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Flashcards in Disorders of the Prostate Deck (40)
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1

1. What is the most common benign tumor?

2. Incidence increases with age. How so?

3. Risk factors? 2

1. Benign Prostatic Hyperplasia

2. Incidence increases with age
8% - age 31-40
50% - age 51-60
90% - men over 80 years old

3. Risk factors
Poorly understood
-Maybe some genetic predisposition
-Maybe some racial factors

2

Benign Prostatic Hyperplasia
Pathophysiology
1. Growth begins in the what?

2. Over time, a “what” forms around the adenomatous hyperplasia?

3. As gland enlarges, there is INCREASED resistance to what?

4. Eventually, emptying will not be complete and with each voiding there will be residual urine which predisposes to what? 2

5. Hyperplastic prostate is highly vascular and predisposed to bleeding which can result in what?

1. periurethal glandular tissue.

2. surgical capsule

3. urine flow with subsequent bladder muscle hypertrophy.

4.
-infection and
-decreases time until next micturation reflex.

5. painless hematuria.

3

Benign Prostatic Hyperplasia
Clinical Presentation:
1. Obstructive symptoms? 6

2. Irritative symptoms? 3



3. What may be the presenting scenario?

1.
-Hesitancy
-Weak stream
-Decrease caliber of stream
-Incomplete emptying of the bladder
-Straining
-Postvoid dribble

2.
-Frequency
-Nocturia
-Urgency

3. Sometimes UTI or acute urinary retention

4

Benign Prostatic Hyperplasia
Hx?
1. It is critical to assess what?

Many men do not like to talk about these kinds of symptoms, much less complain about them.

1. It is critical to assess how much a patient is bothered by his symptoms
--More often than not, these symptoms will not be why the patient has come to you!

5

Benign Prostatic Hyperplasia
1. More important than documenting the size is what?

AUA Symptom Score
Scores range from 0 – 35
2. Mild: ?
3. Moderate: ?
4. Severe: ?


**Notice that the diagnosis is based almost entirely on history!

1. objectively documenting the severity.

2. 0-7
3. 8-19
4. 20-35

6

Benign Prostatic Hyperplasia
1. DRE: What are we looking for?

2. What should we check for in the neuro exam? 2

3. Which labs? 3

1. Size and consistency of prostate should be noted
***Size of the gland doesn’t necessarily correlate with the degree of mechanical obstruction

2. Neurological exam
-Sphincter tone
-Reflexes

3. Labs
-Always get a urinalysis! (why?)
-Creatinine
-PSA (+/-)

7

1. Consistancy of the Prostate should be what?

2. Induration if detected, should alert the possibility of what?

1. Consistency should be smooth, firm, elastic enlargement of the prostate

2. Induration, if detected, must alert the possibility of
-cancer, then further investigation is needed, (i.e PSA, Ultrasound, biopsy)

8

Benign Prostatic Hyperplasia
Imaging? 3

Imaging not standard procedure, is recommended only in the presence of concomitant urinary tract disease, or complications from benign prostatic hyperplasia?
4

Imaging
1. PVR
2. Renal ultrasound
3. TRUS

Imaging not standard procedure, is recommended only in the presence of concomitant urinary tract disease, or complications from benign prostatic hyperplasia
1. UTI’s
2. Hematuria
3. Renal Insufficiency
4. History of stones.

9

Benign Prostatic Hyperplasia (BPH)
Goals of therapy: Relieve Symptoms of what?
5


Delay further prostate enlargement also

Relieve symptoms of
1. incomplete bladder emptying,
2. feelings of urgency to urinate,
3. weak urinary stream,
4. having to push or strain to start urinating and
5. having to get up multiple times in the night to urinate.

10

BPH Management
Medications? 5

Medications:
1. Alpha-1 adrenergic antagonists (alpha-blockers)
2. 5-alpha-reductase inhibitors
3. Anticholinergic agents
4. Phosphodiesterase-5 (PDE-5) inhibitors
5. Herbal

11

Benign Prostatic Hyperplasia
Medical Options for treatment:
5

1. α-blockers


2. 5-α-Reductase inhibitors


3. Anticholinergics

4. PDE-5 inhibitors


5. Alternative Therapies


12

α-blockers
1. Primarily for what?

5-α-Reductase inhibitors
2. Works how?

Anticholinergics
3. Works how?

PDE-5 inhibitors
4. Helps with what things? 2


5. Alternative Therapies? 1

1. Primarily for symptomatic relief

2. Reduces prostate size (efficacy restricted to patients with larger prostates)

3. Reduces irritative voiding symptoms

4. Symptomatic relief and ED

5. Saw Palmetto

13

Benign Prostatic Hyperplasia
1. First line? 4

2. Second line (first line medical)? 2

3. Third line?

1. First line
If symptoms are mild (AUA score less than 7), no medical treatment is recommended. Watchful waiting!!
-Limit fluid before bedtime
-Avoid decongestants
-Double void
-Void frequently

2. Second line (First line medical)
Pharm therapy if AUA is >7
-Use alpha blocker in patient who is also hypertensive
-5-alpha-reductase inhibitor if prostate is enlarged to 40g or more.

3. Third line
-Combination therapy

14

Benign Prostatic Hyperplasia
Surgical Options:
Indications for prostatectomy include?
5

-Refractory acute retention
-Hydronephrosis
-Repeated UTIs due to obstruction
-Recurrent or refractory gross hematuria
-Elevated Cr level that responds to a period of bladder decompression with catheter drainage

15

What is the most common procedure for BPH?

Transurethral Resection of the Prostatectomy (TURP)

16

Transurethral Resection of the Prostatectomy (TURP)
Has classically been associated with what? 2

Has classically been said to be associated with
-incontinence and
-erectile dysfunction;

however, recent research comparing TURP patients with watchful waiting showed same incidences

17

Benign Prostatic Hyperplasia
1. Perhaps better choice for younger men with smaller prostates; reduces risk for retrograde ejaculation and subsequent infertility?

Transurethral Laser surgery (PVP)
2. Less what?

3. Simple Prostatectomy
Used for what? 2

4. Disadvantages? 2

Note: ***Operations for BPH leave a small amount of residual prostate tissue, risk for future malignancy is the same

1. Transurethral Incision of the Prostate (TUIP)

2. Less bleeding
-Long term follow-up comparative data not yet available

3.
-For large prostates to big for TURP
-Patients with BPH and bladder stones

4. Longer stay in hospital and higher chance of blood loss

18

Benign Prostatic Hyperplasia
Urinary retention:
1. Ways that it can present? 2

2. Dx? 3

3. Tx? 4

1.
-Can progress over time without symptoms
-Can be acute and painful

2. Diagnosis
-PVR
-Renal ultrasound
-Cr level

3. Treatment
-Medication (Alpha-blocker/5 alpha-reductase inhibitor)
-Foley catheterization
-Self cath
-SP tube

19

Acute Bacterial Prostatitis
1. What is it?
2. Any bacteria that can cause a UTI can cause acute bacterial prostatitis, including?6

1. Swelling and irritation (inflammation or infection) of the prostate gland that develops rapidly.

2. Any bacteria that can cause a UTI can cause acute bacterial prostatitis, including:
-E-coli
-Enterococci
-Klebsiella
-Protus mirabilis
-Psuedomonas
-Staph

20

Acute Bacterial Prostatitis
1. Some sexually transmitted infections can cause acute prostatitis, typically in men younger than age 35. These STI’s include? 4

2. Prostatitis from an STI usually comes when after sexual contact with infected partner?

1.
-Chlamydia
-Gonorrhea
-Trichomonas
-Ureaplasma urealyticum

2. soon after sexual contact with an infected partner.

21

Acute Bacterial Prostatitis
1. In men older than 35 what typically causes this?

2. E. coli prostatitis may occur spontaneously or after? 3

1. In men older than age 35, E. coli and other common bacteria typically cause prostatitis.

2. E. coli prostatitis may occur spontaneously or after:
-Epididymitis
-Urethritis
-Urinary tract infections

22

Acute prostatitis may also develop from problems involving the urethra or prostate, such as?

7

1. Bladder outlet obstruction
2. Catheterization or cystoscopy
3. Prostate biopsy
4. Trauma
5. Phimosis
6. Anal intercourse
7. Transurethral surgeries

23

Acute Bacterial Prostatitis
Symptoms of acute prostatitis are more likely to start quickly and cause greater discomfort. They may include the following?
8

1. Abdominal pain (usually right above the pubic bone)
2. Pain and burning with urination
3. Fever, chills, flush
4. Inability to completely empty the bladder (urinary retention)
5. Low back pain
6. Pain with bowel movement
7. Painful ejaculation
8. Pain in the area between the genitals and anus (perineal pain)

24

Acute Bacterial Prostatitis
DX?
4

1. Do a good physical exam
Refrain from prostate massage, or even DRE, this could cause sepsis

2. Urinalysis and culture
3. CBC
4. PSA

25

Acute Bacterial Prostatitis
Tx:
1. Abx? 3

2. Abx caused by an STD? 2

3. For severe cases?

4. What may reduce the discomfort that occurs with bowel movements?

1. Antibiotics, most often
-trimethoprim-sulfamethoxazole (Bactrim or Septra),
-fluoroquinolones (Floxin or Cipro),
-tetracycline or a tetracycline derivative such as doxycycline -- for at least 4 weeks

2. A shot of
-ceftriaxone followed by a 7-day course of
-doxycycline (for men with prostatitis caused by an STD)

3. A hospital stay and IV antibiotics (for severe cases)

4. Stool softeners

26

Chronic Bacterial Prostatitis
1. May evolve from what?

2. What is the most common cause?

1. May evolve from acute bacterial prostatitis, but many men have NO history of acute infection.

2. Gram-negative rods are the most common cause

27

Gram-negative rods are the most common cause of chronic bacterial prostatitis execpt for what gram pos?

One gram positive organism (Enterococcus) is associated with chronic infection.

28

Chronic Prostatitis
Can present much differently than acute prostatitis
Symptoms can include?
4

1. Frequency, dribbling, loss of stream volume and force, double voiding, hesitancy, and urgency

2. May or may not have pelvic or perineal pain

3. May have intermittent discomfort in low back and/or testicles

4. May have hematuria, hematospermia, or painful ejaculations

29

Chronic Prostatitis
Examination reveals what?
4

1. enlarged prostate with a
2. variable amount of asymmetry,
3. bogginess, and
4. tenderness (not typically exquisitely tender like acute prostatitis)

30

Chronic Prostatitis
-What is the work-up to classify chronic prostatitis?
4

1. U/A is usually normal unless a secondary cystitis is present.

2. Analysis of Expressed Prostatic Secretions (EPS)

3. If no prostatic secretions can be obtained: Pre- and Post-
Prostate Massage Urines

4. Lab analysis