Prostate Disorders

Question 1

Etiologies of acute prostatitis?

Answer 1

• think bacteria causing urethritis, cystitis, epididymitis
• e.coli
• proteus
• klebsiella, enterobacter, Serratia
• pseudomonas
• staph aureus
• chlamydia and GC
• salmonella typhi and GC

Question 2

• Acutely ill, fevers, chills, malaise, myalgia, dysuria, irritative voiding sxs (freq/urge) pelvic or perineal pain and cloudy urine
• history of trauma (fall on perineum, motorcycle, bike, horse)
• also dribbling urine, voiding hesitancy, urinary retention

Answer 2

Acute prostatitis

Question 3

what would be seen on exam for acute prostatitis?

Answer 3

• DRE: firm, edematous, tender prostate
• palpable urinary bladder indicates urinary retention
• labs: leukocytosis, pyuria, bacteriuria, +/- pos. blood cultures, increased ESR/CRP, increased PSA
• defer PSA screening for one moth till prostatitis treated

Question 4

diagnosis of AP?

Answer 4

• On DRE: edematous, tender prostate= acute prostatitis (gentle palpation, vigorous massage causes pain and increases bacteremia)
• gram stain & culture of UA (gram stain can guide initial therapy)
• blood cultures not needed (unless sepsis suggested) if staph aureus cultured from UA, blood culture should be accomplished
• diagnosis is often based on symptoms alone

Question 5

complications of AP?

Answer 5

• bacteremia
• epididymitis
• chronic prostatitis
• prostatic abscess
• metastatic infection (endocarditis, spinal/sacroiliac infection)

Question 6

management of AP?

Answer 6

• empiric therapy based on presumed infecting organism, pending culture results
• should adequately treat gram-negative organisms and penetrate prostatic tissues
• ciprofloxacin 500mg PO BID x 4 to 6 weeks
• levofloxacin 500mg PO daily x 4 to 6 weeks
• Bactrim one PO BID x 4 to 6 weeks
• if sexually active and or 35yo or younger- treat for GC and chlamydia
• post prostatic surgery (nosocomial)

Question 7

• bacterial infection of the prostate lasting > 3 months
• illness will yield the same bacterial strain in all UA cultures
• bacteria: E.coli, klebsiella, proteus and pseudomonas are most common
• special considerations in HIV: serratia, salmonella, etc.
• subtle presentation: recurrent UTI (urgency, dysuria, perineal pain, low grade fever)
• exam findings: Nml DRE, or boggy or firm
• diagnosis based on H&P

Answer 7

Chronic Prostatitis

Question 8

management of CP?

Answer 8

1st line

• ciprofloxacin 500mg PO bid x 6 to 12 weeks
• levofloxacin 500mg PO saily x 6 to 12 weeks

2nd line

• bactrim PO bid X 6 to 12 weeks

Question 9

• proliferation of glandular tissue, smooth muscle and connective tissue
• starts at age 40-45 years

Answer 9

BPH

Question 10

difference between storage symptoms and voiding symptoms?

Answer 10

• Storage (irritative) symptoms- frequency, urgency, nocturia, incontinence (these cause more bothersome symptoms for the patient)
• voiding- weak stream, straining to void, urinary intermittency or urinary hesitancy

Question 11

BPH complications?

Answer 11

• Acute urinary retention
• UTIs
• bladder stones
• formation of bladder diverticula
• renal and ureter damage
• not a risk factor for prostate cancer (BPH is centrally located and cancer is primary in the periphery)

Question 12

what would be seen on physical and digital rectal exam of BPH?

Answer 12

Physical exam

• DRE, abd, pelvis, perineum
• +/- focused neuro exam

Digital rectal exam

• estimate prostate size
• should be firm, nontender
• tenderness= prostatitis
• asymmetry/nodules= cancer

Question 13

what labs should be done on BPH?

Answer 13

• UA on all: R/O pyuria, glycosuria, proteinuria, bacteria (if positive additional w/u)
• urine culture- not normally needed
• serum creatinine- not normally needed
• PSA- no need unless to assess prostate volume for BPH tx

Studies

• symptom questionnaire
• post-vooid residual volume: evaluates for retention (nml < 12ml, urologists are concerned if > 250ml
• uroflowmetry: documents amount of obstruction

Question 14

who should be referred to urology?

Answer 14

• severe symptoms of pain
• men under 45 years
• abnormality on DRE
• hematuria
• elevated PSA
• Dysuria
• incontinence
• retention

Question 15

BPH lifestyle modification?

Answer 15

• limit fluid prior bed/travel
• limit PO diuretics
• limit intake of bladder irritants (spicy foods)
• avoid constipation
• increase activity and exercise
• weight control
• timed voiding regimens
• kegel exercises
• double-voiding techniques

Question 16

BPH medical treatment

Answer 16

Alpha adrenergic receptor blocker

• initial therapy (in most cases)
• improvement seen w/i days
• receptors on prostatic smooth muscle, blocks signals, leading to relaxation of the bladder neck and prostatic urethra smooth muscles

Question 17

prazosin, alfuzosin

Answer 17

selective alpha adrenergic antagonists: fewer adverse effects

Question 18

extended duration 2nd gen alpha-1 adrenergic antagonists

Answer 18

Terazosin, doxazosin, tamsulosin

Question 19

side effects of BPH medications?

Answer 19

• terazosin and doxazosin- hypotension, dizziness (bedtime dosing)
• terazosin and doxazosin- lower incidence if increase titrated dosing
• monitor blood pressure when initiating
• hypotension worsened w/concomitant use of PDE 5 (sildenafil)

Question 20

Associated with cataract operations (triad)

• intraoperative miosis (despite pre-op dilation)
• iris prolapse
• a billowing flaccid iris

avoid starting alpha blockers if planned cataract surgery- start post-surgery

intraoperative precautions by opth

Answer 20

Intraoperative floppy iris syndrome & tamsulosin

Question 21

• Great for BPH combined with ED
• slight improvement vs placebo
• relax the smooth muscle fibers of the bladder and prostate
• not superior to alpha blockers and no benefit by adding PDE5 to alpha blocker
• slight improvement w/ increased ADRS
• Side effects: headache, flushing, dyspepsia, nasal congestion, back pain

Answer 21

Phosphodiesterase type 5 inhibitors

Tadalafil, Sildenafil

Question 22

• prevent progression of BPH
• takes months for reduction
• best for prostates > 35 grams
• block conversion of testosterone to dydrogesterone, preventing BPH progression rather than acute symptom treatment
• Efficacious in treating LUTS due to prostate enlargement
• maxium effect seen in 6-12 months
• tx must continue indefinitely to prevent sxs relapse

Answer 22

5-alpha reductase inhibitors

finasteride (selective type 2) and Dutasteride (nonselective)

Question 23

indications for surgical treatment?

Answer 23

• lower urinary tract symptoms (frequency, urgency, nocturia, incontinence, weak stream, straining to void) - the most common indication
• refractory urinary retention- should have failed two or more voiding trials on PO meds
• recurrent UTI- recurrent UTI attributed to BPH is considered a sign of progressed disease
• recurrent gross hematuria- rule out other etiologies
• recurrent bladder stones or calculi- these are signs of end stage bladder decompensation

Question 24

Reasons to defer PSA screening

Answer 24

• Sxs suggestive of prostatitis (defer 6-8 weeks (sxs resolutions) )
• acute urinary retention of urethral instrumentation (defer 2 weeks)
• recent prostate biopsy or TURP (defer at least 6 weeks)
• most accurate results in patients that abstain 48 degrees prior to the test

Question 25

• great for moderate to severe BPH sxs and documented prostatic enlargement

Answer 25

Finasteride + doxazosin

• combination was assoicated with greater reduction of sxs clinical progression, urinay retention, renal insufficiency, recurrent UTIs and incontinence
• those with larger prostates showed greater improvement

Dutasteride + tamulosin

• superior to monotherapy w/ either drug
• improved BPH sxs and clinical progression, especially w/ those with prostate volumes > 30ml