BPH, Urethra & Penis Disorders, Scrotal Mass, Torsion Flashcards
Function of the prostate
- gland that makes fluid for ejaculation
- produces PSA protein
Why are glands hard to treat with antibiotic?
No blood flow
Lab to screen for prostate cancer
PSA
Causes of elevated PSA
enlarged prostate, infection, prostate cancer
Function of ejaculatory duct
carries sperm from testes
fluid from seminal vesicles and fluid from prostate
testes mainly composed of what 2 things
sperm and testosterone
vasectomy destroys what structure
vas deferens
Most common benign tumor in men
BPH
Elevated risk of BPH begins at what age?
40
Location of BPH
around urethra - transition zone of prostate
Why do rectal exam for prostate cancer?
cancer most commonly occurs in peripheral zone of prostate on rectal/posterior side
*may miss BPH
2 categories of BPH symptoms and how they are caused
obstructive - mechanical (BOO) or dynamic (adrenergic tone)
irritative - detrusor muscle hypertrophy and hyperplasia
irritative symptoms of BPH
- Increased frequency
- Urgency and difficulty postponing urination
- Discomfort when urinating
- Nocturia
obstructive symptoms of BPH
Hesitation Straining when urinating Weak or intermittent stream Sense that bladder hasn't emptied completely Dribbling
DDX of voiding complaints in males
Urethral stricture/bladder neck contracture
Urinary tract infection
Carcinoma of the bladder (hematuria resistant to abx gets urology referral)
Neurologic disease
Diabetes mellitus
suspected BPH lab work-up
serum creatinine
look for infection and hematuria
imaging of kids with UTI
< 2 yrs old
any boy
any GU anomalies
any child with recurrent (>3/yr)
Man with hematuria needs what imaging?
CT urogram
Refer to urology
Man with elevated creatinine needs what imaging?
renal/bladder US
How to manage BPH with IPSS score 0-7 (mild sx’s)?
watchful waiting
How to manage BPH with IPSS score +7 (mod to severe sx’s)?
Nonselective α-Blockers
- Terazozin (Hytrin)
Selective α1a-receptor blockers
- Tamsulosin (Flomax)
MOA of alpha blockers in BPH
relaxation of prostate smooth muscle (rich in adrenergic nerve supply)
MOA of 5α-reductase inhibitor in BPH
Blocks conversion of testosterone to dihydrotestosterone (DHT)
treats prostate epithelium
5α-reductase inhibitor rare side effects
ED, decreased libido, gynecomastia
Examples of 5α-reductase inhibitor
Dutasteride (Avodart)
Finasteride (Proscar, Propecia)
1st line therapy for BPH in man with moderate to severe symptoms
alpha blocker
Cons of 5-alpha-reductase inhibitors
need 6 month therapy to see maximum benefit
only helpful in very large prostate (> 40 cm3)
When should 5a-reductase inhibitor be added to alpha blocker in BPH therapy?
Very large palpated prostates
Hemorrhagic prostates
What plant has been claimed to treat BPH, but has no research to support?
Palmetto berry
Absolute surgical indications of BPH
Urinary retention refractory to medical management
Recurrent urinary tract infection
Recurrent gross hematuria
Renal insufficiency
Eval of hemorrhagic prostates
- Image upper tracts
- Have urology r/o bladder cancer with cystoscopy
Gold standard surgery for BPH
Transurethral resection of the prostate (TURP)
Hypospadias
Failure of urethral folds to close at tip of penis
Occurs in 1 in every 300 male children
When to refer hypospadias?
bothers patient
complaints of diminished stream
urethral stricture and meatal stenosis symptoms
Decrease in urinary stream
Spraying or double stream
Postvoiding dribbling.
2 risk factors of urethral stricture
trauma and infection
meatal stenosis
scarring of urethral opening at external meatus
phimosis and paraphimosis
problems with foreskin
tight over tip is phimosis or tight farther down past glans is paraphimosis
Treatment of paraphimosis
Usually treated by firmly squeezing glans for 5 minutes to reduce the tissue edema; then skin drawn forward over the glans
Antibiotics
Signs of Peyronie’s Disease
Curvature of penis and painful erection
No pain when penis is in non-erect state
Pathophysiology of Peyronie’s Disease
fibrous plaque involving tunica albuginea
~Dupuytren’s contracture
Peyronie’s Disease treatment and management
- Observation; spontaneous remission occurs in about 50%
- Vit E may be tried but generally don’t work
- Refer if unable to perform intercourse
What is Priapism?
prolonged erection
Main concern of priapism?
impotence
2 types of priapism?
ischemic: obstruction of venous drainage; painful; emergency!
non-ischemic: too much blood flow to penis; not painful; no treatment
Drug that causes ischemic priapism
Trazodone
Treatment of priapism in sickle cell patient
treat sickle cell and priapism will go away
massive blood transfusions, exchange transfusions, or both
Causes of ischemic priapism
30-50% idiopathic
Meds for ED
Psychotropic drugs - Trazodone!
Sickle cell disease
Causes of non-ischemic priapism
Trauma
Pelvic arteriovenous malformations (AVMs)
Acute spinal cord injury
Treatment of ischemic priapism
MEDICAL EMERGENCY
Narcotic analgesia
Initial tx with Terbutaline (adrenergic agonist)
Corporal irrigations
Surgical shunt
collection of peritoneal fluid between layers of tunica vaginalis
hydrocele
Always get _____ to eval scrotal mass.
U/S
Hydrocele may be reaction as a result of what?
testicular cancer, torsion, epididymitis
Transillumination of hydrocele differentiates scrotal mass from _______.
varicocele
What differentiates a complex hydrocele from a simple one?
septations on US
Treatment of hydrocele
NO ASPIRATION
simple - observe
complex - refer for surgery
What is epididymis cyst and spermatocele?
Painless fluid accumulation on sup/post to testes
clear fluid -> epididymis cyst
clear fluid + dead sperm -> spermatocele
Treatment of epididymis cyst and spermatocele?
No treatment unless bothersome
Male comes in with no sx’s but unable to have children. On palpation of scrotum feels like “bag of worms”
varicocele
In what position should patient be in to eval for varicocele?
Both supine and upright
Perform Valsalva maneuver while standing to accentuate dilation
Right testicular vein drains into ________ and left testicular into ________.
vena cava
renal vein
Get _____ for all right sided varicoceles.
CT scan
“bellclapper deformity”
testicular torsion in which testis rotates freely within tunica vaginalis
Risk factors for testicular torsion
trauma
increased testicular volume associated w/ puberty
testicular tumor
history of cryptorchidism
What PE most sensitive to testicular torsion?
absence of cremaster reflex
Testicular torsion occurs most commonly in what age group?
men younger than 25
Testicular pain with “blue dot sign” and 2-3 mm nodule
torsion of appendix testis
How soon should testicular torsion be treated to salvage testicle?
< 6 hrs from sx onset
Testicular torsion treatment
Immediate surgical exploration and testicular salvage or orchiectomy
Manual detorsion is quick and non-invasive (rotate away from midline, 25% success rate)
DDX painful testicular swelling
Epididymitis Orchitis/Mumps Testicular torsion Torsion of Appendix testes Incarcerated Inguinal Hernia
DDX painless testicular swelling
Hydrocele Varicocele Unincarcerated Inguinal Hernia Nephrotic Syndrome Testicular Tumors Fragile-X syndrome Klinefelter Syndrome
