Men’s Health 🕴🎩👔 Flashcards
What part of the prostate proliferates in BPH
Transitional zone
What is the most common benign tumor in men 40-80 yrs old
BPH
What kind of sx will a guy with BPH experience
Frequency
Urgency
Hesitancy
Weak stream
Dribbling
(All due to the tumor pressing on the prostatic urethra)
Type 2 diabetes = risk factor for BPH?
True
How long must urinary symptoms continue before a dx of BPH can be made?
At least 3 months*
What can you do in the primary care setting to diagnose BPH?
DRE- symmetry, firmness, nodules
UA- r/o blood, infection
PSA
BUN/Creat- check kidney function
What kinds of things might change a PSA?
What will not?
Avoid checking PSA after ejaculation, trauma, or catheterization **
DRE will not affect PSA levels
What behavior modifications may help BPH
Avoid caffeine/alcohol
Fluid restriction before bed or going out
Double voiding to promote complete emptying
What 2 classes of meds can treat BPH
Alpha 1 blockers **first line- tamsulosin, doxazosin, etc
5-alpha reductase inhibitors- finasteride, dutasteride
What do alpha 1 blockers do to help BPH
Relax smooth muscle in urinary tract and prostate
What are the common side effects of alpha-1-blockers?
Orthostatic hypotension
Dizziness
Ejaculatory dysfunction
What do 5-alpha reductase inhibitors do to help BPH
Decrease prostate size via antiandrogen effects
What are the common side effects of 5-alpha reductase inhibitors
Decreased libido
Sexual dysfunction
What are the kinds of surgical options available to men with BPH?
TURP= transurethral radical prostatectomy
TUNA- Transurethral needle ablation
TUMT- transurethral microwave thermotherapy
Prostatic stent
Suprapubic prostatectomy
What age men get acute bacterial prostatitis
Young and middle aged men via the urethra (sexy bugs or poopy bugs swim up)
What may come along with acute bacterial prostatitis
UTI
Urethritis
What can happen if you dont treat acute bacterial prostatis right away
Sepsis
Abscess
Metastatic infection
Is acute bacterial prostatis a big deal
Yes it is a very serious infection and thsse people are very sick
What are the sx of acute bacterial prostatitis
UTI symptoms
Fever, myalgia, malaise
Perineal/pelvic pain
What will a gentle DRE on a pt with acute bacterial prostatitis reveal
Tender and edematous prostate 🤮
Will help differentiate this from a UTI
How do you treat acute bacterial prostatitis?
If toxic=admit to hospital
If stable and reliable=
Fluoroquinolone or Bactrim for 6 weeks***
TAKES A LONG TIME
When should you repeat the urine culture when you treat acute bacterial prostatits
After 7 days of antibiotic therapy
But still treat for the whole 6 weeks
What is chronic bacterial prostatitis
Chronic/recurrent urogenital symptoms with evidence of bacterial infection of the prostate
What will you find on physical exam of chronic bacterial prostatits ?
Recurrent UTI
Pelvic pain, bladder obstruction, hematuria
Prostate usually NORMAL, but might be tender
Labs are frequently NORMAL, but might be elevated
A bunch of vague SHIT
What is the gold standard for diagnosing chronic bacterial prostatits
Prostatic fluid analysis***
Usually diagnosed presumptively though based on hx of symptoms
How do you treat chronic bacterial prostatitis
Fluoroquinolone for 6 weeks
Bactrim is alternate
What is the other name for chronic prostatitis
Chronic pelvic pain syndrome
What is the definition of chronic prostatits/chronic pelvic pain syndrome
Chronic pelvic pain for at least three of the last 6 months with no identifiable cause
(Diagnosis of exclusion)
Is prostatits/chronic pelvic pain syndrome a common problem
Yes, affects 10% of men
Why do men with prostatits/chronic pelvic pain syndrome come in to see their PA
Pain
Hard to pee
Blood in semen
…in a Relapsing-remitting pattern over many months!
How do you treat prostatits/chronic pelvic pain syndrome?
No uniformly accepted regimen
Alpha blockers, antibiotics, and 5-alpha reductase inhibiots are the most effective meds
Psychological support
What is the most common cancer diagnosed in men in the age group of 60-79 yrs
Prostate cancer
Does prostate cancer grow fast
Slow growing
What kind of cells are in prostate cancer
Slow-growing, malignant neoplasm of adenomatous cells of the prostate gland
What usually leads to the discovery of prostate cancer?
80% diagnosed after elevated PSA
20% after abnormal DRE *** NEVER SKIP THE DRE
What is the prognosis for prostate cancer
Its the 2nd leading cause of cancer death in men, but only a 3% chance of killing you
Who needs to be screened for prostate cancer
> 10 yrs life expectancy
Family hx of prostate cancer
Black men
What will you feel on DRE if they have prostate cancer?
Nodular
Asymmetric
Would you expect to see hematuria or hematospermia in prostate cancer
NO, very rare
What kinds of sx do people with prostate cacner have
Usually asymptomatic middle aged men
Might have urinary sx due to concomitant BPH
How is prostate cancer diagnosis confirmed
Prostate biopsy (transrectal ultrasound guided)
DRE can only detect tumors in what parts of the prostate
Posterior and lateral
What is the threshold of PSA to determine when a biopsy is needed
There isnt an absolute threshold
How is Prostate cancer staged?
Tumor Node Metastases (TMN system)
Gleason score
Is it an easy straightforward approach to treating prostate cancer
No, it is dependent on many factors, and there are whole websites with nomograms that help you figure it out
After someone is treated for prostate cancer, how often do they need to be screened for cancer?
Total PSA every 6-12 months x 5 yrs, then annually
If PSA rises, refer to onco
Most cases of erectile dysfunction have a_______ cause
Organic
What age do men start having trouble with ED
Early 40s
How do you get an erection
Primary a vascular phenomenon triggered by neurological signals and facilitated only in the presence of appropriate hormonal conditions and psychological mindset
What type of men have the LOWEST prevalence of ED
Active males without chronic medical conditions who maintain healthy life choices
⛹️♂️🚴🏻♂️🤽🏼♂️🧗🏻♂️
What are some possible etiologies of ED?
Vascular- cardiovascular dz, HTN, DM, HLD, smoking, major surg
Neurological- spinal cord/brain injury, parkinson, Alzheimer’s, MS, stroke
Local penis factors- Peyronies dz, cavernous fibrosis, fracture
Hormonal- hypogonadism, hyperprolactinemia, hyper/hypothyroidism, hyper/hypocortisolism
Drug induced- HTN drugs, antidepressant,s antipsychotics, antiandrogens, recreational drugs
Psychogenic- performance anxiety, traumatic past experiences, relationship probs, anxiety, depression, stress
(he said “I really like this table” but idk if this would actually be on the test)
What is a nocturnal tumescence test?
It is a way to see if the patient gets erections at night.
If he does, you can determine that the ED is of a psychogenic origin, not organic.
What needs to be in the work up of a pt with ED
Detailed history
DRE, Secondary sex characteristics, femoral and peripheral pulses, breast exam, testicular volume
Fasting glucose/HbA1C
CBC/CMP
TSH
Lipid profile
Serum total testosterone
JSUT READ IT ONCE OR TWICE
What is the FIRST line management for ED?
PDe-5 inhibitors:
sildenafil, Vardenafil, Tadalafil, Avanafil
What are the 2nd line treatments for ED
Vacuum ejection device
Penile Self Injectables
Intraurethral suppository- MUSE (alprostadil)
What is the 3rd line treatment for ED
Penile prosthesis surgery
Who usually gets urethritis?
Young sexually active males
What are the 2 types of urethritis
Gonococcal (caused by N. Gonorrehae)
Non-gonococcal- chlamydia, mycoplasma, trichomonoas
Why will a man with urethritis come in to see his PA
Dysuria
Urethral discharge
inflamed meatus
(May be asymptomatic too)
How do you diagnose urethritis?
Gram stain of urethral secretions
First void urine for NAAT (nucleic acid amplification testing)
What will you see on gram stain if the partients urethritis is caused by Gonorrhea (gonococcal urethritis)
PMN cells and Gram negative diplococci
How do you treat Gonococcal urethritis?
Ceftriaxone 250mg IM + Azithromycin 1000mgx 1 dose
If PCN allergy: Gentamycin 240mg IM + Azithromycin 2g x 1 dose
(Treat partners if appropriate, no sex for 7 days. No retest needed)
Howe do you treat non-gonococcal urethritis
Azithromycin 1 gram PO
OR
Doxycycline 100mg PO BIDx 7 days
(Treat partners if appropriate, no sex for 7 days. No retest needed)
What is this:
Infection of the epididymis via vas deferens
Epididymitis
How do young men vs old men get epipdidymitis?
Young: STDs
Old: urinary pathogens
What will a guy with epipdidymitis complain about
Acute, UNILATERAL scrotal pain that radiates to the flank.
Hemiscrotal swelling and tenderness which might progress to a red, fluctuant mass.
Fever, chills
What is Prehns sign
Elevation of the scrotum provides relief of pain
Will Prehns sign be positive or negative in epipdidymitis?
POSITIVE*****
Elevating scrotum will make the pain better
How do you treat epipdidymitis if you think it was caused by Chlamydia/Gonorrhea? (Young patient)
Ceftriaxone 250mg IM and Doxycycline 100mg BID x 10 days
+NSAIDS for pain relief
How do you treat epipdidymitis if you think an enteric organism caused it? (Old guy_
Levofloxacin 500mg QD x 10 days
OR
Ofloxacin 300mg BID x 10 days
(+ NSAIDS for pain relief)
What is epididymoorchitis?
epipdidymitis that spread to the testicle
What is a possible viral cause of epidydymoorchitis?
Mumps
How do you treat epididymoorchitis?
If mumps caused it: supportive care
If bacterial: treat same way as epipdidymitis
What is this:
Venous varicosity in the pampiniform plexus (spermatic vein)
Varicocele
Which side of the scrotum do varicoceles usually appear
LEFT due to LONGER spermatic vein
Could also be bilateral
**
What should you think if a patient has an isolated varicocele on the RIGHT side of their scrotum
CANCER***
What does a varicocele feel like
Bag of worms
What will make a varicocele change size
Increases in size with Valsalva
Gets smaller when supine or scrotum is elevated
What are the risks of a varicocele?
Testicular atrophy
Infertility
(Compare both testes if you suspect atrophy of one)
If your patient has a varicocele and they lay down and it doesnt get any smaller, what do you need to do
CT scan for outlet obstruction
How do you treat varicocele?
Ligation of spermatic vein only if symptomatic, infertility concerns, or testicular atrophy
What ages usually get testicular torsion
Neonates
Post-pubertal boys
What kinds of activities can cause testicular torsion
Vigorous physical activity
Trauma
What are the signs/sx of testicular torsion
Acute onset of unilateral scrotal pain with hemp scrotal swelling
Pain on palpation, without relief with elevation
Bell-clapper deformity
Absent cremasteric reflex
How do you diagnose testicular torsion
Doppler ultrasound
What is the treatment for testicular torsion
Usually requires surgery
While waiting for OR, attempt manual detorsion (turn the testicle LATERALLY)
What ages usually get testicular cancer
15-35
What are the risk factors for testicular cancer?
Cryptorchidism
Klinefelter (47XXY)
Family hx
What are the signs/sx of testicular caner?
PAINLESS, solid, nodule on testicle
Dull ache or heavy sensation in lower abdomen, perianal area, or scrotum
Inguinal lymphadenopathy
Para-aortic lymphadenopathy
What do you need to do on physical exam if you suspect testicular cancer
assume that all firm, hard, fixed areas are cancer until proven otherwise
Check for supraclavicular lymphadenopathy
Abdominal exam for para-aortic LAD
Chest exam to look for gynecomastia or thoracic involvement
(Basically always look for SPREAD and lymph node involvement)
How do you diagnose testicular cancer?
ultrasound/CT
Tumor markers: β-HCG, LDH, α-fetoprotein (AFP)
Most primary testicular tumors are _________cell tumors
Germ (95%)
Two types of germ cell tumors:
Seminoma-35%
Nonseminoma-65%
What is the treatment of testicular caner?
Radical inguinal orchiectomy
Radiation and chemotherapy (only seminoma tumors respond to radiation)
Offer sperm banking prior to tx
Since only seminoma testicular tumors respond to radiation, what do you do for nonseminoma tumors?
Nerve-sparing retroperitoneal lymph node dissection
NOT SURE IF THIS SI IMPORTANT
How often after testicular cancer tx do you need to do surveillance
Checkups every 3 months for 2 years then every 6 months, then every year after 5 years
(Not sure if this is important)
What is the prognosis for testicular cancer
94% survival with treatment for low risk
60-80% survival with treatment for disseminated cancer
What do you need to tell all your male patients to do
Self testicle exams
What are the two types of inguinal hernia
Direct
Indirect
Where do femoral hernias occur
Medial aspect of femoral canal
Where do direct hernias protrude through
Hesselbach’s triangle
Where do indirect hernias go
Through internal inguinal ring, through inguinal canal and into the scrotum
What is the most common type of hernia
Indirect, especially on the R side
What is the least comon type of hernia?
Femoral- more common in women
Which kind of hernia is most likely to become strangulated
Femoral
What will happen if a hernia strangulates?
Bowel obstruction
Peritonitis
Toxic appearance (pt will look v sick)
What is the treatment for hernias?
Definitive treatment for ALL hernias is surgery.
If reducible: elective surgery is viable
Watchful waiting if the inguinal hernia has minimal/no symptoms
Bladder cancer is more common in (men/women)
Men (7x)
What two things increase risk for bladder caner
Smoking*
Chemical dyes
What are the 3 types of bladder cancer
Transitional cell 90%
Squamous cell 7%
Adenocarcinoma 2%
Why is bladder cancer often a delayed diagnosis
Misdiagnosed as UTI
What to look for on DRE of bladder cancer pt
Induration of prostate
What are the sign/sx of bladder cancer
A bunch of blood in the urine, no pain
Obstructive urinary sx
If spreading: para-aortic LAD, hepatomegaly, supraclavicaulr LAD, periumbilical nodules
What is the gold standard for diagnosis and staging of bladder cancer?
Cystourethroscopy***
What are the treatment options for bladder cacner?
Transurethral resection of Tumor
Intra-vesical chemotherapy (inject drug right into bladder)
If muscle invasive- systemic chemotherapy and radical cystectomy (remove entire bladder)
What are the 4 types of incontinence?
Urge
Stress
Mixed
Incomplete emptying (overflow)
What kind of incontinence:
Uncontrolled loss of urine that is preceded by a strong i unexpected urge to void
Involves uninhibited bladder contractions
Urge incontinence
“All of a sudden i have to pee and then it all comes out”
What type of incontincenc:
Leakage with exertion, Valsalva
Stress
What causes stress incontinence ?
Urinary sphincter dysfunction, usually due to prostate surgery
What causes incomplete emptying incontinence?
Impaired detrusor contractility and/or bladder outlet obstruction
What is the typical presentiatin of incomplete emptying incontinecne (overflow)?
Nocturnal enuresis
What is the treatment for URGENCY incontinence
Antimuscarinic (tolterodine, fesoterodine, oxybutynin)
α-blockers if BPH present (tamsulosin, etc)
What is the treatment for STRESS incontincenc
Condom catheters
Penile clamp
Surgery
What is the treatment for overflow incontinence
α-blockers
What are some red flags of incontoinence that should make you refer to urology
Severe sx
Pelvic pain
Hematuria
Elevated PSA/abnormal DRE
Recurrent urinary infections
Previous pelvic radiation/surgery
Neurological disease
