Uro- Disorders of the Prostate

What is BPH?

nonmalignant growth of the prostate tissue that leads to lower urinary tract sx; incidence inc w/ age

What are RF for BPH?

DM, diet, genetics, obesity, metabolic syndrome

What is BPH hormonally dependent on?

Testosterone and DHT

What enzyme metabolizes testosterone into DHT?

Type II 5 alpha-reductase

In the pathogenesis of BPH, does DHT work locally or systemically?

Locally

BPH results from an increase in cell (size/numbers)

Numbers

What are the MC presenting sx of BPH?

frequency, urgency, straining to void, dribbling, incomplete bladder emptying, weak urine stream

What causes static obstructive sx?

obstruction d/t enlargement of prostate

What causes dynamic obstructive sx?

obstruction d/t smooth muscle tone

What are irritative sx of BPH?

urgency, frequency, nocturia

*d/t bladder outlet resistance

What are obstructive sx?

hesitancy, weak stream, decreased force, incomplete emptying, straining, post-void dribbling

What is prostatic stroma composed of?

smooth muscle and collagen and is rich in adrenergic nerve supply

What is "Occult BPH" or "subclinical BPH"?

pts are asx or minimal sx

prostate size on DRE does not correlate w/ sx

What is the International prostate symptom score (IPSS)?

score used to identify patients who need therapy and monitoring response to therapy in BPH

IPSS score for mild BPH:

0-7

IPSS score for moderate BPH:

8-19

IPSS score for severe BPH:

20-35

What test is good at evaluating the volume of the prostate for pre-op planning?

transrectal US

alt: abd US

What test provides a good estimate of prostate size, shape, degree of obstruction, and view of the bladder?

*ALWAYS performed prior to surgery

cystoscopy

What test can be used to r/o bladder cancer if pt has irritative bladder sx from BPH?

Cytology

What patients should undergo imaging when diagnosing BPH?

pts with hematuria, urolithiasis, increased Cr, increased PVR, hx of upper UTI

What pts can be monitored rather than starting tx for BPH?

IPSS < 7, mild sx, not experiencing complications, meds will not improve or change quality of life

*f/u x 6-12 months to reassess

What kind of receptors mediate smooth muscle tension in BPH?

Alpha-1 adrenergic receptors

What class of drugs decreases resistance along the bladder neck, prostate, & urethra, thus allowing easier passage of urine in BPH?

Alpha adrenergic blockers

What drugs are selective short acting alpha blockers?

Alfuzosin

What drugs are selective long acting alpha blockers?

Doxazosin, Terazosin, Sildosin, Tamsulosin

What are SE of alpha blockers?

orthostatic hypotension, ejaculation changes, nasal congestion, weakness, floppy iris syndrome

What drugs are 5-alpha-reductase inhibitors?

Finasteride (Proscar), Dutasteride (Avodart)

What medication class can benefit BPH patients with lower urinary tract sx and enlarged prostates?

5-alpha-reductase inhibitors

When using 5-alpha-reductase inhibitors, how long can it take for maximal reduction in prostate volume?

6 months of therapy

What are SE of 5-alpha-reductase inhibitors?

decreased libido, ejaculation changes, ED

Alpha-blocker + 5-alpha-reductase inhibitor combos for BPH

*beneficial for pts w/ prostates > 40g and obstructive sx

Doxazosin + Finasteride

Dutasteride + Tamsulosin

What class of medication mediates smooth relaxation in LUT and is beneficial for pts w/ BPH and ED?

PDE5-inhibitors

Which medications are PDE5-inhibitors?

Tadalafil, Sildenafil

What medication class can be used to treat BPH to control sx of overactive bladder by decreasing Ach effects on smooth muscle?

(especially in combo with alpha blockers)

Antimuscarinics

What antimuscarinic drug can be used for BPH pts w/ overactive bladder sx?

Tolterodine (detrol)

For pts with BPH and ED, which should be treated first? What medication should be used?

Establish Alpha-1 blocker dose before treating the ED

What are supplement options for BPH?

Saw palmetto, African plum, rye pollen, pumpkin seeds

What are non-pharm options for BPH?

avoid fluids 4 hrs before bed, smoking cessation, wt loss, dietary modifications, double voiding

What are absolute indications for surgery to treat BPH?

refractory urinary retention, recurrent UTI, recurrent gross hematuria, vesicular calculi, renal insufficiency

What is the standard for relieving bladder outlet obstruction sx secondary to BPH?

*for pts who fail medical therapy

TURP

What is the TURP procedure?

reduces the size of the prostate by using a cutting loop and coag to produce adequate channel for urine flow

What is the alternative to TURP that comes closest to matching its results in sx relief and improvement in flow rates?

TUIP

What is the TUIP procedure?

limited to creating a channel in the prostatic urethral along w/ an incision of the bladder neck; no prostate tissue removed

*typically done on smaller prostates (<30g)

TUMT or TUNA:

delivers heat via urethral catheter or transrectal route, and heat causes cell death; associated with prostatic swelling, need catheter until swelling subsides

TUMT

TUMT or TUNA:

uses high-frequency radio waves to produce heat, causing thermal injury to the prostate via transurethral device with needles

-not recommended by AUA guidelines for treatment of BPH

TUNA

What is transurethral laser vaporization?

minimally invasive procedure that uses a laser fiber to vaporize rather than cut the prostatic tissue

*inc safety profile, but no tissue available for pathology

What is transurethral electrovaporization?

uses vaporizing electrode to vaporize rather than cut the prostatic tissue

*inc safety, but no tissue for pathology

What is Holmium laser enucleation (HoLEP)?

uses a laser fiber and irrigation fluid to create a vaporization bubble that ablates prostatic tissue

*preferred in prostates > 75-100 g

What is a prostatic stent?

clips are placed into the walls of the prostate to “move” tissue out of way

*good for pts who aren’t surgical candidates

ex: UroLift

What are complications of prostatic stents?

encrustation, pain, incontinence, tissue overgrowth

What is the procedure for tx of BPH when the prostate is too large to remove endoscopically (>75 g)?

open simple prostatectomy

What is prostatitis?

infection or inflammation of the prostate gland that presents as several syndromes with varying clinical features

4 syndromes of prostatitis

- Acute bacterial

- Chronic bacterial

- Chronic prostatitis/chronic pelvic pain syndrome

- Asymptomatic inflammatory prostatitis

What is the MC urologic dx in men < 50 yo?

prostatitis

What organisms usually cause acute bacterial prostatitis?

E.coli -MCC

STIs, enterococcus, staph, klebsiella, enterobacteria, pseudomonas

What are sx of acute bacterial prostatitis?

fever, malaise, myalgia, dysuria, prostate enlargement, difficulty voiding

What is the outpatient tx for acute bacterial prostatitis?

tx empirically 2-4 wks pending culture: Bactrim, FQ, or ampicillin with genatmycin

What is the inpatient tx for acute bacterial prostatitis?

IV Levo or Ceftriaxone

high risk for abx resistance → zosyn; alt → meropenem

What is the tx for STI prostatitis?

chlamydia → Doxy or Azitrho

Neisseria → Ceftriaxone

In addition to abx, what other pharmacologic therapy may help with sx of acute bacterial prostatitis?

Alpha-blockers (Tamsulosin)

*may improve outflow obstruction until inflammation subsides

What is chronic bacterial prostatitis?

chronic/recurrent urogential sx w/ evidence of bacterial infection of the prostate

What organisms may cause chronic bacterial prostatitis?

E. coli, pseudomonas, enterococcus

What would an abn UA in chronic bacterial prostatitis indicate?

secondary cystitis

What is the dx test for chronic bacterial prostatitis?

semen culture (inc leukocytes, lipid-laden macrophages)

What abx can be used for chronic bacterial prostatitis?

Bactrim DS or FQs, 6-12 weeks

What is chronic prostatitis?

recurrent/chronic GU, prostatic, or pelvic pain w/o evidence of UTI

What are sx of chronic prostatitis?

hesitancy, poor flow, frequency; chronic pelvic pain, sexual dysfunction

What is the most reliable test to identify prostatic inflammation?

prostate biopsy

What is the tx for chronic prostatitis?

trial of abx, acupuncture, lifestyle modifications, PT

What is chronic pelvic pain syndrome?

Unexplained chronic pelvic pain in men associated with irritative voiding sx

*dx of exclusion

What are clinical features of chronic pelvic pain syndrome?

unexplainable chronic pelvic pain, absence of pyuria and bacteriuria, no hx of UTI

Chronic pelvic pain syndrome is divided into what 2 categories?

Inflammatory and non-inflammatory

*inflammatory has increased leukocytes

What is the chronic prostatitis symptom index (NIH-CPSI)?

9 questions with 21 items to assess pt history in inflammatory chronic pelvic pain syndrome

How does inflammatory chronic pelvic pain syndrome present?

prostate may feel normal, boggy, or indurated with tight anal sphincter

How does non-inflammatory chronic pelvic pain syndrome present?

physical exam is typically unremarkable, but may see increased anal sphincter tone with periprostatic tenderness