What is the most common area affected by Benign Prostate Hyperplasia?
Transition
Peri-Urethral
What is the most common site of prostate carcinoma?
Peripherial Prostate Tissue
When palpating the prostate via digital rectal exam, what area of the prostate is being palpated?
Posterior Peripherial region – region commonly associated with cancer
If a 74 year old male presents to the office complaining of increased urinary frequency with a weakened stream over the last several years, what might be the pathologic process of these symptoms?
Constant flow of testosterone–> DHT causes hyperproliferation of the glands and stroma of the prostate in the transition area, eventually obstructing flow
A 76 year old male presents to the office with increased urinary frequency, feeling unable to completely empty his bladder, and frequent nocturia. A PSA is screened to be 30. What should be of most concern?
–Prostate Cancer
Normal PSA – 0-4
BPH PSA –4-10
Cancer Risk –10+
What is the difference between normal histology of BPH and precursory lesion?
BPH – glandular and stromal nodules
HGPIN – larger nucleoli with heterochromatic nuclei
If a 80 year old patient expresses concern in the office after years of experiencing BPH that he may have prostate cancer, does he?
– BPH Does NOT increase risk for prostate cancer
A 28 year old male presents to the ED complaining of lower back and abdominal pain with dysuria and fever over the last week. Upon DRE that patient’s prostate is tender to palpation, what might be the pathology responsible for these symptoms?
Acute Prostatitis from reflux from UTI. - E. Coli - Pseudomonas - Klebsella Most typically experienced by young men and will have a slightly elevated PSA (4-10)
If a 35 year old male presents to the office with dysuria, mild lower abdominal pain, and has a history of several UTIs in the last few years. He states he has had these same symptoms before. Upon microUA he has 12WBC/field view without any bacteria present. What could be the cause?
95% of chronic prostatitis is non-bacterial due to recurrent UTIs and colonization of the prostate
– Chlamydia
– Ureaplasma Urealyticum
– Trichomonas
Influx of lymphocytes between the glands of the prostate, chronic inflammation
A 68 year old male presents to the office experiencing dysuria, abdominal discomfort several weeks after undergoing a TURP procedure. He originally got better after the procedure, but has developed these symptoms when he was symptom free after the procedure? What might the pathologic etiology of his symptoms?
Aggregation of multinucleated histiocytes / Macrophages
– Granulomatous Prostatitis, typically after instrumentation trauma to the prostate.
Additional causes, TB / AIDs patients (without instrumentation)
What are the risk factors for prostate cancer?
- Elevated PSA 10+
- Increased age (50+)
- Family History
- Africa American
What is the difference in histology between a grade 3 and 4 in Gleason Scoring of prostate tissue?
Grade 3 – glands are smaller than normal, loss of double cell layer in the glands. Glands still separated.
Grade 4 – Prominent nucleoli and FUSION of Glands
How do you grade a prostate tissue same that has different patterns within it
You add the number of the most common pattern (5) to the number of the least common pattern (3).
Thus 5+3 Gleason Scoring.
What is distinct about a Grade 5 score on prostate histology?
- No distinct glands can be observed
- Small single cells throughout
- High risk for metastatic spread
A 58 year old African American male presents to the hospital with a left sided hip fracture from a low trauma fall. He does not have any history of osteoporosis or kidney disease. What might be a test that can confirm diagnosis and most likely differential?
Prostate Cancer – Test PSA
- Most common spread of prostate cancer is to the pelvic bones and vertebrae.
- Elevated Alk phosphatase (from bone degradation)
What are the three regions of the urinary tract that are regulated for micturation?
- Detrusor Muscle
- Internal Sphincter
- External Sphincter
What kind of receptors and nerve brings sympathetic innervation to the bladder?
- B3 Receptor = receives innervation to inhibit detrusor
- Alpha-1 Receptor = receives innervation to maintain contraction of the internal sphincter.
Remember: You don’t want to be pee’ing during a sympathetic response.
What does the Pontine Micturition Center do?
Stimulates sympathetic response to maintain bladder control until an appropriate time to relieve.
Subconsciously preventing urination.
Coordination Center between Para/Symp/Conscious
What does the Pelvic parasympathetic function contribute to bladder control?
Activates the detrusor muscle contracting bladder to push out the urine.
How can you increase conscious bladder control?
Kegal Exercises – Pudendal Nerve, carries somatic innervation to the external urinary sphincter.
Can be trained and strengthened with pelvic floor exercises.
What is the micturation reflex and how is it controlled?
As the bladder expands due to fluid level the bladder stretch receptors send feedback to the brain to empty the bladder. This is a constant signal sent by the bladder.
– Micturation Center inhibits this reflex by increasing sympathetic response to bladder, until necessary and releasing the inhibition.
If a patient is having difficulties with urinary incontinence, what could be possible reasons why?
- overactive detrusor (not enough inhibition)
- - urethral sphincter dysfunction (not enough tone)
What is the difference between Stress incontinence and regular urinary incontinence?
Stress incontinence – most closely due to weak sphincters and when there is a stress, such as coughing or sneezing they are unable to hold the urine back.
– Kegels/Pelvic Floor Exercises
What are at risk of developing stress incontinence?
- Many women after vaginal deliveries develop this
- Pelvic floor trauma
- bladder prolapse
- menopause
If a 30 year old female who has had 3 vaginal deliveries is still experiencing stress incontinence over a year after her last delivery, what might be your recommendation?
- Pelvic Floor Exercises
- - Duloxetine (non-FDA approved) - increases neural output strengthening the sympathetic tone/inhibition.
What is the main cause of overactive bladder syndrome?
- urination independent of actively telling the bladder to go
- bladder spasms from parasympathetic input, loss of inhibition my sympathetic tone.
- ** Inflammation caused by UTI – irriate the bladder ***
How might a patient with overactive bladder present?
- Increased urgency/frequency
- Urge incontinence, leaking on the way
- Nocturia
What might be the etiology of the incontinence if a patient who feels as though they don’t empty their bladder completely and occasionally experience episodes of incontinence throughout the day.
Most likely if they do not have any stressers such as coughing, exercising, etc. then most likely Overflow Incontinence. When the bladder is over filled, but since they have difficulty voiding it forces its way out unknowingly .
If a 43 year old female presents to the office complaining of increased frequency and urgency and sometimes she is unable to make it all the way to the bathroom without dripping on herself. Her UA is negative for leukoesterase and nitrites.
Overactive Bladder
- Recommend Kegel Exercises (Pelvic Floor)
- Lower overall fluid intake
Meds
- Oxybutynin / Tolterodine (Anticholinergic)
- Myrbetriq (B3 agonist)
Why would you not want to give a patient an Alpha-1 agonist to help maintain internal sphincter tone?
Alpha-1 also contract blood vessels and will cause hypertension!
When might you give myrbetriq to a patient to help with their bladder regulation?
Alpha-3 Agonist, which selectively targets the receptors in the bladder inhibiting the detrusor muscle, helping with overactive bladder symptoms.
What are the most common causes of urinary retention?
- Too much anticholinergic – preventing stimulation
- Too much alpha-agonists – preventing release
- Too much narcotics – preventing neural outflow
- *Obstruction – BPH/Strictures
When is it most common for patients to experience urinary retention?
After surgery, due to Anticholinergics used for sedation still affecting bladder function after awakening.
What are the classic symptoms of urinary retention?
- -weak stream, difficult to start
- -straining to urinate
- -overflow incontinence without warning
- -hydronephrosis/dilated ureters on US
What could you recommend to a 58 year old man with BPH who has 1-2 episodes of urinary incontinence without warning per month and has 300cc post-void residual in the office?
- Self-cathererization to relieve himself
- Treat UTI – if present (can exacerbate)
- STOP the interfering medications
- TURP, if due to too much obstruction
