Male Reproductive Disorders & Surgeries Flashcards
Benign Prostatic Hyperplasia (BPH)
- non-inflammatory enlargement of prostate gland resulting from increase in # of epithelial cells and amount of stromal tissule
- MOST COMMON UROLOGICAL PROBLEM IN MALE ADULTS
- 1/2 men will experience BPH in their lifetime and 1/2 of these men with have lower UTI symptoms
-Occurs in nearly all men with functioning testes - research is unclear whether BPH predisposes men to the development of prostate cancer
Etiology of BPH
Hormonal changes with aging
Pathophysiology of BPH
- develops in inner part of prostate - cancer more likely to develop in outer part
- enlargement compresses urethra -> eventual partial or complete obstruction
- leads to development of clinical symptoms (LUTS - lower urinary tract symptoms)
- increased risk of UTI, compromised upper urinary tract function
- bladder initially amplifies strength of detrusor contraction -> initially successful -> eventually overwhelms detrusor ability -> decline in urinary stream, feelings of incomplete bladder emptying
- may have UTI and hematuria
Risk Factors BPH (5)
- aging
- physical inactivity
- diabetes
- obesity
- familial history in first-degree relative
Protective Factors BPH
- diet of fruit & veggies; lycopene (red pigment)
- physical activity
BPH Clinical Manifestations
Bothersome ‘ LUTS’ result from obstruction
Gradual onset: may not be noticed until enlargement has been present for some time. nocturia is often the presenting symptom
BPH: obstructive symptoms
- decrease in the calibre & force of urinary stream, hesitancy, intermittency, dribbling
BPH: Irritative Symptoms
Associated with inflammation or infection
- Urinary frequency, urgency, dysuria, bladder pain, nocturia, incontinence
BPH: Complications
- urinary retention, UTI & possible sepsis, calculi, renal failure
Diagnostics
- history and physical
- DRE
- PSA levels - not helpful diagnostically.
- Urinalysis with culture
- postvoid residual
- ultrasound
- cysto-urethroscopy
DRE - BPH
prostate should be evaluated for size, symmetry and consistency. in BPH - prostate is symmetrical, enlarged, firm and smooth
BPH Collaborative Care: Active Surveillance
“watchful waiting”
- dietary changes (decreasing caffeine & artificial sweeteners, limiting spicy or acidic foods)
- avoiding decongestants & anticholinergic medications (prevent bladder contraction)
- restricting evening fluid intake
- timed voiding schedule
BPH - Drug Therapy
- combination therapy most effect
- 5a-reductase inhibitors - inhibits conversion of testosterone into DHT in prostate gland. (dutasteride or finasteride)
- a-adrenergic receptor blockers - selectively relax smooth muscle of prostate, bladder neck & proximal urethra. Tamulosin. provide symptomatic reief
BPH - Invasive therapy
- when obstruction is severe, severe LUTS, recurrent UTI, hematuria, bladder stones, or upper urinary tract distress -> intermittent or indwelling catheter may temporarily relieve symptoms
- TURP (transurethral resection of the prostate) - GOLD STANDARD.
- Transurethral incision of the prostate (TUIP) moderate to severe symptoms & small prostates. done under local and as effective as TURP in symptom relief
- prostatectomy: surgery of choice for larger prostates. remove the entire prostate, seminal vesicles & part of bladder neck.
BPH - Minimally invasive Therapy
- Transurethral microwave thermotherapy (TUMT) - heat causes death of tissue
- Transurethral needle ablation (TUNA) - increases temperature & causes localized necrosis
- Laser prostatectomy - visual or U/S guidance
TURP
- GOLD STANDARD
- Done under spinal or general anesthetic
- associated with good outcomes in 90% of patients
- HOLD ASA or anticoagulants preop
- Pain and UTI are most common preop problems necessitating TURP
TURP: Preop Care
- Urinary drainage must be restored before surgery
- use of lidocaine jelly ++ helpful
- may require coude (curved tip) catheter
- antibiotics usually given before invasive procedures
- patient education on common alterations in sexual function is important - retrograde ejaculation not harmful but orgasms might be less pleasurable
TURP: Postop Care
- 4 main complications
Main complications:
- hemorrhage
- bladder spasms
- urinary incontinence
- Infection
Manage CBI - rate determined by colour of drainage. Goal is light pink with no clots. Small clots are expected for 24-36h, but bright red blood can indicate hemorrhage
Avoid activities that increase abdominal pressure (straining) -
Remove CBI 2-4 days postop: trial of void 6h after cath removal
Urinary dribbling/incontinence common intially; can usually improve with Kegel exercises over first 2 months postop
Dietary interventions/bowel protocol to avoid straining; adequate fluid intake
Prostate Cancer
- malignant tumour of prostate gland
- Androgen-dependent adenocarcinoma (overgrowth of cells in a gland) - after age of 50 men have increased DHT - potent form of testosterone that leads to development of prostate ca
- majority of tumours in outer aspect of prostate
- usually slow growing but progressive if left untreated
- can metastasize through direct extension, lymph system, or bloodstream
Prostate Cancer - Causes
- approx 1 in 7 men will be diagnosed with prostate cancer during their lifetime
- age
- ethnicity
- family
- diet
Prostate-Cancer Risk Factors
- > 50 years of age
- black>white>asian
- family history
- high levels of testosterone
- diet high in fats & low in vegetables & fruits
- occupational exposure to cadmium
- genetic link-mutations in luminal and basal cells of the prostate. also links to BRAC1 and BRAC2.
- Testosterone and DHT are essential to growth & development of prostate -> play important but poorly understood role in cancer development
Prevention of Prostate Cancer (3)
- Eat a wide variety of fruits & vegetables each day - consumption of tomatoes, tomato-based products, & garlic may protect against prostate cancer
- be physically active
- Maintain a healthy weight
Clinical Manifestations of Prostate Ca
Generally asymptomatic during early stages
Urinary symptoms may occur (similar to BPH)
- difficulty starting or stopping urination
- slow stream
- painful urination or ejaculation
- dribbling
- frequent urination
- loss of urinary control
- blood in urine or ejaculate
- night time voiding
Clinical Manifestations of Advanced Prostate Cancer
- weight loss
- fatigue
- backache or sciatica-like pain, or swelling of legs that doesn’t go away
Diagnosis of Prostate Ca
- DRE: gold standard. feels hard nodular and asymmetrical
- often diagnosed before symptoms occur
- PSA screening: NOT RECOMMENDED. not specific to cancer but when cancer exists it is useful marker of tumour volume.
- prostate biopsy required for diagnosis
- transluminal ultrasound if suspected
- Prostate Cancer Associated 3 (PCA3) is a gene in urine specific to prostate cancer
- After diagnosis: Bone scan, CT, MRI
PSA Screening
- No provincial screening program in BC - if screening is going to be done, men between the ages of 55 and 69 most benefit
- PSA is used for monitoring established prostate cancer & metastatic disease or detection of early recurrence, where prostate cancer is already known
- diagnostic adjunct in combination with other tests in symptomatic men
- PSA Screening NO LONGER RECOMMENDED
Diagnosis of Prostate Ca: Staging and Grading (3)
Whitmore-Jewett - stages A-D
TNM Classification System
- tumor: characteristics of the primary tumor
- nodes: involvement of lymph nodes
- Metastasis: evidence of spread
Gleason scale (2-10)
- grading of tumour based on histology
- provides an indication of the risk for spread
- based on how well-differentiated tumour cells appear on microscopic analysis: poorly differentiated cells are associated with more aggressive forms of cancer
Collaborative Care: Prostate Cancer
Watchful waiting - chemo is not standard.
Chemotherapy - not standard. treatment for those with hormone-resistant cancer in late-stage disease
Hormone therapy - block testosterone production to reduce tumour growth. selection or combination of bilateral orchiectomy, estrogens, gonadotropin-releasing hormone analogs, & anti-androgens
Radical prostatectomy - removal of entire prostate, seminal vesicles, part of bladder -> risk for ED & incontinence, catheter in place for 1-2 weeks
Cryotherapy - injection of liquid nitrogen that destroys cancer cells by freezing tissue. Risks: if not done carefully it can damage surrounding tissue
Treatment Side Effects Prostate Ca
Hormonal side-effects: hot flashes, muscle atrophy, loss of libido, ED, gynecomastia, cardiovascular disease
Specific surgical side effects: risk for incontinence or ‘dribbling’, risk for impotence
Chemotherapy an radiation therapy SE: depends on type of therapy, nausea, vomiting, fatigue, hair loss
Testicular Cancer
- Relatively rare
- 5 year survival rate
- Most common type of cancer in males age 15-29
- more common: in right testicle, in males with hx of undescended testes, in males with a family hx of testicular anomalies or cancer
Predisposing factors: HIV, orchitis, maternal exposure to synthetic estrogen (diethylstibestrol), testicular ca in contralateral testis
Testicular Cancer: clinical manifestations
- slow or rapid onset depending on type of tumor
- painless lump, scrotal swelling, and/or feeling of heaviness
- scrotal mass usually nontender and very firm
- sometimes concurrent lower abd/scrotal/perianal dull ache or heavy sensation
Diagnosis of Testicular Cancer
- palpation of firm mass
- ultrasound
- serum alpha-fetoprotein, LDH, and hCG, CBC/LFTs
- CXR and/or CT abdo/pelvis to detect metastases
Testicular Cancer: Collaborative Care
- early recognition: TSE from the age of 15
- fertility and sperm banking should be discussed preop, Tx can affect both erections and fertility
- surgery: orchiectomy or radical orchiectomy (removal or affected testis, spermatic cord, and regional lymph nodes)
- postop care: surveillance, chemotherapy/radiation
- 97% remission rates with early recognition
- treatment-related toxicity significant
Vasectomy
- Def’n: bilateral surgical ligation of the vas deferens for the purpose of sterilization
- 15-30 min in duration
- outpatient procedure under local anesthesia
- usually irreversible
- does NOT affect production of hormones nor ejaculation
- Not ‘reliable’ until 6 months postop: alternate forms of contraceptions should be used until verification occurs
