Men's Health Flashcards
UTI in men
Dysuria is the most frequent chief complaint in men with UTI. The combination of dysuria, urinary frequency, and urinary urgency is about 75% predictive for UTI. Fever, CVA tenderness, discharge and a urine sample. Consider blood cultures as endocarditis can occur.
Causes of adult male UTIs include prostatitis, epididymitis, orchitis, pyelonephritis, cystitis, urethritis, and urinary catheters. In young males, a UTI is usually a structural problem so refer to urology.
Admit any toxic appearing patient for IV Fluoroquinolone or third generation cephalosporin should be used. For milder or outpatient, bactrim or augmentin may be used.
Varicocele
abnormal dilation of the pampiniform plexus and spermatic veins in the spermatic cord and scrotum. Can cause infertility during growth.
Develop slowly, usually painless. Majority are left sided or bilateral. Right sided raises concern for underlying pathology.
Bluish color shows through the scrotal skin; when the patient stands, palpation of the soft mass reveals a “bag of worms” on the proximal spermatic cord or described that way by patient.
Surgical intervention needed if volume difference of 20% or more along with abnormal semen analysis.
Epididymitis
acute or chronic inflammation of the epididymis and is the most common cause of acute scrotal pain in men, with the majority of cases occurring at ages 14 to 35
Low grade fever, chills, heavy sensation in scrotum along with intense pain (less common blood in semen, discharge). Scrotum is often red, tender.
Elevating the scrotum partly relieves the pain (Phren sign) and presence of Cremaster Reflex intact.
Do a urine and CBC, consider STI screening.
IM Ceftriaxone and doxycycline for 10 days (younger than 35). older men use levofloxacin or ciprofloxacin for 10+ days. Antipyretics and antiemetics as needed with bed rest.
Orchitis
System infection and inflammation in testicles that may coexist with prostatitis or epididiyfitis from systemic viral or STI.
The patient may report a gradual onset of acute or moderate pain, testicular swelling, and fever; he may have a concomitant hydrocele and scrotal wall thickening
As with epididymitis, testicular edema may be so pronounced that it is difficult to distinguish the testes from the epididymis. Palpation may reveal swollen, very tense testes that are painful, and the patient may be febrile. Inflammation of the testis usually involves systemic viral infections (commonly mumps)
Do a urine and CBC, consider STI screening.
IM Ceftriaxone and doxycycline for 10 days (younger than 35). older men use levofloxacin or ciprofloxacin for 10+ days. Antipyretics and antiemetics as needed with bed rest.
Spermatocele
Benign, painless sperm-filled cyst of the epididymis from an obstruction of the efferent duct. Commonly occur after vasectomies.
Painless, cystic mass separate from testis and usually superior or inferior to it. Generally moveable, firm, painless with distinct border. Cn be transilluminated.
No treatment needed unless discomfort due to increasing size.
Hydrocele
Most common cause of painless scrotal swelling. Accumulation of fluid within the tunica vaginalis surrounding the testicle; it may also result from a patent processus vaginalis at birth and sometimes closes spontaneously within the first 1 to 2 years of life
Usually a painless presentation that is present for long period, may resolve and recur. May be result of trauma, hernia, torsion, or complication of epididymitis. Sometimes it may occur due to a tumor.
Palpation reveals a painless mass that appears easily on transillumination (a hematocele will not). The hydrocele may fluctuate in size and is identified by a smooth, tense scrotal mass.A hydrocele that is noted in men older than 30 years can be secondary to a testicular tumor
Treatment is watchful waiting as most resolve in newborns by one year.
Testicular Torsion
Torsion is an obstruction of blood flow to the testes because of a twisting of the arteries and veins in the spermatic cord, occurs most often in 12-18 years of age.
Sudden onset of extreme pain, abd pain, N/V, testicle rides high, and absent cremasteric reflex are highly suggestive. The spermatic cord is highly tender and swollen.
Urgent surgical referral, 6 hours or less.
Torsion of the appendix testis
An appendage (appendix testis) on the testicles that is vestigial tissue may twist, making it difficult to distinguish from a testicular torsion
a small area of cyanosis (blue dot sign) may be present on the scrotal skin and indicates torsion of the appendix testis
Usually self-limiting but rest, ice, NSAIDs, and scrotal support. Surgical referral may be needed.
Trauma to testes
Trauma to the scrotum and testicles results in 4% to 8% of testicular torsions and it should be included in the differentials of any scrotal trauma. Trauma to scrotum often results in hydrocele / hematocele.
If all scrotal contents are intact, trauma injuries can be treated symptomatically with ice, elevation, scrotal support, and bed rest. However, if there is concern that the testicle has been ruptured or penetrated, or if other contents are not palpated as intact, immediate surgical exploration and intervention should be undertaken.
Scrotal-inguinal hernia
A scrotal-inguinal hernia results when a segment of the bowel slips through the internal inguinal ring, where it may remain in the inguinal canal or pass into the scrotal sac. An inguinal hernia may occur as a result of a defect in the anterior abdominal wall or because of a patent process vaginalis
When a hernia becomes strangulated or is uneducable, this compromises the blood supply and requires emergent surgical reduction
Scrotal swelling, mild to moderate pain on straining, scrotal heaviness, and the possible presence of a bulge are common complaints. The edema is increased after standing in an erect position but decreases when the patient is recumbent. Easily identified on ultrasound.
If herniated bowel is reducible, surgical referral for possible future repair is indicated. Difficulty in reducing a hernia is cause for urgent surgical intervention. However, pain may indicate incarceration of the bowel or complete inability to reduce the hernia, which is cause for immediate emergency department referral and surgical exploration.
Testicular tumor
most common symptom or finding associated with a testicular tumor is a palpable mass that is often accompanied by edema or a sensation of fullness or heaviness in the scrotum.
Inquiry should focus on previous trauma to the scrotum or perineal area and the history or presence of cryptorchidism, pain, swelling, or sensations in the scrotum. The physical examination should include inspection and palpation of the abdomen, perineal area, scrotal sac, testes, and surrounding lymph nodes. Palpation should be performed with both hands to assist in differentiating between a mass located on the body of the testicle and a mass located on or within the epididymis
Any solid firm mass on the testicle body needs prompt referral to specialist is needed for identification and staging. Many tumors are misdiagnosed, consider ultrasound or transillumination.
Testicular Cancer stats
Testicular cancer occurs most often at ages 20 to 39 years and is the most common form of cancer in men aged 15 to 34 years, although these tumors have also been reported in infants and in older men
White males are at higher risk and undescended testes have 17% higher risk.
Elephatiasis
massive scrotal lymphedema, thickened scrotal skin, and, in severe cases, skin ulcerations. a filariasis (parasitic disease) that affects the scrotum, causing massive scrotal lymphedema.
If suspected, refer to infectious disease.
Undescended Testes
Diagnosis should be made by three months of age with repair between 6 months and one year of age.
Prostate cancer stats
Other than skin cancer, cancer of the prostate is the most common malignant neoplasm in men in the United States and the second leading cause of cancer death in men of all races
most common type of prostate cancer is adenocarcinoma
Prostate cancer symptoms
Presenting symptoms of prostate cancer may include urinary hesitancy, urgency, nocturia, frequency, and hematuria, although the patient is usually asymptomatic in early stages of the disease. Symptoms tend to increase in intensity during a 1- to 2-month period.
A firm nodule on rectal examination, induration, or a stony, asymmetric prostate is suggestive of prostate cancer. In early-stage disease, the findings on prostate examination will generally be normal.
Prostate cancer screening recommendations
Measurement of the PSA level combined with DRE if elevated is considered the most sensitive and specific screening method for prostate cancer. Some controversy exists regarding initial PSA screening and interval testing.
PSA > 4 with abnormal DRE finding, refer for biopsy. Note that ejaculation within 48-72 hours of testing can cause a false elevation in PSA.
PSA screening is not recommended for men younger than age 40 years. Routine screening is not recommended for men aged 40 to 54 years who have average risk. For patients younger than 55 years with higher risk, providers should individualize decisions for prostate screening. A shared decision-making approach to prostate cancer screening for men 55 to 69 years should be implemented. The greatest benefit of PSA screening is evidenced for men 55 to 69 years
DRE findings
n both BPH and prostatitis, there may be an abnormal DRE finding and/or PSA test result. In BPH, the prostate typically feels rubbery with no palpable nodules on DRE. In prostatitis, the DRE will usually reveal a tender, boggy prostate. in prostrate cancer it may have nodules, asymmetric, or stony.
Normal prostate gland is 4x3x2 cm
BPH Manifestations
Men with BPH can also have bladder outlet obstruction (BOO), lower urinary tract symptoms (LUTS), or a combination of these problems. Hematuria is uncommon.
The size of enlarged prostate does not correlate to symptom severity. BPH is not a risk factor for rectal cancer.
BOO and LUTS
Bladder Outlet Obstruction - urinary hesitancy, decreased caliber and force of stream, post-void dribbling
Lower Urinary Tract Symptoms - frequency, urgency, nocturia, voiding disturbances
BPH Meds
Terazosin and doxazosin need to be initiated at bedtime to reduce dizziness and postural effects. They are good if patient also has HTN.
Tamsulosin (Flomax) is a sulfa drug.
finasteride and dutasteride are 5A-reductase inhibitors and can cause sexual side effects and gynecomastia.
BPH treatment
Watchful waiting with lifestyle modifications.
Alpha antagonists relax smooth muscle in bladder neck, prostate capsule, urethra.
5-A-reductase inhibitors shrink the prostate but can take 6+ months for symptom effect. Combo medications can also be used.
PDE-5 inhibitors can be used if erectile dysfunction also exists.
TURP or balloon dilation if medications do not work.
Prostatitis
Prostatitis, or inflammation of the prostate gland, is a common problem in the adult male population. Bacterial prostatitis (both acute and chronic) is caused by bacterial inflammation.
Fever, chills, malaise, myalgias, and arthralgias are common with acute bacterial prostatitis. Genitourinary symptoms include hesitancy, frequency, urgency, nocturia, dysuria, and a sensation of incomplete bladder emptying. PSA levels may be falsely elevated.
The prostate may be enlarged or boggy. Urine findings in acute include pyuria, bacteruira and hematuria. In chronic, it may be normal.
Inpatient treatment requires IV fluroquinolones. Outpatient may be managed with bactrim or fluroquinolones for 3 weeks. Other antibiotics do not penetrate the prostate epithelium.
ALWAYS RULE OUT STI FIRST! IF STI PRESENT THEN TREAT THAT
Testosterone deficiency
Hypogonadism may be primary, secondary or mixed. Primary hypogonadism results from problems in the testes themselves, which causes primary testicular failure. This is associated with low testosterone levels, impaired sperm production and elevated FSH & LH levels. Secondary hypogonadism results from central defects of the hypothalamus or pituitary gland, which causes secondary testicular failure.
Obesity, unhealthy diet, lack of exercise are risks
Insomnia, impaired cognition, fatigue, reduced vitality, low libido, reduction in erections, reduced muscle mass are symptoms
Long term effects include decreased bone density, muscle loss, impaired mood and cognition, CV disease risk, poor quality of life
Proven testosterone deficiency requires testosterone replacement, either with daily testosterone gel or long-acting testosterone injections every 3 months. The therapeutic goal is to achieve and maintain serum testosterone levels in the low to middle normal range
