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107 Cards in this Set

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What are the male sex accessory tissues?
- Prostate, seminal vesicles, and the bulbourethral glands.
- Require the continued function of the testes for their development, growth and maintenance of secretions that form the ejaculate
What are the functions of the Prostate?
- Its main function is to secrete a milky, alkaline fluid into the urethra at the point of ejaculation.
The prostate fluid also helps to nourish and protect the sperm during intercourse and forms the main bulk of ejaculate volume.
(It's about the size of a walnut and lies immediately below the urinary bladder, surrounding the upper part of the urethra)
What are the anatomic parts of the prostate and how are they situated?(inferiorly, superiorly, etc.)
- It is conical in shape.
- It has a base superiorly, which lies against and is continuous with the bladder neck. The urethra enters the base.
- The apex lies inferiorly on the upper surface of the urogenital diaphragm.
- It is a fibromuscular glandular organ that surrounds the urethra and lies between the neck of the bladder above and the urogenital diaphragm below
What is the innner fibrous capsule of the prostate called?
True Capsule
What is the outer fibrous sheath which is a part of the visceral layer of the pelvic fascia (formed of adipose connective tissue containing smooth muscle fibers)?
False Capsule
The false capsule is thickened posteriorly to form the ______________ that separates the prostate from the ampulla of the rectum.
the Denonvillier's fascia
What lies anterior to the pelvis?
– Symphysis pubis separated from it by extraperitoneal fat in the retropubic space (Space of Retzius).
– Puboprostatic ligaments: Each lie on either side of the midline.
What lies posterior to the pelvis?
– Denonvillier's fascia separating it from the rectum.
– The two ejaculatory ducts pierce the upper part of the posterior surface.
What lies lateral to the pelvis?
– It is embraced by the anterior fibers of the levator ani as they run posteriorly from the pubis.
What is the widest and the most dilatable part of the urethra?
the prostatic urethra
From where to where does the prostatic urethra extend?
- It begins at the neck of the bladder and becomes continuous with the membranous urethra.
What is the longitudinal ridge on the posterior wall of the prostatic urethra which runs the whole length of the prostatic urethra?
urethral crest
What is the depression on the summit of the urethral crest which is an analog of the uterus and vagina in the female?
Prostatic utricle
What arteries supply blood to the prostate?
– Branches of the inferior vesical and middle rectal arteries.
What is the venous drainage of the prostate?
deep dorsal vein of the penis and numerous vesical veins--> prostatic venous plexus (lies b/w true and false capsules)
--> internal iliac veins
How do the lymph vessels to and from the prostate drain?
– Drain into sacral, internal, and mainly external iliac lymph nodes.
– These lymph vessels drain the capsule and the glandular tissue.
What is the nerve supply to the prostate?
– Mainly from the inferior hypogastric plexus(sympathetic and parasympathetic). The sympathetic stimulates the prostatic smooth muscle contraction during ejaculation.
What does the prostate develop from embryonically?
- Five epithelial buds form in a paired manner on the posterior side of the urogenital sinus--> These invade the mesentery to form the prostate==> so the Urogenital sinus develops into the prostate!
- Occurs via DHT stim.***
Which prostate cell is rich in PSA?
epithelial cells
Which prostate cell layer has actin-rich smooth muscle, vimentin-rich fibroblasts, and endothelial cells assoc'd w/ fibronectin, and alk Phos+?
Stromal cells
What is the prostate made of?
1) Epithelial cells (basal, transient proliferating, columnar secretory, neuroendocrine cells)
2) Stromal cells (SM, Fibroblast, endothelial)
3) Tissue matrix (extracellular, cyomatrix, nuclear matrix)
Most testosterone (97%) circulates in the bloodstream bound to one of which two proteins?
1) SHBG
2) Albumin
Which is the more important form of testosterone: free or bound?
- A small percentage of testosterone (2–3%) remains unbound (this is the important testosterone)
– DHT is ____ times more potent as a male sex hormone than testosterone and binds to androgen receptors (AR) within the _________ cells.
– DHT is 2.5 times more potent as a male sex hormone than testosterone.
– DHT binds to androgen receptors (AR) within the glandular cells.
What are the four zones of the prostate?
4 zones: 1)the anterior, 2)peripheral zone, 3)transition zone and 4)central zone.
In which zones do BPH more commonly develop?
- BPH is mainly in the central & transition areas.
Define Prostatitis.
•Multifactorial Sxs, overlapping with those of BPH
•Multifactorial and often mysterious etiology
•Often chronic
•Few proven txts
•Low predictability of success with any given txt
How does the NIH classify Prostatitis?
•Acute bacterial prostatitis (most easily treated)
•Chronic bacterial prostatitis
•Chronic nonbacterial prostatitis, or chronic pelvic pain syndrome (very frequent doctor visits)(CPPS)
–Inflammatory CPPS
–Noninflammatory CPPS
•Asymptomatic inflammatory prostatitis
What is the prevalence of Prostatitis?
- Overall prevalence est'd b/w 5% and 9% (higher by some accts)
- accounted for 1% of all visits to FPs and 8% of urologist visits
What agents usually cause acute/chronic bacterial prostatitis?
– Generally gram-negative uropathogens
– Common pathogens: E.coli; also Klebsiella, Pseudomonas, enterococci; others (w/ GU tract, pick a gram negative organism b/c they like this tract)
– Only 5% of chronic cases are clearly bacterial
What are possible causative agents to chronic nonbacterial prostatitis?
– Etiology remains unclear in most cases
– Neurogenic inflammation, chronic organ dysfunction may be involved
– Occasionally ejaculatory duct obstruction or seminal vesicle infection is cause
– Uric acid metabolism/reflux may be to blame in some cases
What are other putative causes of chronic prostatitis?
– Chronic pelvic floor muscle tension or spasms
• Problem not necessarily in prostate
– Autoimmune activity
• Evidence of abnormal T-cell activity, inflammatory cytokines in sufferers
–Hidden, difficult-to-culture bacteria, other micro-organisms
–Neuro-dysfunction
–Effect of Reiter’s syndrome
–Chemical irritation
–Dysfunctional voiding
–Uric acid
What is pelvic floor dysfunction often associated with?
pelvic floor dysfunction is often associated with lower urinary tract dysfunction.
What are the symptoms of prostatitis?
•Pain, discomfort, in pelvic area
•Tenderness in prostate
•Voiding dysfunction: Frequency, pain, incomplete emptying. Often have no control of bladder. May need to sit & do valsalva to get urine out. Intermittent pain in pelvic areas, shooting stabbing pain. Nl blood tests. W/ prostatitis, do NOT do DRE.
•Malaise, fever, chills in cases of infection
What is the best way to deagnose Prostatitis?
by postativ maage
What is the txt for acute bacterial cases and the optimal drug(s) used?
- 4 to 12 wks of Abx (in case its an underlying condition that we don’t know about) eradicates infection in 60 to 80%; often recurs in <6 months
- Fluoroquinolones are optimal choice (also sulfas, erythromycins, tetracyclines)
What is the txt for recurrent bacterial cases?
Abx may be given prophylactically (antiinflammatories are used a lot)
What is the txt for refractory bacterial cases?
suppressive antibiotics may be useful along with prostatic massage (Surgery is last resort; Endoscopic transurethral prostatitis)
BPH is clinically evident in what % of population by what age?
- Clinically evident in 50% of men by age 50, in 80% by age 80 (average age of patient w/ BPH is 52 & avg age of pt w/ prostate CA is 67)
What 2 factors play a permissive role in development of BPH?
1) Androgens (testosterone, DHT)
2) Nervous supply to prostate (allows maximal growth)
what is the static component and dynamic component of BPH development?
- Static component = Hyperplasia of the prostate narrows the urethral lumen
- Dynamic component = Prostatic smooth muscle tone, mediated by ***alpha-adrenergic receptors (this is why we use alpha blockers!), can further obstruct the bladder outlet.
What 2 conditions in BPH can cause lower urinary tract symptoms?
1) gland enlargement and
2) increased smooth muscle tone
Is the prevalence of Histological Hyperplasia in Worldwide Studies increasing or decreasing?
Increasing.
What do the 1st changes in BPH involve?
- The first changes in BPH involve proliferation of glandular tissue in the transitional zone.
What is the mechanism by which the bladder wall thickens in BPH?
- Bladder wall thickening is secondary to a huge prostate. The bladder works hard for a long time, and then stops working b/c it can't compensate for the changes anymore.
What structure marks the point beyond which you don't want resect prostate tissue b/c of danger of inducing incontinency?
- Don't want to resect prostate tissue distal to the verumontanum b/c you can damage the exernal urethral sphincter--> incontinency.
What are the factors involved in the etiology of BPH?
1) Androgens (T, DHT): permissive role
2) Estrogens: Significant role in canine model, role in humans is less clear
3) Stromal-epithelial interactions: Paracrine growth factor signaling (Cell proliferation, Apoptosis)
4) Inflammatory cells in the prostate
5) Smooth muscle controlled by adrenergic nerves
6) Nervous supply: permissive role and allows for maximal growth
What are the symptoms of bladder outlet obstruction caused by BPH?
– Hesitancy
– Weakness of urinary stream
– Intermittent urinary stream
– A feeling of incomplete bladder emptying and need for repeat voiding
– Bladder ‘irritability,’ (bladder irritated from so much contracting) as manifested by urinary frequency, nocturia** (‘get up every hour to urinate’), and urinary urgency
Does the prevalence of LUTS in normal males increase or decrease with age?
increases
What are the steps in Dx and evaluation of BPH?
1) Evaluate urinary sxs using the American Urological Association Symptom Score; assesses severity
2) History
3) Focused neurovascular exam of the LE and saddle regions
4) DRE
5) Urinalysis: RBC > 4 (hematuria) per HPF of uninfected urine requires IV urography and cystoscopy to R/O CA of the kidney or bladder
What steps are included in the initial evaluation of patients presenting with LUTS/BPH?
- History
- IPSS(Internat'l Prostate Sx Score) and bother question
- PE and DRE
- Urinalysis
- PSA
- Voiding diary
LUTS is assoc'd with what factors?
- Suscpicious DRE
- Hematuria
- Abnl PSA
- Pain
- Infection
- Palpable bladder
- Neurologic disease
In what conditions do you NOT want to check/rely on the PSA test?
Don't check PSA w/ infections or irritation b/c the PSA value goes up w/ bladder retention.
What are the potential complications of BPH?
•Urinary retention
•Renal impairment
•Urinary tract infection
•Gross hematuria
•Bladder stones if urine is sitting there
•Bladder decompensation where it doesn’t work well anymore
•Overflow incontinence as a result of retention. If >1L in bladder, it’ll hold up kidneys and you’re get hydronephrosis.
How are alpha receptors distributed in the LUT?
- Alpha receptors of bladder on outside of wall
- very concentrated on prostatic urethra & bladder neck
What does alpha receptor activity mediate and what are the effects of their overactivity?
- Alpha receptors mediate prostate smooth muscle tone
- Overactivity --> inc'd tone --> increasing LUTS and reduction in flow rate
What factors influence the density of alpha receptors found in the LUT?
- Density of adrenergic receptors changes with prostate size and age (you get older & receptors all migrate to bladder neck or those along bladder neck don’t work as well)
How many alpha receptors have been IDed to date?
- To date, 3 alpha 1 adrenoreceptor subtypes have been IDed ==> a, b, and d
What structures/conditions have an abundance of alpha-1 receptors?
1) Smooth muscle of bladder neck,
2) prostatic capsule, and
3) adenoma
What does stimulation of a1-adrenergic receptors on prostate smooth muscle mediate?
•Bladder outlet obstruction.
What are the txt options for mild LUTS symptoms?
1) Reassurance
2) Observation
What are the txt options for moderate LUTS symptoms?
1) Medical therapy
2) Minimally invasive therapy (MIT)
3) Transurethral Resection of Prostate (TURP)
4) Observation
What are the txt options for severe LUTS symptoms?
1) Medical Therapy
2) MIT
3) TURP
4) Open Surgery
What are long-acting selective alpha-1 blockers used to txt BPH?
– Terazosin
– Doxazosin
– Tamsulosin
– Alfuzosin
What are the benefits to treating w/ alpha-blockers?
•Rapid improvement of urinary flow (5x improvement w/in 8 hours)
•Reduce symptoms of LUTS
•Similar efficacy among the various agents in this class
•Modest effects on sexual dysfunction
What are the adverse events seen w/ use of alpha blockers?
•Fatigue
•Orthostatic hypotension leading to dizziness, vertigo, or syncope upon standing
•Impotence
•Decreased libido
•Edema
•Retrograde ejaculation
•Rhinitis
•Dyspnea or wheezing
•Headache
•Angina
•Arrhythmia
What are the alpha blockers primarily used for?
- used for symptomatic relief
What is the MOA of Finestride?
- inhibits type II 5-reductase conversion of testosterone to DHT by 80%–90%
- It is the best drug for prostate
What are the main effects of 5-alpha reductase inhibitors?
•Shrinks overall gland size, reduces obstruction
•Decreases obstructive events
•Reduces need for surgical intervention and AUR in glands greater than 40 g
•Must be taken for at least 3 months before efficacy can be determined
•Adverse events minimal
•50% reduction in serum PSA levels (these shrink the veins of the prostate)
What are the effects of Finestride on the levels of DHT, testosterone, PSA, and total prostate volume?
•DHT is reduced by
–70% in serum
–90% in prostate
–34% in skin
•T increases by 10%
•PSA is reduced on average by 50%
•Total prostate volume decreases by 15%–25%
which PSA level (bound or free) is UNaffected by Finestride?
Free PSA levels
What are the minimally invasive techniques used to txt BPH?
•Transurethral needle ablation (TUNA)
•Transurethral microwave therapy (TUMT)
•Laser resection or ablation
•Electrovaporization
•Transurethral incision of the prostate (TUIP)
•Water-Induced Thermotherapy*
•Ethanol Invection*
•Intraprostatic stents (very uncommon)
What are the advantages to using TURP?
•90% experience symptom improvement
•Less invasive than open prostatectomy
What are the disadvantages to using TURP?
•Requires regional or general anesthesia
•Potential complications:
–Infection
–Bleeding
–Reoperation: Rare
–Rarely, impotence and
incontinence
When are open prostectomies the preferred txt?
•Reserved for men with large prostates (>100 g) and those with bladder cancer. (avg prostate, 20-30 grams)
What are the advantages and disadvantages to open prostectomies?
– Positives: Follow-upsurgery rarely necessary
– Negatives: Abdominal incision, longer convalescence vs. transurethral approaches, hemorrhage potential
What is lifetime risk, mortality and morbidity rates for Prostate CA?
- Most common internal CA in men
- 2nd most common cause of CA death in men
- Lifetime risk: 1/6
What are the risk factors to developing prostate CA?
•Age
•Race--*African-American*(50% greater IR than in caucasians)
•Family history (~9%)
•Diet (animal fat-- red meat, dairy prods, veg.oil)
•PSA
•PIN
What region(s) of the world have the lowest and highest rates of Prostate CA?
- The lowest rates are in the Asian countries, where dietary fat is lowest and soy intake is highest.
- The highest rates are in the Western countries, where dietary fat is the highest and soy consumption is almost non-existent.
What are screening/diagnostic tools for prostate CA?
•Digital Rectal Exam(DRE)
•PSA: a screening tool to decide whether biopsy is needded; NOT an indicator of severity/grade of CA or txt.
•Ultrasound-guided biopsy
What is a PSA and how does it help screen for prostate CA?
•A glycoprotein (mw=34kD) secreted exclusively by prostate epithelium; a protease
•Enters serum in prostate disease/trauma states
•If serum level 4-10 ng/ml ~1/4 chanceof CaP; >10 ng/ml ~ 2/3 chance of CaP
What is the advantage and disadvantage to evaluating PSA levels?
•Has the highest positive predictive value of any single test, but not specific for CaP:
–Many men with BPH have
PSA > 4.0 ng/ml
–25% of men with CaP have
PSA < 4.0 ng/ml
What are ways to make PSA levels more CA-specific?
Use:
- Age-adjusted levels
- PSA Density
- PSA Velocity
- % Free PSA
How is the PSA level best evaluated?
Since 68% of those WITH prostate cancer have a PSA <4, we look more at trends. Get biopsy if:
- PSA doubles from 1 chk
to the next,
- PSA > 4,
- PSA density: 100 g.
What are the current recommendations for PSA testing?
•Offer PSA testing annually along with DRE, if life expectancy >10 years:
* Caucasian men- start @
50 y/o
* African-American men- 45
y/o
* All with + family hx- 40
y/o
Where are the biopsy cores taken from to enhance diagnostic sensitivity of the biopsy?
- Typically, 8, 10, or 12 biopsy cores are taken from the peripheral zone
The prostate gland is divided into what two primary zones?
1) a transition zone, which surrounds the urethra, and
2) a peripheral zone, which surrounds the transition zone and is primarily located in a posterior location adjacent to the rectum.
Where do 75-85% of prostate cancers originate?
- Early lesions can develop in the peripheral zone-- where 75-85% of prostate cancers originate
- more easily detectable upon DRE,
- very unlikely to yield symptoms early in the course of the disease.
What are the staging tools for prostate CA?
•Prostate Specific Antigen (PSA)
•Digital Rectal Exam (DRE)
•Bone Scan
•CAT Scan
•Gleason Grade
How is the Gleason scoring system determined?
- In a schematic from 1 to 5.
- The scoring system is obtained by looking for a primary histologic pattern of CA, assigning a Gleason grade to it, and then looking for a secondary histologic pattern, and assigning a Gleason grade to that.
- Thus, two Gleason grades are added together, primary and secondary, and a score is obtained.
- 1st # = predominant cell type, and the basis of txt.
- 1 = well differentiated and 5 = poorly differentiated.
How is stage T1 defined?
T1: a microscopic tumor confined to prostate gland; palpated gland feels NL
How is a stage T1a tumor defined?
- found in the prostate tissue removed for reasons other than CA; <5% of specimen malignant
How is a stage T1b tumor defined?
- same a T1 but >5% of specimen contains CA
How is a stage T1c tumor defined?
- found through biopsy done in response to an elev'd PSA test or to an abnl US exam; may be less extensive than a T1b tumor
How is a stage T2 tumor defined?
- palpable tumor confined to the prostate gland
How is a stage T2a tumor defined?
- tumor confined to less than 1/2 of 1 lobe
How is a stage T2b tumor defined?
- tumor affecting more than 1/2 of 1 lobe
How is a stage T2c tumor defined?
- tumor involving both lobes.
How is a stage T3 tumor defined?
- tumor that has begun to expand beyond the prostate
How is a stage T3a tumor defined?
- tumor that protrudes beyond the prostate
How is a stage T3b tumor defined?
- tumor that has invaded the seminal vesicles
How is a stage T4 tumor defined?
- tumor that has fixed and has pushed well beyond the prostate into adjacent structures
What is the txt for mets CaP?
- Castration b/c c it will slow CA down and pt. could live w/ it for 13 years
Why are bone scans and CAT scans useful as staging tools?
- Both done to make sure pts. don’t have mets disease b/c they wouldn’t get surgery
- CAT scan is good for finding lymph nodes >1 cm --> can often do a pelvic lymphadenectomy at time of surgery
___% of men present with early disease and are potentially curable.
75%
What are optional txts for prostate CA and how are they chosen?
•Conventional Surgery
•Robotic Surgery
•Radiation (seed)
•Hormone Therapy
•Chemotherapy (no chemo for prostate CA right now)
•Watchful Waiting

•Txt depends on the stage of the CA, as well as the age and other medical conditions of the pt. Txt may consist of 1 of the above, or a combo of these.
What are the possible levels of prostate CA at diagnosis?
1) local-regional dz spread: localized w/in gland or can break thru capsule and invade nearby tissue
2) systemic spread: can escape prostate and invade lymph nodes--> invade other organs; preferentially invade bones