Prostatitis & BPH

Question 1

what is prostatitis
- differentiate between acute & chronic

classifications of acute, chronic and chronic pelvic pain syndrome & asymptomatic inflammatory prostatitis (NEW)

Answer 1

inflammation (commonly due to infection) of the prostate gland

• acute: an acute, short-term infection
• chronic: recurrent, longstanding infection-like symptoms caused by bacteria

Classificiations
acute prostatitis
- leukocytosis in the prostatic fluid
- systemic signs of infection (fever, chills, etc.) not always seens
- postive bacterial culutre

chronic prostatitis
- wax & wain symptoms (coming and going)
- no systemic signs
- leukocytosis in the fluid
- postive bacterial culture

inflammatory & non-inflammatory chronic pelvic pain syndrome
- inflammatory: signs of leukocytosis in sample; no postive bacterial culutre
- non-inflammatory: no leukocytosis or postive bacterial culture (but pain symptoms)

Asymptomatic Inflammatory Prostititis
- leukocytosis in sample and/or bacterial culutre
- but NO clinical symptoms

Question 2

pathogens of prostatitis

Etiology

Answer 2

e. coli most common (65%-80%)
- other gram negative infections: pseudomonas, klebsiella, enterobacter, serratia

• enterococcus (gram +)
• +/- if chalymida or gonnorrhea causes it: can still use or cover with doxy. if suspicious or get a test\

Etiology
- alterned host function & structure & immune defense issues
- lubricants & other chemicals can cause
- psychological factors
- dysfunctional voiding (sitting full bladder can harbor bacteria)
- previous transuretheral surgery (inc. risk for infection)

Question 3

Presentation - Signs & Symptoms of prostatitis

Answer 3

• **PAIN
• difficulty voiding; obstructive (cant get it all out) or irratative (urgency to go)
• dysuria (burining)**
• painful ejaculation
• systemic symptoms (fever, nausea, vomiting) – think more acute
• pelvic floor pain: irritated organs rub against the floor & make it painful (defication too)

remember chronic will be intermittent, acute may have more systemic symptoms

on exam….
- boggy, warm & tender prostate = think ACUTE
- tender only = think chronic
- uncomfortable to paplate on the rectal exam

Question 4

Work-up & diagnosis for Prostititis
labs & imaging

Answer 4

labs
- urinalysis with microscopy (to see leukocytosis)
- urine culture (to see infection)
- can do a prostatic secretion culture: to induce the possibility of pathogens making it to the urine to cx.

do NOT check PSA 4-6 weeks after symptoms have resolved – it will be elevated

imaging (not needed)
- can do TRUS of prostate or UDS or bladder scan (assess emptying)

can do NIH-chornic prostatitis symptom idex score to get idea of how its affecting thier quality of life

Question 5

Treatment for Prostititis
- medications
- duration
- additional treatment for symptoms

Answer 5

prostate is difficult for treatment: need to penetrate for longer (4-6 weeks)

Antibiotics
- floroquinolones cipro or levo (avoid in 1st round if you can due to systemic SE)
- bactrium
- doxycycline (can be good for suspected STI)

Chronic: can usually be cured with a second round of abx.

Symptomatic Treatment
- anti-inflammatory: NSAIDS/steroids
- alpha blockers: +/- help for the obstructive voiding symptoms/incomplete emptying (help to induce emptying)
- 5-alpha reductase: to shrink the prostate (may be helpful in chronic)
- best help: pelvic floor thearpy

Question 6

what is BPH
pathology
when do you treat

Answer 6

BPH: Benign Prostatic Hyperplasia

Pathology
- an increase in the number of prostate cels (normally in the transitional zone) which is arround the prostatic urethra therfore with potential to impeed flow
- the hyperplasia creates discrete nodules
- extremely common with increased age

treatment only necessary if they have BOTHERSOME symptoms

Question 7

BPH: Symptoms

Answer 7

can have IRRITATIVE or OBSTRUCTIVE symptoms

Storage (Irritative)
- urge incontienence (leaking out)
- frequency
- urgecny to go
- nocturia

Obstructive (Voiding)
- weak stream
- hesitatancy & intermittent stream
- post void dribbling
- incomplete emptying

Question 8

BPH: Diagnosis

evaluation and labs and imaging

Answer 8

• history and physical first!!!
• IPPSS: an objective measure of their symptoms & good for tracking efficacy of treatment

labs
- urinalysis

imaging (not “imaging” but tests) – not needed
- PVR: post-void residual testing
- uroflowmetry (using US to see how they empty)

additional: Invasive
- cystoscopy
- urodynamic testing (2 catheter procedure)
- prostate ultrasound

Question 9

BPH: Management
1st line
meds

Answer 9

1st line: Behavior Modifications
- double voiding: trying again
- timed voiding
- limiting irritants of the bladder
- limit nighttime fluids
- avoid diuretics in the PM
- stop smoking
- address OSA and other co-morbidities

Medications
alpha blockers: best 1st line & quick (days)
- relaxes smooth muscle of the bladder neck and prostate to allow for release (decreased obstruction)
- this is a dilator/relaxor: side effects of hypotension, dizzy, lightheaded, retrograde ejaculation, floppy iris syndrome
- names :tamsulosin, doxazosin, alfuzosin, silodosin, terazosin

5-alpha-reductase inhibitors : takes 6 months
- blocks conversion of testosterone to DHT (which therefore reduces prostate volume by 20%)
- if on 5ARIs – PSA is cut in half, must double levels while monitoring
- side effects: reduced testosterone (active): reduced libido, ejaculatory dysfunction, depression, gynecomastia
- names: finasteride, dutasteride

combo med: alpha blocker + 5-alpha reductase inhibitor

PDE5i as additve with alpha blockers

anticholenergics or beta-3 agonists: for irritative symptoms: slows the bladder down & reduces the urgency to go – but watchthis can put them into retention

Question 10

BPH:
indications for surgery
Surgical management

Answer 10

Indications for Surgery
- renal insufficiency becuase of BPH
- urinary retention even with meds & refractory LUTS
- recurrent UTIs, stones or hematuria

Most Common
TURPS: transurethral resection of the prostate:
GOLD STANDARD SURGERY: leaves shell, takes core of prostate out; cannot be used in large prostates > 80g
Urolift : compresses the prostate (staple into place) ; only < 80 g
Holmium Laser Enucleation of the prostate: no size cut-off, chews up the prostate and sucks it up; leaves shell
Robotic Simple Prostatectomy: scoop prostate out and leave shell, still innervated!

others:
- REZUM
- aquablation
- open simple prostectomy
- greenlight laser TRUP