7. Non muscle invasive bladder tumors; Disorders of the male genital organs

Question 1

Non-muscle invasive bladder tumors

Answer 1

Bladder cancer is divided into non-muscle invasive (80%) and muscle invasive types (20%).
NMIBC: stages Tis, Ta, and T1.
invasive is beyond T2 and up.

Median age is 70 years.
Male to females 3:1
White to black 4:1

90% are urothelial/transitional cell carcinoma.
Typically papillary.
Other types: sessile, infiltrating, nodular, and mixed.

Usually located on the bladder floor where carcinogens settle.

Question 2

Bladder cancer staging.

Answer 2

• Carcinoma in situ: Flat tumor
• Ta: Affects epithelium but is a growing tumor
• T1: Invades subepithelial connective tissue
Muscle invasive bladder tumor (20%):
• T2: Invades detrusor muscle
• T3: Invades perivesical fat
• T4: Invades prostate, uterus, vagina, abdominal wall

Question 3

Carcinogens that cause bladder cancer

Answer 3

• Iron and aluminum processing
• Industrial painting - analine dyes
• Smoking
• Previous chronic infection
• Schistosoma haematobium
• Cyclophosphamide chemotherapy
- Phenacetin

Question 4

Bladder cancer symptoms

Answer 4

Painless hematuria

Question 5

Diagnosing bladder cancer

Answer 5

• Urinary cytology: Look for exfoliated cancer cells. Very useful in in carcinoma in suit or high-grade malignancy. However, a positive sample may indicate a tumor anywhere in the urinary tract (not specific)
• Cystoscopy: The gold standard in proving bladder cancer.

Question 6

Treating bladder cancer

Answer 6

For non-muscle invasive bladder cancer:
Transurethral resection of the bladder (TURB) + adjuvant chemo and sometime BCG immunotherapy, especially in the case of multicentric tumors.

Resection of the underlying muscular bladder is necessary for correct pathological staging. Reoccurrence is common.

• Adjuvant chemotherapy: To reduce reoccurrence. Doxorubicin, epirubicin and mitomycin.
• Bacillus Chalmette-Guerin immunotherapy (BCG): It is prepared from a strain of the attenuated (virulence-reduced) live bovine tuberculosis bacillus, Mycobacterium bovine, that has lost its virulence in humans, but still elicits an immune response.
• BCG is put directly into the bladder through a catheter. The body´s immune system cells are attracted to the bladder and attack the cancer cells as well.

Question 7

Disorders of the male genital organs (7)

Answer 7

Erectile dysfunction

Priapism

Anejaculation/aspermia

Retrograde ejaculation

Premature ejaculation

Painful ejaculation

Hypogonadism

Question 8

Erectile dysfunciton

Answer 8

It is usually an age related problem that becomes increasingly more common in men
over 40.

The significance of ED is that it may frequently prove to be a marker for undiagnosed diseases such as HTN, DM, ischemic heart disease, hyperlipidemia, neurological conditions and endocrine disease.

Erectile dysfunction can be caused by psychological, vascular, hormonal, neurological or iatrogenic factors.

Question 9

Diagnosing the cause of ED

Answer 9

Patient history, physical exam, and standard lab tests for possible link to HTN, DM, ischemia, hyperlipedima, endocrine disorders.
-Prolactin, TSH, Testosterone, Lipids, Glucose levels, Blood counts.

International Index of Erectile Function questionnaire to take the sexual history.

• Nocturnal Penile Tumescence Test
• Neurological Testing for diabetic neuropathy and compression of spinal cord due to pelvic injury.
• Doppler ultrasound following injection of prostaglandin to the corpus cavernosum.
• Internal Pudendal Artery Arteriography - to evaluate penile arterial anatomy. Indicated in young patients with ED secondary to traumatic arterial injury.
• Cavernosography - Infusion of radio-contrast material into the corpus cavernosa after prostaglandin injection to evaluate veno-occlusive insufficiency and to visualize sight of venous leakage.

Question 10

Treating ED

Answer 10

Stop smoking, abusing alcohol and recreational drugs.

Lose weight and exercise.

Change medication if on anti-hypertensive, beta-blockers, thiazide diuretics, or antidepressants.

Drug treatment.
• Viagra/sildenafil: First-line treatment. It acts by inhibiting cGMP-specific phosphodiesterase type 5, an enzyme that promotes degradation of cGMP, which
regulates blood flow in the penis.

• Intracavernosal injections: Prostaglandin injections.
• Vacuum constriction device
• Medicated urethral system for erection (MUSA): Prostaglandin can be inserted into urethra for local absorption.
• Penile prosthesis implantation: Implantation of silicon prostheses into corpora cavernosa. A pump is placed in the scrotum to inflate the cylinders.
• Vascular surgery: Indicated only in young patients with pelvic or perineal trauma with pure arteriogenic dysfunction.

Question 11

Priapism

Answer 11

Persistent erection (>4hours) unrelated
to stimulation. 

Causes:
• 60% idiopathic
• Intracavernous injection (therapy
for impotence)
• Leukemia
• Sickle cell syndrome
• Trauma
• Antidepressants (trazodone)
• CO poisoning

Two types:
- High flow: Non-ischemic/arterial priapism caused perineal trauma, causing loss of regulation of arterial blood flow. No pain and no emergency.

• Low flow: Physiological obstruction of venous drainage causing clotting of blood in corpora cavernosa.
  Glans and corpora spongiosum are typically not tense.
  Painful and medical emergency. Attempt to cool the penis. Make a puncture.

Others: Stuttering priapism (hemoglobinopathies) and malignant priapism (from metastases).

Question 12

Anejaculation/aspermia

Answer 12

Complete absence of ejaculation. Usually connected with central or peripheral nervous system disease:

• Autonomic neuropathy
• DM
• Traumatic spinal cord injury
• Iatrogenic
• Drug related

Question 13

Retrograde ejaculation

Answer 13

Semen passes predominantly backwards into bladder. Usually the result of internal sphincter dysfunction combined with uncoordinated relaxation of
external sphincter.
Diagnosis with presence of spermatozoa in post-orgasmic urine.

Treatment: Ephedrine and midodrine. Allosteric activator of Epinephrine of alpha and beta receptors.

Imipramine and despramine can also be useful. TCAs.

Question 14

Premature ejaculation

Answer 14

Unable to control ejaculation for sufficient length of time during vaginal penetration (less than 2 min).

Treatment: Behavioral therapy (stop-start, squeeze). Paroxetine or fluoxetine can be helpful.

Question 15

Painful ejaculation

Answer 15

Usually do to lower urinary tract infection. Can also be caused by obstruction of the ejaculatory duct.

Question 16

Hypogonadism (testosterone deficiency syndrome)

Answer 16

Reduced or absent secretion of testosterone with associated symptoms. 4-10mg is secreted daily in healthy testicles.

• Primary hypogonadism: Testicular dysfunction
• Secondary hypogonadism: Dysfunction in hormonal pathway.

Diagnosis: Biochemical tests and measure levels of testosterone
Treatment: Give injections of testosterone.