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Prostatitis (Prostate Infection): Types

by Carlo Raj, MD
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    00:02 Our topic is prostate pathology.

    00:05 I’ll walk you through some infections and I’ll walk you through BPH and then finally get into what’s known as your prostate cancer.

    00:12 I’ll begin our discussion by looking at acute bacterial prostatitis.

    00:17 Think about the prostate and now there might be infection.

    00:22 So now with this infection, how is the patient going to present? Lower back pelvic pain.

    00:27 Do not confuse this with pyelonephritis or urinary tract infection.

    00:34 Keep it as a differential.

    00:36 In a male, the prostate should come to mind.

    00:39 Dysuria, frequency, tender, warm, enlarged prostate.

    00:45 Dysuria, frequency, what about that? Be careful, do not confuse this with BPH.

    00:51 Okay.

    00:51 So two differentials with the first two presentations.

    00:55 Lower back pain, maybe pyelonephritis being a differential or urinary tract infection with suprapubic pain.

    01:03 Or number two here, with frequency as a differential, BPH.

    01:08 How can you rule out one from the other? The next statement.

    01:11 Upon digital rectal examination, warm, enlarged prostate.

    01:16 DRE.

    01:17 Digital rectal.

    01:19 Warm, enlarged, what does it feel like? See my big nose? You press on big nose and it’s kind of soft and boggy.

    01:29 That’s protatitis.

    01:31 If it feels like my ugly chin and it’s gritty, that’s not good.

    01:35 That’s prostate cancer.

    01:38 Next, etiology, sexually transmitted infections such as gonococcal, Chlamydia, usual suspects.

    01:43 And BPH with what’s known as coliform or E. coli in elderly.

    01:49 Understand the statements here.

    01:50 Pathogenesis: Young patient with sexually transmitted infection.

    01:54 Uh-oh.

    01:55 Acute bacterial prostatitis.

    01:57 If you have a male who’s older, 67-72, has frequency and you don’t find an increase in PSA and you can’t feel any prostate issues because this is BPH, imagine now if there’s frequency and unable to properly void when he goes to the bathroom.

    02:19 The perfect nidus or environment for urinary tract infection, E. coli, E. coli, E. coli.

    02:24 Here comes the E. coli, up the urethra, climbing up the urethra, causing prostatitis.

    02:33 Chronic prostatitis: What’s interesting when you go into practice and, you know, you’re going through internal medicine, so on and so fourth.

    02:42 And then you suspect prostatitis, oftentimes, you’ll find a chronic prostatitis being an issue, very common.

    02:49 And what’s amazing, is the fact abacterial chronic prostatitis is the most common.

    02:55 Abacterial.

    02:57 But yet – and the reason for that – The understanding behind this, for you as a clinician, you’ve heard of infectious endocarditis and culture-negative endocarditis.

    03:09 But culture negative, really remember, the HACEK organisms, endocarditis, the type of Haemophilus and you have Kingella and all those crazy – Eikenella, you know what I’m talking about.

    03:21 Even though its organisms, it came back to be culture-negative because these are perhaps fastidious organisms, the high maintenance, difficult to properly culture.

    03:30 Abacterial protatitis.

    03:32 Even though we call it abacterial, we just don’t have the proper tools to maybe perhaps diagnose the infection.

    03:40 Important, chronic.

    03:42 Our topic is BPH.

    03:44 With benign prostatic hyperplasia, who’s your patient? Almost always elderly, 67, 70, 72, whatever.

    03:53 And what does he tell you? “Hey, doc, I’m having a hard time going to the –“ Or “I actually go to the bathroom a lot, but when I go, nothing really comes out.” Increased frequency, inadequate voiding.

    04:06 And now at this point, you’re worried about BPH perhaps.

    04:11 There’s no fever, right? So this isn’t acute bacterial prostatitis even though you should be thinking to yourself, “Is my patient having back pain and fever?” Oh, that BPH was lending itself to infection.

    04:26 And what is this? This is hyperplasia, caused by? Androgens.

    04:32 Really? Uh-hmm.

    04:33 What’s the name of the drug that you’re going to give here to combat BPH? Something that’s combats androgen.

    04:39 What’s the name of that drug? It’s a 5-alpha reductase inhibitor.

    04:43 What is that called? Finasteride.

    04:45 Now, when you get into residency, you’ll it to be interesting.

    04:48 You see my head? I don’t have much hair.

    04:50 I used to have hair once upon a time.

    04:52 I was quite proud of it, but I call it kharma.

    04:54 And I used to comb the heck out of it.

    04:57 It used to get wavy. What’s my point? I’m losing my hair.

    05:00 I refused to take a drug that’s available that’s more cosmetic in nature that inhibits the same enzyme as finasteride, 5-alpha reductase, But guess what? When you get into residency, you will find your colleagues, males that are young, right? Or so we think, and they’re taking – Well, I’m not going to say too much, but we’ll just say that Propecia and finasteride play the mechanism of action exactly the same.

    05:25 Propecia will be for the hair, where you have finasteride, which is BPH.

    05:30 Both inhibit the enzyme, but obviously one’s going to be covered by insurance, the other one is so much not.

    05:36 Let’s just leave it that.

    05:37 Let’s move on.

    05:38 Now, with BPH, can you feel the prostate? No.

    05:42 I mean, I’m sorry. Let me rephrase that.

    05:45 With BPH, can you feel the lesions in the prostate? Your answer? No.

    05:51 Prostate cancer, yes you can.

    05:54 Remember please in BPH, where do find the lesion? Around the urethra, peri-urethral, that’s a central zone.

    06:01 You can’t feel that on digit rectal examination.

    06:04 Prostate cancer as far you’re concerned, remember, when you take your boards, they have to give you clues to move in one direction or the other.

    06:12 For prostate cancer, yes you can feel it luckily and you’ll find an increase in PSA.

    06:17 BPH, good topic, great in terms of its basic pathology and integration into pharmacology.

    06:25 One last question, I got to give you this.

    06:28 You have one stone, knock out two birds.

    06:31 Your patient -- always, always, look for blood pressure.

    06:36 If the blood pressure is normal in your elderly patient and it’s just BPH, your answer: a 5-alpha reductase inhibitor.

    06:44 If your elderly patient has blood pressure of 160/90 and has BPH, your answer is a –sin drug.

    06:53 All right? Terazosin, so on and so forth.

    06:57 Prostate adenocarcinoma.

    06:59 This is an adenocarcinoma.

    07:01 What does that mean to you? Glandular, glandular, glandular.

    07:04 Isn’t that what the prostate does? It secretes fluid into the seminal vesicle, mixes it all up and then when the time is right, what have you? Erection, ejaculation, emission, so on and so forth.

    07:16 But adenocarcinoma, it’s glandular. Glandular.

    07:19 As far as you’re concerned, you’ll be paying attention to PSA.

    07:24 What if you also find increase in alk phos? Uh-oh.

    07:28 PSA and alkaline phosphatase, why was I so dramatic about that? Because now, the prostate cancer has metastasized from the prostate to the vertebrae through your Batson paravertebral plexus.

    07:42 And now, upon your x-ray, what does this bone look like? Hot.

    07:46 What does hot mean? Clinically hot then means that it’s opaque and white.

    07:51 It’s an osteoblastic type of metastasis.

    07:54 Prostate adenocarcninoma, you can feel it, increased PSA.

    08:00 Always look to see as to whether or not there is metastasis.


    About the Lecture

    The lecture Prostatitis (Prostate Infection): Types by Carlo Raj, MD is from the course Male Reproductive System Diseases.


    Included Quiz Questions

    1. Tender stony hard prostate on digital rectal exam
    2. Lower back pain
    3. Frequency
    4. Dysuria
    5. Lower abdominal pain
    1. Chronic prostatitis is always abacterial.
    2. Pyelonephritis, UTI, and BPH are in the differential diagnosis.
    3. In bacterial acute prostatitis the prostate is boggy tender on DRE.
    4. STD’s are the causes of acute prostatitis in Young men.
    5. E. coli and BPH are the causes of acute prostatitis in elderly.
    1. Benign prostatic hypertrophy is easy to palpate by digital rectal exam.
    2. In bacterial acute prostatitis the prostate is boggy tender on digital rectal exam.
    3. Prostate cancer is easy to palpate by digital rectal exam.
    4. Prostate cancer affect mainly the peripheral zone.
    5. Benign prostatic hypertrophy mainly affects the periurethral zone.
    1. Terazosin
    2. Doxycycline
    3. Tazocin
    4. 5-alpha reductase inhibitor
    5. Finasteride
    1. Osteolytic bony metastasis
    2. Glandular type of cancer
    3. Affect mainly the peripheral zone
    4. Associated with high PSA
    5. Stony hard prostate on digital rectal exam

    Author of lecture Prostatitis (Prostate Infection): Types

     Carlo Raj, MD

    Carlo Raj, MD


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