Inflammatory and pain conditions of male urinary tract Flashcards
NIH Classification of prostatis (4)
I. Acute bacterial prostatitis II. Chronic bacterial prostatitis IIIA. Chronic prostatitis/pelvic pain syndrome, inflammatory IIIB. Chronic prostatitis/pelvic pain syndrome, noninflammatory IV. Asymptomatic inflammatory prostatitis
Granulomatous prostatitis is diagnosed by the histologic finding of ____ with or without other inflammatory cells. It is commonly found on specimens from ___ and ____
Granulomatous prostatitis is diagnosed by the histologic finding of epithelioid granulomas with or without other inflammatory cells (Uzoh et al., 2007). It is commonly found on specimens from transurethral resections and prostate biopsies
IgG4-related disease is a fibroinflammatory condition characterized by several features: tendency to form __ at multiple sites, __ and ___, ___, and often, but not always, elevated levels of serum IgG4
IgG4-related disease is a fibroinflammatory condition characterized by several features: tendency to form tumorlike lesions at multiple sites, dense infiltrate of lymphocytes and IgG4 +plasma cells, characteristic pattern of fibrosis, and often, but not always, elevated levels of serum IgG4
Category I Prostatitis: Acute Bacterial Prostatitis
Risk factors for the development of acute prostatitis include: (7)
Risk factors for the development of acute prostatitis include
unprotected sexual intercourse, specifically insertive anal intercourse, phimosis, condom catheter use, indwelling urethral catheters, and urinary tract instrumentation, including endoscopic procedures and prostate biopsy
The presentation of category I prostatitis is acute symptoms of a urinary tract infection (UTI), characteristically including __ and ___. Some patients have symptoms suggestive of systemic infection, such as malaise, fever, and myalgias
The presentation of category I prostatitis is acute symptoms of a urinary tract infection (UTI), characteristically including urinary frequency and dysuria. Some patients have symptoms suggestive of systemic infection, such as malaise, fever, and myalgias
. Acute prostatitis should be considered in any man who presents with a febrile UTI. Febrile UTI in men can be from pyelonephritis, acute cystitis, or prostatitis
bacteria also have significantly higher rates of septicemia (Kim et al., 2015). Acute prostatitis should be considered in any man who presents with a febrile UTI. Febrile UTI in men can be from pyelonephritis, acute cystitis, or prostatitis
Acute prostatitis is the one situation in which one may palpate a truly ___ from __ and __. The prostate is tender and swollen in__of cases
Acute prostatitis is the one situation in which one may palpate a truly “boggy” prostate from edema from inflammation. The prostate is tender and swollen in 60% to 90% of cases
in acute bacterial prostatitis: Caution should be used to avoid __ that could lead to bacterial dissemination and sepsis.
Caution should be used to avoid aggressive palpation that could lead to bacterial dissemination and sepsis.
Antibiotics are the mainstay of therapy for acute bacterial prostatitis. The most recent European Association of Urology (EAU) guidelines on treating UTIs recommend the parenteral administration of high-dose bactericidal antibiotics such as a broad-spectrum ___, ___ cephalosporin, or a ____. In initial therapy, any of these can be combined with an aminoglycoside
Antibiotics are the mainstay of therapy for acute bacterial prostatitis. The most recent European Association of Urology (EAU) guidelines on treating UTIs recommend the parenteral administration of high-dose bactericidal antibiotics such as a broad-spectrum penicillin, third-generation cephalosporin, or a fluoroquinolone. In initial therapy, any of these can be combined with an aminoglycoside
___ should be suspected in men with high fever or a history of immunosuppression such as diabetes or HIV or who do not respond to initial therapy after 48 hours
Prostatic abscess should be suspected in men with high fever or a history of immunosuppression such as diabetes or HIV or who do not respond to initial therapy after 48 hours
__ should be used if long-term drainage is needed.
A suprapubic tube should be used if long-term drainage is needed.
Chlamydia spp. can cause prostatic infection by an a___ after urethral inoculation in animal models (Pal et al., 2004). The main argument is the difficulty of attributing the findings of Chlamydia spp. in the __ or ___ to prostate infection alone given the possibility of urethral contamination, as Chlamydia spp. are a common cause of urethritis
Chlamydia spp. can cause prostatic infection by an ascending route after urethral inoculation in animal models (Pal et al., 2004). The main argument is the difficulty of attributing the findings of Chlamydia spp. in the expressed prostatic secretions or semen to prostate infection alone given the possibility of urethral contamination, as Chlamydia spp. are a common cause of urethritis
prostatitis dx: The diagnosis is currently made by the ___ and ___ test also called the ____. The VB3 specimen gives information as to a persistent prostatic source of bacteria. The patient provides a midstream pre-massage urine specimen and a urine specimen (____) after prostatic massage to obtain ___
The diagnosis is currently made by the pre-massage and post-massage test (or two-glass test). The VB3 specimen gives information as to a persistent prostatic source of bacteria. The patient provides a midstream pre-massage urine specimen and a urine specimen (initial 10 mL) after prostatic massage to obtain expressed prostatic secretions (EPS)
prostatis : In men with human immunodeficiency virus (HIV), cultures should be sent not only for the usual bacteria but also for:
more atypical organisms, including anaerobes, anaerobes, fungi, and TB
chronic prostatis dx: Urine should be assessed for ___. If present in the setting of infection, it should be rechecked ___ after resolution of infection to look for resolution of the hematuria. Persistent hematuria should prompt an evaluation. Physical examination should evaluate for ___. Abdominal examination is necessary to rule out other causes of abdominal/suprapubic pain. Scrotal examination is needed to evaluate for any associated areas of inflammation and possible infection such as the___ and ___. A digital rectal examination is indicated to look for prostate size and any abnormalities to suggest prostate cancer. It is important to assess for bladder outlet obstruction and urinary retention. Retention of urine may predispose to recurrent urinary tract infection. A postvoid residual urine of more than ___ has been correlated with increased risk of infection
Urine should be assessed for hematuria. If present in the setting of infection, it should be rechecked 4 to 6 weeks after resolution of infection to look for resolution of the hematuria. Persistent hematuria should prompt an evaluation. Physical examination should evaluate for fever. Abdominal examination is necessary to rule out other causes of abdominal/suprapubic pain. Scrotal examination is needed to evaluate for any associated areas of inflammation and possible infection such as the epididymis and testis. A digital rectal examination is indicated to look for prostate size and any abnormalities to suggest prostate cancer. It is important to assess for bladder outlet obstruction and urinary retention. Retention of urine may predispose to recurrent urinary tract infection. A postvoid residual urine of more than 180 mL has been correlated with increased risk of infection
chronic prostatis: Imaging is not recommended/ recommended for men with a UTI and history of diabetes, chronic kidney disease, stones, voiding difficulties, neurologic disease, poor response to antibiotics, infection with urea-splitting bacteria, or hematuria more than 1 month after the infection
Imaging is recommended for men with a UTI and history of diabetes, chronic kidney disease, stones, voiding difficulties, neurologic disease, poor response to antibiotics, infection with urea-splitting bacteria, or hematuria more than 1 month after the infection
PRostatitis tx: Penetration into the prostate, therefore, is dependent on ___, and the factors that influence this transport are :(5)
preferred meds used: ___
The prostate capillary bed lacks active transport mechanisms for antibiotics. Penetration into the prostate, therefore, is dependent on passive transport (no capillary bed), and the factors that influence this transport are drug concentration, lipid solubility, degree of ionization or charge, degree of protein binding, and size and shape of the molecule
chronic prostatis tx: __ and ___ are the antibiotics of choice not only because of their tissue penetration but also because of their spectrum of coverage, which includes gram-negatives, including Pseudomonas, gram-positives, and atypical pathogens such as Chlamydia spp. and genital Mycoplasma spp. Duration of treatment is based on expert opinion; the recommendation is ___
Fluoroquinolones such as ciprofloxacin and levofloxacin are the antibiotics of choice not only because of their tissue penetration but also because of their spectrum of coverage, which includes gram-negatives, including Pseudomonas, gram-positives, and atypical pathogens such as Chlamydia spp. and genital Mycoplasma spp. Duration of treatment is based on expert opinion; the recommendation is 4 to 6 weeks.
chronic prostatis tx : Beyond Quinolones
give examples
cefoxitin
Piperacillintazobactam achieves prostatic levels that would be adequate to treat infections from E. coli, Klebsiella, and Proteus but not adequate levels to treat Pseudomonas
fosfomycin has in vitro activity against E. coli with antimicrobial resistance, includingChapter 56 Inflammatory and Pain Conditions of the Male Genitourinary Tract
ESBL strains
For patients whose symptoms are refractory to medical therapy, TURP has been used with results of 52% to 67% of patients responding to TURP down to the surgical capsule
Not all patients with chronic bacterial prostatitis need imaging.
In men younger than 45 years old with a first event of acute UTI, imaging showed no abnormalities. It is recommended, however, in this group to rule out ___. Men with a flow rate of more than ___ should be further evaluated
Not all patients with chronic bacterial prostatitis need imaging.
In men younger than 45 years old with a first event of acute UTI, imaging showed no abnormalities. It is recommended, however, in this group to rule out urethral stricture. Men with a flow rate of more than 15 mL/min should be further evaluated
The term prostatitis implies inflammation of the prostate gland. However only about __ of men with clinical CPPS have been found to have prostatic inflammation on biopsy
The term prostatitis implies inflammation of the prostate gland. However only about one-third of men with clinical CPPS have been found to have prostatic inflammation on biopsy
CPPS: On awakening, serum cortisol levels rise; there is a significantly ____ in men with CPPS compared with controls. Men with CPPS also have a lower/higher ___ level and blunted ACTH rise in response to stress than men without symptoms
On awakening, serum cortisol levels rise; there is a significantly greater cortisol rise in men with CPPS compared with controls. Men with CPPS also have a lower baseline adrenocorticotropic hormone (ACTH) level and blunted ACTH rise in response to stress than men without symptoms
There have been few biomarkers that correlate with symptoms in CP/CPPS. One of these markers is ___), a neuropeptide that plays a role in nociception
There have been few biomarkers that correlate with symptoms in CP/CPPS. One of these markers is nerve growth factor (NGF), a neuropeptide that plays a role in nociception
CPPS symptoms: severe symptom was ___, followed by urinary frequency and obstructive voiding symptoms. The most frequent site of pain was the __
severe symptom was pain in the pelvic region, followed by urinary frequency and obstructive voiding symptoms. The most frequent site of pain was the perineum
The prevalence of ED in men with CP/CPPS is reported at ___
The prevalence of ED in men with CP/CPPS is reported at 15% to 40%
men with CP/CPPS were ___ more likely to self-report a history of cardiovascular disease, most commonly hypertension. A follow-up study by Shoskes et al. found ___ in men with CPPS compared with controls
men with CP/CPPS were six times more likely to self-report a history of cardiovascular disease, most commonly hypertension. A follow-up study by Shoskes et al. found greater arterial stiffness in men with CPPS compared with controls
Men with CP/CPPS were__ more likely to self-report a history of nervous system disease compared with asymptomatic age-matched controls
Men with CP/CPPS were 5 more likely to self-report a history of nervous system disease compared with asymptomatic age-matched controls
UPOINT: THE “SNOWFLAKE HYPOTHESIS”: the largest domain has been __ and ___, and the smallest domain has been the __ category. Men with CP/CPPS generally are characterized by multiple domains. In an early description, only one in five men were positive for only one domain, one-third of men were characterized by two domains, and the rest by three or more domains
UPONT snowflake theory: the largest domain has been organ-specific and urinary, and the smallest domain infectious category. Men with CP/CPPS generally are characterized by multiple domains. In an early description, only one in five men were positive for only one domain, one-third of men were characterized by two domains, and the rest by three or more domains
Evaluation for Men With Chronic Pain and Chronic Pelvic Pain Syndrome: enumerate
Mandatory
Evaluation for Men With Chronic Pain and Chronic Pelvic Pain Syndrome:
recommended
Optional
Role of anti-inflamattory on CPS:
Results from meta-analyses indicate that anti-inflammatory medications are considered to have ____ for some patients. They are likely INEFFECTIVE/EFFECTIVE if used alone but useful in combination therapy with an __ and a muscle relaxant that also has ___
Results from meta-analyses indicate that anti-inflammatory medications are considered to have beneficial effects for some patients (Thakkinstian et al., 2012). They are likely ineffective if used alone but useful in combination therapy with an alpha-blocker and a muscle relaxant that also has anti-inflammatory properties
In conclusion, anti-inflammatory monotherapy is not recommended but can be used as part of multimodal therapy
Dutasteride at 0.5 mg was studied in the ___, a 4-year, randomized, double-blind, placebo-controlled study of prostate cancer risk reduction. The NIH-CPSI survey was used to measure baseline and change in symptom severity. The dutasteride group noted a ______ CPSI total score compared with placebo
Overall, 5α-reductase inhibitor (5ARI) medications appear to be
effective in some patients.
The decision in whom to use 5ARI medications must also be made in the context of side effects, including: ___
This indicates that they may be best used in ___ with CP/CPPS who also have voiding symptoms from BPH
Dutasteride at 0.5 mg was studied in the REDUCE trial, a 4-year, randomized, double-blind, placebo-controlled study of prostate cancer risk reduction. The NIH-CPSI survey was used to measure baseline and change in symptom severity. After 48 months, the dutasteride group noted a significant decrease of 6 points or greater in CPSI total score compared with placebo (49% vs. 37%, P = 0.0033) (Nickel et al., 2011). Overall, 5α-reductase inhibitor (5ARI) medications appear to be
effective in some patients. This is demonstrated when the previous trials are subjected to a meta-analysis, with significant reduction in
NIH-CPSI scores compared with placebo (−4.6, 95% CI −8.7 to −0.5) (Anothaisintawee et al., 2011). The decision in whom to use 5ARI medications must also be made in the context of side effects, including reduced volume of ejaculate, erectile dysfunction, and decrease in libido (Thompson et al., 2003). This indicates that they may be best used in older patients with CP/CPPS who also have voiding symptoms from BPH (Rees et al., 2015a).