Prostate disorders Flashcards
what is gross hematuria alwasy assumed to be
cancer, unless proven otherwise
what are irritative voiding symptoms
- Urgency
- Dysuria
- Frequency
- Nocturia
what are obstructive voiding symptoms
- Hesitancy
- Dribbling
- Decreased force or caliber of stream
- Interruption of stream
what are types of urinary incontinence
- overflow incontinence
- urge incontinence
- stress incontinence
- total incontinence
what is the MC route of acute bacterial prostatitis infections
ascent up the urethra (can occur due to cystitis or urethritis)
what are risk factors for acute bacterial prostatitis
Factors predisposing GU infections such as:
- catheters
- prostate biopsy
- urethral stricture
anecdotal risks (no strong supporting evidence)
* trama
* dehydration
* sexual abstinence
what are the MC causative organisms in acute bacterial prostatitis
gram negative rods such as:
- E. coli (58-88%)
- psuedomonas (3-7%)
- proteus (3-6%)
other pathogens such as G+ bacteria and STDS can also cause it
how common is acute bacterial prostatitis
Relatively rare (~4% of prostatitis)
what are symptoms of acute bacterial prostatitis
- fever/chills (common)
- malaise (common)
- pain (peripheral, sacral, suprapubic)
- irritative voiding s/s
- occasionally obstructive voiding s/s
what are physical exam findings of acute bacterial prostatitis
a digital rectal exam showing hot and very tender prostate
what is contraindicated in acute bacterial prostatitis
prostatic massage due to risk of septicemia
what lab findings are seen in acute bacterial prostatitis
- CBC - leukocytosis and left shift
- urinalysis - pyuria, bacteriuria, hematuria
- urine culture - + for causative agent
when is imaging obtained in acute bacterial prostatitis? what imaging is used?
if there is no response to abx in 24-48 hours get a pelvic CT or transrectal US to assess for prostatic abscess
once a patient is diagnosed with acute bacterial prostatitis what should they recieve? why?
all patients should recieve a gram stain +C/S so you can adjust abx according to results!
what is type of patient is appropriate for outpatient treatment?
- no comorbidites
- no s/s of sepsis
- able to take PO abx
what indicated the need for hospitalization in an acute bacterial prostatitis patient
- severe s/s
- compicated case (surgical drainage)
- suspected bacteremia
what is the IV abx treatment for acute bacterial prostatitis that is NOT nosocomial
- Glouroquinolone +/- aminoglycoside
- amp/gent
what is the IV abx treatment for nosocomial acute bacterial prostatitis
- IV carbapenem
- IV broad spectrum PCN +/- aminoglycoside
- IV broad spectrum cephalosporin +/- aminoglycoside
what is the oral abx treatment for acute bacterial prostatitis
- bactrim BID
- cipro BID or levo QD
- if <35 or high risk sexual behavior consider G+C coverage (idk what this means)
how long should abx therapy last for acute bacterial prostatitis? what should be monitored during this time?
4 weeks
monitor the following to ensure resolution:
- UA/UC
- rectal exam
- inflammatory markers
what are the MC causative agents in chronic bacterial prostatitis
gram negative rods!
- E. coli (MC 75-80%)
- klebsiella
- enterococcus
- proteus
- pseudomonas
what is the MC routes of infection for chronic bcterial prostatitis
- ascent up urethra (MC)
- complicaiton of ABP
- many dont have any hx of acute prostatitis
what are the symptoms seen in chronic bacterial prostatitis
- some are asymptomatic
- irritative voiding s/s (MC)
- may see obstructive s/s
- pain that is dull, poorly located, in suprapubic, perineal or low back regions
what are the PE findings for chronic bacterial prostatitis
DRE would often be normal but may show boggy/spongy, tender, enlarged and/or indurated prostate
what labs are seen in chronic bacterial prostatitis
- UA - normal unless cystitis present
- prostatic secretions - increased WBC(>10) with + culture and lipid laden macrophages
- urine culture - negative (often + for causative organism AFTER prostatic massage
when is imaging needed in chronic bacterial prostatitis
“usually not needed” but if you do get imaging you may see prostatic calculi
what is the treatment for chronic bacterial prostatitis
- fluoroquinolones or bactrim!
- anti inflammatory agents
- sitz baths
how long should chronic bacterial prostatitis patients be on abx
at least 6 weeks and up to 12 weeks.
what must you educate your patient on when having them on abx for 6-12 weeks
educate them of the SE of prolonged use such as C diff, CNS toxicity, tendimopathy
what is nonbacterial prostatitis/chronic pelvic pain syndrome
Characterized by pelvic pain/discomfort in men, accompanied by urologic symptoms and/or sexual dysfunction
what is the difference between nonbacterial prostatitis and chronic pekvic pain syndrome
- inflammatory is nonbacterial aka chronic protatitis
- non-inflammatory is CPPS aka prostatodynia
how common is prostatitis and at what age does incidence of prostatitis peak in?
2-10% of adult men have protatitis and MC form is nonbacterial or CPPS
5th decade of life
what is the etiology of CPPS or non bacterial prostatits
unknonw
what are the sympotms of nonbacterial prostatitis or CPPS
- irritative/obstructive voiding
- pain in peripheral, lower abdomen, or low back (often dull and poorly localised)
- may present with another type of chornic pain syndrome such as fibromyalgia
what are the PE findings for nonbacterial prostatitis or CPPS
- DRE showing tenderness in 50% of patients
what are the lab findings in nonbacterial prostatitis or CPPS
- UA - unremarkable
- prostatic secretions - incerased WBC if inflammatory, normal if noninflammatory. negative culture!
- urine culture - negative!
when is imaging obtained in nobacterial prostatitis or CPPS
mainly to rule out other pathologies
what is treatment for nonbacterial prostatitis or CPPS
- newly diagnosed - abx therapy such as flouroquiniolones or erythromycin for 6 weeks.
discontinue abx in 2 weeks if no improvement - urainary symptoms - alpha blockers
- 5-a-reductase inhibitors
- NSAIDS
- sitz baths
- CAM
- PT
what are the alpha blockers used for urinary symptoms
- tamsulosin/sildosin/alfuzosin (less SE)
- prazosin, terazosin and doxazosin can also be used!
what is the mechanism for alpha blockers treating urinary symptoms
Alpha-blockers - block 𝛼-1 receptors in the bladder neck and smooth muscle in the prostate, causing relaxation and increased urethral size
what are the 5-a-reductase inhibitors and when are they NOT reccomended
- finasteride, dutasteride
- not reccomended in young men d/t decreased semen volume
what are sequelae that may need to be addressed individually during the treatment of nonbacterial prostatitis or CPPS
- Neuropathic pain
- Psychosocial disorders
- Pelvic floor muscle dysfunction
- Sexual dysfunction
a nice lil chart for ya
what is benign prostatic hyperplasia
MC benign tumor in men causing increase in both glandular and stromal components of the prostate
what is hte epidemiology for BPH
- 8% of men 31-40
- 50% of men 51-60
- Over 80% of men 80+
- black men are more likely to have severe s/s and need surgery
- asian men are less likely than black or white men to have BPH
how common are obstructive voiding s/s in BPH
- 25% of 55-yr-old men
- 50% of 75-yr-old men
what are risk factors for BPH
- higher free PSA levels
- prostatitis
- heart disease
- BB use
- lack of exercise
- obesity
what decreases risk of BPH
- NSAIDS
- excessive ETOH use
- smoking
- exercse
this just doesnt sound right but she said it in class that these things all reduce likelihood of BPH ¯_(ツ)_/¯
what is the etiology of BPH
multifactoral etiology including:
- aging prostate are more sensitive to androgens and growth factors
- aging stops normal cell death
- testosterone, dihydrotestosterone and estrogen may be involved
what are the 2 mechanisms of obstruction in BPH
- mechanical obstruction due to narrowing of urethral lumen or bladder neck
- dynamic obstruction d/t alpha receptor stimulation (causes increased constriction to prostatic urethra)
note: Prostate size does not always correlate with symptoms!
what are the symptoms of BPH
- obstructive voiding s/s such as:
- Urine hesitancy
- Decreased force and caliber of stream
- Sensation of incomplete bladder emptying
- Double voiding (urinating within 2 hours)
- Straining to urinate
- Postvoid dribbling
- also irritative voiding sympotms such as urgency, frequency and nocturia
symptoms are very slow onset and gradually progress
what causes the irritative voiding symptoms in BPH
- Due to secondary response of bladder to increased outlet resistance
- Detrusor muscle hypertrophy and hyperplasia, collagen deposition
what assesses severity of BPH symptoms
AUA symptom score!
https://urology.weillcornell.org/sites/default/files/aua_symptom_score_web.pdf
what does the PE show in BPH
DRE showing smooth, firm, symmetric, elastic enlargement of prostate
what would induration or assymetric enlargement of the prostate indicate
possible cancer
aside from DRE, what exams should be completed in a patient with BPH and why?
neuro exam - to rule out neurogenic bladder
Lower abdominal exam - to evaluate for distended bladder
what labs are seen in BPH
- UA - normal (may see hematuria)
- PSA - used to screen for cancer (may be elevated even in absence of cancer)
- prostate Bx - only done if concern for cancer (done transrectally or transperineally
when is imaging indicated in BPH
- usually not needed
- US indicated if high serum Cr or UTI
- upper GU tract imaging only if complications arise or comorbid GU disease present
she said we will go through this chart over the rest of the lecture so honestly wouldnt be bad to memorize this
what is considered mild BPH and what is the treatment
- mild = AUA score of 0-7
- treatment is watchful waiting! (this can also be done for patients who dont want treatment)
how common is spontaneous regression of BPH
50%!!
who is NOT a candidate for watchful waiting
- Refractory urinary retention
- Large bladder diverticula
- Recurrent UTI or gross hematuria
- Bladder stones
- CKD
what are the three types of alpha receptors
𝞪1a - 70% of adrenoreceptors in prostate, bladder neck
𝞪1b - smooth muscle of vasculature
𝞪1d - prostate, bladder neck, detrusor, sacral spinal cord
what alpha blockers may be slightly more effective in treating BPH but have more SE
Doxazosin and terazosin may be slightly more effective than tamsulosin, but have more SE
what are the a1-blockade agents
Prazosin (Minipress) - 1–5 mg BID
Doxazosin (Cardura) - 1–8 mg daily
Terazosin (Hytrin) - 1–10 mg daily
what are the a1a-blocker agents
Silodosin (Rapaflo) - 4 or 8 mg daily
Tamsulosin (Flomax) - 0.4 or 0.8 mg daily
Alfuzosin (Uroxatral) - 10 mg daily
what are typical a1-blockade agent SE
- orthostatic hypotension (underlined)
- dizziness (underlined)
- tiredness
- retrograde ejaculation
- rhinitis
- HA
- Floppy iris syndrome (underlined, this is a cataract surgery complication in patients taking a1-blockers)
what are DDI for alpha blockers
- antihypertensives
- PDE-5 inhibitors (cause significant drops in BP when taken with alpha blockers)
what is the MOA of 5-a-reductase inhibitors
converts testosterone to dihydrotestosterone
inhibiting this enzymes reduces the size of the prostate gland!
how long does it take to see full benefits from 5-a-reductase inhibitors?
- 6 months
what are the full benefits from 5-a-reductase inhibitors
- reduces prostate size by 20%
- can reduce the need for surgwhat arery
- reduce PSA by 50%
- may reduce risk of prostate cancer
what are the two 5-a-reductase inhibitors
- finasteride (proscar) - 5mg oral QD
- dutasteride (avodart) - .5mg oral QD. this one may be more effective!
- jalyn (brand combo of dutasteride and tamsulosin)
what are SE of 5-a-reductase inhibitors
- decreased libido
- erectile or ejaculatory dysfucntion
what is considered to be the first line treament for BPH
Combination therapy with an alpha blocker + 5-alpha-reductase inhibitor is considered first-line and superior to either treatment alone
what are phosphodiesterase-5 inhibitors (PDE 5) used for
men with BPH + ED symptoms
what is the PDE 5 inhibitor that we learned
tadalafil (cialis) 5 mg daily
what is phytotherapy
herbals approved in europe for treatment of BPH, not FDA approved.
saw palmetto is MC agent and its not reccomended as first line treatment
what surgical therapy is available for treatment of BPH
- transurethral resection of the prostate (TURP)
- Transurethral incision of the prostate (TUIP)
- open/robotic simple prostatectomy
- Laser therapy (TULIP)
- transurethral Needle ablation of prostate (TUNA)
- Transurethral Electrovaporization of prostate
- hyperthermia
- implant to open prostatic urethra (UroLift)
- Water Vapor Thermal Therapy (Rezum)
what is transurethral resection of the prostate (TURP)
- resectoscope is used to trim away excess prostate tissue around urethra.
- requires spinal anesthesia and 1-2 day hospital stay
what are the risks of TURP
- retrograde ejaculation (75%)
- ED (5-10%)
- urine incontinence (<1%)
what are the complications that could occur with TURP
- bleeding
- urethral stricture
- bladder neck contracture
- perforation of prostate capsule
- transurethral resection syndrome
what is transurethral resection syndrome
Hypervolemic, hyponatremic state caused by absorption of hypotonic irrigation solution
greater risk of procedure is >90 minutes but is not as common now d/t newer surgical methods
what are the s/s of transurethral resection syndrome
- NV
- confusion
- HTN
- bradycardia
- visual disturbances
- seizures
- muscles weakness/spasms
- coma
what is the tx for transurethral resection syndrome
- diuresis
- hypertonic saline
what is transurethral incision of the prostate (TUIP)
Resectoscope is inserted into urethra and 1-2 small grooves are cut into the bladder neck which opens the channel and improves urine flow.
more rapid and ess complications than TURP
what is open/robotic simple prostatectomy and when is it used
- used when prostate is too large to remove endoscopically (glands >100g)
- suprapubic or retropubic approach to prostatectomy
what are the pros and cons open/robotic simple prostatectomy
Pros:
Robotic-assisted simple prostatectomies tend to have shorter hospital stays, less blood loss, less need for catheter
cons:
- higher risk of complications and longer recovery
- complications include bleeding, UTI, retrograde ejaculation, ED< urinary incontinence, urethral stricture
what is laser therapy or transurethral laser-induced prostatectomy (TULIP)
laser prostectomy done under transrectal US guidance, afterwards the prostate tissue is sloughed naturally for up to 3 months.
what are the advantages and disadvantages of TULIP
advantages - minimal blood loss, less transurethral
resection syndrome, outpatient, can be used in pts on anticoagulants
Disadvantages - cannot save tissue sample for pathology, longer post-op catheterization, increased irritative voiding s/s, higher cost
what is transurethral needle ablation of prostate (TUNA)
- Specially designed urethral catheter with radiofrequency needles that penetrate the prostatic urethra
- Radiofrequencies used to heat tissue causing necrosis of prostatic tissue and sloughing
- Similar improvement in symptoms when compared to TURP
what is transurethral electrovaporization of prosate
- Resectoscope inserted through urethra
- Heat vaporization of prostatic tissue
- Usually requires longer to complete than a TURP
what is treatment of BPH via hyperthermia
- Transurethral catheter delivers microwaves to heat and damage prostatic tissue
- No comparison data for outcomes
what is implant to open prastatic urethra (UroLift)
Uses special device to place implants that “hold open” prostatic lobes
less morbidity and complications
(Minimal impact on erectile or ejaculatory function)
may be done outpatient under local anesthesia
approved for prostates <80g
what is water vapor thermal therapy (Rezum)
Uses special device to deliver steam into prostatic tissue to cause thermal destruction
Minimal impact on erectile or ejaculatory function
May be done outpatient/in clinic
what is the MC non-skin cancer in US men
prostate cancer!!!
(bet ya didnt see that one comin)
what is the 2nd leading cause of cancer related death in men
prostate cancer
what are risk factors for prostate cancer
- black race/ethnicity
- positive fam hx
- high dietary fat intake
what are the risks related to prostate cancer in the average 50 year old US man
- 40% - risk of latent prostate cancer
- 16% - risk of clinically evident prostate cancer
- 2.9% - risk of death due to prostate cancer
what are the PE findings in a patient with prostate cancer
- DRE - focal nodules or areas of induration withiin prostate (most cancers have palpably normal prostates)
- lower extremity lymphedema if lymph node metastises
what are symptoms of prostate cancer
- obstructive voiding s/s (if large or locally extensive cancer)
- back pain/fractures if axial skeleton metastises
what is the MC site of prostatic cancer metastises
axial skeleton
How will labs present in prostate cancer
- elevated PSA (sign of cancer)
- elevated BUN/cr (if urinary retention/obstruction)
- elevated alk phos/hypercalcemia - if bone metastases
what is the standard method for detection of prostate cancer
transrectal US-guided biopsy
(may also do transperineal prostate biopsy)
what other imaging modalities are used to evaluate the possibility of prostate cancer
- Transrectal US - staging, guiding biopsy
- MRI - evaluation of prostate plus lymph nodes
- CT - no used to identify or stage prostate cancer (Can help detect lymphatic metastases and intra-abdominal metastases)
- Radionuclide Bone Scan - to detect bony metastases
what are most prostate cancers? where to they arise?
adenocarcinomas
usually arise in periphery of prostate
what is the system used to stage prostate cancer
- gleason system
- 1 (well-differentiated) to 5 (undifferentiated)
Also graded by extent of spread - T1-T4
T1 - Clinically inapparent (not seen on imaging or palpated
on exam) - elevated PSA only
T2 - Tumor confined within prostate, visible or palpable
T3 - Tumor extends through prostate capsule, may invade seminal vesicles
T4 - Tumor is fixed or invades adjacent structures
when is surveillance indicated for prostate cancer
- Some pts may be candidates for observation for small, well-differentiated cancers
- If life expectancy > 10 yrs - usually should undergo tx
what is a radical prostatectomy?
Removal of prostate, seminal vesicles, ampulla of vas deferens
Local recurrence is uncommon - more likely in advanced cancers
Follow-up with radiation may improve survival
when is radical prostatectomy not used?
Rarely used if stage T4 or + lymph node metastasis
what are the risks of radical prostatectomy
- erectile dysfunction
- urinary incontinence
- infection
what are the options for radiation therapy in prostate cancer
- external beam radiotherapy
- transperineal implantation of radioisotopes
+ biopsy >18 months after radiation - 20-60%
when is chemotherapy primarily used in prostate cancer
in metastatic disease
what is cryosurgery and when is it used?
- Liquid nitrogen placed in prostate with US guidance
- Used for small, localized prostate cancers
- biopsy rates - 7-23%
How responsive are prostate cancer patients to androgen therapy?
70-80% of metastatic patietns will respond to androgen therapy
what are the medications used for androgen deprivation therapy?
- LHRH agonists
- LHRH antagonists
- adrenal suppressants
(doing an orchiectomy is also considered “androgen deprivation therapy” just FYI!)
what are the LHRH agonists?
- leuprolide
- goserelin
- triptorelin
- histrelin
what are the available methods of LHRH and what are their SE?
May be given as depot injection or implant
SE - ED, hot flashes, gynecomastia, may see anemia
what are the LHRH antagonists
degarelix
what are the available methods of LHRH antagonists and what are their SE?
Given as monthly subcutaneous injection
No initial “testosterone flare” seen with LHRH agonists
SE - ED, hot flashes, weight gain, increased LFTs
what are the adrenal suppressents?
- ketoconazole
- corticosteroids
what does survival depend on? what is good vs bad prognosis?
- Survival depends on differentiation and extent of spread
- Gleason grades 1-2 are usually confined to prostate
- Gleason grades 4-5 are usually locally extensive or metastatic
T1-T2 - 80% of pts; 100% 5-yr survival rate
T3-T4 (no metastases) - 12% of pts; 100% 5-year survival rate
T4 with metastases - 4% of pts - 30% 5-year survival rate
what is PSA
glycoprotein produced only by cells of the prostate gland (can be produced by benign or malignant cells)
what does PSA correlate with
the volume of prostate tissue!
If no history of prostate cancer tx - PSA level correlates with volume and stage of disease
Organ confined - <10mcg/L
Advanced - >40mcg/L
what is the purpose of using PSA
Can be used to help detect cancer, stage cancer, monitor response to treatment, and detect cancer recurrence
- only 20% of pts who undergo prostatectomy for localized cancer have normal PSA
- 98% of patients with metastatic prostate cancer will have elevated PSA
what does rising PSA after treatment for cancer indicate?
recurrence of cancer :(
what is considered normal, intermediatly elevated and highly elevated PSA? what are the cancer probabilities for each of these?
- Normal - 0-4 mcg/L (0-4 ng/mL)
- Intermediate - 4.1-10 mcg/L (4.1-10 ng/mL) 18-30% will have cancer, Usually signifies localized cancer
- High - >10 mcg/L (>10 ng/mL), 50-70% will have cancer
what medications influence PSA levels? How do each of these influence it?
- 5-alpha-reductase inhibitors - reduce by 50%
- NSAIDs or acetaminophen - lower PSA levels
- Statins - reduce PSA by 4.1% per year
- Thiazides - ~26% reduction over 5 yrs
what are non-cancer causes of elevated PSA
- Benign Prostatic Hyperplasia (BPH)
- Prostatic inflammation/infection
- Perineal trauma (prostatic massage, biopsy, surgery, vigourous bicycle riding all avoid measuring w/in 6 weeks. sex can increase it mildly)
DRE not believed to have significant impact on PSA!
what is Free PSA and when is it used?
- Free PSA - measures unbound (free) PSA vs. total PSA levels
- Used especially if PSA is intermediate (4.1-10 mcg/L)
- Lower % of free PSA = higher likelihood of cancer
- free PSA <10% - 56% chance of cancer
- Free PSA >25 - 8% cancer chance
what is PSA velocity? what level suggests higher chances of cancer
- measures amount of change in PSA level in serial measurements
- > 0.35 mcg/L/yr increase - higher chance of cancer
what is the USPSTF screening reccomendation
- Intermediate (grade C) for men 55-69
- Recommends against routine in men 70+
what is the NCCN and EAU screening reccomendation
Recommend doing screenings at age 40 and 45, and starting annual screening from ages 50 until 65 or 75
what is the AUA screening reccomendation
- Only screen ages 40-55 if high risk
- Screen ages 55-69 annually
- Do not screen if: Patient is 70+ years old or Patient life expectancy is <10 years
what is the DRE and PSA screening recommendation from NCCN, EAU and AUA
- Optional baseline DRE and PSA at age 40 (if high-risk)
- If <0.6 and normal DRE, repeat at age 45
when should you start annual DRE and PSA
- If abnormal DRE, PSA, + family hx, or black male taking a 5-alpha-reductase inhibitor
- At age 50-55 if normal PSA/DRE findings at age 40 and 45 and no other areas of concern
when should you discontinue DRE and PSA screening
- PSA <1.0 at age 65
- PSA <3.0 at age 75
- Life expectancy < 10 years
wow that one was a lotttt…
just a lil guy
