Prostate

Question 1

acute bacterial prostatitis -risk factors

Answer 1

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

Question 2

acute bacterial prostatitis- SSX

Answer 2

sudden onset of fever, chills, myalgia
LUTS- frequency, dysuria, urgency and nocturia
may see inability to void
low back pain/perineal pain/rectal pain

Question 3

acute bacterial prostatitis- PE

Answer 3

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

Question 4

acute bacterial prostatitis- DX

Answer 4

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

Question 5

chronic bacterial prostatitis- SSX

Answer 5

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

Question 6

chronic bacterial prostatitis- PE

Answer 6

DRE – moderate tenderness, boggy, enlarged, soft prostate

Question 7

chronic bacterial prostatitis- DX

Answer 7

May be incidental bacteriuria
Perform post-massage urine C &S, EPS culture, semen culture
>10 leukocytes/HPF
RT-PCR for occult infx

Question 8

chronic bacterial prostatitis- TX

Answer 8

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

Question 9

chronic nonbacterial prostatitis- what is it?

Answer 9

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

Question 10

chronic nonbacterial prostatitis- SSX

Answer 10

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

Question 11

chronic nonbacterial prostatitis- PE

Answer 11

Prostate palpation: mildly tender (variable), boggy, enlarged (rarely)
Assess tenderness of pelvic floor and sidewalls
Also examine for hernia, testicular masses and hemorrhoids

Question 12

chronic nonbacterial prostatitis- DX

Answer 12

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

Question 13

chronic nonbacterial prostatitis- grouped with which other dx?

Answer 13

fibromyalgia, IBS, CFS
Grouped with IC/PBS as UCPPS (Urologic Chronic Pelvic Pain Syndromes)
“biopsychosocial” conditions (need multivector approach!)

Question 14

chronic nonbacterial prostatitis- tx

Answer 14

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

Question 15

BPH- pathology

Answer 15

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

Question 16

BPH- SSX

Answer 16

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

Question 17

BPH- PE

Answer 17

smooth, firm, rubbery, NT enlargement, nonodules,

If Indurated incr suspicion of CaP (PSA, TRUS, Bx)

Question 18

BPH- Dx

Answer 18

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

Question 19

BPH- Tx

Answer 19

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

Question 20

Prostate CA- risk factors

Answer 20

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)

Question 21

CaP- screening

Answer 21

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

Question 22

CaP- SSX

Answer 22

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

Question 23

CaP- DX

Answer 23

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)

Question 24

PSA ranges that should prompt further investigation

Answer 24

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

Question 25

CaP- Naturopathic tx

Answer 25

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

Question 26

Angiokeratomas

Answer 26

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

Question 27

hydrocele

Answer 27

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 

Question 28

spermatocele

Answer 28

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

Question 29

varicocele

Answer 29

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.

Question 30

Epididymitis/orchitis

Answer 30

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

Question 31

Testicular torsion

Answer 31

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)

Question 32

Testicular torsion- SSX

Answer 32

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

Question 33

Testicular torsion- Dx

Answer 33

Color doppler

Question 34

Testicular torsion- Tx

Answer 34

 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

Question 35

cryptochordism

Answer 35

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

Question 36

hypospadias

Answer 36

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

Question 37

epispadias

Answer 37

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.