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Adult Clinical Medicine > Men's Health > Flashcards

Men's Health Flashcards

1
Q

Describe the location of the prostate

A
  • Below the bladder
  • Above the urogenital diaphragm
  • Behind the pubic symphysis
  • In front of the rectum
  • Around the urethra

*anterior disease is hard to detect w/ rectal exam

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2
Q

Describe the structure of the prostate

A
  • Stromal (fibromuscular) and glandular (epithelial) components
  • Three lobes (Left & Right, Median)
  • Surrounded by a capsule (expands inward and can compress the urethra)

*Produces seminal fluid

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3
Q

How do you estimate the weight/size of the prostate

A

20 g: 2 finger widths (normal prostate)
30 g: 3 finger widths
40 g: 3 finger widths ++
>40 g: bigger

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4
Q

What should you document a prostate DRE

A
  1. note size/estimate weight
  2. Texture: Firm, nodular, boggy
  3. Asymmetry
  4. Tenderness
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5
Q

Types of prostatitis

A
  1. Common inflammatory condition of the prostate gland
  2. Acute bacterial prostatitis (ABP)
  3. Chronic bacterial prostatitis (CBP)
  4. Nonbacterial prostatitis (NBP)/prostatodynia
  5. Other (rare) e.g. gonococcal prostatitis
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6
Q

Symptoms of ABP

A
  1. Fever and chills
  2. Malaise
  3. Perineal and low back pain
  4. Irritative voiding symptoms: burning, frequency, urgency, nocturia
  5. Obstructive voiding symptoms: difficulty initiating stream, retention

**ACUTELY ILL– needs to be taken seriously!

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7
Q

What is the most common cause of ABP and what is the tx

A
  • Ascending infection - gram negative rods (e. coli, klebsiella)
  • Uncommon, potentially serious
  • Treatment is generally with IV antibiotics
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8
Q

What are sx of CBP

A
  1. Generally less severe than ABP
  2. Some patients are asymptomatic
    May have some or all of the following:
  3. Irritative voiding symptoms: burning, frequency, urgency, nocturia
  4. Pelvic and/or perineal pain
  5. Postejaculatory pain (occasionally)
  6. Hematospermia (occasionally)

*Common, often persistent and frustrating

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9
Q

What is the most common type of prostatisis

A

NBP/prostatodynia

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10
Q

Describe the presentation of NBP/prostatodynia

A
  1. Typically afebrile
  2. No bacteria on culture, no response to antibiotics
  3. DRE can be normal or mildly tender
  4. Symptoms similar to CBP
  • *Undetermined cause
  • *Urinary tract disease must be excluded
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11
Q

Prostatitis DDX

A
  1. UTI
  2. BPH
  3. Prostate cancer
  4. Bladder cancer
  5. Urethral stricture
  6. Neurogenic bladder
  7. Interstitial cystitis
  8. Hernia
  9. Musculoskeletal
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12
Q

Describe the evaluation of prostatitis

A
  1. PE -attention to abdominal and genital exam, hernias
  2. DRE - prostate typically swollen and tender
  3. UA - pyuria (WBCs) usually seen in ABP
  4. Prostatic fluid culture via prostatic massage*
    - EPS (expressed prostatic secretions)

*Contraindicated in ABP

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13
Q

When is prostatic message contraindicated

A

in ABP

*high risk of urosepsis in elderly

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14
Q

how Do you dx NBP/prostatodynia

A
  • Need 2 rounds of abx (different classes) bc you need to exclude Urinary tract disease/bacterial process
  • often refer to urology
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15
Q

What is the tx of CBP

A
  1. FQ (cipro, levofloxacin)- Abx of choice!
  2. SMX-TMP-less effective but still an option

*tx for 4 weeks minimum

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16
Q

What is the tx of NBP

A
  1. NSAIDS*
  2. alpha– blockers (relax prostate and bladder neck)
  3. 5 alpha-reductase inhibitors – helpful if patient also has BPH
  4. Dietary restriction - avoidance of alcohol*, caffeine, pseudoephedrine, other irritants
  5. Sitz baths
  6. Prostatic massage
  7. Counseling
  8. Surgery (see BPH)
    OR…how about the Dila-Therm?
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17
Q

What signifies an abnormal DRE for prostatiis

A

boggy
tender
stimulates urge to pee

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18
Q

What is the most common benign tumor in men over 60

A

Benign Prostatic Hyperplasia (BPH)

*Affects roughly 50% at age 60, 90% at age 85

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19
Q

What is Benign Prostatic Hyperplasia (BPH) characterized by?

A
  1. prostatic enlargement,
  2. obstruction of bladder outlet,
  3. voiding symptoms

**Prostate size does not correlate with degree of obstruction

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20
Q

Only __% of men with anatomical BPH will ever need treatment, however…
__% of American males over 50 have moderate to severe symptoms…ASK ABOUT IT!!

A

50%

30%

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21
Q

Describe the basic pathophysiology of BPH

A
  • Increase in cell number
  • Capsule limits outward growth, urethra obstructed
  • Etiology not well understood but androgens play a necessary role
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22
Q

BPH can lead to:

A
  1. severe bladder dysfunction
  2. recurrent UIT
  3. bladder stones
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23
Q

Most BPH involves ___ tissue, some cases have a ___ component

A

stromal

glandular

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24
Q

What are obstructive sx of BPH

A
  1. Hesitancy (delay/difficulty in initiating stream)
  2. Weak urinary stream
  3. Feeling of incomplete bladder emptying
  4. Intermittency (stopping and starting several times during voiding)
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25
Q

What are irritative sx of BPH

A
  1. Urgency (feeling of little warning when urge develops)
  2. Frequency (frequent urination with short intervals)
  3. Nocturia
  4. Dysuria
  5. Feeling of incomplete bladder emptying
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26
Q

Describe the evaluation of suspected BPH

A
  1. PE -attention to abdominal and genital exam, hernias
  2. DRE - size, texture
  3. Urinalysis - pyuria or hematuria
  4. Serum creatinine– long standing could cause VUR renal scarring
  5. May consider: Uroflowmetry, pressure-flow studies, cystoscopy, ultrasound, biopsy
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27
Q

Describe the scoring of AUA symptoms score

A

*good to assess symptom changes (response to meds, progression)

0-7: mild
8-19: moderate
20-35: severe

*opens door for discussion

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28
Q

What are management strategies for BPH

A
  1. Watchful waiting
  2. Correction of aggravating factors
  3. Medical treatment
  4. Minimally invasive therapies: fluid restriction
  5. Surgical therapies
  6. Other (laser, stents)
  7. Beer?
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29
Q

Who is the ideal candidate for watchful waiting with BPH

A
  1. Mild symptoms (AUA symptom score 7 or less)
  2. No recurrent UTI
  3. No gross hematuria
  4. No bladder stones
  5. No urinary retention
  6. No renal insufficiency
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30
Q

What are ways for correction of aggravating factors in BPH

A
  1. Fluid restriction, particularly before bedtime
  2. Avoidance of caffeine, alcohol
  3. Tight control of diabetes
  4. Medications (diuretics, decongestants, anti-cholinergics– PSEUDOPHED)
  5. Treatable neurologic conditions
  6. Recurrent UTIs or prostatitis
  7. Coexisting urologic conditions
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31
Q

In men over 50, always ask about

A
  1. sexual function
  2. concerns about urination

*30% of males over 50 have moderate-severe symptoms of BPH

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32
Q

What medications can be used to treat BPh

A
  1. Alpha-blockers
  2. 5-alpha reductase inhibitors (5aRI)
  3. Phytotherapy– saw palmetto berry and Trinovin (soy isoflavone extract)
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33
Q

How do alpha-blockers work to treat BPH

A
  1. Prostatic smooth muscle cells have type a1-adrenoceptors (a1-AR) - norepinephrine
  2. Bind to and block a-adrenoceptors on smooth muscle
  3. Binding to a1-AR on smooth muscle of fibromuscular stroma causes relaxation of the prostate, greater urine flow
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34
Q

What are side effects of alpha-blockers (used to tx BPH)

A
  • Side effects related to binding to non-prostatic receptors
    1. dizziness
    2. fatigue
    3. somnolence
    4. postural hypotension
    5. flu-like symptoms
    6. retrograde ejaculation
    7. others (nausea, erectile dysfunction, etc)
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35
Q

Selective long-acting a-blockers medications used in BPH:

A
  • No significant difference in efficacy among these
    1. a1-AR blockers: terazosin (Hytrin), doxazosin (Cardura)
    2. a1a-AR blockers: tamsulosin (Flomax), alfuzosin (Uroxatral) - more selective for prostate receptors, FEWER side effects
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36
Q

How do you choose an alpha-blocker for BPH

A
  1. Cost: Significant differences in price, terazosin (Hytrin) and doxazosin (Cardura) are cheaper
  2. Side effects: 90% of patients tolerate these well
  3. Try terazosin or doxazosin first line and switch to tamsulosin (Flomax) or alfuzosin (Uroxatral) if poorly-tolerated
  4. alfuzosin has most favorable side-effect profile, particularly re: ejaculatory and erectile dysfunction
37
Q

How do 5-alpha Reductase Inhibitors (5aRI) help manage BPH

A
  • Androgen suppression, targets epithelial (glandular) component, decreasing prostatic size via cellular regression
  • Unlike a-blockers, take time to work…1 to 6 months
  • Lower PSA values…Be careful! Double measured values
38
Q

Examples of 5-alpha Reductase Inhibitors (5aRI) help manage BPH

A

finasteride (Proscar) and dutasteride (Avodart)

*Both are expensive, dutasteride has slightly better side effect (decreased libido, ejaculatory/erectile dysfunction) profile

39
Q

Describe the use of phytotherapy for BPH

A
  1. Saw palmetto berry (Serenoa repens) - many small studies with conflicting results. One decent study (STEP study) showed no benefit.
    - No significant adverse events.
    - Most common side effect: GI distress Unregulated - poor quality control
  2. Trinovin - soy isoflavone extract. No convincing data.
40
Q

What are minimally invasive ways to manage BPH

A
  1. thermal ablations, various heat sources
  2. Transurethral needle ablation of the prostate (TUNA)
  3. Interstitial laser thermal therapy (ILTT)
  4. Transurethral microwave therapy (TUMT)
41
Q

When is minimally invasive management appropriate for BPH

A
  1. Safer than surgical approaches though not as successful
  2. Outpatient, minimal anesthesia, lower complication rate
  3. Appropriate for patients who fail or are unable to tolerate medical therapy, poor surgical candidates
  4. Not appropriate for men with severe symptoms, greatly enlarged prostates
  5. Long-term outcomes unknown
    * Can not biopsy tissue
42
Q

What is transurethral resection of the prostate (TURP) a good choice

A
  • Treatment of choice for moderate to severe symptoms
  • Consider for patients who:
    1. fail medical treatment,
    2. have refractory urinary retention,
    3. recurrent UTI,
    4. persistent hematuria,
    5. bladder stones,
    6. renal failure
43
Q

What are long term complications of transurethral resection of the prostate (TURP)

A
  1. retrograde ejaculation (70%),
  2. impotence (14%),
  3. partial incontinence (6 %),
  4. total incontinence (1%)
  5. Risky with large (>50g) prostates
44
Q

What are complications of TURP surgery

A
  1. bleeding
  2. clot retention
  3. infection
  4. capsular perforation
45
Q

Surgeon is able to directly visualize procedure

Uses radiofrequency loop to generate prostatic chips

A

TURP

46
Q

Surgical removal of the inner portion of the prostate

Suprapubic or retropubic approach

A

Simple open prostatectomy

47
Q

When is Simple open prostatectomy indicated

A
  1. Indicated for prostates larger than 50-75g, for which TURP is considered risky
  2. Still most effective treatment with low retreatment rates but high morbidity (e.g. retrograde ejaculation approaches 100%)
48
Q

Complications of Simple open prostatectomy

A
  1. Open surgery with potential complications (e.g. post-op ileus, DVT, wound infection)
49
Q

What is the most common CA in males

A

prostate CA (1 in 6 lifetime)

  • Most common non-skin malignancy
  • Second to lung cancer in cancer mortality in men
50
Q

What are risk factors for prostate cancer

A
  1. age
  2. fhx (2-10x)
  3. race (AA) (1.3x)
  4. high dietary fat (1.6-1.9x)
  5. No specific genes identified but BRCA genes do increase risk
  6. Unproven: vitamin D,E, selenium deficiency, cadmium exposure (welding), STD, high calcium intake
51
Q

__ and __ do not have a significant risk factor for prostate cancer

A

BPH and vasectomy

52
Q

Symptoms to prostate CA

A
  • Typically do not appear until cancer is advanced
    1. Cancer usually starts in peripheral tissues and by the time urinary symptoms develop (obstructive or irritative symptoms, hematuria) it is often regionally advanced
    2. May present as bone pain (with increased serum alkaline phosphatase) from metastatic disease
53
Q

Early dx of prostate Ca is usually achieved by ___

A

DRE and PSA testing

*Transrectal ultrasound (TRUS)-guided needle biopsy is the standard method of confirming diagnosis

54
Q

Is screening with PSA recommended

A

Routine use of PSA increases detection of cancer BUT has not been shown to reduce morbidity or mortality from prostate CA

In other words: mass screening using PSA may result in detection and invasive treatment of many cancers that might never have become a problem

55
Q

PSA elevations can occur with

A
  1. massage,
  2. biopsy,
  3. infection,
  4. infarct, and
  5. BPH
56
Q

The PLCO and ERSPC studies about PSA testing concluded what

A

PLCO
-No mortality benefit from combined PSA and DRE testing

ERSPC

  • Minimal mortality benefit from PSA testing
  • Absolute reduction of 7 prostate cancer deaths per 10,000 men screened (or…1400 men needed to be screened to prevent 1 prostate cancer death)
57
Q

What are talking points for prostate CA screening so that informed decision making

A
  1. Prostate CA is an important health problem; it is one of the most frequently diagnosed cancers in the United States and a leading cause of cancer death in men.
  2. Prostate CA screening is controversial, and men should be involved in making the decision whether or not to be screened.
  3. Prostate cancer screening may reduce the chance of dying from prostate cancer. However, the evidence is mixed and the absolute benefit is small.
  4. Surgery and radiation therapies are the treatments most commonly offered in an attempt to cure prostate cancer; however, they can lead to problems with urinary, bowel, and sexual function
  5. Many CA detected by screening are considered “overdiagnosed”, meaning that they never would have caused problems during a man’s lifetime
58
Q

What are the screening recommendations of prostate CA

A
  1. No one recommends DRE
  2. USPSTF – Recommends against screening with PSA.
  3. American Cancer Society - Involve patients in informed decision making. For those who elect to be screened, start at age 50. Do not offer to men with a life expectancy of less than 10 years.
  4. American Urologic Association – No screening for average-risk men ages 40 to 54, men older than 70, or men with a life expectancy of less than 10 to 15 years. Decisions should be individualized for higher-risk men ages 40 to 54, and the AUA noted that some men over age 70 in excellent health might benefit from screening. The AUA strongly recommends shared decision making.
59
Q

What are treatment options for prostate CA

A
  1. Watchful waiting
  2. Radical prostatectomy
  3. Radiotherapy/Brachytherapy
  4. Hormonal (antiandrogen) therapy
60
Q

Describe the watchful waiting management option for prostate CA

A
  1. May be appropriate in elderly patients with life-expectancy less than 10 years
  2. Patients with well-differentiated tumors (Gleason 2 to 4)
  3. Patients with Gleason scores of 7 to 10 have a much higher risk of death with watchful waiting
  4. Re-evaluate every 6 months
61
Q

Complete excision of prostate and re-anastomosis of bladder and urethra

A

radical prostatectomy – done for prostate CA

62
Q

When is radical prostatectomy a good tx option for prostate CA

A
  1. Appropriate for clinically localized cancer
  2. May be most beneficial in early prostate cancer
  3. Surgical morbidity correlated with surgeon experience
63
Q

What are the different tx approaches for radical prostatectomy

A

Retropubic approach - avoids abdominal cavity but higher rate of impotence

Suprapubic approach - preferred method

DaVinci robotic prostatectomy - laparoscopic technique

64
Q

Radical Prostatectomy - complications

A
  • Surgeon’s experience important.
    1. Neurovascular bundle. Supplies the penis and easily injured during surgery
    2. Urinary incontinence (around 10 % in most centers)
    3. Impotence
    4. Lower incidence of impotence with nerve-sparing procedures (both or 1 neurovascular bundle is spared)
    5. Rectal injury, uncommon
65
Q

External source of radiation
Multiple treatments, typically over 6-8 weeks
Success approaches that of radical prostatectomy

A

Radiation - Electron Beam (EBRT)

66
Q

Complications of Radiation - Electron Beam (EBRT)

A
  1. Can have significant GI side effects and share complications of radical prostatectomy
    * Urinary incontinence rates less than with radical
67
Q

Radioactive seeds implanted in prostate

A

Radiation - Brachytherapy

68
Q

Pros of Radiation Brachytherapy

A

Pros:
-Less impact on surrounding tissue than EBRT
Minimally invasive surgery, typically rapid recovery

69
Q

SE of Radiation Brachytherapy

A
  1. Side effects comparable to radical prostatectomy

* However, in a recent NCI study, patients report better quality of life following brachytherapy

70
Q

When is Hormonal (anti-androgen) Therapy a good option for prostate CA

A

Usually reserved for advanced cancer

71
Q

Side effects of Hormonal (anti-androgen)

A
  1. impotence,
  2. hot flashes,
  3. osteoporosis,
  4. weight gain
72
Q

examples of Hormonal (anti-androgen) used for prostate CA

A
  1. LH Releasing Hormone (LHRH) agonist: Lupron

2. Antiandrogens: Flutamide

73
Q

Describe the follow up of prostate CA

A
  1. PSA every 6 months for 5 years, then every year
  2. Any elevation that is detectable (>0.4ng/ml) needs to be pursued
  3. DRE yearly (Debatable)
  4. Clinical exam every 6 months for 5 years
74
Q

what is erectile dysfunction

A

The persistent inability to attain a penile erection sufficient for intercourse

75
Q

Who does ED effect

A
  1. Affects 20-30 million American men

2. Age dependent, affects 15-25% of men over 65

76
Q

Negative impacts of ED

A
  1. neg. impact on quality of life,
  2. self-image,
  3. relationships
77
Q

describe the mechanics of a flaccid state

A

-small terminal arteries leading to the cavernous sinuses are constricted, reducing inflow of blood. Venous plexus open.

78
Q

describe the mechanics of an arousal state

A
  1. Parasympathetic chain of events leading to release of nitric oxide (NO) in the corpora cavernosum.
  2. NO activates an increase in cyclic guanosine monophosphate (cGMP), a second messenger.
  3. Increased cGMP causes smooth muscle relaxation responsible for erection.

*Phosphodiesterase 5 (PDE-5) cleaves cGMP, inactivating it

79
Q

Causes of ED

A
  1. psychogenic- performance anxiety, relationship/marital discord, anxiety, depression
  2. organic
  3. iatrogenic
  4. environmental: smoking, alcohol, drugs of abuse
80
Q

What are organic causes of ED

A
  1. Vasculogenic - arterial problems most common (DM, CAD)
  2. Neurogenic - spinal cord injury, MS, etc
  3. Hormonal - hypogonadism, hyperprolactinemia, thyroid dysfunction
  4. Mechanical - Peyronie’s, anatomic abnormalities
81
Q

What type of meds can cause ED

A 
Antidepressants
	SSRIs
	Tricyclics (TCAs)
	Atypicals
Antihypertensives
	Beta-blockers
	Diuretics
	Clonidine
Antipsychotics
Anxiolytics
	Benzodiazepines
Miscellaneous
	Corticosteroids
	Cimetidine (Tagamet)
	Finasteride (Proscar)
	Gemfibrozil (Lopid)
	Niacin
	Phenytoin (Dilantin)
82
Q

Describe the PE of ED

A
  1. CV: BP, bruits, signs of peripheral vascular disease
  2. Feminization: gynecomastia, body hair changes
  3. Neuro: peripheral sensory exam
  4. Genital: penile abnormalities (e.g. Peyronie’s), testicular atrophy
  5. Rectal: DRE, sphincter tone, “anal wink”, bulbocavernous reflex
  6. Consider psychological evaluation
83
Q

What Labs do you get for ED

A

CBC, BMP (glucose & electrolytes), lipids, TSH, testosterone
Urinalysis

*get color doppler US if you suspect vascular disease

84
Q

Describe the use of testosterone for ED

A

*Normal levels change during the day with peak level in the am.
Decline with age

  1. Age-adjusted, first-morning free testosterone levels most accurate
    - If testosterone low = hypogonadism–> check prolactin, LH, FSH
    - If prolactin high, get pituitary MRI
85
Q

Treatment of ED

A
  1. Treat secondary causes
  2. Lifestyle change (smoking, exercise, EtOH, diet)
  3. Oral medications
  4. Urethral suppositories
  5. Vacuum constriction devices
  6. Penile self-injection
  7. Surgical options
86
Q

What med is used for ED

A

PDE-5 Inhibitors
Increase cGMP levels in corpora cavernosum
Require arousal…not an aphrodisiac!

ex. Sildenafil (Viagra)

87
Q

What are side effects of PDE-5 Inhibitors

A
  1. HA
  2. flushing
  3. dyspepsia
    * *CONTRAINDICATED W/ NITRATES
88
Q

What are surgical options for ED

A
  1. Implants
    - Inflatable, pump-assisted
    - Malleable
    - Most invasive option
  2. Vascular reconstruction

Adult Clinical Medicine (26 decks)

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