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GU > Prostate Disorders - Exam 2 > Flashcards

Prostate Disorders - Exam 2 Flashcards

1
Q

What is the primary function of the prostate? How do prostate diseases normally manifest?

A

production of fluid that mixes with sperm to form semen

often present as urinary symptoms

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2
Q

What does gross hematuria in the urine usually indicate?

A

cancer until proven otherwise!!

hematuria can be only at the beginning, end or throughout the stream

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3
Q

Hesitancy, dribbling, decreased force or caliber of stream, interruption of stream are what type of voiding symptoms?

A

obstructive!!

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4
Q

overflow, urge, stress, total are what type of voiding symptom? Briefly describe each

A

incontinence

overflow: so full the bladder leaks
urge: strong urge to go
stress: when you sneeze, cough a little urine leaks out
total: urine comes out whenver

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5
Q

What is the MC route of pathogens in acute bacterial prostatitis? What are the risk factors for acute bacterial prostatitis? What is ABP likely to co-occur with?

A

ascent up the urethra

catheter, prostate biopsy, urethral stricture

likely to co-occur with UTI or bladder infection

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6
Q

What are the MC pathogen for ABP? How common is it?

A

E. coli - 58-88%, Pseudomonas - 3-7%, Proteus - 3-6% (gram - rods)

relatively rare only 4% of all prostatitis

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7
Q

fever, chills, malaise, suprapubic, perineal, low back pain, irritative or obstructive voiding symptoms

What am I?

A

Acute bacterial prostatitis

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8
Q

What will ABP DRE feel like? Should you give a prostatic massage?

A

DRE: hot, exquisitely tender prostate

DO NOT give prostate massage: CI due to risk of septicemia

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9
Q

When would you want to order imaging in ABP? What imaging?

A

if no response to abx in 24-48 hrs

Pelvic CT or transrectal US to assess for prostatic abscess

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10
Q

What is the tx for acute bacterial prostatitis? When do you need to consider in-pt therapy?

A

Abx directed at the causative agent

in-pt: severe s/s, needing surgical drainage or suspected bacteremia

per Jensen: better to admit than to NOT admit

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11
Q

What is the empirical IV tx for ABP? What is the tx for nosocomial ABP?

A

empirically: fluoroquinolone +/- aminoglycoside , or ampicillin/gentamicin

nosocomial: IV carbapenem or IV broad-spectrum PCN/cephalosporin +/- aminoglycoside

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12
Q

What is the oral tx for ABP? Which one does Jensen prefer? What else do you need to consider? **How long do you continue therapy?

A

TMP-SMZ (Bactrim DS) 800-160 mg BID- Jensen prefers this one

Fluoroquinolone (ciprofloxacin 500 mg BID, levofloxacin 500 mg QD)

Consider G+C coverage if age <35 or high-risk sexual behavior

**continue therapy for 4-6 weeks

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13
Q

What is the MC cause of chronic bacterial prostatitis?

A

E. coli

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14
Q

What is the difference between ABP and chronic bacterial prostatitis PE?

A

acute: DRE with will be warm and tender

chronic: DRE is ofter NORMAL but can be boggy, tender, enlarged, or indurated

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15
Q

during a DRE how much of the prostate should you be able to feel if normal? What is the texture of a normal prostate?

A

normal prostate: should be able to reach above prostate with finger

enlarged prostate: you will NOT be able to reach the top and feel the curve of prostate

normal texture should feel the same as the tip of your nose

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16
Q

Why is the UA normal in chronic bacterial prostatitis?

A

because bacteria are “locked away” in the prostate so they will not show up in the urine

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17
Q

What will the prostatic secretions of chronic bacterial prostatitis show?

A

Increased WBCs (>10 per hpf) with + culture

lipid-laden macrophages

urine culture will be positive for organisms after the prostatic massage

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18
Q

What is the tx for chronic bacterial prostatitis? How long do they need to continue taking?

A

Fluoroquinolones or TMP-SMZ are preferred
2nd line - doxycycline, macrolides
Possible alternatives - prolonged cephalosporins, fosfomycin

for a LEAST 6 weeks

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19
Q

What do you need to counsel your patient on when prescribing the appropriate tx for chronic bacterial prostatitis?

A

counsel on the long-term effect of abx use: quinolones - C. difficile diarrhea, CNS toxicity, tendinopathy

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20
Q

What are some supportive care measures for bacterial prostatitis? How common are relapses?

A

anti-inflammatory agents, alpha blockers, sitz baths

very common and require repeat abx

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21
Q

______ is characterized by pelvic pain/discomfort in men that is accompanied by urologic symptoms +/- sexual dysfunction. What are the two variations?

A

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

inflammatory and non-inflammatory

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22
Q

inflammatory prostatitis is also known as ________

non-inflammatory prostatitis is also known as ______

Which one is the MC? What age does it peak?

A

inflammatory: Nonbacterial Prostatitis, aka Chronic Prostatitis)

non-inflammatory: CPPS, aka Prostatodynia

Nonbacterial prostatitis/CPPS is the MC form (vs. CBP or ABP)- peaks in the 50s

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23
Q

irritative voiding or obstructive voiding, LBP that is often dull and poorly localized. May have hx of IBS or fibromyalgia. PE is unremarkable

What am I?
What will the urine culture show?

A

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

urine culture is likely negative

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24
Q

What will the prostate secretions show in a pt with Chronic Prostatitis/Chronic Pelvic Pain Syndrome?

A

increased WBC if inflammatory (chronic/nonbacterial prostatitis)
normal if noninflammatory
negative culture

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25
Q

What is the tx for Chronic Prostatitis/Chronic Pelvic Pain Syndrome? How long do they need to continue treatment?

A

tx varies due to s/s and not fully knowing the underlying cause

alpha-blockers : Tamsulosin/Silodosin/Alfuzosin
aimed at treating urinary symptoms

for alpha blockers: need to continue for longer than 6 weeks if some improvement

5-𝛼-reductase inhibitors - finasteride, dutasteride

Anti-inflammatories - NSAIDs

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26
Q

What chronic prostatitis tx is NOT recommended in younger men? Why?

A

5-𝛼-reductase inhibitors - finasteride, dutasteride due to decreased semen volume

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27
Q

What are the main s/s difference between ABP, CBP, nonbacterial prostatitis (chronic prostatitis) and prostatodynia (chronic pelvic pain syndrome). Draw the chart from lecture

A
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28
Q

What is the MC benign tumor in men? MC as you _____

A

benign prostatic hyperplasia

MC as you age

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29
Q

T/F: All men to have BPH have symptoms

A

FALSE! not everyone is symptomatic

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30
Q

What are some risk factors for benign prostatic hyperplasia?

A

higher free PSA levels
prostatitis, heart disease
beta-blocker use
lack of exercise
obesity

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31
Q

What four factors can decrease your risk of BPH?

A

NSAIDs, excessive ETOH use, smoking, exercise

excessive ETOH use and smoking are due to decreased testosterone

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32
Q

What is the etiology of BPH?

A

multifactorial!!

prostate becomes more sensitive to androgens and growth factor as you age

aging prostate stops normal cell death

testosterone, dihydrotestosterone and estrogen may be involved in development

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33
Q

What are the 2 ways BPH obstructs?

A

mechanical obstruction due to narrowing of the urethral lumen and bladder neck

dynamic obstruction due to alpha-receptor stimulation which causes increased constriction to prostatic urethra

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34
Q

What type of voiding is associated with BPH?

A

both irritative voiding and obstructive voiding

obstructive voiding: due to mechanical blockage

irritative voiding: due to urgency, frequency and nocturia

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35
Q

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 am I?

A

Benign prostatic hyperplasia

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36
Q

What are the irritative voiding symptoms of BPH caused by?

A

Due to secondary response of bladder to increased outlet resistance

Detrusor muscle hypertrophy and hyperplasia, collagen deposition

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37
Q

______ assesses the severity of BPH symptoms

A

AUA symptom score

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38
Q

What will the DRE of BPH feel like? If you find ____ or _____ need to think it could be possible cancer

A

smooth, firm, symmetric, elastic enlargement of prostate

Induration or asymmetric enlargement → possible cancer

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39
Q

What are 2 lab finding that could correlate with a BPH dx?

A

UA- may see hematuria but not always

PSA: may be elevated even when no cancer is present

40
Q

When would imaging be needed in BPH? What would you possibly order?

A

US - may be indicated if high serum Cr or UTI

41
Q

What is the tx for mild BPH? What is considered mild? _____ is also possible in 50% of patients

A

watchful waiting!

mild symptoms with a score between 0-7 or pts who do NOT want tx

spontaneous regression in 50% of patients

42
Q

What are the 5 criteria that disqualify a person from “watchful waiting” as their BPH treatment?

A

Refractory urinary retention
Large bladder diverticula
Recurrent UTI or gross hematuria
Bladder stones
CKD

43
Q

What are the symptom score categories according to the AUA symptom score questionnaire?

A

0-7: mild

8-19: moderate

20-35: severe

44
Q

What are the 3 types of alpha receptors? What areas do each target specifically? Which ones are slightly more effective in relieving BPH symptoms but have more SEs?

A

𝞪1a - 70% of adrenoreceptors in prostate, bladder neck

𝞪1b - smooth muscle of vasculature

𝞪1d - prostate, bladder neck, detrusor, sacral spinal cord

Doxazosin and terazosin may be slightly more effective than tamsulosin, but have more SE

45
Q

Prazosin (Minipress)
Doxazosin (Cardura)
Terazosin (Hytrin)

What drug class?
What are the SE?
What are the DDI?

A

𝞪1-blockade Agents

orthostatic hypotension, dizziness and floppy iris syndrome

anti-HTN, PDE-5 inhibitors (will drop BP)

46
Q

Silodosin (Rapaflo)
Tamsulosin (Flomax)
Alfuzosin (Uroxatral)

What drug class?

A

𝞪1a-blockade Agents

47
Q

______ MOA converts testosterone to dihydrotestosterone. What is the end effect? How long does it take to reach therapeutic effects? What pt population is it more effective in?

A

5-𝞪-reductase inhibitors

reduces the size of prostate gland

takes ~6 months of treatment to see full benefit

More effective in men with larger prostates

48
Q

T/F: All 5-𝞪-reductase inhibitors reduce PSA by 50%. What are the 2 drugs in this class?

A

True!

Finasteride
Dutasteride-> may be slightly more efficacious

49
Q

What is the first line pharm therapy for BPH? What is the goal?

A

alpha blocker + 5-alpha-reductase inhibitor is considered first-line and superior to either treatment alone

goal is to shrink prostate

50
Q

______ is the PDE-5 inhibitor that is used in BPH

A

Tadalafil (Cialis)

Not superior to alpha-blockers, no extra benefit as adjunct

51
Q

_______ is the herbal that is commonly used in BPH treatment. Is it FDA approved?

A

Saw Palmetto

NOT FDA approved

52
Q

**What is the gold standard of prostate surgeries? Do you need to be hospitalized?

A

TURP: Transurethral Resection of the Prostate

yes, require spinal anesthesia and 1-2 day hospital stay

53
Q

What are the risks with TURP? **What are the complications?

A

Risks - retrograde ejaculation (75%), ED (5-10%), urine incontinence (<1%)

Complications - bleeding, urethral stricture, bladder neck contracture, perforation of prostate capsule, Transurethral Resection Syndrome

54
Q

______ is the hypervolemic, hyponatremic state caused by absorption of hypotonic irrigation solution. What increases this risk?

A

Transurethral Resection Syndrome

is procedure lasts greater than 90 minutes

55
Q

What type of procedure?

A

TURP

56
Q

______ is when resectoscope is inserted into urethra and 1-2 small grooves are cut into the bladder neck to open the channel and improve urine flow

A

Transurethral Incision of the Prostate (TUIP)

57
Q

What type of procedure?

A

Transurethral Incision of the Prostate (TUIP)

58
Q

____ is used when the prostate is too large to remove endoscopically. How large does the gland need to be? What is their risk of complication and duration of hospital stay?

A

Open/Robotic Simple Prostatectomy

Glands >100 g usually require open prostatectomy

Higher risk of complications and longer recovery but shorter hospital stay

59
Q

What procedure?

A

open simple prostatectomy

60
Q

What is happening in a Robotic Waterjet Therapy (Aquablation)? What size gland? How are the outcomes compared to TURP?

A

Prostate is mapped out pre-treatment to identify tissue to be destroyed without affecting nerves, ejaculatory ducts

30-150 mL

lower risk of stricture, incontinence, and possibly less sexual dysfunction

61
Q

What is a TULIP? What are the advantages? disadvantages?

A

Transurethral laser-induced prostatectomy (TULIP)

laser destroys prostate tissue and done under transrectal US guidance

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

62
Q

What type of procedure?

A

TULIP

laser resection of the prostate

63
Q

What is a TUNA? How do post-tx symptoms compare?

A

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 improvements in symptoms when compared to TURP

64
Q

What procedure?

A

TUNA

65
Q

What is UroLift? What are the risks? Do you have to be admitted? What size prostates?

A

Implant to Open Prostatic Urethra (UroLift)
Uses special device to place implants that “hold open” prostatic lobes

May be done outpatient/in clinic, under local anesthesia

Approved for prostates <80 g

66
Q

What procedure?

A

UroLift

67
Q

What procedure?

A

Water Vapor Thermal Therapy
(Rezum)

68
Q

_____ uses special catheter device device to open up urethral lumen and improve urine flow. What medication is used? What is the purpose of the medication?

A

Catheter Balloon Dilation (Optilume)

(paclitaxel)

prevent regrowth or refusion of anterior prostatic lateral lobes

69
Q

What procedure?

A

Optilume BPH Catheter System

70
Q

_____ is the MC non-skin cancer in US men and
2nd leading cause of cancer-related death in men. What are the risk factors?

A

prostate cancer

Increased Age-> MAJOR one!
Black ethnicity
+ family hx of prostate cancer
High dietary fat intake

71
Q

**How will most cancers palpate on exam? Where is the MC site of prostatic metastasis?

A

Most cancers have palpably normal prostates

Axial skeleton metastasi

72
Q

Why would prostate cancer have an elevated BUN/Cr?

A

urinary retention or obstruction

73
Q

How do you dx prostate cancer? What are the common places?

A

US-guided biopsy is standard method for detection either transrectal or transperineal

74
Q

**What imaging would you want to order if lymph nodes are also involved?

A

MRI- can help determine if bx is needed

75
Q

How is histology staged in prostate cancer? What types are confined to the prostate vs locally extensive or metastatic?

A

Histologically staged by Gleason system
1 (well-differentiated) to 5 (undifferentiated)

Gleason grades 1-2 are usually confined to prostate
Gleason grades 4-5 are usually locally extensive or metastatic

76
Q

______ is now the preferred initial treatment recommendation for men with ______ prostate cancer and _____ clinical features

A

Active surveillance

well-differentiated

low-risk

77
Q

What are the 4 parts of prostate cancer active surveillance?

A

Serial PSAs, serial DREs, periodic MRIs, biopsies as needed

78
Q

What is the patient criteria should undergo tx for prostate cancer?

A

If life expectancy > 10-15 yrs and cancer shows concerning features - usually should undergo tx

79
Q

____ is one tx for prostate cancer. What are the risks? Who is NOT a candidate for this type of tx?

A

Radical Prostatectomy

erectile dysfunction, urinary incontinence, infection

Rarely used if stage T4 or + lymph node metastasis

80
Q

_____ form of prostate cancer tx is used for small, localized prostate cancer. How does it work?

A

Cryosurgery

Liquid nitrogen placed in prostate with US guidance

81
Q

______ is a LHRH that is given has injection or implant for prostate cancer

A

leuprolide

82
Q

_____ is LHRH antagonist that is given as a monthly subq injection. What is an added benefit?

A

degarelix

No initial “testosterone flare” seen with LHRH agonists

83
Q

What are the 2 adrenal suppressants that are used in prostate cancer?

A

ketoconazole and corticosteroids

84
Q

What type of cancer is MC in prostate cancer?

A

adenocarcinomas that usually arise in periphery of prostate

85
Q

______ glycoprotein produced only by cells of the prostate gland. What does it correlate with?

A

Prostate Specific Antigen (PSA)

volume of prostate tissue

86
Q

T/F: PSA is only produced by malignant cells of the prostate.

A

FALSE!! Produced by benign or malignant cells

87
Q

What are 4 uses for PSA?

A

detect cancer
stage cancer
monitor response to treatment
detect cancer recurrence

88
Q

T/F: Pts with prostate cancer will have an elevated PSA

A

FALSE!! Some pts will have a normal PSA with prostate cancer

89
Q

What are the normal, intermediate and high PSA level ranges? What percent of patients that undergo prostate cancer screening will have an elevated PSA?

A
90
Q

What can the PSA level tell you have the volume/stage of prostate cancer?

A

If no history of prostate cancer tx - PSA level usually correlates with volume and stage of disease

Organ-confined - <10 mcg/L
Advanced - >40 mcg/L

91
Q

If your pt is on one of these 5 medications need to think that their PSA is actually higher than reflected by their lab value. **What is the major one?

A

**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

92
Q

**If you pt is on _______, what do you need to do their PSA so it is accurate?

A

5-alpha-reductase inhibitors

need to double the value on the lab report

93
Q

What are the 3 non-cancer causes of elevated PSA?

A

Benign Prostatic Hyperplasia (BPH)

Prostatic inflammation/infection

Perineal trauma (Prostatic massage, biopsy, surgery all count but DRE does NOT impact PSA level)

94
Q

When is free PSA commonly used? What does the results tell you?

A

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% chance of cancer

aka higher free PSA increases chances of it NOT being cancer

95
Q

What does PSA velocity measure? _____ have a higher chance of cancer

A

measures amount of change in PSA level in serial measurements (aka need to compare it against previous results)

> 0.35 mcg/L/yr increase - higher chance of cancer

96
Q

What are the AUA guidelines for screening for prostate cancer?

A

Baseline PSA between ages 40-45 for high-risk, 45-50 otherwise

Routinely screen every 2-4 years ages 50-69

97
Q
A

GU (13 decks)

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