Male GU- Adults Flashcards
Erectile Dysfunction- pathophysiology
Consistent inability to maintain an erect penis with sufficient rigidity to allow for intercourse
Most common sexual problem in men
Neded for an erection
- intact parasympathetic + somatc supply
- Unobstructed arterial inflow
- Adequate venous contriction
- Hormonal simulation
- psychological desire
Erectile Dysfunction- cause
Dec in arterial flow from porgressive vascular disease - lead to further psychogenic component Meds - SSRI - BB - Clonidine - Spironolacttone - Thiazide - Ketoconazole - Cimetidine Psych factors - Depression, Stress Neuro - stroke, SCI, MS Bicycling - prolonged pressure on pudendal & convernosal nerves/compromises blood flow to cavernosal artery -> penile numbness & impotence Endocrine disorders - testosteron def - unsure if low T clinics work - Hypo/hyperthyroidism
Erectile Dysfunction- epidemiology
50% - 40-70
Inc w/ inc age
Sedentrary life Obesity Smoking Comorbidities - DM, HTN, obesity, OSA, dyslipidemia, smoking, RLS CV - ED and CV linked Watching TV Lower frequency of sexual activity
Erectile Dysfunction- S/S & PE
H&P questions: Chronic, occasional, situational? Nl erections? - early morning, sleep? Chronic medical conditions? Trauma to pelvis? Pelvic or prosttate radiation? Peripheral vascular surgery? Medications taking Use of drugs, alcohol, tobacco?
PE: Look for sacrring Plaque formation of peyronie dis Testicular atrophy Peripheral neuropathy HTN
Erectile Dysfunction- labs & imaging
CBC
UA
TSH
Lipid panel
Serum Testosterone
Glucose
Prolactin - serum testosterone or prolactin abnormal -> FSH & LH measurement
Nocternal penile tumescence testin g- help diff b/t organic and psychogenic issue
Direct injection of vasoactive substance into penis -> erection if vascular system intact
- Prostaglandin E1
- if no erection - eval arterial and venous vasculature
- U/S - cavernous arteries, pelvic arteriorgraphy, cavernosonography
Erectile Dysfunction- treatment
If truly psychogenic -> behaviorally oriented sex therapy
- organic cuases also might benefit form sex therapy
Low T may benefit from testoertone replacment
- injection, gel, or patches - wear gloves when applying, will transfer
- SE: HTN, worsen BPH, worsen CHF< inc breat cancer, hepatic toxicity, VTE, prostate cancer, application site pruritis, virilization in those exposed
- not a lot of evidence showing this helps
Wt loss if obese
Phosphodiesterase-5 inhibitors (PDE-5)
- Main treatment
- Sustaining levels of cyclic GMP w/in the penile corpora caernosa to allow for erections in reposne to appropriate sexual stimuli
- Sildenafil - Viagra, Vardenafil - Levitra, Tadalafil - Cialis -> 45-60m prior to sex
- Avanafil - Stendra - 15-30min prior to sex
- Contra on nitrates!! - delay giving nitrates w/in 24 hr -> drop BP
- w/ alpha-blocker -> dec BP
- SE: blue vision (sildenafil), sudden hearing loss
Penile Injections
- Alprostadil - Caverject
- Prostaglandin E1 injected into base of penis -> smooth muscle relaxation in corpus cavernosum
- inject 10-20m before sex
- Erection can last >60min
Erectile Dysfunction- prognosis
Intraurethral alprostadil
- Prostaglandin E1
- Instert into urethra -> massage penis for 1 min to equally distribute the med
- SE: penile pain and bleeding
- DO NOT USE - sickel cell anemia, sickle cell trait, leukemia, MM, any other conditions w/ inc priapism
Vacuum erection device
- in conjection w/ occlusive penil rings - vacuum pressure to encourage inc arterial inflow -> draws blook into penic penis and limits venous blood loss from corporas cavernosa by holding blood in penis
- Difficulty ejactulating - ring compresses penile eurtra
- PDE-5 inhibitors - used along
- Erection lasts until elastic ring is removed - max 30min
- penile bruising
Surgical Options
Penile prosthesis
- Rigid - semirigid - move it up or down when needed
- inflatable - w/in scrotum - inflat for sex, deflate for nl life
Surgeries for arterial system
- vascular reconstruction
- arterial bypass
Varicocele- pathophysiology
Dilation and tortious veins of the pampiniform plexus and spermatic veins - surround the spermatic cord
Usually Left sided - L gonadal vein is longest in body
- high intravascular pressure - compressed b/t aorta & SMA
Veins dilate -> valve leafets become incompeatent -> backwards flow
Puberty & enlarges w/ time
Varicocele- S/S & PE
Asymptomatic
Dull, aching scrotal discomfort - worse w/ standing, relieved w/ sitting/laying down - less pressure
Atrophy of left testicle
Dec fertility
Left-sided scrotal fullness on valsalva
Large left sided scrotal mass - ““bag of worms””
- decompress/disappears when lays down
Varicocele- diagnosis
If R sided - need to look at IVC issues
Varicocele- labs & imaging
Semen analysis
Varicocele- treatment
Most don’t need intervention
<21 yo
- atrophy and/or abnormal semen analysis -> surgical ligation or percutaneous venous embolization - might return to nl after surgery
- Semen analysis nl-> monitor w/ semen analysis every 1-2yr
Older men
- fertility desired -> sermen analysis every 1-2 yrs
- Scortal support
- NSAIDs
Surgery
Ligation
- endoscopic - most common
- Microsurgical approach - dec recurrence, complication rates
Interventional radiology - vessel embolization
Hydrocele- pathophysiology
Collection of peritoneal fluid b/t parietla dn visceral layers of tunica vainalis
- idiopathic - arises over a long period of time
- Acute reactive - inflammatory conditions of scrotal contents -> epidiymitis, torsion, appendiceal torsion
Hydrocele- S/S & PE
Soft, small-> massive collections of several liters
Pain/disability - depends on size
Transilluminates well
Hydrocele- diagnosis
Diagnosis uncertain -> U/S
Hydrocele- treatment
Don’t need intervention
Surgery - excision of hydrocele sac
- indicated - symptomatic w/ pain/pressure, scrotal irriation
Cant just aspirate it
Spermatocele- pathophysiology
An epidermal cyst in head of epididymis - >2cm
Inc freq w/ mo who used idethylstilbestrol during prego
Spermatocele- S/S & PE
asymptomatic
Feels like - soft round mass on head of epididymis
Spermatocele- treatment
Don’t require treatment
Surgery - chronic pain
BPH- pathophysiology
Very Common
Develops - periurethral or transitional zone of prostrate
- inc in stromal tissue and glandular components
Older age & functioning lydig cells are needed
Pathogeneiss - not completely understoo
- prostatic tissue reverts to embryonic state in which its unusllay sensitive to growth factors
Prolieration of smooth muscle and epithelial cells
BPH- epidemiology
50% of men 40-50
80% of men >80
Obesity Heart diseaes Black men Alcohol consuption - esp >3drinks/day - dec risk - protective - reduce androgen levels
BPH- S/S & PE
asymptomic
Lower urinary tract symptoms - LUTs
- Storage symptoms - inc daytime frequency, nocturia, urinary incontinence
- Voiding symptoms - slow urinary stream, splitting/spraying of stream, intermittnet stream, hesitancy, straining to void, terminal dribbling
- can result - urinary retention, hydronephrosis, UTIs
From - direct bladder outlet obstruction, inc smooth muscle tone and resistance w/in gland
PE
- DRE - assess prostate size and consistency
- Nl prostate approximately the size of a walnute - firm, nontender
- should not be tender
- assess rectal sphincter tone
BPH- diagnosis
Uroflow - meaure voided volume, avg flow, voiding time, pressure flow Bladder scan - post-void residual - after uroflow
BPH- labs & imaging
UA - look for hematuria, UTI PSA - pitfalls - needed to eval benign - abl - >4ng/ml BMP - Cr - renal failure/obstruction suspected
U/S, MRI, CT - not usually required
BPH- treatment
Behavior Mod
- avoid fluids prior to bed
- reduce consumtpion of caffeine, alcohol
- double voiding for more complete bladder emptying
Alpha-1 Adrenergic antagonists
- good intial therapy for symptomatic BPH
- Relax smooth muscle in the bladder neck, prostate capsule, prostatic urethra
- terazosin, doxazosin - Cardur, Tamsulosin - Flomax, Silodosin- Rapaflo
- GIVEN AT BEDTIME - due to SE
- SE - hypotension, dizziness, ejaculatory dysfunction
- contra - PDE-5 inhibitors - take at diff times
5-alpha reductase inhibitors
- reduce the size of the prostate - symptom relief after 6-12m
- Finasteride - Proscar, dutasteride- Avodart
- Dec incidence of prostate cancer
- SE - dec libido, ED, ejaculatory, dysfunction
- Prego shouldn’t touch these - prevent nl development of external and internal genatalia
- PSA concentrations will dec
- severe - combine w/ alpha-1 antagonists
Anticholingerics - help relax detrusor muscles
Bet3 adrenergic - detrusor relaxation
Phosphodiesterase inhib
Herbal - not recommended - saw palmetto, beta-sitosterol, cermilton, pygeum africanum
BPH- prognosis
Surgery - persistent or progressive symptoms
- Tried combo therapy for 1-2y
- Transurethral resection of prostate - TURP
- Transurethral ablation
- Simple prostatectomy - open, laparoscopic, robotic assisted
- Prostatic arterial embolization - feeding arteries are selectively embolized to induce ischemic necrosis & volume reduction of prostate
- Complications - sexual dysfunction, postprostatectomy syndrome, bleeding, urethral strictures, urinary incontinence
BPH- complications
- Acute urinary retention
- Recurrent UTIs
- Hydronephrosis
- Renal Failure”
Urolithiasis- pathophysiology
50% recurrence
Struvite stone - UTI - proteus, klebsiella Uric acid stone - acidic urine - chronic diarrhea, gout, ketogenic Ca consumption - dec stone formation
Concentration product
Saturated - salt crystals not dissolve
Theromodynamic solubility product - Ksp
- CP at point of saturation
Randall’s plaques - Ca phos crystals from interstitum and erode through renal papillary epithelium
- deposit on of nidus - remaining attached to papilla
