4 · Prostate Disorders

BPH, prostatitis, and prostate cancer — distinguished by the rectal exam and PSA behavior.

Benign prostatic hyperplasia (BPH)

Enlargement of the transitional zone → obstructive voiding (hesitancy, weak stream, incomplete emptying, nocturia).
PSA may be mildly elevated (normal <4). Avoid anticholinergics and antihistamines (worsen retention).
Treat: alpha-blocker (tamsulosin) for symptoms; 5-alpha-reductase inhibitor (finasteride) to shrink the gland; TURP definitive.

Prostatitis

Fever, chills, low back pain + urinary frequency/urgency/dysuria; DRE = boggy, warm, tender, enlarged prostate; UA pyuria.
<35 y: GC/chlamydia → ceftriaxone + doxycycline. >35 y (E. coli): fluoroquinolone or TMP-SMX ×4–6 wk (chronic 6–12 wk).
⭐ Do NOT vigorously massage the prostate in acute prostatitis — risk of bacteremia/sepsis.

Prostate cancer

Arises in the peripheral zone; DRE = hard, irregular, nodular. Tumor marker PSA (also up in BPH/prostatitis).
Screening start: 50 (average-risk white men); 40 for Black men or family history/BRCA. Diagnose with TRUS-guided biopsy; Gleason grading; bone is the common metastatic site (osteoblastic).

BPH pharmacology & red flags

Drug class	Example	Side effects
α-1 blocker (rapid relief)	Tamsulosin, doxazosin, terazosin	Orthostatic hypotension, dizziness, retrograde ejaculation
5-α-reductase inhibitor (shrinks gland)	Finasteride	Sexual/ejaculatory dysfunction; lowers PSA ~50%

⭐ Red flags that argue AGAINST simple BPH: rapid onset, symptoms before age 50, or filling (storage) symptoms without voiding symptoms — look for another diagnosis.

Prostatitis — the four types

Type	Key features	Treatment
I — acute bacterial	Fever, dysuria, perineal pain; tender boggy prostate; UA pyuria; PSA transiently ↑	Fluoroquinolone or TMP-SMX ~4 weeks; no prostate massage
II — chronic bacterial	Recurrent UTIs, less pain; positive expressed secretions	Fluoroquinolone/TMP-SMX 6–12 weeks
III — chronic pelvic pain (nonbacterial)	Pelvic pain, negative cultures; most common	Alpha-blocker ± doxycycline
IV — asymptomatic inflammatory	Incidental WBCs, no symptoms	Usually none

Prostate cancer — added pearls & current screening

Adenocarcinoma; metastasizes to bone (osteoblastic) → advanced disease brings bone pain, pathologic fractures, and spinal cord compression. Vasectomy and BPH do NOT increase risk.
Diagnosis: transrectal ultrasound-guided biopsy; PSA >4; CT/MRI for staging; androgen-deprivation (e.g., leuprolide) / antiandrogen for advanced disease.

⭐ Screening — know both frameworks: the USPSTF (current) advises shared decision-making for PSA in men 55–69 and recommends against screening at ≥70. The ACS/AUA discussion ages your course uses are ~50 (average risk) and 40–45 for Black men or a positive family history/BRCA.