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Clin med sem 2 > Male GU- Adults > Flashcards

Male GU- Adults Flashcards

1
Q

Erectile Dysfunction- pathophysiology

A

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
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2
Q

Erectile Dysfunction- cause

A 
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
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3
Q

Erectile Dysfunction- epidemiology

A

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
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4
Q

Erectile Dysfunction- S/S & PE

A 
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
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5
Q

Erectile Dysfunction- labs & imaging

A

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

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6
Q

Erectile Dysfunction- treatment

A

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
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7
Q

Erectile Dysfunction- prognosis

A

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

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8
Q

Varicocele- pathophysiology

A

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

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9
Q

Varicocele- S/S & PE

A

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

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10
Q

Varicocele- diagnosis

A

If R sided - need to look at IVC issues

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11
Q

Varicocele- labs & imaging

A

Semen analysis

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12
Q

Varicocele- treatment

A

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

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13
Q

Hydrocele- pathophysiology

A

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
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14
Q

Hydrocele- S/S & PE

A

Soft, small-> massive collections of several liters
Pain/disability - depends on size
Transilluminates well

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15
Q

Hydrocele- diagnosis

A

Diagnosis uncertain -> U/S

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16
Q

Hydrocele- treatment

A

Don’t need intervention
Surgery - excision of hydrocele sac
- indicated - symptomatic w/ pain/pressure, scrotal irriation

Cant just aspirate it

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17
Q

Spermatocele- pathophysiology

A

An epidermal cyst in head of epididymis - >2cm

Inc freq w/ mo who used idethylstilbestrol during prego

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18
Q

Spermatocele- S/S & PE

A

asymptomatic

Feels like - soft round mass on head of epididymis

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19
Q

Spermatocele- treatment

A

Don’t require treatment

Surgery - chronic pain

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20
Q

BPH- pathophysiology

A

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

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21
Q

BPH- epidemiology

A

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
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22
Q

BPH- S/S & PE

A

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
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23
Q

BPH- diagnosis

A 
Uroflow
- meaure voided volume, avg flow, voiding time, pressure flow
Bladder scan
- post-void residual 
- after uroflow
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24
Q

BPH- labs & imaging

A 
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

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25
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
26
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
27
BPH- complications
- Acute urinary retention - Recurrent UTIs - Hydronephrosis - Renal Failure"
28
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
29
Urolithiasis- cause
Calcium oxalate - most common Calcium phosphate - hypercalciuria, hyperoxaluria, hyperuricosuia, hypocitrauria, low urine pH, renal tubular acidosis, hypomg Uric Acid - low urine pH, hyperuricosuria, low urine volume - excess animal protein, obesity, diarrhea, ketogeinic diet, myeloproliferative dis Struvite - Mg ammonium phosphate - proteius, klebsiella, pseudomonas, staph Cystine other
30
Urolithiasis- epidemiology
``` 10-15% lifetime Inc w/ age 30-50y Caucasian M>F SouthEast Summer - dehydrated Obesity - inc Na, low urine pH Fhx hx of prior stones Enteric oxalate absorption - diet, bariatric surgery ```
31
Urolithiasis- S/S & PE
Pain - renal capsular distension - constant achy back pain, N&V - ureteral spam - paroxsmal stabbing pain, flank -> groin> scrotum/labia - resolves quickly Hematuria LUTs UTI - struvite Incidental CVA tenderness
32
Urolithiasis- labs & imaging
``` UA +/- C&S CBC BMP Renal US CT w/o contrast KUB - uric acid, cystine - radiolucent ```
33
Urolithiasis- treatment
``` Analgesic - Ketorolac - Toradol - +/- morphine Antiemetic - Zofran IV fluid- rehydration ``` Spontaneous passage - 1/3 renal - 2/3 ureteral - <5mm Medical expulsive therapy (MET) - Tamsulosin - Flomax - Strain urein - U/S and KUB in 2w Surgery Indicated in: - UTI - intractable pain - solitary kidney - failted MET - Asymptomatic >5mm
34
Urolithiasis- prognosis
``` Surgery Ureteroscopy - laser lithotripsy - ureteral, renal <1cm - homium laser - stent Percutaneous nephrostolithotomy - reanl >1cm - lower pole, staghorn calcu - holium laster, ultrsonic lithotripter - nephrosotomy tube Extrcorporeal shock wave lithotripsy - Renal >1cm - non-invasive - Stent Consider - location, size, composition ``` Prevent - drink lots of water - Ca - minimize oxalate - Minim animal protein - minim salt
35
Penile Cancer- pathophysiology
<1% of cancer in men in the US More developed countries - Africa, Asia, South America Squamous cell carcinoma - 95%
36
Penile Cancer- epidemiology
``` HPV Phimosis - uncircumcised more likely - pathologic - scaring down of foreskin HIV Smoking Hispanic, Asian/pacific islander 60yo ```
37
Penile Cancer- S/S & PE
Lump, mass, ulceration of penis - most common glans | Inguinal lymphadenopathy - 30-60%
38
Penile Cancer- diagnosis
Biopsy | - if clear w/out biopsy - sent straight to OR
39
Penile Cancer- treatment
Low risk - TIS, Ta of glans, T1a/b of glans/shaft skin - partial penctomy - 1-2cm of neg margins - radiation - laser ablation - MOH - topical - fluorouracil, imiquimod High risk - bulky, T2-T4 - more common - Penectomy - brachytherapy - seeds for radiation
40
Bladder Cancer- pathophysiology
Most common maligancy of urinary system Lining - urothelial Transitional cell carcinoma - found in ureter and kidney too 3 categories - non-muscle invasive - muscle invasive - met
41
Bladder Cancer- S/S & PE
HEMATURIA - gross or microscopic - >3RBC/hpr - urethral source - beginning of urination - bladder neck - terminal - kidney, ureter - throughout voiding Irritative voiding symp - frequency, urgency, hesitancy Pain - met dis? Incidental - very rare!!
42
Bladder Cancer- diagnosis
Cystoscopy - coral appearance
43
Bladder Cancer- labs & imaging
``` Office cystocopy Cytology - transitional cells - don’t need to get CT a/p Imaging of upper tract - U/S ```
44
Bladder Cancer- treatment
TURBT - deep enough to get muscle - under anesthesia - pathologic evaluation will help diff muscle invasive vs noninvasive Non-muscle invasive - low - 1 dose of intravesical chemo - intermediate - extended course of intravesical chemo - high - extended course of intravesical chemo, +/- systemic chemo, consider cystectomy Muscle invasive - radical cystectomy Met - platinum based chemo
45
Prostate Cancer- pathophysiology
Very common - 3rd leading cause of cancer death - 60% of 80yr Met - BONE
46
Prostate Cancer- S/S & PE
DRE - abnormal - asymmetric, nodules, masses Asymptomatic
47
Prostate Cancer- diagnosis
Inc PSA or abnormal DRE - repeat PSA? - Prostate biopsy -> TRUS TRUS- trasrectal ultrasound guided biopsy - 12 cores - sent for path - Pos - treat - neg - observation? - if PSA is high/rising -> 18-24 core biopsy - prep w/ enema and abx - inc risk of UTI and sepsis Gleason core - combo of 2 most prevalent tissue types from biopsy - range 2-5 - Score added - range 6-10 - Gleason + TNM -> guide treatment
48
Prostate Cancer- labs & imaging
PSA - controversial - many reasons why it can be elevated - glycoprotein produced by prostate epithelial cells - >4ng/ml - false low - proscar, avodart
49
Prostate Cancer- treatment
Determined by: - age, medical condition - extent of dis - Gleason score - PSA - outcome/complications ``` Local dis, very low risk - PSA<10, nl DRE, low gleason <6, <3 pos cores - active surveillance Local, low risk - PSA <10, nl DRE, low Gleason <6, >3pos cores - surveillance, radiation, radical prostatectomy Local, intermediate risk - PSA >10, gleason 7, larger/both lobes - RT, radical prostatectomy Localized, high risk - PSA>20, gleason 8+ - RT, radical prostatectomy ``` Stage IV - lymph node involv/distant mets - RT +/- ADT - chemo F/U - serial PSA to assess for recurrence - Follow w/ serial CT scans
50
Testicular Cancer- pathophysiology
Most common in 15-35yo - 21.4% of all neoplasms -> most common solid tumor Germ Cell Tumors - 95% - AFP, bHCG - Seminoma - from seminiferous tubules - Non-seminoma - originate from sperm/ova cells Stromal Tumors - 5% - inhibin - leydig cell tumors - testosterone - Sertolic cell tumors - estradiol - granulosa cell tumor - mis/undiff
51
Testicular Cancer- cause
Seminoma - local disease - testicle - stage 1 - Stage II - 15% - Stage III <5% - no inc bhCG or AFP - sensitive to radiation NSGCT - present w/ distant mets - in bhCG and AFP - less sensitive to readiation
52
Testicular Cancer- epidemiology
Hx of cryptorchidism FHx of testicular cancer Personal hx of testicular Intra-tubular germ cell neoplasia
53
Testicular Cancer- S/S & PE
Found incidentally Painless, unilateral mass in scrotum scrotal pain - 20% Back and flank pain - rare
54
Testicular Cancer- diagnosis
Staging - path - imaging - CT c/a/p - Serum markers - after orchiectomy - clinic vs patholog - TNMS - Staging - I, II, III
55
Testicular Cancer- labs & imaging
Scrotal US Serum tumor markers - bHCG - 24-36hr half-life - seminoma, choriocarcinoma, EC - AFP- 5-7d half-life - yolk sac tumor, embryonal carcinoma - LDH - if neg - check inhibin, testosterone, estradiol Staging imaging - pre op CXR - pre op CT c/a/p Recommend sperm banking
56
Testicular Cancer- treatment
Inguinal surgical approach - if marker neg, <2cm mass, benign dis, or stromal tumor -> testes sparing surgery - marker pos or concern -> inguinal radical orchiectomy Chemo/RT - based on clinical/path staging Radical orchiectomy - impact gonadal hormone levels, fertility, bone health, psycho-social well being
57
Testicular Cancer- prognosis
``` Very good Stage I - >98% in both Stage IIA/B - >95% in both Stage Iic or III - good - 86% S, 92% NSGCT - Int - 72% S, 80%, NSGCT - Poor - 48% NSGCT ```
58
Renal Cell Carcinoma- pathophysiology
3rd most common GU cancer 80-85% of renal neoplasms ``` Transitional cell - most common Oncocytomas Collecting duct tumors Renal Sarcomas Wilms - children ``` Occurs sporadically Scandinavia, North America
59
Renal Cell Carcinoma- epidemiology
``` M>F 50-70yo Smoking Leather tanners, shoes workers, asbestos Obesity HTN Dialysis ```
60
Renal Cell Carcinoma- S/S & PE
50% found incidentally Slow growing - 2-5mm per year Classic triad - flank pain, hematuria, palpable abdominal mass Hematuria - 40% Systemic - fatigue, wt loss, hyperca, heptic dysfunction
61
Renal Cell Carcinoma- diagnosis
Biopsy | - pseduo-hypoxia driving angiogenesis - most vascularized solid tumors
62
Renal Cell Carcinoma- labs & imaging
``` CBC BMP LFTs Alkaline phosphatase UA ``` Cross sectional imaging - CT or MRI a/p - CT chest once RCC confirmed
63
Renal Cell Carcinoma- treatment
Stage I-III - surgery - curative - observation Stage IV - Nephrectomy + metastasectomy or cytoreductive RN - Can't resect -> first line: sunitinib, pazopanib, temsirolimus, - Second line - clinical trial, sorafenib, sunitinib, temsirolimus, IFN, high dos IL2 Chemo rarely used - resistant
64
Renal Cell Carcinoma- prognosis
``` 5 year survival Stage 1- 95% Stage 2 - 88% Stage 3 - 59% Stage 4 - 5-15% ```
65
Anal Cancer- pathophysiology
Uncommon Treated by colorectal/oncology surgeons Squamous cell - most common Colon Cancer - adenocarcinoma High correlation w/ cervical cancer
66
Anal Cancer- cause
Not related to - hemorrhoids, fissures, fistulas Lower incident w/HPV vaccines
67
Anal Cancer- epidemiology
``` HPV HIV Multiple partners Receptive anal intercourse Smoking ```
68
Anal Cancer- S/S & PE
Rectal Bleeding Anorectal pain Sensation of mass/fullness Asymptomatic
69
Anal Cancer- labs & imaging
``` DRE Inguinal lymph node Biopsy CT C/A/P +/- PET Anoscopy HIV GYN eval ```
70
Anal Cancer- treatment
``` Primary - combo radiation + chemo - cure w/out surgery - preserve anal sphincter - optimize if surgery needed later Following RT and chemo - restage -> surgery if needed - Abdominalperineal resection (APR) - less common - removal of anus - colostomy required - local excision - more common ``` Met - RT and Chemo

Clin med sem 2 (30 decks)

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