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Prostate conditions Flashcards

1
Q

Prostate anatomy

A 
Single wall shaped gland
Golf Ball size
Inferior to bladder
Surrounds urethra
Continuos growth
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2
Q

Acute bacterial Prostatitis MC organism

A

GNB - E coli, Pseodomonas

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3
Q

Acute bacterial Prostatitis typically occurs how?

A

Ascending inf or infected urine into prostatic ducts

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4
Q

Acute bacterial Prostatitis can be concomitant w/?

A

UTI or epididymis

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5
Q

Two ducts of the prostate

A

Prostatic duct

Ejaculatiry duct

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6
Q

Acute bacterial Prostatitis S/S

A 
Abrupt
-Perineal, sacral, or suprapubic pain (vague)
Fever
Irritative voiding
\+- obstructive voiding
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7
Q

Acute bacterial Prostatitis PE

A 
High fever
Warm, inflamed very TTP prostate
— gentle DRE
— *NO prostatic massage
(dont risk septicemia)
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8
Q

Acute bacterial Prostatitis Labs

A 
UA/Cx*
-pyuria
-bacteriuria 
-hematuria
CBC ^WBC
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9
Q

Acute bacterial Prostatitis TXT

A

ABX per Cx/s, STI RFs for 4-6wks
1st Ampicillin + aminoglycoside prior Cx
(IV) Fluoro + aminoglycoside
(Ciprof/levof + gentam OR tobra)

(PO) fluro (ciprof/levof) OR TMP-SMX
-After 24-48 afebrile period

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10
Q

Acute bacterial Prostatitis Admit criteria

A

Septicemia
Comorbids
Unreliable pt (F/U)

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11
Q

Why is Acute bacterial Prostatitis ABX TXT so long?

A

4-6wk because prostate is hard to penetrate w/ ABX

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12
Q

Acute bacterial Prostatitis TXT of urinary retention?

A

PerQ suprapubic tube

CI - cath = septicemia

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13
Q

Acute bacterial Prostatitis Post TXT requirement

A

Test of cure - F/U UA, prostatic secretion Cx

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14
Q

Pts w/ Chronic bacterial Prostatitis may not present w/ what?

A

+- Hx of acute infection

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15
Q

Chronic bacterial Prostatitis S/S

A

Irritative voiding S/S
Low back pain
Perineal pain
+- hx of UTIs

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16
Q

Chronic bacterial Prostatitis PE

A 
Unremarkable or
Prostate is
-NL
-Boggy
-Indurated
Palpable prostatic calculi
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17
Q

Chronic bacterial Prostatitis Labs

A

UA/Cx
Prostatic massage secretions - >10/hpf WBC
-culture both
CBC - ^Wbc

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18
Q

Chronic bacterial Prostatitis TXT

A 
ABX - 6-12wks
TMP-SMX
Levof 750 or ciprof 500
BID all
Symptomatic care
-NSAIDs (indo/ibup)
-sitz bath
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19
Q

Chronic bacterial Prostatitis TXT failure step

A

Try 2nd longer course of Antibiotics

-consider infected prostate stone

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20
Q

MC prostatitis

A

Chronic Non-bacterial Prostatitis

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21
Q

How is Chronic Non-bacterial Prostatitis Dx?

A

Dx of exclusion

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22
Q

Chronic Non-bacterial Prostatitis presents

A

Same as Chronic bacterial Prostatitis but w/ absolutely no Hx of UTIs

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23
Q

Chronic Non-bacterial Prostatitis Labs

A

^WBC w/in prostatic secretions
-IND-inflam not inf
All Cx negative

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24
Q

Chronic Non-bacterial Prostatitis TXT

A

Warranted to use ABX against atypical organisms.
-Ureaplasma
-Mycoplasma
-Chlamydia
— erythromycin 250 PO QID x14d > reeval > alt txt or continue 3-6wks
NSAIDs
Sitz bath

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25
Q

What is prostatodynia?

A

Non-inflammatory D/O of pain/uncomfortable sensations in the perineum.

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26
Q

MC prostatodynia pop

A

Young/middle aged males

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27
Q

Causes of prostatodynia?

A

Voiding dysfx

Pelvix floor musculature dysfx

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28
Q

W/ prostatodynia how is the pts prostate status?

A

Normal

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29
Q

prostatodynia S/S

A

Same as Chronic prostatitis
-NO Fever/Hx UTI
+- hesitating, flow interruption
Hx of voiding difficulty

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30
Q

prostatodynia PE

A

Nothing

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31
Q

prostatodynia Labs

A

Normal UA/prostatic secretion

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32
Q

prostatodynia TXT

A 
Spasms > alpha-blk
-terazosin
-doxazosin
Pelvic floor muscle dysfx
-Diazepam 
-biofeedback techniques
Symptomatic
-sitz bath
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33
Q

Unresponsive prostatodynia TXT reflex

A

Urodynamic testing - R/O voiding dysfx

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34
Q

Look at chart

A

Slide 29 prostatic deck

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35
Q

BPH pathogenesis

A

Multifactorial and under endocrine control otherwise unknown

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36
Q

2 factors essential for BPH?

A

Dihydrotestosterone (DHT)

Aging

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37
Q

DHT pathology of BPH

A

5-alpha-reductase converts testosterone to DHT which promotes prostate cell proliferation (hyperstatic process)

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38
Q

BPH growth pattern

A

Nodular w/ varying amounts of stroma or epithelial growth occuring in the transition zone surrounding urethra

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39
Q

Prostatic stroma composed of?

A

Smooth muscle and collagen

- adrenergic nerves

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40
Q

5-alpha-reductase inhibitor TXT concepts

A
  • decreases prostate tone/outlet resistance

- responds better w/in Epithelium

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41
Q

prostate hyperplasia pathophysiology

A

Mechanical obstruction of urethra - higher bladder resistance

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42
Q

Efficency of DRE to eval prostate?

A

Poorly correlates w/ S/S

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43
Q

Types of S/S ass/w BPH?

A

Obstructive voiding - hyperplasia growth

Irritative voiding - 2/2 outlet resistance of the bladder

44
Q

BPH obstructive S/S

A 
Hesitancy/straining to void
Decreased force/caliber
Incomplete empyting sensation
Double void
Post void dribble
45
Q

BPH irritative S/S

A

Urgency
Frequency
Nocturia

46
Q

Most important tool for BPH evaluation?

A

American Urological Association (AUA) symptom index

-self administered 7- questionnaire

47
Q

BPH Hx to R/O

A

Prostate cancer
UTI
Neurogenic bladder
Urethral stricture

48
Q

Prostate characteristics for BPH

A

Smooth, firm, elastic anlargement

49
Q

Indurations of prostate req?

A

Further W/U req to R/O cancer - PSA, TRU/S, Bx

50
Q

Abd exam for BPH?

A

Look for bladder distension (sig S/S of obstruction)

51
Q

BPH labs

A

UA - (R/O hematuria/infection)
PSA
BUN/creatinine (R/O obstructive - postrenal azotemia)

52
Q

If AUA score is >=8 consider special tests?

A

Urodynamic studies

Post void residual (PVR)

53
Q

BPH - Renal U/S or CT is only recommended if

A 
Concomitant urinary tract disease
BPH complications
-Hematuira
-UTI
-CKD
-Hx stones
54
Q

BPH obstructive DDx

A 
Urethral stricture
Bladder neck contracture
Bladder stones
Prostate cancer
Other DDX - (UTI, Bladder cancer, nuerogenic bladder)
55
Q

BPH - TXT options for AUA 0-7 (mild S/S)

A

Observation
-progression uncertain; possible spon resolve possible
F/U interval not defined

56
Q

BPH - TXT options for AUA >8 (mod-severe S/S)

A

Observe
Surgery
Medical therapy

57
Q

BPH - Absolute surgical indications*

A 
Refrac UA retention (failing cath removal)
LRG bladder diverticula
BPH sequelae of
- Recurrent UTI
- Recurrent/persistent gross hematuria
- Bladder stones
- CKD (renal insufficiency/failure)*
58
Q

BPH - Rx

A

Alpha blockers

  • Prazosin
  • Doxazosin
  • Terazosin

Alpha-1a blockers (selective w/ fewer SEs)

  • Tamsulosin
  • Alfuzosin
59
Q

BPH - 5-alpha-reductase inhibitors MOA

A

Blocks conversion of testosterone to DHT

60
Q

5-alpha-reductase inhibitors use is best for?

A

Enlarged prostates >40mL on U/S - will have symptomatic* improvement

61
Q

Durations req for 5-alpha-reductase inhibitors - BPH TXT

A

6mos for max efx

62
Q

5-alpha-reductase inhibitors Rx’s?

A

Finasteride

Dutasteride

63
Q

Finasteride - important concept to consider w/ BPH?

A

Will reduce PSA by 50%
- If pt takes Finasteride double PSA results and compare to pre-finasteride PSA levels
(Improve or same or Worse?)

64
Q

BPH combination therapies?

A

Alpha blocker + 5-alpha-reductase inhibitor
(Doxazosin + finasteride)
Safe/effective

65
Q

Other BPH Rx therapy?

A

PDE-5 inhibitors

-Tadalafil - FDA approved for BPH and/or urinary tract S/S w/ ED

66
Q

BPH pixie dust therapy

A

Phytotherapy

67
Q

BPH minimally invasive prosecures

A

TULIP - transurethral laser-induced prostatectomy
TUNA - transurethral needle ablation of prostate
TUEV - transurethral electrovaporization of prostate
Microwave hyperthermia (burn)
Implant to open prostatic urethra

68
Q

BPH conventional surgery?

A

TURP - transurethral resection of prostate
- most performed endoscopically
- req spinal anesthesia
- 1-2d hospital stay
Superior flow/symptom improvement vs minimal invasive therapy

69
Q

If inable to perform TURP endoscopically then reflex?

A

TUIP - transurethral incision of prostate OR

Open simple prostatectomy - (too large to remove)

70
Q

Other off-label TXTs of BPH?

A

Botox injection - not FDA approved

71
Q

Essentials to Dx prostate Cancer?

A

Induration on DRE or PSA elevation

Asymptomatic (rarely systemic S/S (wgt loss/bone pain)

72
Q

MC non-cutaneous cancer in men?

A

Prostate Cancer

73
Q

2nd leading cause of cancer-related deaths?

A

Prostate cancer

74
Q

RFs for prostate cancer?

A

Aging, black, Fam Hx prostate cancer, high fat intake

75
Q

Prostate cancer S/S?

A 
Most - early Dz = asymptomatic
Symptoms = locally advanced or Mets
- bone pain
- lumbar spine pain
Obstructive/irritative S/S
76
Q

Prostate cancer PE?

A

DRE > induration

cant appreciate entire gland however

77
Q

Prostate cancer labs?

A

PSA - NL = <4ng/mL
-Most cancers confined to prostate = <10ng/mL
-Advanced cancer Dz = >40ng/mL
BUN/Cr - elevated if urinary retention/obstruction
Increased ALP or hypercalcemia (Skeletal Mets)

78
Q

Does PSA absolutely exclude/include cancer Dx?

79
Q

Can initial TXT be based on PSA alone?

80
Q

Elevated PSA pts should be?

A

Referred for U/S and Bx

81
Q

Abnl PE but normal PSA level pts should be?

A

Referred for U/S and Bx

82
Q

TRU/S guided Bx performed if?

A

Following ABNL DRE or elevated PSA - Definitive Dx

83
Q

What is definitive Dx of prostate cancer?

A

TRU/S guided Bx

84
Q

Other imaging for Prostate cancer?

A

MRI - eval prostatic lesions + regional lymph nodes

Bone scan - Mets/bone pain

85
Q

Indications for bone scan in a pt w/ prostate cancer?

A

Advanced local lesions
S/S of Mets- bone pain
High-grade Dz
PSA elevations >20ng/mL

86
Q

TXT of localized prostate cancer is based on?

A

Based on tumor grade/stage, pt age/health

87
Q

Prostate cancer TXT should always be considered for pts w/?

A

expected survival in excess of 10yrs

88
Q

Older pts w/ low risk prostate cancer should be TXT how?

A

Active surveillance

89
Q

Prostate cancer TXT?

A

Radical prostatectomy

90
Q

What is removed w/ Radical prostatectomy

A

Seminal vesicles, prostate, ampullae or vas deferrens

91
Q

Prostate cancer - Ideal candidates for Radical prostatectomy

A

Stage T1-T2 cancers (not advanced tumors or METs)

92
Q

Recurrence rates posr Radical prostatectomy for prostate cancer?

A

Uncommon recurrence

93
Q

Pts w/ positive prostate cancer margins considered for?

A

Adjuvant TXT

- radiaiton (POS margins or androgen deprivation for lymph node mets)

94
Q

Prostate cancer - bracytherapy TXT is?

A

Implantation of permanent or temporary radioactive substance into prostate
-Palladium, Iodine, Iridium

95
Q

Prostate cancer - Cryosurgery TXT is?

A

Using liquid nitrogen to destroy tissue

96
Q

Androgen deprivation is?

A

Suppressing androgens via hormonal therapy to control prostate cancer (Most are hormonal dependent)

97
Q

Population indicated for androgen deprivation?

A

Men w/ Mets > imrpoves control of distant disease

98
Q

Prostate cancer prognosis?

A

CAPRA nomogram

  • PSA
  • Gleason grade
  • staging
  • percent positive Bx
  • pt age
99
Q

Prostate cancer PVT techniques?

A 
Antioxidants - Lycopene/polyphenols (green tea)
Cruciferous veggies - broccoli
Vitamin D 
Omega-3's
decreased BMI
Smoking cessation/ETOH
High fiber/low fat diet
100
Q

Prostate cancer screening protocol?

A 
Avg risk white male = 50yo
45yo if
- Black
-positve fam hx (1st degree Dx prior to 65yo)
-BRCA1 mutation
101
Q

AGE/PSA correlation?

A

PSA gradually increases w/ age

102
Q

What age to D/C PSA tests?

A

If expected life is <10yrs

103
Q

USPSTF screening recommends

A

against routine screening

104
Q

PSA velocity notes

A

serial PSA values (better than random PSA)

  • may increase specificity for cancer detection
  • rate of PSA change >0/75ng/mL per yr = higher risk cancer
105
Q

PSA density is? and results?

A

Free PSA/Total PSA

  • > 25% free PSA > cancer unlikely
  • <10% free PSA > 50% chance of cancer

Urology (7 decks)

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