Male GU Disorders Flashcards
Pain in GU disorders
o Can be severe
- Urinary tract obstruction (kidney stones) - Inflammation
o most severe when it involves the parenchyma of a GU organ
- Pyelonephritis - Prostatitis - Epididymitis
o Inflammation of the mucosa of a hollow viscous usually produces discomfort
- Cystitis - Urethritis
o Tumors - No pain unless :
- Obstruction - Extend beyond the primary organ to involve adjacent nerves - Gastrointestinal symptoms - Nausea - Vomiting - Ileus
Renal pain
o Ipsilateral costovertebral angle just lateral to the sacrospinalis muscle and beneath 12th rib
o Acute distention of the renal capsule
o Renal pain may also be confused with pain resulting from irritation of the costal nerves, most commonly T10-T12
-Not colicky in nature
-Severity of radicular pain may be altered by changing position
o Pyelo is usually diffuse pain
o Colicky is usually sharp pain
uretheral pain
o Usually acute and secondary to obstruction
- Midureter (Rt side) referred to the right lower quadrant (McBurney's point) and simulate appendicitis - Midureter (Lt side) referred over the left lower quadrant and resembles diverticulitis. - Scrotum in the male or the labium in the female. - Lower ureteral obstruction frequently produces symptoms of bladder irritability (frequency, urgency, and suprapubic discomfort)
o Sometimes right kidney stones can mimic an appendicitis
o Kidney stones have a colicky waxing and waning quality to them
vesical (bladder) pain
o Vesical pain is due to
- Overdistention - Inflammation
prostatic pain
o Inflammation with secondary edema and distention of the prostatic capsule o Poorly localized -Lower abdominal -Inguinal -Perineal -Lumbosacral -Rectal pain -Irritative urinary symptoms (frequency and dysuria) -Acute urinary retention
o Poorly localized often means its in the prostate
Penile pain
o Pain in the erect penis is usually due to Peyronie’s disease or priapism
o Pain in the flaccid penis
-usually secondary to inflammation in the bladder or urethra
-referred pain that is maximally at the urethral meatus
o Paraphimosis
o Priapism is erection lasting 4-6 hrs í usually Viagra or even sickle cell can cause this
o Peyronie’s Disease upward penile curvature - common
o Paraphimosis í usually an iatrogenic problem; gets edematous and stuck
Testicular pain
-Epididymitis
-Torsion of the testicle
o Chronic scrotal pain
-Hydrocele
-Varicocele
-Dull, heavy sensation that does not radiate
-Referred pain to kidneys or retroperitoneum
o Pretty common, differential is wider í is it acute or chronic
o Epididymitis is usually localized to epididymis
o Torsion í usually younger men (high school, etc.) í accompanied with n/v and requires surgical intervention
o Chronic pain í think prostatitis, sometimes epididymitis
-Hydrocele and varicocele tend to be a heavy feeling
-Referred pain usually indicates prostate, not testicle
Lower urinary tract symptoms
o Irritative Symptoms -Urinary frequency -Nocturia -Dysuria -Incontinence -Stress -Urge o Obstructive Symptoms -Decreased force of urination -Urinary hesitancy -Intermittency -Post void dribbling -Straining o Obstructive is usually seen with prostate enlargement o Irritative is usually associated with infection
Infection sxs
o Urethral Discharge: -Most common symptom of venereal infection o Fever and Chills: -Pyelonephritis -Prostatitis -Epididymitis (acute)
Past medical history
o Systemic diseases that may affect the GU system
-Diabetes Mellitus
-Multiple Sclerosis - due to demyelinating of nerve fibers affecting bladder control.
-TB - reactivation can occur (rarely) anywhere in GU but usually kidney
-Schistosomiasis
o Family history
-Prostate cancer
-Stones (cystine)
-Renal tumors (some types)
o The more first degree relatives that had prostate cancer means your patient has a higher likelihood of having prostate cancer
o Cigarette smoking
-Urothelial carcinoma, mostly bladder cancer
-Erectile dysfunction
o Chronic alcoholism
-Impaired urinary function
-Sexual dysfunction
-Testicular atrophy, decreased libido
physical examination
o General Observations " Visual inspection of the patient " Cachexia " Malignancy, TB " Jaundice or pallor " Gynecomastia " Endocrinologic disease " Alcoholism " Hormonal therapy for prostate cancer
physical examination findings: kidneys
o The most common abnormality detected on examination of the kidneys is a mass
physical examination findings: bladder
o At least 150 ml of urine in it to be felt
o Percussion is better than palpation
o A bimanual examination, best done under anesthesia, is valuable to asses bladder tumor extension
physical examination findings: penis
o The position of the urethral meatus " Variations of hypospadius (right) o Priapism " sickle cell disease " ED medications
physical examination findings: scrotum and contents
o Painful " Torsion " Epididymitis o Painless " Spermatocele " Hydrocele " Varicocele o Transillumination " Cystic vs solid o Painless solid testicular mass is tumor until proven otherwise
rectal and prostate examination in the male
o Digital rectal examination (DRE):
“ Every male after age 50 years (controversial)
“ Men of any age who present for urologic evaluation
male GU disorders
o Benign Prostatic Hyperplasia (BPH) o Erectile dysfunction o Hypogonadism o Varicocele o Hydrocele
Benign prostatic hyperplasia
o Common problem
“ 40-50% men aged 51-60 years
“ >80% men >80 years
o Considerable disability
o Low rate of mortality
o Size/volume of the prostate increases with age, leading to symptoms
o If every man lives long enough, his prostate will become enlarged
Natural history of BPH
o Weight of prostate increases with age
o Muscle cells in the enlarging prostate gland have increased tone
o Urinary flow rates decrease with age
o Post void residual increases due to pressure on the urethra from the prostate
o Develops in the periurethral or transitional zone of the prostate
o Fibromuscular enlargement
Diagnosis of BPH
o Frequency of urination, nocturia, hesitancy, urgency, weak urinary stream (LUTS)
o Symptoms appear slowly, progress gradually
o Rule out more serious diagnoses before settling with BPH
“ UTI/Prostatitis, urethral stricture, bladder or prostate cancer, bladder calculi, neurogenic bladder
o One of the ways to distinguish BPH from prostate cancer is progression rate í super fast = infection or cancer, BPH is slow
o Urinalysis or urine culture to make sure that prostatitis is not the underlying problem
evaluation of BPH
o Digital rectal exam - Size, consistency, nodules, induration, symmetry
o Neurologic exam
o Rectal sphincter tone
o Urinalysis - UTI, hematuria
o Serum creatinine - Bladder outlet obstruction, renal/pre-renal dz
o If you examine the prostate and it feels warm and boggy -> most likely prostatitis
o Asymmetrically enlarged -> more worrisome for prostate cancer
o Nodular enlargement -> not normal
o BPH is symmetric, smooth enlargement
o Hematuria could be infection or malignancy
Diagnosis of BPH
o Serum Prostate Specific Antigen (PSA)
->4.0 ng/mL → look for prostate carcinoma
-Total serum PSA, %free PSA, ratio free-to-total
-% free PSA low in prostate cancer, high in BPH
o Maximal urinary flow rate
-<15 mL/sec indicates obstruction
o Post void residual urine volume
->12 mL abnormal in men
Optional studies in BPH
o Pressure-flow studies o Urethrocystoscopy o Intravenous urography o Abdominal ultrasound o Abdominal X-Ray (KUB) o Reserved for unusual patients o Done by Urology Department
treatment of BPH
o Treat symptoms
o Prevent urinary retention, renal failure
o Treat all men with behavior modification
o Watchful waiting for mild BPH
o Medications for moderate BPH
-α-1-adrenergic antagonists
-5-α-reductase inhibitors
-PDE-5 inhibitors
o Invasive therapy for severe BPH
-TURP most often used
o These should be tailored to symptoms but may include avoiding fluids prior to bedtime or before going out, reducing consumption of mild diuretics such as caffeine and alcohol, and double voiding to empty the bladder more completely. They should also avoid medications that can exacerbate symptoms (eg, diuretics) or induce urinary retention.
o Everyone with BPH need to be couseled on behavior modification like avoiding diuretics, etc.
o Alpha 1 adrenergic antagonists are first line!!, the others are alternative therapy
o Frequent catheters, urinary retention, AUA over 20 need to be recommended for surgery
