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36 Cards in this Set
- Front
- Back
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BPH symptoms
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symptoms of difficulty starting his urinary stream, worsening nocturia, and a feeling of incomplete emptying of his bladder. Occassionally, he feels the sudden urge to urinate, but has not had incontinence of urine
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PE with BPH?
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DRE – assess prostate size
Urinalysis – check for WBC, hematuria PSA – baseline and/or rule out cancer Neuro exam – rule out neurogenic bladder US |
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If you taking metformin, you have
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HTN and DM
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Assessing prostate size
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Normal prostate = walnut
Enlarged prostate – described in progressively larger citrus fruits – lime, lemon, orange, grapefruit; more precisely by mL |
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TX for BPH?
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-Alpha blockers
Alpha-1 and alpha-2; alpha-2 concentrates in prostate – more specific and less risk for orthostatic hypotension; still cause dizziness. -5-alpha reductase inhibitors Blocks converstion to DNT, suppressing prostate enlargement. Takes up to 2 mos to see results; Side effects = decreased testosterone |
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Alpha adrenergic blockers in BPH and SE
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-MOA –
Alpha 1a receptors – 70% concentrated in prostate Alpha 1b receptors – common in vasculature Both non-selective and selective alpha blockers decrease symptoms of BPH by relaxing smooth muscle in the bladder neck -Side effects – Postural hypotension – worse with non-selective blockers; a risk esp in elderly. Dizziness |
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Alpha adrenergic blockers
-Uroselective |
Tamsulosin
Alfuzosin |
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Alpha adrenergic blockers
Non-uroselective |
Doxazosin
Terazosin |
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Alpha adrenergic blockers used with other meds?
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Use with PDE-5 inhibitors – caution advised; risk of hypotension by potentiation of smooth muscle relaxation in the vasculature
Tamsulosin 0.4mg daily should not cause increased risk of hypotension |
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5-alpha reductase inhibitors in BPH and SE?
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MOA – reduce size of the prostate by blocking conversion of testosterone to dihydrotestosterone (DHT); takes 6-12 months to work
Works best in men with larger prostate volumes Side Effects – Ejaculatory dysfunction and decreased libido Theoretical risk of bone loss not evident in studies Works best in concert with alpha adrenergic blockers |
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Viagra
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PDE-5 inhibitor
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When would you refer BPH patient to urology for surgical assessment?
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Meds cease to give relief
If younger than 50 Symptoms of urinary retention PSA > 4ng/mL Develops positive exam findings |
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PROSTATIC MASSAGE is CONTRAINDICATED, when?
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ACUTE prostatitis!!
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AP tx for for gonorrhea and chlamydia 33 y/o
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Rocephin and azithromycin or doxycycline
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AP tx for for gonorrhea and chlamydia 55 y/o
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Gram negatives – E. Coli, Proteus Mirabilis, Pseudomonas Aeruginosa
Trimethoprim/sulfamethoxazole or fluoroquinolones |
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How long do you TX? Acute prostatitis
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4-6 weeks
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Prostatic abscess
Diagnosed by |
CT abd/pelvis if abx do not bring down fever in hospitalized patients
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complications of ABP
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6 weeks once afebrile
Prostatic abscess Diagnosed on CT abd/pelvis if abx do not bring down fever in hospitalized patients Chronic bacterial prostatitis |
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chronic prostatitis and 4 glass urine eval
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Initial void (10 mL – urethral specimen)
Midstream void (10mL – bladder specimen) with culture EPS – prostatic fluid Post prostatic massage void(10mL) |
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chronic prostatitis TX
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First line – flouroquinolones;trimethoprim/sulfamethoxazole
4-12 weeks |
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What is the PSA?
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Prostate specific antigen,
increases with hypertrophy or cancer (and sometimes infection) of the prostate |
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“Normal” PSA
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<4ng/mL- pt don't have prostate; this cutoff detects 70+% of prostate CA
>10 ng/mL has 60% PPV for prostate CA; |
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free PSA” or unbound PSA
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increased in benign processes;
free PSA/total PSA <25% when total PSA btwn 4ng/mL and 10ng/mL diagnoses 95% of cancers |
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what is the cut off age for PSA?
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Don’t screen over age 75,
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AUA says on PSA
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screening doesn’t improve outcomes…BUT…if you’re going to screen, you should probably screen men between the ages of 50-75
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USPSTF says on PSA
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don’t screen anyone, it doesn’t detect clinically significant cancers and make outcomes differences; esp don’t screen men >75
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After a PSA what's next step, slightly elevated PSA with prostate cancer.
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Refer to urology for transrectal ultrasound and biopsies
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How will you follow the progression of cancer in this patient? What are possible therapies that can be offered that aren’t surgical?
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Follow PSA
5-alpha reductase inhibitors – can shrink prostate and decrease risk of cancers over long term LHRH antagonists – leuprolide, etc; anti-androgens |
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Golden number for PSA?
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10 and >10
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If your patient developed a palpable mass, or PSA went above 10ng/mL what treatment options would be offered, and what is the likelihood of success?
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Androgen deprivation – LHRH antagonists (luteinizing hormone-releasing hormone) and antiandrogens
Localized radiation or brachytherapy 10 year survival usually 70-80% with low grade non-invasive tumors Prostatectomy – usually transurethral; may be robotic |
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LAb for Acute prostatitis, UTI, STI (urethritis), Urosepsis
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PE
ABD; CV; GU; Lab Initial and midstream UA Midstream urine culture Urethral swab or urine sample for N. gonorrhea and C. trachomatis; microscopic exam of urine for trichomonads |
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patient with acute bacterial prostatitis.
What are the likely organisms? |
Sexually transmitted – N. gonorrhea, C. trachomatis-flaggella tx metranitozol, Trichomonas vaginalis
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list some fluroquinolones
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Ciprofloxacin
Levofloxacin Moxifloxacin Ofloxacin Norfloxacin Gatifloxacin Gemifloxacin Sparfloxacin Lomefloxacin |
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TMP/SMX
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BActrim/Septra
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chronic prostatitis also called
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chronic pelvic pain
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can shrink prostate and decrease risk of cancers over long term, give what drug?
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5-alpha reductase inhibitors
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