CLINICAL UROLOGY
From the annual Family Practice Review Course, sponsored by the University of Vermont College of Medicine,
Burlington
| PROSTATITIS —Samuel J. Trotter, MD, Associate Professor of Surgery, Division of Urology, University of Vermont
College of Medicine, and Chair, Division of Urology, Fletcher Allen Health Care System, Burlington
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| Classification: National Institutes of Health (NIH) Chronic Prostatitis Collaborative Research Network developed
Chronic Prostatitis Symptom Index (NIH-CPSI) used to evaluate patient’s pain, urinary function, and quality of life
(QOL); acute bacterial prostatitis—category I; rare (5% of prostatitis cases); acute onset; look for voiding symptoms
(eg, pain when voiding, frequency, urgency), suprapubic or perineal discomfort, and fever; responds to antibiotic therapy;
chronic bacterial prostatitis—category II; patients have history of recurrent urinary tract infections (UTIs); may be asymptomatic
between acute episodes or have history of chronic pelvic pain syndrome (CPPS); prevalence 5% to 15%;
CPPS—category III; inflammatory and noninflammatory disorders; symptoms may be periodic and involve pain (eg,
perineal, suprapubic, penile, testicular) during or after ejaculation, irritative voiding symptoms, and erectile dysfunction;
consider diagnosis if duration of symptoms >3 mo; significantly affects QOL and mental and physical health; men with
prostatitis have similar Sickness Impact Profile scores as men with myocardial infarction, angina, or Crohn’s disease; asymptomatic
inflammatory prostatitis—category IV; pathologic diagnosis; patients may have elevated prostate-specific
antigen (PSA); inflammatory cells present in pathologic specimen
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| Evaluation: physical examination not diagnostic (texture of prostate gland or discomfort associated with digital rectal examination
[DRE] not diagnostic); DRE can rule out other abnormalities (eg, nodules); however, DRE can cause sepsis or
bacteremia in patients with acute bacterial prostatitis; 4-glass urine collection technique—gold standard; distinguishes
between infection in urethra, bladder, and prostate; not commonly performed because of discomfort to patient; time-consuming
and expensive; microbiology—Enterobacteriaceae (eg, Escherichia coli, Serratia, Klebsiella, Proteus,
Pseudomonas) and gram-positive enterococci; urethral organisms (eg, Staphylococcus epidermidis, Corynebacterium,
Bacteroides) can colonize prostate, but significance unknown; cytology—may or may not differentiate between inflammatory
and noninflammatory CPPS; urodynamics—used to evaluate urinary tract disorders that mimic chronic nonbacterial
prostatitis (eg, vesical neck obstruction, functional obstruction or pseudodyssynergia, impaired bladder
contractility, acontractile bladder, detrusor instability); endoscopy—used to differentiate prostatitis from bladder cancer
(carcinoma in situ) or to find urethral stricture; transrectal ultrasonography (TRUS)—used to assess and drain prostatic
abscess and diagnose prostatic cysts or obstructed seminal vesicles; prostatoliths almost routine finding on TRUS;
prostate biopsy—not indicated
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| Etiology: bacterial infections—gram-negative uropathogens, eg, E coli, Pseudomonas, Serratia, Klebsiella, Enterobacter
; gram-positive bacteria, eg, enterococci, possibly Staphylococcus; altered prostatic host defenses—increased
incidence associated with urethral catheters, transurethral surgery, chronic UTIs, acute epididymitis, and secretory dysfunction
of prostate (results in decreased levels of fructose, citric acid, zinc, magnesium, and calcium); dysfunctional
voiding—increased incidence found in patients with high-pressure flow patterns, particularly prostadynia; intraprostatic
ductal reflux—reflux of urine into prostatic ducts may result in chronic bacterial prostatitis or nonbacterial prostatic
inflammation and contribute to formation of prostatoliths (composed of substances found only in urine);
immunologic alterations—biopsies in men with chronic prostatitis show increased levels of immunoglobulins, particularly
IgA and IgG; prostatitis may be autoimmune process; neural dysregulation—acquired abnormality of central nervous
system (CNS) results in insufficient conscious control of striated pelvic floor muscles; interstitial cystitis—may
be more common in men than previously thought; psychologic causes—major depression more common in men with
prostatitis, compared to men with chronic low back pain
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| Treatment: antimicrobial therapy—fluoroquinolones have best therapeutic response; α-blockers—eg, terazosin, doxazosin,
tamsulosin (Flomax), alfuzosin (Uroxatral); prostate and bladder neck rich in α-adrenergic receptors; some studies
show symptomatic improvement in 40% to 50% of patients treated with α-blockers and antimicrobial therapy; anti-inflammatory
agents—may offer some symptomatic relief; muscle relaxants—eg, diazepam, cyclobenzaprine (Flexeril), methocarbamol
(Robaxin); inconclusive results from very small study; antianxiety agents may play role by relaxing pelvic floor
muscles; hormone therapy—aimed at shrinking prostate; finasteride of potential benefit; phytotherapeutic agents—
limited studies looking at bee pollen extract and bioflavinoids; physical therapy—recommend prostate massage or frequent
ejaculation to break up prostatic secretions and increase drainage; studies show prostate massage offers same symptomatic
relief as antibiotic therapy; biofeedback training to relax pelvic floor muscles difficult, time-consuming, and
associated with limited success; minimally invasive therapies—avoid balloon dilation of prostate; consider minimally invasive
surgery to ablate prostate tissue; thermotherapy may offer benefit; surgery—radical transurethral resection of prostate
(TURP) and radical prostatectomy not recommended; last resort
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| LOWER URINARY TRACT PROBLEMS —Richard T. Kershen, MD, Assistant Professor of Surgery, Division of Urology,
University of Vermont College of Medicine, and Director, Female Urology and Voiding Dysfunction Clinic, Fletcher
Allen Health Care System, Burlington
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Benign Prostatic Hyperplasia (BPH)
| Mechanism: anatomic obstruction—stromal and epithelial elements proliferate, increasing size of prostate; prostate
surrounded by thick capsule of collagen and smooth muscle; as adenoma grows, urethra compressed and pressure increased
on capsule of prostate; dynamic obstruction—dense adrenergic innervation of bladder neck and prostate can
lead to overactivity of prostate and high resting tone that can lead to alteration in bladder function; bladder obstruction
can result in hyperactive detrusor contractions and loss of compliance; chronic bladder obstruction can lead to detrusor
decompensation (bladder unable to contract because of chronic distention) and urinary retention
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| Evaluation: obtain clinical history; look for aggravating factors, eg, diabetes mellitus (can result in sensory difficulties
with bladder or functional disorder), neurologic disease (can lead to neurogenic overactivity); note previous surgery to
prostate (patient may have obstruction because of scar tissue or stricture) or colorectal resection (bladder may have been
denervated and lost contractile ability); obtain International Prostate Symptom Score (IPSS) before initiation of therapy,
then check scores to evaluate therapeutic course; note QOL score (most important question in determining treatment);
perform physical examination and DRE to rule out prostate cancer and determine if patient good candidate for 5-α-reductase
inhibitor (ie, very large prostate); obtain PSA level if patient >50 yr of age or has positive family history, urinalysis
to rule out infection, and, in some patients, flow rate and postvoid residual, both before and after therapy; flow rate—
typical uroflow curve bell-shaped, with 25 mL/sec to 30 mL/sec maximum flow; depressed or flattened curve with slow
flow seen in patients with outlet obstruction; postvoid residual—50 mL upper limit of normal; obtain postvoid residual
in patient with high IPSS score; elevated residual can increase risk for infection, stone formation, and renal insufficiency
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| Treatment: α-blockers—relax prostatic stromal and capsular smooth muscle; improve symptoms by 30% to 45% relative
to placebo; flow rates improve by 20% to 30%; tamsulosin and alfuzosin more uroselective, have minimal effect on
blood pressure, and do not require dose titration; terasozin and doxazosin require slow increase of dose to avoid postural
hypotension; decrease blood supply to prostate; effective in patients with chronic refractory hematuria; 5-α-reductase
inhibitors—inhibit conversion of testosterone to dihydrotestosterone (more potent to androgen receptors in prostate); reduce
size of prostate to alleviate anatomic obstruction; finasteride (Proscar; inhibits reductase type 2) and dutasteride
(Avodart; inhibits both reductases) have similar efficacy; side effects include erectile dysfunction, decreased libido, and
breast enlargement; 20% to 25% decrease in prostate volume at 2 yr; using finasteride for 1 yr reduces PSA levels by
50% (consider when screening patients for prostate cancer); Proscar Long-Term Efficacy and Safety Study (PLESS)
showed 5-α-reductase inhibitors reduce risk for acute urinary retention by 50%; may also help avoid surgery; avoid
monotherapy in most patients (not as effective clinically in relieving symptoms as α-blocker; clinical effect takes 1 to 3
mo); recommend use in patient with enlarged prostate or in patient at risk for prostate cancer; combination therapy—
Medical Therapy of Prostatic Symptoms (MTOPS) study found patients given finasteride and doxazosin had greater
symptom improvement and decreased risk for clinical progression and surgery; antimuscarinic agents—effective in relieving
voiding symptoms but associated with increased risk for urinary retention; follow patients closely; obtain flow
rates and postvoid residual before and after initiation of therapy; herbal therapy—patient may already be on variety of
herbal supplements; few scientific studies exist that evaluate efficacy of these agents; saw palmetto may have some 5-α-
reductase inhibitor activity, but does not have same effect as finasteride on PSA levels; recommend 5-α-reductase inhibitor
in symptomatic patient taking saw palmetto; surgical therapy—office-based therapies include microwave thermotherapy
and transurethral needle ablation; recommended for patient with milder symptoms and those who cannot tolerate
α-blockers; results last 1 to 2 yr; consider laser prostatectomy for long-term therapy (vaporizes prostatic tissue with minimal
blood loss; uses normal saline solution, so risk for fluid absorption less than with TURP); recommend open prostatectomy
in patient with extremely enlarged prostate
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Voiding Disorders in Women
| Evaluation: reversible causes—identify “DIAPERS” (drugs, infection, vaginal atrophy, psychologic causes, endocrine
causes, restricted mobility, stool impaction); look for atrophic vaginitis or atrophic urethritis in postmenopausal patient with
voiding symptoms (vaginal examination reveals periurethral atrophy); consider drugs that affect voiding function, psychologic
causes (excessive drinking leading to excessive urine output), diuretic hormone abnormality, poor mobility, and fecal impaction;
irreversible causes—screen patients for hematuria to rule out bladder tumor or inflammatory conditions of bladder;
neurologic disorders (eg, multiple sclerosis, Parkinson’s disease, stroke); look for other contributing factors (eg, diabetes mellitus);
clinical history—determine predominant symptom; assess severity (what worsens symptoms?) and QOL; look for associated
symptoms of overactive bladder or pelvic pain; note gravidity, parity, and labor history; check for previous surgeries
that affect bladder function (eg, hysterectomy or surgery for incontinence); have patient fill out voiding diary; physical
examination—evaluate external genitalia, looking for atrophy or caruncle; use “Q-tip test” to look for urethral hypermobility
and diagnose genuine or anatomic stress urinary incontinence (differentiate from static or stovepipe urethra associated with
childbirth injury or hysterectomy); perform half-blade speculum procedure to evaluate for compartmental prolapse, cystocele,
rectocele, or enterocele; rectal examination reserved for patient suspected of neurologic abnormality or fecal impaction; perform
focused neurologic examination where appropriate, checking for perineal sensation and pelvic floor reflexes; assess
postvoid residual in patients suspected of stress or urge incontinence; stress-induced overactivity of bladder diagnosed as
mixed incontinence; look for UTI or hematuria; reserve blood work for complex disorders; refer to urologist—if patient
does not respond to initial treatment, has mixed incontinence, has hematuria without infection on urinalysis, has symptoms
suggestive of retention (elevated postvoid residual or obstructive voiding symptoms), unexplained neurologic or metabolic disease,
pelvic prolapse, or patient motivated to resolve stress incontinence; reserve urodynamic testing for patients with more
complex voiding dysfunction and incontinence
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| Treatment: overactive bladder—recommend behavior modification (or physical therapy) combined with pharmacotherapy;
second-line treatment involves injecting botulinum toxin into bladder, InterStim therapy (sacral nerve modulation) in
patients with refractory urge incontinence, and bladder augmentation in patients with severe refractory overactive bladder
because of neurologic voiding dysfunction; behavioral therapies include looking at voiding diary with patient, reduction of
caffeine intake, timed voiding, and Kegel exercises; antimuscarinic agents—inhibit bladder overactivity, increasing capacity,
decreasing frequency, and preventing symptoms of overactive bladder (screen patients for narrow-angle glaucoma);
produce 20% to 30% reduction in urinary frequency in most patients, reduce incontinence in 50% to 80% of
patients, increase voided volume, and alleviate nocturia; side effects include blurred vision, dry mouth, constipation, and
possible CNS effects (elderly most susceptible); solifenacin associated with fewer complaints of dry mouth; darifenacin
associated with slightly higher complaints of constipation; transdermal patch of oxybutynin minimizes dry mouth; trospium
(Sanctura) has low risk for CNS effects; oxybutynin (Ditropan XL) safe in patients with refractory symptoms and
can be titrated to 30 mg; stress incontinence—recommend pelvic muscle exercises and pelvic floor physical therapy; Kegel
exercises effective when done properly; biofeedback may be effective; recommend topical estrogen cream in patients
with atrophic vaginitis; consider bulking agents that increase intraurethral resistance; consider midurethral sling made from
polypropylene mesh or pubovaginal sling made of patient’s or donated tissue
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Educational Objectives
| The goal of this program is to educate the listener about prostatitis, benign prostatic hyperplasia (BPH), and voiding disorders
in women. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Identify the categories of prostatitis.
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| 2. Determine appropriate therapy for a patient with prostatitis.
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| 3. Describe the mechanisms involved in BPH.
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| 4. Discuss the treatment options for BPH.
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| 5. Identify the cause of a voiding disorder in a female patient.
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Discussed on This Program
Alfuzosin HCl [Uroxatral]
Bee pollen extract
Cyclobenzaprine HCl [Flexeril]
Darifenacin HBr [Enablex]
Diazepam [Diastat, Diazepam Intensol, Valium]
Doxazosin mesylate [Cardura]
Dutasteride [Avodart]
Finasteride [Propecia, Proscar]
Ibuprofen (various brands)
Methocarbamol [Robaxin, Robaxin-750]
Oxybutynin chloride [Ditropan, Ditropan XL, Osytrol]
Saw palmetto (Serenoa repens)
Solifenacin succinate [VESIcare]
Tamsulosin HCl [Flomax]
Terazosin HCl [Hytrin]
Trospium chloride [Sanctura]
Suggested Reading
Berger RE: Predictors of quality of life and pain in chronic prostatitis/chronic pelvic pain syndrome: findings from the
National Institutes of Health Chronic Prostatitis Cohort Study. J Urol. 174:1842, 2005; Culligan PJ et al: Urinary incontinence
in women: evaluation and management. Am Fam Physician. 62:2433, 2000; Dull P et al: Managing benign
prostatic hyperplasia. Am Fam Physician. 66:77, 2002; Dull P: Transdermal oxybutynin (oxytrol) for urinary incontinence.
Am Fam Physician. 70:2351, 2004; Kershen RT et al: Preview of new drugs for overactive bladder and incontinence:
darifenacin, solifenacin, trospium, and duloxetine. Curr Urol Rep. 5:359, 2004; Kershen RT et al: De novo
urge syndrome and detrusor instability after anti-incontinence surgery: current concepts, evaluation, and treatment. Curr
Urol Rep. 3:345, 2002; Kershen RT et al: Blood flow, pressure and compliance in the male human bladder. J Urol.
168:121, 2002; Kozlowski R et al: Chronic ischemia alters prostate structure and reactivity in rabbits. J Urol. 165:1019,
2001; Slawson D: Terazosin helpful in patients with chronic prostatitis. Am Fam Physician. 67:2206, 2003; Stevermer
et al: Treatment of prostatitis. Am Fam Physician. 61:3015, 2000; Weiss BD: Selecting medications for the
treatment of urinary incontinence. Am Fam Physician. 71:315, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the following
has been disclosed: Dr. Kershen is on the Speaker’s Bureau at Pfizer, Inc. and Odyssey Pharmaceuticals, Inc.
Drs. Trotter and Kershen were recorded June 8-11, 2005 at the annual Family Practice Review Course, sponsored by
the University of Vermont College of Medicine, Burlington. The Audio-Digest Foundation thanks the speakers and
the sponsor for their cooperation in the production of this program.
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