PROSTATE DISORDERS Flashcards
most common benign tumor
BPH (benign prostatic hyperplasia)
incidence of BPH increases with ______
AGE
8% - age 31-40
50% - age 51-60
90% - men over 80 years old
risk factors for BPH
the risk factors for BPH are not well understand
- may be some genetic predisposition
- may be some racial factors
SYMPTOMS OF BPH
- hesitancy
- weak stream
- decreased caliber of stream
- incomplete emptying of bladder
- straining
- post-void dribbling
- frequency
- nocturia
- urgency
OBSTRUCTIVE SYMPTOMS OF BPH
- hesitancy
- weak stream
- decreased caliber of stream
- incomplete emptying of bladder
- straining
- post-void dribbling
IRRITATIVE SYMPTOMS OF BPH
- frequency
- nocturia
- urgency
screening for severity of BPH
AUA
0-7 = mild 8-19 = moderate 20-35 = severity
prostatic hyperplasia is a part of normal aging and is hormonally dependent on an increase in ________________________ production
dihydrotestosterone
physical exam for BPH
DRE
Size and consistency of prostate should be noted
LABS for BPH
- UA (may do urine culture if UA is abnormal/WBCs)
- Creatinine
- PSA = +/-
what are we looking for in the UA for BPH
- blood
- WBCs (infection)
- protein (renal dysfunction)
IMAGING FOR BPH
***Imaging is not standard for BPH - only recommended to order imaging in the presence of concomitant urinary tract disease, or complications of BPH (hematuria, hx of stones, hx of UTIs/UTI, renal dysfunction, increased creatinine, etc)
- PVR
- renal US
- TRUS (trans-rectal ultrasound)
PVR = post-void residual test = measures the amount of urine remaining in bladder after urinating
- 2 ways = cathether & US
- with Cath = urinate, then stick cath up to see how much urine is remaining in the bladder
- with US = before urinating and after - see how much volume of urine is remaining in bladder
- renal US = to check for hydronephrosis
- TRUS = to check bladder & prostate size (both would be enlarged)
goals of BPH therapy
- relieve symptoms
- delay further prostate enlargement
BPH MEDICATION CLASSES
Alpha-1 adrenergic antagonists (alpha-blockers)
5-alpha-reductase inhibitors
Anticholinergic agents
Phosphodiesterase-5 (PDE-5) inhibitors
Herbal
alpha-1 adrenergic antagonists (alpha blockers) MOA
smooth muscle relaxation
- so causes smooth muscle relaxation of prostate & bladder neck –> decreased urethral resistance and decreased obstruction –> increased urinary outflow
- Indications = provides rapid symptom relief but no effect on clinical course of BPH
this med would be effective in smaller prostates where the size is so enlarged that you would want a medication that shrinks prostate size
Rapid function
SE OF ALPHA BLOCKERS
- ***HYPOTENSION
- orthostatic hypotension
- dizziness
- retrograde ejaculation
guidelines for BPH treatment
FIRST LINE If symptoms are mild (AUA score <7), no medical treatment is recommended. Watchful waiting!! - Limit fluid before bedtime - Avoid decongestants - Double void - Void frequently
SECOND LINE (First line medical)
Pharm therapy if AUA is >7
- Use alpha blocker in patient who is also hypertensive
- 5-alpha-reductase inhibitor if prostate is enlarged to 40g or more.
THIRD LINE
Combination therapy
BPH treatment if pt also hypertensive
alpha blocker
BPH treatment if prostate is enlarged to 40g or more
5 alpha reductase inhibitor
alpha blocker meds
- Tamsulosin (Flomax) = most uroselective
- Alfuzosin
- Doxazosin
- Terazosin
5-alpha reductase inhibitor drugs
Finasteride (Proscar)
Dutasteride (Avodart)
5-alpha reductase inhibitor drugs MOA
Androgen inhibitor
Inhibits the conversion of testosterone into dihydrotestosterone –> suppresses prostate growth & reduces bladder obstruction
not as rapid functioning as alpha blockers
has a positive effect on the course of BPH (both size reduction and decreases need for surgery, unlike alpha blockers)
SE = ED, decreased libido, breast tenderness / enlargement
herbal treatment for BPH
saw palmetto
treatment for BPH & ED
PDE-5 inhibitors
Cialis / Viagra
how do anticholinergics help with BPH when a SE of anticholinergics is urinary retention?
- helps with irritative symptoms by causing the bladder to relax (no pee)
doesn’t help with obstructive symptoms, because not relaxing the prostate or bladder neck, but so that don’t have to urinate all the time even when there is residual urine in the bladder
**Operations for BPH leave a small amount of residual prostate tissue, risk for future ___________is the same
malignancy
surgical operation for BPH that is perhaps better choice for younger men with smaller prostates;
reduces risk for retrograde ejaculation and subsequent infertility
Transurethral Incision of the Prostate (TUIP)
Most common surgical procedure for BPH
TURP = Transurethral Resection of the Prostate
Retrograde ejaculation resulting in infertility is a common complication of which BPH surgery
TURP = Transurethral Resection of the Prostate
Has classically been said to be associated with ______________ & __________; however, recent research comparing TURP patients with watchful waiting showed same incidences
incontinence and erectile dysfunction
INDICATIONS FOR A PROSTATECTOMY FOR BPH
Refractory acute retention Hydronephrosis Repeated UTIs due to obstruction Recurrent or refractory gross hematuria Elevated Cr level that responds to a period of bladder decompression with catheter drainage
BPH surgical procedure that has:
For large prostates to big for TURP
Patients with BPH and bladder stones
Longer stay in hospital and higher chance of blood loss
simple prostatectomy
what is acute bacterial prostatitis
Swelling and irritation (inflammation or infection) of the prostate gland that develops rapidly.
acute bacterial prostatitis can be due to which bacterial agents
E-coli******** Enterococci Klebsiella Protus mirabilis Psuedomonas Staph
most common bug causing acute bacterial prostatitis
E. COLI
acute bacterial prostatitis can be caused by which STDs
Chlamydia
Gonorrhea
Trichomonas
Ureaplasma urealyticum
most common STDs to cause acute bacterial prostatitis
Chlamydia
Gonorrhea
E. coli prostatitis may occur spontaneously or after:
Epididymitis
Urethritis
Urinary tract infections
Acute prostatitis may also develop from problems involving the urethra or prostate, such as:
Bladder outlet obstruction Catheterization or cystoscopy Prostate biopsy Trauma Phimosis Anal intercourse Transurethral surgeries
Prostatitis is rare in young boys.
viral prostatitis may be seen in children, however, from a viral cause: ___________ = most common
MUMPS
who is at increased risk of developing acute bacterial prostatitis
Men ages 20 - 35 who have multiple sexual partners are at an increased risk. Also at high risk are those who engage in anal intercourse, especially without using condoms.
Men age 50 or older who have an enlarged prostate are at increased risk for prostatitis due to their risk of urinary tract infection.
ACUTE BACTERIAL PROSTATITIS SYMPTOMS
Abdominal pain (usually right above the pubic bone)
Pain and burning with urination
Fever, chills, flush
Inability to completely empty the bladder (urinary retention)
Low back pain
Pain with bowel movement
Painful ejaculation
Pain in the area between the genitals and anus (perineal pain)
Diagnostics for acute bacterial prostatitis
- UA & urine culture
- CBC
- PSA +/-
Treatment for acute bacterial prostatitis
- Bactrim or fluoroquinolones (cipro or ofloxacin) x at least 4 weeks
- Ceftriaxone IM + Doxy for prostatitis caused by STD
- A hospital stay and IV antibiotics for severe cases
- Stool softeners may reduce the discomfort that occurs with bowel movements.
most common type of prostatitis
nonbacterial prostatitis
termed male chronic pelvic pain syndrome
nonbacterial prostatitis
nonbacterial prostatitis presents the same as ______________________________, just without the __________
chronic bacterial infection, just without a bacterial infxn
**have recurrent symptomatic exacerbations (which is why its termed male chronic pelvic pain syndrome)
treatment for nonbacterial prostatitis
erythromycin
don’t know what’s causing it, so covering for mycoplasma, chlamydia, and ureaplasma
(also mentioned = doxy & azithro)
lab findings for nonbacterial prostatitis
UA = normal
prostate secretions = increased leukocytes, but no growth shown on culture!
chronic bacterial prostatitis = may evolve from _________________________ but many times men have NO hx of an acute infxn
acute bacterial prostatitis
CAUSE of chronic bacterial prostatitis (bugs)
GRAM NEGATIVE RODS (1 gram positive)
- E. coli*****
- enterococci
- treponema
- trichomonas
- Gardnerella
SYMPTOMS OF CHRONIC BACTERIAL PROSTITIS
Can present much differently than acute prostatitis
Frequency, dribbling, loss of stream volume and force, double voiding, hesitancy, and urgency
May or may not have pelvic or perineal pain
May have intermittent discomfort in low back and/or testicles
May have hematuria, hematospermia, or painful ejaculations
chronic prostatitis exam
enlarged prostate with a variable amount of
o asymmetry o bogginess o tenderness (not typically exquisitely tender like acute prostatitis)
Diagnostics for chronic bacterial prostatitis
- UA = usually normal
- EPS = expressed prostatic secretions
- if can’t get EPS = do pre & post prostatic massage urines
- obtain gram stains, leukocyte count, and culture from these
treatment of chronic bacterial prostatitis
- Bactrim x 2-3 months
- Fluoroquinolone (cipro) x 4 weeks
- Can use Doxycycline as well (especially if concerned about Chlamydia)
**EPS or Post-prostatic massage should be evaluated at the end of the treatment period to demonstrate cure (if evidence of infection still present, longer course of antibiotics may be indicated)
TURP = for refractory chronic prostatitis
For both situations (acute & chronic) α-blockers - e.g. Tamsulosin (Flomax) can help with symptoms, also anti-inflammatories and sitz baths
PROSTATODYNIA =
non-inflammatory disorder of the prostate
with voiding dysfunction & pelvic floor muscle dysfunction
SYMPTOMS OF PROSTATODYNIA
same as chronic prostatitis, but no hx of UTI
- have hesitancy & stop/start of urine flow
LABS OF PROSTATODYNIA
UA = normal EPS = normal # of leukocytes
TREATMENT FOR PROSTATODYNIA
alpha blockers
diazepam for pelvic floor muscle dysfunction
biofeedback / PT
