Frequency of passing urine is Night only or diurnal , explain how start and progress , difficult to start , difficulty pass urine , stream poor , dribbling pass urine with out your knowledge , Those symptoms may be due to underline prostate gland problem.
Perinial pain , painfull ejaculation , Urethral discharge , vesicles or rash in perennial area are features of prostatitis.
malignant ,infective ,Obstructive
, irritating , sex symptoms
They are at risk of UTI ,Stone , Structural abnormality
Epididymoochitis , perennial trauma
Dysuria , color change ,↑↓ UOP , abdominal pain , fever,
lump and bump in genital area. , recurrent UTI
injury to back
( neurogenic bladder )
Surgical to prostate / PMH – STD, Prostate, DM , CA, long
term drugs , ( anticholinergic tricyclic sympathomimetic) over the counter
medication
Sexual history
EX- GCS Renal angle tenderness , Genitalia , PR(
Anal spincter tone , lessions , Prostate ,Mucosa move over prostate, lumber
spine curvature
Back examination ,
Abdomen – balatable kidney , renal angle tenderness ,
░IX –
UFR, Urine culture ,
FBS ,fbc ,esr,CRP, PSA
-----------? 1st void urine for gonoria clamedia
std screening ,
Prostetic messege fluids ( urine ),
seminal fluid analisis ,
▓Prostatitis
- Doxycycline 100 mg n 6 week to 11/2 month ,+ metronidazole levofloxacin ( oral only )
▓Acute
prostatitis – Amox genta (hospital) after settle , quinolone trimethroprin ( 2
week )….E coli , STD
▓Chemical
prostatitis – seminal vesical duct obstruct with microcalculi
▓ Acute
nun STI see culture report , change antibiotic accordingly ( Next follow up ) Augmentin
for nun STI 1 month .
█ How
decide nun STI – PH of discharge
E coli , clamedia , gonnoria ,
Drinking fluid more, Pass urine after sex and regular ,
SNAPS
Redflag s high fever , chils, ---infection goes up seems
█BPH
Obstructive Symptoms -- USS Pelvic +
rectal Biopsy + UDS - post void urine residual , flow rate ,
bladder pressure , electrical activity ) ,
█Exam
and PSA (>10) ---------à
urologist for USS guided biopsy -à
elderly watch full waiting , CA PSA > 20 , < 10 YR life / > 10 YR ,
young , PSA < 20 refer for surgery /
PSA high in prostatitis as well ( NL - <4)
█▓▓Few
days later patient come with scrotal pain epididymis ochitis ----take history
examine rule out torsion ----antibiotic, analgesic , scrotal support
▒Hormonal
-Orchiectomy surgical / medical
According to the level of the severity , age , Patients
wishes
░ Wait
and watch if > 70 and no significant symptoms that can effect patients
quality of life
▒radiotherapy
– significant symptoms , no fit for surgery , does not want surgery
Brachytherapy – higher amount radiotherapy
▒surgery
--- Radical therapy / endoscopic ( TURP )
Anesthetic and surgical
SE – PMS , Diarrhea
, mood
▒Traditional
--- not sure validity , or SE
▓ Follow
up with RFT, DRE, PSA
Prostetodinamia – culture negative ----treatment
with diazepam and amitriptyline like
Antichorlinergic – couse retention and then lead
to overflow incontinence ,
Antidepression – cause antichorlinergic effect as
well
BPH alfa blocker start ( quick ) --------relax , penesterate
----Shrink the volume /take longer the action , Psycho support , Caffein and
alcohol less, stop drinking before going to bed , urodynamic studies to find
significant of obstruction urine flow 10-20 ml/sec severe obstruction
TURP - Surgery is the gold standard of treatment, but it
does not help every patient. Avoid sex 1 month after operation , Retrograte
ejaculation , impotence complication follow up need PSA, PREX
These
drugs are notused for obstruction due to BPH, but rather for bladder
instability (frequency, urgency) which may mimic or coexist with BPH.
Anticholinergics
such as propantheline bromide, penthienate bromide and oxybutynin or tricyclic
antidepressants with anticholinergic effects such as imipramine, nortriptyline
and amitriptyline are occasionally used where there are severe irritative
symptoms but few obstructive symptoms. These drugs should only be considered
after a urodynamic assessment which confirms bladder instability and excludes
significant obstruction
Benign symptomatic prostatic
hypertrophy will affect up to 25% of men. Transurethral resection of the
prostate is an effective therapy, but has adverse effects and may not be
required in less severe cases. Medical therapies such as alpha blockers and
5alpha reductase inhibitors may be indicated in uncomplicated cases or in
patients who are unfit, unwilling or waiting to undergo surgery. Alpha1
adrenergic blocking drugs such as prazosin and terazosin are more effective
than placebo at relieving obstructive urinary symptoms. Finasteride (a 5alpha
reductase inhibitor) acts by blocking the conversion of testosterone to active
intracellular dihydrotestosterone and will often decrease the size of the
prostate. Although it has minimal adverse effects, finasteride only slightly
improves urinary flow rates. It may take 6months for the maximum benefit to
occur and finasteride must be continued indefinitely, otherwise the prostate
will return to its previous size and symptoms will return.
Complications of urethral
obstruction
- retention
- bladder stones
- recurrent infections
- renal failure
- large residual urine volume
"wait and watch" approach. See whether symptoms improve
with time. Moderate to severe BPH need treatment with drugs.
Alpha blockers
Selective alpha1 adrenergic blocking drugs can be used in patients who do
not need urgent surgery. Other indications include patients unwilling to
undergo surgery or awaiting surgery, and those in whom surgery is
contraindicated. Drug treatment is inappropriate if the patient has any of the
serious complications of urethral obstruction.The alpha blockers work by decreasing the smooth muscle tone of the prostate and bladder neck. They are more effective at relieving obstructive symptoms than irritative symptoms. As alpha1 adrenergic blocking drugs are also antihypertensives, patients may develop hypotension. Caution is advised when prescribing for frail patients and those with a history of syncopal attacks or postural hypotension. Starting treatment at a low dose then increasing it slowly to achieve a balance between symptomatic response and adverse effects is recommended. Once patients are stabilised on treatment, they should be reviewed annually for an examination of the prostate and measurement of prostate specific antigen (PSA).1The drugs have no effect on PSA concentrations. Results are rapid and can generally be evaluated by 4 weeks. When used for more than two years, prazosin becomes less effective and higher doses may be required. This may be due to tachyphylaxis or a progressive increase in prostatic size which is not influenced by prazosin's effects on muscle tone.
Fenesterate
As finasteride reduces prostate volume, the concentration of PSA falls by 50% from pretreatment levels. This fall must be taken into consideration at the routine annual check. Failure of PSA to decrease during treatment may signal unrecognised prostate cancer or noncompliance. However, a decrease in PSA does not exclude prostate cancer.An increase of more than 0.75 nanogram/mL is an indication for referral and possible biopsy. Patients with suspected prostate cancer or the complications of obstruction are not suitable for finasteride complications of obstruction are not suitable for finasteride treatment.
Conclusion –
Medical therapy will have an increasing role in symptomatic BPH, but our current lack of understanding of the disease limits our ability to predict which patients are going to respond to which treatment. As our understanding improves, we may be able to select the most effective treatment for each individual patient.
