Prostate Gland

About the size of a large chestnut ( about the size of a testis) and surrounds the urethra and the bladder neck a11d is devoid of distinct capsule.

The physiological function of the prostate is not entirely known but it produces the major of ejaculatory fluid, which contains fibrinolysis. This enzyme liquefies the coagulated semen, a process important for11t for sperm motility.

Another important anatomic issue concerns the two nerve bundles that control erection that run along the surface of the prostate These nerves can be identified and moved before excising the prostate.

Acute Bacterial Prostatitis

• 1. Least common.

• 2. seen in young and elderly

• 3. Usually a systemic il1ness -chills, fever and malaise

• 4. Usually acute onset, pt has dysuria, frequency,

• inhibited voiding, low back pain, suprapubic discomfort, and perineal pain.

• 5. May have painful ejaculations or pain when defecating.

• 6. Hematuria may be present anytime during the course of th illness.

• 7. If urinary retention occurs pt may have edema.

• 8. U. A. contains WBC’s and bacterria

Chronic Bacterial Prostatitis

• 1. Seem in older men

• 2. Systemic illness is not usually present

• 3. Symptoms tend to come and go

• 4. Pt. will demonstrate varying signs of

• bladder outflow obstructions.

• 5. Pain on ejaculation, blood in urine and or sperm may be present.

• 6. HALLMARK FEATURE IS RECURRING UTI, PT. USUALLY ASYMPTOMATIC AND

• URINE IS STERILE BETWEEN EPISODES.

• 7. Prostatic calculus may be seen .

• 8. UA contains bacteria and pyuria.

Etiology

• Ascending infection from urethra most COMMON, spread by blood or lymph.

• Most common pathogens; E.COLI(80%), PROTEUS, ENTEROBACTER, PSEUDOMONAS, STREPTOCOCCUS, FEACALIS, AND STAPHYLOCOCCUS

Non bacterial Prostatitis

• Most common -eight times more common than bacterial prostatitis.

• Pt has mild perineal pain, dysuria, frequency ,or urgency but no s&s of systemic illness.

• Penile discharge is common. URINE has WBC but no bacteria ins urine or expressed secretion

History

• 1. Ask about onset and course of il1ness

• 2. Inquire about assoc. symptoms such as discharge, urethral meatal itching, fever, incontinence,painful ejaculation, back or perineal pain, decreased urine stream ,blood in urine

• 3. Ask about prior urinary infections, and the successes of TX.

• 4. Ask if sexual partner if having any urinary problems

• 5. Ask if pt has had new sexual partners.

• 6. Ask about any infection of any sort cold etc.

Physical Exam

• 1. General exam for any systemic illness.

• 2. check for bladder distention and any abdominal tenderness.

• 3. Assess external genitalia.

• 4. Carefully palpate prostate ( vigorous exam can cause bacteremia)

• In acute prostatitis prostate is VERY TENDER, swollen and boggy .

• In chronic and nonbacterial prostatitis prostate is irregular and mildly tender, prostate may FEEL normal.

Differential Diagnoses

• 1. Acute is usually from the normal presentation.

• 2. Chronic is less clear and may look like other disorders.

PRESENTS WITH PERINEAL OR BACK PAIN ACCOMPANIED WITH UNILATERAL TESTICULAR PAIN OR DYSURIA. THERE ARE NO WBC OR BACTERIA IN AN EXPRESSED SECRETION AND IN THE URINE. USUALLY SEEN IN MALES BETWEEN 22 AND 55

• B. BENIGN PROSTATE HYPERPLASIA

• C. UREATHRAL STRICTURE

• D. BLADDER CARCINOMA

• 3. Nonbacterial Prostatitis often resembles cystitis and nongonococcal urethitis

Management of Acute Prostatitis

• 1. Hospitalization and I. V. antibiotic therapy may be needed, abscess is sometime present and

needs very aggressive therapy.

• 2. Initial outpatient TX BACTRIM 160/800mg b.i.d. for 14 to 30 days ( 30 DAYS MOST OFTEN RECOMMEND) Noroxin 400 mg for 14 to 28 days

• PT TEACHING: Sitz baths, bed rest

• For pain analgesics, antiinflammatories, and stool softeners.

• If over 50 refer re. poss BPH

• If persist REFER

Chronic Prostatitis

• 16-24 week course of Bactrim B.I.D. or Noroxin 400 mgsB.I.D. or Cipro 500 mgs B.I.D

• 2. Cultures 4-6 weeks

• 3. Prophylactic drugs if persist; 80 mg BACTRIM hs or MACRODANTIN 100 mg indefinitely

• 4. If refractory refer .

• Teach patients to: ( for all type of prostatitis)

• 1. Avoid coffee, tea and ETOH

• 2. No 0. T .C. drugs with anticholinergic properties

• Follow- up

• For bacterial prostatitis return in 4-6 weeks for UA and C&S of urine and expressed prostrate secretions

Benign Prostatic Hypertrophy (BPH)

• Nodular Hyperplasia ( BENIGN REDUNDANT ALL HYPERPLASIA ARE BENIGN) A benign

adenoma of the prostrate gland

• Very common after age 50. Seen in 20% of men @ age 40, 70% of men at age 60, and 90% see by age 80.

• 500,000 TURPS are done yearly and by the age of 65 it is second to cataract extraction.

• 25% all males will require TX for BPH

Etiology

• Not totally clear however several factors come into to play

• Increased 5a-dihydotestosterone (DTI-I) the active form of testosterone

• Increases estrogen ( it may be that the estradiol levels possible "sensitize" the prostate to the growth-promoting effects of DHT)

• Stimulation of the A-adrenergic nerve ending interfering with the opening of the bladder neck internal sphincter

Clinical Presentation

• Gradual worsening of the following:

– a weak urine stream, abdominal straining to void, hesitancy,

– incomplete emptying of the bladder, dribbling, frequency, nocturia, and urgency

Complications are as follows:

a. more susceptible to UTIs

b. Can lead to incontinence

c. acute urinary retention.

Diagnosis

1. HISTORY

A. ONSET AND DURA TION OF SYMPTOMS

B. ANY PAIN OR HEMATURIA

C. ANY BACK OR BONE PAIN, ANOREXIA, OR WT. LOSS

D. COMPLETE MEDICAL HISTORY ESP DIABETES, GU PROBLEMS, NEURO.PROBLEMS

E. USE OF ANY OTC COLD OR SINUS MEDS

Questions on I-PSS

• 1 Incomplete Emptying

• 2 Frequency

• 3 Intermittency

• 4 Urgency

• 5 Weak Stream

• 6 Straining

• 7 Nocturia

• Last Question refers to the patient's perceived quality of life.

International Prostate Symptom Score

• The International Prostate Symptom Score (I-PSS) is based on the answers to seven questions concerning urinary symptoms and one question concerning quality of life.

• Each question concerning urinary symptoms allows the patient to choose one out of six answers indicating increasing severity of the particular symptom. The answers are assigned points from O to 5. The total score can therefore range from 0 to 35(asymptomatic to very symptomatic).

• The first seven questions of the I-PSS are identical to the questions appearing on the American Urological Association (AUA) Symptom Index which currently categorizes symptoms as follows:

• Mild (symptom score less than or equal to 7)

• Moderate (symptom score range 8-19)

• Severe (symptom score range 20-35)

The International Consensus Committee (ICC) under the patronage of the WorldHealth Organization (WHO) recommends the use of only a single question to assess the quality of life. The answers to this question range from "delighted" to "terrible“ or 0 to 6. Although this single question mayor may not capture the global impact of benign prostatic hyperplasia (BPH) symptoms or quality of life, it may serve as a valuable starting point for a doctor-patient conversation.

• The ICC recommends that physicians consider the following components for a basic diagnostic workup: history; symptoms; physical exam; appropriate labs, such as U/A, creatinine, etc.; and DRE or other evaluation to rule out prostate cancer.

Exam

1.ABDOM. EXAM TO FIND; ANY DISTENDED BLADDER DESTENTION, RENAL TENDERNESS, OR MASS

2. DRE:

– BPH PROST ATE IF ENLARGED, SMOOTH, SYMMETRICAL WITHOUT MEDIAN SULCUS or

– PROSTATE CA. ASYMMETIUC, NODULAR WITH HARD AND FIXED MASS

– GOOD GEN NEURO TO CHECK FOR OTHER DISEASES (EG. MS)

Diagnostic Testing

1. UA, CREATININE FOR URINARY FUNCTION (Remember formula for estimating creatinine if no 24 hour urine)

2. PSA

3. DRE

4. DO OTHER URODYNAMIC STUDIES IF POSSIBLE

Mangement

If AUA score is less than 7:

• watchful waiting

• evaluate pt annua1ly

• limit fluid after dinner

• no decongestants, ETOH , anticholinergics

If AUA score greater than 8:

• OFFER INFORMATION RE: BENEFITS AND HARM OF WATCHFUL WAITING

• SURGERY FOR THE FOLLOWING:

– Refractory urinary retention who have failed at least one attempt at cath. removal

– Recurrent urinary tract infections, gross hematuria, bladder or renal insufficiency

Managment

• BPH TX WITH MEDS may or may not help with size or S & S

• ALWAYS DO DRE AND PSA PRIOR TO STARTING MEDS,

1. TERAZSOIN ( HYTRIN) 2-10 MG QD. START WITH 0.5 ALPHA BLOCKER

2. MINIPRESS 2-5 QD

3. CARDURA START WITH 1 MG QD MAX AT 16 MG/DAY

4. FINASTERIDE (PROCAR) HELP IN DECREASING SIZE 5 MG. QD

5. SURGERY

• TURP( INSTRUMENT MAKE ONE OR TWO SMALL INCISIONS TO DECREASE PRESSURE ON URETHRA.

• OPEN PROSTATECTOMY

• NEW TXS WITH LASER, MICROWAVE THERMAL THERAPY, STENTS

6. TEACHING

• S&S RETENTION AND OBSTRUCTIONS