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PBL SEM 4 > structure and function of prostate gland and potential treatments for BPH > Flashcards

structure and function of prostate gland and potential treatments for BPH Flashcards

1
Q

prostate disease can be _____ or _______

A

benign or malignant

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2
Q

benign prostatic enlargement vs hypertrophy vs hyperplasia vs obstruction

A

enlargement = clinical

hypertrophy (increase in size or volume of cell) and hyperplasia (number of cells) = histologic

obstruction = urodynamic (symptomatic)

avoid the term ‘prostatism’

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3
Q

what is dysuria?

A

pain passing urine

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4
Q

what does the upper urinary tract consist of?

A

kidney and ureter

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5
Q

what does the lower urinary tract consist of?

A

bladder, prostate and urethra

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6
Q

what lower urinary tract storage symptoms are there?

A

failure to store

  • frequency
  • nocturia
  • urgency
  • urge incontinence
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7
Q

what lower urinary tract voiding symptoms are there?

A
  • hesitancy
  • poor stream
  • straining
  • intermittency
  • feeling of incomplete voiding
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8
Q

what are post micturition symptoms?

A

a feeling of incomplete emptying (used to be under voiding symptoms)

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9
Q

what is frequency?

A

voiding less than every 2 hours

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10
Q

what is nocturia?

A

voiding 2 or more times during the night

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11
Q

what is urge incontinence?

A

when you leak before reaching the toilet

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12
Q

what are red flag symptoms?

A
  • pain = dysuria
  • blood = haematuria
  • leak at night = enuresis
  • recurrent infection
  • symptoms of renal failure
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13
Q

what are 2 causes of dysuria?

A

bladder infection or stone

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14
Q

what are things to assess in examination?

A
  • general = gait, tremor, pedal edema
  • abdomen = palpable bladder
  • genitalia = phimosis, meatal stenosis, swelling/tenderness of testis or epididymis
  • rectal exam rubbery, smooth, midline groove
  • neurological bulbocavernosal reflex, lower limb reflexes
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15
Q

what could pedal oedema be a sign of?

A

renal failure — check creatinine

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16
Q

palpable bladder : acute vs chronic retention

A

acute = palpable and painful

chronic = palpable and painless

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17
Q

what is phimosis?

A

inability to retract foreskin

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18
Q

what is meatal stenosis?

A

narrowing of the opening of the urethra

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19
Q

what can swelling/tenderness of testis or epididymis be a sign of?

A

epididymis orchitis — can occur if patients have problems emptying their bladder properly and so develop infection

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20
Q

why should you test anal sphincter function?

A

sacral plexus (S2-S4) supplies both the anal sphincter and the bladder — therefore if the anal sphincter tone is slow, the bladder function is also affected

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21
Q

aim of DRE?

A

estimate size of prostate — normally can reach top and not more than 2 fingers wide

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22
Q

how is a bulbocavernosus reflex carried out?

A

squeeze the glands penis in men and touch the clitoris or labium minus in women to stimulate the reflex, while checking for a reflex contraction of the external anal sphincter

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23
Q

what differential diagnoses are there?

A
  • prostate — benign enlargement/cancer
  • bladder — overactive/underactive
  • urethra — stricture
  • infection — cystitis/prostatitis
  • psychological — anxiety
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24
Q

what are the zones of the prostate gland?

A

central, peripheral, fibromuscular and transitional

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25
describe the peripheral zone
- largest zone — contains 70% of the gland - outer portion in posterior most portion of gland
26
describe the central zone
- the portion of the prostate located between the 2 ejaculatory ducts - accounts for 20% of the gland
27
describe the fibromuscular stroma
- contains no gland - anterior in gland
28
what zone directly surrounds the urethra?
transitional zone
29
what happens when the transitional zone becomes enlarged?
causes obstruction of the urethra
30
most malignancies of the prostate occur in which zone?
peripheral
31
relations of the prostate gland
superior = bladder inferior = sphincter lateral = levator ani muscle anterior = pubic symphysis posterior = rectum
32
33
describe the structure of the prostate
- inverted pyramid - 15-20 gms - 2 by 3 by 4 cm - consists of smooth muscle, stromal and glandular - ratio changes with disease
34
most of the problem with BPH occurs in what area?
transitional zone
35
what are the functions of the prostate?
fertility - PSA enzyme - semen liquefaction - antegrade ejaculation — muscularis ejaculatorius - contributes to 25% ejaculate volume — acidic - milieu for sperm to thrive Nutrition Antimicrobial (Zn, selenium)
36
what is seminogeline?
- in semen - causes coagulation in semen - coagulant lysed in the female genital tract by the PSA - PSA activated by acidic milieu of female genital tract
37
what % of semen comes from the seminal vesicle? acidic or alkaline?
70% - alkaline
38
is the contribution of the prostate to semen alkaline or acidic?
acidic
39
what happens to the semen in ejaculatory duct obstruction?
becomes acidic — part coming from seminal vesicle is absent
40
pathogenesis of the enlargement
- increase in number of cell vs reduced apoptosis - balance - androgen/oestrogen ratio — receptor signalling affected - imbalance of growth factors — EGF, KGF, IGF vs TGF (transforming - only one that reduces the growth of the prostate, all the others increase the growth) static component — sheer size of gland dynamic component — smooth muscle action
41
investigations
- urinalysis and msu for culture — infection or haematuria - urea electrolytes and creatinine - PSA - flow rate and post void scan optional - imaging — US - flexible cystoscopy
42
you can be 90% certain it is a UTI if both what are present?
leucocytes and nitrites
43
management
- check for abnormal findings - history : red flags - examination : palpable bladder/phimosis/abnormal feeling prostate - bloods : renal impairment/raised PSA - urine — UTI/haematuria - assess symptom severity : IPSS
44
what is IPSS?
International Prostate Symptom Score = 7 questions, assesses severity of symptoms
45
IPSS score is out of what?
35
46
when should you reassure the patient (no specific treatment)?
- mild symptoms - normal investigations — eGFR/post void residual, PSA/MSU - patient’s preference
47
what treatments are available?
- medical — alpha blockers, 5 alpha reductase inhibitors, anticholinergics, combinations - catheters - minimally invasive - surgery
48
what receptors does the smooth muslce component of the prostate have?
alpha 1a adrenergic receptors
49
what happens if you block the alpha receptors in the prostate?
smooth muscle relaxes - channel opens - helps with obstruction
50
examples of alpha receptor blockers
tamsulosin, alfuzosin, terazocin, doxazocin
51
advantages and disadvantages of alpha receptor blockers
advantages: - quick onset - does not affect PSA - symptomatic relief disadvantages: - headaches - postural hypotension - retrograde ejaculation - has no effect on prostate growth
52
what are 2 examples of 5 alpha reductase inhibitors?
finasteride, dutasteride
53
what do 5 alpha reductase inhibitors do?
prevents conversion of testosterone to dihydrotestosteone — shrinks the prostate with time
54
what components do they address? a receptor blockers vs 5 alpha reductase inhibitors
a receptor blockers = dynamic component 5 alpha reduces inhibitors = static component
55
advantages vs disadvantages of 5 alpha reductase inhibitors
advantages: - symptomatic relief - shrink prostate - reduce risk of retention - promote hair growth in male pattern baldness disadvantages: - slow onset - reduced libido/weak erection - gynaecomastia - affect PSA
56
testosterone vs dihydrotestosterone potency
dihydrotestosterone is many times more potent than testosterone
57
what are anticholinergics used for?
to control associated storage symptoms
58
what do phosphodiesterase 5 inhibitors cause?
nitric oxide mediated smooth muslce relaxation
59
what phototherapy agents can be sued?
saw palmetto (serenata repens), pygeum africanum
60
what is prostate embolisation?
block blood supply of the prostate
61
what are minimally invasive treatments?
- water vapour - embolisation - stent to pull lobes apart
62
what proper surgical options are there?
- transurethral resection of prostate TURP - remove a bit at a time - holmium enucleation of prostate HoLEP - remove all at once

PBL SEM 4 (50 decks)

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