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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3055_Библиотеки_им_академика_М_И_Перельмана.pdf
478
discussed further as it has not been sufficiently studied to
determine natural history or need for treatment.
Decision-Making/Differential Diagnosis
Acute Bacterial Prostatitis
Patients with acute bacterial prostatitis will present with rela-
tively sudden-onset urologic symptoms including irritative
(dysuria, frequency, urgency) and/or obstructive symptoms
[3]. Risk factors include BPH, recent genitourinary infections,
high- risk sexual behavior or history of sexually transmitted
infection, and procedural or surgical prostate manipulation
such as urethral catheterization or transrectal biopsy. Physical
exam and laboratory analysis will provide evidence of bacte-
rial infection of the prostate.
Other genitourinary tract infections like cystitis and urethri-
tis can present similarly, and the differential diagnosis can be
broad. Among gastrointestinal conditions, diverticulitis and
proctitis can present with lower abdominal pain and fevers and
should be considered if urinary symptoms are not prominent.
Finally, clinicians should consider prostatic abscess if fevers or
other symptoms persist despite appropriate antibiotics.
Chronic Bacterial Prostatitis
Some patients with acute bacterial prostatitis will continue to
have chronic or recurrent urogenital symptoms with evidence
of bacterial infection of the prostate [4]. When symptoms
Table 30.1 NIH
classification of prostatitis
(1999)
I. Acute bacterial prostatitis
II. Chronic bacterial prostatitis
III. Chronic prostatitis/chronic
pelvic pain syndrome
A. Inflammatory
B. Noninflammatory
IV. Asymptomatic inflammatory
prostatitis
M. Fried
479
have lasted for 3 months or longer with identical culture
results, the disease is classified as chronic bacterial prostatitis.
Risk factors for this entity are unclear, but retrospective
analyses have suggested prior manipulation of the urinary
tract, and higher prostate volumes may be risk factors for
chronic bacterial prostatitis [5].
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
(CP/CPPS)
The NIH separates this entity into an “inflammatory” and
“noninflammatory” category [2]. Presence of inflammatory
cells expressed in prostatic secretions, post-prostate massage
urine or seminal fluid distinguishes the inflammatory cate-
gory. In addition to pain and lower urinary tract symptoms
(LUTS), CP/CPPS has a much higher incidence of sexual
dysfunction including erectile dysfunction and ejaculatory
pain than other etiologies of prostatitis [6].
Other Chronic Etiologies
Interstitial cystitis/bladder pain syndrome is a complex disor-
der characterized by chronic bladder discomfort. More com-
mon in women than men, the pain or pressure is usually
relieved by voiding. It commonly coexists with other chronic
pain syndromes including fibromyalgia and irritable bowel
syndrome [7].
Bladder cancer most commonly presents with painless
hematuria. However, voiding symptoms or abdominal pain
may be present in carcinoma in situ or locally advanced dis-
ease, respectively (Fig. 30.1).
Key History and Physical Exam
The chronicity and severity of symptoms is the most impor-
tant information to gather initially. Patients with acute bacte-
rial prostatitis may require inpatient admission if there is
suspicion for bacteremia (persistent fevers or chills) or if they
cannot tolerate oral medications. Failed outpatient manage-
ment is also an indication for admission [3].
30. Prostate Problems
480
Fig. 30.1 Approach to patient with symptoms concerning for prostatitis
Symptoms concerning for prostatitis
(dysuria, lower abdominal pain
Acute onset of
symptoms
Tender/edematous prostate on exam?
Yes
Symptoms
concerning for
bacteremia (high
fever, inability to
tolerate food?
Yes
Refer to
ED for IV
antibiotics
and inpatient
treatment
No
Treat acute
bacterial
prostatitis
(see table 2)
No
Urethral
dischage
or history
concerning
for sexually
transmitted
infection?
Treat for STI
(see table 2)
Urinalysis
indicative of
infection
(positive nitrites,
leukocyte
esterase)
Treat for
cystitis
Chronic or
recurrent symptoms
History of acute prostatits
Yes
Tender/edematous
prostate on exam?
and/or
urinalysis/urine culture
indicative of infections
Yes
Treat for
chronic
bacterial
prostatitis
No
Consider
chronic
prostatitis/
chronic pelvic
pain syndrome
No
Urinalysis
Hematuria
present
Urine
cystology
and refer to
urology
for
cystocopy
Urinalysis
unremarkable
Consider
interstitial
cystitis/bladder
pain syndrome
Stepwise
management,
consider
referral to urology
cystocopy
Evidence of
infection
(bacteria,
leukocyte
esterase,
nitrites
Treat for
chronic
bacterial
prostatis
Consider
evaluation
for predisposing
factors
M. Fried
481
Most patients with prostatitis can be treated as outpa-
tients. If so, a full characterization of urinary complaints with
attention to irritative or obstructive symptomatology is
important to both determine risk factors and comorbid con-
ditions such as BPH. Clinicians should also take a full sexual
history to determine the need to treat for sexually transmit-
ted infections and should also evaluate for erectile dysfunc-
tion or pain with erections. Gastrointestinal symptoms should
be evaluated, including constipation, diarrhea, and tenesmus
if diverticulitis or proctitis is suspected. A medical history
significant for similar symptoms in the past may suggest
chronic bacterial prostatitis, and history of sexually transmit-
ted infections or urologic procedures is also relevant [3].
The physical exam of a patient with suspected prostatitis
should include both a full genitourinary (GU) exam and digi-
tal rectal exam (DRE). The GU exam should check for phi-
mosis which increases risk for bacterial prostatitis as well as
ulcers, vesicles, or discharge that may suggest an STI. The
DRE should assess for tenderness, edema, and size of the
prostate. If acute bacterial prostatitis is suspected, DRE
should be done gently or avoided as vigorous prostatic mas-
sage can induce bacteremia. Patients with acute or chronic
bacterial prostatitis typically have the classic “boggy” or
edematous prostate. This should be absent in CP/CPPS. If
obstructive symptoms predominate, a post-void bladder
residual volume may be assessed by ultrasonography.
The laboratory evaluation of prostatitis includes a urinaly-
sis and urine culture in all patients. The urine collected should
be midstream as abnormalities of early-stream urine reflect
urethral meatus pathology, while abnormal findings in late-
stream urine reflect bladder pathology. Prostatic fluid sam-
pling, performed by collecting a urinalysis and culture after
prostatic massage, may be useful especially when evaluating
for chronic prostatitis. Serum complete blood count and cre-
atinine level should be checked for leukocytosis or renal
insufficiency indicative of systemic infection or hydronephro-
sis, respectively. Additionally, a human immunodeficiency
virus (HIV) screening test should be offered to all patients in
30. Prostate Problems
482
addition to Neisseria gonorrhea and Chlamydia trachomatis
PCR testing if indicated. Urine cytology may be considered if
hematuria and risk factors for bladder cancer (smoking, age
>40) are present. Serum levels of prostatic specific antigen
(PSA) will likely be elevated in the setting of prostatitis. This
may be useful when entertaining other organ systems in the
differential diagnoses. If prostate cancer screening is planned,
it should be deferred until 1 month after the symptoms of
prostatitis are completely resolved.
Treatment
Antibiotics are the mainstay of therapy for acute and chronic
bacterial prostatitis. Both entities can be treated empirically
while awaiting culture data. Table 30.2 lists optimal choices
for empiric treatment of bacterial prostatitis [8]. Chronic or
recurrent bacterial prostatitis should be treated with one of
these agents for at least 6 weeks [9]. Culture-directed therapy
should commence once that data is available. In addition to
antibiotics, evaluation into predisposing behavioral or ana-
tomic risk factors should be considered and may require
assistance from urologic specialists.
The treatment of CP/CPPS is far more challenging. The
NIH chronic prostatitis symptoms index (NIH-CSPI) is a use-
ful tool for tracking response to therapy [10]. Alpha-adrenergic
Table 30.2 Empiric treatment of acute bacterial prostatitis (all
courses 10 days unless otherwise specified) [8]
• Ciprofloxacin 500 mg every 12 h
• Levofloxacin 500 mg once daily
• Trimethoprim-Sulfamethoxazole: one double-strength tab
orally every 12 h
If patient has risk factors for STIs:
• Ceftriaxone 250 mg intramuscularly × one dose
• Doxycycline 100 mg twice daily
M. Fried
483
antagonists, antibiotics, and 5-alpha-reductase inhibitors are
the three main classes of therapies with good evidence of effi-
cacy [11]. In one study the combination of tamsulosin 0.4 mg
daily and ciprofloxacin 500 mg twice daily for 6 weeks had the
best response compared to placebo [12]. Given the high
prevalence of comorbid psychosocial problems in this group
of patients, referral for cognitive behavioral counseling is a
reasonable option. Acupuncture and physical therapy are
alternative options that may be helpful as well.
Benign Prostatic Hyperplasia
BPH is characterized by lower urinary tract symptoms (LUTS)
such as urinary hesitancy (difficulty initiating micturition),
incomplete voiding, or weak stream. BPH is uncommon in men
younger than 40 years of age, but histologic evidence of the
condition is near universal in men over 80 years of age [13].
Decision-Making/Differential Diagnosis
It is important to recognize that LUTS are not specific for
BPH, and the presence of these symptoms may indicate several
different disorders [14]:
• Overactive bladder (OAB): Will have a predominance of
storage symptoms without evidence of outlet obstruction.
However, longstanding BPH may cause bladder remodel-
ing that increases risk for developing OAB with concomi-
tant outlet obstruction.
– Sometimes subcategorized into neurogenic and non-neu-
rogenic. Prior stroke, Parkinson’s disease, multiple sclero-
sis, or spinal cord injury may lead to neurogenic OAB.
• Urethral stricture (including bladder neck obstruction or
contracture): Usually patients will have a history of ure-
thral trauma, urethral instrumentation, or urethritis.
• Bladder calculi or bladder carcinoma: These may present
with gross hematuria or pain in bladder region in addition
to LUTS.
30. Prostate Problems
484
• Prostatitis: This is characterized by lower abdominal/pelvic
pain usually with irritative symptoms. See above.
• Prostate carcinoma: This is often asymptomatic, consider
screening with PSA.
• Medications causing LUTS: These may include antidepres-
sants, diuretics, bronchodilators, and antihistamines.
Key History and Physical Exam
When men present with LUTS, the clinician should first
evaluate the severity of the symptoms. This can be done by
using a validated tool such as the International Prostate
Symptom Score (IPSS) [15]. When a patient complains of
obstructive urinary symptoms, it is important to identify
which of the following categories are present:
• Storage symptoms: urgency, daytime frequency, nocturia,
and urgency incontinence (defined as involuntary leakage
accompanied or preceded by urgency)
• Voiding symptoms: slow stream, flow that stops and starts
(intermittency), straining to void, terminal dribble, or
dysuria
• Post-micturition symptoms such as sensation of incomplete
emptying and post-micturition dribble (occurring after
leaving the toilet as opposed to the terminal dribble)
The physical exam should include a GU exam as well as
DRE to assess the size, texture, and presence of nodularity
concerning for prostate cancer. If OAB is suspected, a
focused neurologic exam is also indicated. The laboratory
workup could include urinalysis and urine culture if prostati-
tis is being considered. The decision to send a PSA is dis-
cussed below (Fig. 30.2)
Treatment
Behavioral modification is the first step regardless of symptom
severity [16]. Such interventions include avoiding fluids prior
to bedtime and reducing natural diuretics like caffeine and
alcohol. Classifying a patient’s symptoms has important thera-
M. Fried
485
Fig. 30.2 Approach to patient with lower urinary tract symptoms
Patient presents with lower urinary tract symptoms (LUTS)
Quantify symptoms -
consider using a
validated tool such
as international
prostate symptom
score (IPSS)
Detailed history
Medications that
may cause LUTS:
antidepressants,
diuretics,
bronchodilators,
antihistamines
Neurologic symptoms
or prior neurologic
injury
Higher probability
of neurogenic bladder
or non-BPH bladder
outlet obstruction.
Consider check of post
void residual by US or
referral to urology
Digital rectal exam
with concerning
features (nodularity)
Discuss prostate
cancer screening
with PSA, and
obtain urology
referral
Yes No
Predominant
storage symptoms
(urgency, nocturia,
daytime frequency)
Consider
overactive bladder
(OAB)
Antimuscarinic
agent
Predominant
voiding symptoms
(slow stream,
intermittency,
straining to void)
Benign prostatic
hyperplasia likely,
especially if
age > 40
Medical Treatment:
Surgical Treatment:
refer to urology
for evaluation
1. Prostate-specific
alpha-adrenergic
antagonist
2. 5-alpha
reductase inhibitors
Check post-void
residual prior to
initiating therapy
for OAB,
use caution if >
250-300mL
Prior urologic diseases
(prostatits, UTIs) or
procedures
Stop medication if
possible
30. Prostate Problems
486
peutic implications. Those patients who have storage symp-
toms may benefit from prostate-specific alpha blockers such as
tamsulosin with or without the addition of 5-alpha-reducase
inhibitors such as finasteride. The addition of an antimuscarinic
agent may be useful if the patient has OAB [17]. Oxybutynin
and tolterodine are examples of such agents and, as a class,
have significant side effects such as dry mouth, blurry vision,
and drowsiness that often limit the patient’s tolerability.
Peripherally acting antimuscarinics, e.g., darifenacin, theoreti-
cally have fewer side effects. It is prudent to ensure that
patients do not have elevated post-void residual volumes
(greater than 300 mL) prior to initiating an antimuscarinic
agent. Herbal medications like saw palmetto have traditionally
been used to treat BPH. However, a recent Cochrane meta-
analysis found that saw palmetto was not more effective than
placebo in reducing LUTS in men with BPH [18].
Surgical treatment remains an option in the setting of
medication failure or intolerance. At this point referral to a
urologist is indicated.
Prostate Cancer
Prostate cancer is the most commonly diagnosed non-skin
cancer in men with an expected 180,000 new cases in 2016
[19]. The majority of cases are diagnosed in men older than 60.
However, with prostate-specific antigen (PSA) screening rates
declining, we may soon see a shift in the epidemiology of this
disease. This continues to be an area of controversy and cur-
rent guidelines vary dramatically among various organizations
for both screening and treatment of prostate cancer.
Decision-Making/Differential Diagnosis
The differential diagnosis for prostate cancer includes the
other diagnoses discussed in this chapter. However, the deci-
sion to screen for prostate cancer using serum PSA levels is
among the most complex and controversial issues in medicine.
Data from large, well-designed randomized trials are inconsis-
tent in mortality reduction, and those that do support screen-
M. Fried
487
ing suggest a small absolute risk reduction [20, 21]. The harms
from screening are also significant and include risk of infec-
tious complications of biopsy, overdiagnosis of cancers that
would never become clinically significant as well as high mor-
bidity from prostate cancer treatment including operative
mortality and postoperative incontinence, sexual dysfunction,
and bowel problems [22]. Due to these complexities, the US
Preventive Services Task Force (USPSTF), the panel which
makes evidenced based recommendations for various screen-
ing tests, has given PSA screening a grade D, recommending
against the service [23]. The American Urological Association
(AUA) 2013 consensus statement recommends shared deci-
sion-making for men aged 55–69 and to avoid routine screening
with PSA outside of this age group [24].
Key History and Physical Exam
Risk factors for prostate cancer may influence a patient’s
decision about whether to undergo screening for the disease.
The most important risk factor for prostate cancer is age
[25]. Outside of this, prostate cancer is more common in
Black than White or Hispanic men, and the age of onset is
earlier in African- Americans than comparative groups [26].
An affected first- degree relative is also associated with an
increased risk of prostate cancer.
Although once thought to be a reliable screening tool, the
DRE is not recommended to evaluate for prostate cancer.
However, incidentally found nodularity, asymmetry, or indu-
ration on DRE may influence the decision to use PSA as a
screening tool for prostate cancer.
Treatment
Surgery and radiation therapy have been the treatments most
commonly offered for men diagnosed with prostate cancer.
However, a recently published study that compared active
monitoring, radical prostatectomy, and external beam radio-
therapy suggests that prostate-cancer-specific mortality is low
and not significantly affected by treatment [27].
30. Prostate Problems