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Lecture 9: Prostate Disorders Flashcards

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1
Q

What is the primary function of the prostate?

A

Production of fluid that mixes with sperm to form semen.

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2
Q

What is gross hematuria always by default?

A

Cancer

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3
Q

What are the irritative voiding symptoms?

A
  • Urgency
  • Dysuria
  • Frequency
  • Nocturia
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4
Q

What are the obstructive voiding symptoms?

A
  • Hesitancy
  • Dribbling
  • Decreased force or caliber of stream
  • Interruption of stream
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5
Q

What are the 4 types of incontinence?

A
  • Overflow
  • Urge
  • Stress
  • Total
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6
Q

What is the MC etiology of acute bacterial prostatitis?

A

G- rods, specifically E. coli

Others include pseudomonas or proteus.

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7
Q

How does acute bacterial prostatitis typically present?

A
  • Fever, chills, malaise
  • Pain - perineal, sacral, or suprapubic
  • Irritative voiding s/s
  • Obstructive voiding s/s (sometimes)
  • DRE will present with a hot, exquisitely tender prostate.

CI: Prostatic massage

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8
Q

How do labs present for acute bacterial prostatitis?

A
  • CBC: leukocytosis w/ left shift
  • UA: pyuria, bacteriuria, hematuria
  • UC: for causative agent
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9
Q

If acute bacterial prostatitis has no response to abx after 24-48 hrs, what should we order?

A

Pelvic CT or transrectal US to r/o abscess.

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10
Q

What are primary abx to use for acute bacterial prostatitis?

A
  • IV: fluroquinolone +/- aminoglycoside, or amp/gent empirically.
  • Oral: Bactrim DS, Cipro/levo.

4 weeks of therapy.

Should consider G+ coverage for younger pts.
Nosocomial will use carbapenems.

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11
Q

How can I differentiate acute from chronic bacterial prostatitis?

A
  • Chronic bacterial prostatitis usually presents with a NORMAL DRE.
  • No fever, chills, or malaise generally.

A hot prostate = acute.

Any other prostate finding is generally more suggestive of chronic.
Normal prostate/cervix = same texture as the tip of your nose.

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12
Q

How do labs for chronic bacterial prostatitis typically present?

A
  • UA: Normal unless cystitis present.
  • Prostatic secretions: Increased WBCs with lipid-laden macrophages.
  • UC: negative, but will be + for causative organism after massage.

Imaging is generally not needed.

If imaging is ordered, calculi may be seen.

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13
Q

What are the two primary abx for chronic bacterial prostatitis?

A
  • Fluoroquinolones
  • Bactrim

6 weeks

May go up to 12 weeks, and may need to repeat.

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14
Q

What are the primary SE a patient should be counseled on regarding fluoroquinolones?

A
  • C. diff diarrhea
  • CNS toxicity
  • Tendinopathy
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15
Q

What is the MC form of pelvic pain syndrome between CPPS and ABP?

A

Chronic/non-bacterial.

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16
Q

What are the S/S of CPPS?

A
  • Irritative voiding or obstructive voiding
  • Pain: perineal, lower abd, low back, often dull and poorly localized.
  • Less likely to have hx of UTI than in CBP
  • DRE: tenderness only in 50%.
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17
Q

How do labs typically present for CPPS?

A
  • UA: normal
  • Prostatic secretions: Increased WBCs = inflammatory (chronic/nonbacterial prostatitis)
  • Normal secretions if non-inflammatory
  • Negative cultures
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18
Q

What is the difference between CPPS and nonbacterial/chronic prostatitis?

A
  • Inflammatory: Non-bacterial/chronic
  • Non-inflammatory: CPPS/prostatodynia
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19
Q

What is the treatment for newly diagnosed CPPS/NBP?

A

If abx-naive:

  • Fluoroquinolones
  • Erythromycin

6 weeks.

d/c after 2 weeks if no improvement.

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20
Q

For the urinary symptoms of CPPS/NBP, what is the first line treatment?

A

Alpha-1 blockers, such as tamsulosin.

Relaxes urethra and makes it bigger.

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21
Q

What are the adjunct therapies for CPPS/NBP?

A
  • 5-alpha-reductase inhibitors (finasteride)
  • NSAIDs
  • Sitz baths
  • CAM
  • PT
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22
Q

Summary of ABP, CBP, NBP, and CPPS

A
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23
Q

What are the primary risk factors for BPH?

A
  • High free PSA
  • Prostatitis
  • Heart disease
  • BB use
  • Lack of exercise/obesity
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24
Q

What are the two ways BPH causes obstruction?

A
  • Mechanical obstruction (narrowing)
  • Dynamic obstruction (constriction due to alpha-receptor stimulation)

Size does not always correlate with symptoms.

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25
How does BPH typically present?
* Very slow onset. * Obstructive voiding * Irritative voiding * DRE: smooth, firm, elastic, symmetric enlargement.
26
What can we use to assess the severity of BPH symptoms?
AUA symptom score
27
What DRE findings of a prostate might suggest cancer?
Induration or asymmetric enlargement.
28
How do labs typically present for BPH?
* UA: normal or hematuria * PSA: can be elevated even if no cancer * Prostate Bx: only if concerned for cancer
29
What findings might prompt us to do an US for BPH?
* High serum Cr * UTI
30
For mildly symptomatic patients with BPH, what is the treatment?
Watchful waiting | Only concerned if they have complications.
31
What are the complications that would make us worried about a patient's BPH?
* Refractory urinary retention * Large bladder diverticula * Recurrent UTIs or gross hematuria * Bladder stones * CKD
32
What are the 3 alpha receptors?
1. a1a = 70% in prostate and bladder neck 2. a1b = smooth muscle of vessels 3. a1d = prostate, bladder, detrusor, sacral spinal
33
What is the consensus regarding selective vs non-selective alpha blockers?
Generally same efficacy. | Doxazosin/terazosin are slightly better, but more SE. ## Footnote Both are NON-selective
34
What are the typical a1 blocker SEs?
1. **ORTHOSTATIC HYPOTENSION** 2. **DIZZINESS** 3. Floppy iris syndrome post cataract surgery
35
What drugs should we not use a1 blockers with generally?
* AntiHTNs * PDE-5 inhibitors (Viagra) | Can bottom out someone's BP very fast.
36
What is the purpose of 5-alpha-reductase inhibitors?
Reducing size of prostate gland by preventing conversion of testosterone to DHT.
37
What are the caveats to using a 5-alpha-reductase inhibitor?
* 6 months to work * Reduces PSA by 50% * May reduce risk of prostate cancer
38
What are the 5-alpha-reductase inhibitors and the main SE?
* Finasteride (cheaper) * Dutasteride (more efficacious) * Jalyn (dutasteride+tamsulosin) * SEs: decreased libido, ED, or ejaculatory dysfunction. | Lower DHT.
39
What is the first-line therapy for BPH?
Combo therapy of an alpha-1 blocker + 5-alpha-reductase inhibitor.
40
What is tadalafil for?
Patients with both BPH and ED. | Not more efficacious
41
What herbal can be used for BPH treatment?
Saw Palmetto | NOT FIRST-LINE, NOT FDA APPROVED
42
What is the most common surgery for BPH?
TURP | Transurethral resection of the prostate (Endoscopically) ## Footnote Generally longer hospital stays than the other procedures.
43
What are the complications and risks of TURPs?
* Risks: retrograde ejaculation, ED, urine incontinence * Complications: Bleeding, urethral stricture, bladder neck contracture, perforation of prostate capsule, TUR syndrome
44
What is transurethral resection syndrome?
* Hypervolemic, hyponatremic state * Caused by absorption of hypotonic irrigation solution * Presents as N/V, confusion, HTN, bradycardia, visual disturbances, muscle weakness/spasms, coma | MC in procedures that take longer than 90 minutes.
45
What is the treatment for TUR syndrome?
Hypertonic saline + diuresis ## Footnote Gettting rid of the hypervolemia and boosting the hyponatremia.
46
What kind of patients is TUIP usually indicated for?
* Mild-mod symptoms * Small prostates with elevated bladder neck | Quicker surgery and less complications.
47
When is open/robotic simple prostatectomy indicated?
* Prostate too big to remove endoscopically * Suprapubic/retropubic approach * High risk of complications and longer recovery. | Usually a gland > 100g
48
What are the benefits/cons of a TULIP procedure? | Transurethral laser-induced prostatectomy
* Pros: minimal blood loss, less TUR syndrome, OP, can use even with anticoags. * Cons: Can't biopsy, higher cost, longer post-op catheterization, 3 months of prostate sloughing.
49
What is a TUNA procedure? | Transurethral needle ablation of prostate
* Radiofrequency needles to penetrate prostate * Heat tissues to cause necrosis
50
What are the other 2 heat related therapies for prostate treatment besides TUNA and TULIP?
* Transurethral electrovaporization of prostate * Hyperthermia (microwaves)
51
What is the one surgery that does not involve damaging the prostate?
* UroLift, which simply holds open the prostate. * Done OP w/ local anesthesia * Only works on glands < 80g
52
What therapy uses steam to damage the prostate?
Water vapor thermal therapy (Rezum) | Minimal impact, with less sloughing.
53
What are the risk factors for prostate cancer?
* Black * FMHx of prostate cancer * High dietary fat intake
54
How does prostate typically feel on DRE?
* Normal (MC finding) * Focal nodules * Induration
55
What is the MC symptom of prostate cancer metastasis?
Lower back pain, implying axial skeleton metastasis.
56
What labs may be elevated in prostate cancer and what do they signify?
* Elevated PSA: cancer * Elevated BUN/Cr: Urinary retention or obstruction * Elevated Alk Phos/hypercalcemia: bony metastases
57
What is the standard method for detecting prostate cancer?
Transrectal US guided biopsy | Need multiple biopsies.
58
What are CT and radionuclide bone scans mainly used for in prostate cancer?
Checking for metastases.
59
How is prostate cancer staged?
* Gleason system (1-5) for differentiation. * Spread is T1-T4 ## Footnote At T2 is when the tumor is visible/palpable.
60
What tissue type are most prostate cancers?
Adenocarcinomas. | Periphery of prostate.
61
When is tx indicated for prostate cancer?
Life expectancy > 10 yrs
62
What is removed in a radical prostatectomy?
* Prostate * Seminal vesicles * Ampullae of vas deferens | Only if NOT T4 or lymph node metastases. ## Footnote Adding radiation post-sx may help as well.
63
For a small prostate tumor, what are the alternatives to radical prostatectomy?
* Radiation therapy using external beam radiotherapy or transperineal implantation of radioisotopes. * Cryosurgery with US guidance
64
What is chemo used for in prostate cancer?
Treating metastases.
65
What is the pharmacological therapy for prostate cancer?
* Androgen deprivation therapy using either LHRH agonists (Leuprolide) or LHRH antagnonists (degarelix). * Adrenal suppressants (ketoconazole, or corticosteroids) * Orchiectomy as well can be done.
66
Whats the main difference between using a LHRH agonist vs a LHRH antagonist?
There is no initial testosterone flare in antagonists.
67
What grades of gleason and spread have the best outcomes for prostate cancer?
* T1-T4 **with no metastases** = 100% 5-year survival. * Gleason 1-2 are usually confined to just the prostate. | 80% of pts are T1-T2.
68
What is PSA and what makes it?
* Glycoprotein made by both benign and malignant prostate cells. * Correlates with prostate tissue size | PSA should normally be LOW.
69
What kind of prostate cancer will potentially show normal PSA?
A highly localized tumor. | If metastasized, it should almost always be high.
70
If a patient presents with a high PSA (> 10mcg/L) what is the likelihood they have prostate cancer?
50-70%
71
What PSA level suggests advanced prostate cancer?
> 40mcg/L | If confined to the prostate, prob < 10 mcg/L
72
What medications can affect PSA levels?
* 5-a-reductase: 50% * NSAIDs or acetaminophen: lowers * Statins: lowers by 4.1% annually * Thiazides: 25% reduction over 5 yrs.
73
What are the NON-cancerous causes of elevated PSA?
* BPH * Prostatic inflammation/infection * Perineal trauma
74
What is free PSA and when is it used?
* Measures unbound vs total. * Used in intermediate (4.1-10 mcg/L) PSA levels. * Lower free PSA < 10% = much higher likelihood of cancer.
75
What PSA velocity is suggestive of cancer?
> 0.35mcg/L/yr
76
At what age should PSA NOT be screened in?
Over 70 is a nono
77
When do we typically start PSA screenings?
55! | 40 if higher risk
78
When do we typically do DREs for prostate cancer?
Once at 40 and 45, unless the high risk factors are present.

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