Week 8 Flashcards
what characterizes acute prostatitis?
acute, symptomatic infxn of the prostate characterized by (+) uropathogen on urine culture and generalized sx of acute inflammation
what characterizes chronic prostatitis?
chronic infxn of prostate characterized by recurrent UTIs and localization of the uropathogens to prostate-specific tissues
what characterizes chronic prostatitis/chronic pelvic pain syndrome?
chronic (>3 mos) genitourinary pn in the absence of bacteria (no infxn) localized to the prostate
what characterizes inflammatory CPPS?
significant WBCs (>10-20/hpf) in the semen, expressed prostatic secretions or voided bladder urine
what characterizes non-inflammatory CPPS?
insignificant WBCs found
what characterizes asx inflammatory prostatitis?
no specific CP/CPPS sxs found but WBCs or bac found in EPS or in prostate tissue bx
what is acute bacterial prostatitis? what bug causes it most of the time? what other bugs can cause it? what can cause it?
infxn of prostate with pathogens from colorectal flora (E. coli MC, proteus, klebsiella, enterobacter, pseudomonas)
can be caused by increased intraprostatic ductal reflux resulting in urine moving bacteria into the prostate via ejaculatory and prostatic ducts into peripheral zone
RFs for acute bacterial prostatitis?
young men (20-30 yo) sexually active prior abx exposure dehydration phimosis unprotected anal intercourse trauma increased prevalence in immunocompromised status occ hematogenous or lymphatogenous spread of rectal bac (after prostate bx)
ssxs of acute bacterial prostatitis? PE?
sudden onset of spiking fever, chills, malaise, arthralgia, myalgia
LUTS: dysuria, nocturia, urgency and frequency
may see acute urinary retention
low back pn/perineal/rectal pn
PE: prostate (gentle DRE): acutely tender, firm, warm, swollen - PROSTATE MASSAGE C/I B/C MIGHT SPREAD INFXN
labs and imaging for acute bacterial prostatitis?
labs: hematuria, bacteriuria, pyuria, cloudy urine (midstream catch)
urine gram stain and culture
elevated PSA (may confuse w/dx of CaP)
CT mb needed to ddx prostatic abscess
tx and management considerations of toxic acute bacterial prostatitis?
if toxic acute prostatitis - culture guided IV abx to prevent systemic complications such as cystitis, PN, orchitis, sepsis, infertility
observation/hospitalization and if indicated cath’ing
plus outpt fluoroquinolones (cipro) for 2-4 wks
tx and management of non-toxic acute bacterial prostatitis?
bed rest
analgesics
hydration
oral abx (TMP-SMX, one double strength tab PO q 12 hr or cipro 500 mg PO q 12 hr)
alpha blocker to improve outflow obstruction
consider alternating hot and cold to pelvic area
complications of acute bacterial prostatitis?
bacteremia
epididymitis
chronic prostatitis
prostatic abscess
what can chronic prostatitis result from? MC pathogen if it is present?
can result from acute prostatitis or w/o previous infxn
if dt bac then E. coli MC
what findings make you start to consider chronic prostatitis?
- pt has dysuria and frequency w/o acute sxs
- pt has recurrent UTIs w/o hx of cath’ing
- pt has incidental hematuria or bacteriuria
RFs for chronic prostatitis?
usu > 30 yo, western lifestyle prostatic calculi immune or AI dz urine reflux alkaline pH (>6.4) prostatic fluid
what %age of ABP progresses to chronic? what %age of these cases will have obvious bac?
5% of ABP will progress to chronic
of those consistent with CBP only 5-10% have obvious bac
presentation of chronic bacterial prostatitis? PE?
recurrent UTI (intermittent/relapsing) fatigue chronic pn sexual dysfuxn, ejaculatory pn milky urethral d/c PE with DRE: moderate tenderness, boggy, enlarged, soft prostate
dx of CBP?
mb incidental bacteriuria
perform post-massage urine culture and sensitivity, EPS culture, semen culture
>10 leukocytes/hpf in EPS
tx for CBP? what can happen after tx? how long do you need to give abx to assure lower recurrence? naturopathic tx options?
TMP-SMX 80-400 mg BID or oral fluoroquinolones for 4+ weeks (500 mg cipro BID)
sxs mb relieved during tx but after abx done can lead to recurrence
abx if given 6-12 tend to produce a cure with few relapses
naturopathic: saw palmetto, quercetin, probiotics, prostatic massage, sitz bath, ejaculation at least every 3 days to drain prostatic ducts, suppositories with calendula and vit A, aesculus hippocastanum
tx for treatment-refractory CBP pts?
intermittent abx of acute episodes, low dose abx suppression, radical transurethral prostatectomy or simple open prostatectomy
criteria for chronic nonbacterial prostatitis?
- no objective cause is found to explain sxs
- sxs relate to anatomical area around prostate
- refractory to tx
presentation of chronic nonbacterial prostatitis? PE findings?
pain in pelvic region > 3 mos
disability out of proportion to PE/lab findings!
dysuria, urgency
low back/perineal pn referred to tip of penis
sense of rectal fullness after unsuccessful defecation
sexual dysfxn, post-ejaculation pn, decreased libido
possible hemospermia
fatigue, stress
PE: prostate palpation - mildly tender, boggy, rarely enlarged, assess tenderness of pelvic floor and sidewalls, also examine for hernia, testicular masses and hemorrhoids
labs of chronic nonbacterial prostatitis?
UA, urince C/S, EPS cell count and culture, CBC and blood cultures if sepsis
mb hematuria, PSA <4
if inflammatory WBCs present in semen, EPS, VB3
if non-inflammatory WBCs not present in samples
a urethral swab is indicated to r/o chlamydia, gonorrhea if four glass urinalysis is (=)
consider: TRUS, abd CT, flowmetry, IVP
chronic nonbacterial prostatitis is similar to what other somatic syndromes?
fibromyalgia, IBS, CFS, IC, CPPS, “biopsychosocial conditions”
theories of etiology of CP/CPPS?
psychological stress increasing local production of IL-10, IL-6
infection from otherwise normal bac in prostatic fluid
AI vs prostate
low T leading to prostate inflam
increased NGF, increasing sensitivity of pelvic nerves
genetic: differences in DNA sequences that regulate cytokines
ddx of chronic nonbacterial prostatitis?
include workup for CaP, obstructive uropathy, bladder cancer, urethritis, neurogenic bladder
treatment considerations for chronic nonbacterial prostatitis?
alpha-blocker therapy for newly dx, alpha-blocker-naive pts abx for newly dx, abx-naive pts finasteride, elmiron, opioids, amitriptyline, gabapentin *invasive surgical therapies not recommended heat therapy cernilton 500 mg TID quercetin potassium citrate to alkalinize urine biofeedback acupuncture E-stim myofascial release therapy immunomodulating agents muscle relaxants pudendal nerve modulation prostatic massage identify and remove food allergens anti-inflam diet constitutional hydrotherapy, sitz baths support groups
asx inflammatory prostatitis presentation? tx for what group of pts and what is the tx?
no subjective sxs but WBCs found in prostate secretions or in prostate bx
abx tx for selected pts w/elevated PSA and infertility
sxs of prostatic obstruction are related to what?
age!
at 55 yo, 25% report obstructive voiding sxs
at 75 yo, 50% complain of decrease in force and caliber of urinary stream
RFs for benign prostatic hyperplasia?
genetic predisposition
age
race
meds (antihistamines, diuretics, opiates, TCAs, anticholinergics)
etiology of BPH?
hyperplastic nodules and associated BPH sx can result from excessive proliferation of cell types and impaired preprogrammed cell death
effects of aging dec of T, increase in E, increase in SHBG on prostate tissue?
dec T, inc E, inc SHBG lead to inc amount and activity of intraprostatic DHT which inhibits prostatic stem cell death and promotes transition zone growth
pathology of BPH?
cells in the transition zone undergo hyperplasia from stimulation by DHT and E, not malignant, no METS
BPH sxs from what two things?
obstruction: due to intrusion into the urethral lumen or bladder neck leading to incr bladder outlet resistance
resistance: leads to irritative voiding complaints; detrusor muscle hypertonicity and hyperplasia, collagen deposition, possible diverticular formation and weakened bladder wall
ssxs and PE of BPH?
early mb asx
obstructive sxs include hesitance, decreased force, caliber of stream, sensation of incomplete emptying, double voiding, straining to urinate, post-void dribbling
irritative sxs include urgency, frequency and nocturia
PE: smooth, firm, rubbery, NT enlargement, no nodules, median bar can be mistaken for a nodule
what finding on DRE should increase your suspicion for CaP?
induration and enlargement
what labs to order with suspicion of BPH?
UA to exclude infxn or hematuria, C and S necessary
BUN and Cr to assess renal fxn
PSA levels (have to do before DRE or 2 wks after DRE as f/u to r/o CaP)
what imaging to workup BPH?
TRUS
IVP if concomitant urinary tract dz
optional: cystometrogram pressure flow studies, post-void residual urine, uroflowmetry
DDX of BPH?
CaP, urinary bladder dysfxn, UTI, IC, chronic prostatitis, enlarged non-hyperplastic prostate
complications of BPH?
UTI, bladder stones, obstructive nephropathy, renal failure
treatment for BPH?
watchful waiting
alpha-blockers, alpha-1 adrenergic blockers
selective alpha blockers, 5 alpha-reductase inhibitors,
prostatic stent, YAG laser, TUNA, BDP, TURP, TUMT, PVP
discourage straining to urinate, avoid fluids after 7 pm, avoid EtOH, caffeine, salt, diuretics, spicy foods, meats with hormones, consume foods high in EFAs, consume high fiber foods, serenoa repens, urtica, curcubita pepo, soy for phytoestrogenic effect, beta-sitosterols in rice bran, alanine, glutamine, glycine, physiotherapy, protomorphogens, prostatic massage, sitz baths
SEs of alpha blocker therapy for BPH?
caution use in those with sulfa allergy
can cause retrograde ejaculation, hypotension
caution use in those with cataracts surgery
benefits of 5 alpha-reductase inhibitors in treating BPH? SEs?
helpful for men w/prostate greater than 40 cm^2
can decrease PSA levels
after 6 mos of use decr risk of infxn, decr need for surgical intervention
SEs include decr libido, ED, possible incr risk for CaP
prognosis and tx for men with prostate less than 60 cm? complications of BPH?
watchful waiting combined with naturopathic therapies is reasonable though not proven approach
complications include acute urinary retention, recurrent infections, intestinal herniation, hemorrhoids
