Exam 19 - Renal09,10,11 - Prostate, Prostate Cancer, Incontinence

Front 1

lecture 9 – Prostate

Back 1

ok

Front 2

... is a noncancerous enlargement of the prostate gland.

EPIDEMIOLOGY
-An estimated 25% of males >... years old have symptomatic BPH.
-Increased ... and normal ... status are risk factors.
-No racial differences

GENETICS
- First-degree relatives of patients with ... onset BPH have 4X the risk for development of BPH.

Back 2

BPH
50
age
androgen (testosterone)
early

Front 3

The back end of the prostate is made up of tissue called the ... zone. 80% of the time, cancer is at the ... end of the prostate. That’s why the ... is so important. Note induration, nodularity, asymmetry, etc. The DRE is also impt to try and detect cancer or a nodule.

Back 3

peripheral
back
digital rectal exam

Front 4

SIGNS AND SYMPTOMS :

... symptoms
—Hesitancy, weak stream, straining to void, in¬complete bladder emptying, prolonged micturition, acute or recurrent urinary retention

... symptoms
—Urgency, frequency, nocturia, urge incontinence

Back 4

Obstructive
Irritative

Front 5

PATHOPHYSIOLOGY:

BPH develops in the ... transition zone of the prostate. Histologic changes occur as the result of hyperplasia of the stromal nodules. Stimulation of the prostatic smooth muscle leads to increased resistance of the prostatic urethra.
Prostate growth is under the control of ... and its active metabolic .... BPH develops when growth factor production is increased from DHT. Increased resistance leads to detrusor instability and ultimately detrusor decompensation with ... residual urine volumes, ... micturition, and urinary hesitancy.

Back 5

periurethral
testosterone
dihydrotestosterone
larger
decreased

Front 6

CAUSES/RISK FACTORS :

Increasing ... and normal ... states are the only known risk factors.
Cellular proliferation leading to hyperplasia occurs as the result of an imbalance between growth factors inducing excessive cell division and decreased growth factors with reduced apoptosis.

Back 6

age
hormonal

Front 7

HISTORY

Symptoms of voiding dysfunction
-Sensation of incomplete bladder emptying after voiding, urinary frequency, urinary intermittancy, urinary urgency, decreased urinary stream, hesitancy in initiation urination, nocturia —International prostate symptom score sheet: Mild (score <...); moderate (score ...-...); severe (score ... - ...)

Back 7

7
8 - ¬19
20–35

Front 8

PHYSICAL EXAMINATION

Abdomen
--Palpable bladder secondary to retained urine (usually must be >150 mL to be palpable in adults) – not often done now. Ultrasound done more routinely.

... examination
-To determine size, consistency, palpable nodules, and anatomic limit of prostate and to assess anal sphincter tone

Back 8

Digital rectal

Front 9

LABORATORY TESTING:

... by dipstick on microscopic examination of spun specimen to rule out urinary tract infection or hematuria.; serum ... to determine presence of renal insufficiency

Serum ... in combination with digital rectal examination to detect possible carcinoma of the prostate.

Back 9

Urinalysis
creatinine
prostate-specific antigen

Front 10

IMAGING:

Transrectal ... of the prostate for accurate assessment of prostate size in patients with large prostates. (impt to get if going to put them on drugs)

Renal ultrasonograhy if serum creatinine elevated to determine the presence of hydronephrosis

Back 10

ultrasound

Front 11

lecture 10 – prostate cancer

Back 11

ok

Front 12

EPIDEMIOLOGY: prostate cancer

Most common solid tumor in U.S. males

Mean age at diagnosis: ... years, rare <50

Unknown if racial. differences are environmental or genetic or a combination (ask about family history)

High rate of ... unimportant cancer in men over 70; a benign disease but in certain segments of the population, it can be lethal.

Back 12

65
clinically

Front 13

Staging:

typically, spreads locally (prostate gland to local periprostatic tissue to ... lymph nodes) and in more aggressive dz will see spread to distant lymph nodes. One of the most common sites of metastasis is the ... system. Only in end stage disease in pts w/ widely disseminated disease do we see it spread to the lungs and possibly liver.

PSA value – if less than ..., low likelihood of metastatic disease; if greater, typically a bone scan is obtained.

Back 13

pelvic
skeletal
10

Front 14

Staging of PCA:

Traditional. staging system: A, B, C, D; preferred staging is TNM (see also Section VII)
-T1 (A): ..., clinically confined to gland (diagnosis of this stage often made on PSA elevation)
-T2 (B): ..., clinically confined to gland
-T3 (C): palpable, local extension of tumor ... of gland
-T4 (C): palpable fixed local extension
-Tany N1-3 (D1): ... lymph node metastases
-Tany Nany M1 (D2): distant metastatic disease: bone, lung, liver, CNS

Back 14

nonpalpable
palpable
outside
pelvic

Front 15

Pathophysiology:

normal prostate size for 25-30 y/o males is about ...-... grams. Primary fx is to produce fluid or contribute to ejaculate volume (sustains life of sperm in the ejaculate).
Most common form of prostate cancer is ... of the prostate.

Back 15

20-25
adenocarcinoma

Front 16

Prostate produces PSA, a ... secreted into ejaculate, a protease that liquefies seminal fluid; small amount of PSA in serum normally; prostate diseases ... PSA in serum.

Back 16

protein
increase

Front 17

PSA:

-Traditional "normal" up to ... ng/mL too high for young men; many now use 0 to 2.5 ng/mL as normal cut-off.
-Free PSA: "total" PSA (as noted above) is the traditional test; "free" PSA is the proportion of total PSA that is not bound to other proteins in the serum (i.e., free).
- Lower free PSA: ... risk of CaP
-Probability of cancer: based on PSA and %FPSA results

Back 17

4.0
higher

Front 18

SIGNS AND SYMPTOMS

... symptoms in early stage; most cases detected by PSA and/or digital rectal examination (ORE)
-Symptoms of local growth: urinary obstructive or irritative voiding symptoms, occasional impo¬tence, hematuria, hematospermia
Late stage: symptoms of ...: bone pain, low back pain, weight loss, malaise. Very late: spinal cord compression from vertebral metastases

Back 18

No
metastases

Front 19

Monitoring:

... is gold standard. should decline w/ treatment. If PSA rises and pt had surgery, consider giving ...

Back 19

PSA
external beam radiation

Front 20

PSA is gold standard for ... but not for ...

Back 20

monitoring
diagnosis

Front 21

Lecture 11 – incontinence

Back 21

ok

Front 22

... - the complaint of any involuntary loss of urine

Back 22

incontinence

Front 23

... urinary incontinence. The symptom is the complaint of involuntary leakage on exertion or on sneezing or coughing. The sign is the observation of involuntary urinary loss from the urethra synchronous with exertion, sneezing, or coughing.

Back 23

Stress

Front 24

... urinary incontinence. The symptom is the complaint of an involuntary leakage accompanied by or immedi¬ately preceded by urgency. The sign is the observation of involuntary urinary loss from the urethra that is accom¬panied by or immediately preceded by urgency.

Back 24

Urge

Front 25

... urinary incontinence. The complaint of an invol¬untary leakage of urine associated with urgency and also with exertion, effort, sneezing, or coughing.

Back 25

Mixed

Front 26

... incontinence is the complaint of involuntary loss of urine that is unaccompanied by either urge or stress.

Back 26

Unconscious (unaware)

Front 27

... urinary incontinence is the complaint of a continuous leakage.

Back 27

Continuous

Front 28

... is the complaint of a involuntary loss of urine immediately after passing urine.

Back 28

Postmicturition dribble

Front 29

... incontinence is not a symptom or condition but rather a term used to describe leakage of urine associated with urinary retention.

Back 29

Overflow

Front 30

... incontinence is the observation of urine leakage through channels other than the urethra (e.g., fistula or ectopic ureter).

Back 30

Extraurethral

Front 31

Urinary incontinence is more prevalent in ... than in men, making ... itself a risk factor.

Incontinence does show ... prevalence during young adult life (20% to 30%), a broad peak around middle age (30% to 40%), and then a steady increase in elderly women (30% to 50%).

Back 31

women
gender
increasing

Front 32

Urinary incontinence in men is half as prevalent as it is in women. Incontinence in men increases with ... and appears to rise more steadily than it does in women.

Stress incontinence in men is ... unless attributable to prostate surgery, neurologic injury, or trauma.

Back 32

age
rare

Front 33

From a functional and anatomic perspective, it is intuitive to consider the lower urinary tract as a two-part system: the urinary bladder as a ..., and the bladder outlet as a ... mechanism.

During bladder filling at physiologic rates, detrusor pressure remains nearly constant because of a special property of the bladder known as ....

When ... is impaired, low bladder compliance ensues. This is manifest as a steep rise in detrusor pressure during bladder filling .

Back 33

reservoir
sphincteric
accommodation
accommodation

Front 34

Normal storage of urine is dependent on :

... mechanisms that activate sympathetic and somatic pathways to the bladder outlet and

... systems in the brain that suppress parasympathetic excitatory outflow to the bladder.

... stimulation also inhibits the bladder body musculature and transmission in the bladder parasympathetic ganglia.

The ... reflex is normally under voluntary control and is organized in the rostral brain stem (the pontine micturition center).

Back 34

spinal reflex
tonic inhibitory
Sympathetic
micturition

Front 35

... (ISO): Impairment of various intrinsic factors are responsible for the normal coaptation and closure of the urethra. Urethral mucosal seal and inherent closure from collagen, fibroelastic tissue, smooth and striated muscles, etc., may be lost secondary to surgical scarring, radiation, or hormonal and senile changes.

Back 35

Intrinsic sphincter deficiency

Front 36

... incontinence: from urinary retention, usually occurs from lower motor paralytic neurogenic bladder disorders

Back 36

Overflow

Front 37

... incontinence: in epispadias¬exstrophy complex due to absence of bladder neck and urethra. Ectopic ureters in females usually open in the urethra distal to the sphincter urethrae or in the vagina, thereby causing constant leakage.

Back 37

Total urinary

Front 38

... bladder: Multiple reversible and irreversible etiologies that lead to malfunction of one or both normal bladder functions (storage/emptying)

Definitions
-...: insuppressible involuntary bladder contractions during filling (spontaneous or provoked). associated w/ neurological disease
-...: similar syndrome but without definable neurologic disorder
-...: detrusor contraction with an involuntary contraction of the urethral/periurethral striated sphincter

Back 38

Neurogenic
Detrusor hyperreflexia
Unstable detrusor
Detrusor–sphincter dyssynergia