6 Men's Health Flashcards
Most common benign tumor in men ages 40-80
BPH
Androgens cause proliferation of fibrostromal tissue in the transitional zone that can lead to compression of the prostatic urethra
Benign Prostatic Hyperplasia (BPH)
As the prostate enlarges, obstruction can occur
Men with BPH experience…
Irritative (frequency, urgency) and/or obstructive (hesitancy, weak stream, dribbling) urinary symptoms
What are the four zones of the prostate and which one enlarges in BPH?
Transitional zone** (BPH)
Central zone
Peripheral zone
Fibromuscular zone
DDx to rule out before attributing symptoms to BPH
Urethral stricture Bladder neck contracture Carcinoma of the prostate Carcinoma of the bladder Bladder calculi Urinary tract infection and prostatitis Neurogenic bladder
Things that can be risk factors for BPH, besides just being an old man
T2DM (—>nocturia)
Sx of neurologic disease
Sexual dysfunction
Gross hematuria or pain (more suggestive of tumor/stone)
Urethral trauma, urethritis, or urethral instrumentation
Family Hx of BPH or prostate cancer
Meds that impair bladder function or increase outflow resistance
Clinical features of BPH
Prevalence: Age 41-50 (50%, 51-50 (50%), 60-70 (70%)
Blacks>white>Asians
Hx of at least 3 months of bothersome urinary symptoms
Hx of recurrent urinary tract infections, gross hematuria
How do you diagnose BPH?
DRE —> symmetry, firmness, nodules
UA to r/o blood, infection
Prostate specific antigen (PSA) - avoid after ejaculation, trauma, or catheterization
BUN/Cr
Optional: max urinary flow rate, post-void residual volume, urine cytology
Treatment options for BPH
Behavior modification (avoid caffeine, EtOH, meds that make it worse; fluid restriction before bed; double voiding)
Alpha1 adrenergic antagonists**
MOA - relax smooth muscle in UT and prostate
SE - orthostatic hypotension, dizziness, ejaculatory dysfunction
5-alpha reductase inhibitors (Finasteride, dutasteride)
MOA - decreases prostate size via antiandrogen effects
SE - decreased libido and sexual dysfunction
Surgical approaches to BPH
TURP - transurethral radial prostatectomy
TUNA - transurethral needle ablation
TUMT - transurethral microwave their other app
Prostatic stent
Suprapubic prostatectomy
Many more
Clinical features of acute bacterial prostatitis
ACUTE ONSET of urinary frequency, urgency, and dysuria with obstructive voiding symptoms
Perineal/pelvic pain
Fever/chills, myalgia, malaise
How do you diagnose acute bacterial prostatitis?
DRE (gentle) reveals tender and edematous prostate
Prostate exam helps differentiate from UTI
Urine gram stain/culture
Will also have leukocytosis, pyuria, elevated PSA and ESR
How to treat acute bacterial prostatitis
If toxic, admit and state IV abx
Treat outpatient if patient stable/reliable
FLUOROQUINOLONE (levofloxacin, Citroen) or Bactrim for 6 WEEKS (need a long course because prostate hard to penetrate)
Gram stain/urine culture can help guide abx with atypical pathogens
Repeat urine culture after 7 days abx - if still positive, consider alternative regimen
Chronic or recurrent urogenital symptoms with evidence of bacterial infection of the prostate
Chronic bacterial prostatitis
May follow acute bacterial prostatitis
Risk factors/epi similar to acute bacterial prostatitis
Clinical features of chronic bacterial prostatitis
Sx can be subtle
Recurrent UTI
May see pelvic pain, bladder outlet obstruction, or hematuria
Prostate exam may reveal tenderness/hypertrophy but usually is normal
Labs for infection/inflammation may be elevated but are frequently normal
Dx and treatment of chronic bacterial prostatitis
Can be made using prostatic fluid analysis (gold standard)***
More often, diagnosed presumptively based on Hx of urinary symptoms
Treat with fluoroquinolone for min of six weeks, bactrim as alternative
Recurrent episodes generally treated the same way
Chronic pelvic pain for AT LEAST THREE of the preceding SIX MONTHS in the absence of other identifiable causes
Chronic prostatitis/chronic pelvic pain syndrome
Diagnosis of exclusion, divided into inflammatory and non-inflammatory subsets
Etiology is unknown and it is unclear to what extent symptoms are due to the prostate
Evaluating a patient for chronic pelvic pain syndrome
Hx - focused on pain, urinary Sx, sexual function, overall QOL
PE - complete genital and rectal exam, with non-tender or mildly tender prostate
UA and culture
Imaging as necessary to r/o torsion, abd pain etc
Clinical features of chronic pelvic pain syndrome
Pain in perineum, lower abdomen, testicular, penis, and with ejaculation
Void difficulties
Blood in semen
Typically experience relapsing-remitting pattern over many months
How do you treat chronic pelvic pain syndrome?
No uniformly accepted regimen
Alpha blockers, abx, and 5-alpha reductase inhibitors are the most effective meds and can be used in combo
Psychological support
Urology referral
Most common cancer diagnosed in men in the age group 60-79
Prostate cancer
Slow-growing malignant neoplasm of adenomatous cells of the prostate gland - malignant but stays confined for a long time
80% of prostate cancer is diagnosed subsequent to…
An elevated PSA
20% after abnormal DRE
Prostate cancer is the ___________ cause of cancer death in men, but only _______ chance to die
Second leading cause of cancer death
2.9% chance to die
Prostate cancer screening should be targeted to…
Those with >10 years life expectancy
Family Hx of prostate cancer
Black men
Methods: DRE, PSA, PCA3 (prostate cancer antigen 3 gene)
Clinical features of prostate cancer
Middle aged man, generally w/o symptoms if disease is early
Urinary frequency, urgency, nocturia, and hesitancy all common but often due to concomitant BPH
Advanced prostate cancer may cause bone pain, fatigue, weight loss
Rarely presents with hematuria or hematospermpia
DRE - modular prostate, asymmetric prostate
How do you diagnose prostate cancer
Abnormal prostate exam/abnormal PSA —> prostate biopsy (usually transrectal ultrasound guided)
DRE can only detect tumors in the POSTERIOR and LATERAL aspects of the prostate
No absolute threshold of PSA to determine when a biopsy is needed - must consider age, race, prostate volume, FHx, DRE findings, change from baseline
How are prostate cancers staged?
Tumor Node Metastases system
Gleason Score:
• Histological grading based on architectural structure
• Assists with treatment and prognosis
• Two scores, primary and secondary grades of tumor
How do you treat prostate cancer?
Choice of treatment depends on many factors
Patient specific - consider age, staging, comorbidities, lifestyle
Options include: • Observation • Radical prostatectomy • Radiation therapy • Androgen deprivation therapy
What should surveillance after prostate cancer treatment look like?
Total PSA every 6-12 months x 5 years and then annually
If PSA rises, then referral is warranted
Recurrence and/or metastatic workup - physician visit and serum PSA every 3-6 months
The inability to attain or maintain a penile erection that is satisfactory for sexual performance
Erectile Dysfunction
Primarily a vascular phenomenon, triggered by neurologic signals and facilitated only in the presence of an appropriate hormonal condition and psychological midset
Most cases have an organic cause
Meds that can cause ED
SSRIs Spironolactone Clonidine, methyldopa Thiazide diuretics Ketoconazole Cimetidine And on and on
Lowest prevalence of ED is found in…
Active males without chronic medical conditions who maintain healthy lifestyle choices
Risk factors for ED
Male gender DM Obesity HTN HLD CVD Smoking Meds Age
What ED finding is suggestive of a vascular or neurologic disease rather than a psychological one?
Complete loss of nocturnal erections
Working up some dude with ED 🍆
Detailed Hx
PE should include DRE, secondary sex characteristics, femoral and peripheral pulses, breast exam, testicular volume
Fasting glucose/HbA1c CBC/CMP TSH Lipids Serum testosterone
Nocturnal tumescence test to distinguish psychogenic/organic cause
Duplex Doppler can identify arterial obstruction or venous leak
Treatment of ED
Address underlying cause - psychotherapy, testosterone therapy, adjust meds, lifestyle changes
FIRST LINE MED: phosphodiesterase-5 inhibitors (Sildenafil, vardenafil, tadalafil, avanafil)
Second line: vacuum erection device, penile self injectables, intraurethral suppository
Third line: penile prosthesis/surgery
Urethritis is most common in…
Young, sexually active males
Gonococcal urethritis is caused by…
Neisseria gonorrhoeae
Causes of non-gonococcal urethritis
Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, and others
Clinical features of urethritis
May be asymptomatic
Male with c/o onset of dysuria and urethral discharge
May see inflamed meatus
Diagnosing urethritis
Mucopurulent/purulent discharge
Gram stain of urethral secretions
First void urine (NOT clean catch) for NAAT nuclei acid amplication testing
What will you see on the gram stain in gonococcal urethritis?
Polymorphonuclear cells and GRAM-NEGATIVE DIPLOCOCCI in the urethral exudate
How do you treat gonococcal urethritis?
Ceftriaxone 250 mg IM + Azithromycin 1000mg (1 dose)
If PCN allergy, Gentamycin 240mg IM + Azithromycin 2 grams (1 dose)
How do you treat non-gonococcal urethritis?
Azithromycin 1 gram ORALLY
Or
Doxycycline 100mg PO BID x 7 days
What else do you need to know about treating urethritis, other than the drugs?
Treat partners if appropriate
No retest needed IF TREATED WITH FIRST LINE REGIMEN
Use combo treatment b/c if you have one you usually have both
Infection of the epididymis via the vas deferens
Epididymitis
Young men: associated with STDs
Old me: associated with urinary pathogens
Clinical features of epididymitis
Acute, unilateral dull to severe scrotal pain radiating to ipsilateral flank
Hemiscrotal swelling and tenderness which may progress to erythematous, fluctuating mass
Fever, chills
(+) Prehn’s sign
If left untreated, can result in orchitis, abscess, or infertility
Why do you do a scrotal U/S in epididymitis?
To r/o testicular torsion or an abscess
Treatment for epididymitis
If pt Hx suspicious for chlamydia or gonorrhea:
Ceftriaxone 250 mg IM x1 and Doxycycline 100mg BID for 10 days
If enteric organism:
Levofloxacin 500mg qd x 10 days or Ofloxacin 300mg BID x 10 days
Advise adjunct use of NSAIDS for pain relief
Infection with involvement of the testicle by retrograde infection
Epididymoorchitis
What condition is associated with mumps?
Epididymoorchitis (look for paroditis)
Clinical features of epididymoorchitis
Acute, ipsilateral testicular swelling and tenderness
Fever
+/- bothersome urinary symptoms
Treatment for Epididymoorchitis
If mumps suspected, supportive care
If bacterial pathogen suspected, treat similar to epididymitis
Venous varicosity in the pampiniform plexus (spermatic vein)
Varicocele
Present in 15-20% of post-pubertal males
Varicocele typically presents on which side of the scrotum?
Left, due to longer left spermatic vein
But can occur bilaterally too
RIGHT-SIDED ONLY varicocele is suspicious for pelvic/abdominal malignancy
What are the clinical features of varicocele
Post-pubertal male with reported Hx of scrotal swelling
“Bag of worms”
Dull, achy testicular pain relieved with support or supine
Can cause testicular atrophy and infertility
Varicocele increases in size with ________ and decreases in size when _________.
Increases with Valsalva
Decreases when supine or if the scrotum is elevated
How do you diagnose varicocele?
PE - if no decompression in recumbent position, CT scan for outlet obstruction
Doppler scrotal U/S
How do you treat varicocele?
Ligation of the spermatic vein if symptomatic, infertility concerns, or testicular atrophy
Supportive care if mild symptoms and no reproductive concern
Twisting of the testis on the spermatic cord causing compromised circulation and ischemia
Testicular torsion
Testicular torsion is more common in…
Neonates and post-pubertal boys
Often occurs after vigorous physical activity or minor trauma
Clinical features of testicular torsion
Acute onset of scrotal pain, unilateral with hemiscrotal swelling
Pain on palpation, without relief with elevation (-) Prehn’s sign
Bell clapper deformity
Absent cremasteric reflex
How do you diagnose testicular torsion
DOPPLER U/S of scrotum —> limited or loss of flow to spermatic cord and testis
Treatment of testicular torsion
Manual detorsion - doesn’t really work but worth a shot while you’re waiting
Urologic emergency requiring SURGICAL DETORSION and ORCHIOPEXY
Most common age group affected by testicular cancer
15-35
Risk factors for testicular cancer
Personal Hx of testicular cancer
Cryptorchism
Klinefelter syndrome - risk for germ cell tumors
Family Hx
Clinical features of testicular cancer
Painless, solid testicular swelling or nodule (consider cancer until proven otherwise)
Dull ache or heavy sensation in the lower abdomen, perinatal area, or scrotum
Inguinal LAD or para-aortic LAD
+/- abd pain or with pulmonary symptoms or neuro defects
Most common location of metastasis of testicular cancer
Abdomen
Lungs
Brain
What should you do if you suspect testicular cancer?
Scrotal U/S
CT abdomen/pelvis
Tumor markers: Beta-HCG, lactate dehydrogenase (LDH), alpha fetoprotein (AFP)
What are the different types of testicular tumor?
95% are germ cell tumors
Seminoma 35%
Nonseminoma 65%
The type determines the treatment course
Treatment of testicular cancer
Radical inguinal orchiectomy
Radiation and chemotherapy with medical oncologist based on tumor staging
Seminatous tumors are RADIOSENSITIVE
Nonseminatous tumors are RADIORESISTANT
Nerve sparing retroperitoneal lymph node dissection for nonseminatous tumors, stage dependent
Offer sperm banking prior to treatment
What should surveillance for testicular cancer entail?
Office visit q 3 months for first 2 years, 6 months then yearly after 5 year mark
CXR, tumor markers and CT AB/pelvis
Genital exam at every visit
A protrusion, bulge, or projection of an organ or a part of an organ through the body wall that normally contains it
Hernia
______ hernias protrude through Hesselbach’s triangle
Direct
_______ hernias develop at the internal inguinal ring and can travel through the inguinal canal into the scrotum
Indirect
Hernia occurring at the medial aspect of the femoral canal
Femoral hernia
________ hernias are due to weakness in the floor of the inguinal canal
Direct inguinal hernia
________ hernias are the most common type
Indirect inguinal hernias
Indirect inguinal hernias more commonly occur on the _____ side
Right
Most are congenital but don’t present until later in life
Femoral hernias are the least common type but are more common in _____.
Women
Most likely to become incarcerated/strangulated
Clinical features of inguinal hernias
Heaviness, discomfort with straining
Painless bulge
N/V, abd distension and pain, redness, fever if incarcerated/strangulated
Strangulated hernia can cause bowel obstruction, peritonitis, and toxic appearance
How do you diagnose hernias?
Hx and PE
U/S if in doubt or to r/o other conditions
Treatment for hernias
Definitive treatment is always surgical
Repair is urgent for incarcerated or strangulated hernias
If reducible, elective surgery is viable
Second most common urologic malignancy that is 7x more common in men
Bladder cancer
Bladder cancer is heavily associated with…
Tobacco Use
Exposure to chemical dyes
What are the most common cell types for bladder cancer?
Transitional cell carcinoma (90%)
Squamous cell carcinoma (7%)
Adenocarcinoma (2%)
Clinical features of bladder cancer
Painless gross hematuria or microscopic hematuria most common presenting symptom
Obstructive or irritative urinary symptoms can occur
Local advancement may present with para-aortic LAD
Metastatic disease may present with hepatomegaly, supraclavicular LAD, or periumbilical nodules
Pain consistent with the areas of invasion or metastasis
Gold standard for diagnosing and staging bladder cancer
Cystourethroscopy
Will also want to do urine cytology (bladder cells)/urine-based tumor markets, and CT with urography to evaluate upper tracts
Treatment options for bladder cancer
Transurethral resection of the bladder tumor
High grade tumors will require intra-vesicular chemotherapy
Muscle invasive tumors - neoadjuvant systemic chemotherapy prior to radical cystectomy
What are the different types of incontinence?
Urge incontinence - uncontrolled loss of urine that is proceeded by a strong, unexpected urge to void
Stress incontinence - leakage with exertion, valsalva due to urinary sphincter dysfunction
Mixed of the above
Incomplete emptying incontinence - impaired DETRUSOR contractility or bladder outlet obstruction (much less common)
__________ is the most common cause of stress incontinence
Prostate surgery
WHich type of incontinence usually presents as nocturnal enuresis?
Incomplete emptying incontinence (overflow)
What are the treatment options for incontinence?
Urgency incontinence:
• Antimuscarinic (tolterodine, fesoterodine, oxybutynin)
• Alpha blockers if BPH
Stress incontinence:
• Condom catheters, penile clamp
• surgical options
Overflow incontinence
• Alpha blockers
When should you refer to urology for complicated incontinence?
Severe symptoms Pelvic pain Hematuria Elevated PSA/abnormal prostate exam Recurrent urologic infections Previous pelvic radiation or surgery Neurologic disease
