Prostate Disorder Flashcards
Where does the prostate sit and what is itβs job?
Liquid portion of semun
Sits at the base of the penis (which is why ED is common with prostatis) inferior to the bladder (which is why UTIs are common)
DRE allows you to feel
Gross vs microscopic hematuria. Also initial, terminal, total
Gross = visible to naked eye, more blood (concerning of cancer)
Microscopic = you need a microscope
initial (blood after first voiding)
Terminal (at the end of urinating)
Total (throughout urination)
Irritative voiding symptoms
Inflammation in the bladder
Urgency
Dysuria (painful)
Frequency
Nocturia (waking up in the middle of the night)
Obstructive voiding symptoms
Hesitancy
Dribbling (still leak after peeing)
Decreased force ((low water pressure in water hose) or caliber of stream (more pinpoint with high pressure)
Interruption of stream (randomly stops)
Means that there is an obstruction
Urinary incontinence
Overflow
Urge (involuntary and pee w/out
Stress (laughing, coughing)
Total (no mental switch, just randomly void with no triggers and no control over bladder)
What is acute bacterial prostatitis?
ascent up urethra
Can occur in setting of cystitis, urethritis
What are the risk factors for prostatitis?
factors predisposing to GU infections
Catheter, prostate biopsy, urethral stricture
Anecdotal risks - no strong evidence to support
Trauma (bike riding, horseback riding)
Dehydration
Sexual abstinence
What is the MC causative agent of acute bacterial prostatitis?
G- rods are most common pathogen
E. coli - 58-88%,
What are the s/s of acute bacterial prostatitis?
Fever, chills, malaise - common
Pain - perineal, sacral, or suprapubic
Irritative voiding s/s
Occasionally obstructive voiding s/s
DRE - Hot, exquisitely tender prostate
Prostatic massage contraindicated - risk of septicemia!
What are the labs of acute bacterial prostatits?
CBC - leukocytosis and left shift
Urinalysis - pyuria, bacteriuria, hematuria
Urine culture - + for causative agent
When do you order imaging for acute bacterial prostatits?
If no response to abx in abx
Pelvic CT or transrectal US to assess for prostatic abscess
What is the IV treatment for acute bacterial prostatitis that is not nosocomial?
fluoroquinolone +/- aminoglycoside , or ampicillin/gentamicin empirically
What is the IV treatment for acute bacterial prostatitis that is nosocomial?
IV carbapenem or IV broad-spectrum PCN/cephalosporin +/- aminoglycoside
What are the two categories used for oral therapy of ABP?
Bactrim or fluoroquinolone (cipro)
What is the MC causitive organism of chronic bacterial prostatits?
E coli climbing up the urethra
sometimes no hx of acute prostatitis
What are the s/s of prostatitis?
Some are asymptomatic
Most - irritative voiding symptoms; may see obstructive voiding s/s
Pain - dull, poorly located, in suprapubic, perineal or low back regions
History of recurrent bacteriuria or UTIs
DRE - often normal (because we only feel a small part of the tissue)
May see boggy (spongy), mild tender, enlarged, and/or indurated prostate
NOT hot, not
What is the texture of a prostate/cervix?
Tip of the nose
boggy/spongy feels like a sponge
What are the labs of CBP?
UA - normal unless cystitis also present
Prostatic secretions - Increased WBCs (>10 per hpf) with + culture
Lipid-laden macrophages
Urine culture - negative
+ for causative organism after prostatic massage
what is the imaging of CBP?
usually not needed
Prostatic calculi may be visible
what is the treatment for CBP?
Same as acute
fluroquinolones or bactrim for 6-12 weeks (but prolonged treatment may need to C dif)
Why is CBC normal for chronic prostatitis vs
Puss is already in collecting ducts
chronic = walled off puss in microabcesses = not show up in CBC (massage releasese this though)
What is a non-pharm treatment for CBP?
sitz bath
What is non-bacterial prostatits?
MC cause of prostatitis
similar symptoms to chronic prostatits
often neurologic, but as inflammatory markers
what are the s/s of non-bacterial prostatis?
Irritative voiding or obstructive voiding
Pain - perineal, lower abdominal, or low back
Often dull and poorly localized as with CBP
May have hx of other pain syndromes (e.g. IBS, fibromyalgia)
Less likely to have hx of UTI than in CBP
DRE - tenderness in 50% of pts
What is the UA and prostatic secretion analysis of nonbacterial prostatits?
UA - unremarkable
Prostatic Secretions
increased WBC if inflammatory (chronic/nonbacterial prostatitis)
normal if noninflammatory
negative culture
Urine culture - negative
Imaging - mainly to rule out other pathology
e.g., obstruction in pts with obstructive voiding s/s
How do you treat nonbacterial prostatits?
hard to treat, but actually use antibiotics for 2 weeks (stop if they are not improving)
fluoroquinolones
often treated based on symptoms (pain = NSAIDs)
-alpha blockers -osin
5-πΌ-reductase inhibitors - finasteride, dutasteride
-sitz baths
-acupuncture, cernilton
Pelvic floor physical therapy
Treatment of psych disorders
What are the selective alpha blockers?
-osin
tamsulosin is MC
What is benign prostatic hyperplasia?
MC benign tumor in men (increases with age)
-increases glandular and stromal components
over 80% over 80 have it! But often asymptomatic
Apart from age, what are risk factors for benign prostatic hyperplasia?
Black men - more likely to have severe s/s and to need surgery
Asian men - less likely than black or white men to have BPH
Increased risk - higher free PSA levels, prostatitis, heart disease, beta-blocker use, lack of exercise, obesity
Decreased risk - NSAIDs, excessive ETOH use, smoking, exercise
Why does age lead to BPH?
Aging prostate seems to become more sensitive to androgens and growth factors
Aging prostate may also stop normal cell death
Testosterone, dihydrotestosterone, and estrogen may be involved in development
What are the two ways that BPH leads to obstruction?
Mechanical (stopping urine flow)
Muscles are constricted due to excessive stimulation of alpha-receptor
How does BPH typically come on?
Comes on slowly
What are the s/s of obstructive voiding of BPH?
Obstructive voiding - mechanical blockage
Urine hesitancy
Decreased force and caliber of stream
Sensation of incomplete bladder emptying
Double voiding (urinating within 2 hours)
Straining to urinate
Postvoid dribbling
What are the s/s of irritative voiding in BPH?
urgency, frequency, nocturia
Due to secondary response of bladder to increased outlet resistance
Detrusor muscle hypertrophy and hyperplasia, collagen deposition
How can you determine how bad the BPH of a patient is?
AUA symptom score
based on symptoms - and asks if it effects them
What is the DRE for BPH?
- smooth, firm, symmetric, elastic enlargement of prostate
Induration or asymmetric enlargement β possible cancer
What are the s/s of a neuro exam for BPH?
normal, but r/o neurogenic bladder
What are the s/s of lower abdominal exam for BPH?
might have a distended bladder
What are the labs for BPH?
UA - often normal
May see hematuria
PSA - may help screen for prostate cancer
Can be elevated in BPH even when no cancer is present
Prostate Bx - usually only done if concern for cancer
Transrectal or transperineal
When is BPH imaged?
often not needed
US - may be indicated if high serum Cr or UTI
Upper GU tract imaging - only if complications arise or comorbid GU disease present
When do you do watchful waiting for BPH?
mild symptoms (score 0-7) or pts who do not want tx
Not all pts will experience s/s progression!
Up to 50% have spontaneous regression
Limited data on natural course of disease
When are you not a candidate for BPH?
basically if no major s/s
Refractory urinary retention
Large bladder diverticula
Recurrent UTI or gross hematuria
Bladder stones
CKD
What are the 3 types of alpha blockers?
πͺ1a - 70% of adrenoreceptors in prostate, bladder neck
πͺ1b - smooth muscle of vasculature
πͺ1d - prostate, bladder neck, detrusor, sacral spinal cord
What are the a1-blockade agents?
Prazosin
Doxazosin
Terazosin
What are the selective a1a
silodosin
tamsulosin
alfuzosin
What are the SE of a1 blockers?
orthostatic hypotension, dizziness, tiredness, retrograde ejaculation, rhinitis, and headache
Floppy Iris Syndrome - cataract surgery complication in pts taking πͺ1-blockers
What are the DDI of a1 blockers?
antihypertensives, PDE-5 inhibitors can cause significant drops in BP when taken with alpha blockers
What is the MOA of 5-πͺ-reductase inhibitors?
5-πͺ-reductase - converts testosterone to dihydrotestosterone
Inhibiting this enzyme reduces size of prostate gland
Takes ~6 months of treatment to see full benefit
Reduces prostate size by ~20% - may reduce need for surgery
when are 5-πͺ-reductase inhibitors used?
More effective in men with larger prostates
All 5-πͺ-reductase inhibitors reduce PSA by 50%
Should double PSA value when comparing to pre-treatment PSA
May reduce risk of prostate cancer (reduces testosterone level)
What are the two 5-πͺ-reductase inhibitors?
Finasteride
Dutasteride
What are the SE of Finasteride and Dutasteride
similar to low T
Decreased libido, erectile or ejaculatory dysfunction
What is first-line therapy of BPH?
alpha blocker + 5-alpha-reductase inhibitor is considered first-line and superior to either treatment alone
What is the PDE 5 inhibitor and what is it used for?
Tadalafil
Approved for use in men with BPH + ED symptoms
Not superior to alpha-blockers, no extra benefit as adjunct
itβs expensive though :(
What surgery is used for BPH?
Transurethral Resection of the Prostate (TURP)
leads to retrogade ejaculation sometimes
