Lecture 21 - Men's Health Part 1 Flashcards
Epi of acute vs chronic prostatitis
Acute: younger males (20-40)
Chronic: >55y/o
Prostatitis
inflammatory condition (not necessarily an infection)
What are the types of prostatitis?
Type 1 - acute bacterial prostatitis
Type 2 - chronic bacterial prostatitis
Type 3 - Chronic abacterial prostatitis (more common than chronic bacterial)
Type 4 - asymptomatic inflammatory prostatitis
Type 1 Prostatitis Pathogenesis
acute bacterial prostatitis
post-intercourse of post-instrumentation urethral infection
urethral infection ascends
reflux of infected urine into prostatic urethra, ejaculatory ducts, prostatic ducts
What are the risk factors of type 1 prostatitis?
intraprostatic urine reflux unprotected sex phimosis, urethral stricutre lower UTI, epidiymitis BPH indwelling catheter Prostate bx
always suspect gonorroeae should be suspected in the sexually active <35y/o
What is the most common pathogen responsible for type 1 prostatitis?
E. coli (MC)
Psuedomonas
Proteus
Klebsiella
always suspect gonorroeae should be suspected in the sexually active <35y/o
What is the clinical presentation of Type 1 prostatitis?
local suprapubic or rectal pain systemic sxs: -fever -chills -malaise -N/V Lower urinary tract sxs: -dysuria -frequency -urgency
more than 75% have fever and dysuria
about 50% have pelvic pain and chills
if ever there is hematuria, you have to bring the pt back once they are sxs free to assess them for bladder cancer
What does the PE show for type 1 prostatitis?
lower abdominal tenderness
distended bladder
perineal tenderness
enlarged, tender prostate
must do prostate exam but don’t do prostate massage
What is the DDx for type 1 prostatitis?
prostatic abscess
prostate cancer
urethritis
UTI
How do you dx type 1 prostatitis?
CBC --leukocytosis with left shift Urinalysis/Microscopy -pyuria (leukocytes) -bacteriuria Urine culture -looking for causative agent - if pt is febrile -- midstream collection
PSA - not helpful for ABP, may be elevated
Biopsy contraindicated –could lead to sepsis
What is the treatment for type 1 prostatitis?
age <35, risk of STI?
-treat N. gonorroeae, and C. trachomatis
- Ceftriaxone 250mg IM x 1 or 400 mg PO x 1
- AND azithromycin 1000mg PO x 1
Then add…
Age >35, low risk of STI? -Ciprofloxacin x 4 weeks OR -levofloxacin x 4 weeks OR -bactrim x 4 weeks
Severe infection?
- inpt management
- IV ampicillin and gentamicin OR levofloxacin (aminoglycocides)
- -only inpt for 2-3 days
- total treatment 6-8 weeks
What can you do for prevention of type 1 prostatitis?
treat comorbid conditions (ex. BPH)
wear condoms
What treatment is used for urinary retention with prostatitis type 1?
may be alpha blocker (terazosin)
is possible, pass foley cath
if obstructive, suprapubic cystostomy
Prostatitis type 2
chronic bacterial prostatitis
pathogenesis, etiology, and risk factors similar to ABP
Presentation:
- recurrent UTIs that respond to ABX
- pain - lower abdominal, perineal, testicular, scrotal, rectal, back (NO FEVER)
- lower urinary tract sxs - dysuria, frequency, hesitancy, weak urinary stream
- painful ejaculation, change in color of semen, retarded ejaculation, ED
LUTS
lower urinary tract sxs
dysuira
frequency
urgency
dribbling
What is the presentation of type 2 prostatitis?
- recurrent UTIs that respond to ABX
- pain - lower abdominal, perineal, testicular, scrotal, rectal, back (NO FEVER)
- lower urinary tract sxs - dysuria, frequency, hesitancy, weak urinary stream
- painful ejaculation, change in color of semen, retarded ejaculation, ED
if ever there is hematuria, you have to bring the pt back once they are sxs free to assess them for bladder cancer
How do you dx type 2 prostatitis?
urine microscopy and culture often normal
urine microscopy after prostate massage –> pyuria, bacteriuria
urine culture after prostate massage –> bacterial growth
How do you treat type 2 prostatitis?
start with NIH chronic prostatitis sxs index
ABX:
-ciprofloxacin 500mg PO BID x 6 weeks
OR
-Bactrim 80/400 PO BID x 4-6 weeks
recurrence is COMMON
-may require low dose suppressive therapy
may require alpha blocker therapy if retention occurs
Type 3 prostatitis
chronic abacterial prostatits/chronic pelvic pain syndrome
no demonstrable infection
local sxs - pelvic pain, urinary sxs, ejaculatory dysfunction
Use NIH CPSI to quantify/monitor severity
2 types:
- inflammatory - WBC in semen, prostatic secretions, or urine post-massage
- non-inflammatory - no WBCs
tx; refer to urology
What is the treatment for type 3 prostatitis?
refer to urology
What are the 2 types of type 3 prostatitis?
- inflammatory - WBC in semen, prostatic secretions, or urine post-massage
- non-inflammatory - no WBCs
Type 4 prostatitis?
asymptomatic inflammatory prostatitis
no sxs
WBCs in prostatic secretions or in prostate tissues found incidentally during prostate evaluation for other reasons
no tx warranted
questions of increased association with BPH and/or prostate cancer
Two glass test
pre and post prostate massage sampling for urine culture to help dx type 1 prostatitis
BPH
benign prostatic hypertrophy
not really a disease, just a product of aging
Prevalence of BPH
increases with age
40y/o - 20%
90y/o - 90%
What is the path behind BPH?
testosterone is converted to dihyrdotestosterone (DHT) by enzyme 5AR
high levels of DHT are found in the prostate
When DHT is absent (castrated males) BPH never develops
Nodule formation in the periurethral zone of the prostate results in extrinsic compression of the prostatic urethra –> impaired voiding
What is the clinical presentation of BPH?
LUTS
- hesitancy
- weak stream
- interrupted stream
- incomplete voiding
- straining to void
- dribbling
- nocturia
- incontinence
Recurrent UTIs
PE:
-enlarged prostate on DRE
-should be 2 fingerbreadths or less
How do you dx BPH?
lab work:
- urinalysis - look for evidence of UTI
- urine culture - only done if UA abnormal of hx suggestive of UTI
- PSA -should be measured in any man who has at least 10 year life expectancy
- -PSA level correlated with size of prostate
imaging
-US, only if significant abnormality on DRE or elevated PSA
American Urological association symptom index
used for BPH dx
Score 0-7 = mild
8-19 = moderate
20-35 = severe
What is the drug therapy for BPH?
alpha blockers
- selective short term: prazosin, alfuzosin, indoramin
- selective long term: terazosin, doxazosin, slow-release (SR) alfuzosin
- partially subtype: tamsulosin, silodosin
PDE5 inhibitors (phosphdiaesterase inhibitor) -Tadalafil - used when pt also has h/o of ED
5 alpha reductase inhibitors
- finesteride
- ductasteride
Anticholinergics - must have low/normal post-void residual volume (PVR)
What is the follow up for Type 1 prostatitis?
we must check that they have fully irradiated the infection or else it might be chronic
so have them come back once they are done with their abx treatment –roughly 4 weeks –then do prostatic massage and urine culture
What is the most commonly dx non-skin cancer in men?
prostate cancer
second most common cause of cancer DEATH in men
What are the risk factors of prostate cancer?
age: rarely seen in men <40 (uncommon in men <50)
family hx: several potential genetic links, but not causative gene
Race: White 1 in 6, AA 1 in 5
lifestyle factors do NOT seem to play a role
prostatitis and BPH do not predict cancer occurence
What is the path of prostate cancer?
exact cause for malignant transformation unknown/varies by type
most form adenocarcinoma; few for SCC
location:
- peripheral zone - 70%
- central zone - 15-20%
metastasis – occurs late in disease –most common location –> bone
What is the clinical presentation of prostate cancer?
most cases detected through SCREENING (PSA or DRE) of ASYMPTOMATIC pts
sxs that may be present early in disease process:
- bladder obstruction (LUTS)
- back pain
- hematuria
sxs of metastatic or advanced disease:
- weight loss
- anemia
- bone pain
- leg weakness and sensorineural deficits (spinal cord compression)
What is the PE of prostate CA?
GEN - evidence of cachexia?
ABD - lower abdominal pain/swelling indicating bladder distention
DRE - examiner dependent; precision vs accuracy favors on provider over multiple providers
MSK - bony tenderness
NEURO - look for evidence of compression of spinal cord or spinal nerves
Hyperplasia vs hypertrophy?
hyperplasia –new cell growth
hypertrophy – the preexisting cells are getting bigger
Nodules + LUTS =
50% chance prostate cancer
Elevated PSA
not specific for prostate cancer
PSA can be elevated in which conditions?
prostate cancer advanced age BPH prostatitis prostate massage cystoscopy biopsy
What are the screening guidelines for prostate cancer?
LOOK UP
How do you dx prostate cancer?
elevated PSA and/or suspicious DRE finding
transrectal US (high false negative rates)
MRI or CT - visualization of regional lymph node involvement
Bone scan - helpful for staging
Gleason Score
prostate cancer staging
histologic scoring of biopsy
based on cellular architecture
high gleason = poor prognosis
may affect decision on how to manage
TMN
tumor staging
tumor size
node involvement
metastasis
used to gauge prognosis
will help direct therapeutic approach
What is the treatment for local prostate cancer?
low risk, low grade, low gleason score
- active surveillance
- -DRE, PSA testing, repeat bx to monitor progression
intermediate risk, high-grade, high gleason score
- radical prostatectomy - not necessarily curative, dramatic impact on QOL
- radiation therapy - only used post-radical prostatectomy for positive surgical margins
- cryosurgery - less commonly used (provider dependent); minimally invasive, fewer adverse events compared to radical prostatectomy
Treatment of metastatic prostate cancer?
Androgen deprivation therapy
- primary prostate cancer is hormone dependent
- orchietomy and/or luteinizing hormone releasing hormone analogs are first line
bone targeting agents
- bisphosphonates and RANK-L
chemotherapy - docetaxel - reversed for those who fail ADT
