BPH, prostate infections, Prostate/bladder/testicular CA and Incontinence Flashcards Preview

Clinical Medicine II > BPH, prostate infections, Prostate/bladder/testicular CA and Incontinence > Flashcards

Flashcards in BPH, prostate infections, Prostate/bladder/testicular CA and Incontinence Deck (58):

what is needed to develop BPH

a functioning testicle


is BPH age related and is it understood

BPH is not fully understood but appears to be multifactorial and under the control of the endocrine system


what is the frequency of BPH in the male community

20% age 41-50 yr and 80% age >80 yr have BPH


What types of tissue compose the prostate

stromal and epithelial tissue make up the prostate
* these tissues can give rise to BPH


Where does prostate cancer originate

prostate cancer: from peripheral zone of the prostate


where does BPH originate

in the periurethral and transition zones


what types of voiding sx are associated with BPH and what are examples of these

both obstructive and irritative voiding sx
*obstructive: decreased force and caliber of stream, intermittent stream and urinary hesitancy (caution with allergy meds)

*Irritative sx: frequency, urgency, nocturia (and dysuria?)


DRE may reveal what in BPH and what may be more indicative of malignancy over BPH

DRE may show uniform or focal enlargement of the prostate
*focal may represent malignancy rather than BPH (need further eval)
*sx rather than size dictate tx


If focal enlargement of the prostate is found upon DRE, what might you fear

fear malignancy... further eval is indicated (prostate ultrasound and tissue biopsy


what dictates prostate tx

sx not size of prostate


What lab findings should be performed when assessing BPH

BUN/Cr: assess kidney function
UA: r/o infection and hematuria
PSA: cancer detection


when should PSA testing be offered to pt?

asymptomatic M > 40 yr with life expectancy of at least 10 yr
*debate on checking PSA in men > 75 yr


When should imaging be performed in BPH pt

*imaging not necessary in pt with mild or moderate sx UNLESS hematuria present or Upper urinary tract disease suspected


What is uroflowmetry and what is used for

a uroflow eval may be useful in assessing BPH
*total volume must >150mL of urine for this test to be considered reliable


What measurement should be used to help guide BPH tx and a pt's response to tx

POST VOID residual urine measurement


what is cystourethroscopy and when is it used

invasive procedure
use cystourethroscopy when BPH dx is uncertain


what are some ddx when considering BPH

disorders that cause bladder outlet obstruction:
*urethral stricture
*bladder neck contractures
*bladder calculi
*cancers of the bladder or prostate
*UTI and neurologic disease


Besides med tx, how can you treat BPH

avoid caffeine, cold/allergy meds (this act like cholinergic thus antagonize "rest and digest".. they cause vasoconstriction rather than relaxing/voiding)


What is the mainstay med tx for BPH

Alpha blockers! bc inhibit vasoconstriction and relax wall of prostate
1. Cardura or Hytin
2. Flomax (30 min after meal)
3. Uroaxtral (w/ meal)
4. Rapaflo (w/ meal)


what type of meds are cardura, hytin, flomax, uroaxtral, and rapaflo?? what should you let patients know about these meds?

alpha blockers commonly used to treat BPH.. relax wall of prostate and inhibit vasoconstriction

*SE: stuffy nose, dizziness, retrograde ejactuation
(these meds oppose sympathomimetics such as allergy/cold meds such as sudafed)


Besides alpha blockers, what other times of meds may be helpful for BPH

Type II 5-alpha reductase inhibitors: Proscar, Avodart


What are the SE of the BPH meds Proscar and Avodart. What class of meds are these?

Proscar and avodart are type II 5-alpha reductase inhibitors (prevent testosterone to DHT conversion)

SE: low libido, breast tenderness,hair growth
*can take up to 9 months to work thus not for acute tx of urinary retention


What surgical options are available for BPH, which option is the gold standard and what are pros/cons for each?

1. TURP:Transurethral resection of the prostate, aka "roto rooter" is GOLD Standard for BPH tx
pros = high likelihood of objective and subjective sx improvement
cons: complications such as incontinence and retrograde ejaculation

2. Green light laser
Pro: less bleeding
Con: don't get tissue for pathology

3. TUNA: transurethral Needle Ablation
cons: takes 6 wks to see benefit


What is gold standard surg tx for BPH

transurethral resection of the prostate (TURP)
*complications: retrograde ejaculation, incontinence


What are pros/cons of green light laser surg tx for BPH

pro: less bleeding
con: no tissue for pathology


How is TUNA (transurethral Needle Ablation) surg tx for BPH performed

TUNA = Place interstitial radiofrequency (RF) needles through the urethra and into the lateral lobes of the prostate, causing heat-induced coagulation necrosis. A coagulation defect is created
*takes 2 wk to see benefit


what is the prognosis for BPH

excellent depending on severity and tx; w/ appropriate tx, BPH patients have normal life


In primary care, how should you approach BPH pts

they CAN be treated in primary care
*if urinary retention, send to urology for further eval
*hospital f/u for urinary retention; make sure on alpha blocker


What types of prostatitis are there (4 different)

1. acute bacterial prostatitis
2. chronic bacterial prostatitis
3. chronic prostatitis w/o infection
4. symptomatic inflammatory prostatitis


what are s/sx associated with prostatits

*dysuria, urgency, frequency, weak stream
*perineal pain
*suprapubic pain
*testicle/scrotal pain
*fever, chills (if acute bacterial)
(pt may have any or all of these sx)


pt presents with ED, testicular pain, dysuria, weak stream, suprapubic and perineal pain, fever and chills... what could this potentially be

acute bacterial prostatitis


What is Acute Bacterial Prostatitis and what causes it

Acute bacterial prostatitis = infection of prostate *often caused by the same bacteria that cause bladder infections (E. coli, Klebsiella, Proteus
*can be acquired as an STD (chlamydia, GC)
*infection can spread to prostate through blood stream


What are some risk factors for Acute Bacterial Porstatitis

anything that sllows bacterial colonization or infection of the prostate with potentially pathogenic bacteria:
1. phimosis
2. Unprotected penetrative anal rectal intercourse
3. UTI
4. Acute epididymitis
5. Indwelling urethral catheters and condom catheter drainage
6. Transurethral surgery


how should you treat acute prostatitis

*if STD: Ceftriaxone (Rocephin) 250 mg IM + Doxycycline 100 mg BID x 10 d
- the ceph for GC and tetracycline for chlamydia
*Cipro 500 mg BID or Levaquin 500 mg qd
*may need a blocker to assist with urination
*supportive care


What is chronic bacterial prostatitis and what sx are associated

Chronic bacterial prostatitis: uncommon illness with ongoing bacterial infection in the prostate.
*generally no sz, occasionally low grade fever/infection


What is chronic prostatitis w/o infection. Sx?

aka CHRONIC PELVIC PAIN SYNDROME = condition of recurrent pelvic, testicle or rectal pain w/o evidence of bladder infection
*sx: painful urination or ejaculation, ED


what is the etiology of chronic prostatitis w/o infection and what sx are present

Cause/etiology of chronic prostatitis w/o infection are NOT UNDERSTOOD
sx: recurrent pelvic, testicle or rectal pain w/o evidence of bladder infection


what tx recommendations are there for prostatitis beyond meds

sit in warm tub of water
avoid bladder irritants (ie anything acidic or spicy)
avoid sitting
timed voiding
frequent ejaculation


What is the prevalence of prostate cancer in men

*incidence does not match prevalence as ~40% of men at autopsy have prostate cancer


what PE, lab findings, s/sx might you find in a man with prostate cancer

*DRE: focal nodules or induration (usually asymp)
*20% have wt loss or bone pain
*PSA elevation (may need bone scan - main sz is mets to sacral or low back.. complain of low back pain)


What are tx options for prostate cancer

watchful waiting
Radical prostatectomy, radiation
possibly androgen deprivation (bc androgens stimulate prostate growth)


what is urinary incontinence and how is it classified?

urine leaks involuntarily.. classified as
1. Urge incontinence
2. Total Incontinence
3. Stress Incontinence
4. Overflow Incontinence


What is urge incontinence

URGE = uncontrolled loss of urine preceded by strong unexpected urge to void (ie pregnant women , neuro abnormalities, or men with bph)


what is total incontinence

TOTAL = pt loses all urine all the time (stroke pt or pt with nerve loss)


What is stress incontinence

STRESS = loss of urine associated with increased intra-abdominal pressure (cough, sneeze or exercise)
*no leaking in supine position; cause = weakness in musculature of the pelvic floor (multiparous women, pelvic surg pt)


What is overflow incontinence

results from chronically distended bladder additional urine; intravesical pressure > outlet pressure = pt dribbles


What is the most important in evaluation urinary incontinence?

HISTORY! this is the most important step
PE is important to exclude Neuro abnormalities (urge), distended bladder (overflow) and rectal exam (stress/total - ie due to decreased rectal tone)


What dx studies are important in a workup for a pt with incontinence

*UA and cultures: exclude UTI
*Post void US or cath: determine if Residual Urine
*cystoscopy to eval bladder anatomy

*pt with severe incontinence may require further urodynamic studies


how do you treat a pt with URGE incontinence

URGE type: may respond to antimuscarinics aka cholinergics
- Vesicare, Detrol, Sanctura
- caution with narrow angle glaucoma and in men
- tell pt to avoid dietary irritants to bladder
- SE: dry mouth, constipation


How do you treat a pt with stress incontinence

STRESS type: usually surg tx; try kegel exercises


What is the outlook like for pt with incontinence

depends on type and severity


What are important things to be aware of regarding bladder cancer

Bladder cancer is 2nd most common Urologic CA
*M:W = 7:1
*risk factors: SMOKING, exposures to DYES and SOLVENTS (account for 75% newly dx cases)


What are typical clinical findings associated with Bladder cancer

*HEMATURIA (gross or micro, chronic or intermittent) is presenting sz in 85-90% of pt with bladder cancer

*Freq/urgency in small % pt due to size/location of cancer

*hepatomegaly or supraclavicular LAD if mets
*LE LAD due to locally advanced cancers


What are dx findings consistent with bladder CA

UA: gross or micro hematuria
*Anemia: due to chronic blood loss or mets to bone marrow

Urine Cytology: useful in detecting cancer at time of initial presentation

CT urogram: checks upper tracts ie Bladder cancer

Cystoscopy and TURP: for dx and staging of cancer


DDx bladder cancer.. hematuria

bc hematuria is most common sign of cancer...
stones, hematological disorders, infection or trauma


how do you treat bladder cancer

Intravesical chemo, surg, radiotherapy, gen chemo, or combination of any of these


what is the prognosis for pt with bladder cancer

depends on tx and extent of cancer


How should we approach hematuria in the primary care setting?

Blood in urine = NOT NORMAL (even if pt on coumadin)
*workup with CT urogram to check kidney function and urine cytology
*refer to urology for cystoscopy