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Clin Med - Repro > Lecture 21 - Men's Health Part 1 > Flashcards

Lecture 21 - Men's Health Part 1 Flashcards

1
Q

Epi of acute vs chronic prostatitis

A

Acute: younger males (20-40)

Chronic: >55y/o

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2
Q

Prostatitis

A

inflammatory condition (not necessarily an infection)

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3
Q

What are the types of prostatitis?

A

Type 1 - acute bacterial prostatitis
Type 2 - chronic bacterial prostatitis
Type 3 - Chronic abacterial prostatitis (more common than chronic bacterial)
Type 4 - asymptomatic inflammatory prostatitis

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4
Q

Type 1 Prostatitis Pathogenesis

A

acute bacterial prostatitis

post-intercourse of post-instrumentation urethral infection

urethral infection ascends
reflux of infected urine into prostatic urethra, ejaculatory ducts, prostatic ducts

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5
Q

What are the risk factors of type 1 prostatitis?

A 
intraprostatic urine reflux
unprotected sex 
phimosis, urethral stricutre
lower UTI, epidiymitis 
BPH 
indwelling catheter 
Prostate bx

always suspect gonorroeae should be suspected in the sexually active <35y/o

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6
Q

What is the most common pathogen responsible for type 1 prostatitis?

A

E. coli (MC)
Psuedomonas
Proteus
Klebsiella

always suspect gonorroeae should be suspected in the sexually active <35y/o

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7
Q

What is the clinical presentation of Type 1 prostatitis?

A 
local suprapubic or rectal pain 
systemic sxs: 
-fever
-chills
-malaise
-N/V
Lower urinary tract sxs: 
-dysuria 
-frequency
-urgency

more than 75% have fever and dysuria

about 50% have pelvic pain and chills

if ever there is hematuria, you have to bring the pt back once they are sxs free to assess them for bladder cancer

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8
Q

What does the PE show for type 1 prostatitis?

A

lower abdominal tenderness
distended bladder
perineal tenderness
enlarged, tender prostate

must do prostate exam but don’t do prostate massage

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9
Q

What is the DDx for type 1 prostatitis?

A

prostatic abscess
prostate cancer
urethritis
UTI

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10
Q

How do you dx type 1 prostatitis?

A 
CBC --leukocytosis with left shift 
Urinalysis/Microscopy 
-pyuria (leukocytes) 
-bacteriuria 
Urine culture
-looking for causative agent 
- if pt is febrile -- midstream collection

PSA - not helpful for ABP, may be elevated

Biopsy contraindicated –could lead to sepsis

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11
Q

What is the treatment for type 1 prostatitis?

A

age <35, risk of STI?
-treat N. gonorroeae, and C. trachomatis
- Ceftriaxone 250mg IM x 1 or 400 mg PO x 1
- AND azithromycin 1000mg PO x 1
Then add…

Age >35, low risk of STI?
-Ciprofloxacin x 4 weeks 
OR
-levofloxacin x 4 weeks
OR
-bactrim x 4 weeks

Severe infection?

  • inpt management
  • IV ampicillin and gentamicin OR levofloxacin (aminoglycocides)
  • -only inpt for 2-3 days
  • total treatment 6-8 weeks
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12
Q

What can you do for prevention of type 1 prostatitis?

A

treat comorbid conditions (ex. BPH)

wear condoms

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13
Q

What treatment is used for urinary retention with prostatitis type 1?

A

may be alpha blocker (terazosin)
is possible, pass foley cath
if obstructive, suprapubic cystostomy

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14
Q

Prostatitis type 2

A

chronic bacterial prostatitis

pathogenesis, etiology, and risk factors similar to ABP

Presentation:

  • recurrent UTIs that respond to ABX
  • pain - lower abdominal, perineal, testicular, scrotal, rectal, back (NO FEVER)
  • lower urinary tract sxs - dysuria, frequency, hesitancy, weak urinary stream
  • painful ejaculation, change in color of semen, retarded ejaculation, ED
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15
Q

LUTS

A

lower urinary tract sxs

dysuira
frequency
urgency
dribbling

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16
Q

What is the presentation of type 2 prostatitis?

A
  • recurrent UTIs that respond to ABX
  • pain - lower abdominal, perineal, testicular, scrotal, rectal, back (NO FEVER)
  • lower urinary tract sxs - dysuria, frequency, hesitancy, weak urinary stream
  • painful ejaculation, change in color of semen, retarded ejaculation, ED

if ever there is hematuria, you have to bring the pt back once they are sxs free to assess them for bladder cancer

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17
Q

How do you dx type 2 prostatitis?

A

urine microscopy and culture often normal
urine microscopy after prostate massage –> pyuria, bacteriuria
urine culture after prostate massage –> bacterial growth

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18
Q

How do you treat type 2 prostatitis?

A

start with NIH chronic prostatitis sxs index

ABX:
-ciprofloxacin 500mg PO BID x 6 weeks
OR
-Bactrim 80/400 PO BID x 4-6 weeks

recurrence is COMMON
-may require low dose suppressive therapy

may require alpha blocker therapy if retention occurs

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19
Q

Type 3 prostatitis

A

chronic abacterial prostatits/chronic pelvic pain syndrome

no demonstrable infection
local sxs - pelvic pain, urinary sxs, ejaculatory dysfunction
Use NIH CPSI to quantify/monitor severity

2 types:

  • inflammatory - WBC in semen, prostatic secretions, or urine post-massage
  • non-inflammatory - no WBCs

tx; refer to urology

20
Q

What is the treatment for type 3 prostatitis?

A

refer to urology

21
Q

What are the 2 types of type 3 prostatitis?

A
  • inflammatory - WBC in semen, prostatic secretions, or urine post-massage
  • non-inflammatory - no WBCs
22
Q

Type 4 prostatitis?

A

asymptomatic inflammatory prostatitis

no sxs

WBCs in prostatic secretions or in prostate tissues found incidentally during prostate evaluation for other reasons

no tx warranted

questions of increased association with BPH and/or prostate cancer

23
Q

Two glass test

A

pre and post prostate massage sampling for urine culture to help dx type 1 prostatitis

24
Q

BPH

A

benign prostatic hypertrophy

not really a disease, just a product of aging

25
Q

Prevalence of BPH

A

increases with age

40y/o - 20%
90y/o - 90%

26
Q

What is the path behind BPH?

A

testosterone is converted to dihyrdotestosterone (DHT) by enzyme 5AR
high levels of DHT are found in the prostate
When DHT is absent (castrated males) BPH never develops
Nodule formation in the periurethral zone of the prostate results in extrinsic compression of the prostatic urethra –> impaired voiding

27
Q

What is the clinical presentation of BPH?

A

LUTS

  • hesitancy
  • weak stream
  • interrupted stream
  • incomplete voiding
  • straining to void
  • dribbling
  • nocturia
  • incontinence

Recurrent UTIs
PE:
-enlarged prostate on DRE
-should be 2 fingerbreadths or less

28
Q

How do you dx BPH?

A

lab work:

  • urinalysis - look for evidence of UTI
  • urine culture - only done if UA abnormal of hx suggestive of UTI
  • PSA -should be measured in any man who has at least 10 year life expectancy
  • -PSA level correlated with size of prostate

imaging
-US, only if significant abnormality on DRE or elevated PSA

29
Q

American Urological association symptom index

A

used for BPH dx

Score 0-7 = mild
8-19 = moderate
20-35 = severe

30
Q

What is the drug therapy for BPH?

A

alpha blockers

  • selective short term: prazosin, alfuzosin, indoramin
  • selective long term: terazosin, doxazosin, slow-release (SR) alfuzosin
  • partially subtype: tamsulosin, silodosin
PDE5 inhibitors (phosphdiaesterase inhibitor) 
-Tadalafil - used when pt also has h/o of ED

5 alpha reductase inhibitors

  • finesteride
  • ductasteride

Anticholinergics - must have low/normal post-void residual volume (PVR)

31
Q

What is the follow up for Type 1 prostatitis?

A

we must check that they have fully irradiated the infection or else it might be chronic

so have them come back once they are done with their abx treatment –roughly 4 weeks –then do prostatic massage and urine culture

32
Q

What is the most commonly dx non-skin cancer in men?

A

prostate cancer

second most common cause of cancer DEATH in men

33
Q

What are the risk factors of prostate cancer?

A

age: rarely seen in men <40 (uncommon in men <50)

family hx: several potential genetic links, but not causative gene

Race: White 1 in 6, AA 1 in 5

lifestyle factors do NOT seem to play a role

prostatitis and BPH do not predict cancer occurence

34
Q

What is the path of prostate cancer?

A

exact cause for malignant transformation unknown/varies by type
most form adenocarcinoma; few for SCC

location:
- peripheral zone - 70%
- central zone - 15-20%

metastasis – occurs late in disease –most common location –> bone

35
Q

What is the clinical presentation of prostate cancer?

A

most cases detected through SCREENING (PSA or DRE) of ASYMPTOMATIC pts

sxs that may be present early in disease process:

  • bladder obstruction (LUTS)
  • back pain
  • hematuria

sxs of metastatic or advanced disease:

  • weight loss
  • anemia
  • bone pain
  • leg weakness and sensorineural deficits (spinal cord compression)
36
Q

What is the PE of prostate CA?

A

GEN - evidence of cachexia?
ABD - lower abdominal pain/swelling indicating bladder distention
DRE - examiner dependent; precision vs accuracy favors on provider over multiple providers
MSK - bony tenderness
NEURO - look for evidence of compression of spinal cord or spinal nerves

37
Q

Hyperplasia vs hypertrophy?

A

hyperplasia –new cell growth

hypertrophy – the preexisting cells are getting bigger

38
Q

Nodules + LUTS =

A

50% chance prostate cancer

39
Q

Elevated PSA

A

not specific for prostate cancer

40
Q

PSA can be elevated in which conditions?

A 
prostate cancer
advanced age 
BPH 
prostatitis  
prostate massage 
cystoscopy
biopsy
41
Q

What are the screening guidelines for prostate cancer?

A

LOOK UP

42
Q

How do you dx prostate cancer?

A

elevated PSA and/or suspicious DRE finding

transrectal US (high false negative rates)

MRI or CT - visualization of regional lymph node involvement
Bone scan - helpful for staging

43
Q

Gleason Score

A

prostate cancer staging

histologic scoring of biopsy
based on cellular architecture
high gleason = poor prognosis
may affect decision on how to manage

44
Q

TMN

A

tumor staging
tumor size
node involvement
metastasis

used to gauge prognosis
will help direct therapeutic approach

45
Q

What is the treatment for local prostate cancer?

A

low risk, low grade, low gleason score

  • active surveillance
  • -DRE, PSA testing, repeat bx to monitor progression

intermediate risk, high-grade, high gleason score

  • radical prostatectomy - not necessarily curative, dramatic impact on QOL
  • radiation therapy - only used post-radical prostatectomy for positive surgical margins
  • cryosurgery - less commonly used (provider dependent); minimally invasive, fewer adverse events compared to radical prostatectomy
46
Q

Treatment of metastatic prostate cancer?

A

Androgen deprivation therapy

  • primary prostate cancer is hormone dependent
  • orchietomy and/or luteinizing hormone releasing hormone analogs are first line

bone targeting agents
- bisphosphonates and RANK-L

chemotherapy - docetaxel - reversed for those who fail ADT

Clin Med - Repro (18 decks)

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