Diseases of the Prostate

acute bacterial prostatitis
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Terms in this set (19)
acute bacterial prostatitis
a bacterial infection of the prostate that presents within a short time frame; caused by bacteria associated with UTIs (most commonly E coli, then Pseudomonas aeruginosa and Klebsiella)

caused by ascending urethral infection most commonly; rarely direct inoculation of the prostate or spread from another source occurs

risk factors include BPH, GU infections, STIs, immunocompromised patients, prostate manipulation

clinically presents with fever, chills, irritative symptoms (painful urination, frequency), obstructive symptoms (bladder outlet obstruction, hesitancy), perineal pain; also painful ejaculation, hematospermia and painful defecation

DRE is contraindicated as it can result in bacteremia (other sources say use a gentle DRE); prostate is tender to palpation

H&P alone is usually sufficient for diagnosis; UA and midstream UC before abx (35% of UC will not produce an organism)
chronic bacterial prostatitis
bacterial infection of the prostate that causes symptoms over a longer period of time; bacteria normally associated with UTI (most common is E coli followed by enterococcus); less than 5% of cases are due to this; risk factors include conditions allow for retrograde movement of urine into urethra and prostate (urethral stricture, BPH, history of STI or instrumentation, presence of foreskin)

clinically presents as pain (lower back, pelvis, genitalia), painful urination, pain during ejaculation, difficulty voiding (i.e. obstructive symptoms) sexual dysfunction, anxiety, stress, depression

symptoms last for 3 mos or longer; cultures consistently grow the same organism
chronic pelvic pain syndrome
formerly known as chronic abacterial prostatitis; chronic pain (lasting >3 mos) related to changes in the prostate, but without positive cultures, and which causes around 90% of cases of prostatitis

damage to prostate triggers central pain sensitization, resulting in chronic neuropathic pain (similar to fibromyalgia, endometriosis and irritable bowel syndrome); risk factors are unknown

presents with pain (lower back, pelvis, genitalia), painful urination, pain during ejaculation, difficulty voiding (i.e. obstructive symptoms), sexual dysfunction, anxiety, stress, depression, which lasts >3 mos

lab testing will show no consistently positive cultures; diagnosis of exclusion (chronic bacterial prostatitis and other conditions must be excluded); overlaps with interstitial cystitis (i.e. similar clinical situation of chronic pelvic pain that is not associated with bacterial infection)
asymptomatic inflammatory prostatitis
prostatitis in which there is no back pain or other symptoms; the diagnosis is made when leukocytes or bacteria are found in the urine during work-up for another condition, and other conditions can be excluded
granulomatous prostatitis
produces induration, and thus can mimic cancer; there it is often biopsied; associated with BCG (bacille calmette-guerin), which can be used for the treatment of bladder cancer
benign prostatic hyperplasia (BPH)
enlargement of the prostate gland due to hyperplasia of glandular and stromal elements (condition used to be referred to as benign prostatic hypertrophy, but enlargement of gland is likely due to combination of both)

due to excessive androgen-dependent proliferation of glandular and stromal components of the organ; DHT has the greatest activity in the disease process

50% of men >40 have histologic evidence of this; of which 30-50% will develop lower urinary tract symptoms (storage, voiding, and post-micturition); patients can have hematuria

grossly, the gland is larger than normal; involves the central portion of the gland adjacent to the urethra (inner transition zone) and thus can compress the urethra; nodules are well-circumscribed, tan and bulge from the cut surface of the gland; microscopically there are nodules of hyperplastic glands divided by proliferated stromal elements

DRE is more used to detect prostate adenocarcinoma
increased risk for UTIs, bladder hypertrophy and hydronephrosis as the enlarged prostate can potentially block urine flow, putting strain on the bladder leading to hypertrophy and causing back-up of urine, leading to hydronephrosis; post-renal azotemia can occur; essentially no increased risk for carcinoma associated with BPH
complications of BPH
level of PSA correlates with the total volume of the prostate; a PSA of 1.5 ng/dL indicates a prostate of >30 g; prostate volume can be measured via US testing

treatment can include transurethral resection of the prostate, blockade of formation of DHT with 5-alpha-reductase inhibitors; relaxation of prostatic smooth muscle with blockade of alpha-1 adrenergic receptors
diagnostic testing and treatment for BPH
prostatic adenocarcinoma
neoplastic process involving the prostate and which is derived from epithelial cells (other tumors can occur in the prostate, but this is the most common one); highest rates in African-Americans and Scandinavian countries and environment (i.e. people that move from Japan - low risk country, to United State - high risk country, their risk increases)

25% of cases of cancer in men with most being > 50 years of age; most pts are asymptomatic; cancer arises in the peripheral regions (peripheral zone), so the tumor is less likely to cause urinary tract obstruction; pts can have hematuria and can also present with metastatic disease - mets to the bone are most common and are often osteoblastic (one of a few tumors known to produce osteoblastic metastases)
grossly, it is often not visible, but when visible may be an ill-defined tan-gray or yellow-tan mass; microscopically at low power there are small glands back-to-back

at higher power, there is a single cell layer; prominent nucleoli; mitotic figures are uncommon; blue mucin and crystals; perineural invasion is common
pathologic changes seen with prostatic adenocarcinoma
Gleason gradeused to grade prostatic adenocarcinoma; it is based upon the two most common histologic types present in the tumor being examined with each type graded from 1 to 5, with 3 being well-formed glands, 4 being some joining of glands, and 5 being mostly single cells and clusters of cells. A typical Gleason grade might be 4+3, meaning the most common architectural pattern is a 4 and the second most common architectural pattern is a 3.androgen-regulated promotor of the TMPRSS2 gene-ETS fusion (others: activation of PI3K/AKT, mutation of tumor suppressor gene, PTEN)genetic changes associated with prostatic adenocarcinomaatypical glands; prostatic intraepithelial neoplasia (PIN); Intraductal carcinoma of the prostate (IDC-P)precursor and possible precursor lesions for prostatic adenocarcinomaprostatic intraepithelial neoplasia (PIN)can be low grade or high grade; histology shows benign ducts lined by atypical cells; low-grade has no nucleoli and high grade has nucleoliintraductal carcinoma of the prostate (IDC-P)solid or dense cribriform pattern (not seen in PIN); loose cribriform or micropapillary pattern (can be seen in PIN), but with marked nuclear atypia or necrosis (both not seen in PIN)•If PSA was <4 ng/mL: most likely not cancer (if PSA is 2.1 to 3.6 ng/mL, risk for cancer is 4.6%; if PSA is 3.1 to 4.0 ng/mL, risk for cancer is 6.7%) •If PSA was >10 ng/mL: most likely cancer (99.5% chance of Gleason grade 7 or greater) •If PSA was >4 ng/mL but <10 ng/mL: uncertainhistorical interpretation of PSAcan detect insignificant tumors; can miss tumors; not specific to cancer; other causes of increased PSA include BPH, prostatitis, prostatic infarcts, instrumentation, ejaculationlimitations of PSAfree PSAPSA that is not protein bound; a higher percentage of free PSA indicates a lower risk for prostatic adenocarcinomahormonal therapy; radiation (i.e. insertion of radioactive rods into prostate); prostatectomy; prognosis is variable as the cancer can be relatively indolent to very aggressive and testing cannot distinguish between the twotreatment and prognosis for prostatic adenocarcinoma