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
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
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
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
Urolithiasis- labs & imaging
UA +/- C&S CBC BMP Renal US CT w/o contrast KUB - uric acid, cystine - radiolucent
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
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
Penile Cancer- pathophysiology
<1% of cancer in men in the US
More developed countries - Africa, Asia, South America
Squamous cell carcinoma - 95%
Penile Cancer- epidemiology
HPV Phimosis - uncircumcised more likely - pathologic - scaring down of foreskin HIV Smoking Hispanic, Asian/pacific islander 60yo
Penile Cancer- S/S & PE
Lump, mass, ulceration of penis - most common glans
Inguinal lymphadenopathy - 30-60%
Penile Cancer- diagnosis
Biopsy
- if clear w/out biopsy - sent straight to OR
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
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
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!!
Bladder Cancer- diagnosis
Cystoscopy - coral appearance
Bladder Cancer- labs & imaging
Office cystocopy Cytology - transitional cells - don’t need to get CT a/p Imaging of upper tract - U/S
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
Prostate Cancer- pathophysiology
Very common - 3rd leading cause of cancer death
- 60% of 80yr
Met - BONE
Prostate Cancer- S/S & PE
DRE
- abnormal - asymmetric, nodules, masses
Asymptomatic
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
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
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
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
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
Testicular Cancer- epidemiology
Hx of cryptorchidism
FHx of testicular cancer
Personal hx of testicular
Intra-tubular germ cell neoplasia
Testicular Cancer- S/S & PE
Found incidentally
Painless, unilateral mass in scrotum
scrotal pain - 20%
Back and flank pain - rare
Testicular Cancer- diagnosis
Staging
- path
- imaging - CT c/a/p
- Serum markers - after orchiectomy
- clinic vs patholog
- TNMS
- Staging - I, II, III
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
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
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
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
Renal Cell Carcinoma- epidemiology
M>F 50-70yo Smoking Leather tanners, shoes workers, asbestos Obesity HTN Dialysis
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
Renal Cell Carcinoma- diagnosis
Biopsy
- pseduo-hypoxia driving angiogenesis - most vascularized solid tumors
Renal Cell Carcinoma- labs & imaging
CBC BMP LFTs Alkaline phosphatase UA
Cross sectional imaging
- CT or MRI a/p
- CT chest once RCC confirmed
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
Renal Cell Carcinoma- prognosis
5 year survival Stage 1- 95% Stage 2 - 88% Stage 3 - 59% Stage 4 - 5-15%
Anal Cancer- pathophysiology
Uncommon
Treated by colorectal/oncology surgeons
Squamous cell - most common
Colon Cancer - adenocarcinoma
High correlation w/ cervical cancer
Anal Cancer- cause
Not related to - hemorrhoids, fissures, fistulas
Lower incident w/HPV vaccines
Anal Cancer- epidemiology
HPV HIV Multiple partners Receptive anal intercourse Smoking
Anal Cancer- S/S & PE
Rectal Bleeding
Anorectal pain
Sensation of mass/fullness
Asymptomatic
Anal Cancer- labs & imaging
DRE Inguinal lymph node Biopsy CT C/A/P \+/- PET Anoscopy HIV GYN eval
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
