Prostate Disorders | Clinical Medicine

The video introduces two main prostate disorders: Benign Prostatic Hyperplasia (BPH) and Prostatitis. BPH is characterized by an enlarged prostate due to hyperplasia, primarily in the transition or periurethral zone, leading to compression of the prostatic urethra. This compression results in urine retention, which can cause overflow incontinence, urinary tract obstruction leading to acute kidney injury (AKI), or urinary tract infections (UTIs).

Prostate hyperplasia in BPH is primarily caused by dihydrotestosterone (DHT), which is converted from testosterone by the enzyme 5-alpha reductase. As men age, especially over 40, increased DHT levels contribute to this condition. Symptoms include increased detrusor irritability, leading to urgency and frequency of urination. Patients also experience hesitancy, a weak urine stream, and dribbling due to bladder distension and outlet obstruction. A digital rectal exam (DRE) typically reveals a symmetrically enlarged, non-tender prostate.

Prostatitis refers to inflammation of the prostate gland, with acute and chronic forms. Acute prostatitis is often caused by infection: gonorrhea or chlamydia in men under 35, and E. coli in men over 35. This leads to intense prostate inflammation, urethral compression, and potential urine retention. Chronic prostatitis is typically caused solely by E. coli and involves milder inflammation and compression. Both forms can present with urgency, frequency, and dysuria (painful urination).

Acute prostatitis is marked by systemic inflammatory responses such as high fever, leukocytosis (increased white blood cell count), and severe pelvic/perianal pain, with an extremely tender prostate on DRE. Chronic prostatitis, however, lacks fever and leukocytosis but still causes pelvic pain. A key distinction is the 'voiding LUTS' (Lower Urinary Tract Symptoms) in BPH versus the 'storage LUTS' and dysuria in prostatitis. Complications of prostate disorders include urinary tract obstruction leading to postrenal AKI (evidenced by hydronephrosis, elevated BUN/creatinine, and decreased urine output) and urinary tract infections (cystitis or pyelonephritis) due to bacterial colonization from urine retention. Prostate abscesses can develop from acute prostatitis if untreated or worsening.

Diagnosis of BPH involves symptom evaluation (storage and voiding LUTS), PSA levels (elevated but not specific for cancer), and a DRE (enlarged, rubbery, firm, non-tender prostate). Acute prostatitis diagnosis includes CBC (leukocytosis), fever, pelvic pain, tender DRE, and urinalysis. Prostate massage to obtain prostatic fluid for culture is ideal but carries a risk of sepsis. Chronic prostatitis is difficult to diagnose; white blood cell count may be normal, and urine cultures can be variable. Prostate massage and a 'four-glass test' are often used.

Treatment for BPH aims to reduce bladder outlet obstruction. Medical therapies include alpha-1 blockers (e.g., tamsulosin) to relax the prostate and 5-alpha reductase inhibitors (e.g., finasteride) to shrink the prostate by reducing DHT conversion. Combination therapy is also common. Surgical intervention, such as Transurethral Resection of the Prostate (TURP), is an option for persistent symptoms. Acute prostatitis requires antibiotics: ceftriaxone and doxycycline for STIs, or fluoroquinolones (like ciprofloxacin) for E. coli, typically for 4-6 weeks. Chronic prostatitis also uses fluoroquinolones for similar durations. For prostate abscesses, a transrectal ultrasound is used for diagnosis, and drainage may be required.