Prostate Disorders Flashcards
Gross hematuria is always ___ until proven otherwise
cancer
Irritative voiding symptoms
Urgency
Dysuria
Frequency
Nocturia
Obstructive voiding symptoms
Hesitancy
Dribbling
Decreased force or caliber of stream
Interruption of stream
s/s of Incontinence
Overflow
Urge
Stress
Total
Most common route for Acute Bacterial Prostatitis
ascent up urethra
Can occur in setting of cystitis, urethritis
risk factors for Acute Bacterial 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
MC pathogen for acute bacterial prostatitis
G- rods
E. coli - 58-88%, Pseudomonas - 3-7%, Proteus - 3-6%
Other pathogens - G+ bacteria, STDs, etc.
Fever, chills, malaise - common
Pain - perineal, sacral, or suprapubic
Irritative voiding s/s
Occasionally obstructive voiding s/s
DRE - Hot, exquisitely tender prostate
these s/s are indicative of what
acute bacterial prostatitis
what is contraindicated for a DRE?
Prostatic massage contraindicated - risk of septicemia
lab findings for acute bacterial prostatitis
CBC - leukocytosis and left shift
Urinalysis - pyuria, bacteriuria, hematuria
Urine culture - + for causative agent
imaging for acute bacterial prostatitis
if no response to abx in 24-48 hrs
Pelvic CT or transrectal US to assess for prostatic abscess
tx guidelines of acute bacterial prostatitis
- All patients should receive Gram stain + C/S
- Adjust according to culture results! - Outpatient - no major comorbidities, no s/s of sepsis, able to take PO abx
- Hospitalize - severe s/s, complicated case (e.g. surgical drainage), suspected bacteremia
tx for acute bacterial prostatitis
- IV - fluoroquinolone +/- aminoglycoside , or ampicillin/gentamicin
- Nosocomial - IV carbapenem or IV broad-spectrum PCN/cephalosporin +/- aminoglycoside - Oral - TMP-SMZ, Fluoroquinolone (ciprofloxacin, levofloxacin)
- Consider G+ coverage if age <35 or high-risk sexual behavior - Continue for 4 wks
- Monitor UA/UC, rectal exam, inflammatory markers to ensure resolution
MC pathogen of chronic bacterial prostatitis? others?
G- rods
E. coli - 75-80%
Klebsiella, Enterococcus, Proteus, Pseudomonas
MC route of chronic bacterial prostatitis
ascent up urethra
May be complication of ABP
Many pts have no hx of acute prostatitis
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
May see boggy (spongy), tender, enlarged, and/or indurated prostate
these s/s are indicative of what dx?
chronic bacterial prostatitis
Some are asymptomatic
lab findings for chronic bacterial prostatitis
- 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
imaigng for chronic bacterial prostatitis
not needed
prostatic calculi possible
tx for chronic bacterial prostatitis
- Fluoroquinolones or TMP-SMZ
- for at least 6 wks
- May continue up to 12 weeks
- SE quinolones - C. diff diarrhea, CNS toxicity, tendinopathy - Supportive - anti-inflammatories, sitz baths
- Difficult to cure - relapses are common
- Require repeat courses of abx
Characterized by pelvic pain/discomfort in men, accompanied by urologic symptoms and/or sexual dysfunction
Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
types of Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
- Inflammatory (Nonbacterial Prostatitis - Chronic Prostatitis)
- Non-inflammatory (CPPS - Prostatodynia)
MC prostatitis form worldwide? when?
Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
Incidence peaks in the 5th decade
cause of Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
unknown
Believed to likely be noninfectious cause
- 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
these s/s are indicative of what dx?
Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
lab findings for Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
1.UA - unremarkable
2. Prostatic Secretions
- increased WBC if inflammatory (chronic/nonbacterial prostatitis)
- normal if noninflammatory
- negative culture
3. Urine culture - negative
imaging for Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
mainly to rule out other pathology
e.g., obstruction in pts with obstructive voiding s/s
tx for Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
- Difficult due to unknown cause - varies depending on s/s
- Newly diagnosed - abx if abx-naive
- fluoroquinolones, erythromycin
— Given for 6 wks
— May consider d/c after 2 wks if no improvement -
Urinary sx - 𝛼-blocker
- Tamsulosin/Silodosin/Alfuzosin - selective; less SE
- Prazosin, terazosin, doxazosin can be used
- May continue for > 6 weeks if benefit is seen -
Adjunct (Meds)
- 5-𝛼-reductase inhibitors - finasteride, dutasteride
- NSAIDs
— Steroids may help but generally not used due to SE -
Adjunct (Nonpharm)
- Sitz baths - for symptomatic relief
- CAM - acupuncture, cernilton (pollen extract), quercetin (bioflavinoid) may offer some small benefit
- PT - myofascial release, biofeedback
MOA of alpha-blockers
block 𝛼-1 receptors in the bladder neck and smooth muscle in the prostate, causing relaxation and increased urethral size
what medication is Not recommended for younger men d/t decreased semen volume to tx Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome?
5-𝛼-reductase inhibitors
what other sequelae may need to be addressed individually for Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
Neuropathic pain
Psychosocial disorders
Pelvic floor muscle dysfunction
Sexual dysfunction
MC benign tumor in men
More common with increasing age
BPH
- 8% of men 31-40
- 50% of men 51-60
- Over 80% of men 80+
Obstructive voiding s/s present in BPH is MC with
25% of 55-yr-old men
50% of 75-yr-old men
risk factors for BPH
- Some evidence for genetic component
- 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
cause of BPH
multifactorial
- 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
2 mechanisms of obstruction of BPH
- Mechanical obstruction - d/t narrowing
- Urethral lumen
- Bladder neck - Dynamic obstruction - due to alpha-receptor stimulation
- Causes increased tone (constriction) to prostatic urethra
Prostate size does not always correlate with sx
s/s 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 - Irritative voiding - urgency, frequency, nocturia
- secondary response of bladder to increased outlet resistance
- Detrusor muscle hypertrophy and hyperplasia, collagen deposition
Usually begin slowly, progress gradually
what assesses the severity of BPH sx?
AUA symptom score
during a DRE you feel a smooth, firm, symmetric, elastic enlargement of prostate
what could be the possible dx?
BPH
Induration or asymmetric enlargement prostate during a DRE is indicative of what
possible cancer
Besides a DRE what other physical exams should you do?
Neuro exam - to rule out neurogenic bladder
Lower abdominal exam - to evaluate for distended bladder
lab findings of BPH
- UA - often normal, possible 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
imaging for BPH?
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
pt with BPH has sx scoring a 6, what would be the best next step/management?
watchful waiting
- For mild sx (score 0-7) or pts who do not want tx
- Not all pts will experience s/s progression!
- Up to 50% have spontaneous regression
Observation for BPH is NOT ideal if:
Refractory urinary retention
Large bladder diverticula
Recurrent UTI or gross hematuria
Bladder stones
CKD
meds for BPH
- alpha blockers
- 𝞪1-blockade Agents
- 𝞪1a-blockade Agents - 5-𝞪-reductase inhibitors
- Phosphodiesterase-5 inhibitors (PDE 5)
- Phytotherapy
alpha blocker + 5-alpha-reductase inhibitor - first-line and superior to either tx alone
3 types of alpha receptors
where are these receptors?
- 𝞪1a - 70% of adrenoreceptors in prostate, bladder neck
- 𝞪1b - smooth muscle of vasculature
- 𝞪1d - prostate, bladder neck, detrusor, sacral spinal cord
how selective are alpha blockers?
some are, some not
all alpha blockers have roughly the same equal efficacy, but what 2 may be slightly more effective than tamsulosin, but have more SE?
Doxazosin and terazosin
Prazosin
𝞪1-blockade Agents
Doxazosin
𝞪1-blockade Agents
Terazosin
𝞪1-blockade Agents
which 𝞪1-blockade Agent needs dose titration?
terazosin