RENAL & GENITOURINARY Last edited: 3/6/2024
2. PROSTATE DISORDERS
I. PATHOPHYSIOLOGY II. COMPLICATIONS OF III. DIAGNOSTIC APPROACH TO IV. TREATMENT OF
A. BENIGN PROSTATIC PROSTATE DISORDERS PROSTATE DISORDERS PROSTATE DISORDERS
HYPERPLASIA (BPH) A. URINARY TRACT OBSTRUCTION A. ASSESS FOR THE PRESENCE OF BPH A. BENIGN PROSTATIC HYPERPLASIA (BPH)
B. PROSTATITIS B. URINARY TRACT INFECTION (UTI) B. ASSESS FOR THE PRESENCE OF PROSTATITIS B. PROSTATITIS
C. PROSTATITIS C. PROSTATE ABSCESS C. ASSESS FOR THE PRESENCE OF A PROSTATE ABSCESS
00:42
I. Pathophysiology
A. Benign Prostatic Hyperplasia (BPH) 00:42
1. Pathophysiology:
o Hyperplasia of prostatic tissue in transition zone →
↑Compression of urethra → ↑Narrowing of urethra →
Bladder outlet obstruction →
↑Detrusor irritation and ↑Urine retention →
Lower urinary tract symptoms (LUTS) arise
2. Causes of BPH:
↑Prostate Hyperplasia
o Old age (> 40yr) → ↑Testosterone conversion to
Dihydrotestosterone in the prostate → ↑Cell proliferation and
enlargement of the prostate gland
3. Classical Findings of BPH:
Lower Urinary Tract Symptoms (LUTs)
o Hyperplasia of prostatic tissue in transition zone →
↑Compression of urethra → ↑Narrowing of urethra →
Bladder outlet obstruction → ↑Detrusor irritation →
Storage LUTs
Urgency, Frequency, and Nocturia
o Hyperplasia of prostatic tissue in transition zone →
↑Compression of urethra → ↑Narrowing of urethra →
Bladder outlet obstruction → ↑Urine retention →
Voiding LUTs
↑Urine stream, ↑Dribbling, and hesitancy
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B. Prostatitis 07:37
a) Acute Prostatitis b) Chronic Prostatitis
Pathophysiology: Pathophysiology:
o Bacterial infection of the prostate → o Bacterial infection of the prostate →
Acute inflammation of the prostate → Chronic inflammation of the prostate
↑Compression of urethra → → Mild compression of urethra →
↑Narrowing of urethra → Mild narrowing of urethra →
Bladder outlet obstruction → Bladder outlet obstruction → Mild
↑Detrusor irritation and ↑Urine detrusor irritation and mild urine
retention → retention → Lower urinary tract
Lower urinary tract symptoms (LUTS) arise
symptoms (LUTS) arise
Causes: Causes:
o Gonorrhea or Chlamydia → o Recurrent infections with [Link] →
Sexually transmitted infection Chronic infection of the prostate
of the prostate Classical Findings:
Assess for patients < 35 y o Lower Urinary Tract symptoms (LUTs)
o [Link] → Infection of the prostate Bacterial infection of the prostate →
Assess for patients > 35 y Chronic inflammation of the
prostate → Mild compression of
Classical Findings: urethra → Mild narrowing of
o ↑Fever and ↑WBC urethra → Bladder outlet
This is related to acute infection of obstruction → Mild detrusor
the prostate irritation → Storage LUTs
o Tender and boggy prostate on DRE • Urinary frequency and urgency
This is secondary to enlarged and
infected prostate
o Lower Urinary Tract symptoms (LUTs)
Bacterial infection of the prostate →
Acute inflammation of the prostate
→ ↑Compression of urethra →
↑Narrowing of urethra → Bladder
outlet obstruction → ↑Detrusor
irritation → Storage LUTs
Urinary frequency and urgency
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C. Prostatitis
a) Acute Prostatitis
Pathophysiology: Acute <35y
o Bacterial infection of the prostate → Acute inflammation of
Gonorrhea
the prostate → ↑Compression of urethra → ↑Narrowing of Chlamydia
urethra → Bladder outlet obstruction →
↑Detrusor irritation and ↑Urine retention →
Lower urinary tract symptoms (LUTS) arise
Infection
Causes: Tender +
o Gonorrhea or Chlamydia → Sexually transmitted infection of on DRE Prostate
the prostate Inflammation
Assess for patients < 35 y
o [Link] → Infection of the prostate Compression
Assess for patients > 35 y of Urethra
Classical Findings: Urine Retention
o ↑Fever and ↑WBC Acute
Fever Detrusor Irritability
This is related to acute infection of the prostate
WBC
o Tender and boggy prostate on DRE Pelvic Storage LUTS
This is secondary to enlarged and infected prostate Pain
o Lower Urinary Tract symptoms (LUTs)
Bacterial infection of the prostate → Acute inflammation of
the prostate → ↑Compression of urethra → ↑Narrowing of Urgency
urethra → Bladder outlet obstruction → ↑Detrusor irritation Frequency
→ Storage LUTs
Dysuria*
Urinary frequency and urgency
b) Chronic Prostatitis
Pathophysiology: >35y Chronic
o Bacterial infection of the prostate → Chronic inflammation of
E. coli
the prostate → Mild compression of urethra →
Mild narrowing of urethra →
Bladder outlet obstruction → Mild detrusor irritation and mild
urine retention → Lower urinary tract symptoms (LUTS) arise
Infection
Causes:
+ Tender
o Recurrent infections with [Link] → Chronic infection of the Prostate on DRE
prostate Inflammation
Classical Findings:
o Lower Urinary Tract symptoms (LUTs) Compression
Bacterial infection of the prostate → Chronic inflammation of of Urethra
the prostate → Mild compression of urethra → Mild
Urine Retention
narrowing of urethra → Bladder outlet obstruction → Mild
Chronic
detrusor irritation → Storage LUTs Detrusor Irritability Fever
• Urinary frequency and urgency WBC
Storage LUTS Pelvic
Pain
Urgency
Frequency
Dysuria*
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II. Complications of Prostate Disorders
A. Urinary Tract obstruction B. Urinary Tract Infection (UTI)
Pathophysiology: Pathophysiology:
o BPH and acute prostatitis → o BPH and acute prostatitis →
Compression of urethra/bladder outlet → Compression of urethra/bladder outlet →
Retention of urine in bladder → ↑Retrograde flow of urine → Retention of urine in bladder → ↑Urinary stasis →
↑Distention of ureter and kidney → Hydronephrosis arises → ↑Bacterial colonization → ↑Risk of infection
↓GFR Presentation:
Presentation: o Dysuria and Urinary frequency
o Postrenal AKI o UA with microscopy with evidence of infection:
↑Creatinine and ↑BUN LE and Nitrite (+)
↓Urine output Urine WBC > 100
Renal U/S with hydronephrosis ↑Bacteriuria
C. Prostate Abscess
Pathophysiology:
o Acute prostatitis → Infection that becomes walled
off/encapsulated in and around the prostate
Presentation:
o ↑Fever and ↑WBC
This is related to acute
infection of the prostate
and now abscess
o ↑Pain in perianal region
Oftentimes so severe
patients is unable to sit
down because of the pain
o ↑Risk of sepsis
Bacteria from abscesses and
prostate can seed into the
bloodstream → Sepsis
• This can be exacerbated by DRE
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III. Diagnostic Approach to Prostate Disorders
Diagnostic Approach to
Prostate Disorders
Suspect BPH Suspect Prostatitis
Obtain Obtain
PSA and DRE CBC , UA with Urine Culture +/- Prostate massage
↑WBC WBC
Enlarged, + UA and Urine culture
PSA > 4 Variabele UA and Urine culture
Firm,
Rubbery
Diagnotic of Acute Prostatitis Suspect Chronic Prostatitis
Suspect Prostate abscess?
Diagnostic of BPH
Obtain Obtain
Transrectal U/S DRE
Nontender and boggy during
Abnormal U/S (+)
prostate massage via four-glass test
Prostate Abscess Diagnostic of Chronic Prostatitis
A. Assess for the presence of BPH B. Assess for the presence of Prostatitis
1. Obtain Prostate-Specific Antigen and DRE 1. Obtain CBC, and Urine Analysis
Indications: with Urine Culture after Prostate Massage
o Assess for the presence of BPH Indications:
Abnormal Findings: o Assess for the presence of prostatitis
o ↑ Prostate-Specific Antigen (PSA) Abnormal Findings:
This can be elevated in both BPH and prostate cancer o ↑WBC on CBC
• It's important to monitor the trend of PSA levels as a This can be elevated in acute prostatitis also often
steady rise may suggest cancer over BPH associated with fever and pain over the perianal region
o Digital Rectal Exam (DRE) o (+) UA and (+) Bacterial Growth on Urine Culture
shows an enlarged, firm, and rubbery prostate in BPH This is present in acute prostatitis as there is an acute
• As compared to prostate cancer which would reveal a hard infection of the prostate that is intimately connected to the
and irregular prostate urinary tract (at the urethra level)
• It is suggested to try and avoid prostate massage in
suspected acute prostatitis as this can seed bacteria into
the bloodstream. However, if massaged, it is very tender
and boggy in acute prostatitis
o Nontender and Boggy Prostate on Prostate Massage
Consistent with chronic prostatitis, and often these patients
have variable UA and Urine culture results, and it is difficult
to diagnose
FIGURE 1. DIGITAL RECTAL EXAM (DRE)
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C. Assess for the presence of a Prostate abscess
1. Obtain a Transrectal U/S
Indications:
o Worsening Fever, leukocytosis, and pain in a patient with acute
prostatitis suggesting prostate abscess
Abnormal Findings:
o Hypoechoic or Anechoic mass in the prostate that appears
fluid-filled
FIGURE 2. PROSTATIC ABSCESS
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IV. Treatment of Prostate Disorders
A. Benign prostatic hyperplasia (BPH)
1. Medical Management
a) Alpha-1 Blockers
Agents:
o Tamsulosin
BPH Treatment
o Doxazosin
o Terazosin
Indications:
o Mild-moderate
sized BPH with mildly
elevated PSA
Purpose: Large Prostate Mild-Moderate sized prostate
↑↑PSA Mild elevation in PSA
o Relax internal urethral sphincter →
Allow urine to exit by ↓Bladder outlet obstruction
Shrink size? Symptom relief?
b) 5-Alpha Reductase Inhibitors
Agents:
o Finasteride 5-Alpha Reductase
Alpha-1 Blockers
o Dutasteride Inhibitors
Indications:
o Severe BPH with
moderately elevated
PSA
Refractory to combination medical therapy?
Purpose:
o ↓Size of prostate tissue →
↓Compression of urethra → Transurethral Resection
Allow urine to exit by ↓Bladder of Prostate (TURP)
outlet obstruction
Monitoring:
o Monitor for improvement in LUTS with Alpha-1 blockers and 5-
alpha reductase inhibitors
o Monitor for ↓PSA levels with 5-alpha reductase inhibitors
o Monitor BP with Alpha-1 blockers
o Monitor for Erectile dysfunction or ↓Libido with 5-alpha
reductase inhibitors
2. Surgical Management
Therapies:
o Transurethral resection of the prostate (TURP)
Indications:
o BPH refractory to medical management (e.g. combination
therapy)
Purpose:
o Debulk the prostate gland to reduce bladder outlet obstruction
and reduce LUTS
Monitoring:
o Monitor for fewer episodes of LUTS
FIGURE 3. TRANSURETHRAL RESECTION OF PROSTATE (TURP)
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B. Prostatitis
1. Medical Management 2. Surgical Management
Therapies: Therapies:
o Ceftriaxone PLUS Doxycycline o TURP
o Fluoroquinolones Indications:
Indications: o Refractory chronic prostatitis
o Ceftriaxone PLUS Doxycycline Purpose:
Acute Prostatitis secondary to gonorrhea/chlamydia o To remove the inflamed and infected tissue from the prostate
o Fluoroquinolones to reduce LUTS
Acute or chronic prostatitis secondary to [Link] Monitoring:
Purpose: o Monitor for fewer episodes of LUTS
o Eradicate infectious material from the prostate thus reducing
inflammation
Monitoring:
o Monitor for improvement in fever, pain, and WBC count in
acute prostatitis
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