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Flashcards in Prostate Disorders Deck (29)
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1
Q

Incidence of BPH increases w/ what? RFs?

A
  • MC benign tumor
  • incidence increases with age:
    8% at 31-40
    50% 51-60
    90% over 80
  • RFs:
    poorly understood
    maybe some genetic predisposition
    maybe some racial factor{s
2
Q

PP of BPH?

A
  • growth begins in periurethral glandular tissue
  • over time, a surgical capsule forms around adenomatous hyperplasia
  • as gland enlarges there is increased resistance to urine flow w/ subsequent bladder muscle hypertrophy
  • eventually emptying won’t complete and w/ each voiding there will be residual urine which predisposes to infection and decreases time until next micturation reflex
  • hyperplastic prostate is highly vascular and predisposed to bleeding which can result in painless hematuria
3
Q

Clinical presentation of BPH?

A

obstructive sxs:

  • hesitancy
  • weak stream
  • decrease caliber of stream
  • incomplete emptying of bladder
  • straining
  • postvoid dribble

irritative sxs:

  • frequency
  • nocturia
  • urgency
  • sometimes UTIs or acute urinary retention may be presenting scenario
  • sxs can wax and wane over short period of time but will gradually progress over many yrs
4
Q

Hx ?s to ask pt about suspected BPH? What can you use?

A
  • critical to ask how much a pt is bothered by sxs
  • Objectively document severity - give pt AUA sx scale to score sxs
  • scores range from 0-35
    0-7: mild
    8-19: moderate
    20-35: severe
    *dx is based almost entirely on hx
5
Q

PE and labs for BPH?

A
  • PE:
    DRE: size and consistency of prostate (size of gland doesn’t necessarily correlate w/ degree of mechanical obstruction
  • consistency should be smooth, firm, elastic enlargement of prostate
  • induration if detected - must alert possibilty of cancer and then further investigation is needed (PSA, US, bx)
  • neuro exam: sphincter tone, reflexes
  • labs: UA - infection, blood?
    creatinine
    PSA (+/-)
6
Q

Imaging for suspected BPH? When is imaging indicated?

A
  • PVR
  • renal US (bilateral hydronephrosis- if from BPH)
  • TRUS
  • imaging not std procedure, is recommended only in presence of concomitant urinary tract diseaes, or complications from benign BPH:
    UTIs
    hematuria
    renal insufficiency
    hx of stones
7
Q

Goals of BPH therapy?

A

relieve sxs of:

  • incomplete bladder emptying
  • feelings of urgency to urinate
  • weak urinary stream
  • having to push or strain urinating
  • having to get up mult. times in night to urinate
  • delay further prostate enlargement
8
Q

Meds for BPH?

A
  • Alpha-blockers: cardura, flomax: quick acting, for sx relief
  • 5-ARIs: takes 3-4 months to see effect, reduces prostate size (only effective in larger prostates)
  • anticholinergic agents: reduces irritative voiding sxs (can cuase retention of urine)
  • PDE-5 inhibitors - sx relief and ED
  • herbal - Saw Palmetto
9
Q

Guidelines for tx of BPH?

A

1st line:

  • if sxs mild (AUA score of less than 7): no medical tx is recommended, Watchful waiting!
  • limit fluid b/f bedtime
  • avoid decongestants
  • double void
  • void frequently

2nd line (first line medical):

  • pharm therapy if AUA greater than 7
  • use alpha blocker in pt who is also HTN, 5-ARI if prostate is enlarged to 40 g or more

3rd line: combo - Jalyn (avodart+flomax)

10
Q

Surgical options for BPH? Indications for postatectomy?

A

indications for prostatectomy:

  • refractory acute retention
  • hydronephrosis
  • repeated UTIs due to obstruction
  • recurrent or refractory gross hematuria
  • elevated Cr level that responds to period of bladder decompression w/ catheter drainage
  • TURP: MC surgical procedure for BPH
    complication: retrograde ejac (infertility), classically said to be assoc with incontinence and ED but not confirmed
  • TUIP: better choice for younger guys with smaller prostates, reduces risk for retrograde ejac
  • PVP: transurethral laser surgery - less bleeding
  • simple prostatectomy:
    for large prostates too big for TURP, for pts with BPH and bladder stones, longer stay in hospital and higher chance for blood loss
11
Q

Urinary retention - as complication of BPH - dx and tx?

A
  • can progress over time w/o sxs
  • can be acute and painful
  • dx:
    PVR
    renal US
    Cr level
  • tx:
    med: alpha blocker/5-ARI
    foley cath
    self cath
    SP tube
12
Q

What is acute bacterial prostatitis? Causes?

A
  • swelling and irriation (inflammation or infection) of prostate gland that develops rapidly
  • MC etiologies:
    E. coli**
    enterococci
    klebsiella
    protus mirabilis
    pseudomonas
    staph
  • some STIs can cause this, typically in men younger than 35:
    chlamydia
    gonorrhea
    trichomonas
    ureaplasma urealyticum
  • prostatitis from STI usually comes soon after sexual contact w/ infected partner
13
Q

MC cause of acute bacterial prostatitis in men older than 35? What may this occur after? Other causes of acute bacterial prostatitis?

A
  • E. coli and other bacteria
  • may ocur spontaneously or after:
    epididymitis
    urethritis
    UTI
  • may also develop from problems involving the urethra or prostate:
    bladder outlet obstruction
    cath or cystoscopy
    prostate bx
    trauma
    phimosis
    anal intercourse
    transurethral surgeries
14
Q

Who is at increased risk for acute bacterial prostatitis?

A
  • rare in young boys
  • men 20-35 who have multiple sexual partners are at increased risk, also at high risk are those who engage in anal intercourse, especially w/ using condoms
  • men 50 and older who have enlarged prostate are at increased risk for prostatitis due to their risk of UTI
15
Q

Sxs of acute bacterial prostatitis?

A
  • more likely to start quickly and cause greater discomfort
  • abdominal pain (right above pubic bone)
  • pain and burning with urination
  • fever, chills, flush
  • inability to completely empty bladder (urinary retention)
  • low back pain
  • pain w/ BM
  • painful ejac
  • pain in area b/t genitals and anus (perineal pain)
16
Q

Dx acute bacterial prostatitis?

A
  • good PE: don’t do prostate massage or DRE (could cause sepsis)
  • UA and culture
  • CBC
  • No PSA - will be high from infection
17
Q

Tx of acute bacterial prostatitis?

A
  • abx: bactrim or septra, floxin or cipro, doxycycline - for at least 4 wks
  • shot of ceftriaxone followed by 7 day course of doxy (for men w/ prostatitis caused by STD)
  • hospital stay and IV abx (for severe cases)
  • stool softeners may reduce discomfort that occurs w/ BM
18
Q

What is chronic bacterial prostatitis? Causes?

A
  • may evolve from acute bacterial prostatitis but many men have no hx of acute infection
  • gram - rods are MC cause
  • 1 gram + rod (enterococcus) is assoc. w/ chronic infection
19
Q

How does chronic prostatitis present?

A
  • can present much diff than acute prostatitis
    sxs:
  • frequency, dribbling, loss of stream volume and force, double voiding, hesitancy, and urgency
  • may or may not have pelvic or perineal pain
  • may have intermittent discomfrot in low back and/or testicles
  • may have hematuria, hematospermia, or painful ejaculations
20
Q

PE findings of chronic prostatitis?

A
  • exam reveals enlarged prostate w/ variable amt of asymmetry, bogginess, and tenderness (not typically exquisitely tender like acute prostatitis)
  • pt won’t have fever and chills, doesn’t look ill like in acute prostatitis
21
Q

W/U for chronic prostatitis?

A
  • UA usually normal unless secondary cystitis present
  • analysis of EPS
  • if no secretions can be obtained: pre and post prostate massage urines
  • lab analysis will include gram stain, leuk count, culture and sensitivity
22
Q

Management of chronic prostatitis?

A
  • bacterial:
    bactrim for 2-3 months
    cipro for 4 wks
    can use doxy (esp if chlamydia a concern)
  • EPS should be eval at end of tx period to demonstrate cure
  • nonbacterial:
    doxy (or other abx active against atypicals such as azithro)
  • for both situations - a-blockers (flomax) can help w/ sxs, also NSAIDs, sitz baths
  • TURP is an option when repeated courses of abx and other measures fail
23
Q

How common is nonbacterial prosatitis? Cause?

A
  • MC form of prostatitis
  • cause unknown, speculation about chlamydiae, mycoplasma, ureaplasma and viruses
  • inflammatory or autoimmune
  • presenation is identical to that of chronic w/o any UTI present
  • recureent sx exacerbations termed male chronic pelvic pain syndrome
24
Q

Presenation, labs and tx of nonbacterial prostatitis?

A
  • same presentation as chronic bacterial prostatitis, but no hx of previous infection
  • labs:
    UA is normal, EPS: increased leukocytes
  • tx:
    uncertain of cause tx against mycoplasm, chlamydia, ureaplasma - erythromycin - 4-6 wks
  • sx relief: flomax
25
Q

What is prostatodynia? Presentation?

A
  • noninflammatory disorder of the prostate
  • includes voiding dysfxn and pelvic floor dysfxn
  • presentation:
    sxs similar to chronic prostatitis, no hx of UTI, hesistancy and stop/start of urinary flow
  • PE:
    unremarkable, increased sphincter tone and periprostatic tenderness may be observed
  • this is a dx of exclusion
26
Q

Labs and tx of prostatodynia?

A
- labs:
UA normal
EPS: normal amt of leukocytes
urodynamic studies: normal
- tx:
alpha-blockers
diazepam for pelvic muscle dysfxn
biofeedback/PT
27
Q

What BPH meds decrease serum PSA concentrations? Similarities b/t cancer and BPH?

A
  • 5-ARIs (Proscar)
  • impt b/c PSA levels overlap considerably in men with BPH and prostate cancer
  • enlarged in both BPH and cancer
28
Q

Common complication of TURP therapy?

A
  • retrograde ejac - leading to infertility (don’t recommend to pts that want kids)
29
Q

Hallmark signs of acute prostatitis?

A
  • perineal pain and exquisite tenderness of prostate