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CAM III > GU part 2 > Flashcards

GU part 2 Flashcards

1
Q

Components of ED

A

Impotence
Peyronie’s dz
Trauma
Ejaculatory dysfunction (EjD)

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2
Q

When does ED increase?

A

Age
Smoking
CVD
Does not correlate with testosterone levels

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3
Q

Mechanism of erection

A

Psychologic or tactile sexual stimulation initiates pathway
Parasympathetic fibers from sacrospinal cord levels S2-S4 join pelvic plexus
Nerve signals carry through pelvic plexus into cavernous nerves of penile corpora cavernosa

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4
Q

Chemical reaction of erection

A

Sexual stimulation that releases nitric oxide (NO) by cavernous nerves into neuromuscular junction
NO activates enzyme guanylyl cyclase
Guanylyl cyclase converts GTP into cGMP
cGMP activates protein kinase G enzyme
Protein kinase G activates protein kinase but decreased intracellular calcium
Decreased smooth muscle calcium causes neuromuscular relaxation and cavernosal artery dilation
Increased blood flow and penile erection occurs
Venous outflow mediates erectile detumescence

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5
Q

Causes of erectile dysfunction

A 
Neuromuscular junction d/os
Endocrine d/os
Vascular dz
Neurogenic erectile dysfunction
Medication-induced erectile dysfunction
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6
Q

Neuromuscular junction disorders that cause ED

A

Examples- MS, Parkinson’s dz
>60% of pts with ED respond to PDE-5 inhibition
Low dose medical tx successful in most cases

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7
Q

Endocrine disorders for ED- pathology

A

Testosterone metabolically inactive
Dihydrotestosterone metabolically active
Testosterone plays permissive role in ED
Testosterone affects libido
Testosterone replacement corrects ED in pts with very low serum testosterone
Testosterone replacement rarely helps ED if only mildly low

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8
Q

S/sx of ED caused by endocrine disorders

A 
Weakness
Fatigue
Lack of motivation
Lack of libido
Weight gain
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9
Q

Testosterone preparations

A 
Depo-testosterone injections 300 mg IM q 2 wks
Aveed 750 mg IM week 0, 4, then every 10 wks
AndroGel 1.62% 5 grams to skin q AM
Fortesia 40 mg (4 pumps) daily
Axiron 60 mg (2 pumps) daily
Testim 5 gms (one pack) to skin q AM
Androderm patch to skin q day
Compounded topical testosterone
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10
Q

DM and ED

A

MC endocrine d/o affecting erectile function
Causes atherosclerotic small vessel vascular dz
Also causes loss of function to autonomic nerves
DM also causes dysfunction of neuromuscular junction via arterial and smooth muscle of penile corpora cavernosa

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11
Q

Endocrine disorders that cause ED

A

Hypothyroidism
Hyperthyroidism
Adrenal dysfunction

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12
Q

Vascular dz and ED

A

ASCVD results in mechanical obstruction of vascular lumen
Endothelial dysfunction in ASCVD interrupts neural control of vascular smooth muscle function
Results in decreased corpora cavernosal arterial pressure
Treatable with PDE-5 inhibitors or vasoactive intracorporal injection
Venoocclusive dz- venous leak- initial rigidity, but quick detumescence before ejaculation

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13
Q

Neurogenic ED

A

Spinal cord injury or peripheral nerve injury may prevent initiation of erectile cascade

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14
Q

Spinal cord injury ED tx

A

Respond to tactile sensation, but require medical therapy to maintain erection

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15
Q

Psychogenic ED

A

Temporal lobe involved

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16
Q

Pelvic fx and ED

A

Causes pudendal nerve damage and ED

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17
Q

Medication-induced ED

A 
Substitution within class of meds rarely helps ED
Proceed directly to tx of ED
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18
Q

Options for medical tx of ED

A

Oral PDE-5 inhibitors
Intraurethral alprostadil
Intracavernous vasoactive injections
Yohimbine

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19
Q

What are the PDE-5 inhibitors?

A 
Cialis (tadalafil)
Levitra (vardenafil)
Staxin (vardenafil)
Viagra (sildenafil)
Stendra (avanafil)
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20
Q

MOA of PDE-5 inhibitors

A

Inhibits PDE-5 breakdown of cGMP
Increases NO and cGMP levels resulting in maintained erections
Sexual stimulation necessary for vasoactive pathways to work with PDE-5 inhibitors

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21
Q

CIs and caution for PDE-5 inhibitors

A

Generally first line therapy
CIed if used with nitrates (hypotension)
Caution when used with alpha-blockers (4-hr separation)

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22
Q

Benefits of PDE-5 inhibitor therapy

A

Can be taken orally
Well-tolerated by most pts
High success rate when used appropriately
Results in natural erection

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23
Q

Vacuum constriction device for ED (Response II, VET-CO)

A 
Vacuum plastic tube around penis
Rubber constrictive device at base of penis
May be used with PDE-5 inhibitors
Safe
Often preferred by elderly
No longer covered by Medicare
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24
Q

Soma therapy- ED

A 
Peyronie's correction therapy
Prostatectomy recovery therapy
Drug enhancement therapy
Penile implant enhancement therapy
Concomitant use with other therapies
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25
Q

Pharmacologic injection therapy- ED

A

Vasoactive agents injected into corpus cavernosa
Agents include PGE1, papaverine, phentolamine
PGE1 used as monotherapy
Papaverine and phentolamine is double mix
PGE1, papaverine, phentolamine is triple mix

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26
Q

Complications of pharmacologic injection therapy for ED

A

Priapism
Penile curvature
Efficacy 90%
60% of pts stop using within 1 yr

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27
Q

Intraurethral drug therapy for ED

A

PGE1 intraurethral pallet
Less effective than intracavernous injection
Useful in pts who must be on nitrates
Painful urethral irritation

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28
Q

Penile prosthesis for ED

A

Semi-rigid always firm
Inflatable three piece prosthesis more natural
90% partner and pt satisfaction rate
Most effective long-term tx for ED

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29
Q

Clinical problems associated with androgen deficiency

A 
Muscle wasting
Decreased body hair
Decreased hematopoiesis
Increased fxs
Increased fat
Poor concentration ability
Osteoporosis
Sexual dysfunction
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30
Q

Cause of Peyronie’s dz

A

Scar that forms on corpus cavernosum

31
Q

What is the MC type of prostate CA?

A

95% adenocarcinoma
MC cancer in men
Second most common cause of death in men

32
Q

Epidemiology of prostate CA

A

More common in AA men, low socioeconomic groups, high-fat diet, prostatitis
Selenium, Vit E and lycopene not preventative
No relationship to smoking or sexual activity

33
Q

Prostate CA detection and dx

A

Screening in pts with >10 yr life expectancy
PSA and DRE age 50-80
Abnl DRE or PSA signals need for prostate bx

34
Q

PSA

A

Produced by benign and malignant prostate tissue
Can be elevated by many causes
Increases with age
PSA rises >0.5 nanograms/mL per yr concerning

35
Q

Causes of increased PSA

A 
BPH 
Prostatitis
UTI
Prostate trauma
Prostate carcinoma
Prostate infarction
36
Q

Prostate cancer diagnostic study

A

TRUS/BX- prostate u/s transrectal with needle bx
Prostate cancers have hypoechoic appearance
8-12 cores taken under Xylocaine infiltration anesthetic
Abx coverage for bx
93% accuracy

37
Q

Prostate CA and Gleason grading system

A

Grade tumors on a scale of 1-5 (good to bad)
Grade secondary histology pattern from 1-5
Expressed as primary + secondary = total
High Gleason: 6 MC
Gleason total 8-10 most aggressive

38
Q

How is the secondary score calculated on the Gleason grading system?

A

Calculated after the hypothetical removal of the worst tumors

39
Q

Tx options for localized prostate CA

A 
Openn Radical prostatectomy
Robotic radical prostatectomy
Brachytherapy (I-125 seeds)
External beam radiation therapy (EBRT)
Cryosurgery
Hormonal therapy
HIFU
Watchful waiting
40
Q

Radical prostatectomy

A 
Can be performed by incision or robotic
Pt should have a >10 yr life expectancy
Overnight stay in hospital
PSA goes to 0 postoperatively
SEs
-Incontinence
-Erectile dysfunction
--The better the erection before the surgery, the better it will be afterwards
41
Q

Radiation therapy for prostate cancer

A 
Brachytherapy (I-125 or palladium seeds)
External beam radiation therapy 5 days a week x 6-8 wks
-Electrons
-Protons
Brachytherapy +/- EBRT x 5 wks
Cyberknife
SEs:
-ED (30-100%)
-Incontinence
-Bowel side effects
-Often preferred in poor surgical candidates
42
Q

Prostate cancer cryosurgery

A

5 probe freezing of prostate
2 freeze and thaw cycles
Transrectal monitoring
Most useful in radiation failures

43
Q

Hormonal therapy in prostate cancer

A

Prostate cancer growth accelerated by testosterone
Testosterone inhibition by orchiectomy or luteinizing hormone-releasing hormones (LHRH) analogs decrease testosterone
Rapid tumor regression can occur
Duration of response variable- yrs generally
SEs occur

44
Q

SEs of androgen deprivation therapy

A 
Hot flashes
Loss of libido
Impotence
Osteoporosis
Decreased facial hair
Loss of muscle mass
Weight gain
Mental status changes
45
Q

Antiandrogens in prostate cancer

A 
Use with LHRH agonist
Block circulating androgen effect on prostate cancer
Agents:
-Casodex (bicalutamide
-Nilandron (nilutamide)
Eulexin (flutamide)
46
Q

Advanced prostate cancer tx

A

Zytiga with prednisone
Xtandi
Chemo for advanced carcinoma

47
Q

Vaccine therapy in prostate cancer

A

Provenge
Use before chemo
Activates pt lymphocytes against prostate cancer antigens

48
Q

Penile carcinoma

A

Squamous cell carcinoma uncommon in US
Neonatal circumcision has protective effect
Penile cleansing has preventative effect
Related to cigarette smoking and other tobacco use
Related to HPV 16 and 18

49
Q

S/sx of penile carcinoma

A 
Painless mass on glans, penis or sulcus
Foul-smelling d/c
Inguinal lymphadenopathy
Generally delayed dx d/t embarrassment
Dxed by bx
50
Q

Penile carcinoma tx

A 
Laser ablation of tumor
Partial penectomy with 2 cm margin
Total penectomy
Inguinal lymphadenectomy
Chemotherapy, if advanced
Radiation therapy, if advanced
51
Q

Testicular cancer

A

MC solid malignancy in men age 15-34

52
Q

Testicular cancer s/sx

A 
Painless mass on testicle 
Painful scrotum (tumor hemorrhage)
Scrotal enlargement
Diagnostic studies
-Scrotal u/s- shows mass
-Alpha-fetoprotein, beta hCG, LDH
-CT scan of abdomen and pelvis
53
Q

Diagnosis of testicular cancer

A

AFP- elevated only in non-seminomatous tumors
Beta hCG- increased with seminoma or nonseminomatous tumors
Abdominal CT scan- retroperitoneal nodes in periaortic aorta
CXR or CT- lung site of distant metastasis

54
Q

Histology of testicular cancer

A 
Embryonal cell carcinoma
Seminoma
Teratoma
Yoke sac tumor
Choriocarcinoma
55
Q

Testicular cancer tx

A 
Radical inguinal orchiectomy
Chemo
Radiation
Retroperitoneal lymph node dissection (RPLND)
Active surveillance after orchiectomy
56
Q

Chemo in testicular cancer

A

Radiation therapy useful in advanced dz

Retroperitoneal lymph node dissection (RPLND) curative in many cases

57
Q

RPLND and testicular cancer

A 
Use for pre-chemo or to remove retroperitoneal teratoma resistant to chemo
SEs
-Lymphocele
-Chylous ascites
-Small bowel resection
-Retrograde ejaculation- 20%
58
Q

Chemo SEs for testicular cancer

A

Raynaud’s phenomenon
Infection
Cardiac toxicity
0.55 risk of secondary malignancy

59
Q

Varicocele

A

Abnormal dilation of veins of pampiniform plexus
Subclinical varicocele in 30% of male population
Seen in up to 505 of men with primary infertility
Seen in 80% of pts with secondary infertility

60
Q

S/sx of varicocele

A

Scrotal heaviness, testicular atrophy, infertility
Bag of worms
Semen analysis- decreased sperm counts
Scrotal ultrasound/Doppler shows increased venous flow (Valsalva maneuver)

61
Q

When should a varicocele be corrected?

A

Infertility
Testicular atrophy
Pain

62
Q

Unilateral varicoceles have _______ effect on spermatogenesis

A

Bilateral

63
Q

Surgery for varicocele

A 
Open ligation
Laparoscopic varicocelectomy
70% improvements in semen parameters after varicocelectomy
Complications:
-Hydrocele
-Testis atrophy or loss
64
Q

Sc of epididymitis and orchitis

A

Acute scrotal pain
Fever
Swelling

65
Q

MC cause of epididymitis and orchitis in men <35 yo

A

N. gonorrhoeae

C. trachomatis

66
Q

MC cause of epididymitis and orchitis in men >35 yo

A

E. coli

67
Q

Epididymitis dx

A

Differentiate from acute testicular torsion (twisting)
PE- epididymal swelling and tenderness
WBC in urine
Scrotal u/s shows increased epididymis size and blood flow

68
Q

Epididymitis tx

A 
Abx
- <35 yo: Doxycycline
- >35 yo: Cipro and TMP-SMX x 4 wks
Orchiectomy rarely necessary
Chronic epididymitis- epididymectomy
69
Q

Hydrocele

A

Serous fluid collection within tunica vaginalis of scrotum
Translucent almost clear fluid
Complaint of heaviness in scrotum, scrotal pain and scrotal mass
Diagnosis- transillumination of hydrocele
Scrotal ultrasound definitive
Causes- trauma, infection, tumor, idiopathic
Tx- surgical removal, 25% recurrence

70
Q

Testicular torsion

A

True urologic emergency
Twisting of testicular arterial blood supply
Sx- acute scrotal pain, swelling, nausea, vomiting
6-8 hour window to fix before irreversible testicular infarction and necrosis occurs
Typically in pts <21 yo

71
Q

Dx and tx of testicular torsion

A

Surgical exploration if index of suspicion is high
Scrotal u/s with Doppler useful in differentiating from epididymitis
Bilateral orchiopexy- 3 point fixation
Testicular salvage rate 70%
Delay in surgery- salvage rate 40%

72
Q

Phimosis

A

Tightness of foreskin- cannot retract
Associated with scarring and infection
Common in neonates, decreases with age
Tx: cirumcision

73
Q

Paraphimosis

A

Edema of foreskin proximal to retracted foreskin
Tx is reduction
Recurrent then circumcision

74
Q

Balanitis

A

Infection of foreskin
More common in diabetics or immunocompromised pts
Tx with Nystatin ointment or powder
Recurrent balanitis: circumcision

CAM III (12 decks)

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