Dz of prostate Flashcards
what is LUTs
lower urinary tract symptoms
effects 15-50% of men >40yo
pt impact increased risk of falls, decreased QOL, depression and Impaired ADL
causes of LUTS
dysfuntion of bladder, prostate
neurologic dz
medical condition
medications
normal bladder function
stores 300-500ml of urine
empties to completion after urge
abnormal function (failure to store)
voiding small amounts frequently
uncontrollable urge
incomplete emptying
function of prostate gland
Secretes prostatic fluid that is a thin, milky substance w/ an alkaline pH
overactive bladder syndrome
syndrome including urinary urgency w or w/o incontinence and urinary freq and noctura
BPH
asymptomatic microscopic detection of prostatic hyperplasia, the benign proliferation of the prostate stoma and epithelium
LUTS storage issues
urgency frequency noctuira urge incontinence stress incontinence overflow incontinence
LUTs voiding
hesitancy poor flow/weak stream intermittency straining to void terminal dribbling prolonged urination urinary retention
how to determine cause of symptoms
weak flow think prostate
voiding small amounts think bladder
good flow, norm volume thing other medical conditions
take home message about OAB and BPH
40-50% of men have coexisting symptoms
OAB tx
anticholinergics, antimuscarinic
bladder training, biofeedback, pelvic floor muscle therapy, electrical stimulation
surgical if necessary
OAB tx guidelines by AUA/SUFU
1st line: behavioral therapy and +/- pharmacologic therapy
2nd line: anticholingergics antimuscarinics
3rd line: surgery
OAB pharmacologic agents
Solifenacin
Oxybutinin
Fesoterodine
Tolterodine
BPH
MC benign tumor in men
genetic componenet
incidence increased w/age reaching 90% by 70’s
BPH patho
characterized by proliferation of prostate dihydrotestosterone (DHT) is the major hormone responsible for DHT
BPH s/s
obstructive/ irritative symptoms
chronic obstruction predisposes to recurrent UTI
Acute urinary bladder obstruction
BPH PE
complete GU/GI
prostate exam: comment on the size and consistency of gland thought this does not correlate to severity of symptoms
neuro exam
BPH labs
U/A exclude infection and hematuria: normal
PSA- used when screening for prostate CA in combo with DRE
use is controversial
BPH imaging
CT or Renal U/S only if there is presence of other urinary tract dz or complications of UTI
Cystoscopy only if considering surgery to help determine what approach to use
BPH tx
based on severity of dz
watchful waiting reserved for pts with mild dz and UAS score 0-7
medical therapy
surgery
BPH medical therapy
alpha blockers
a-1 blockers
a-2 blockers
5α-reductase inhibitors
alpha blockers MOA
relax smooth muscle in the bladder neck and prostate gland reducing bladder outlet obstruction and increasing peak urinary flow rates
alpha 1 blockers
requires dose titration
S/E: orthostatic hypoHTN, dizziness, fatigue, ejaculation, rhinitis
Ex: terazosin, Doxazosin, Prazosin
alpha 1a blockers
receptors are localized to prostate and bladder neck therefore fewer side effects
Ex: Tamsulosin, Silodosin
5α-reductase inhibitors MOA
MOA blocks the conversion of testosterone to dihydrotestosterone
decreases prostate size
reduces baseline PSa 50%
5α-reductase inhibitors
Finasteride
Dutasteride
PDE-5 inhibitor MOA
enhances smooth muscle relaxation in prostate, bladder and urethra
Not used 1st line
Used to tx s/s of BPH in men w/ urinary symptoms and ED
PDE-5 inhibitor drugs
Tadalafil, Sildanefil, Vardenafil
BPH combo 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
BPH tx for small prostate and low PSA and IPSS <7
watchful waiting
BPH tx for prostate large, PSA high and IPSS <7
5 alpha reductase
BPH tx for moderate or severe symptoms with small prostate and low PSA level, IPSS>7
alpha blocker
BPH tx for moderate to severe symptoms with large prostate and high PSA, IPSS>7
5 alpha reductase
or in combo with alpha blocker
BPH surgery
TURP
transurethral resection of the prostate
endoscopic prostatectomy
TUIP
used in men w/mod to severe symptoms and small prostate w/ posterior commissure hyperplasia or elevated bladder neck
Open simple prostate
performed when prostate is too large to remove endoscopically
acute bacterial prostatitis
caused by E.coli and pseudomonas where bacteria ascents up the urethra and reflux of infected urine into prostate ducts
acute bacterial prostatitis symptoms
perineal, sacral, surapubic pain
fever
irritative voiding complaints
acute bacterial prostatitis PE
fever
warm and tender prostate feels boggy
acute bacterial prostatitis labs
CBC will show leukocytosis w/ left shift
U/A pyuria, bacteriuria and hematuria
GC/Chl probe if risk for STD
Urine culture will be positive
acute bacterial prostatitis umcomplicatied age<35 risk of STD tx
treat as an STD
Ceft 250mg IM or Cefixime plus doxy
acute bacterial prostatitis umcomplicatied age>35 low risk of STD tx
Fluoroquinolone (cipro, levo or bactrim)
acute bacterial prostatitis hospitalization
paranteral antibiotics (ampicilling and aminoglycosides) till sensitivity Urethral catheterization or instrumentation CI
chronic bacterial prostatitis
may evolve from acute bacterial prostatitis
chronic bacterial prostatitis symptoms and PE
symptoms: irritative voiding low back pain perineal and suprapubic discomfort dysuria many pts report hx of recurrent UTI PE: unremarkable and afebrile prostate may feel normal or boggy
chronic bacterial prostatitis labs
U/A normal
Expressed prostate reveals leukocytes
Positive culture of prostate secretions or post prostatic message
chronic bacterial prostatitis tx
bactrim
Ciprofloxacin
Olfloxacin
NSAID and sitz bath
nonbacterial prostatitis
dx of exclusion
MC of all the prostatitis’s
nonbacterial prostatitis presentation
mimics chronic bacterial prostatitis except no hx of UTI
nonbacterial prostatitis labs
all cultures are negative
Leukocytes expressed in prostatic secretions shows inflammation
nonbacterial prostatitis tx
NSAID or Sitz bath for symptomatic relief
diet restrictions if certain food make symptoms worse
prostatodynia
noninflammatory d/o that affects young and middle aged men
prostatodynia etiology
voiding dysfunction
pelvic floor musculature dysfunction
prostatodynia symptoms and PE
symptoms: irritative voiding, no UTI Hx
hesitancy, interruption of flow and may describe lifelong hx of voiding trouble
PE: prostate normal
increased sphincter tone
prostatodynia labs
U/A normal
prostatic secretion normal num of leukocytes
Urodynamic testing may show voiding and pelvic floor dysfunction
prostatodynia tx
sitz bath biofeedback to help with muscle dysfunction alpha blocking agents terazosin doxazosin
ED
inability to attain or maintain erection for sex
ED is higher is these populations
DM, Obesity, BPH, HTN, Low HDL, cardiovascular dz
ED RF
smoking spinal cord injury Hx of radiation or surgery of prostate meds psychosocial
Ed patho
failure to initiate
failure to fill
failure to store adequate blood volume in lacunar network
MC type of ED
Vasculogenic-distrubance of blood flow to and from penis
Other is Neurogenic from d/o that affect the spine
ED med induced
thiazides, B-blockers, CCB, digoxin, SSRI, TCA
ED Tx
Lifestyle changes: weight loss, exercise, smoking cessation, deccrease alcohol, refrain from recreation drugs PDE-5 inhibitors Testosterone therapy Penile devices Psychological therapy surgery
ED PDE-5 inhibitors
treats psychogenic, diabetic, vaculogenic
onset 60-120 min
CI w/ men using nitrates, CHF or cardiomyopathies
other ED tx
testosterone for hypogonadism
Vacuum constrictive devices
Intraurethral alprostadil
Infracavernosal injectiong
