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
What is prostatodynia? Presentation?
- 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
Labs and tx of prostatodynia?
```
- labs:
UA normal
EPS: normal amt of leukocytes
urodynamic studies: normal
- tx:
alpha-blockers
diazepam for pelvic muscle dysfxn
biofeedback/PT
```
27
What BPH meds decrease serum PSA concentrations? Similarities b/t cancer and BPH?
- 5-ARIs (Proscar)
- impt b/c PSA levels overlap considerably in men with BPH and prostate cancer
- enlarged in both BPH and cancer
28
Common complication of TURP therapy?
- retrograde ejac - leading to infertility (don't recommend to pts that want kids)
29
Hallmark signs of acute prostatitis?
- perineal pain and exquisite tenderness of prostate
