Prostate Flashcards
(37 cards)
acute bacterial prostatitis -risk factors
young men (20-30) sexually active (unprotected anal intercourse) prior Abx use dehydration trauma (bike riding and catheritization)
acute bacterial prostatitis- SSX
sudden onset of fever, chills, myalgia
LUTS- frequency, dysuria, urgency and nocturia
may see inability to void
low back pain/perineal pain/rectal pain
acute bacterial prostatitis- PE
DRE (gentle!)
prostate will be acutely tender, warm, firm and swollen
postate massage is C/I (can spread infx!)
acute bacterial prostatitis- DX
UA- hematuria, pyuria, bacteriuria, and cloudy urine
elevated PSA (although not of clinical value, may confuse with CaP but PSA will return to normal after 14 D of tx)
C & S
chronic bacterial prostatitis- SSX
Recurrent UTIs Fatigue Chronic pain (perineal, lower abdominal, testicular, penile) Sexual dysfunction, ejaculatory pain Milky urethral d/c
chronic bacterial prostatitis- PE
DRE – moderate tenderness, boggy, enlarged, soft prostate
chronic bacterial prostatitis- DX
May be incidental bacteriuria
Perform post-massage urine C &S, EPS culture, semen culture
>10 leukocytes/HPF
RT-PCR for occult infx
chronic bacterial prostatitis- TX
TMP-SMX for 6-12 weeks or fluoroquinolones for 4 weeks Probiotics Prostate massage 1-2x per day Sitz baths Ejaculation min 3x per week Calendula and vit A suppositories
chronic nonbacterial prostatitis- what is it?
Not a discrete entity–used with the following criteria:
1) no objective cause is found to explain symptoms
2) symptoms relate to anatomical area around prostate,
3) refractory to treatment
chronic nonbacterial prostatitis- SSX
Pain in pelvic region >3mos
*disability out of proportion to PE/lab findings!
Dysuria, urgency
Low back/perineal pain referred to tip of penis
Sense of rectal fullness after unsuccessful defecation
Sexual dysfunction, post-ejaculation pain, decreased libido
Possible hemospermia
Fatigue, stress
chronic nonbacterial prostatitis- PE
Prostate palpation: mildly tender (variable), boggy, enlarged (rarely)
Assess tenderness of pelvic floor and sidewalls
Also examine for hernia, testicular masses and hemorrhoids
chronic nonbacterial prostatitis- DX
May see hematuria, PSA <4 (though not indicated to run)
Inflammatory—WBCs present in semen, EPS, VB3
Non-inflammatory—WBCs not present in samples
A urethral swab is indicated to rule out Chlamydia and Gonorrhea
Urine cytology and cystoscopy indicated if hematuria
Consider: TRUS; abdominal CT, Flowmetry, IVP
chronic nonbacterial prostatitis- grouped with which other dx?
fibromyalgia, IBS, CFS
Grouped with IC/PBS as UCPPS (Urologic Chronic Pelvic Pain Syndromes)
“biopsychosocial” conditions (need multivector approach!)
chronic nonbacterial prostatitis- tx
alpha blockers Abx neuromodulating agents (amitryptiline, gabapentin) Cernilton (500mg tid) Quercitin Potassium citrate to alkalinize the urine Biofeedback Acupuncture E-stimulation Myofascial Release Therapy Immunomodulating agents Muscle relaxants Pudendal nerve modulation Prostatic massage Identify and remove food allergens (aggravations by citrus, tomato, coffee, beer, soda) Anti-inflammatory diet Constitutional homeopathy and hydrotherapy (sitz bath) Support groups
BPH- pathology
Cells in the transition zone undergo hyperplasia, (not hypertrophy) from stimulation by DHT and E; not malignant, no mets
BPH- SSX
Early, may be asymptomatic
Obstructive sx: hesitancy, decr force and caliber of stream, sensation of incomplete emptying, double voiding (within 2 hrs), straining to urinate, post-void dribbling
Irritative: urgency, frequency, nocturia
BPH- PE
smooth, firm, rubbery, NT enlargement, nonodules,
If Indurated incr suspicion of CaP (PSA, TRUS, Bx)
BPH- Dx
UA to exclude infection or hematuria; C&S if necessary
Serum BUN and creatinine to assess renal fxn
PSA levels*: wait 2 wks after DRE, as FU to R/O CaP. Can see elevated PSA in BPH, needs to be divided by prostate volume to get accurate impression
Free PSA to assess risk of CaP
Cystology if hematuria and a smoker
Transrectal US
Upper tract imaging (IVP) if concomitant urinary tract dz
Optional: cystometrogram, pressure flow studies, post-void residual urine, uroflowmetry
BPH- Tx
watchful waiting Alpha blockers Avoid anticholinergics 5-alpha reductase inhibitors Surgical Avoid food triggers Botanicals like Serenoa and Urtica Soy
Prostate CA- risk factors
advancing age
African Americans
1st deg relative (prostate or breast CA)
High animal product consumption, alcohol and coffee
Increased androgen exposure (early balding, early age shaving)
CaP- screening
No longer screen men >75 year
Screen every 4 years
Screening age with average risk: 50yo
Earlier screening (age 40-45) highly encouraged in populations with a higher disease prevalence & higher mortality rates:
1. African American men
2. Men with significant FHx (CaP in relatives younger
than age 65)
3. Men with BRCA1 or 2 mutations
Screening= measuring PSA leves, DRE no longer recommended as a screening tool due to the higher incidence of CaP around the urethra and not on the periphery of the gland where it would be palpable
CaP- SSX
Usu asymptomatic early then poss dysuria, difficulty voiding, frequency, urinary retention, low back or flank pain, hematuria, persistent wt loss (>10 lbs) (suggest locally advanced)
Sexual dysfunction: difficulty achieving ejaculation, painful ejaculation
Obstructive or irritative sx may suggest tumor growth into the urethra or bladder neck, or direct extension
Mets to bones causes pain and/or cord compressions➔ paresthesia, weakness, urinary or fecal incontinence
DRE: induration of prostate (F/U with PSA, TRUS, Bx)
Single, discrete firm/hard nodule suggests CaP (ONLY POST. PALPABLE)
Diffuse enlargement of median bar: BPH
Painful: suggests prostatitis
CaP- DX
PSA (not very specific as many things can raise levels such as DRE, BPH, recent ejaculation, etc)
Azotemia
Prostate BX
TRUS (measures prostate density and size)
Axial CT/MRI
RT-PCR (to measure prostate cells circulating)
PSA ranges that should prompt further investigation
PSA >7ng/mL should be referred to urologist
Levels between 4-7 ng/mL repeat in several weeks, if persists >4 ng/ml, refer
With PSA 4-10 ng/mL likelihood of CaP is 25%; >10 ng/mL likelihood of CaP is >50%
Mild total PSA level (under 10 ng/mL) less likely aggressive CaP (0.5% risk of bonemets)
A total PSA of >10 ng/ml – often associated with bone mets