MMD Male pathology
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BPH affects 1/4 of all men ages ___-___
__ is a glandular organ of the male reproductive tract that produces fluid used for sexual lubrication. It sits periurethral.
Hyperplasia of the prostate typically arises in the zone of the prostate immediately adjacent to the ___
Histologic changes in the prostate can begin as early as _ yo and escalate steadily with age. Clinical signs or manifestations can begin around age __
__ is caused by a benign growth in the prostate that has stromal and muscular hypertrophy and is encapsulated within a rubbery nodule
Explain the pathophysiology of how BPH causes urinary retention and futher damage to the GU tract
- The growth of BPH nodudle do not allow the prostate to snap open during urination allowing urinary flow
- chronic resistance to the opening of the prostate for urinary passage (or a chronic intravesical pressure of 40cm H2O during voiding) increases collagen deposition on the walls of the detrusor and detrusor hypertrophy
- detrusor hypertrophy produces scar tissue, contractures and trabeculatiosn alon with pockets of cellules and diverticula
- If there is an incresed resitance throught th eprostate even further then the bladder has to squeeze even harder which chan blow out the already damaged wall leading to dialation, distention and weakening.
- At the point the bladder can begin backing up urine into the kidneys and cause damage to ureters and hydronephrosis
Diagnostic studies for the dx of BPH include
- Cystometrogram/pressure flow
- Symptom score of IPSS
- 0-7 is mild rarely need tx
- 8-19 is moderate and typically prospective studies requrie minimum score of 14-15 treated
- 20-35 is severe and is always treated b/c of the risk for bladder and kidney failure
What is the most commonly used assessment tool for underlying bladder issues?
Peak flow rate
A max flow on peak flow evaluation should be around __
for a peak flow rate test is it better to have more or less area under the curve?
What is a transrectal ultrasound and when would you do one?
- in evaluation of BPH
- Different echo texture around urethra means BPH
- similar to fibroids in uterus
- Broadening mass throught hte anterior or the prostate
- when growth is under the urethra = symptomatic more but do better with surgery
- Enlargement of the stromal tissue at the opening is typically found in younger guys and they dont do as well with medical treatment
In BPH, enlargement of the stromal tissue around the opening of the prostate is
A. Found in older men
B. is found in young men with bad surgical outcome
C. is associated with a benign completely asymptomatic coruse
D. the most symptomatic
B. Stromal tissue around the opening of the prostate is found in younger men and goesnt do as well with surgcal threarpy it does better with medical managment
(this multiple choice question has been scrambled)
When growth in BPH is under the urethra, pts are (more or less) symptomatic but tend to have (better? or worse?) surgical outcomes
- more symptomatic
- better surgical outcomes
What are the two main drug classes used for the treatment of BPH
- 5alpha reductase inhibitors
(alphablockers or 5 alphas) are better for a small prostate with less glandular growth and more muscle hypertrophy
name some alpha blockers
terazosin, doxazosin, tamsulosin, alfuzosin
SEs of alpha blockers
headache and orthostasis
How do alpha blockers work?
alpha adrenergic antagonists relax the outlet without imparing bladder body contration and facilitate better opening of the prostate during voiding
__ (alpha blockers or 5 alpha reductase I) are best for a prostate that has glandualr hypertrophy not muscular, large prostates.
5-alpha reductase inhibitors
name 2 5alpha reductase inhibitors
how do 5 alpha reductase inhibitors work?
- inhibit enzymatic process of dihydrotestosterone to testosterone and changes the intracellular process
- Causes atrophy and induces apoptosis of the prostate
- Light hormonal therapy
What are the SEs of 5 alpha reductase inhibitors
- Sexually related sx
- decresaed libido
- breast enlargement
What are some minimally invasive therapies for BPH?
- thermotherapy: usually gives 2-3 yrs of sx relief
- Microwave: probe blased in prostate, microwaves transmitted up the probe and head the inside of the prostate to kill the tissue. Goal is to create a lesion of coagulative necrosis. Core hemorrhagic necrosis peaks at 8-14 days then starts to resolve
- Interstitial laser
- Hot water balloon
How does microwave/thermotherapy for BPH work?
- thermotherapy: usually gives 2-3 yrs of sx relief
- Microwave: probe blased in prostate, microwaves transmitted up the probe
- and head the inside of the prostate to kill the tissue. Goal is to
- create a lesion of coagulative necrosis. Core hemorrhagic necrosis peaks
- at 8-14 days then starts to resolve
__ is a surgical proceedure for BPH that is most effective, it is potentally bloody operation so it is preferable to do only in relatively young and healthy pts
- resection of the prostate in BPH
- goes with endoscope through urethra
- scrapes off hypertrophy in prostate creating a permanent patent funnel
- gland volume 30-100g electrocaudery TUR syndrome
- essentially a sphinchterotomy
- Small glands in younger pts
What are the benifits of using contact laser therapy for BPH resection?
- Boils the tissue off
- uses saline
- less blood loss
- large glands are easier to resect this way
- less cath use
- cant give saline with surgical b/c of bleeding (saline in wound = bad)
For BPH glands over 100g what type of surgery do you have to do
__ is the most common cancer seen in men other than skin cancer
prostate cancer tends to be (slow growing? or aggressive?)
__ is the most common type of cancer causing prostate cancer
T or F prostate cancer are typically not reponsive to androgens?
False. Prostate cancer typically arises from cells that produce seminal fluid and are receptive to androgens testosterone, dehydroepiandosterone and dihydrotestosterone
Describe the progression/pathophysiology of prostate cancer
- it is typically an adenocarcinoma that arises from cells that produce seminal fluid
- early displasia is small clumps of cancer cells confined to an otherwise normal prostate gland this can be either classified as carcinoma in situ (histological changes suggestive of cancer) or PIN prostatic intrepithelial neoplasia thoguth to be a precurosor to true cancer
- Small stromal clumps then grow bigger and spread to the stroma of the prostate which is when the typical tumor develops and the disease becomes clinical with typical sx and signs
Prostate cancer likes to mets to...
- Bones (rout to bones is through the prostatic venous plexus draining the prostate and connecting to the vertebral veins)
- Lower uterus... oh wait sry ureters
What are the risk factors for developing prostate cancer?
- Ethnicity (african americans high risk, native americans and asians low risk)
- environmental factors
Sx of prostate cancer include
- difficulty urinating
- erectile dysfunction (difficulty achieving an erection, painful ejaculation)
- Frequent urination
- difficulty starting and maintaining a steady stream of urine
- Advanced disease: most common mets to bone of vertebrae pelvis and ribs causing pain
- spinal cord copression causes leg weakness and urinary and fecal incontinence
Diagnostic studies for prostate cancer??
- Digital rectal exam
- Endorectal MRI
- Bone scan
T or F ultrasound is the test of choice for diagnosing prostate cancer
FALSE ultrasound has no roll in diagnosing prostate cancer
Grade _ prostatic cancer is slow growing and not likely to be metastatic
Grade __ and __ are more likely to be faster growing and met
What is PSA and why do you order it?
- Serine protease antigen
- Serine protease is produced by both normal and malignant prostate tissues
- Its half life is 2-3 days
- false + occur in BPH, ejactulation, prostatitis, and prostatic infarcts, endoscopic manipulation and biopsy
- standard cutoff is 4.0 above is abnormal
- does not corrolate with the tumor stage or extent
What is the treatment for low risk prostate cancer?
- monotherapy is sufficient for nearly all
- eventually the pt will need surgery
- active surveillance
Arterial supply to the penis is mediated by what spinal segments
___ is a drug that inhibits the parasympathetic nerves from releaseing ACH. (ACH catalyzes the conversion of cAMP to AMP causing smooth muscle relaxation and blood to flow from the penis
MOA of sildenafil
NO is realeased from teh cavrounous nerves and catalyzes the conversion of GMP to cGMP in the cavernous smooth muscle cells cGMP facilitates the smooth muscle relaxation via protein kinase action and leads to ED. Sildena fil and other PDE 5 agntns catalyze the conversion of cGMP to 5 GMP abolisthing the effector or relaxation
What are the categories of ED?
What are the two most common causes of ED?
diabetes and atherosclerosis
What are some drugs that can cause ED?
- Antihypertensives: thiazide diuretics and beta blockers
- Estrogens and GnRH agonists
- H 2 receptor blockers and spironolactone
- antidepressante and antipsycotics: neuroleptics, tricyclics and selective serotonin reuptake inhibitors
- Recreational drugs: ethanol, cocaine, marjiuanna
What are some risk factors for ED?
- diabetes mellitus
- coronary artery disease
- lipid disorders
- advancing age
- peripheral vascular disease
- endocrine or neurologic disorders
- surgery near bowel bladder prostate or vascular proceeures
Sx of ED
- loss of libido
- inability to initate or maintain an erection
- Ejaculatory failure
- premature ejactulation
- inability to achieve orgasm
Diagnostic examinations for ED
- measure serum testosterone and prolactin
- maybe penile arteriograpy or electromylography
- doppler ultrasound
- postage stamp test
What is the Tx of ED?
- Correct the underlying disorder or d/c the drug
- Oral PDE5: sildenafil, tadalafil, vardenafil. onset approx 60-100mins, contraindicated in men recieving nitrate therapy for CHF
- Vaccume devices or injection of alprostadil into the urethra or corpora cavernosa
- penile prosthesis
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