Lecture 22 - Men's Health Part 2 Flashcards
What are the effects of testosterone?
increases libido increase lean body mass increase grip strength increase self-reported physical function increase vertebral bone density
no improvement in depression scores
no decrease in fracture risk
no improvement in cognitive function
no enhanced response to phosphodiesterase inhibitors
What is evidence of low testosterone on hx or PE?
decreased sex drive decreased sexual activity inability to maintain erections (ED and low T typically co-exist) reduced beard growth loss of muscle mass decreased testicular size gynecomastia
What levels of T indicate possible testosterone deficiency?
<300 ng/dL
What is the work up for low testosterone?
check LH to r/o other problems
if LH is high = primary hypogonadism (testicular problem)
if normal or low = secondary hypogonadism (HPG axis problem)
What is the treatment for low testosterone?
Goal is to return testosterone level to “mid-normal” range
Testosterone Enanthat or Cypionate - IM injection once every 2 weeks
Nongenital Testosterone Patch - applied daily
Testosterone Gel - applied daily, concern for transfer of medication to others who come into contact with the pt
Buccal Adhesive testosterone
SubQ Crystalline Testosterone implants
What is a “normal” testosterone for an 80 y/o?
300
a 20 year old has 1000, and it decreases about 100 per decade of life
Testosterone Enanthate or Crypionate
testosterone treatment
IM injection once every 2 weeks; rise in testosterone with DHT within 24 hours; injections followed by changes in mood, sexual desire, and energy
Nongenital Testosterone Patch
testosterone treatment
applied daily, usually one patch sufficient
Testosterone Gel
testosterone treatment
applied to armpit –MC used today
applied daily, concern for transfer of medication to others who come in contact with the pt/get, wide variability in absorption requires frequent monitoring of serum testosterone levels; higher DHT to testosterone levels compared to normal, healthy men
Buccal Adhesive Testosterone
dissolving pill help against buccal mucosa twice daily; may cause/mucosal erosion
SubQ Crystalline Testosterone implants
surgical implantation; lasts 6 months; may have fibrosis around implant and scar tissue formation
What are the CV effects of testosterone therapy?
trial: older men on testosterone therapy with h/o chronic disease (DM, CVD, HTN, increase lipids) had greater number of CV events compared to placebo
Retrospective analysis (x2): higher frequency of CV events in older men on testosterone therapy with preexisting heart disease
basically if the have a hx, they will have a 2x greater risk of having hx (ex. heart attack) again
What effects does testosterone therapy have on prostate cancer?
no evidence connects cause and effect of exogenous testosterone therapy and prostate cancer
BUT prostate cancer tumor growth will be increased with exogenous testosterone therapy
subclinical prostate cancer will rapidly progress if the pt is on exogenous testosterone therapy
must be stopped if there is presence or suspicion of prostate cancer
“feeding the tumor”
What screening must you do for men on testosterone therapy?
DRE and PSA every 3 months for the first year and then twice a year thereafter
Should you check testosterone for all men?
NO
only if pt is symptomatic
Testicular torsion
most commonly caused by abnormality, sometimes TRAUMA <25 y/o twisting of the testis block blood from spermatic cord sudden onset of acute scrotal pain
90% salvage at 6 hours
50% salvage at 12 hours
10% salvage at 24 hours
PE: ABSENT CREMASTERIC REFLEX
elevated scrotum on affected side
What is the physical exam of a pt with testicular torsion?
PE: ABSENT CREMASTERIC REFLEX
elevated scrotum on affected side
enlarged painful testis
abnormal testicular lie
What is the treatment for testicular torsion?
confirm dx with doppler US
do not delay time to surgery
manual detorsion is a temporary fix –but surgery is required to prevent recurrence
Epididymitis
acute inflammation of the epididymis
most common cause of acute scrotal pain in all age groups
typical age range 14-35 y/o
etiologies
- sexually active men <35y/o (gonorrhea, chlaymidia)
- Men >35 y/o or those who practice anal sex (E.coli)
Presentation:
gradual onset of unilateral scrotal pain
frequently accompanied by urinary sx (ex. dysuria)
epididymal and/or testicular swelling
Dx.
urethral swab for GC and chlamydia (but often negative)
may need US to r/o testicular torsion
Tx:
ABX direct at likely pathogen –Ceftriaxone + azithromycin or fluoroquinolone
What pathogens cause epididymitis?
sexually active men <35y/o:
gonorrhea, chlaymidia
Men >35 y/o or those who practice anal sex: E.coli
What is the presentation of of epididymitis?
gradual onset of unilateral scrotal pain
frequently accompanied by urinary sx (ex. dysuria)
epididymal and/or testicular swelling
How do you dx epididymitis?
urethral swab for GC and chlamydia (but often negative)
may need US to r/o testicular torsion
How do you tx epididymitis?
ABX direct at likely pathogen –Ceftriaxone + azithromycin or fluoroquinolone
Orchitis
caused by mumps virus
unilateral testicular swelling and scrotal edema 4-5 days after parotitis secondary to mumps
must r/o testicular torsion (doppler US)
tx: symptomatic: -bed rest -hot or cold packs -scrotal elevation
What is the presentation of orchitis?
unilateral testicular swelling and scrotal edema 4-5 days after parotitis secondary to mumps
must r/o testicular torsion (doppler US)
What is the treatment for orchitis?
symptomatic:
- bed rest
- hot or cold packs
- scrotal elevation
Varicocele
dilation of testicular vein and pampiniform plexus
common ~15% of adult men
40% of infertility cases have varicocele
90% occur on LEFT side
“bag of worms”
increases in size with standing or valsalva maneuver
can try surgical repair if infertile but poor success rate of pregnancy
Hydrocele
fluid collection between layers of the tunica vaginalis
nearly 5% of infants
incomplete or delayed closure of the processus vaginalis
may have infectious or trauma etiology
10% of testicular cancer present with hydrocele
tense, smooth scrotal mass that easily transilluminates
usually resolve on their own in <1 year
in adult men, US to r/o tumor; otherwise may require surgical drainage and repair
Spermatocele
aka “epidiymal cyst”
benign cystic collection of fluid arising from epidiymis
smooth painless mass
transilluminates
may use US to confirm but usually unnecessary
no tx required unless painful
can surgically excise but side effect of infertility or chronic pain
Testicular cancer epi and risk factors
rare ~1% of all cancers in men
leading cause of cancer in men 15-35 y/o
average age of dx 34 y/o
RF:
- cryptorchidism
- family hx of testicular cancer
- tobacco use
- caucasian
- previous h/o testicular cancer
- infertility
What is the clinical presentation of testicular cancer?
discrete PAINLESS mass on the testicle testicular swelling (73%) testicular pain in up to (46%) scrotal "heaviness" or "firmness" may look like epididymitis; if treatment failure to this, then think cancer! sx of metastatic disease --back pain
confirm with scrotal US
What is the work up for testicular cancer?
scrotal ultrasound
measure serum biomarkers pre op - AFP, hCG, LDH
What is the treatment for testicular cancer?
surgery: unilateral orchiectomy with pathological evaluation
post-op: CT of chest, abd, and pelvis to look for mets
What is the prognosis of testicular cancer?
5 year survival - 95%
distant mets: 71%
What adjuvant therapy is used in testicular cancer?
treatment options depend on type (seminoma vs nonseminoma) and grade (Stage 1, 2a, 2b, 3)
options include:
- local irradiation (low grade seminomas)
- regional lymph node irradiation
- 3 drug chemo
- retroperitoneal lymph node dissection
Phimosis
inability to retract the foreskin over the glans penis
10% of uncircumcised males at 3 years of age
5% of uncircumcised males at 16 years of age
painful erections
hygiene issues may ensue d/t difficult cleansing area
may require circumcision
Paraphimosis
retracted foreskin of uncircumcised penis can not be returned to normal anatomic position
results in venous occlusion, edema, arterial insufficiency of the distal penis
requires immediate manual reduction
permanent therapy/prevention requires circumcision or dorsal slit
Priapism
persistent erection of at least 4 hours
3 types:
ischemia - veno occlusive with little or no blood flow through the corpora cavernosa; painful, rigid erection
non-ischemic - fistula formation between cavernosal artery and corpora cavernosa usually due to trauma; high flood of blood into and out of corpora cavernos; penis is not rigid and not painful
Suttering - periods of painful ischemic priapism followed by periods of flaccidity and detumescence
Ischemic priapism is common complications of sickle cell disease
often requires drainage and irrigation with sympathomimetic (phenylephrine)
Treatment of priapism
often requires drainage and irrigation with sympathomimetic (phenylephrine)
What are the 2 types of erectile dysfunction?
Organic - 80% vascular neurogenic anatomic hormonal
Psychogenic
depression
anxiety
What drugs can cause ED?
anti HTN - diuretics, BB, alpha blocker antidepressants - SSRIs, MAOIs, tricyclics Benzodiazepines Antipsychotics antiandrogens digoxin antihistamines niacine phenytoin ketoconazole
excessive EtOH
How do you dx ED?
Hx
International Index of Erectile Function
Treatment of ED
treat underlying conditions when possible
Phosphodiesterase type 5 (PDE5)
- sildenafil, tadalafil, vardenafil = FIRST LINE
local injection of alprostadil
What are the contraindications of PDE5 treatment?
NITRATE use
alpha blockers
retinitis pigmentosa
conditions predisposing to priapism
