Term
| what are the 2 major neoplasms affecting the prostate? |
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Definition
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Term
| is BPH a precursor of CA? |
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Definition
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Term
| where does most prostate CA arise from? |
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Definition
| the peripheral zone - which makes up most of the prostate |
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Term
| where does BPH arise from? |
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Definition
| the transitional zone which is composed of the periurethral glands (more prone to obstruction) and only makes up 5% of the prostate |
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Term
| where do the seminal vesicles lie in relation to the prostate gland? why is this important? |
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Definition
| above the prostate - prostate CA can invade them, causing greater extension of cancer & affects its staging |
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Term
| what happens to the median sulcus of the prostate as prostate CA progresses? |
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Definition
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Term
| what should an enlarged prostate be referred to until a pathologic dx is made? |
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Definition
| “enlarged prostate, clinically benign” b/c BPH is technically a pathologic dx |
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Term
| when do the first changes towards BPH occur? |
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Definition
| ~35 - but microscopic BPH increases with age in all male populations |
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Term
| how many men develop palpably enlarged prostates and are symptomatic? how many of these men require tx? |
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Definition
| 50% develop symptomatic/palpably enlarged prostates, and 50% of that number require tx (~25% of ALL men will require treatment for symptomatic BPH by age of 80) |
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Term
| what is the pathogenesis of BPH? |
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Definition
| normal growth/function of the prostate is androgen (DHT) dependent, and the hypothalamic-pituitary-testis-prostate axis creates the hormonal milieu which can lead to BPH |
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Term
| what are the symptoms of increasing prostate size and obstruction? |
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Definition
| weak stream, straining, hesitancy, incomplete emptying, dribbling, acute and chronic urinary retention, and irritative symptoms: frequency, urgency, nocturia, and incontinence ("overflow" or paradoxical type). (*irritative symptoms disappear in ~50% of pts after sx) |
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Term
| what is the most important criteria for BPH therapy? |
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Definition
| the symptom and bother score - to determine if medication can be used rather than sx and/or if the pt is willing to live w/benign symptoms. only ~10% actually require procedure. |
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Term
| what are the 7 questions of the international prostate symptom score (IPSS)? how is it used? |
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Definition
| 1) sensation of incomplete emptying 2) frequency (number of times voiding every 2 hrs) 3) intermittency 4) urgency 5) weak stream 6) straining 7) nocturia. |
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Term
| what is the bother score/BPH impact index? |
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Definition
| 1) how much discomfort did urinary problems cause you? 2) how much did you worry about your health? 3) how bothersome has trouble with urination been? 4) how much of the time have you been unable to do the things you usually do? |
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Term
| how are IPSS scores interpreted? |
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Definition
| all questions are graded 1-5 for the past month for a max score of 35. 83% of the population scores 0-7 and less than 10 don't require tx. 8-20: moderate score (can be treated based on bother score) and greater than 20: severe score (requires tx) |
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Term
| what is the pathophysiology of urinary obstruction due to BPH? |
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Definition
| dynamic obstruction: due to contraction of prostatic smooth muscle tone. static obstruction: due to mechanical bulk effect of prostatic adenoma (benign). |
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Term
| are alpha 1 sympathetic receptors found on the prostatic and bladder neck? what does this mean for possible rx tx? |
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Definition
| yes - alpha 1 sympathetic receptors are found on the prostatic and bladder neck and alpha blockers can block them, allowing smooth muscle relaxation and opening of the bladder neck |
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Term
| what are the effects of bladder outlet obstruction? |
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Definition
| increasing post-void residual volumes (bladder hypertrophy -> decompensation of the detrusor -> increased post void volume -> UTI/calculi), bladder trabeculation (corrugated) or diverticula, acute/chronic urinary retention, bilateral ureteral dilation/hydronephrosis, renal parenchymal damage, and azotemia/renal failure |
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Term
| what should be in the ddx for BPH? |
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Definition
| urethral stricture, bladder neck contracture, prostate CA, prostatitis/UTI, bladder neoplasm, and bladder calculus |
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Term
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Definition
| history (symptoms, symptom+bother score), physical exam (DRE, palpate for bladder distention), urinalysis (all pts w/UT symptoms), cystoscopy/ cytology (if hematuria), serum PSA in select pts (all pts over 50, african americans: @ 40 and pts w/fam hx: @ 35), prostatic location studies (some pts), PVR (post-void residual - any pt w/ increased frequency & urgency), urine flowmetry (normal rate of flow: 20cc/s), TRUS guided bx (transrectal US - w/ >PSA or abnormal DRE), CT (hematuria, staging CA), cystourethroscopy (maybe if hematuria), urodynamic evaluation (pressure flow/CMG if irritative symptoms), and DRE (pt stands over table) |
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Term
| what does CA feel like on DRE? |
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Definition
| areas of hardness, induration, nodularity (like knuckle of thumb as opposed to thenar eminence -> BPH) |
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Term
| what are absolute indications for BPH tx? |
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Definition
| symptom score >20, urinary retention due to BPH, upper tract dilation, and renal insufficiency. (high incidence of developing urinary retention with symptom score >20) |
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Term
| what are relative indications for BPH tx? |
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Definition
| symptom score 10-20, recurrent UTI and hematuria |
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Term
| what alpha blockers are used to treat BPH? what % of pts will show improvement w/these? |
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Definition
| terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin which 75% of pts will see improvement with. |
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Term
| what ADRs are associated with alpha blockers? |
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Definition
| dizziness (most common, orthostatic HTN), tachycardia, tiredness, nasal congestion, and retrograde ejaculation. |
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Term
| why might tamsulosin stop ejaculation? which alpha blocker has less of an effect on this? |
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Definition
| b/c bladder neck muscles have to contract for ejaculation. alfuzosin has less of an effect on ejaculation. |
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Term
| what are the 5-alpha-reductase inhibitors prescribed for BPH? efficacy? ADRs? |
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Definition
| finasteride and dutasteride which reduce prostate size by 20% in 49% of pts and/or at least keep gland from further enlargement. minimal ADRs: occasional breast tenderness or slight change in erectile function. |
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Term
| what are the phytotherapeutics? what is their possible MOA? |
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Definition
| serenoa repens (saw palmetto), pygeum africanum (african plum tree), hypoxis rooperi (south african star grass) - may act by inhibition of 5-alpha-reductase, anti-inflammatory, estrogenic, interference with growth factors, antiandrogenic, etc. |
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Term
| can alpha-blockers and 5-alpha-reductase inhibitors be combined? |
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Definition
| yes, this is an appropriate and effective tx for pts. pts can go off the alpha blocker in a year. |
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Term
| what kind of medication is used for overactive bladder symptoms (if present)? |
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Definition
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Term
| what is approaching the gold standard for prostate removal? |
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Definition
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Term
| what are sx treatments available for BPH? |
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Definition
| transurethral resection of prostate (TURP) – *gold standard (prostate removed piece by piece w/o incision), transurethral vapor resection (TVAP), suprapubic prostatectomy (SPP), retropubic prostatectomy (RPP), and transurethral incision of prostate (TUIP) |
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Term
| how many cells are in a 1 cc (palpable) tumor? how many cell divisions does this take? how long does prostate CA take to grow to this size? -don't really need to know this for exam- |
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Definition
| a billion - the result of 30 divisions (40 is 1 L/2.2 K and fatal). prostate CA takes 6-8 years to grow to 1 cc (doubles every ~3 months, a relatively slow rate). -don't really need to know this for exam- |
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Term
| where does prostate CA classically met to? |
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Definition
| regional lymph nodes then bone (*blastic*) |
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Term
| what are the different classifications for prostatitis? |
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Definition
| category I: acute bacterial prostatitis. category II: chronic bacterial prostatitis. category III: chronic pelvic pain syndrome (IIIA inflammatory and IIIB non-inflammatory) category IV: asymptomatic inflammatory prostatitis. |
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Term
| what characterizes acute bacterial prostatitis (category I prostatitis)? |
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Definition
| pt is very ill, often due to e. coli infection (also pseudomonas/enterococcus) usually due to *refluxing infected urine or *retrograde from anterior urethra - but could also be hematogenous or lymphatic. usually the infection produces acute cystitis (urgency/frequency/dysuria), and may progress to abscess. |
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Term
| what are the signs and symptoms of acute bacterial prostatitis (category I prostatitis)? |
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Definition
| fever (mod-high), burning, increased frequency, dysuria, urgency, occasionally hematuria. slowing of the stream, may progress to acute urinary retention. prostate/perineum very tender to palpation. urinalysis: pyuria, bacteruria, hematuria. |
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Term
| how is acute bacterial prostatitis (category I prostatitis) treated? |
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Definition
| usually acute bacterial prostatitis will respond dramatically to antibx (fluoroquinolones PO/IV) but the pt may require hospitalization for IV fluids, bed rest, and pain control. transurethral instrumentation for *urinary retention should be avoided (also avoid DRE: both can produce bacteremia) and trochar cystotomy should be used instead. |
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Term
| what characterizes chronic bacterial prostatitis (category II prostatitis)? |
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Definition
| causative agents typically gram-negative aerobes (same as acute) and route of infection is the same as in acute. symptoms are usually *vague, not severe (ie. low back and perineal discomfort and varying degrees of voiding discomfort). DRE should be done (prostate not likely tender), occasionally urethral discharge is seen. |
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Term
| what is seen on lab work for chronic bacterial prostatitis (category II prostatitis)? |
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Definition
| urinalysis will show likely pyuria and a cx should be performed. prostatic expression will usually show WBCs. |
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Term
| is recurring infection common in acute/chronic bacterial prostatitis (prostatitis category I/II)? |
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Definition
| yes - either acute/chronic bacterial prostatitis may progress to acute epididymitis or and upper UTI |
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Term
| what is tx for chronic bacterial prostatitis (category II prostatitis)? |
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Definition
| long term - antibx for 1-2 mos, possibly combined w/sitz baths and anti-inflammatory drugs. |
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Term
| can a DRE on a chronic bacterial prostatitis pt help hasten resolution? |
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Definition
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Term
| what is another name for chronic pelvic pain syndrome? |
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Definition
| chronic abacterial prostatitis (as referred to in out path lectures) |
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Term
| what characterizes chronic pelvic pain syndrome (prostatitis category IIIA/B)? |
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Definition
| maybe do to autoimmune etiology, a dx of exclusion b/c UTI almost never exists, even though signs and symptoms are similar to bacterial prostatitis. often anxiety/depression is involved. *most common prostatitis* |
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Term
| what characterizes chronic pelvic pain syndrome category III A (inflammatory)? |
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Definition
| WBCs are found in ejaculate/prostatic expressions - *but no organisms can be identified* (oddly, many of these pts will improve w/antibx even though no bacteria are found)* |
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Term
| what characterizes chronic pelvic pain syndrome category III B (non-inflammatory)? |
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Definition
| dx is on *symptoms alone, no positive cx or WBCs |
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Term
| what is tx for chronic pelvic pain syndrome category III A/B? |
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Definition
| antibx: 4-6 wks due to possibility of mycoplasma/chlamydiae/trichamonas/ureaplasmas w/broad spec (flagyl, clindamycin, doxycycline). NSAIDs, muscle relaxants, 5-alpha reductase inhibitor (finasteride), prostatic massage, sitz bath, biofeedback, psychological counseling, and encouragement of normal sexual activity |
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Term
| what characterizes asymptomatic inflammatory prostatitis (category IV prostatitis)? |
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Definition
| no symptoms, but an incidental finding on a path report for something else (increased PSA). usually no tx required. |
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Term
| what happens if chronic bacterial prostatitis or asymptomatic inflammatory prostatitis progresses to a prostatic abscess? |
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Definition
| signs/symptoms may be similar to acute bacterial prostatitis. 70% of abscesses may be due to e. coli and they may require US for dx. fluctuation on DRE may be noted. tx: antibx and perineal/transurethral drainage |
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