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Flashcards in Prostate Deck (37):
1

acute bacterial prostatitis -risk factors

young men (20-30)
sexually active (unprotected anal intercourse)
prior Abx use
dehydration
trauma (bike riding and catheritization)

2

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

3

acute bacterial prostatitis- PE

DRE (gentle!)
prostate will be acutely tender, warm, firm and swollen
postate massage is C/I (can spread infx!)

4

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

5

chronic bacterial prostatitis- SSX

Recurrent UTIs
Fatigue
Chronic pain (perineal, lower abdominal, testicular, penile)
Sexual dysfunction, ejaculatory pain
 Milky urethral d/c

6

chronic bacterial prostatitis- PE

DRE – moderate tenderness, boggy, enlarged, soft prostate

7

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

8

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

9

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

10

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

11

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

12

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

13

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!)

14

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

15

BPH- pathology

Cells in the transition zone undergo hyperplasia, (not hypertrophy) from stimulation by DHT and E; not malignant, no mets

16

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

17

BPH- PE

smooth, firm, rubbery, NT enlargement, no nodules,
If Indurated incr suspicion of CaP (PSA, TRUS, Bx)

18

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

19

BPH- Tx

watchful waiting
Alpha blockers
Avoid anticholinergics
5-alpha reductase inhibitors
Surgical
Avoid food triggers
Botanicals like Serenoa and Urtica
Soy

20

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)

21

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

22

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

23

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)

24

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 bone mets) 
A total PSA of >10 ng/ml – often associated with bone mets

25

CaP- Naturopathic tx

1. Panax ginseng, dong qua (angelica), and Berberis aquifolium.
2. Antioxidants will reduce adverse effects
3. Melatonin and PSK (Tametes versicolor = turkey tails) helpful in combo with ablation therapy and with chemotherapy
4. Ginger, pyridoxine, L-glutamine and acupuncture help reduce nausea and vomiting
5. CoQ10 reduces ill effects of chemotherapy on the heart
6. Diet: low fat, broccoli, lycopene-rich foods (tomato, watermelon, strawberry), Dean Ornish study: vegan diet
7.. Selenium 200-400 micrograms/d, Vitamin D, Vitamin E  seen as Increasing risk of CaP!  (SELECT trial using synthetic E)
Honey for radiation therapy skin healing
    Connective tissue support post-surgical
      3. Botanicals
    Crinum latifolium (Sold as Crila®) shows promise in prostate anti-tumor effects. Used in 
                         Vietnam        Sci Pharm. 2011 Jun;79(2):323-35
                    Green tea: anti-prostate cancer activity in vitro
      Immunomodulating botanicals
      Serenoa repens
                    Pomegranate  230 ml juice/d
      Modified Citrus Pectin to reduce mets for surgery
         4. Mind-Body Medicine
                    Support groups
      Stress management technique of choice
         5. Hydrotherapy
      Constitutional hydro
                     Sitz bath
         6. Constitutional homeopathy

26

Angiokeratomas

benign vascular ectasias (dilated capillaries and venules) commonly on scrotum and penis
benign cosmetic

27

hydrocele

1. non-tender fluid-filled sac located on the anterior/inferior surface of the testicle, enlarges 
2. A very large hydrocele may not always transilluminate 
Diagnosis – ultrasound
Treatment—surgical removal only if uncomfortable; Consider Apis, Sil, Graph, Puls 

28

spermatocele

1. Small, painless mass on the superior, posterior pole of the testicle (on vas deferens), may follow epididymitis.
2. Contains dead spermatozoa
Diagnosis-- ultrasound or aspiration.
Treatment Considerations
a. Ignore if small without symptoms
b. Aspiration vs. surgical removal
c. Consider homeopathic Ruta, castor oil packs, and
calc fluor cell salts

29

varicocele

Due to gravity’s downward pull on venous valves as a result of upright posture, valve incompetence leads to dilatation of pampiform plexus
1. A “bag or worms”  located along spermatic cord, may extend below testicles, 80% on left side, worsens with valsalva maneuver and with standing
2. Appearance of a new varicocele or worsening of an old
Diagnosis – angiography most reliable
Sequellae—Infertility 80%, Low semen count and motility
Treatment Considerations
1. ligation or sclerotherapy. Radiologic embolization
2. Naturopathic therapy of a mild varicocele: oral aesculus, collinsonia, achillea.

30

Epididymitis/orchitis

Acute –the result of an ascending LUT infection, GC or chlamydia
Chronic – symptoms similar to chronic prostatitis – w/ or w/o infection
Risk factors: sexually active, sexual abuse; infrequent urination; urinary tract malformation
SSX: Painful, swollen epididymis; overlying skin may look like peau d’orange; mb fever
Diagnosis: elevating the testes will RELIEVE the pain

31

Testicular torsion

Severe scrotal pain after an episode of trauma or during intensive exercise; or spontaneous in sleep.
Common age range 10-25 yo
Most boys who develop torsion have the variant “bell clapper” anatomy (testicle freely rotates)

32

Testicular torsion- SSX

Acute onset pain, poss N&V
Affected testicle higher, epididymis may be anterior
Pain may radiate to the abdomen “acute abdomen”
Assume torsion until proven otherwise
Swollen, tender, erythematous scrotum: difficult to discern structures
Elevation of the scrotum does NOT relieve pain

33

Testicular torsion- Dx

Color doppler

34

Testicular torsion- Tx

 1. Emergency surgical intervention (de-torsion) to prev testicular necrosis; Blood flow must be restored < 6 hrs to preserve 100% of testicle.  If delayed 24 hrs, preservation drops to 20%
 Do not attempt to manually de-torse the testicle, increases risk!
 2. Use high doses of oral enzymes and flavonoids to help repair tissues
 3. Reperfusion support: ginkgo, curcumin, salvia miltiorrhiza

35

cryptochordism

Failure of the testicles to descend normally into the scrotum in infancy. (most by 3 mos-1 yr)
Most common malformation of the male reproductive tract. Inc risk of torsion and infarction. 
Causes
1. Maternal exposure to environmental toxins (xenoestrogens) esp during 1st trimester
2. Maternal cigarette smoking

36

hypospadias

Urethral opening on ventral surface of penis, develops when fusion of the urethral folds is incomplete
SSX: Found on inspection at birth: abnormal, hooded appearance or ambiguous genitalia, Children: diverted urine and spraying, Chordee (ventral bowing) can cause intercourse problems, Meatus could be stenotic
Inc incidence of cryptorchidism

Dx: Buccal smear and karyotyping to establish genetic sex
Urethroscopy and cystoscopy, excretory urogram

37

epispadias

Failure of midline penile fusion in embryogenesis
Opening on dorsal surface of the glans, penis (penile type), or penopubic type 
Risk factor – family history. Often associated with horseshoe kidney, solitary kidney, hypoplastic kidney or megaureter 
Diagnosis – on inspection at birth and sometimes pre-natal w/ US
Treatment – Surgical closure is usually completed within the first 48 hours after birth 

>>The best naturopathic approach to hypospadias and epispadias is to counsel mothers to avoid exposure to xenoestrogenic chemicals and excessive ingestion of phytoestrogens.