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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
Q

describe the peripheral zone

A
  • largest zone — contains 70% of the gland
  • outer portion in posterior most portion of gland
26
Q

describe the central zone

A
  • the portion of the prostate located between the 2 ejaculatory ducts
  • accounts for 20% of the gland
27
Q

describe the fibromuscular stroma

A
  • contains no gland
  • anterior in gland
28
Q

what zone directly surrounds the urethra?

A

transitional zone

29
Q

what happens when the transitional zone becomes enlarged?

A

causes obstruction of the urethra

30
Q

most malignancies of the prostate occur in which zone?

A

peripheral

31
Q

relations of the prostate gland

A

superior = bladder
inferior = sphincter
lateral = levator ani muscle
anterior = pubic symphysis
posterior = rectum

32
Q
A
33
Q

describe the structure of the prostate

A
  • inverted pyramid
  • 15-20 gms
  • 2 by 3 by 4 cm
  • consists of smooth muscle, stromal and glandular
  • ratio changes with disease
34
Q

most of the problem with BPH occurs in what area?

A

transitional zone

35
Q

what are the functions of the prostate?

A

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
Q

what is seminogeline?

A
  • 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
Q

what % of semen comes from the seminal vesicle? acidic or alkaline?

A

70% - alkaline

38
Q

is the contribution of the prostate to semen alkaline or acidic?

A

acidic

39
Q

what happens to the semen in ejaculatory duct obstruction?

A

becomes acidic — part coming from seminal vesicle is absent

40
Q

pathogenesis of the enlargement

A
  • 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
Q

investigations

A
  • 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
Q

you can be 90% certain it is a UTI if both what are present?

A

leucocytes and nitrites

43
Q

management

A
  • 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
Q

what is IPSS?

A

International Prostate Symptom Score = 7 questions, assesses severity of symptoms

45
Q

IPSS score is out of what?

A

35

46
Q

when should you reassure the patient (no specific treatment)?

A
  • mild symptoms
  • normal investigations — eGFR/post void residual, PSA/MSU
  • patient’s preference
47
Q

what treatments are available?

A
  • medical — alpha blockers, 5 alpha reductase inhibitors, anticholinergics, combinations
  • catheters
  • minimally invasive
  • surgery
48
Q

what receptors does the smooth muslce component of the prostate have?

A

alpha 1a adrenergic receptors

49
Q

what happens if you block the alpha receptors in the prostate?

A

smooth muscle relaxes - channel opens - helps with obstruction

50
Q

examples of alpha receptor blockers

A

tamsulosin, alfuzosin, terazocin, doxazocin

51
Q

advantages and disadvantages of alpha receptor blockers

A

advantages:
- quick onset
- does not affect PSA
- symptomatic relief

disadvantages:
- headaches
- postural hypotension
- retrograde ejaculation
- has no effect on prostate growth

52
Q

what are 2 examples of 5 alpha reductase inhibitors?

A

finasteride, dutasteride

53
Q

what do 5 alpha reductase inhibitors do?

A

prevents conversion of testosterone to dihydrotestosteone — shrinks the prostate with time

54
Q

what components do they address? a receptor blockers vs 5 alpha reductase inhibitors

A

a receptor blockers = dynamic component

5 alpha reduces inhibitors = static component

55
Q

advantages vs disadvantages of 5 alpha reductase inhibitors

A

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
Q

testosterone vs dihydrotestosterone potency

A

dihydrotestosterone is many times more potent than testosterone

57
Q

what are anticholinergics used for?

A

to control associated storage symptoms

58
Q

what do phosphodiesterase 5 inhibitors cause?

A

nitric oxide mediated smooth muslce relaxation

59
Q

what phototherapy agents can be sued?

A

saw palmetto (serenata repens), pygeum africanum

60
Q

what is prostate embolisation?

A

block blood supply of the prostate

61
Q

what are minimally invasive treatments?

A
  • water vapour
  • embolisation
  • stent to pull lobes apart
62
Q

what proper surgical options are there?

A
  • 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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