EXam 3 Men's Health

Question 1

BPH:Clinical Presentation

Answer 1

 Decreased urinary flow
 Hesitancy
 Post-void residual
 Nocturia
 Urgency
 Dysuria
 Urge and overflow incontinence

Question 2

BPH:Exam Findings

Answer 2

 Enlarged prostate (larger than walnut size)
 Gross Hematuria
 Distended bladder
* Increased post-void residual

Question 3

BPH:Diagnostics

Answer 3

 Elevated pH
 Elevated serum creatinine
 Elevated PSA-less than 10ng/mL
 Urine culture- sometime positive for bacteria
 AUASI questionnaire
* Mild -> 0-7
* Moderate -> 8-19
* severe case -> 20 or greater

Question 4

BPH:Management

Answer 4

 Mild-Moderate (0-7)
* Watchful waiting
 Moderate (8-19)
* Initiate medication
 High (=>20)
* Vigorous treatment
* Refer to urologist

Question 5

BPH:Management Medication

Answer 5

• Selective alpha1-adrenergic agonists
• Relaxes bladder neck (titrate dose)
• Prazosin (Minipress) 1 to 5 mg bid
• Terazosin (Hytrin) 1 to 10 mg qd
• Doxazosin (Cardura) 1 to 8 mg qd
• Silodosin (Rapaflo) 4-8 mg daily
  o Subtype alpha1-adrenergic blockers (no titration)
   Relaxes smooth muscles in the bladder neck and prostate
   Eases pressure on the urethra and bladder
• Tamsulosin (Flomax) 0.4 or 0.8 mg qd
• Alfuzosin (UroXatral) 10 to 15 mg qd (immediately after the same meal each day)
  o 5-alpha-reductase inhibitors
   Reduce size (but may take 6 months)
• Finasteride (Proscar)
• Dutasteride (Avodart)
  o Combo 5 alpha reductase inhibitor with alpha blocker
   Finasteride or Dutasteride with an alpha blocker
   Tamsulosin/dutasteride (combodart)

Question 6

Erectile Dysfunction: Classification and clinical symptoms

Answer 6

 Inability to maintain erection
 Lack of sexual desire
* Classification:
* Mild: failed erection 2/10 attempts
* Moderate: in between
* Severe: failed erection all attempts

Question 7

Erectile Dysfunction: Evaluation

Answer 7

 Detailed medical, sexual, and social hx.

Question 8

Erectile Dysfunction: Diagnostic work up

Answer 8

 fasting glucose, lipids, TSH
 Testosterone level (normal level is <300; best assessed between 0700-1000 am; begins to decline after age 30), PSA, CBC, BMP

Question 9

Erectile Dysfunction: Screening tools

Answer 9

• International Index of Erectile Function (IIEF)
• NPTR- during sleep
• Color Doppler sonography- measures vascular causes

Question 10

Erectile Dysfunction: Management

Answer 10

 Lifestyle medications: 25% of cases are due to ETOH use, smoking, recreational drugs.

Question 11

Erectile Dysfunction: Management

Answer 11

 Medications: Hormone replacement Therapy (Testosterone)
* Testosterone injections range from 100 to 200 mg every two weeks to 50 to 100 mg weekly
* Phosphodiesterase-5 inhibitors — For first-line therapy of ED, we recommend the PDE5 inhibitors because of their efficacy, ease of use, and favorable side-effect profile.
 Sildenafil, vardenafil, tadalafil, and the newest option, avanafil, appear to be equally effective, but tadalafil has a longer duration of action and avanafil has a more rapid onset

Question 12

Erectile Dysfunction: Patient Education

Answer 12

 Patient education: management of chronic conditions-> DM, HTN, Stress, safety if using testosterone replacement formulations (dangerous if transferred to partner)

Question 13

Prostatitis: Risk Factors

Answer 13

 Age (>50)
 History of Prostatic Calculi
 Previous UTI

Question 14

Prostatitis: Clinical Presentation

Answer 14

 Tenesmus
 Pain in the lower back or with urination
 Persistent desire to empty bowel or bladder
 Obstructive symptoms- weak urine stream, incomplete bladder emptying, terminal dribbling

Question 15

Prostatitis: Physical Exam

Answer 15

 Prostate exam: with care! Vigorous stimulation of the prostate can result in septicemia.
 In a patient with acute bacterial prostatitis, the prostate will often be tender, enlarged, or boggy.
 If chronic the exam may reveal a tender prostate but it may not be swollen or boggy.
 GU exam:
* acute onset of irritative (e.g., dysuria, urinary frequency, urinary urgency) or obstructive (e.g., hesitancy, incomplete voiding, straining to urinate, weak stream) voiding symptoms.
* Patients may report suprapubic, rectal, or perineal pain.
* Painful ejaculation, hematospermia, and painful defecation may be present
* Systemic symptoms, such as fever, chills, nausea, emesis, and malaise, commonly occur, and their presence should prompt physicians to determine if patients meet clinical criteria for sepsis.

Question 16

Prostatitis: Diagnostics

Answer 16

o CBC
o UA and culture
o CT or US
o Needle biopsy
o In men younger than 35 years who are sexually active, and in men older than 35 years who engage in high-risk sexual behavior,
 Gram stain of urethral swabs, a culture of urethral discharge, or a DNA amplification test should be obtained to evaluate for N. gonorrhoeae and C. trachomat

Question 17

Prostatitis: Management

Answer 17

 NSAIDs, muscle relaxants, anticholinergics, warm sitz baths.
 Avoid caffeine and spicy foods, etoh, lots of fluids
 NEVER FOLEY CATH!
 Treat as outpatient if does not have a fever.
 Hospitalize if - toxic, immunocompromised, proven or suspected abscess, or signs of urosepsis
 Causative organisms for prostatitis will guide your treatment and duration of treatment
o Gram Negative: Klebsiella, Pseudomonas, Enterobacter, E. Coli, Proteus Mirabilis and N. Gonorrhoeae
o Gram Positive: Streptococcus faecalis and staph aureus

Question 18

Prostatitis: Management Medication

Answer 18

o Men with bacterial prostatitis may be treated on an outpatient basis
o 4 to 6 weeks with antibiotics such as ofloxacin (Floxin) 400 mg PO bid q12h, ciprofloxacin 500 mg PO q12h, or norfloxacin 400 mg PO q12h
 Alternatives
o Trimethoprim and sulfamethoxazole (TMP-SMX), 160 mg/800 mg
o Bactrim, Septra, Cotrim, one double-strength (DS) tablet q12h
o Doxycycline 100 mg q12h
 Men younger than 35 years who are sexually active and men older than 35 years who engage in high-risk sexual behavior should be treated with regimens that cover N. gonorrhoeae and C. trachomatis
o Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1 g in a single oral dose
 Chronic bacterial prostatitis
o The best cure rates in chronic bacterial prostatitis are associated with treatment with TMP-SMX, although other antibiotics such as carbenicillin, erythromycin, cephalexin, and the quinolones are effective as well
o The patient with chronic infection is usually treated for 6 to 12 weeks

Question 19

Testicular Torsion: Clinical presentation

Answer 19

 Acute pain & swelling (most common)
 Resent injury/trauma
 Pain worse with elevation
 Diaphoresis, N/V

Question 20

Testicular Torsion: Physical Exam

Answer 20

 Absence of cremasteric reflex
 Involved testicle higher in scrotum “bell-clapper”
 Small palpable lump on superior pole of testis “blue dot sign”

Question 21

Testicular Torsion: Diagnostic Tests

Answer 21

 Color Doppler US or radionuclide scanning
Management

Question 22

Testicular Torsion: Management

Answer 22

 Emergency intervention/surgery

Question 23

Hydrocele: Clinical presentation

Answer 23

 Swelling in scrotum or inguinal canal
 Painless
 Heaviness in the scrotum

Question 24

Hydrocele: Physical exam

Answer 24

 Trans illumination -trapped fluid appears pink/yellow/red-testis and hydrocele won’t illuminate
 Swelling in groin and upper scrotum

Question 25

Hydrocele: Diagnostic Test

Answer 25

 US, testicular
nuclear scan,
abdominal x-ray series

Question 26

Hydrocele: Management

Answer 26

 Monitoring to self-resolve or if complication presents-refer for surgical intervention

Question 27

Epididymitis: Clinical Presentation

Answer 27

 Signs and symptoms of UTI/ Penile discharge/ tender prostate/ pain in tip of the penis
 Blood in the semen
 Discomfort in the lower abdomen or pelvis
 Lump near the testicle
Less common symptoms are:
 Pain during ejaculation
 Pain or burning during urination
 Painful scrotal swelling (epididymis is enlarged)
 Tender, swollen, and painful groin area on affected side
 Testicle pain that gets worse during a bowel movement

Question 28

Epididymitis: Physical Exam

Answer 28

 elevation of the testicle will relieve discomfort

Question 29

Epididymitis: Diagnostic

Answer 29

US of the scrotum

Question 30

Epididymitis: Management

Answer 30

 NSAIDS
 Ice scrotal support

Question 31

Epididymitis: Management Medications

Answer 31

 If caused by STI→ ceftriaxone 250mg IM x1 plus Doxycycline 100 mg po BID x 14 days
o If allergic to Cetriaxone may use Ofloxacin 300 mg po BID or Levoflaxin 500 mg po daily x 10 days.
 Non-STD cause→ Ciprofloxacin 750mg po BID; Bactrim DS BID x 2-3 weeks

Question 32

Testicular cancer: Clinical presentation

Answer 32

• scrotal swelling,
• painless enlargement of testes,
• heaviness in lower abdomen, scrotum or perineal area,
• firm non-tender lump,
• enlarged nodes in abdomen and supraclavicular area

Question 33

Testicular cancer: Diagnostic

Answer 33

• Biochemical markers can be helpful to diagnose but are mostly used to follow progression or remission.
  o These include human chorionic gonadotropin (hCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH).
  o Scrotal ultrasound is useful diagnostic tool to diagnose testicular cancer

Question 34

Testicular Cancer: Treatment

Answer 34

Orchiectomy