DIAGNOSTIC TESTING Flashcards
TESTOSTERONE DEFICIENCY SYMPTOMS
⦁ decreased energy ⦁ decreased libido ⦁ decreased muscle mass ⦁ decreased body hair ⦁ hot flashes ⦁ gynecomastia ⦁ infertility
testosterone is produced in the testes by the
Leydig cells
_____ stimulates production of testosterone
LH
Negative feedback loop = testosterone inhibits the production of ____________ and therefore
GnRH
and therefore FSH / LH
Single most important diagnostic test for male hypogonadism
TESTOSTERONE
what testosterone test is ordered
serum total testosterone
= free testosterone + protein bound testosterone
normal serum total testosterone range
300-800 ng/dL
Abnormal testosterone binding to the sex hormone binding globulins (may need a free testosterone test)
If SHBG increased then____ free testosterone
If SHBG decreased then _____ free testosterone
less
more
If SHBG increased then less free testosterone: seen in what conditions
Aging, hyperthyroidism, increased estrogen, liver disease, HIV, antiseizure drugs
If SHBG decreased then more free testosterone: seen in what conditions
Obesity, insulin resistance, T2DM, hypothyroidsm, increased GH, exogenous androgens, glucocorticoids, nephrotic syndrome
when are testosterone levels the highest
morning
- so collect sample at 8AM when testosterone levels are the highest
- If normal – stop testing
- If abnormal – repeat 1-2 more times to confirm
⦁ 1st time = abnormal, 2nd time = abnormal = stop
⦁ 1st time = abnormal, 2nd time = normal = need a 3rd test
if testosterone is actually low, check
- check LH & FSH
- when testosterone is low & LH/FSH are high = primary hypogonadism (Klinefelter)
- when testosterone is low & LH/FSH are not elevated = secondary hypogonadism (DM, liver or kidney disease, aging)
primary hypogonadism = testosterone is ____ and FSH/LH are
low
high
(Klinefelters)
secondary hypogonadism = testosterone is ____ and FSH/LH are _______
low
not elevated
(DM, liver or kidney disease, aging)
PSA is secreted by the
epithelial cells of the prostate
PSA is present in low levels in the serum & present in the semen
function of prostate
to liquify the semen in the seminal coagulum to allow sperm to swim freely
CAUSES OF AN ELEVATED PSA
PSA = Indirect measurement of prostate glandular size in men without cancer
⦁ Normal values increase with age
⦁ Values can vary by race: Blacks have higher PSA levels than white
⦁ BPH
⦁ Prostate Cancer
⦁ Prostatic inflammation or infection
⦁ Perineal trauma (rarely DRE, bike riding, sex - persists for 48-72 hrs post-sex)
PSA & PROSTATE CANCER
- used to determine extent of cancer
- used to track response to treatment
- used as a screening method for detection
⦁ controversial; lacks sensitivity & specificity
CAUSES OF DECREASED PSA
⦁ Obesity (delays early detection - may partially explain the worse outcomes in obese men with early prostate cancer)
⦁ Meds
- 5-ARIs (50% or more) - which is why you're supposed to double their PSA value - NSAIDS - Statins - Thiazides
which meds decrease PSA
5- ARIs
NSAIDS
STATINS
THIAZIDES
free PSA = __________ when there is no cancer,
________with aggressive forms of cancer
higher
lower
rate of change in PSA values over time
PSA VELOCITY
time it takes to double the PSA
PSA DOUBLING TIME
(serum PSA/ prostate volume
PSA DENSITY
PSA DENSITY
(serum PSA/ prostate volume); if ratio > 1:1 = increased risk for prostate cancer
- PSA = higher in men with BPH
- PSA density = sometimes used for men with BPH to try to adjust for this
- PSAD measures the volume (size) of the prostate with TRUS and divides the PSA number by prostate volume
- a higher PSA density indicates a greater likelihood of cancer*
to adjust for the fact that men with BPH have higher PSA, sometimes use _____________ instead
PSAD = PSA density
- a higher PSA density indicates a greater likelihood of
cancer
PSA VELOCITY
- the rate of change in PSA over time
- a PSA that is quickly rising = more suspicious for cancer
- however, a PSA that is already high or quickly rises to a concerning level will quickly lead to further evaluation
- usually perform a transrectal prostate biopsy
FREE / TOTAL PSA (PSA II)
- the % of free PSA decreases as total PSA increases in serum of men with prostate cancer (lower free PSA = cancer, high free PSA = non-cancer; so if free PSA decreases (meaning bound PSA increases = will increase total PSA = cancer))
- the ratio of free / total PSA, especially in men with normal PSA values, can be helpful in diagnosing those with possible cancer
- the question is…what is the percentage cutoff?
so if free decreases and total increases = think cancer
high free PSA = think
BPH
high bound PSA (low free PSA) = more likely to be from prostatic cancer cells
Free and total prostate-specific antigen:
Only useful with PSA of
4-10
MAINSTAY OF INVESTIGATING MALE FERTILITY POTENTIAL
semen analysis
process of semen analysis
⦁ abstain from sex for 2-3 days
⦁ collect all ejaculate; obtained by masturbation
⦁ analyze within 1 hour
⦁ provides immediate information
macroscopic sperm analysis
- viscosity
- volume
- pH
microscopic sperm analysis
- sperm concentration / count
- motility
- morphology
- viability (supravital stain)
- leukocyte count
- search for immature germ cells
normal semen analysis
- volume
- concentration
- initial forward motility
- normal morphology
o volume > 1cc
o concentration > 2 x 106/ cc
o initial forward motility > 50%
o normal morphology > 60%
No measurable sperm in the semen
AZOSPERMIA
Less than 15 million sperm/ml
OLIGOSPERMIA
conditions with azospermia
Klinefelters Hypogonadotrophic -hypogonadism ductal obstruction (absence of vas deferens)
conditions with oligospermia
Anatomic defects
Endocrinopathies
Genetic factors
Exogenous (e.g. heat)
PROSTATIC SECRETIONS PROCESS
- four-glass test = first void 10mL, then mid-stream sample 10mL, then expressed prostatic secretion, then first voided 10mL after massage
- this is quite uncomfortable/painful for the patient
- compare voided urine before prostatic massage to urine voided after prostatic massage to see if prostatic massage causes any leakage of white cells / bacteria into the urine
**Avoid this procedure in acute bacterial prostatitis = risk for induction of bacteremia or sepsis
DIAGNOSIS OF UTI
UA WITH CULTURE
URINE CULTURE COLLECTION
- in adults & older children, a mid stream urine sample usually reliiable represents the urine in the bladder (clean catch)
- do NOT use samples from urinary bags, pedi-bags or bedpans to diagnose UTI (all are contaminated)
- most reliable sample = obtained via catheterization or suprapubic aspiration in infants (often less traumatic than catheterization)
MOST RELIABLE URINE SAMPLE
obtained via catheterization or suprapubic aspiration in infants (often less traumatic than catheterization)
Traditional gold standard for significant bacteriuria __________ cfu/mL of urine
> 100,000
Some argue criteria for bacteriuria is only 100 cfu/mL of a uropathogen in symptomatic females or 1,000 in symptomatic males.
measuring sensitivity of bacteria to antibiotics in urine
Measure sensitivity of bacteria to antibiotics
⦁ agar diffusion = Kirby-Bauer Test (disc diffusion test) OR E-test (strip test)
⦁ broth dilution
For solid media = use disc diffusion test (Kirby-Bauer Test)
For liquid media = use MIC test (minimum inhibitor concentration) - cloudiness means that the bacteria can grow that concentration antibiotic
when concerned about bladder cancer
get urine cytology & cystoscopy
initial = urine cytology
diagnosis of bladder cancer = cystoscopy
process of urine cytology
- perform microscopic cytology of urinary sediment, or saline bladder wash to detect malignant cells (saline wash = more accurate)
- microscopic cytology = more sensitive in high grade tumors or carcinoma in situ, but can be falsely negative in 20% of cases
Peak flow urine rates = measures
how fast urine is passed
pressure flow study
have a urodynamic catheter in the bladder that allows the measurement of pressure & urine flow during voiding
urodynamics can be done to assess symptoms such as
Urinary incontinence Frequent urination Sudden, strong urges to urinate Painful urination Problems starting a urine stream Problems emptying the bladder Recurrent UTI
urodynamic testing
- uroflowmetry
- PVR
- Cystometry (measures bladder pressure, leak point pressure, and pressure flow studies)
- Electromyography
- Video dynamics
UROFLOWMETRY
- screening tool for patients with suspected bladder outlet obstruction; measures peak flow (speed of urine in mL/sec)
- reserved for patients with severe symptoms where invasive therapy is considered; this is done by a urologist
- used in urethral stricture
normal PVR value
< 50 mL
unless pt is > 60 = then normal PVR = 50-100
Can distinguish bladder outlet obstruction from impaired detrusor function
cystometry
- Assesses detrusor activity, sensation, capacity and compliance
Cystometry is rarely done, because it is invasive; Urologist referral for this!
