Final Flashcards
1
Q
Is prostate intra or retro?
A
retro
2
Q
what are the 2 regions of the prostate?
A
- fibromuscular region/stroma
- glandular region (posterior)
3
Q
which reigion has less clincal significance?
A
fibromuscular region/stroma
4
Q
what are the 4 zones of the prostate?
A
- peripheral
- central
- transitional
- periurethral glandular tissue/zone
5
Q
how much of the prostate does the peripheral zone take up?
A
70%
6
Q
how often (percent) are cancers found in the peripheral zone?
A
70%
7
Q
which zone is considered the “eggcup” holding the egg of the central gland
A
peripheral zone
8
Q
how much of the prostate does the central zone take up?
A
25%
9
Q
how often (percent) is cancer in the central zone?
A
5%
10
Q
what is located in the central zone?
A
vas deferns
seminal vesicles
11
Q
what makes up the transitional zone?
A
lateral aspects of the proximal prostatic urethra
5% of glandular tissue
12
Q
how often (percent) is cancer found in the transitional zone?
A
20%
13
Q
periurethral glandular zone
A
tissue that lines the proximal prostatic urethra
14
Q
what is the prostatic urethra divided by (proximal and distal)?
A
verumontanum
15
Q
what does the “surgical capsule” seperate?
A
inner and outer gland
NOT A TRUE CAPSULE
16
Q
What is transabdominal good for looking at?
A
gross porastate
bladder evaulation
17
Q
transabdominal sonographic appearance of the prostate
A
- heterogenous
- should be symmetrical
- limited resolution
18
Q
what is the approx size and weight of the prostate?
A
weight-20 grams
measurement-4cmx3cmx3.8cm
19
Q
what zones have similar echotexture?
A
central and transition
20
Q
are you able to distinguish the 4 zones of the prostate with TRUS?
A
nope
21
Q
what do we divide the prostate into?
A
- central or inner gland
- peripheral or outer gland
22
Q
transrectal probe frequency
A
7-11 MHz
23
Q
what are some sonographic applications expanded with TRUS?
A
- size and echotexture
- evaluation of BPH
- Prostatis
- detection of masses
- sonographic correlation of findings from DRE
24
Q
TRUS to a lesser degree
A
male infertitiy
25
sonographic appearance of peripheral or outer gland
- uniform, homogenous texture
| - slighty more echogenic than inner gland
26
sonographic appearance of central or inner gland
- more hypoechoic
| - heterogenous
27
what are some benign conditions of the prostate?
- normal varients
- BPH
- prostate cysts
- prostatitis
28
benign ductal ectasia (normal varient)
- older
- atrophy and dilation of prostatic ducts
- single or grouped
- tubular structures in the peripheral zone
29
prostatic calcifications (normal variants)
- normal finding
- more common in elderly
- bright echogenic foci clumps in prostate
30
corpora amylacea (normal varient)
- proteinaceous debris
- sound attenuation
- create twinkle artifact
- no clincal sigificance
- along surgical capsule
31
what does BPH stand for?
benign prostatic hypertrophy or hyperplasia
32
what is BPH?
- enlarged prostate (greater than 40 grams)
- not serious
- usually happens with all men as age
33
what is the etiology for BPH?
unclear
| maybe due to hormones
34
what part of the gland is affected in BPH?
all components
(fibrous, muscular, and glandular elements)
PRIMARILY AFFECTS TRANSITIN AND PERIURETHRAL ZONES
35
What are symptoms of BPH?
```
-asymtomatic
lower urinary tract symtoms:
-Frequency
-nocturia
-weka stream
-trouble starting or stopping
```
36
BPH has a small risk for complete blockage, why may this happen?
result in urinary retention
- bladder stones
- bladder infection
- kidney damage
37
what may BPH to do the bladder?
may push prostate into bladder
38
what is the typical sonographic appearance of BPH?
enlargement of the inner gland
- nodules with distinct margins
- calcifications
- parenchymal degenerative cysts
- retention cysts
- may buldge into bladder
39
what is considered the standard treatment for BPH?
TURP
40
what are some other treatments for BPH?
- watchful waiting
- medical therapy
- open surgery
- laser therapy
41
do we treat an asymptomatic patient with BPH?
no
42
what do we need to exclude before TURP?
- neurologic disorders
- diabetes
- local urinary conditions
43
whta are some prostate cysts?
- parenchymal
- retention
- congenital
- ejaculatory duct
- cystic tumors
- abscesses
44
where are most cysts?
midline
45
what is associated wirth BPH?
parenchymal Degenerative and retention with BPH
46
appearance of congenital cysts?
- sonographically the same
| - tear dropped shaped
47
what is utrical cysts associated with?
unilateral renal agenesis
48
what is ejaculatry cysts associtaed with?
infertility
49
what cyst os most common associated with BPH?
parenchymal degenerative cysts
50
where are parenchymal degenerative cysts located?
transition zone
51
what can happen if parenchymal degenerative cysts are large?
contribute to urinary or ejaculatory obstruction
52
what do parenchymal degenerative cysts look like sonographically?
unilocular or thinly septated multilocular cyst in a BPH nodule in the transitional zone
53
where are retention cysts located?
focal cysts on the surface of the prostate
54
why do retention cysts occur?
duct obstruction
55
appearances of retention cysts?
-small
56
where are congenital cysts located?
in or close to midline
| -Wolffian or pronephric ducts or mullerian ducts
57
congenital cysts are usually asymtomatic, when do they become symptomatic?
if infected
(Prostatic utricle cysts
Mullerian duct cysts)
58
what are utrical cysts (congenital cysts) caused by?
dilation of prostatic utricle
59
what are utrical cysts (congenital cysts) associated with?
unilateral renal agenesis
60
where are uitrical cysts (congenital cysts) located?
always midline
61
Where are mullerian duct cysts (congenital cysts)
mainly midline
| no associations
62
what is the sonographic appearance of mullerian and utricle cysts?
- same sonographically
- tear dropped shaped pointy end to vermontanum
- thick walled
- cause obstruction of ejaculatory ducts is large
- develop calcifications
- both can become symptomatic, painful or infected, rarely becomes tumors
63
ejaculatory duct cysts appearance
- usually small
- fusiform in shape
- typically pointed at both ends
- infertility
- can cause perineal pain
64
what may a ejaculatory duct cyst also be seen as?
- cystic dilation of ejaculatory duct
| - diverticula of duct
65
cystic neoplasms (tumors)
- rare
| - cystadenoma and cystadenocarcinoma have been seen
66
what is the most common etiology of prostate abscesses?
coliform organisms such as E.Coli
67
what does a prostatic abscess look like sonographically?
- thick
- irregular walls
- debris within fluid
68
what is a treatment for prostatic abscess?
transrectal aspiration or TURP drainage and antimicrobia therapy
69
cysts caused by parasites are rare in _________
western countries
70
ALL BENIGN CYSTS important points:
- have potential to cause ejaculatory obstructions if become large
- have potential to become infected leading to symtoms
- if buldge capsule can mimic solid nodule on DRE
71
are cystic tumors rare or common?
RARELY DEVELOP
72
What are areas for classification for prosatitis?
- acute bacterial prostatitis
- chronic bacterial prostatitis
- chronic prostatitis/chronic pelvic pain symdrome
- asymptomatcic inflammatory prostatitis
73
which prostitis characterizaton is most common?
Chronic prostatitis/chronic pelvic pain syndrome
74
what are some subtypes of Chronic prostatitis/chronic pelvic pain syndrome?
- inflammatory
| - non inflammatory
75
which prostatitis is not apart of the 4 classifications of prosatitis?
granulomatous
76
sonogrpahic appearance of prostatitis?
- can appear normal on TRUS
- non specifiic US findings associated with most types
- some can cause elevation of PSA or hard lump
77
when may we see elevation of PSA or hard lump
- asymtomatic inflammatory
| - granulomatous
78
what does prostatitis refer too?
chronic pain syndrome
79
prostatitis for men under 50
leading cause of visits to urologist
80
prostatitis for men over 50
3rd most common cause, after BPH and cancer
81
what is the least common type of prostatitis?
acute bacterial
82
what is the sonographic appearance of acute bacterial prostatitis?
findings only seen in 1/2 of men
- edema
- enlargment
- increased blood flow
- venous engorgement
- hypoechoic peripheral halo
- patchy echo changes
83
what is the treatment for acute bacterial prostatitis?
antibiotics
| abscess can occur in 0.5-2.5% of patients
84
which type of prostatitis have no US findings?
chronic bacterial prostatitis
85
what are the symoptoms of chronic bacterial prostatitis?
recurrent episodes of bacterial UTI-like symptoms
86
what is the treatment for chronic bacterial prostatitis?
6-12 weeks of antimicrobial therapy
87
what is the most common form of prostatic inflammation?
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP)
| 90% cases
88
which type of prostatitis is difficult to understand and treat?
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP)
89
what is the etiology of Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP)?
unknown
90
prostatitis inflammartory type A
Diagnosed by leukocytes in prostate secretions, urine or semen
91
prostatitis non inflammartory type B
No evidence of inflammation also called “prostatodynia”
92
what is the treattment to Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP)?
may respond to
- antibiotics
- alpha blockers
- nonsterodial anti-inflammatory drugs
- analgesics
93
what does Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP) look like sonographically?
```
usually appears normal
Or nonspecific findings
-Peripheral hypoechoic areas
-Calcifications
-Venous congestion
-Increased arterial flow
-Bladder neck thickening
-Hypoechoic prostatic rim
-Periurethral hypogenicity
```
94
Asymptomatic inflammatory prostatitis
-No hx of genitourinary pain complaints but inflammatory changes histologically
-Usually chronically elevated or fluctuating PSA
>10ng/mL
95
what does Asymptomatic inflammatory prostatitis look like sonographically?
- Multiple inflammatory areas
- Mimics cancer
- Biopsy needed to exclude cancer
96
Granulomatous prostatitis Etiology
- usually idiopathic
| - can follow prior instrumentation maybe caused by bacteria, fungi, and parasites
97
what is Granulomatous prostatitis commonly caused by in north america?
BCG-bacille Calmette-Guerin
98
BCG
-instilled into bladder to treat TCC
-leaks into prostate
(can cause Granulomatous prostatitis)
99
Granulomatous prostatitis
- Can mimic cancer on DRE & TRUS
- Elevates PSA
- Biopsy needed
100
TRUS and Prostatitis
-Limited to acute prostatitis
-Problem
too painful
-U/S can mimic cancer
Hypoechoic
Hypervascular
101
who does prostate cancer usually occur in?
men over 50
102
what is 95% of prostate cancers?
adenocarcinomas
103
what is 5% of prosate cancer?
many different types that do not elevate PSA
104
prostate cancer is the _____ leading cause of cancer deaths
2nd
| 1st is lung
105
prostate cancer is the ____ most common male malignancy worldwide
4th
106
what are standard tests for prostate cancer screening?
PSA
| DRE
107
PSA density
- ratio of PSA to prostate volume
| - Assumes cancer increase PSA more than benign conditions
108
PSA velocity
- not used as much
| - role in active survelliance
109
Free/Total PSA ratio
cancer total PSA increases so ratio would increase
110
what are some indications for an inital biopsy?
- abnormal DRE
- abnormal TRUS
- unexplained elevation of PSA
- Excessive PSA velocity
- positive chips at TURP
- metastatic adenocarcinoma when primary not evident
111
what could appear on US that would indicate an initial biopsy?
suspicuous hypoechoic or vascular areas sampled by 10-12-core pattern
112
what are some indicatons for a repeat biopsy?
- initial biopsy is negative, strong clinical suspicion
- PSA over 10 or rising
- initial suspicious histology (atypical cells, microcancer)
- follow up of men under surveillance
113
do initial or repeated biopsies have a more extensive sampling pattern?
repeat biopsy
114
core pattern for repeat bipsy?
13-15 core patten
115
sameples of repeat biopsies areas?
- lateral periperal zone (2)
- medial peripheral zone (3)
- transition zone (1)
- midline (1)
- base (1)
116
where are only a few cancers found?
midline
| transition
117
what is the equipment for a biopsy?
TRUS
| Biopsy gun
118
what is the preparation for a TRUS biopsy?
- consent
- cleansing enema
- broad-spectrum antobiotics
- STOP anticoagulating agents several days prior (aspirin, warfarin)
119
what kind of biopsy gun is used?
18 gauge
| doctor controls the gun and probe
120
how does an automatic biopsy gun work?
- collecting core samples of the prostate
- sample suspocious nodules first
- systemic samples taken after
121
what are minor side effects of biopsy?
- blood in urine, stool, sperm
- last few days to weeks
- ejaculate can be discoloured for months
122
what are some significant complications of biopsy? (1-2%)
- sepsis
- large hematoma
- urinary retention
- significant rectal bleeding
123
what are some significant complications of biopsy? (1-6%)
- hypotensive vasovagal-like reaction
- 30-60 minutes after
- sweating, nausea, vomiting, bradycardia
124
where is most of prostate cancer found?
periphral zone (70%)
125
where is prostate cancer easy to detect?
peripheral becasuse homogenous texture and the cancer stands out
126
where is 20% of prostate cancer found?
transition zone
127
where is cancer difficult to detect?
transition zone becuase its heterogenous and area of BPH nodules
128
what are clues for detecting cancer in the transition zone?
poorly marginated hypoechoic area and focal loss of surgical capsule
129
abterior midline tumor
- very difficult to detect
- far from probe and obtructed from urethra
- become very large before detection
130
what is the classic sonographic appearance of prostate cancer?
hypoechoic nodule in the peripheral zone (along capsule)
131
what modality is not good at detecting prostate cancer?
CT
132
what modalities have sensitivity similar?
DRE
PSA
MRI
133
______ of prostate cancer is not detectable
30-50%
134
_____ of prostate cancer is isoechoic?
30%
135
how else may the prostate appear with cancer?
hypoechoic, hyperechoic, calcifications
136
what appearance switches with prostate cancer?
replace entire peripheral zone more hypoechoic peripheral versus more hyperechoic inner gland
137
what other function helps determine cancer?
power doppler
138
what is staging and histologic grading?
determine treatment, options and prognosis
139
what does staging and histologic grading integrate?
clinical
imaging
pathologic staging info
140
what is staging?
- extent of the disease
- broken down into clinical pathological staging
- imaging can be used to help
141
what is used to estimate extent of prostate cancer?
DRE
PSA
imaging
142
cTX
primary tumor canot be assessed
143
cT0
no evidence of primary tumor
144
stage cT1 (a,b,c)
not palpable and not visable on imaging
145
stage cT2 (a,b,c)
palpable on DRE, confined to prostate
146
stage cT3
- cT3a
- cT3b
extends through prostate capsule
cT3a-periprostatic soft tissue
cT3b-seminal vesicles
147
stage T4
- tumor is fixed or invades adjacent structures other than SV
- bladder neck, external sphincter, rectum, levator mucles, pelvic wall
148
which staging is considered more accurate for prognosis of prostate cancer?
pathological staging
149
what does pathological staging require?
histologic evaluation of prostate, SV, lymph nodes
150
pT2
organ confined
151
pT3
extraprostatic extension
152
pT4
invasion of rectum, levator muscles and pelvic wall
153
histologic grading system
gleason scoring system
| -microscopic pathological spectrum
154
how is histologic grading determined?
glandular differentiation and histologic aggressiveness
155
what is the score for histologc grading?
6-10
156
higher score in histologic grading=
worse prognosis
157
what is the therapy for prostate cancer?
- radical prostatectomy
- radiotherapy
- focal therapy
- watchful waiting
- active surveillance
158
what is the gold standard for therapy?
radical prosatectomy
| -low grade cancer-90%
159
focal therapy
- cryotherapy
- radiofrequency ablation therapy
- HIFU
160
active surveillance
-DRE and serial PSA
-Ultrasound guided bx
All to ensure cancer is maintaining low risk
161
therapy effcts of sonographic appearance
- therapies can alter appearance of the prostate gland
- not able to detect recurrent cancer
- systemic 10 core biopsy if needed
162
MRI and its roles
- detect cancer
- Stage cancer
- accuracy is improving
163
how is MRI improving?
- use of endorectal and pelvic coils
- contrast agents
- specialized sequences
164
what are pitfalls of MRI?
- availability
- cost
- time
- intolerance of endorectal coil
165
CT and its role
- plays NO role in primary tumor detection or local staging
- helps with detection of lymphadenopathy and distant Mets
- value in radiotherapy planning and confirming seed placement with brachytherapy
166
do radionuclide bone scans play a role in primary tumor detection or local staging?
NO
167
when do we detect bone metastases in men?
with skeletal symtoms or PSA over 10
168
what are pitfalls of TRUS?
- large blood vessels in pelvis
- pelvic kidneys can mimic mass
- anterior meningoceles mimic masses behind rectum
169
what is hematospermia?
macroscopic presence of blood in semen
170
is hematospermia usually benign or malignant?
mostly benign and typically resolves
171
what are the causes of hematospermia?
- iatrogenic/traumatic
- infectons or inflammatory
- ductal obstruction, cysts, calc in seminal ducts
- systemic factors (hypertension)
- vascular abnormalities
- idiopathic
172
what happens within the seminal vesicles?
each vesicle tapers medially to from a short duct whoch joins the vas defernes to form an ejaculatory duct
173
where is the seminal vesicle located?
situated at the base of the bladder and suprior to the prostate gland and inferior to the vas deferens and ureters
174
seminal vesicles in transabdominal ultrasound
- TRV left and right are seen together
- SAG they are seen seperatley
- should be symmetric
175
axial US anatomy on TRUS of seminal vesicles
relatively hypoechoic
| multiseptated structures
176
axial US anatomy on TRUS of vas deferens
adjacent to SV
| -uniform muscluar tubes ejaculatory ducts-2 can be followed to the verumontanum
177
how can the internal sphincter appear?
hypoechoic
178
are seminal vesicles symptomatic?
most are asymtomatic but can cause symptoms if large
179
what are seminal vesicle cysts associated with?
- Ipsilateral renal anomalies
- Adult polycystic disease
- Hemivertebra
- Ipsilateral absence of testis
180
what pathologies can mimic SV or prostate cyst?
- ectopic ureterocele
- cowper's duct cyst
- bladder diverticulum
181
cowper's duct cysts
urogenital diaphragm below apex of prostate
182
who may calcifications be seen in?
calcifications in vas deferens and SV with diabetes and infection
183
diabetic calcifications
- involve walls
| - look like train tracts on X-Ray
184
infectious/inflammatory calcifications
- luminal and segmental
| - occasionally 1 cm eggshell calc seen in SV
185
rarely SV are involved by what?
tumors
abscesses
amyloidosis
186
when is TRUS used for infertility?
failure of pregnancy after 1 year unprotected intercourse
187
Male factor solely responsible in ______ couples with infertility
20%
188
where is infertility usually detected in men?
abnormal semen analysis
189
what are male factors for infertility?
-pretesticular
-testicular
posttesticular
190
postesticular
- causes include azoospermia and oligospermia
| - related to obstructive issues
191
what is the role of TRUS for male infertility?
- Identify anatomically correctable ejaculatory duct obstructions and anomalies
- Using contrast agents show patency of ejaculatory ducts
- retrieve sperm from seminal vesicles
