Male problems Flashcards by Cathy Wang

What is benign prostate hyperplasia

Common benign condition in men caused by hyperplasia of the stromal and epithelial cells of the prostate

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Benign prostate hyperplasia most commonly affect

older men, 40-80 years olds
Black ethnicity

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Symptoms of benign prostate hyperplasia

Nocturia (most common early symptom)
Hesitation in initiating urination
Reduced force of urination
Retention of urine
Incontinence (overflow, urgency incontinence)
Post-urination dribbling

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Because BPH causes bladder outflow obstruction, it can also lead to

Recurrent UTI
Impaired renal function
Haematuria

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What score is used to classify the symptoms of BPH

IPSS (International prostate symptoms score)

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Investigations for BPH

Urine dipstick
U+E
PSA (prostate specific antigen)
Rectal exam
US pelvis with post-void bladder volume - see extent of obstruction
Urinary frequency-volume chart

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What conditions can raise PSA

Prostate cancer
BPH
Prostatitis
Ejaculation

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What would the rectal exam for benign prostate hyperplasia be like

Smooth, symmetrical prostate enlargement

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Management of benign prostatic hyperplasia

Reassurance and monitor
If IPSS >8
- alpha-1 antagonists (tamsulosin, alfuzosin)
If significantly enlarged prostate
- 5 alpha-reductase inhibitors (finasteride)

Alpha-1 antagonist + 5 alpha-reductase inhibitor if moderate-severe voiding symptoms + prostatic enlargement

Surgery If needed

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Examples of alpha-1 antagonists

Tamsulosin
Alfuzosin

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Function of alpha-1 antagonists in managing BPH

Promotes relaxation of the smooth muscle of the prostate and bladder to reduce voiding symptoms

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Side effects of alpha-1 antagonists

Dizziness
Postural hypotension
Dry mouth
Depression

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Function of 5-alpha reductase inhibitors

Blocks the conversion of testosterone to di-hydrotestosterone to REDUCE the size of the prostate

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Does alpha-1antagonists reduce the size of the prostate

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Why is it helpful to block the production of di-hydrotestosterone in managing BPH

Because di-hydrotestosterone induces growth of prostate

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Example of 5-alpha reductase inhibitors

Finasteride

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Does finasteride (5-alpha reductase inhibitor) work immediately

No, it takes around 6 months to see improvement

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Side effects of 5-alpha reductase inhibitors

Erectile dysfunction
Reduced libido
Ejaculation problems
Gynaecomastia

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When are 5-alpha reductase inhibitors indicated

If there is significant enlargement of the prostate

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What is the name of surgery for BPH

Transurethral resection of the prostate (TURP)

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Which form of malignancy is prostate cancer part of

Adenocarcinoma

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Prostate cancer mostly affects

> 40 years olds

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Risk factors of prostate cancer

Increasing age
Afro-Carribean ethnicity
Obesity
Family history
Cadmium batteries

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Is BPH a pre-malignant condition of prostate cancer

No, it does not increase the risk of prostate cancer. Both can occur in a patient at the same time

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What are the 3 zones of the prostate

Central zone Peripheral zone Transitional zone

Where is the central zone located at

Surrounds the ejaculatory ducts

Where is the transitional zone located at

Surrounds the prostatic urethra

Where is the peripheral zone located at

Posterolaterally

Prostate cancer most commonly arise from

Peripheral zone

What condition most commonly occurs in the transitional zone

BPH

Symptoms of prostate cancer

Asymptomatic at early stage Late stages - haematospermia - haematuria - obstruction - urinary hesitancy, reduced flow - bone pain (metastasis) - weight loss, fatigue, anorexia

Why is prostate cancer usually asymptomatic at early stages

Because it occurs at the peripheral zone so it is unlikely to cause obstructive symptoms early on

Prostate cancer usually metastasises to

Bones and lymph nodes

Investigations for prostate cancer

Multiparametric MRI (replaced transrectal ultrasound guided biopsy) Bloods - PSA PR exam Bone scan

What may PR exam show in prostate cancer

Enlarged, hard, irregular, asymmetrical prostate

What is the scoring used for the results of multi parametric MRI

Likert scale

If Likert scale is >/3, you should

Offer a multi-parametric MRI influenced prostate biopsy

Management of prostate cancer

If early (T1, T2) - Observation and follow ups if late - anti-androgen therapy - radical prostatectomy - radiotherapy If metastatic - anti-androgen therapy

What is a common side effect of radical prostatectomy

Erectile dysfunction

Radiotherapy may increase the risk of

Bladder, colon and rectal cancer following radiotherapy for prostate cancer

What are the agents in hormonal therapy used for prostate cancer

GnRH agonist - Goserelin Bicalutamide Cryproterone acetate Abiraterone

Bicalutamide is a

non-steroidal anti-androgen which blocks the androgen receptor

Cryproterone acetate is a

steroidal anti-androgen

Abiraterone is a

androgen synthesis inhibitor

Testicular cancer is the most common malignancy affecting

Men 20-30 years old Younger age group compared to prostate cancer

Risk factors of testicular cancer

Infertility Cryptorchidism FH White caucasians Klinefelter's syndrome

What is cryptorchidism

When one or both testicles fail to descend (undescended testicles)

Testicular cancer is usually a ____ cell tumour

Germ cell tumour

Testicular cancer can also be non-germ cell tumour. What are the non-germ cell tumours called

Leydig cell tumours Sarcomas

What are leydig cells

Cells in seminiferous tubules that produce testosterone

What are the types of germ cell tumours

Seminoma Teratoma Yolk sac tumour Choriocarcinoma Embryonic

What is seminoma

germ cell tumours that arise from seminiferous tubules

Which type of germ cell tumour is more common

Seminoma

Which types of germ cell tumours have worse prognosis

Teratoma Embryonal cell carcinoma These metastasise quicker

Describe the prognosis of seminoma

95% cure rate, very responsive to radiotherapy

Teratomas are rarely

Rarely occur on their own, usually associated with other non-seminomatous tumours

Describe the age groups commonly affected by seminoma and teratoma

Seminoma - >30 years old Teratoma - <30 years old

Symptoms of testicular cancer

Painless lump Hydrocele Gynaecomastia

What are the signs of advanced testicular cancer

Neck lumps Bone pain Abdominal mass

How does testicular cancer cause gynaecomastia

Due to increase in oestrogen:androgen ratio

What are the investigations for testicular cancer

Bloods - AFP - hCG - LDH US testicle (first line) CT chest, abdomen

Describe the presence of tumour markers in seminoma/non-seminoma testicular cancer

Seminoma - raised hCG in 20% but AFP is NOT RAISED Non-seminoma - raised hCG in 80% and raised AFP

Management of testicular cancer

Radical inguinal orchidectomy Re-check tumour markers 1 week post operation Chemotherapy post op

Risk factors of penile cancer

50-60 years old Asian, African HPV Smoking Phimosis causing chronic inflammation

What is phimosis

the inability to retract the foreskin of the penis causing inflammation due to poor hygiene

Most common form of penile cancer

Squamous cell carcinoma

investigation for penile cancer

biopsy

Management for penile cancer

if on foreskin - Circumcision If on glans (head) - glans resurfacing or glansectomy

What is hydrocele

Collection of fluid between the two layers (parietal and visceral) of the tunica vaginalis

Causes of hydrocele

Communicating: Patency of processus vaginalis -> peritoneal fluid drain down into the scrotum Non-communicating: Excessive fluid production

Communicating hydrocele is common in

newborn babies

Symptoms of hydrocele

Soft, smooth, non tender swelling around one of the testes Transilluminate with pen torch

Investigation for hydrocele

Usually clinical US if indicated

When is US indicated for hydrocele

In adult patients to exclude underlying malignancy (testicular cancer can cause hydrocele

Management of hydrocele

Communicating hydrocele in babies can resolve spontaneously within first few months If not -> surgical repair Non-communicating hydrocele usually resolve in 2 years

What is varicocele

abnormal enlargement of the testicular veins

What are the testicular veins called

Pampiniform plexus

Varicocele is more common on the left / right

Left

Why is varicocele more common on the left

Due to increased resistance to flow because left gondola vein needs to drain into the left renal vein first whereas the right drains straight into inferior vena cava