GU Flashcards
1
Q
Testicular cancer is divided into what 2 etiologies?
A
Non-seminiferous
- Embryonal cell carcinoma (15%)
- Teratoma (5%)
- Mixed cell type (40%)
•Choriocarcinoma (<1%)
Seminiferous
2
Q
si/sx of testicular cancer
A
Painless nodule/enlargement of the testes
- Heavy sensation/dull ache
- Acute testicular pain
- Gynecomastia
3
Q
what do seminoma vs NSGCT testicular cancers look like on US?
A
•Seminoma = hypoechoic lesion w/o cystic area
•NSGCT = not homogenous w/ calcifications, cystic areas, indistinct margins
4
Q
testocular cancer mestastes first to what LNs???
A
•metastases occur first in the retroperitoneal LN’s
5
Q
describe how to differentiate nonseminoma from seminoma based on lab values?
AFP
B-hcG
LDH
A
AFP – warning signs for reoccurrence
- NSGCT - stage and tx guidance
- Never elevated w/ seminomas
Β-hCG
- NSGCT
- Seminomas only 20% of time elevated
LDH - Elevated with either GCT
6
Q
Lab value that is Never elevated w/ seminomas testicular cancer??
A
AFP
7
Q
INC AFP in testiuclar cancer means?
A
AFP – warning signs for reoccurrence
8
Q
staging testicular CA (1-3)
A
•Stage 0 – carcinoma in situ, abnormal cells where sperm develops
- Stage 1 – testicular cancer limited to testis
- Stage 2 – testicular cancer that involved RPLN or para-aortic LN in the region of the kidney
•Stage 3 – spread beyond RPLN
9
Q
•Only reliable method to ID micromets and gold standard for staging of retroperitoneum in testicular cancer??
what category ALWAYS get this??
A
RPLND
NSGCT since higher risk of nodal involvement
10
Q
important risk factor for testicular cancer is what dx?
A
•Cryptorchism
11
Q
How to differentiate seminef vs nonseminef testicular cancer based on LAb values?
A
Seminiferous- NORMAL AFP, sometimes ↑b-hcG
Nonsemi-↑AFP, ↑b-hcG
12
Q
which type of testicular cancer?
- Rarely metastasize (liver, lung, bone, brain)
- Radiosensitive
- Not typically marked by tumor marker elevation
A
seminef
13
Q
tx of seminef testiuclar cancer
stage 1
stage 2
Elevated B-HCG
A
Stage 1 - Orchiectomy typically curative
- Can also do adjuvant chemo 1-2 cycles carboplatin
- Adjuvant retroperitoneal XRT (not chemo candidate)
- Active surveillance w/ compliant pt
Stage 2 seminoma (RPLN/PALN noted on CT)
Stage 2a <2cm involved Lns, _Adjuvant XR_T and/or monitor w/ CT
Stage 2b (2-5cm LN’s) or c (>5cm LNs) Adjuvant chemotherapy
- More extensive RPLN’s
- (bleomycin, etoposide, cisplatin) BEP
Elevated B-HCG - Adjuvant Cisplatin chemotherapy
14
Q
tx of nonseminef tsticular cancer
stage 1
stage 2 (CT vs RPLN)
A
Radical orchiectomy = histology & tx plan
Stage 1 (testicle only) – depends on RF
- 1 or more RF = high risk disease and likely micromets
- Active surveillance (50% relapse rate)
- Chemotherapy (1-2 cycles BEP)
- RPLND
Stage 2 (testicle & RPLN/PALN)
CT only
< 2cm nl markers = RPLND
>2cm or high markers = BEP 3 cycles
RPLND +
<2cm and <4 LN’s = survelliance
>2cm and/or >4 LN’s = BEP 2 cycles
15
Q
Most common male solid malignancy 15-35yo
A
testiuclar canc
16
Q
Second most common male cancer worldwide and cause of cancer related death
A
prostate cancer
17
Q
Most Porstate Cancers are _______and originate in the ____ ____ of the gland
A
adenocarcinoma and originate in the peripheral zone of the gland
18
Q
Gleason Staging is used for what dz?
explain staging
score of 2-6 =
score of 7 =
score of 8-10 =
A
Gleason Staging - Pathologist criteria for architecture of the malignant gland and used to help determine prognosis in prostate CA
- Primary grade (largest area in the prostate) and secondary grade (2nd largest area bx in prostate) from the specimen and then sum of these grades
- 2-10 score
- Correlates tumor volume, pathologic stage, prognosis
score of 2-6 = low-grade or well-differentiated tumor
score of 7 =moderate grade/moderately differentiated tumor
score of 8-10 = high grade or poorly differentiated tumor
19
Q
prostate cancer most common mets are to ???
A
most common mets are axial skeleton
20
Q
prostate cancer staging (1-4)
A
Stage I – not palpable
Stage II – one or both lobes
Stage III – seminal vesicles
Stage IV – bladder or other or organ invasion
21
Q
si/sx of prostate cancer
include late findings
A
Most have no symptoms
- Urinary frequency
- Nocturia, Hesitancy
- Hematuria/ hematospermia
Late findings
•Bone pain - most common mets are axial skeleton (Back pain or pathologic fxs)
- LE lymphedema
- Urinary retention
- Adenopathy
- Weight loss
22
Q
Screening for prostate ca includes?
A
PSA & DRE
23
Q
INC PSA in prostate cancer is useful for??
A
detecting and staging prostate CA
monitoring response to tx
detecting recurrence
24
Q
when screening for prostate cance and INC in PSA can be benign - what should you do to confirm this?
values indicative of cancer?
A
Fractionated PSA - %free PSA relative to total PSA
>30% free PSA ratio = low liklihood cancer
<10% free PSA ratio = assoc w/ CA (50%)
25
what diagnostic method in prostate cancer is Assoc w/ improved detection of CA and risk stratification
name 2 other imaging modalities and their uses?
**_TRUS guided biopsy_** - Assoc w/ improved detection of CA and risk stratification
•If persistently elevated PSA level in the face of negative biopsy then may repeat bx 1- 2X (include transition zone this time)
**MRI** - Better to stage CA than TRUS
**99-technetium bone sca**n - For M staging or axial skeleton mets
26
Prostate cancer w/ persistently elevated PSA level in the face of negative biopsy what is next step...?
may repeat bx 1- 2X (include transition zone this time)
27
tx of prostate cancer
_Active surveillance/watchful waiting_
_Radiation therapy:_ EBRT & Brachytherapy
_Hormone therap_y-Most prostate CA hormone dependent
_Radical prostatectomy +/- pelvic LN dissection_
28
name 2 rools for assessing prognossi of prostate cancer and rtheir uses
**•Kattan Nomogram** - Likelihood pt remains cancer-free @ 5yrs post-prostatectomy or XRT
**•CAPRA Nomogra**m - Likelihood of PSA recurrence 3 and 5 yrs s/p prostatectomy
29
prostate cancer criteria for high intermediate and low risk
T score
Gleason
PSA
**Low risk** – T1-T2a, Gleason \<6, PSA \<10
•Bx only tumor or localized to one lobe of gland
**Intermediate Risk** – T2b, Gleason 7, PSA 10-20
•One half or bilateral prostate tumor
**High Risk** – T2c, Gleason 8-10, PSA \>20
•Bilateral prostate lobe tumor
30
tx for prostate cancer - localized dz
low
intermediate
high risk
**Low risk disease**
Active surveillance (w/ pt comfort)- PSA, DRE
Radiation therapy
Prostatectomy +/- pelvic node dissection
**Intermediate risk disease** - Life expectancy \>10 yrs
_Radiation therapy_: EBRT (+/- ADT) or Brachytherapy
•Combination of EBRT and Brachytherapy
_Prostatectomy w/ pelvic LN dissectio_n
**High-Risk Disease**
EBRT + ADT (2-3 yrs)
EBRT + Brachytherapy + ADT 1 yr
Prostatectomy w/ pelvic LN dissection
31
Locally and regionally advanced prostate disease is defined as
Advanced pathologic stage or positive margins (Imaging studies provide clear evidence of non– organ-confined disease eg, seminal vesicle or periprostatic involvement)
32
Locally and regionally advanced prostate disease TX
**T3b-T4 w/ any Gleason or PSA**: combo of modalities
* Prostatectomy + pelvic LN dissection (+/- adjuvant XRT)
* EBRT + ADT (2-3 yrs)
* EBRT + Brachytherapy + ADT (long term)
* ADT alone (select pts)
**Any T, N1, M0**
* Prostatectomy + pelvic LN dissection (+XRT&ADT)
* ADT
* XRT + ADT (2-3 yrs)
* LN’s usually positive obturator and internal iliac LN chains
33
tx of prostate cancer metastsic dz
what drugs cause flare and what do not
how can we prevent?
**GnRH agonists -** Preferred initial treatment
* Chemical castration
* Leuprolide, Goserelin, Buserelin, Triptorelin
* Can cause _temporary testosterone “flare”_ for short period
**GnRH antagonist** : Degarelix (No flare effect)
CAB (complete androgen blockade)
**•Combine GnRH agonist/antagonist and anti-androgen**
•Flutamide, bicalutamide
_•First few weeks of tx prevent flare_
34
CAB (complete androgen blockade) is used to tx what dz?
what drugb must we also give the pt and why?
**Prostate cancer: Metastatic disease**
**Bisphosphonates**
* Use w/ androgen deprivation to prevent osteoporosis
* Decrease boney pain from mets
35
causes of urinary incontinence can be remebered by this pneumonic?
36
name 5 types of incontinence
Stress
Urge
Overflow
Functional
Mixed
37
explain etiology of these types of incontinence
## Footnote
Stress
Urge
Overflow
Functional
Mixed
Stress - absence of detrusor activity
Urge -a sudden and compelling desire to urinate that is difficult to hold off and is accompanied by involuntary leakage
Overflow - dribbling of urine from overdistension or from incomplete bladder emptying
Functional - ne loss due to cognitive or physical impairment or environmental barriers that interfere with control of voiding
Mixed - combo of these
38
2 main causes of stress incontinence
**•Urethral hypermobility** – most common 80%
displacement of urethra during any sudden increase in abdominal pressure
•Descent of urethra out of the abdominal cavity causes decreased urethral pressure
**•Intrinsic sphincter deficiency**- inability to effectively contract the sphincter muscle
39
incontinience: Associated with increased abdominal pressure (exertion, sneezing, coughing, laughing)
what age group / pop does this most commonly effect
Stress incont
Most common incontinence in younger women (age 45-49)
40
test Useful in differentiating stress from urge incontinence
what are the findings that differentiate the 2?
**Provocative stress testing** - •Goal is to reproduce symptoms of incontinence under the direct visualization of the physician
1. Patient should have a full bladder and standing
2. Patient should be told to relax then cough vigorously
* If urinary loss occurs simultaneously with the cough = **stress**
* If urinary loss is delayed or between coughs = **urge**
41
•Most common cause of urinary incont in men and elderly
Urge
42
detruser function in incontinence
stress
urge
overflow
stress - absence of detrusor activity
urge - Detrusor over-activity
overflow - Detrusor underactivity
43
•Should be performed on patients with suspected urinary retention or potential obstruction
PVR- •Patient should be asked to empty bladder as completely as possible then residual urine is measured
## Footnote
•Normal PVR is \<50mL
44
•PVR \>200mL is consistent w/ ______ incontinence
overflow
45
overflow incontinence is what si/sx?
**•Constant leakage or dribbling**
•The second most common type of incontinence in men
46
si/sx of urge vs overflow incont
urge - a sudden and compelling desire to urinate that is difficult to hold off and is accompanied by involuntary leakage
overflow - dribbling of urine from overdistension or from incomplete bladder emptying
47
Most common combination of Mixed incontinence is
stress and urge
48
tx for stress incontinince
ALL – Kegels, diary
Pseudoephedrine
Estrogen therapy
Macroplastique - (Bulking agent injected into urethral wall to strengthen it)
49
tx of urge incont
Oxybutynin
Tolterodine
Trospium
50
tx of overflow incont
need to rule out obstruction with cystoscopy
Finasteride
Bethanechol
51
tx of functional & mixed incont?
Surgery – TVT
52
overacitve bladder is defines as?
•Voiding 8 or more times during a 24 hours period
AND awakening 2 or more times during the night
53
causes ofoveractive bladder
Causes:
* Urethra obstruction in men
* Bladder stones or tumor
* Involuntary bladder contraction
54
If incontinence is associated with overactive bladder, PVR will be??
no urinary retention -
•(Post Void Residual is normal)
55
nondrug tx of overactive bladder
Bhevaioral Therapy – voiding times
Pelvic floor muscle exercises (Kegel)
Electrical Stimulation - Inhibits spasms of detrusor muscle (post-tibial/sacral) S3, TENS
Lifestyle modifications -Weight loss, Decrease caffeine intake
56
medication tx of overactibe bladder
Medication – caution may cause retention
* Antispasmodics
* Oxybutynin (Ditropan) 2.5-5mg TID or QID or patch q3days
* Tolrerodine (Detrol) 1-2 mg BID
* Solifenacin (Vesicare) 5-10mg daily
57
Neurogenic Bladder si/sx
## Footnote
* Bladder or detrusor hyperactivity
* Sphincter hyperactivity
* Detrusor sphincter dysynergy
* Bladder or detrusor hyperactivity – bladder spasms, urgency, frequency
* Sphincter hyperactivity – incomplete emptying
* Detrusor sphincter dysynergy– bladder contractions against a closed sphincter
58
tx of nuero bladder
Intermittent straight catheterization vs indwelling catheters
RULE OUT INFECTION
Neuromodulation therapy for detrusor spasm
**Medications depend on mechanism**
•_Anticholinergics_ (oxybutynin, tolterodine) – suppress bladder contractions
_•Alpha adrenergic_s (ephedrine, phenylpropanolamine) – increase bladder storage
•_Cholinergics_ (bethanechol) – help complete bladder emptying
_•Alpha-blocker_s (prazosin, terazosin) – help sphincter relaxation
•_Botox_ injected into sphincter to relax it or into detrusor to decrease spasm
59
herniation of the posterior bladder wall and trigone through the anterior wall of the vagina
dx? cause?
cystocele ( bladder prlapse
## Footnote
Caused by weakening of the pelvic floor
* Child birth – most common
* Trauma
60
si/sx of cystocele / bladder prolapse
Maybe asymptomatic
Vaginal bulging or fullness
**Symptoms worse with Valsalva and improve with lying flat**
Pain
Urinary incontinence
Incomplete emptying of bladder
Sometimes coincidental finding on exam – fullness in anterior vagina
61
tx of cystocele / bladder prolapse
_Not a medical emergency, reassurance_
Avoid heavy lifting or straining
Pessary placement
Surgery
* Colporrhaphy
* Colpopexy
* Transabdominal mesh taping – ONLY through abdomen
62
# define UTI
most commmon pathogen
significant bacteriuria in the _setting of symptoms of cystitis or pyelonephritis_
Most common cause-Escherichia Coli (approx. 86%)
63
si/sx of lower vs upeer UTI
**Signs and Symptoms of lower urinary tract infections**
* Frequency
* Urgency
* Nocturia
* Hematuria
* Dysuria
* Pelvic or low back pain
**Signs and Symptoms of upper urinary tract infections**
* Same as above PLUS may also have
* Fever
* Flank pain
* Nausea/vomiting
64
UTI diagnostics:
urine dip -
UA -
Urine dip - +nitrites, +leukocyte esterase
Urinalysis - +WBCs, +/-RBCs , look for low levels of squamous cells in clean catch
65
what makes a UTI complicated?
what must ALWAYS be done w/ complicated UTI?
**REQUIRE urine cx**
* Men
* History of Frequent UTIs
* Immunocompromised
* Diabetes
* Pregnancy §
* ost menopausal
* Urologic Abnormalities: Stones , Stents, Catheters , Neurogenic Bladder, H/o kidney transpant
66
tx of Acute uncomplicated cystitis
* Macrobid 100mg BID x 5days
* Keflex 250mg QID x 5 days
* Bactrim DS 1 tab po BID x 3days
* Cipro 250mg BID x 3 days
67
tx of complicated cystits
preg vs nonpreg
**non-pregnant women and in men** without evidence of prostatitis _(longer course-7 days_) INVREASE DSY OF TX
* Cipro 500mg po BID x7 days
* Macrobid 100mg po BID x 7 days
**Pregnancy**
* Augmentin or Keflex x 7days
* No Fluroquinolones
* NO Macrobid in third trimester
68
the presence of bacteria in a midstream clean catch urine sample of a patient without symptoms of an UTI
dz?
most common cause
Asymptomatic Bacteremia
e. coli
69
criteria for asymptomatic bacteriuria by culture
* For women:
* For men and pregnant women
* Catheterized specimen male or female
**•For women:** 2 consecutive specimens with at least 100,000 CFU/mL of same bacteria
**•For men and pregnant women**: one specimen with at least 100,000 CFU/mL
**•Catheterized specimen male or female**: one specimen with at least 100,000 CFU/mL
70
do we tx asymp bacteremia?
With few exceptions, most patients do not benefit from treatment
71
Asymptomatic Bacteremia tx needed if?
**•Pregnant patients with bacteriuria** - Low birth weight, preterm labor, pyelonephritis result
•Screen all pregnant patients at first prenatal visit
**•Patients three months post renal transplant**
•**Prophylactically** in patients undergoing urinary tract or prostate procedures with associated bleeding
_Treat based on urine culture sensitivity._
* Category B antibiotics in pregnancy for 3-7 days
* Repeat urine culture to confirm clearing of bacteria in 1-2 weeks
72
describe Testicular Descent
•Testis descent has 2 phases:
1. transabdominal descent - dependent on insulin-like hormone 3 (INSL3).
2. inguinoscrotal descent - dependent on androgens
•A normal hypothalamic-pituitary-gonadal axis is a prerequisite for testicular descent.
73
•In patients with cryptorchidism, the\_\_\_\_\_\_ is not firmly attached to the\_\_\_\_, and the testis is not pulled into the scrotum.
Failure of testicular descent
In patients with cryptorchidism, the gubernaculum is not firmly attached to the scrotum, and the testis is not pulled into the scrotum.
74
dx and tx Cryptorchidism
Laparoscopy (dx & tx)- Diagnostic laparoscopy has nearly 100% sensitivity and specificity and allows for concurrent surgical correction.
75
tx Cryptorchidism
complications?
**•Self-limiting (~6 months)** – if not corrected then CONSULT
•Surgical referral
_•Orchiopexy_
•HCG® ↑ testosterone
_Complication:_
* Infertility
* ↑ risk of Testicular cancer
* Inguinal hernia - 90 % of undescended testes due to patent processus vaginalis
76
name 2 types of Hydrocele and their causes
**Non-communicating**
* Trauma
* Epididymitis
* Testicular torsion
* Varicocele
* Testicular tumor
**Communicating (patent processus vaginalis)**
• intra-abdominal fluid/pressure
_•discovered in infancy_ - due to patent processus vaginalis –occur following increased intra-abdominal fluid or pressure (due to shunts, peritoneal dialysis, or ascites) likely from an imbalance of secretion and reabsorption of fluid from the tunica vaginalis.
77
si/sx of hydrocele
* •Non-communicating
* •Communicating
Scrotal swelling
* •Non-communicating - constant
* •Communicating – transient
+/- pain
•(+) transillumination - assess for fluid – differentiate from hematocele (if possible), hernia, or solid mass.
78
tx of hydrocele , complications?
children
adolescants
adults
**Children**
* Non-communicating - observation for 1-2 years +/- surgery
* Communicating - surgery
**Adolescents**: non-communicating
* R/o underlying pathology
* Surgical consult
**Adults**
* R/o underlying pathology
* Surgery
•
_Complications_: Infertility
79
scrotum feels like (“bag of worms”) t hat may disappear in supine position
Varicocele
80
varicocele is caused by
more common on what vein?
Dilated pampiniform plexus (L\>R)
* _•L spermatic vein_ – comes off renal vein à more pressure
* _•R spermatic vein_ off the vena cava
81
varicoele will disappear in what position?
Tortuous swelling, scrotal mass “bag of worms” that may disappear in supine position, discoloration
82
tx indications for varicoele
tx?
1) the varicocele is palpable on physical examination of the scrotum;
2) the couple has known infertility;
3) the female partner has normal fertility or a potentially treatable cause of infertility;
4) the male partner has abnormal semen parameters or abnormal results from sperm function tests.
_If indicated:_
* Embolization
* Surgical correction
83
Hypospadias
causes?
RF?
Caused by failure of fusion of the urethral folds, endodermal differentiation, and ectodermal ingrowth in gestational weeks 8 to 20.
RF: LBW
84
differentiate b/w
## Footnote
Hypospadias –
Severe hypospadias –
**Hypospadias** – urethra opens at underside of penis
**Severe hypospadia**s – urethra opens at base of penis
•More of the penis is fused to the body so its smaller (micropenis)
85
hypospadias surger is needed: what must you NOT do?
may need what pre-surgery?
* Don’t circumcise – foreskin used in repair
* Surgical – may need testosterone tx pre-surgery to enlarge penis
86
differentiate b/w
## Footnote
Phimosis
Paraphimosis
**Phimosis** -Inability to fully retract the penile foreskin without complications
* •Normal in infants and children
* •Not normal in adults – not always pathologic
**Paraphimosis** - in ability to put foreskin back once retarded
87
pediatric population –
acute urinary tract obstruction- obstructive voiding symptoms.
may indicated what male dz?
Paraphimosis
88
tx of paraphi
_Manual retraction of foreskin_ (time-permitting)
* •Grade 2 or 3
If it does not respond / severe -\> _Dorsal slit procedure_
_Circumcision – ultimate tx_
89
tx indications and tx options for phimosis
**Treatment Indications –**
* urinary problems
* sexual dysfunction
* history of paraphimosis
* hygiene issues
**If indicated:**
* Manual stretching
* Steroid creams
* Circumcisionv
90
severe testicular pain
Negative cremasteric reflex
Dx?
test torsion
91
what is bell clapper” deformity
significance?
•High riding testis with long axis oriented horizontally instead of longitudinally “bell clapper” deformity à HIGH chance to develop torsion
92
tx of test torsion
Detorsion surgery w/ gubernacular fixation
93
si/sx Fornier’s Gangrene
**Severe pain that starts in the abdomen & migrates to the gluteal muscles, scrotum and penis**
**normal cremasteric reflex**
Edema
blisters, bullae, subcutaneous gas
crepitus fever, Tachycardia, hypotension
94
Most common cause of acute onset scrotal pain in adults males
route of infection?
epidiymits
Route of infection-urethra to ejaculatory duct down the vas deferens to epididymis
95
Unilateral
Fever
Scrotal swelling and pain -\> Radiating pain to flank
+ Phren Sign
dx?
Epididymitis
96
name 2 types of Epididymitis
most common pathogens?
**Sexually transmitted : N. gonorrhea, C. trachomatis**
* most common in men \<35
* associated w/ urethritis
**Non-sexually transmitted : E. coli**
* most common in older men
* associated w/ UTI & prostatitis
* obstructive uropathy from BPH
Trauma
Autoimmune
97
Epididymitis sexual vs nonsexual
## Footnote
* associated w/ urethritis
* associated w/ UTI & prostatitis
Sexually transmitted -associated w/ urethritis
non sex- associated w/ UTI & prostatitis
98
Epididymitis Cremasteric reflex is...?
normal
99
tx epidiymitis
sex
nonsex
Bed rest , _Scrotal elevation ,_ Ice
**Sexually Transmitted: Gon & Chlam**
•Doxycycline + Ceftriaxone
•
**Non-sexually transmitted/ low-risk**
* Levoflox
* or Bactrim
100
what is phren sign?
dx?
Phren Sign: lift scrotum & pain is relieved
epodymitis
101
Orchitis most likely caused by?
other causes?
**Viral:**
_**•Mumps\*\***_ due to decrease vaccination rates
•Cocksackie, EBV
**Bacterial causes-** usually in conjunction w/ epididymitis
_•14-35_ = N. gonorrhea
_•Boys \<14 & men \>35_ - E.coli
_Older men with bacterial infection_ usually due to BPH
102
si/sx orchitis
Mumps: Associated parotitis which presents 4-7 days prior
* Unilateral in 70% of cases
* Can mimic testicular torsion
Fever , Malaise, Myalgias
Swollen red painful testicle -\> Bilateral in 14 %
103
tx orchitis
Scrotal elevation
NSAIDS
Ice
104
Acute Bacterial Prostatitis most common opathogen & route of infection
**Gram-negative rods**_Most common E coli and Pseudomonas_
* •Proteus species
* • Enterobacteria (Klebsiella, Enterobacter, Serratia species)
**Most likely route of infection**-
1. ascent up the urethra
2. •Reflux of infected urine into prostatic ducts
105
si/sx of acute bact prostatitis
Perineal, suprapubic, and back pain
May have obstructive sx- urinary retention
Pelvic tenderness (generalized)
**DRE- exquisite (PAINFUL prostate)**
•Prostate is tender, edematous, warm
106
# define Chronic Bacterial Prostatitis
pathogen?
route of infection?
Chronic or recurrent urogenital symptoms with evidence of bacterial infection of the prostate: **gram – rods (E. coli)**
•Entry of microorganisms into prostate gland is almost _always through the urethra_
107
si/sx of Chronic Bacterial Prostatitis
Irritative voiding symptoms that won’t go away frequency, dysuria, urgency
DRE – prostate not tender
•May feel boggy, normal or firm
108
labs for acute bacterial prostattis
Leukocytosis (↑WBC)with left shift
UA - pyuria, bacteriuria and hematuria
UC will grow offending bacteria
↑ (CRP, ESR)
↑ PSA
109
labs chronic bacterial prostatis
**UA frequently normal**
_•Cx grows offending pathogen_
Expressed prostate secretions (usually done by urologist)
* •Increased leukocytes
* •Increased bacteria
110
tx of acute bact prostatitis
_Empiric antibiotics until cx_
* Ciprofloxacin 5
* Levofloxacin
* Trimethoprim/sulfamethoxazole (Bactrim)
* Gentamycin 5mg/kg QD IV
111
tx chronic bact prostatis
_Abx 4-6 wks_
Ciproflox
Levoflox
Trimethoprim/sulfamethoxazole (Bactrim)
* ↑ resistance but good alternative
112
Clinical syndrome in men defined by pain or discomfort in the pelvic region often accompanied by urologic symptoms or sexual dysfunction
Inflammatory Prostatitis
113
si/sx Inflammatory Prostatitis
Subtle symptoms
_Pain in the perineum, lower abd, testicles, penis_
Voiding difficulties
Blood in semen
Identical to chronic bacterial prostatitis
**Erectile dysfunction, Ejaculatory pain**
**Depression**
114
lab inflam prostatits
UA normal --\> UC no growth
* •No growth on Cx
Expressed prostate secretions
* • Increase in WBC
* •Increase in macrophages
Prostate Bx
114
comapre contrast lab values
chronic bacterial prostatis
inflammatory prostatits
**chronic bacterial prostatis**
UA frequently normal
* **•Cx grows offending pathogen**
_Expressed prostate secretions_
* •Increased leukocytes
* •Increased bacteria
**inflammatory prostatits**
UA normal --\> UC no growth
* **•No growth on Cx**
_Expressed prostate secretions_
* • Increase in WBC
* •Increase in macrophages
115
tx Inflammatory Prostatitis
Tx targeted at symptoms
## Footnote
PT - _Trigger point pelvic muscle spasm_
Psychological support- _CBT_
Tamsulosin
Ibuprophen
_Voiding difficulty:_ 5- apha reductase inhibitors
_Sexual Dysfunction:_ Phosphodiesterase 5 inhibitors fo
116
Urethritis classifications
**gonococcal** : N. gonorrhea
**non-gonococcal (NGU)**: C. trachomatis (most common)
* M. genitalium
* Trichomonas vaginalis
* Treponema pallidum
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si/ sx or urethritius
gon vs non gon
Anxiety
Burning a urethral meatus
Inguinal LAD
Meatus can be red and tender
**Gonococcal**: incubation 4-7 days
* _•Purulent brown/greenish discharge_
* •5-10% asymptomatic
**Non-Gonococcal:** incubation 5-8
* •Dysuria (chlamydia)
* _•White – Watery discharge_
* •More likely to be asymptomatic
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labs / dx of urethritis
UA – gon/chly
**First catch urine without cleansing**
* •+ leukocytes
* •\>10 WBC’s
Gram stain - Genital swab
* Gram stain urethral discharge _Chlamydia_- PMN (Polymorphonuclear neutrophils)
* urethral discharge _Gonorrhea_- intracellular gram-negative diplococci
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tx of urethritis
gon vs non gon
no cx available?
**When cx is not available,** sexually active men should be treated for both
* •Partners within last 60 days need to be treated
* •EPT
* •Test of cure not needed
**NGU (targets Chlamydia and M. genitalium)**
* single dose of Azithromycin 1 g
* or Doxycycline BID 7 days
**Gonorrhea**: Ceftriaxone (Rocephen)
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Most common of the prostatitis syndromes
what is important to know about the dx of this condition?
Inflammatory Prostatitis
dx of exclusion
