Prostate Disorders

INTRODUCTION

Prostatitis syndromes

Includes conditions causing pain in the prostate with lower urinary tract symptoms (LUTS) and fever, which may develop acute or chronic bacterial infection, usually caused by E. coli. Prostate pain syndrome, or prostatodynia means the presence of symptoms typical of prostatitis but without objective evidence of inflammation or infection.

Treatment

Acute prostatitis

• Amoxicillin (or ampicillin) 2 g IV 6 hrly plus

• Gentamicin 120–160 mg IV 12 hrly to max. 5 mg/kg/d until there is substantial improvement, when therapy may be changed to an appropriate oral agent, based on the sensitivity of the pathogen(s) isolated, for the remainder of 14 d

For milder infection, oral treatment with amoxicillin/potassium clavulanate, trimethoprim or norfloxacin is suitable.

Chronic bacterial prostatitis Treatment of this condition is difficult. Antibiotics should be used in patients who are culture positive with pus cells. Advise hot baths, normal sexual activity, no caffeine, good diet.

• Trimethoprim 300 mg (o) daily for 1 mth or

• Norfloxacin 400 mg (o) 12 hrly for 1 mth or

• Ciprofloxacin 500 mg (o) 12 hrly for 1 mth

Chronic prostatitis (chronic pelvic pain syndrome) The commonest cause of prostate pain syndrome. Management is symptom relief (e.g. NSAIDs). Emphasise good voiding habits.

BENIGN PROSTATIC HYPERPLASIA

Investigations

These include:

• urine culture

• kidney function

• prostate specific antigen

• prostatic needle biopsy (with or without transrectal US) if carcinoma suspected

• voiding flow rate to confirm that the symptoms reflect obstruction and not bladder irritability:

  • – measure time to pass 200 mL

  • – significant obstruction if <10 mL/sec

Management

General advice:

• avoid caffeine, esp. coffee

• avoid or reduce alcohol

• avoid fluids before bedtime

• urinate when you need to (do not hang on)

• wait 30 secs after voiding to ensure your bladder is empty

Medical treatment

For milder problems:

• α-adrenergic blocking agents, e.g.:

  • – terazosin 1 mg (o) nocte for 4 d, then 1 mg mane for 3 d → 2 mg mane for 7 d → 5 mg mane for 7 d, then 5–10 mg/d maintenance or

  • – tamsulosin 0.4 mg (o)/d or

  • – prazosin 0.5 mg (o) nocte for 3 d, then 0.5 mg bd for 14 d (watch for postural hypotension) then increase as nec. to max. of 2 mg bd (may postpone surgery for up to 2–5 yrs)

• 5-α-reductase inhibitors, e.g. finasteride 5 mg (o) daily for at least 6–12 mths

• The herbal remedy ‘saw palmetto’ has proven to be as efficacious as finasteride but less so than the α-adrenergic blockers

Surgical treatment Transurethral resection is currently the gold standard of treatment. Holmium laser ablation is effective with minimal invasion.

CARCINOMA OF THE ...