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NP 801 NP Theory 2 > Male GU Health + SDM Schema > Flashcards

Male GU Health + SDM Schema Flashcards

1
Q

Definition

Testicular torsion

A
  • Twisting of spermatic cord w/compromised testicular blood flow (low)
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2
Q

Testicular torsion
Clinical manifestations

A
  • Severe onset pain
  • Pain begins when asleep or post exertion
  • Pain starts in scrotum → localized to lower abd
  • Having hx of similar prior event
  • N/V
  • NO URINARY SX
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3
Q

Testicular Torsion
Objective findings

A
  • Swollen, firm + tender hemiscrotum - red + edematous
  • Affected testis is high riding
  • Testis may be drawn up into scrotum neck
  • (-) cremasteric reflex
  • Mild fever
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4
Q

Testicular Torsion Diagnostics

A
  • Doppler U/S - GOLD STANDARD for most scrotal complaints
  • UA
  • CBC tp r/o ther causes
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5
Q

Testicular Torsion Differentials

A
  • Epididymitis
  • Testicular cancer
  • Orchitis
  • Scrotal trauma
  • Acute inguinal hernia
  • Acute hydrocele
  • Scrotal vasculitis
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6
Q

Testicular Torsion goal of therapy

A

To salvage viable testis + preserve fertility
* 6-8hrs to manually fix testicle
EMERGENCY SURGERY CONSULT

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7
Q

Epididymitis

Definition

A

Most common cause of scrotal pain in adults

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8
Q

Epididymitis most likely causative organisms

A

Chlamydia & Gonorrhea

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9
Q

Epididymitis
clinical manifestations

A
  • Pain in epididymis → entire testicle
  • R-sided testicular pain
  • Dysuria
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10
Q

Epididymitis
Objective findings

A
  • Fever
  • Erythema
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11
Q

Epididymitis Diagnostic testing

A
  • UA
  • Urine culture
  • Urine G + C testing
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12
Q

Epididymitis Differentials

A
  • Hydrocele
  • Varicocele
  • Prostatitis
  • Epididymitis
  • Testicular cancer
  • Testicular torsion
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13
Q

Epididymitis pharmacological treatment

Any age, no anal sex; Any age, √ anal sex; Low risk of STI

A
  • Ceftriaxone + Doxycycline
  • Ceftriaxon + Levofloxacin
  • Levofloxacin
  • NSAIDs for pain
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14
Q

Epididymitis Nonpharmacologic treatments

A
  • Bedrest
  • Scrotal elevation (boxers → briefs for support)
  • Icepacks
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15
Q

Epididymitis Risk Factors

A
  • Most common in younger, sexually active men or older men w/UTI
  • Hx of unprotected sex – sexual Hx
  • New sexual partner
  • Heavy lifting or straining
  • Hx of UTI – older
  • Indwelling catheter
  • Urinary instrumentation
  • S/p transurethral prostate surgery
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16
Q

Hydrocele

definition

A

Pocket of fluid surrounding testicle

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17
Q

Causes of hydrocele

A
  • > 40
  • Acute: Epididymitis, Trauma, Tumor, Radiation sequelae
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18
Q

Hydrocele Clinical manifestations

A
  • Painless swelling of L testicle
  • Feeling of heaviness + dull pain radiating to low back
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19
Q

Hydrocele Objective findings

A
  • Transillumination
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20
Q

Hydrocele diagnostics + differentials

A
  • U/S if not able to transilluminate
  • Epididymitis
  • Hydrocele
  • Prostatisis
  • Testicular cancer
  • Testicular torsion
  • Varicocele
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21
Q

Hydrocele self-limiting?

A

YES

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22
Q

Varicocele

Definition

A

1st appears in adolescence

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23
Q

Varicocele
Clinical Manifestations

A
  • Testes look like a bag of worms
  • Painless, but can be painful
  • Usually L-sided
    • R-sided less common, can lead to infertility
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24
Q

Varicocele Objective Grading

A

G1: palpable only during Valsalva
G2: Palpable when standing
G3: Assessed with light palpation + visual inspection

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25
Q

Varicocele pharm + nonpharm mangement

A
  • NSAIDs
  • Scrotal support
  • R-sided → surgical plan
  • < 21 → eval for testicular atrophy → if have it → Surgery
  • > 21 → Monitor w/semen analysis Q1-2yrs
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26
Q

Testicular cancer

Definition

A
  • Rare cancer; survivable
  • Most common cancer 15-35yrs
  • ↑ risk w/ chrytorchidism (undescended testicle)
  • ↑ incidence in whites
  • FMHx of cancer
  • Peak age 20-39/40
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27
Q

Testicular cancer
clinical manifestations

A

Hard lump on testicle
Feels Heavy, dull, swelling, fulllness
Painless
Can have hydrocele, gynecomastia, epididymitis too
- Metastasis: SOB, cough, LBP, LE swelling

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28
Q

Testicular cancer
Objective Findings

A

Palpate scrotal/testicular mass
Transilluminate area → Look for darkened area

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29
Q

Testicular cancer diagnostics

A

U/S
MRI + CT for mets
CXR for staging
CBC - infxn sx
Tumor markers: AFR, beta-hCG, LDH

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30
Q

Testicular cancer differentials

A
  • Epididymitis
  • Hydrocele
  • Prostatitis
  • Testicular cancer
  • Testicular torsion
  • Varicocele
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31
Q

Testicular cancer treatments
What is treatment dependent on?

A

Chemo + radiation therapy
Surgery - orchiectomy
* Depend on type of testicular cancer, if mets occured

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32
Q

Screening recommended for testicular cancer?

A

USPSTF + AHRQ DO NOT RECOMMEND screening d/t potential harms + likelihood of finding malignancy
- Can do self-exams Q2mos in shower

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33
Q

Take home messages for testicular cancer

A
  • For all solid, firm masses w/in testis, investigate, even if painless
  • Testicular cancer must be considered as DX until proven otherwise
  • If pt w/scrotal pain is tx for epididymitis that does not resolve, consider testicular cancer
  • For young men, consider fertility options such as sperm banking
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34
Q

Testicular Cancer DX chart

A
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35
Q

Causes of scrotal masses Overview

A
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36
Q

Erectile Dysfunction

Definition

A
  • Persistent inability to achieve + maintain penile erection sufficient for satisfactory sex
  • Most common sexual problem in men
    • Causes them to seek medical attention they might now otherwise seek; HCP can discuss lifestyle changes
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37
Q

Causes of ED

A
  • Vasculogenic (HTN, PVD, DM: uncontrolled)
  • Neurogenic (Parkinson’s, CVA, MS, inury)
  • Endocrine (hypogonadism, thyroid diseases)
  • Urologic (malignancy)/ Penile (Peyronies – penis curve)
  • Meds (BBs, SNRIs)
  • Substance use (tobacco, EtOH, illicits)
  • Injuries (trauma, surgery, radiation)
  • Psychogenic
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38
Q

ED a precursor marker for CVD?

A

YES

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39
Q

ED Clinical manifestations

A

Ask about sx of hypogonadism
- ↓ libido
- ↓ erectile quality + frequency incl. nocturnal erections
- Mood changes, ↓ intellectual activity + cognitive fx, spatial orientation, fatigue, depressed mood, irritability
- Sleep disturbance
- ↓ lean body mass
- ↑ visceral fat – overweight
- ↓ body hair + skin changes
- ↓ BMD

40
Q

Always ask about ED if…

Main Risk factors

A
  • Men > 50
  • RFs of ED (DM, HTN, CVD, MS, depression, anxiety, smoking, drug or EtOH abuse, or sedentary lifestyle)
  • Taking meds affecting ED
41
Q

ED objective findings

A
  • PE includes genitourinary + full neuro exam
  • Are you aroused by your partner? IF NO → consider hypogonadism
  • Use International index of ED (IIEF)
    • On scale of 0-5 in past 4wks
42
Q

ED Diagnostics

A
  • Glucose, TSH, lipid profiles (if not assessed in last 12 mos), CBC, CMP
  • Total testosterone (AM x 2); if indicated, free testosterone
    • check hormone levels 8a-10a
  • Testing done to exclude underlying disease as DX made from detailed medical + sexual Hx
43
Q

ED 1st line treatment

A
  • Testosterone replacement (1° hypogonadal state)
  • PDE5 inhibitors
    • Cialis – Tadalafil; Levitra – Vardenafil; Stendra – Avanafil; Viagra – Sildenafil
  • Give lowest full dose 1st – can cut in ½
  • These meds do not work W/O SEX STIMULATION
  • Do not take w/ nitrates → fatal HoTN
  • Anxiety reduction (psychogenic)
  • Lifestyle modification (exercise, wt. loss, quit smoking)
  • Encourage use of film, vids, etc → desire
  • Lubricants
44
Q

ED 2nd line treatment

A
  • Alprostadil (Caverject) available as INJ sol or urethral suppository
  • Surgical + procedural therapy
  • constriction band/ vacuum pump devices noninvasive
  • If this fails → surgical implantation of inflatable penile prosthesis
45
Q

ED Risk Factors

chart

A
46
Q

ED follow-up

A
  • Assess therapeutic outcome:
    • Erectile response
    • SEs
    • Treatment satisfaction
  • TREAT UNDERLYING CAUSE
    • Vasculogenic: Prevent or tx HTN to ↓ ED
    • SA: Refer to tobacco, drug tx
    • Meds: If AE on sexual functioning, change if possible
  • 2° hypogonadal state → endocrine
47
Q

When to consider referral for ED

A
  • Certain diseases (MS, uncontrolled DM)
  • Suspected urologic problem
  • Failure to improve w/standard therapy
  • Severe depression

Sexuality + aging can affect ED
* Physiological changes
* Older W less likely to be sexually active vs. M
* Elders in poor health less likely
* W: lack of desire, vag dryness, + inability to achieve orgasm
* Men’s concerns – erection issues
* Always ask about their perceived issues surrounding sexual dysfunction

48
Q

Prostate Function

A

produce the fluid that nourishes and transports sperm (seminal fluid).

49
Q

Prostatitis types

A
  • Acute bacterial prostatitis - prostage gland acute infection
  • Chronic bacterial prostatitis - “” Chronic infection
  • Chronic pelvic pain syndrome - Pelvic pain w/o bacteria in prostate
    • Inflammatory - HIGH WBC
    • Noninflammatory - LOW WBC
  • Asymptomatic prostatitis - WBC count +/or bacteria in EPS, VB3, semen, or histologic specimens in asymptomatic patients
50
Q

Most common causes of prostatitis

A
  • Ascending UTI; reflux of infected urine; extension of rectal infxn
  • E. coli
51
Q

Bacgerial Prostatitis Urinary + Systemic symptoms

A

Urinary
* Straining, urgency, dysuria, hesitancy, frequency, obstruction, irritation

Systemic
* fever, malaise, arthralgia, myalgia, intense suprapubic pain, chills, nausea, emesis, low back pain, abdominal, pelvic or perineal pain

52
Q

Prostatitis clinical manifestations

A

Chills, Nausea, Urinary frequency + hesitancy

53
Q

Prostatitis Objective Findings

A
  • Check temp - fever
  • MS – back, joint swelling, inflamm
  • Neuro – other etiology
  • Abd – (bladder distension, discomfort)
  • CVA tenderness
  • GU – inspect + palpate
  • Rectal to assess prostate enlargement, bogginess, tenderness
54
Q

Acute Bacterial Prostatitis Objective Findings
What NOT to do?

A
  • Signs of sepsis (↑ HR + HoTN)
  • Distended bladder
  • DRE: Warm, tender, boggy, enlarged prostate
  • DO NOT MASSAGE!!
55
Q

Prostatitis Differentials

A
  • BPH
  • Neurogenic bladder
  • Pyelonephritis
  • Renal calculi
  • Prostate abscess
56
Q

Prostatitis Diagnostics

A
  • UA + C & S (Pyuria, Bacteriuria)
    • > 10 WBC per hpf
    • Urine gram stain
  • **CBC w/diff **(optional)
  • In pts < 35 or > 35 w/ multiple partners
    • Urine GC/CHL
  • In pts w/fever > 101°F: Blood cultures
57
Q

Acute and Chronic Bacterial Prostatitis Pharm treatment

Important to check for these meds?

A
  • Initial tx is empiric based on chief complaint, ROS + Gram (-) bacteria being usual cause
  • Bactrim – good prostate penetration
  • Cipro
  • Levaquin
  • In sexually active men < 35 w/multiple partners → tx to cover GC/CHL
  • Ceftriaxone + Azithromycin or Doxycycline (STI cocktail)
  • Nitrofurantoin NOT B/C d/t poor prostate penetration + risk of AEs for long term use
  • Prophylactic ABX for recurrent bacterial prostatitis

Don’t forget to check for med interactions! Pts on these meds for weeks

58
Q

Prostatitis Nonpharm tx

A
  • Return for urgent tx should sxx return
  • Complete 4-6 wks of abxs
    • Completely better at 4wks – stop
    • If not, keep going to 6wks
  • Should see improvement in symptoms in 2-6ds
  • Infxn deep in gland
59
Q

Prognosis for…
Acute bacterial prostatitis
Chronic bacterial prostatitis
Pelvic pain syndrome

A

Acute: Cured by prompt abx tx
Chronic: Same, but therapeutic filaures/recurrence common
Pelvic: POOR PROGNOSIS - urology referral

60
Q

Prostatitis complications

A
  • Pyelonephritis
  • Sepsis
  • Prostatic abscess
  • Chronic prostatitis – A/w STI
61
Q

When to refer for prostatitis

A

Severe bact prostatitis
Not respondinig to initial tx
Pts w/obstructive sxs

62
Q

BPH/Prostatic Hyperplasia, mLUTS, BOO

Definition

A
  • ID histologically – cells
  • BOO – Bladder outlet obstruction
  • mLUTS (male lower urinary tract sxs) – irritative sxs
63
Q

BOO, mLUTS clinical manifestations

A
  • BOO
    • Urinary hesitance
    • ↓ caliber + force of stream
    • Post-void dribbling
  • mLUTS
    • Urinary frequency
    • Urgency
    • Nocturia
64
Q

BPH Irritative + Obstructive Symptoms

A

Irritative: FUN
- Frequency
- Urgency
- Nocturia
Obstructive: WISE
- Weak stream,
- Intermittent flow,
- Straining to urinate,
- Incomplete Emptying

65
Q

BPH Objective findings

Not incl. concerning findings

A
  • DRE: should be nontender, smooth, rubbery – feel squishy, not hard
  • Lower ABD for bladder distension
  • Neuro exam to include: general mental status, ambulatory status, LE NM fx + sphincter tone
66
Q

BPH Concerning findings

A
  • Abnormal sphincter tone – neurogenic bladder
  • Fever – Prostatitis
  • Hematuria – Bladder Cancer
  • Prostate nodule or induration – Prostate Cancer
  • Tenderness – Prostatitis
67
Q

AUA Symptom Index determining UT symptoms severity

A

Irritative + Obstructive sx mixed for questions
Over the past month, how often have you . . .
* Had a sensation of incomplete emptying
* Had to urinate again less than 2 hours after the last void
* Found you stopped and started again several times
* Found it difficult to postpone urination
* Had a weak urinary stream
* to push or strain to begin urination
* How many times did you typically get up in the night to urinate
Treatment is based on the symptom score: 0-7 = mild; 8-19 = moderate; 20-35 = severe

68
Q

Differential Characteristics of Psychogenic vs. Organic ED

A
69
Q

BPH Diagnostics

A

UA for all men presenting w/LUTS; likely only test
Helps r/o bladder cancer, bladder stones, UTI, urethral strictures

70
Q

When to get Serum PSA for BPH

A
  • Life expectancy > 10yrs: candidate for treatment for prostate cancer
  • 5-alpha reductase INH therapy is planned: (because it will lower PSA)
  • Physical findings suggestive: (abnormal DRE)
71
Q

Meds that aggravate mLUTS

A
  • Anticholinergics incl. Diphenhydramine (Benadryl) Antihistamines
  • Decongestants
  • Diuretics incl. HCTZ, furosemide
  • Opiates
  • TCAs
72
Q

If AUA score mild (0-7) - what treatment?

A

Alpha blocker alone
* Doxazosin, Terazosin – older, longer acting, required dose titration – start at bedtime to avoid dizziness
* Alfuzosin, Tamsulosin – long acting –** Less risk for HoTN – risk of Floppy iris syndrome**
- Relaxes smooth mm, 2-4 wks for improvement
- SE: HoTN, don’t use alone for HTN; HF risk

73
Q

If can’t tolerate alpha blockers, what to try for BPH?

A

5 alpha-reductase INH
* Finasteride + Dutasteride – take 6-12mos to work
- Mech: shrinks prostate; works better w/prostate vol over 40mL; normal is 20-30mL
- Main SE: sexual dysfunction
- Reduction of PSA, must take into account
- Warning of male breast cancer w/finasteride

74
Q

Treatment for mild BPH sxs + scoring < 7 (no med)

A

monitor + annual monitoring

75
Q

When to refer for BPH

A
  • Refer after trying alpha blocker
  • Any pt w/upper tract injury such as hydronephrosis or renal dysfunction, or lower tract injury such as urinary retention, recurrent infection, bladder decompensation; these all require invasive therapy
76
Q

RED FLAGS BPH

A
  • Sxs in setting of autonomic or severe peripheral neuropathy
  • Sxs following invasive tx of urethra or prostate
  • Men < 45 years old
  • Abnormality on exam such as nodule, induration, asymmetry
  • Presence of hematuria in absence of infxn
  • Incontinence
  • Severe symptoms, AUA Symptom Score > 20
77
Q

Prostate Cancer

Definition; risk of dying

A
  • Most common malignant neoplasm after skin cancer in US men
  • Most commonly DX visceral cancer in US
  • Leading cause of cancer death in men > 55, + 2nd leading cause of cancer death in men overall
    Risk of dying is 2.9%
78
Q

Prostate Cancer
Clinical Manifestations

Early, Later

A

Early (1st 1-2 mos):
* Hesitancy
* Urgency
* **Frequency **
* Nocturia

Later
* Back pain
* Impotence
* Bone pain
* Weight loss
* Constipation
* Malaise
* Hematuria
* Rectal pain
* Paresthesias w/LE weakness d/t nerve root compression

79
Q

Prostate Cancer Objective Findings

A
  • Early on, exam normal
  • Firm nodule
  • Induration
  • Stony, asymmetric prostate
80
Q

Prostate Cancer
Differentials

A
  • BPH
  • Prostatitis
  • UTI
  • Prostate Calculi
  • Bladder Outlet Obstruction
81
Q

Prostate Cancer Diagnostics

A
  • DRE – less sensitive vs. PSA – staging
  • PSA – can be normal even w/cancer; not specific for cancer – prostate
    • Can be ↑ w/benign conditions, BPH, prostatitis, + prostate massage or ejaculation
  • CBC w/diff
  • Genomic assays (little data)
82
Q

What if the DRE or PSA is abnormal (prostate cancer diagnostic)

A
  • TR-U/S w/biopsy – GOLD STANDARD Transrectal
  • Transperineal biopsy
  • Multiparametric MRI guided biopsy
  • MRI U/S fusion guided biopsy
    • (+) biopsy + Gleason score > 7 → radionuclide lymph nodes for mets
  • Abd/pelvis CT for regional lymph nodes + mets
83
Q

Gleason Grading Scale for prostate cancer

A
  • Grade 1 = well differentiated; Grade 5 = poorly differentiated
  • Gleason score is the sum of the most common and the next most common findings
  • Score ranges 2-10
  • 2-4, well differentiated, favorable prognosis
  • 5-7, moderate differentiation; most clinically detected tumors are in this range
  • 8-10, poor differentiation, unfavorable prognosis
  • New WHO grading system: Grade Group 1; Gleason Score </= 6; Grade Group 2; Gleason Score 3+4=7; Grade Group 3; Gleason Score 4+3=7; Grade Group 4; Gleason Score = 8; Grade Group 5; Gleason Score = 9 and 10.
  • HIGH SCORE = bad
  • Sum of two scores
84
Q

Initial Staging of Prostate Cancer includes:
(TNM system)

A

TNM: Tumor, regional node, metastasis system
* PSA level
* DRE findings
* TR U/S
* Gleason score

85
Q

Localize Prostate Cancer Risk Stratification + Treatment Recommendations (MIGHT NOT BE ON TEST)

A
86
Q

Prostate Cancer Treatment:
Localized approach

A
  • Watchful waiting
  • Active surveillance
  • Radical prostatectomy
  • External bean radiation therapy
  • Brachytherapy
87
Q

Prostate Cancer Treatment: Locally Advanced

A
  • Androgen deprivation
  • Radiation therapy
88
Q

Prostate Cancer Treatment: Advanced/Metastatic

A
  • Complete androgen ablation
  • Antiandrogens (inhibit binding of androgen to receptor)
  • LHRH agonists (chemical castration)
  • Chemo w/Docetaxel – inhibits cell division
  • Orchiectomy (surgical castration)
89
Q

Prostate Cancer Risk Factors

A
  • Advancing Age
  • African American race – SDOH
  • FMHx – one 1st degree relative doubles risk
  • Geography – Caribbean men of African ancestry, men living in northwestern Europe, NA, Australia
90
Q

Prostate Cancer Treatment Complications

A
  • Anxiety
  • Discomfort of serial testing
  • ED + Loss of libido
  • Incontinence
  • Proctitis, Urethritis
  • Bowel dysfunction including diarrhea, urgency, soiling
  • Loss of stamina
  • Hot flashes
  • Decreased muscle mass
  • Premature osteoporosis
  • Fatigue
91
Q

PSA screening Controversy

A
  • Incidence of prostate cancer rose rapidly when the PSA test began use as a screening tool
  • However, w/time we have seen that screening can reduce mortality but the overall risk reduction is very small.
  • Harms of screening, including invasive testing such as transrectal ultrasound with biopsy and its attendant risk, are substantial
  • Overdiagnosis can lead to invasive treatments which negatively affect quality of life
92
Q

Carlsson and Vickers: Key Practice Points for PCPs

A
  1. Get consent for prostate cancer screening, preferably using the “Simple Schema” decision aid.
  2. PSA screening is only for healthy men aged 45 to 70.
  3. Tailor screening frequency based on PSA level and cease screening for men older than 60 unless PSA is higher than median (1 ng/mL).
  4. For men with elevated PSA (3 ng/mL), repeat PSA.
  5. Use secondary tests, such as marker or imaging before biopsy, or only refer to urologists who do so.
  6. Only refer to urologists who recommend active surveillance to almost all patients with low grade cancer.
  7. Preferably refer to urologists at major academic centers.
93
Q

Using SDM tool (6steps)

A
  • Describe: goal of SDM tool is to initiate a conversation about options – PURPOSE
  • Check: ask if patients wish to read it themselves or to they prefer the comparisons to be vocalized
  • Handover: give the SDM handout tool to the patient with writing implement so they can mark their copy and jot down questions
  • Create space: ask permission to do other tasks if the patient wishes to read the information
  • Ask: encourage questions and discussion
  • Gift: patients should be told they may take the handout with them
94
Q

Simple Schema Part 1: Key facts about prostate cancer and screening

A
95
Q

Simple Schema Part 2: Key take-home messages

A
96
Q

Simple Schema Part 3: Discrete Decision

A
97
Q

Challenges implementing SDM for PCP

A
  • Lack of tools
  • Shortage of time
  • Challenge of integrating into clinical pathways
  • More demanding to practice SDM than to recommend a treatment

NP 801 NP Theory 2 (7 decks)

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