Male GU Flashcards
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Male GU Lateral View - anatomy
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
anatomy of the prostate
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
FUNCTION OF THE PROSTATE GLAND
- Exocrine gland
- Store and secrete basic fluid that constitutes 1/3 of semen
- Secretion of proteolytic enzymes and psa as well as zinc and citric acid
- Keeps basic environment within the acidic vagina allowing sperm to survive
- 20-40 gms (size of walnut) rubbery
- Both glandular and smooth muscle allowing expulsion of semen
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
most common form of cancer in adult males in all age groups
prostate cancer
currently surpasses the incidence of lung cancer
second leading cause of death from cancer in men in the United States.
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
association of age and likelihood of developing prostate cancer
- likelihood of developing prostate cancer increases from 1 in 2,667 in ages 50 – 54 to 1 in 80 for men aged 80 – 84.
- 85% of all prostate cancers are diagnosed in men older than 65 years (Gronberg, 2003) making this a disease of an older, vulnerable population.
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
ten-year survival rate for a man diagnosed with localized prostate cancer
approaches 100% (in 2007)
Called an indolent dz - is clinically latent in 70% of men. More die w/dz than of it
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What is PSA and when is it elevated?
***exam
- Serine protease
- Outstanding semen liquidfier
- Elevated in 3 urologic conditions, not always malignancy
- Prostate cancer
- Infections
- Prostate growth
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What is PSA 3?
***exam
- Gene testing
- urine based test collected after DRE (sufficient # prostate cells to evaluate pts risk for cancer)
- use if repeat psa remains high, suspicion for prostate cancer w/nl psa
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
PSA screening and prostate cancer: when to screen, nl values, how to interpret
***exam
- Serum test
- Guidelines recommend screening at age 40
- Very inexpensive and routine
- Normal values
- Values > 4 ng/ml relates to 27% positive biopsy 2.5% high risk/
- PSA velocity more accurate diagnosis
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
How have rates of prostate cancer changed since introduction of PSA screening?
- From 19,000 cases/year before PSA to 200,000/year now
- Rates now stabilized
Cooperberg, Moul and Carroll (2005) state that “A significant proportion of men with prostate cancer may be over diagnosed, in the sense that diagnosis may not improve their lifespan or quality of life. However, the extent to which over diagnosis represents a true problem relates to the consistency with which diagnosis leads invariably to active treatment” (p. 8125).
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Risk factors for prostate cancer
***exam
- African American men highest
- Family history of male relative
- Diet related (virtually non-existent in countries with low fat diets)
- older age (rare before 40 yo. Most commonly diagnosed in 65+ yo)
- BRCA1 or BRCA2 mutation
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What to do with an abnormal PSA?
***exam
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Further diagnostic tests for prostate cancer
***exam
- Digital rectal exams (routine?)
- Transurethra biopsy
- Transrectal biopsy indications
- False negatives
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Prostate
Gleason scoring from biopsy results
***exam
- Indicates cellular differentiation
- 2-4 well-differentiated
- 5-7 intermediate differentiated
- 8-10 poorly differentiated – poorer prognosis
- TNM system
- T1 nonpalpable
- T4 metastasis
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Prostate Cancer Curative Treatments
- Radical Prostatectomy
- Internal/External Beam Radiation therapy
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Complications of prostate surgery
-
impotence:
- rates following radical prostatectomy: 7 - 72%
- rates following brachytherapy: 5 - 51%%
- May be failure to report pre-existing erectile dysfunction (ED) prior to treatment
- Incontinence, and rectal issues
- urinary incontinence: ~25% (Heidenreich, Ohlmann, Ozgur & Engelman, 2006).
- Rectal discomfort following radiation: ~39% (Heidenreich et al., 2006)
- Fecal incontinence between 8 and 56%.
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What is BPH?
- Benign Prostatic Hyperplasia (BPH)
- Refers to a histological finding
- No inherent clinical meaning
- Many men will have BPH but no symptoms
- Presence of BPH increases with age
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Is BPH the cause of LUTS?
- lower urinary tract symptoms (LUTS) are commonly attributed to enlargement of the prostate.
- BPH is a pathology that leads to enlargement= may obstruct the urethra leading to LUTS.
- Because BPH is a histological finding, it requires a tissue sample for true diagnosis.
- BPH is more prevalent in the more aged population, however not every patient with BPH will have LUTS. Also, not all patients with LUTS have BPH.
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Why use the term LUTS instead of BPH?
Removes implication that symptoms have organ specific cause
symptom based diagnosis, instead of a histological one
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
2 categories of LUTS
- Voiding or obstructive symptoms
- Storage or irritative symptoms
- These divisions then are correlated with particular etiologies.
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What is the International prostate symptom score (IPSS)?
Validated subjective questionnaire for LUTS
Seven symptoms evaluated:
- Weak flow of stream -Intermittency
- Difficulty initiating stream -Nocturia
- Straining to void -Frequency Urgency
Each scored 0-5
Total score 0-7 Mild; 8-19 Moderate; 20-35 Severe LUTS
Bother score: Single concluding question evaluating quality of life with LUTS (1 to 6, one being the most pleased, and 6 being the most dissatisfied) heavily weighed when determine whether or not to intervene, scored 1-6
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What is Bladder Outlet Obstruction (BOO)?
- may develop from progressive BPH and worsen LUTS, especially voiding symptoms
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
How to evaluate Bladder Outlet Obstruction?
- Non-invasive uroflowmetry may provide some objective diagnostic data
- Patient voids into weighed receptacle to measure volume and rate of flow
- Post void residual
- Measured in mls, elevated in BOO
- Near 0 in normal voiding, but no specific cut-off for an elevated PVR
- ultrasound or in/out catheterization
- Bladder Scanner: ultrasonic machine dedicated to measurement of bladder volume
- Measured in mls, elevated in BOO
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
The case for active surveillance of tumors of prostate
In a study of 299 men characterized with indolent tumors and undergoing active surveillance, Klotz (2005) found that after eight years, the disease specific survival rate was 99% and that most men in the sample died of other causes.
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
For whom is active surveillance recommended?
- active surveillance [AS] has been supported in men
- Over the age of 65
- low grade and stage disease
- low and stable serum prostate specific antigen (PSA) levels.
- However, AS has been associated with illness uncertainty
- Used by about 10% of eligible patients
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
How often does PSA rise after local treatment?
May occur in 2/3 of patients treated with radical prostatectomy or radiation.
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Health maintenance and promotion in Male GU cancer
- Penile Self-exams
- Testicular self-exams
- men > 50 years and men with family history of prostate cancer should check prostate specific antigen (PSA) for screening for prostate cancer {PSA can be elevated with inflammation also}
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Some common prostate problems besides prostate cancer
- Benign prostate hyperplasia (BPH) enlargement of prostate secondary to change in sex hormones which causes urethral obstruction so decreased urine outflow & increased potential for urinary tract infection
- This is very common in men > 70 years
- Bacterial prostatitis
- Nonbacterial prostatitis
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Clinical presentation of BPH
- As the gland enlarges, there is a resistance to urine flow
- Bladder muscle hypertrophies
- Emptying becomes incomplete
- Increase in residual urine
- Increase in chance of infection
- Sometimes bladder diverticula
- Acute urinary retention
- Painless hematuria
- Weak stream
- Straining
- Hesitancy
- Nocturia
- urgency
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Significance of an AUA score
(IPSS)
- Incomplete emptying
- Frequency
- Nocturia
- Straining
- Weak system
- Hesitancy
- Interrupted stream
- AUA SCORE > 8 WARRANTS THERAPY for BPH/LUTS
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
How to diagnose BPH/LUTS
•Goroll, page 918 AUA symptom index. Use this screening tool to have
patient complete self assessment
- Obtain a urine, check for blood and or infection
- Would need to see urologist for post void amount. May not need to do
In primary care setting, ?? Cost of specialist
•Imaging, but then again, cost?
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Medications to avoid in BPH/LUTS
watchful waiting
- Diuretics
- Anticholinergics
- Tricyclic antidepressants
- Watch over the counter meds
- Avoid stimulants before bed
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Medications for BPH
- alpha-1-adrenergic antagonists to relax prostate and bladder muscle contractility - Tamsulosin (Flomax) ; terazosin (Hytrin)
- Hypotensive effects
- 5-alpha-reductase inhibitors to reduce size of prostate gland Finasteride (Proscar); dutasteride (Avodart)
- Erectile dysfunction
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Differential if acute scrotal pain in
infection, STI, torsion
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Diagnosing torsion
- Sudden pain
- No cremasteric reflex
- Scrotum not swollen
- Get ultrasound
- Surgical emergency!!
- Have only a few hours (after 12 hrs. Patient will most likely loose testical
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What is prostatitis?
causes
- Acute prostatitis – inflammation and infection requires antibiotics
- Gm negative, e coli, proteus, klebsiella, pseudomonas, enterococci
- Chlamydia
- HIV, watch for fungal: aspergillus
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Presentation of Acute Prostatitis?
Acute Onset
- Fever
- perineal pain
- dysuria
- decreased urine flow
Patient looks ill, be careful not to examine prostate aggressively , this could increase risk for bacteremia
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Outpatient management of acute prostatitis?
start on oral antibiotic treatment x minimum 3-4 weeks
- Cipro
- Bactrim
- Levaquin
- Doxyclycline
- Amoxicillin
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
comfort care for acute prostatitis
- hot sitz baths: 2-3x/days
- bedrest
- tylenol
- stool softeners
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Medical MGMT of chronic prostatitis?
- Difficult to treat
- May need referral
- Prostatic fluids become more alkaline
- Need long term 8-12 weeks
- Doxyclycline
- Cipro
- Sulfa ds
- Alpha blocker
- May need admission to hospital, esp if high fever and ?abscess
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Supportive MGMT of chronic prostatitis
- No etoh
- Coffee
- Tea
- Keep bladder flat
- No anticholinerics
- Watch sedatives, ssri
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Characteristics of penile cancer
squamous cell with fast metastasis due to the abundance of lymph glands, may be more potential for noncircumcised
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Characteristics of testicular cancer
no known etiology however there is a correlation with undescended testicles and testicular cancer later in life, good PX if diagnosed early
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
are seminomas sensitive to radiatio and chemo?
yes
testicular cancer is one of most treatable /curable
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
- Which of the following testicular screening is recommended for adolescent and adult males?
- Monthly self exams
- No screening
- Annual pe of the testicles
- Testicular ultrasound biannually in men with strong history
No screening
low incidence, high cure rate
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Common myths about sexuality and age
- sexual desires diminish with age
- Sex after 40 should be illegal
- sexual intercourse is a young, healthy person’s activity for the purpose of procreation
- Sex in long-term care facilities is against the rules
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Recommended sexuality and contraceptive use Qs
- Can you tell me how you express your sexuality?
- What concerns do you have about fulfilling your continuing sexual needs?
- In what ways has your sexual relationship with your partner changed as you have aged?
- What interventions or information can I provide to help you to fulfill your sexuality?
- What questions do you have about your continuing sexual needs and function?
- Do you use protection against pregnancy?
- Have you had any sexual contact with a partner who may have a sexually transmitted disease?
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What is the PLISSIT Model?
- P obtaining permission from the client to initiate sexual discussion
- LI providing the limited information needed to function sexually
- SS giving specific suggestions for the individual to proceed with sexual relations
- IT providing intensive therapy surrounding the issues of sexuality for that client
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Common viral STIs + Tx
- Herpes Type 1 & 2 – Acyclovir, Famciclovir, Valacyclovir (first episode, recurrence, and suppression regimines)
- HPV – podophyllin, alvara
- HIV – already discussed in earlier class
- Hepatitis A, B, C, D, E (study in GI class)
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Common fungal STIs + Tx
Candida albicans – candidiasis - Diflucan
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Common protozoan STIs + Tx
Trichomonas vaginalis – trichomoniasis Metronidazole (flagyl) Be aware of no ETOH when taking
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Common bacterial STIs + Tx
- Bacterial vaginosis - metronidazole
- Neisseria gonorrhorae – gonorrhea –Ceftriaxone, ciprofloxacin, levofloxacin
- Treponema pallidium – syphillis - penicillin
- Chlamydia trachomates* – chlamydia – azithromycin or doxcycline or ceftriaxone
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Effect of decreased testosterone on erectile function
- seems to have a limited impact on sexual functioning due to the fact that only a minimal amount of testosterone is needed for the purposes of sex.
- The loss of testosterone is not pathological and does not result in sexual dysfunction.
- labeled viropause, andropause and male menopause generally begins between the ages of 46 and 52
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Changes in sexual fx associated with normal aging
- As a result of normal aging changes older men require more direct stimulation of the penis to experience a somewhat weaker erection
- orgasms are fewer and weaker in older men, the force
- amount of ejaculation is reduced
- the refractory period after ejaculation is significantly increased
- The persistent inability to attain and maintain an erection adequate for sexual activity
- The Massachusetts male aging study of 1085 older men indicated that age was an independent risk factor for decreased sexual function in men
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Secondary sexual dysfunction
- Rosen (2006) main predictors of sexual dysfunction are:
- Age
- cardiovascular diseases
- Diabetes
- depression
- other diseases such as strokes, Parkinson’s disease (PD) and Benign Prostatic Hypertrophy (BPH) also interfere with sexual function
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Medications that affect sexual functioning
1) antihypertensives including: ACE inhibitors, Alpha Blockers, Beta Blockers, Calcium Channel Blockers, Clonidine, Methyldopa and Thiazide Diuretics
2) antidepressants including SSRIs, Tricyclic Antidepressants, MAOIs
3) cholesterol lowering medications including statins and fibrates
4) other medications such as antipyschotics (Phenothiazines & Risperdone) seizure medications (Carbamazepine) and H2 Blockers (Cimetidine)
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Strategies for promoting sexual function
- planning for more time during sexual activities,
- being sensitive to changes in one another’s bodies,
- the use of aids to increase stimulation and lubrication,
- the exploration of foreplay
- Masturbation
- sensual touch
- different sexual positions
- education about these common changes associated with sex and aging
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Erectile Dysfunction Treatment Options
- Oral Erectile agents assists with erections by increasing blood flow to penis, be aware of interaction with nitrates
- Sildenafil Citrate (Viagra®) 100 mg: found to be well-tolerated
- Vardenafil HCL(Levitra) 20 mg
- Tadalafil HCL (Cialis)– 20 mg
- Cavernosal injection therapy
- Balloon implants
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Important teaching r/t sexual dysfunction
- Teach what’s down there and how to use it.
- Introduce to resources
- Use as an opportunity to promote health
- Diabetes
- smoking
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Methods to compensate for normal and pathological physical changes r/t sexual dysfunction
- medications
- artificial water-based lubricants (K-Y silky)
- alternative methods of intimacy
- treat pathological conditions when possible
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
% HIV cases are over 50 years old?
11-15% (up from 10% five years ago)
Safe sex rules apply to older adults too
Lillian and the condoms
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Who gets bicycle seat neuropathy and how does it present?
- Common injury in male and female cyclists
- Underreported
- Long distance races
- Perineal numbness
- Related to saddle pressure
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Patho of bicycle seat neuropathy
- Compression of pudendal nerve that innervates genital and perineal regions
- Frequently causes impotence after cycling
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Testosterone and mental health
Low Testosterone Levels linked with higher risk for depression
Their study, which appears in the March issue of the Archives of General Psychiatry, shows that older men with abnormally low free testosterone levels, or hypogonadism, were on average 271% more likely to display clinically significant signs of depression than men with higher testosterone levels.
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What is hypogonadism?
***exam
- failure of the testis to produce physiological levels of testosterone and normal number of spermatozoa
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Primary hypogonadism
***exam
decrease in testosterone and sperm production
primary cause is natural decline in rate of production starting in 3rd decade of life
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Secondary hypogonadism
***exam
Low testosterone 2/2 insufficient stimulation of Leydig cells
Result of hypothalamic and pituitary DOs or lesions - hyperprolacinemia, Kallman syndrome
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Rates of hypogonadism in >45yo
***exam
38.7% > 45 yrs have
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Types of hypogonadism, causes
***exam
- Primary and secondary, we are addressing secondary
- Causes? Chemo, radiation, ETOH abuse, some meds
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
PE in setting of older male w/fatigue, decreased concentration, decreased sex drive, ED
***exam
- Inspect: testes, upper and lower musculature, beard, gynecomastia
- Palpate: scrotum and testes for masses, breasts for masses
- Labs: free testosterone ( 8 am), avoid labs if acute illness
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Hormone replacement in geriatrics, HIV
***exam
- Geriatrics: not in favor of hormone treatment, benefits unproven
- HIV, short term ok
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
How does stress affect testosterone?
***exam
causes release of glucocorticoids which can suppress testosterone levels
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Medications that suppress testosterone
***exam
- Suramin (Germanin)
- Ketoconazole (Nizoral)
- Glucocorticoids
- Alkylating agents
- Chronic opioids
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
S/S low testosterone
***exam
- decreased vigor and libido
- depression
- fatigue
- difficulty concentrating
- hot flashes
- decreased muscle mass
- insulin resistance
- increased body fat
- hair loss
- breast discomfort/gynecomastia
- sleep disturbance
- ED
- decline in mental function
- loss of bone mineral density
- moodiness/irritability
- metabolic syndrome
- atherosclerosis
- no change in deepening voice
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Goal of testosterone replacement therapy
***exam
relieve sx and restore testosterone levels to mid-to-nl range (400 ng/dL - 600 ng/dL)
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Considerations when initiating hormone replacement
***exam
- Check PSA first!
- Refer if primary hypogonadism
- Patch, gel, cream, injection
- evaluate q6 months
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Frequency of testosterone injections
***exam
Q7-10 days for stable therapeutic levels
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Potential risks to testosterone therapy
***exam
- stimulate growth of prostate and breast ca
- worsen sx BPH
- liver toxicity/tumor
- gynecomastia
- erythrocytosis
- testicular atrophy/infertility
- skin dzes
- cause/exacerbate OSA
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Contraindications to testosterone tx?
***exam
- liver toxicity/tumor
- metastatic prostate ca
- undiagnosed prostate nodule / induration
- unexplained elevation of PSA (>3ng/mL): Jerri says may if not going up
- erythrocytosis (hematocrit >50%)
- Severe BPH (IPSS >19)
- Unstable CHF (Class III or IV)
- Untreated OSA
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Testosterone monitoring: why might levels fluctuate?
***exam
- circadian rhythms
- episodic secretions
- measurement variations
- illness
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Initial evaluation before starting testosterone tx?
***exam
- CBC
- CMP
- TSH
- LH
- FSH
- Total and Free testosterone
- PSA (all abnormals referred to urologist who can clear for tx)
- Prolactin
- Estradiol
- DRE
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
What to do if Testosterone <150 ng/dL on 2 morning visits
***exam
MRI to r/o pituitary adenoma or dz
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
How often to monitor testosterone tx and what tests?
***exam
Every 90 days
CBC, total & free testosterone, LH, FSH, estradiol, PSA
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Goals to testosterone tx: life and levels
***exam
- Improved QoL
- Testosterone: 400 - 600 ng/dL
- Free Testosterone: 15 - 20 ng/dL
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Should men <40 be screened with PSA?
No - don’t screen <40 regardless of RFs
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
According to AUA guidelines, should men 40-54 be screened with PSA?
No - not if of average risk
If increased risk, decision should be individualized
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
According to AUA guidelines, should men 55-69 be screened with PSA?
shared decision-making. The greatest benefit of screening is with this age group.
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
According to AUA guidelines, for men who decide they want screening, how often should PSA screening be done?
an interval of every 2 years may be preferred over annual screening
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
According to AUA guidelines, should men 70 or over be screened with PSA?
Don’t screen men 70+ yo or any man with < 10 to 15 yr life expectancy. Some men age 70+ years who are in excellent health may benefit from prostate cancer screening
Exam: screening for prostate ca in high risk groups, hypogonadism and tx w/testosterone
Should DRE be used as a screening tool for prostate cancer, according to AUA guildelines?
There’s no evidence to support DRE as initial screening, with or without PSA. However, DRE may be a useful secondary test in men referred to urologists for elevated PSA.
