urinalysis obstruction

Pathophysiology

• excessive DHT stimulation from testosterone conversion in DHT from 5a-reductase.
• DHT promotes prostate cell survival and hyperplasia

If complete obstruction occurs = painful distention of the abdomen and hydronephrosis

Treatment = 5-alpha reductase inhbitors (finasteride) or a1 adrenergic antagonists

Question 9

Caricnoma of the prostate

Answer 9

Adenocarcinoma of the prostate = most common form of cancer in men (accounts for 20%)

• uncommon before age 50
• causes 10% of male cancer deaths
• pathogenesis = requires androgens ALWAYS (if infertile or castrated = will not happen)
• TMPRSS2-ETS fusion gene is the most known genetic link
• also can be PI3K/AKT or loss of function PTEN

Usually arise in the outer peripheral zone/glands (80%)

Metastasis sites:

• urinary bladder
• rectum
• penis
• bone

Adenocarcinoma is

• heredity
• more common in African Americans and Scandinavians and uncommon in Asians
• multiple alleles are present and with each one that you have it adds a multiplicative effect on your chances of getting this
• western countries get this more than eastern (likely diet but unknown)

Often use PSA assay to determine prostate cancer however this has limitations

• PSA is a product of normal prostate epithelium
• often results in over treatment which can cause morbidity effects (erectile dysfunction, urinary incontinence)
• PSA is also elevated in prostatic infarcts, recent ejaculation or prostatitis
• 20-40% of patients who have prostate cancer will show PSA levels below threshold

Question 10

Treatment of prostate carcinoma

Answer 10

Prostatectomy and radiotherapy are #1
- however you need to have a higher Gleason grade, clinical stage and serum PSA values to do this (also all three are important predictors for outcome with radiotherapy)

Sometimes its okay to taker a “wait and see” approach

Advanced ONLY
- orchiectomy and LRHR agonists (prevent testosterone release)