Shah 11-30-07 The Prostate

Front 1

The main function of the prostate gland is what?

Back 1

to secrete a milky, alkaline fluid into the urethra at the point of ejaculation.

Front 2

The prostate fluid helps to _______ the sperm during intercourse and forms a consistent portion of ejaculate volume

Back 2

nourish and protect

Front 3

Male sex _________ tissues
require the continued function of the testes for their development, growth and maintenance of secretions that form the ejaculate

Back 3

accessory

Front 4

What are the sex accessory tissues?

Back 4

Prostate, seminal vesicles, and the bulbourethral glands

Front 5

The main function of the prostate is to
A.Provide fluid during intercourse for prevention of infection during intercourse

B. To secrete a milky, alkaline fluid into the urethra at the point of ejaculation

C. Produce enzymes that facilitate progression and insemination of the sperm to the female genital tract

D. The Prostate has no major function and is vestigal gland

e. To lubricate the female reproductive tract to enhance sperm survival for reproduction

Back 5

B

Front 6

It is conical in shape. Size of a _____.

Back 6

walnut

Front 7

It has a base, which, superiorly, lies against and is continuous with the ______ neck.

Back 7

bladder

Front 8

In fact, the smooth muscle passes without interruption from one organ to the other. The _____ enters the base.

Back 8

urethra

Front 9

The apex lies inferiorly on the upper surface of the ______ diaphragm

Back 9

urogenital

Front 10

It is a fibromuscular glandular organ, which is ___ cm long

Back 10

~ 3

Front 11

It surrounds the urethra and lies between the neck of the bladder above and the ______ diaphragm below

Back 11

urogenital

Front 12

The prostate gland is divided into four zones

Back 12

transition
anterior
central
peripheral

Front 13

BPH has effect at _____zone

Back 13

transition

Front 14

Which zone will you feel a nodule?

Back 14

peripheral

Front 15

The prostate gland is comprised of 30–50 glands arranged in _____, which empty into the prostatic urethra

Back 15

acini

Front 16

____ capsule: Inner fibrous capsule

Back 16

True

Front 17

False capsule: Outer fibrous sheath which is part of the visceral layer of the pelvic fascia (formed of adipose connective tissue containing _______ fibers).

Back 17

smooth muscle

Front 18

The false capsule is thickened posteriorly to form the _________ fascia that separates the prostate from the ampulla of the rectum.

Back 18

Denonvillier's

Front 19

Anteriorly
Symphysis pubis separated from it by extraperitoneal fat in the retropubic space (Space of Retzius).
________ ligaments: Each lie on either side of the midline.

Back 19

Puboprostatic

Front 20

Posteriorly
________'s fascia separating it from the rectum.
The two ejaculatory ducts pierce the upper part of the posterior surface.

Back 20

Denonvillier

Front 21

Laterally
It is embraced by the anterior fibers of the _______ as they run posteriorly from the pubis.

Back 21

levator ani

Front 22

Which of the following statements regarding prostate anatomic relationships is correct?
A. The prostate is an intraperitoneal organ that lies beneath the bladder and the urogenital diaphragm.
B. The prostate is an extraperitoneal gland that lies beneath the bladder and the urogenital diaphragm.
C. The prostate is an intraperitoneal gland that lies beneath the bladder and above the urogenital diaphragm.
D. The prostate is an extraperitoneal gland that lies beneath the bladder and above the urogenital diaphragm.

Back 22

?

Front 23

It is the widest and the most dilatable part of the urethra

Back 23

Prostatic Urethra

Front 24

On the summit of the urethral crest (what is known as seminal colliculus) - depression called prostatic ______ which is the analog of the uterus and vagina in the female. On the edge of the utricle are the 2 ejaculatory ducts.

Back 24

utricle

Front 25

On each side of the crest there is a groove called the prostatic ______. The ducts of the prostatic glands open into the ______

Back 25

sinus

Front 26

On the posterior wall - longitudinal ridge (urethral _____) which runs the whole length of the prostatic urethra.

Back 26

crest

Front 27

Arteries of the prostate

Back 27

Branches of the inferior vesical and middle rectal arteries.

Front 28

Veins of the prostate

Back 28

Prostatic venous plexus which lies between the true and false capsules. It receives the deep dorsal vein of the penis and numerous vesical veins. It drains into the internal iliac veins.

Front 29

Nerve Supply
Mainly from the inferior hypogastric plexus (sympathetic and parasympathetic).The sympathetic stimulates the prostatic smooth muscle contraction during ______.

Back 29

ejaculation

Front 30

Lymph vessels
Drain into sacral, internal, and mainly external _____ lymph nodes.
These lymph vessels drain the capsule and the glandular tissue.

Back 30

iliac

Front 31

During a radical prostatectomy, a surgeon suspects extracapsular disease and decides to perform a pelvic lymph node dissection. Which of the following nodes should she remove?

A. The sacral, internal iliac and especially the external iliac nodes
B. None given the high risk of obturator nerve injury
C. The pelvic nodes alone given the extracapsular disease
D. Femoral, iliac and aortocaval nodes
E. Femoral nodes only

Back 31

?

Front 32

______ ducts develop into the:
seminal vesicles, epididymis, vas deferens, ampulla

Back 32

Wolffian

Front 33

the Urogenital ______ develops into the prostate!
Occurs via dihydrotestosterone (DHT) stimulation

Back 33

sinus

Front 34

Which of the following is true regarding prostate cell function?

The majority of testosterone is free and is bound to proteins in the prostate by dihydrotestosterone and 5-alpha reductase
The minority of testosterone is free and is converted to dihydrotestosterone by the action of 5-alpha reductase on testosterone in the prostate
Testosterone is 50% bound in the bloodstream and changes to its free form based on the amount of sexual activity
The majority of testosterone is bound to albumin, a protein which also converts testosterone to the more potent dihydrotestosterone

Back 34

?

Front 35

What itis?

Multifactorial symptoms, overlapping with those of benign prostatic hyperplasia (BPH)
Multifactorial and often mysterious etiology
Often chronic
Few proven treatments
Low predictability of success with any given treatment

Back 35

Prostatitis

Front 36

Acute ____ prostatitis (type 1)

Back 36

bacterial

Front 37

_____ bacterial prostatitis (type 2)

Back 37

Chronic

Front 38

Chronic ________ prostatitis (type 3)

Back 38

nonbacterial

Front 39

“chronic pelvic pain syndrome (CPPS)”

2 types

Back 39

Inflammatory CPPS
Noninflammatory CPPS

Front 40

________ inflammatory prostatitis (type 4)

Back 40

Asymptomatic

Front 41

Acute/Chronic Bacterial Prostatitis
Generally gram-______ uropathogens

Back 41

negative

Common pathogens: Escherichia coli; also Klebsiella, Pseudomonas, enterococci; others

Front 42

Only _% of chronic cases of prostatitis are clearly bacterial

Back 42

5

Front 43

Chronic Nonbacterial Prostatitis/CPPS

Etiology remains unclear in most cases
Neurogenic inflammation, chronic organ dysfunction may be involved
Occasionally ejaculatory duct obstruction or seminal vesicle infection is cause
_______ metabolism/reflux may be to blame in some cases

Back 43

Uric acid

Front 44

Other putative causes of chronic prostatitis

Back 44

Chronic pelvic floor muscle tension or spasms
Problem not necessarily in prostate
Autoimmune activity
Evidence of abnormal T-cell activity, inflamma-tory cytokines in sufferers

Hidden, difficult-to-culture bacteria, other microorganisms
Neuro-dysfunction
Effect of Reiter’s syndrome
Chemical irritation
Dysfunctional voiding
Uric acid

Front 45

Large percentage of CPPS pts suffer from a functional ________ syndrome involving varying symptoms not explainable in terms of conventionally defined disease. Their CPPS symptoms may be related to this syndrome

Back 45

somatic

Front 46

Symptoms of prostatitis are multifactorial; may include what?

Back 46

Pain, discomfort, in pelvic area
Tenderness in prostate
Voiding dysfunction: Frequency, pain, incomplete emptying
Malaise, fever, chills in cases of infection

Front 47

Diagnosing Prostatitis

Back 47

Patient history, physical exam, and urinalysis/urine culture in all cases

Front 48

______ prostatitis may be diagnosed based on symptoms and presence of bacteria (5-day cultures preferred)

Back 48

Bacterial

Front 49

Cultures of first voided specimens and ______ prostatic secretion

Back 49

expressed

Front 50

For acute bacterial cases, 4 to 12 weeks of _____ eradicates infection in 60 to 80%; often recurs in <6 months

Back 50

antibiotics

Front 51

_______ are optimal choice (also sulfas, erythromycins, tetracyclines)

Back 51

Fluoroquinolones

Front 52

In refractory cases, suppressive antibiotics may be useful along with _________

Back 52

prostatic massage

Front 53

Surgery for prostatitis?

Back 53

last resort

Front 54

COX-2 inhibitor for prostatitis?

Back 54

(rofecoxib) demonstrated some success in a randomized trial

Front 55

A 38 year-old male presents to you with perineal discomfort, a documented UTI, fevers and chills. You diagnosed him prostatitis. Which are the most likely organisms you should focus antimicrobial treatment towards?

Facultative anaerobes and gram positive organisms
Gram-negative organisms such as E. Coli, Enterococcus and Klebsiella
Gram-positive clustering organisms such as Staph and Strep (groups A and B)
Gram positive cocci in pairs, anaerobes and psuedohyphenated yeasts

Back 55

?

Front 56

A 35 year-old male is diagnosed with first episode of prostatitis by a local family physician in rural Georgia. Cultures are not available but your colleague asks how she should treat the patient. You tell her:

Fluoroquinolones for 4 – 6 weeks followed by another culture and assessment for symptom improvement
Penicillin G with Sitz baths
Daily enemas until symptoms improvement and a negative repeat culture
Immediate transfer to you for surgery, i.e. TURP
Elective benign prostatectomy

Back 56

Fluoro

Front 57

BPH is now known as what?

Back 57

BENIGN
PROSTATIC
ENLARGEMENT

Front 58

LUTS means what? don't call it prostatism

Back 58

lower urinary tract symptoms

Front 59

BOO = bladder ______ _____

Back 59

bladder outlet obstruction

Front 60

BPH is a ______ enlargement of the prostate gland

Back 60

histologic

Front 61

BPH = Histological Presence of Enlarged Prostate Gland
Clinically evident in 50% of men by age 50, in 80% by age ___

Back 61

80

Front 62

_______ play a permissive role in BPH

Back 62

Androgens

Front 63

Prostatic smooth muscle tone, mediated by ____-adrenergic receptors, can further obstruct the bladder outlet (Dynamic component)

Back 63

alpha

Front 64

Both gland enlargement and increased smooth muscle tone can cause ______

Back 64

lower urinary tract symptoms (LUTS)

Front 65

The first changes in BPH involve proliferation of glandular tissue in the ________ zone.

Back 65

transitional

Front 66

Androgens - Testosterone, DHT play permissive role in BPH.
What about Estrogens?

Back 66

Significant role in canine model, role in humans is less clear

Front 67

Symptoms of bladder outlet obstruction caused by BPH include

Back 67

Hesitancy
Weakness of urinary stream
Intermittent urinary stream
A feeling of incomplete bladder emptying and need for repeat voiding
Bladder ‘irritability,’ as manifested by urinary frequency, nocturia, and urinary urgency

Front 68

Evaluate urinary symptoms using the _______ Symptom Score to assesses severity

Back 68

American Urological Association

Front 69

Potential Complications of BPH
Urinary retention
Renal impairment
Urinary tract infection
Gross hematuria
Bladder decompensation
Overflow incontinence as a result of retention
and what else?

Back 69

Bladder stones

from proteus (stone formers)

Front 70

A 62 year-old male has seen a lot of commercials about BPH medications and wants to know if he has it. Which of the following is the correct description/definition of BPH that you can describe for him:

A) Lower urinary tract symptoms due to prostatic urethral narrowing and gland enlargement
B) Lower urinary tract symptoms consisting of prostatic enlargement, bladder dysfunction and lower motor neuron spinal level dysfunction
C) Upper urinary tract symptoms associated with a high-risk of ejaculatory dysfunction and bowel dysfunction
D) Upper urinary tract symptoms due to kidney and bladder dysfunction primarily
E) Asymptomatic condition associated with a high degree of infections, bleeding and ejaculatory disorders

Back 70

A

Front 71

What are the trade names of the BPH drugs?

Back 71

Flomax
Avodart
proscar

Front 72

The smooth muscle of the ______ and prostatic capsule have an abundance of alpha-1 adrenergic receptors

Back 72

bladder neck

Front 73

Eighty percent of all receptors in the prostate are of the _____ subtype.

Back 73

alpha-1A

Front 74

Alpha-1 antagonism may induce _____ in the prostate.

Back 74

apoptosis

Front 75

Prostate smooth muscle tone is mediated via _____ adrenergic receptors

Back 75

alpha 1

Front 76

Smooth muscle of bladder neck, prostatic capsule, and adenoma have an abundance of _____ receptors

Back 76

alpha1-adrenergic

Front 77

Stimulation of ______ receptors on prostate smooth muscle mediates bladder outlet obstruction

Back 77

alpha1-adrenergic

Front 78

80% of all receptors in prostate are ____ subtype

Back 78

alpha1A

Front 79

Benefits of treatment with alpha blockers

Back 79

Rapid improvement of urinary flow
Reduce symptoms of LUTS
Similar efficacy among the various agents in this class
Modest effects on sexual dysfunction

Front 80

Alpha blockers: Adverse events

Back 80

Fatigue
Orthostatic hypotension leading to dizziness, vertigo, or syncope upon standing
Impotence
Decreased libido
Edema
Retrograde ejaculation
Rhinitis
Dyspnea or wheezing
Headache
Angina
Arrhythmia

Front 81

what drugs do the following?
Mechanism of action: Inhibits conversion of testosterone to dihydrotestosterone
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

Back 81

5-alpha reductase inhibitors

Front 82

Normal mass of prostate and mass with symptoms

Back 82

20g

40g = symptoms

Front 83

Important to know day to day about 5 alpha reductase inhibs

Back 83

50% reduction in serum PSA levels.

If it does not go down, prostate MUST be biopsied.

Front 84

Selective Type II 5alpha-Reductase Inhibition With what?

Back 84

Finasteride

Front 85

P.D. is a 61 y.o. male smoker with a history of mild BPE who develops who develops bronchitis. He is seen by his PCP and given Sudafed (Pseudonephrine) which is an alpha receptor agonist to help is symptoms. After two doses, he is unable to urinate. The cause of his retention is most likely due to:

Undiagnosed adenocarcinoma obstructing the bladder neck resulting increased proliferation of prostatic smooth muscle
Decreased alpha-1a receptor activity at the bladder neck and prostatic smooth muscle
Increased alpha-1a receptor activity at the bladder neck and prostatic smooth muscle
Increased conversion of testosterone to dihydrotestosterone at the bladder neck and prostatic smooth muscle
Decreased conversion of testosterone to dihydrotestosterone at the bladder neck and prostatic smooth muscle

Back 85

?

Front 86

Transurethral ____ ablation (TUNA)

Back 86

needle

Front 87

Transurethral _______ therapy (TUMT)

Back 87

microwave

Front 88

Transurethral ______ of the prostate (TUIP)

Back 88

incision

Front 89

Transurethral _____ of the prostate (TURP)

Back 89

resection

Front 90

Gold standard for benign disease

Back 90

TURP

Front 91

With TURP, __% experience symptom improvement
Less invasive than open prostatectomy

Back 91

90% experience symptom improvement
Less invasive than open prostatectomy

Front 92

Potential complications of TURP

Back 92

Infection
Bleeding
Reoperation: Rare
Rarely, impotence and incontinence
PERMANENT retrograde ejaculation

Front 93

Reserved for men with large prostates (>100 g) and those with bladder cancer

Back 93

Open Prostatectomy

Front 94

Positives of open prostatectomy

Back 94

Follow-up surgery rarely necessary

Front 95

Negatives of open prostatectomy

Back 95

Abdominal incision, longer convalescence vs. transurethral approaches, hemorrhage potential

Front 96

PROSTATE CANCER - ______-CARCINOMA

Back 96

ADENO

Front 97

Risk Factors for Prostate Cancer

Back 97

Age
Race---African-American
Family history (~9%) (Shaw thinks this is most important)_
Diet (animal fat)
PSA
ASAP - atypical small acinar ...

Front 98

Eating ______ increases the risk of developing prostate cancer 2.64 times

Back 98

red meat

Front 99

Prostate Cancer Diagnosis

Back 99

Digital Rectal Exam (DRE) (trumps the others)
Prostate Specific Antigen (PSA) TREND (not discrete measurement)
Ultrasound-guided biopsy

Front 100

Check PSA how often?

Back 100

anually

Front 101

Highest positive predictive value of any single test, but not specific for CaP:

Back 101

Prostate Specific Antigen (PSA)

Front 102

Many men with ___ have PSA > 4.0 ng/ml

Back 102

BPH

Front 103

___% of men with CaP have PSA < 4.0 ng/ml

Back 103

25

Front 104

Offer PSA testing annually along with DRE, if life expectancy >10 years:
* Caucasian men - start age __ y.o.
* African-American men - 45 y.o.
* With + family history:
--> 45 for Caucasians
--> 40 for African-Americans

Back 104

50

Front 105

An asymptomatic 43 year-old African-American male with a father who recently died of prostate cancer presents to you with a PSA of 3.7 ng/ml. His PSA values in 2005 – 1.8 ng/ml and in 2006 was 2.5 ng/ml. Your best recommendation would be:



A) Repeat PSA in one year
B) Radical Prostatectomy
c) Antibiotics for 30 days to treat prostatitis
d) Alpha-1a blocker therapy
e) Prostate biopsy

Back 105

?

Front 106

SOC: __ biopsy cores are taken from the peripheral zone to enhance diagnostic sensitivity of the biopsy.

Back 106

12

Front 107

Transitional zone = _____
peripheral zone = cancer

Back 107

BPE

Front 108

The ______ grading system for classifying prostate abnormalities has been widely adopted

Back 108

Gleason

1-6 (only diagnose 3-6)

Front 109

Prostate Cancer: StagingStaging Tools

Back 109

Prostate Specific Antigen (PSA)
Digital Rectal Exam (DRE)
Bone Scan
CAT Scan
Gleason Grade

Front 110

Treatment of prostate disease

Back 110

Conventional Surgery - localized disease
Robotic Surgery - localized disease
Cryoablation – localized or recurrent disease
Radiation – localized, locally advanced and metastatic disease
Hormone Therapy – extensive local disease or metastasis
Chemotherapy – metastatic disease
Watchful Waiting – localized disease

Front 111

Types of radiation therapy for prostate disease

Back 111

Brachytherapy
External Beam Radiotherapy
Proton Beam Therapy

Front 112

Prostate cancer treatment depends on the ____ of the cancer, as well as the ____ and other medical conditions of the patient

Back 112

stage

age

Front 113

A 64 y.o. male is diagnosed with Gleason 6 Prostate Cancer. He seeks advice for treatment. Which of the following is not an accepted treatment for localized prostate cancer?
Radical Prostatectomy
Interstitial Brachytherapy
External Beam Radiation Therapy
Watchful Waiting, i.e. expectant management
Nerve-particle scatter neutron therapy

Back 113

E

Front 114

If prostate cancer spreads (rare), where does it go?

Back 114

lymph nodes
bone