Men's Health Flashcards
What is priapism
Prolonged and painful erection for several hours that is not associated with sexual stimulation or desire
The 2 types of priapism are
Ischemic and non-ischemic
What are causes of priapism
- idiopathic
- medications (ie. intracavernosal injections, medications for ED)
- Cocaine
- Quadrapelgia
Does sickle cell increase or decrease risk for priapism
Increase
What is paraphimosis?
-When the foreskin cannot be returned back to iuts original position because of swelling of the head (glans) of the penis
What are sx of paraphimosis
-Red, swollen and painful glans of the penis
Who is at highest risk of paraphimosis
Uncircumcised infants and toddlers
What is the management of paraphimosis
- Refer to ED
- Requires a small slit in the foreskin to relieve pressure or circumcision
- Is a urological emergency
What are sx of testicular cancer
- nodule in the testicle
- sensation of heaviness or aching
- one larger testicle
- tenderness in the testicle
- new onset hydrocele (from tumor pressing on vessels)
- Affected testicle feels heavier and more solid
At what tanner stage does sperm production begin?
Tanner stage IV
Where are sperm produced?
seminiferous tubules of the testes
What is fournier’s gangrene
-rare, rapid progressing polymicrobial necrotizing fasciitis of the external genitalia and perineum
What are risk factors for fournier’s gangrene
- DM
- Trauma to the urethral/penile area
- Use of SGLT2i
What are sx of fournier’s gangrene
-acute severe pain
-redness
-swelling
of perineum
What are sx of testicular torsion?
- abrupt onset of extremely painful and swollen red scrotum
- acute hydrocele
- inguinal pain
- lower abdominal pain
- nausea
- vomiting
- affected testicle sits higher and closer to the body
- blue dot sign
- absent cremasteric reflex
Cryptorchidism increases patient’s risk for
Testicular cancer
Spermatogenesis is stimulated by the following 2 hormones:
Testosterone and follicle stimulating hormone
What is the function of the epididymis
Storage of immature sperm cells
What is the cremasteric reflex
Testicle is elevated towards the body in response to stroking or lightly pinching the ipsilateral inner thigh (thigh that is on the same side as the testicle)
What is the role of transillumination of the scrotum
-useful for evaluating undescended testicles, hydrocele, spermatocele and other scrotal masses
Which will not transilluminate?
a) Hydrocele
b) Variocele
c) Spermatocele
d) Tumors
Varicocele, and tumors
What is the most common tumor in males age 15-30
Testicular
What is the gold standard diagnosis for testicular cancer?
Testicular biopsy
Regarding testicular torsion, permanent testicular damage results if not corrected in ____ hours and the testicle will need to be surgically removed if not corrected in ____ hours
<6 hours and 24 hours
What is the most common cancer in Men?
Prostate
What are risk factors for prostate cancer
- 50 years +
- Black
- Obesity
- 1st degree relative (2x the risk)
What is the current recommendation for Prostate cancer screening
Routine screening is not recommended as studies have shown that absolute risk reduction with screening is minimal
-individualize based on risk and discuss risk with testing (bleeding, infection, impotence, psychological trauma)
What are sx of prostate cancer
- Often asymptomatic
- Painless and hard fixed nodule or indurated area on the prostate gland on an older man that is deteceted by DRE
- frequent urination
- urinary hesitancy
- nocturia
- decreased force of urination
- incomplete emptying
- hematuria
- elevated PSA >4.0ng/mL
What is the diagnostic test for prostate cancer
biopsy via transurethral ultrasound
How should you management urinary symptoms of prostate cancer?
-alpha blockers (terazosin/hytrin)
What are questionnaires to assess the severity of a patient’s BPH sx
- American urological association urinary symptom score
- International prostate symptom score
What are sx of BPH
Gradual onset of urinary obstructive symptoms such as:
- weak stream
- post void driblling
- feelings of incomplete emptying
- urinary retention
- nocturia
PSA is elevated
Prostate is symmetrically enlarged on DRE
What are some lifestyle changes that may decrease symptoms of BPH
- reduce/eliminate caffeine and alcohol
- avoid fluids after dinner before bed
- avoid use of diuretics if possible
What are the first line medications for BPH
Alpha-adrenergic antagonists
- Tamsulosin (flomax)
- Terazosin (Hytrin)
- Doxazosin (cardura)
What medications should be avoided in patients with BPH
- anticholinergics
- sympathomimetics (cause urinary retention)
Besides alpha-adrenergic antagonists, what are medications including herbal remedies can be used in BPH
1) 5-alpha-reductase inhibitors: FInasteride (proscar)
2) Saw-palmetto
What is an adverse effect of alpha blockers
orthostatic hypotension
While on Proscar (Finasteride) the prostate shrinks by ___ %, so in obtaining a PSA on a patient you must ____ the result
50%, double
In a male patient with BPH and hypertension what medication can you consider to help both conditions
Hytrin
What happens to the prostate gland when you stop taking finasteride (proscar)
-Proscar inhibits type 2 5-alpha-reductase (blocks androgen receptor) and acts directly on the prostate gland to shrink it temporally when on the medication, if a patient stops taking the medication the prostate will return to its original size
Proscar is a category ___ drug. Can it be handled by reproductive aged females?
X; NO Teratogenic and adversely affect male fetus
What is chronic bacterial prostatitis
Chronic >6 week infection of the prostate gland
Causes of chronic bacterial prostatitis
E.Coli and Proteus
What are sx of chronic bacterial prostatits
> 6 week history of suprapubic or perineal discomfort accompanied by irritative voiding symptoms:
- dysuria
- nocturia
- frequency
Prostate may feel normal or boggy; non tender
- Not systemically ill
- may be asymptomatic
What is the treatment of chronic prostatitis?
Ciprofloxacin 500mg PO BID x 4 weeks
Alternatively
Bactrim 1 tab PO BID x 1-3 months
Refer to urology
What is acute prostatitis
Acute infection of the prostate
What are the sx of acute prostatitis
Sudden onset:
- fever
- chills
- suprapubic/perineal pain
- radiation of pain to back or rectum
- urinary symptoms: Frequency, dysuria, nocturia
- DRE: Prostate boggy and tender and warm
- cloudy urine
- pain with bowel movements
What lab tests should you order for prostatitis
CBC, UA, C&S
What are expected findings of labs when a patient has acute prostatitis?
- CBC: Leukocytosis with left shift
- UA: Large amounts of WBC, hematuria
- Urine C&S
What is the medical treatment for acute prostatitis
If <35 or high risk for STI: Ceftriaxone 250mg IM and Doxycycline 100mg BID x 10 days
If >35 years or unlikely STI: Ciprofloxacin/Ofloxacin PO BID or Levofloxacin daily x 10-14 days, or up to 6 weeks
What SSRI has the highest risk of erectile dysfunction?
Paxil
What is the difference between acute and chronic prostatitis?
- Acute is sudden where chronic is gradual
- DRE: Acute= painful, warm, boggy; Chronic= often normal
- Labs: Acute will show changes in CBC, UA where chronic will be likely normal
What is acute bacterial Epididymitis
-infection where bacterial ascends into urethra and reaches the epididymis
What is the likely causes of acute bacterial epididymitis
Noninfectious is the most common:
- Prolonged sitting
- Underlying congenital defect
Infectious
- Chlamydia
- Gonorrhea
What are the sx of acute bacterial epididymitis
- acute onset of a swollen red scrotum that hurts
- Prehn’s sign: Relief of pain with scrotal elevation
- Unilateral testicular tenderness with urethral discharge
- induration of the posterior epididymis
- May have hydrocele
- systemic symptoms like fever
What is Prehn’s sign
Relief of pain with scrotal elevation
What lab tests should you order in suspected acute bacterial epididymitis?
CBC- leukocytosis
UA- Leuks, blood, nitrites
C&S
Urine NAAT chlamydia and gonorrhea
What is the treatment for acute bacterial epididymitis?
If <35 or high risk for STI: Ceftriaxone 250mg IM and Doxycycline 100mg BID x 10 days
If >35 years or unlikely STI: Ofloxacin PO BID or Levofloxacin daily x 10-14 days
Non-infectious think: fluids
What caution should you provide to a patient taking a fluoroquinolone?
Risk of achilles tendon rupture, advise against intense lower extremity activity
What are the causes of erectile dysfunction
Organic
Drug induced
Psychogenic
Reduced libido
What are organic causes of ED
- Aging
- neurological (DM, MS, spinal cord injury)
- Vascular
- Hormonal (Hypogonadism)
What are medication causes of ED
- SSRI esp Paxil
- antipsychotics
- recreational drugs
- ETOH
- Beta blockers
- Thiazides
- smoking
What would make you think the cause of ED is psychogenic
- If pt reports sponatenous early morning erection or normal nocturnal tumescence or can achieve erection with masturbation
- often r/t anxiety, depression, relationship issues, stress
What strategies can help pain management with acute bacterial epididymitis?
- Scrotal elevation
- ice packs
- scrotal rest
- NSAIDs
What labs do you want to check in a pt complaining of ED
- Check for DM (A1C, FBG)
- TSH
- Morning serum testosterone
What is first-line medications for ED
phosphodiesterase type 5
-Sildenafil (Viagra), Tadalafil (Cialsis)
What education should you provide patients regarding administration of Viagra
- Take 1 dose 30-60 minutes before sex; duration of 4 hours; use only 1 dose in 24 hours
- take on empty stomach
- avoid fatty foods for ptimal effectiveness
What are side effects, warnings of CI of viagra
- Caution use with alpha blockers, hx of MI in past 6 months, unstable angina: High risk for hypotension
- Do not use with meds that prolong QT interval (ie. macrolides)
- Can decrease blood to optic nerve causing sudden vision loss
What is the education you provide patients regarding administration of cialis
can be taken several hours before sex due to long duration (lasts up to 36 hours)
Aside from ED what can cialis also be useful for?
BPH
What are CI of ED treatments?
- Concomittant nitrates
- Use of alpha blockers
- Post MI
- Post CVA
- Major surgery
- Avoid combination with grapefruit juice or ETOH
What are AE of ED treatments
- Headache
- Flushing
- Dizziness
- Hypotension
- Nasal congestion
- Priapism
- Visual changes
What is peyronie’s disease?
an inflammatory and localized disorder of the penis that results in fibrotic plaques on the tunica albuginea
What are sx of peyronie’s disease? And what is the managment
- penile pain with erection
- palpable nodules and penil deformity
- 1/2 will spontaneously resolve
- 1/2 will require surgery
What is balanitis
A candidal infection of the glans penis
What are risk factors for balanitis
- Uncircumcised men
- DM
- Immunocompromised states
- Use of SGLT2i
What are sx of balantis
- redness
- pain
- tenderness
- pruritis of the glans
develops over 3-7 days
-exam shows: redness, shallow ulcers with curd-like discharge on the glans
What is the tx of balantis
OTC topical azole creams like clotrimazole 1% or miconazole 2% BID x 7-14 days
What is cryptorchidim
Testicle that does not descend spontaneously by 4 months of age
When will the majority of male testicles descend by
12 months
What is a varicocele
Varicose veins in the scrotal sac
What may a unilateral right-sided varicocele indicate?
A tumor inside the chest, abdomen or pelvis that is compressing a large vein
When in the supine position a benign varicocele should ____ while a pathological varicocele will
Drain; while pathological varicoceles will not drain
What feels like a bag of worms in the scrotal sac
A varicocele
What is a hydrocele
A collection of serous fluid inside the tunica vaginalis
Do varicoceles affect fertility
They can if large enough as they can increase temperature in the scrotum
What is a spermatocele
A fluid filled cyst that contains nonviable sperm
Do spermatoceles affect fertility
NO
What is the imaging of choice with suspected hydroceles, varicoceles or spermatocele
Ultrasound
A 13-year-old male is brought to an outpatient clinic by his father with a c/o sudden onset severe left testicular pain. The pt is nauseated, has vomited. On exam, he has a red, swollen, and tender left scrotum. Absent cremasteric reflex. The abdomen is soft with no rebound or local tenderness, + bowel sounds. Which of the following is recommended?
a) Recommend increased fluids and the BRAT diet
b) Order an ultrasound of the left scrotum
c) Refer to urology
d) Refer to ED
D) Refer to ED
Which of the following is a possible effect of the mumps virus, which can affect male fertility?
a) Salivary gland inflammation
b) Cryptorchidism
c) Orchitis
d) Prostatitis
C) Orchitis
What is the most common cause of balanitis?
a) Pseudomonas
b) Candida albicans
c) Bacteria
d) Virus
b) Candida albicans
A 37-year-old male complains of swelling on the right scrotum that is mildly tender for a few weeks, there is a pressure-like sensation, the right is larger than the left scrotum. Which of the following test is appropriate for this patient
a) Transillumination
b) CBC with diff
c) Ultrasound
d) UA
a) Transillumination
Which of the following meds increased ED
a) Amox
b) Paroxetine
c) Levothyroxine
d) Aspirin
b) Paroxetine
What is the most common clinical manifestation of BPH
Lower urinary tract symptoms:
- weakened stream
- hesitancy
- post-void dribble
- incomplete emptying
- incontinence
- urinary retention
- frequency, urgency, nocturia
- painless hematuria
How is the BPH prostate described
firm, smooth and symmetrically enlarged
Mr. B is 78 years old and is having LUTS. What findings would make you suspect prostate malignancy instead of BPH?
(Select all that apply)
- Urinary retention
- Nodular Prostate gland
- Asymmetrical enlargement
- Hematuria
- Elevated PSA
- Bacteria in urine
- Nodular Prostate gland
3. Asymmetrical enlargement
Mr. B has been dx with symptomatic BPH. His PSA is elevated at 4.0. What can cause a clinically significant elevation in PSA?
1) Ejaculation
2) DRE
3) Cycling
4) Exercise
5) Enlarged prostate gland
1) Ejaculation
3) Cycling
5) Enlarged Prostate gland
Education for pt taking Flomax
- take at bedtime
- watch for lightheadedness
An enlarged boggy warm and tender prostate signifies
Acute Prostatitis
30 year old has suspected acute prostatits. What labs should NOT be part of the initial evaluation?
- PSA
- UA
- C&S
- urethral Swab
- PSA bc it will be elevated r/t to inflammation
Why should gentle prostate exam be performed in setting of likely bacterial prostatitis? Select all that apply
- May cause penile burning
- Increases risk of bacteremia
- Increases risk of UTI
- Increases risk of prosatic abscess
- Its painful
- Increases risk of bacteremia
5. Its painful
An asymmetric, induration, nodularity of a prostate gland is suspicious for prostate cancer
Prostate cancer
If you have a PSA of >4 in a symptomatic male what should you do?
Refer to urology
A 26-year-old male has acute scrotal pain and presents to the clinic. He is diagnosed with epididymitis what is a likely finding?
- He has a hernia
- He has a positive cremasteric reflex
- He has a swollen tender scrotum
- He is running a fever
- He has a + cremasteric reflex (also means he does not have a torsion)
How is an inguinal hernia most commonly diagnosed
Physical exam
What is the only treatment for a hernia
Surgery
