GU part 2 Flashcards
Components of ED
Impotence
Peyronie’s dz
Trauma
Ejaculatory dysfunction (EjD)
When does ED increase?
Age
Smoking
CVD
Does not correlate with testosterone levels
Mechanism of erection
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
Chemical reaction of erection
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
Causes of erectile dysfunction
Neuromuscular junction d/os Endocrine d/os Vascular dz Neurogenic erectile dysfunction Medication-induced erectile dysfunction
Neuromuscular junction disorders that cause ED
Examples- MS, Parkinson’s dz
>60% of pts with ED respond to PDE-5 inhibition
Low dose medical tx successful in most cases
Endocrine disorders for ED- pathology
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
S/sx of ED caused by endocrine disorders
Weakness Fatigue Lack of motivation Lack of libido Weight gain
Testosterone preparations
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
DM and ED
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
Endocrine disorders that cause ED
Hypothyroidism
Hyperthyroidism
Adrenal dysfunction
Vascular dz and ED
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
Neurogenic ED
Spinal cord injury or peripheral nerve injury may prevent initiation of erectile cascade
Spinal cord injury ED tx
Respond to tactile sensation, but require medical therapy to maintain erection
Psychogenic ED
Temporal lobe involved
Pelvic fx and ED
Causes pudendal nerve damage and ED
Medication-induced ED
Substitution within class of meds rarely helps ED Proceed directly to tx of ED
Options for medical tx of ED
Oral PDE-5 inhibitors
Intraurethral alprostadil
Intracavernous vasoactive injections
Yohimbine
What are the PDE-5 inhibitors?
Cialis (tadalafil) Levitra (vardenafil) Staxin (vardenafil) Viagra (sildenafil) Stendra (avanafil)
MOA of PDE-5 inhibitors
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
CIs and caution for PDE-5 inhibitors
Generally first line therapy
CIed if used with nitrates (hypotension)
Caution when used with alpha-blockers (4-hr separation)
Benefits of PDE-5 inhibitor therapy
Can be taken orally
Well-tolerated by most pts
High success rate when used appropriately
Results in natural erection
Vacuum constriction device for ED (Response II, VET-CO)
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
Soma therapy- ED
Peyronie's correction therapy Prostatectomy recovery therapy Drug enhancement therapy Penile implant enhancement therapy Concomitant use with other therapies
Pharmacologic injection therapy- ED
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
Complications of pharmacologic injection therapy for ED
Priapism
Penile curvature
Efficacy 90%
60% of pts stop using within 1 yr
Intraurethral drug therapy for ED
PGE1 intraurethral pallet
Less effective than intracavernous injection
Useful in pts who must be on nitrates
Painful urethral irritation
Penile prosthesis for ED
Semi-rigid always firm
Inflatable three piece prosthesis more natural
90% partner and pt satisfaction rate
Most effective long-term tx for ED
Clinical problems associated with androgen deficiency
Muscle wasting Decreased body hair Decreased hematopoiesis Increased fxs Increased fat Poor concentration ability Osteoporosis Sexual dysfunction
Cause of Peyronie’s dz
Scar that forms on corpus cavernosum
What is the MC type of prostate CA?
95% adenocarcinoma
MC cancer in men
Second most common cause of death in men
Epidemiology of prostate CA
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
Prostate CA detection and dx
Screening in pts with >10 yr life expectancy
PSA and DRE age 50-80
Abnl DRE or PSA signals need for prostate bx
PSA
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
Causes of increased PSA
BPH Prostatitis UTI Prostate trauma Prostate carcinoma Prostate infarction
Prostate cancer diagnostic study
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
Prostate CA and Gleason grading system
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
How is the secondary score calculated on the Gleason grading system?
Calculated after the hypothetical removal of the worst tumors
Tx options for localized prostate CA
Openn Radical prostatectomy Robotic radical prostatectomy Brachytherapy (I-125 seeds) External beam radiation therapy (EBRT) Cryosurgery Hormonal therapy HIFU Watchful waiting
Radical prostatectomy
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
Radiation therapy for prostate cancer
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
Prostate cancer cryosurgery
5 probe freezing of prostate
2 freeze and thaw cycles
Transrectal monitoring
Most useful in radiation failures
Hormonal therapy in prostate cancer
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
SEs of androgen deprivation therapy
Hot flashes Loss of libido Impotence Osteoporosis Decreased facial hair Loss of muscle mass Weight gain Mental status changes
Antiandrogens in prostate cancer
Use with LHRH agonist Block circulating androgen effect on prostate cancer Agents: -Casodex (bicalutamide -Nilandron (nilutamide) Eulexin (flutamide)
Advanced prostate cancer tx
Zytiga with prednisone
Xtandi
Chemo for advanced carcinoma
Vaccine therapy in prostate cancer
Provenge
Use before chemo
Activates pt lymphocytes against prostate cancer antigens
Penile carcinoma
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
S/sx of penile carcinoma
Painless mass on glans, penis or sulcus Foul-smelling d/c Inguinal lymphadenopathy Generally delayed dx d/t embarrassment Dxed by bx
Penile carcinoma tx
Laser ablation of tumor Partial penectomy with 2 cm margin Total penectomy Inguinal lymphadenectomy Chemotherapy, if advanced Radiation therapy, if advanced
Testicular cancer
MC solid malignancy in men age 15-34
Testicular cancer s/sx
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
Diagnosis of testicular cancer
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
Histology of testicular cancer
Embryonal cell carcinoma Seminoma Teratoma Yoke sac tumor Choriocarcinoma
Testicular cancer tx
Radical inguinal orchiectomy Chemo Radiation Retroperitoneal lymph node dissection (RPLND) Active surveillance after orchiectomy
Chemo in testicular cancer
Radiation therapy useful in advanced dz
Retroperitoneal lymph node dissection (RPLND) curative in many cases
RPLND and testicular cancer
Use for pre-chemo or to remove retroperitoneal teratoma resistant to chemo SEs -Lymphocele -Chylous ascites -Small bowel resection -Retrograde ejaculation- 20%
Chemo SEs for testicular cancer
Raynaud’s phenomenon
Infection
Cardiac toxicity
0.55 risk of secondary malignancy
Varicocele
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
S/sx of varicocele
Scrotal heaviness, testicular atrophy, infertility
Bag of worms
Semen analysis- decreased sperm counts
Scrotal ultrasound/Doppler shows increased venous flow (Valsalva maneuver)
When should a varicocele be corrected?
Infertility
Testicular atrophy
Pain
Unilateral varicoceles have _______ effect on spermatogenesis
Bilateral
Surgery for varicocele
Open ligation Laparoscopic varicocelectomy 70% improvements in semen parameters after varicocelectomy Complications: -Hydrocele -Testis atrophy or loss
Sc of epididymitis and orchitis
Acute scrotal pain
Fever
Swelling
MC cause of epididymitis and orchitis in men <35 yo
N. gonorrhoeae
C. trachomatis
MC cause of epididymitis and orchitis in men >35 yo
E. coli
Epididymitis dx
Differentiate from acute testicular torsion (twisting)
PE- epididymal swelling and tenderness
WBC in urine
Scrotal u/s shows increased epididymis size and blood flow
Epididymitis tx
Abx - <35 yo: Doxycycline - >35 yo: Cipro and TMP-SMX x 4 wks Orchiectomy rarely necessary Chronic epididymitis- epididymectomy
Hydrocele
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
Testicular torsion
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
Dx and tx of testicular torsion
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%
Phimosis
Tightness of foreskin- cannot retract
Associated with scarring and infection
Common in neonates, decreases with age
Tx: cirumcision
Paraphimosis
Edema of foreskin proximal to retracted foreskin
Tx is reduction
Recurrent then circumcision
Balanitis
Infection of foreskin
More common in diabetics or immunocompromised pts
Tx with Nystatin ointment or powder
Recurrent balanitis: circumcision
