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)
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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
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acute bacterial prostatitis- PE
DRE (gentle!)
prostate will be acutely tender, warm, firm and swollen
postate massage is C/I (can spread infx!)
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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
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chronic bacterial prostatitis- SSX
Recurrent UTIs
Fatigue
Chronic pain (perineal, lower abdominal, testicular, penile)
Sexual dysfunction, ejaculatory pain
Milky urethral d/c
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chronic bacterial prostatitis- PE
DRE – moderate tenderness, boggy, enlarged, soft prostate
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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
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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
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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
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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
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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
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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
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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!)
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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
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BPH- pathology
Cells in the transition zone undergo hyperplasia, (not hypertrophy) from stimulation by DHT and E; not malignant, no mets
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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
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BPH- PE
smooth, firm, rubbery, NT enlargement, no nodules,
If Indurated incr suspicion of CaP (PSA, TRUS, Bx)
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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
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BPH- Tx
watchful waiting
Alpha blockers
Avoid anticholinergics
5-alpha reductase inhibitors
Surgical
Avoid food triggers
Botanicals like Serenoa and Urtica
Soy
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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)
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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
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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
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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)
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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
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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
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Angiokeratomas
benign vascular ectasias (dilated capillaries and venules) commonly on scrotum and penis
benign cosmetic
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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
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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
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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.
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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
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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)
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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
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Testicular torsion- Dx
Color doppler
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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
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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
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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
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