Male GU Health + SDM Schema Flashcards
Definition
Testicular torsion
- Twisting of spermatic cord w/compromised testicular blood flow (low)
Testicular torsion
Clinical manifestations
- 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
Testicular Torsion
Objective findings
- Swollen, firm + tender hemiscrotum - red + edematous
- Affected testis is high riding
- Testis may be drawn up into scrotum neck
- (-) cremasteric reflex
- Mild fever
Testicular Torsion Diagnostics
- Doppler U/S - GOLD STANDARD for most scrotal complaints
- UA
- CBC tp r/o ther causes
Testicular Torsion Differentials
- Epididymitis
- Testicular cancer
- Orchitis
- Scrotal trauma
- Acute inguinal hernia
- Acute hydrocele
- Scrotal vasculitis
Testicular Torsion goal of therapy
To salvage viable testis + preserve fertility
* 6-8hrs to manually fix testicle
EMERGENCY SURGERY CONSULT
Epididymitis
Definition
Most common cause of scrotal pain in adults
Epididymitis most likely causative organisms
Chlamydia & Gonorrhea
Epididymitis
clinical manifestations
- Pain in epididymis → entire testicle
- R-sided testicular pain
- Dysuria
Epididymitis
Objective findings
- Fever
- Erythema
Epididymitis Diagnostic testing
- UA
- Urine culture
- Urine G + C testing
Epididymitis Differentials
- Hydrocele
- Varicocele
- Prostatitis
- Epididymitis
- Testicular cancer
- Testicular torsion
Epididymitis pharmacological treatment
Any age, no anal sex; Any age, √ anal sex; Low risk of STI
- Ceftriaxone + Doxycycline
- Ceftriaxon + Levofloxacin
- Levofloxacin
- NSAIDs for pain
Epididymitis Nonpharmacologic treatments
- Bedrest
- Scrotal elevation (boxers → briefs for support)
- Icepacks
Epididymitis Risk Factors
- 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
Hydrocele
definition
Pocket of fluid surrounding testicle
Causes of hydrocele
- > 40
- Acute: Epididymitis, Trauma, Tumor, Radiation sequelae
Hydrocele Clinical manifestations
- Painless swelling of L testicle
- Feeling of heaviness + dull pain radiating to low back
Hydrocele Objective findings
- Transillumination
Hydrocele diagnostics + differentials
- U/S if not able to transilluminate
- Epididymitis
- Hydrocele
- Prostatisis
- Testicular cancer
- Testicular torsion
- Varicocele
Hydrocele self-limiting?
YES
Varicocele
Definition
1st appears in adolescence
Varicocele
Clinical Manifestations
- Testes look like a bag of worms
- Painless, but can be painful
- Usually L-sided
- R-sided less common, can lead to infertility
Varicocele Objective Grading
G1: palpable only during Valsalva
G2: Palpable when standing
G3: Assessed with light palpation + visual inspection
Varicocele pharm + nonpharm mangement
- NSAIDs
- Scrotal support
- R-sided → surgical plan
- < 21 → eval for testicular atrophy → if have it → Surgery
- > 21 → Monitor w/semen analysis Q1-2yrs
Testicular cancer
Definition
- Rare cancer; survivable
- Most common cancer 15-35yrs
- ↑ risk w/ chrytorchidism (undescended testicle)
- ↑ incidence in whites
- FMHx of cancer
- Peak age 20-39/40
Testicular cancer
clinical manifestations
Hard lump on testicle
Feels Heavy, dull, swelling, fulllness
Painless
Can have hydrocele, gynecomastia, epididymitis too
- Metastasis: SOB, cough, LBP, LE swelling
Testicular cancer
Objective Findings
Palpate scrotal/testicular mass
Transilluminate area → Look for darkened area
Testicular cancer diagnostics
U/S
MRI + CT for mets
CXR for staging
CBC - infxn sx
Tumor markers: AFR, beta-hCG, LDH
Testicular cancer differentials
- Epididymitis
- Hydrocele
- Prostatitis
- Testicular cancer
- Testicular torsion
- Varicocele
Testicular cancer treatments
What is treatment dependent on?
Chemo + radiation therapy
Surgery - orchiectomy
* Depend on type of testicular cancer, if mets occured
Screening recommended for testicular cancer?
USPSTF + AHRQ DO NOT RECOMMEND screening d/t potential harms + likelihood of finding malignancy
- Can do self-exams Q2mos in shower
Take home messages for testicular cancer
- 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
Testicular Cancer DX chart
Causes of scrotal masses Overview
Erectile Dysfunction
Definition
- 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
Causes of ED
- 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
ED a precursor marker for CVD?
YES
ED Clinical manifestations
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
Always ask about ED if…
Main Risk factors
- Men > 50
- RFs of ED (DM, HTN, CVD, MS, depression, anxiety, smoking, drug or EtOH abuse, or sedentary lifestyle)
- Taking meds affecting ED
ED objective findings
- 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
ED Diagnostics
- 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
ED 1st line treatment
- 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
ED 2nd line treatment
- 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
ED Risk Factors
chart
ED follow-up
- 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
When to consider referral for ED
- 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
Prostate Function
produce the fluid that nourishes and transports sperm (seminal fluid).
Prostatitis types
- 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
Most common causes of prostatitis
- Ascending UTI; reflux of infected urine; extension of rectal infxn
- E. coli
Bacgerial Prostatitis Urinary + Systemic symptoms
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
Prostatitis clinical manifestations
Chills, Nausea, Urinary frequency + hesitancy
Prostatitis Objective Findings
- 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
Acute Bacterial Prostatitis Objective Findings
What NOT to do?
- Signs of sepsis (↑ HR + HoTN)
- Distended bladder
- DRE: Warm, tender, boggy, enlarged prostate
- DO NOT MASSAGE!!
Prostatitis Differentials
- BPH
- Neurogenic bladder
- Pyelonephritis
- Renal calculi
- Prostate abscess
Prostatitis Diagnostics
-
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
Acute and Chronic Bacterial Prostatitis Pharm treatment
Important to check for these meds?
- 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
Prostatitis Nonpharm tx
- 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
Prognosis for…
Acute bacterial prostatitis
Chronic bacterial prostatitis
Pelvic pain syndrome
Acute: Cured by prompt abx tx
Chronic: Same, but therapeutic filaures/recurrence common
Pelvic: POOR PROGNOSIS - urology referral
Prostatitis complications
- Pyelonephritis
- Sepsis
- Prostatic abscess
- Chronic prostatitis – A/w STI
When to refer for prostatitis
Severe bact prostatitis
Not respondinig to initial tx
Pts w/obstructive sxs
BPH/Prostatic Hyperplasia, mLUTS, BOO
Definition
- ID histologically – cells
- BOO – Bladder outlet obstruction
- mLUTS (male lower urinary tract sxs) – irritative sxs
BOO, mLUTS clinical manifestations
- BOO
- Urinary hesitance
- ↓ caliber + force of stream
- Post-void dribbling
- mLUTS
- Urinary frequency
- Urgency
- Nocturia
BPH Irritative + Obstructive Symptoms
Irritative: FUN
- Frequency
- Urgency
- Nocturia
Obstructive: WISE
- Weak stream,
- Intermittent flow,
- Straining to urinate,
- Incomplete Emptying
BPH Objective findings
Not incl. concerning findings
- 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
BPH Concerning findings
- Abnormal sphincter tone – neurogenic bladder
- Fever – Prostatitis
- Hematuria – Bladder Cancer
- Prostate nodule or induration – Prostate Cancer
- Tenderness – Prostatitis
AUA Symptom Index determining UT symptoms severity
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
Differential Characteristics of Psychogenic vs. Organic ED
BPH Diagnostics
UA for all men presenting w/LUTS; likely only test
Helps r/o bladder cancer, bladder stones, UTI, urethral strictures
When to get Serum PSA for BPH
- 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)
Meds that aggravate mLUTS
- Anticholinergics incl. Diphenhydramine (Benadryl) Antihistamines
- Decongestants
- Diuretics incl. HCTZ, furosemide
- Opiates
- TCAs
If AUA score mild (0-7) - what treatment?
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
If can’t tolerate alpha blockers, what to try for BPH?
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
Treatment for mild BPH sxs + scoring < 7 (no med)
monitor + annual monitoring
When to refer for BPH
- 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
RED FLAGS BPH
- 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
Prostate Cancer
Definition; risk of dying
- 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%
Prostate Cancer
Clinical Manifestations
Early, Later
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
Prostate Cancer Objective Findings
- Early on, exam normal
- Firm nodule
- Induration
- Stony, asymmetric prostate
Prostate Cancer
Differentials
- BPH
- Prostatitis
- UTI
- Prostate Calculi
- Bladder Outlet Obstruction
Prostate Cancer Diagnostics
- 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)
What if the DRE or PSA is abnormal (prostate cancer diagnostic)
- 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
Gleason Grading Scale for prostate cancer
- 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
Initial Staging of Prostate Cancer includes:
(TNM system)
TNM: Tumor, regional node, metastasis system
* PSA level
* DRE findings
* TR U/S
* Gleason score
Localize Prostate Cancer Risk Stratification + Treatment Recommendations (MIGHT NOT BE ON TEST)
Prostate Cancer Treatment:
Localized approach
- Watchful waiting
- Active surveillance
- Radical prostatectomy
- External bean radiation therapy
- Brachytherapy
Prostate Cancer Treatment: Locally Advanced
- Androgen deprivation
- Radiation therapy
Prostate Cancer Treatment: Advanced/Metastatic
- Complete androgen ablation
- Antiandrogens (inhibit binding of androgen to receptor)
- LHRH agonists (chemical castration)
- Chemo w/Docetaxel – inhibits cell division
- Orchiectomy (surgical castration)
Prostate Cancer Risk Factors
- 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
Prostate Cancer Treatment Complications
- 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
PSA screening Controversy
- 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
Carlsson and Vickers: Key Practice Points for PCPs
- Get consent for prostate cancer screening, preferably using the “Simple Schema” decision aid.
- PSA screening is only for healthy men aged 45 to 70.
- Tailor screening frequency based on PSA level and cease screening for men older than 60 unless PSA is higher than median (1 ng/mL).
- For men with elevated PSA (3 ng/mL), repeat PSA.
- Use secondary tests, such as marker or imaging before biopsy, or only refer to urologists who do so.
- Only refer to urologists who recommend active surveillance to almost all patients with low grade cancer.
- Preferably refer to urologists at major academic centers.
Using SDM tool (6steps)
- 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
Simple Schema Part 1: Key facts about prostate cancer and screening
Simple Schema Part 2: Key take-home messages
Simple Schema Part 3: Discrete Decision
Challenges implementing SDM for PCP
- Lack of tools
- Shortage of time
- Challenge of integrating into clinical pathways
- More demanding to practice SDM than to recommend a treatment
