Prostate Disorders Flashcards
(130 cards)
1
Q
Gross hematuria is always ___ until proven otherwise
A
cancer
2
Q
Irritative voiding symptoms
A
Urgency
Dysuria
Frequency
Nocturia
3
Q
Obstructive voiding symptoms
A
Hesitancy
Dribbling
Decreased force or caliber of stream
Interruption of stream
4
Q
s/s of Incontinence
A
Overflow
Urge
Stress
Total
5
Q
Most common route for Acute Bacterial Prostatitis
A
ascent up urethra
Can occur in setting of cystitis, urethritis
6
Q
risk factors for Acute Bacterial Prostatitis
A
factors predisposing to GU infections
- Catheter, prostate biopsy, urethral stricture
- Anecdotal risks - no strong evidence to support
- Trauma (bike riding, horseback riding)
- Dehydration
- Sexual abstinence
7
Q
MC pathogen for acute bacterial prostatitis
A
G- rods
E. coli - 58-88%, Pseudomonas - 3-7%, Proteus - 3-6%
Other pathogens - G+ bacteria, STDs, etc.
8
Q
Fever, chills, malaise - common
Pain - perineal, sacral, or suprapubic
Irritative voiding s/s
Occasionally obstructive voiding s/s
DRE - Hot, exquisitely tender prostate
these s/s are indicative of what
A
acute bacterial prostatitis
9
Q
what is contraindicated for a DRE?
A
Prostatic massage contraindicated - risk of septicemia
10
Q
lab findings for acute bacterial prostatitis
A
CBC - leukocytosis and left shift
Urinalysis - pyuria, bacteriuria, hematuria
Urine culture - + for causative agent
11
Q
imaging for acute bacterial prostatitis
A
if no response to abx in 24-48 hrs
Pelvic CT or transrectal US to assess for prostatic abscess
12
Q
tx guidelines of acute bacterial prostatitis
A
- All patients should receive Gram stain + C/S
- Adjust according to culture results! - Outpatient - no major comorbidities, no s/s of sepsis, able to take PO abx
- Hospitalize - severe s/s, complicated case (e.g. surgical drainage), suspected bacteremia
13
Q
tx for acute bacterial prostatitis
A
- IV - fluoroquinolone +/- aminoglycoside , or ampicillin/gentamicin
- Nosocomial - IV carbapenem or IV broad-spectrum PCN/cephalosporin +/- aminoglycoside - Oral - TMP-SMZ, Fluoroquinolone (ciprofloxacin, levofloxacin)
- Consider G+ coverage if age <35 or high-risk sexual behavior - Continue for 4 wks
- Monitor UA/UC, rectal exam, inflammatory markers to ensure resolution
14
Q
MC pathogen of chronic bacterial prostatitis? others?
A
G- rods
E. coli - 75-80%
Klebsiella, Enterococcus, Proteus, Pseudomonas
15
Q
MC route of chronic bacterial prostatitis
A
ascent up urethra
May be complication of ABP
Many pts have no hx of acute prostatitis
16
Q
irritative voiding symptoms; may see obstructive voiding s/s
Pain - dull, poorly located, in suprapubic, perineal or low back regions
History of recurrent bacteriuria or UTIs
DRE - often normal
May see boggy (spongy), tender, enlarged, and/or indurated prostate
these s/s are indicative of what dx?
A
chronic bacterial prostatitis
Some are asymptomatic
17
Q
lab findings for chronic bacterial prostatitis
A
- UA - normal unless cystitis also present
- Prostatic secretions - Increased WBCs (>10 per hpf) with + culture
- Lipid-laden macrophages - Urine culture - negative
- + for causative organism after prostatic massage
18
Q
imaigng for chronic bacterial prostatitis
A
not needed
prostatic calculi possible
19
Q
tx for chronic bacterial prostatitis
A
- Fluoroquinolones or TMP-SMZ
- for at least 6 wks
- May continue up to 12 weeks
- SE quinolones - C. diff diarrhea, CNS toxicity, tendinopathy - Supportive - anti-inflammatories, sitz baths
- Difficult to cure - relapses are common
- Require repeat courses of abx
20
Q
Characterized by pelvic pain/discomfort in men, accompanied by urologic symptoms and/or sexual dysfunction
A
Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
21
Q
types of Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
A
- Inflammatory (Nonbacterial Prostatitis - Chronic Prostatitis)
- Non-inflammatory (CPPS - Prostatodynia)
22
Q
MC prostatitis form worldwide? when?
A
Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
Incidence peaks in the 5th decade
23
Q
cause of Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
A
unknown
Believed to likely be noninfectious cause
24
Q
- Irritative voiding or obstructive voiding
- Pain - perineal, lower abdominal, or low back
- Often dull and poorly localized as with CBP
- May have hx of other pain syndromes (e.g. IBS, fibromyalgia) - Less likely to have hx of UTI than in CBP
- DRE - tenderness in 50% of pts
these s/s are indicative of what dx?
A
Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
25
lab findings for Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
1.UA - unremarkable
2. Prostatic Secretions
- increased WBC if inflammatory (chronic/nonbacterial prostatitis)
- normal if noninflammatory
- negative culture
3. Urine culture - negative
26
imaging for Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
mainly to rule out other pathology
e.g., obstruction in pts with obstructive voiding s/s
27
tx for Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
1. Difficult due to unknown cause - varies depending on s/s
2. Newly diagnosed - abx if abx-naive
- **fluoroquinolones, erythromycin**
--- Given for 6 wks
--- May consider d/c after 2 wks if no improvement
3. _Urinary sx - 𝛼-blocker_
- _Tamsulosin/Silodosin/Alfuzosin_ - selective; less SE
- Prazosin, terazosin, doxazosin can be used
- May continue for > 6 weeks if benefit is seen
4. _Adjunct (Meds)_
- _5-𝛼-reductase inhibitors_ - finasteride, dutasteride
- NSAIDs
--- Steroids may help but generally not used due to SE
5. _Adjunct (Nonpharm)_
- Sitz baths - for symptomatic relief
- CAM - acupuncture, cernilton (pollen extract), quercetin (bioflavinoid) may offer some small benefit
- PT - myofascial release, biofeedback
28
MOA of alpha-blockers
block 𝛼-1 receptors in the bladder neck and smooth muscle in the prostate, causing relaxation and increased urethral size
29
what medication is Not recommended for younger men d/t decreased semen volume to tx Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome?
5-𝛼-reductase inhibitors
30
what other sequelae may need to be addressed individually for Nonbacterial Prostatitis/Chronic Pelvic Pain Syndrome
Neuropathic pain
Psychosocial disorders
Pelvic floor muscle dysfunction
Sexual dysfunction
31
MC benign tumor in men
More common with increasing age
BPH
- 8% of men 31-40
- 50% of men 51-60
- Over 80% of men 80+
32
Obstructive voiding s/s present in BPH is MC with
25% of 55-yr-old men
50% of 75-yr-old men
33
risk factors for BPH
1. Some evidence for genetic component
- Black men - more likely to have severe s/s and to need surgery
- Asian men - less likely than black or white men to have BPH
2. Increased risk - higher free PSA levels, prostatitis, heart disease, beta-blocker use, lack of exercise, obesity
3. Decreased risk - NSAIDs, excessive ETOH use, smoking, exercise
34
cause of BPH
multifactorial
- Aging prostate seems to become more sensitive to androgens and growth factors
- Aging prostate may also stop normal cell death
- Testosterone, dihydrotestosterone, and estrogen may be involved in development
35
2 mechanisms of obstruction of BPH
1. Mechanical obstruction - d/t narrowing
- Urethral lumen
- Bladder neck
2. Dynamic obstruction - due to alpha-receptor stimulation
- Causes increased tone (constriction) to prostatic urethra
Prostate size _does not always_ correlate with sx
36
s/s of BPH
1. Obstructive voiding - mechanical blockage
- Urine hesitancy
- Decreased force and caliber of stream
- Sensation of incomplete bladder emptying
- Double voiding (urinating within 2 hours)
- Straining to urinate
- Postvoid dribbling
2. Irritative voiding - urgency, frequency, nocturia
- secondary response of bladder to increased outlet resistance
- Detrusor muscle hypertrophy and hyperplasia, collagen deposition
Usually begin slowly, progress gradually
37
what assesses the severity of BPH sx?
AUA symptom score
38
during a DRE you feel a smooth, firm, symmetric, elastic enlargement of prostate
what could be the possible dx?
BPH
39
Induration or asymmetric enlargement prostate during a DRE is indicative of what
possible cancer
40
Besides a DRE what other physical exams should you do?
Neuro exam - to rule out neurogenic bladder
Lower abdominal exam - to evaluate for distended bladder
41
lab findings of BPH
1. UA - often normal, possible hematuria
2. PSA - may help screen for prostate cancer
- Can be elevated in BPH even when no cancer is present
3. Prostate Bx - usually only done if concern for cancer
- Transrectal or transperineal
42
imaging for BPH?
often not needed
1. US - may be indicated if high serum Cr or UTI
2. _Upper GU tract imaging_ - only if complications arise or comorbid GU disease present
43
pt with BPH has sx scoring a 6, what would be the best next step/management?
**watchful waiting**
1. For mild sx (score 0-7) or pts who do not want tx
- Not all pts will experience s/s progression!
- Up to 50% have spontaneous regression
44
Observation for BPH is NOT ideal if:
Refractory urinary retention
Large bladder diverticula
Recurrent UTI or gross hematuria
Bladder stones
CKD
45
meds for BPH
1. alpha blockers
- 𝞪1-blockade Agents
- 𝞪1a-blockade Agents
5. 5-𝞪-reductase inhibitors
7. Phosphodiesterase-5 inhibitors (PDE 5)
8. Phytotherapy
**alpha blocker + 5-alpha-reductase inhibitor - first-line and superior to either tx alone**
46
3 types of alpha receptors
where are these receptors?
1. 𝞪1a - 70% of adrenoreceptors in prostate, bladder neck
2. 𝞪1b - smooth muscle of vasculature
3. 𝞪1d - prostate, bladder neck, detrusor, sacral spinal cord
47
how selective are alpha blockers?
some are, some not
48
all alpha blockers have roughly the same equal efficacy, but what 2 may be slightly more effective than tamsulosin, but have more SE?
Doxazosin and terazosin
49
Prazosin
𝞪1-blockade Agents
50
Doxazosin
𝞪1-blockade Agents
51
Terazosin
𝞪1-blockade Agents
52
which 𝞪1-blockade Agent needs dose titration?
terazosin
53
Silodosin
𝞪1a-blockade Agents
54
Tamsulosin
𝞪1a-blockade Agents
55
Alfuzosin
𝞪1a-blockade Agents
56
Typical 𝞪1 SE
1. _orthostatic hypotension, dizziness_, tiredness, retrograde ejaculation, rhinitis, and HA
2. _Floppy Iris Syndrome_ - cataract surgery complication in pts taking 𝞪1-blockers
57
DDI with 𝞪1
1. antihypertensives
2. PDE-5 inhibitors - significant hypotension if combined
58
what enzyme converts testosterone to dihydrotestosterone
5-𝞪-reductase
59
result of inhibiting 5-𝞪-reductase?
how long does this take?
- reduces size of prostate gland
- Takes ~6 months of treatment to see full benefit
- Reduces prostate size by ~20% - may reduce need for surgery
60
All 5-𝞪-reductase inhibitors reduce PSA by what %?
50%
Should double PSA value when comparing to pre-treatment PSA
61
finasteride
5-𝞪-reductase inhibitors
62
dutasteride
5-𝞪-reductase inhibitor
63
which 5-𝞪-reductase inhibitor is more efficacious?
dutasteride
64
what is the branded combo of dutasteride and tamsulosin
Jalyn
65
SE of 5-𝞪-reductase inhibitors
Decreased libido, erectile or ejaculatory dysfunction
66
what med is Approved for use in men with BPH + ED sx?
Tadalafil - PDE5
Not superior to alpha-blockers, no extra benefit as adjunct
67
MC agent of phytotherapy
Saw Palmetto
Herbals are approved in Europe to treat BPH
FDA has not approved any phytotherapy for BPH
Conflicting evidence on data
Not recommended as first line treatment
68
types of BPH conventional surgeries
1. Transurethral Resection of the Prostate (TURP)
2. Transurethral Incision of the Prostate (TUIP)
3. Open/Robotic Simple Prostatectomy
69
- Usually require spinal anesthesia and 1-2 day hospital stay
- Resectoscope is used to trim away excess prostate tissue around urethra
what type of surgery
Transurethral Resection of the Prostate (TURP)
- Greater improvement in symptoms and flow rate than minimally invasive procedures
- Longer hospital stay required than minimally invasive procedures
70
risks with TURP
retrograde ejaculation (75%), ED (5-10%), urine incontinence (<1%)
71
complications with TURP
bleeding
urethral stricture
bladder neck contracture
perforation of prostate capsule
Transurethral Resection Syndrome
72
Hypervolemic, hyponatremic state caused by absorption of hypotonic irrigation solution
Not as common now due to newer surgical methods
what is this dx? s/s? tx?
- Transurethral Resection Syndrome
- N/V, confusion, HTN, bradycardia, visual disturbances, seizures, muscle weakness/spasms, coma
- diuresis, hypertonic saline
73
- Pts with mod-severe sx and small prostates often have an “elevated bladder neck”
- Resectoscope is inserted into urethra and 1-2 _small grooves are cut into the bladder neck_, opening the channel and improving urine flow
that is this surgical intervention
- Transurethral Incision of the Prostate (TUIP)
- More rapid and less complications than TURP - Lower rates of retrograde ejaculation (25%)
74
When prostate is too large to remove endoscopically
Suprapubic or retropubic approach
what is this surgical intervention?
Open/Robotic Simple Prostatectomy
75
Open/Robotic Simple Prostatectomy has higher risk of complications and longer recovery, what are the complications?
- Bleeding, UTI, retrograde ejaculation, ED, urinary incontinence, urethral stricture
76
what type of prostatectomy tends to have shorter hospital stays, less blood loss, less need for catheter
Robotic-assisted simple prostatectomies
77
glands how large (g) usually require open prostatectomy?
>100
78
what are the minimally invasive surgery interventions?
1. Laser Therapy - Transurethral laser-induced prostatectomy (TULIP)
2. Transurethral Needle Ablation of the Prostate (TUNA)
3. Transurethral Electrovaporization of the Prostate
5. Hyperthermia
6. Implant to Open Prostatic Urethra
79
which minimal surgical intervention:
- Done under transrectal US guidance
- Visually directed laser surgery also an option
- Prostate tissue is sloughed for up to 3 months
Laser Therapy
80
advantages of Laser Therapy
minimal blood loss
less transurethral resection syndrome
outpatient
can be used in pts on anticoagulants
81
disadvantages of laser therapy
cannot save tissue sample for pathology
longer post-op catheterization
increased irritative voiding s/s
higher cost
82
- Specially designed urethral catheter with radio-frequency needles that penetrate the prostatic urethra
- Radio- frequencies used to heat tissue causing necrosis of prostatic tissue and sloughing
what type of surgical therapy?
Transurethral Needle Ablation of Prostate - TUNA
Similar improvement in symptoms when compared to TURP
83
Resectoscope inserted through urethra
Heat vaporization of prostatic tissue
Usually requires longer to complete than a TURP
what BPH intervention?
Transurethral Electrovaporization of Prostate
84
Transurethral catheter delivers microwaves to heat and damage prostatic tissue
No comparison data for outcomes
what BPH intervention?
hyperthermia
85
- Uses special device to place implants that “hold open” prostatic lobes
- Less risk for morbidity or complications than prostate resection procedures
- May be done outpatient/in clinic, under local anesthesia
- Approved for prostates <80 g
what BPH intervention?
Implant to Open Prostatic Urethra (UroLift)
Minimal impact on erectile or ejaculatory function
86
- Uses special device to deliver steam into prostatic tissue to cause thermal destruction
- Minimal impact on erectile or ejaculatory function
- May be done outpatient/in clinic
what type of BPH intervention?
Water Vapor Thermal Therapy (Rezum)
87
MC non-skin cancer in US men
2nd leading cause of cancer-related death in men
Prostate Cancer
88
risk factors for Prostate Cancer
Black race/ethnicity
+ family hx of prostate cancer
High dietary fat intake
89
when is prostate cancer more evident/MC than clinically evident?
on autopsy
Most of these are small and contained within the prostate
90
most (40%) of 50 y/o US men have what type of prostate cancer?
risk of latent prostate cancer
16% - risk of clinically evident prostate cancer
2.9% - risk of death due to prostate cancer
91
s/s of prostate cancer
1. DRE - May manifest as focal nodules or areas of induration within prostate
- Most cancers have palpably normal prostates
2. Large or locally extensive cancer - obstructive voiding s/s
3. LN metastasis - lower extremity lymphedema
4. Axial skeleton metastasis - back pain, fractures
- MC site of prostatic cancer metastasis
92
lab findings of prostate cancer?
- Elevated PSA - may be sign of cancer
- Elevated BUN/Cr - if urinary retention or obstruction
- Elevated Alk Phos/Hypercalcemia - if bony metastases
93
what is the standard method for detection of prostate cancer
**Transrectal US-guided biopsy**
- May also do transperineal prostate biopsy
Multiple biopsies taken from prostate gland with spring-loaded 18-gauge biopsy needle under local anesthesia
94
imaging for prostate cancer?
1. Transrectal US - staging, guiding bx
2. MRI - evaluation of prostate + LN
3. CT - no used to identify or stage prostate cancer
- Can help detect lymphatic metastases and intra-abdominal metastases
4. Radionuclide Bone Scan - to detect bony metastases
95
staging for prostate cancer?
T1-T4
T1 - Clinically inapparent (not seen on imaging or palpated) - elevated PSA only
T2 - confined within prostate, visible or palpable
T3 - extends through prostate capsule, may invade seminal vesicles
T4 - fixed or invades adjacent structures
96
most prostate cancers are what type of carcinoma?
adenocarcinoma
Usually arise in _periphery_ of prostate
97
prostate cancers are histologically staged how
Gleason system
1 (well-differentiated) - 5 (undifferentiated)
98
tx for a small, well-diff prostate cancer?
surveillance
If life expectancy > 10 yrs - usually should undergo tx
99
what is removed in a Radical Prostatectomy?
prostate, seminal vesicles, ampullae of vas deferens
100
if a pt has local recurrence after a radical prostatectomy, what are you suspicious of?
advanced cancer
101
Radical Prostatectomy is rarely used in what tumor/cancer staging/severity?
stage T4 or (+)LN metastasis
102
risk factors of radical prostatectomy
ED, urinary incontinence, infection
103
f/u for radical prostatectomy pt?
with radiation may improve survival
104
how can radiation therapy for prostate cancer be done?
- by external beam radiotherapy or transperineal implantation of radioisotopes
- +biopsy >18 months after radiation - 20-60%
105
what tx is Primarily used in metastatic disease prostate cancer?
chemotherapy
106
Liquid nitrogen placed in prostate with US guidance
Used for small, localized prostate cancers
+ biopsy rates - 7-23%
what type of prostate cancer intervention?
cryosurgery
107
70-80% of metastatic pts will respond to what type of therapy?
Androgen Deprivation Therapy
108
what are the tx used for Androgen Deprivation Therapy
- LHRH agonists
- LHRH antagonist
- adrenal suppressants
- orchiectomy
109
leuprolide
LHRH agonists
leuprolide is the main one
goserelin, triptorelin, histrelin
110
degarelix
LHRH antagonist
111
which androgen deprivation therapy May be given as depot injection or implant
LHRH agonist
112
SE of LHRH agonist
ED, hot flashes, gynecomastia, may see anemia
113
which androgen deprivation therapy is Given as monthly subcutaneous injection
LHRH antagonist
114
what is not initially seen with LHRH antagonists compared to the agonists
“testosterone flare”
115
SE of LHRH antagonists
ED, hot flashes, weight gain, increased LFTs
116
what are the adrenal suppressants for androgen deprivation therapy
ketoconazole, corticosteroids
117
Survival from prostate cancer depends on differentiation and extent of spread:
- Gleason 1-2 - confined to prostate
- Gleason 4-5 - locally extensive/metastatic
- T1-T2 - 80% of pts; 100% 5-yr survival rate
- T3-T4 (no metastases) - 12% of pts; 100% 5-year survival rate
- T4 with metastases - 4% of pts - 30% 5-year survival rate
--- (Remainder of patients are ungraded)
118
glycoprotein produced only by cells of the prostate gland
Prostate Specific Antigen (PSA)
119
Prostate Specific Antigen (PSA) is produced by what type of cells/
_benign or malignant_
Serum level is typically low
Correlates with the volume of prostate tissue
120
what Can be used to help detect cancer, stage cancer, monitor response to treatment, and detect cancer recurrence
_PSA_
- 20% of pts who undergo prostatectomy for localized cancer have normal PSA
- Rising PSA after treatment for cancer - recurrence
- 98% of pts with metastatic prostate cancer will have elevated PSA
121
lab results with PSA from prostate cancer
_In screening - 10-15% will have elevated PSA_
- Normal - 0-4 mcg/L (0-4 ng/mL)
- Intermediate - 4.1-10 mcg/L (4.1-10 ng/mL)
--- 18-30% will have cancer
--- Usually signifies localized cancer
- High - >10 mcg/L (>10 ng/mL)
--- 50-70% will have cancer
122
a pt with no hx of prostate cancer has a PSA level of 9 mcg/L, what does this say about the volume and stage of disease?
_organ-confined_
- <10 mcg/L
- >40 mcg/L = advanced
- If no history of prostate cancer tx - PSA level correlates with volume and stage of disease
123
Medications influencing PSA levels:
- 5-alpha-reductase inhibitors - reduce by 50%
- NSAIDs or acetaminophen - lower PSA levels
- Statins - reduce PSA by 4.1% per year
- Thiazides - ~26% reduction over 5 yrs
124
Non-cancer causes of elevated PSA:
1. BPH
2. Prostatic inflammation/infection
3. Perineal trauma
- DRE not believed to have impact
- Prostatic massage, biopsy, surgery _do have impact_
--- Recommended to avoid measuring PSA for ~6 weeks
- Vigorous bicycle riding may cause elevations in PSA
- Sexual activity can minimally elevate (0.4-0.5)
125
what measures unbound (free) PSA vs. total PSA levels?
When is this used MC?
Free PSA
Used especially if PSA is intermediate (4.1-10 mcg/L)
126
Lower % of free PSA = ?
_higher likelihood of cancer_
Free PSA <10% - 56% chance of cancer
Free PSA >25% - 8% chance of cancer
127
what measures amount of change in PSA level in serial measurements? what measurement is indicative of cancer?
PSA velocity
> 0.35 mcg/L/yr increase - higher chance of cancer
128
when to and not to screen for prostate cancer?
1. USPSTF -
- Intermediate (grade C) for 55-69
- Against 70+
2. NCCN & EAU - Recommend for 40 and 45, annual screening from ages 50-65 or 75
3. AUA -
- Only screen ages 40-55 if high risk
- Screen ages 55-69 annually
- Do not screen if:
--- 70+
--- life expectancy <10 years
4. NCCN & EAU + AUA:
- Optional baseline DRE and PSA at age 40 (if high-risk)
- If <0.6 and normal DRE, repeat at age 45
129
When to start annual DRE and PSA:
- If abnormal DRE, PSA, + family hx, or black male taking a 5-alpha-reductase inhibitor
- At age 50-55 if normal PSA/DRE findings at age 40 and 45 and no other areas of concern
130
when to dc screening for prostate cancer/PSA
PSA <1.0 at age 65
PSA <3.0 at age 75
Life expectancy < 10 years
