- result of direct inoculation, transrectal prostate bx, or transurethral manipulation (Pseudomonas); mostly d/t E coli
- acutely ill w/ fevers, malaise, myalgia, etc, voiding sxs, pelvic/perineal ache, cloudy urine
- h.o trauma (fall on perineum, bikes, horses)
- DRE shows firm edematous tender prostate
- labs show leukocytosis, pyuria, bacteriuria, high ESR/CRP, high PSA
Prostatitis - enlarged prostate that compresses urethra
dx based on symptoms; blood cultures not needed, UA cultures/stain can guide tx
emprically treated
what two things should you r/o in HIV positive pts w/ acute prostatitis?
salmonella typhi
GC
likely bacterial etiology for prostatitis in person who traveled to SE asia or northern australia
burkholderia pseudomallei
palpable urinary bladder indicates what?
urinary retention
if staph aureaus is cultured from UA, what should you do?
do blood cultures
5 possible complications of acute prostatitis?
bacteremia
epididymitis
chronic prostatitis
prostatic abscess
metastatic infection– endocarditis, spinal/sacroiliac infection
3 main treatments of acute prostatitis? in case of post-prostatic surgery?
- Cipro 500mg BID PO x 6 wks
- Levo 500 mg PO x 6 wks
- TMP-SMX one PO BID x 6 wks
- post-prostatic surgery: IV carbapenem or broad PCN or ceph. if they got prophylactic fluoroquinolones
when treating acute prostatitis, if fever persists and doesn’t tred downward, what should you do?
r/o prostate abscess
what is the condition? how is it treated?
- recurrent UTI in male
- normal DRE or boggy or firm
- E.coli with higher virulence factor & greater biofilm formation than acute
chronic prostatitis
- same as acute but for 12 wks instead
- proliferation of glandular tissue, smooth muscle & connective tissue starting at age 40-45
- LUTS sx: storage/irritative (frequency, urgency, nocturia, incontinence) & voiding sx (weak stream, straining, hesitancy/intermittency)
- nontender, enlarged prostate on DRE
- complications include acute urinary retention, UTI, bladder stone, diverticula, renal or ureter damage
BPH
NOT a risk factor for prostate cancer
what labs & studies should you get for BPH? (4)
- Labs: UA
- sx questionnaire @ each visit (8-19 is moderate BPH)
- post void residual volume (cath or US)- concern if over 250ml
- Uroflometry– documents amount of obstruction
who should get urology referral? (8)
- severe sx
- under 45 yo
- DRE abnormality
- hematuria
- elevated PSA
- dysuria
- incontinence
- retention
1st line tx of BPH
- lifestyle modifications–includes kegels, timed voiding, double voiding
- initial medical tx for BPH w/ improvement seen in days
- causes bladder neck and prostatic urethra smooth muscle relaxation
- SE: hypotension, dizziness (bedtime dosing)
alpha adrenergic blockers–terazosin, tamsulosin, doxazosin
- extended duration 2nd gen single daily dose
- monitor BP when starting; lower incidence if increased titrated dosing
- hypotension worsened w/ PDE5 (except tamsulosin)
what is this condition? how do you prevent it?
- associated w/ cataract operations
- triad: intraoperative miosis (despite preop dilation), iris prolapse & billowing flaccid iris
- intraoperative floppy iris syndrome
- avoid starting alpha blockers (esp tamsulosin) if planned cataract surgery
- this class is great for BPH + ED
- relaxes bladder & prostate smooth muscle fibers by NO/cGMPc signaling or by improving RhoA/Rho-kinase (ROCK) and reducing ANS hyperactivity
- no change in urine flow rates; slight improvement with increased ADRs
- SE: HA, flushing, dyspepsia, congestion, back pain, myalgias, sinusitis
PDE5 inhibitors
not better than alpha blockers
- best for prostates over 35g or over 1.5 on PSA
- prevents progression of BPH but takes months (6-12mo. for max effect) for reduction
- blocks conversion of testosterone to dihydrotestosterone
- efficacious in tx LUTS d/t prostate enlargement
- must take indefinitely to prevent relapse
- SE: PSA suppression, reduced risk of prostate cance by higher level of high grade prostate cancer, sexual dysfunction, teratogenicity if TOUCHED/ingested by female
5-alpha reductase inhibitors– finasteride & dustasteride
with which class must you get baseline PSA before starting the meds? PSA can also tell if tx is working bc levels should decrease
5-ARI
- multiply PSA by 2 if treated more than 3 mo
combo of what two meds is associated w/ higher sx reduction, reduction in progression, retention, renal insufficiency, recurrent UTIs esp for those w/ larger prostates?
finastride + doxazosin
combo of what two drugs showed improved BPH sx and progression esp for those w/ prostate volumes over 30 ml
dutastride + tamsulosin
natural remedy that is a 5-alpha reductase inhibitor and has antiinflammatory effect
saw palmetto (serenoa repens)
natural remedy that contains a beta-sitosterol which helps urine flowrates and sx scores
hypoxis rooperi (south african star grass)
natural remedy with anti-inflammatory effects
pygenum africanum (african plum)
6 indications for transurethral prostate resection
- LUTS
- refractory urinary retention (2+ failed tx)
- recurrent UTI d/t BPH
- recurrent gross hematuria (r/o other etiologies first)
- recurrent bladder stones or calculi– sign of end stage bladder decompensation
- bilateral hydronephrosis w/ renal impairment
