Mens health Flashcards
What does BPH stand for?
Benign prostatic hyperplasia
What is BPH?
Common condition affecting men in older men which causes enlargement of the prostate when there is hyperplasia of the stromal and epithelia cells. It presents with LUTS.
What are the symptoms of BPH?
Urinary hesitancy, urgency, frequency Nocturia Weak urine flow Straining to pass urine Terminal dribbling after urination Chronic urinary retention - feeling of incomplete emptying
What assessments can be done if a man presents with lower urinary tract symptoms?
Digital rectal examination Abdo exam Urinary frequency volume chart Urine dipstick PSA blood test
Why is PSA not accurate?
It has a high rate of false positives. Can be raised by multiple things - prostate cancer - BPH - prostatitis - UTIs - vigorous exercise - recent prostate stimulation
How does BPH feel on a DRE?
Smooth, symmetrical, slightly soft prostate
How does prostate cancer feel on a DRE?
firm, hard, asymmetrical, irregular and lumpy
How is BPH managed?
Alpha blockers - tamsulosin - 400mg once daily - relaxes smooth muscle
5 - alpha reductase inhibitors - finasteride - 5mg once daily - gradually reduces the size of the prostate
Surgery
How do 5 alpha reductase inhibitors work?
Gradually reduce the size of a prostate by stopping the conversion of testosterone into dihydrotestosterone (the more potent form)
What are the main side effects of finasteride?
Sexual dysfunction
Breast abnormalities
What are the main side effects of tamsulosin?
Postural hypotension and dizziness
Sexual dysfunction
Nausea and vomiting
What are the surgical options for BPH?
TURP - transurethral resection of the prostate
Open prostatectomy
What are some complications of TURP?
Bleeding Infection Urinary incontinence Erectile dysfunction Retrograde ejactulation Urethral strictures
What is the most common cancer in men?
Prostate cancer
Which part of the prostate is mainly affected by prostate cancer?
Peripheral zone
Which part of the prostate is most commonly affected in BPH?
Central zone
What are some risk factors for prostate cancer?
Older age Family history Black african or Caribbean origin Anabolic steroids Smoking
What are the symptoms of prostate cancer?
Most are asymptomatic.
May have LUTS - e.g. hesitancy, increased frequency, weak flow, terminal dribbling and nocturia.
Haematuria
Erectile dysfunction
Symptoms of metastasis - weight loss, bone pain etc.
How is suspected prostate cancer investigated?
DRE
Multiparametric MRI
Prostate biopsy
What are the risks of a prostate biopsy?
False negatives if the biopsy misses the cancerous area.
Pain
Bleeding
Infection
Urinary retention due to short term swelling
Erectile dysfunction (rare)
What is brachytherapy?
A type of internal radiotherapy
What staging systems can be used to assess severity of prostate cancer?
Gleason grading system
TNM staging
How is prostate cancer managed?
Surveillance - if early as normally slow growing External beam radiotherapy Brachytherapy (internal radiotherapy) Hormone therapy Surgery
What is a complication of external beam radiotherapy for prostate cancer?
Proctitis - inflammation of the rectum.
Causing pain, altered bowel habits, bleeding and discharge.
What are side effects of brachytherapy for prostate cancer?
Inflammation in nearby organs - cystitis (bladder) or proctitis (rectum).
Can also lead to ED, incontinence and increased risk of bladder or rectal cancers.
What are the different hormone therapies that can be given for prostate cancer?
Androgen receptor blocks
GnRH agonists
Bilateral orchidectomy to remove testicles
What are the side effects of hormone therapy for prostate cancer?
Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis
What is prostatitis?
Inflammation of the prostate
How does acute bacterial prostatitis present?
Sexual dysfunction, pelvic pain, LUTS, pain with bowel movements
Fever, myalgia, nausea, fatigue.
Sepsis
How does chronic prostatitis present?
At least a 3 month history of :
Sexual dysfunction, pelvic pain, LUTS, pain with bowel movements
Tender and enlarged prostate
What investigations can be done for prostatitis?
Urine dipstick testing to look for infections
Urine microscopy, culture and sensitivity
STI testing
How is acute bacterial prostatitis managed?
Oral antibiotics - ciprofloxacin 500mg twice daily
Analgesia - paracetamol
Laxatives
Hospital admission if systemically unwell
How is chronic prostatitis managed?
Alpha blockers - tamsulosin to relax smooth muscle
Analgesia
Antibiotics if less than 6 months symptoms
Laxatives
What are the complications of acute bacterial prostatitis?
Sepsis
Prostate abscess
Acute urinary retention
Chronic prostatitis
What is testicular torsion?
Twisting of the spermatic cord with rotation of the testicle. This can block the blood supply leading to ischaemia and necrosis if not treated urgently
How does someone with testicular torsion present?
Acute rapid onset unilateral testicular pain.
Often triggered by activity such as sports.
Abdominal pain and vomiting
On examination
- firm, swollen testicle that is elevated and with an abnormal lie (horizontal)
- rotation
- absent cremasteric reflex
What is the cremasteric reflex?
A reflex in males - when the inner part of the thigh is stroke, the cremaster muscle contacts and pulls the ipsilateral testicle up towards the inguinal canal.
What are some risk factors for testicular torsion?
Bell clapper deformity
Age - most common in teenagers
Family history
Exercise and trauma
What are some complications of testicular torsion?
Ischaemia and necrosis of the testicle
Reduced or infertility
What is a bell clapper deformity?
Abnormality in the attachment of the testical and the tunica vaginalis - means the testicle is not fixed in position. The testicle therefore lies more horizontally and is able to rotate within the tunica vaginalis.
How is testicular torsion managed?
Emergency surgery
- orchiopexy - correcting position of the testicles and fixing them in place
- orchiedectomy - removal if surgery is delayed and there is already necrosis
What are the most common causes of scrotal or testicular lumps?
Hydrocele Varicocele Epididymal cyst Testicular cancer Epididymo - orchitis Inguinal hernia Testicular torsion
What is a hydrocele?
A collection of fluid in the tunica vaginalis that surrounds the testicles.
How will a hydrocele present?
Usually painless Soft, scrotal swelling Testicle is palpable within, Irreducible Transilluminates by shining a torch through the skin
How is a hydrocele managed?
Normally conservative.
Surgery, aspiration or sclerotherapy if large / symptomatic.
What surgery may be done for hydroceles in young children?
ligation of the patent processus vaginalis
What can hydroceles be secondary to in older males?
Trauma
Testicular cancer
Testicular torsion
Epididymo-orchitis
What is a varicocele?
Where the veins in the pampiniform plexus become swollen
What are some complications of a varicocele?
Impaired fertility,
Testicular atrophy - reduction in size and function
What is the pampiniform plexus?
A venous plexus found in the spermatic cord which drains the testes into the testicular vein.
Why do most varicoceles occur on the left side?
As the left testicular vein drains into the left renal vein where there is more resistance.
Whereas the right drains directly into the inferior vena cava.
What serious condition may a left sided varicocele indicate and why?
A renal cell carcinoma which obstructs the drainage of the left testicular vein.
What is the role of the pampiniform plexus?
To drain blood from the testes.
Regulate the temperature of the blood entering the tested by absorbing heat from the testicular artery.
This is because there is an optimum temp for the testes to produce sperm
How do varicoceles present?
Throbbing / dull pain or discomfort that is worse on standing
Dragging sensation
Subfertility
On examination
- scrotal mass - feels like a bag of worms - more prominent on standing and disappears when lying down
- asymmetry in testicular size
What tests can be done to aid the diagnosis of varicoceles?
Doppler ultrasound
Semen analysis looking at fertility
Hormonal tests
How are varicoceles managed?
Normally conservatively
Surgery or endovascular embolisation if severe
What is an epididymal cyst?
A fluid filled sac that occurs at the head of the epididymis (top of the testicle)
What are the examination findings for a epididymal cyst?
Soft round lump
Normally at the top of the testicle and associated with the epididymis
Separate from the testicle
How are epididymal cysts managed?
Conservatively as resolves itself
if large of symptomatic then surgical removal or aspiration may be considered.
What are some causes of erectile dysfunction?
Psychological - depression, anxiety, low self esteem, stress, relationship problems Physical conditions - heart disease - atherosclerosis + hypercholesteraemia - hypertension - diabetes - low testosterone - alcoholism \+ many others
How is erectile dysfunction managed?
Lifestyle - decrease stress, reduce alcohol intake etc.
Medications - e.g.
- viagra - sildenafil (25-100mg taken as required - max 1 dose a day)
Testosterone replacement
Treat underlying cause if applicable
How does viagra work?
Enhances the effects of nitric oxide which relaxes the muscles in the penis, hence increasing blood flow.
What are some complications of erectile dysfunction?
Stress or anxiety
Embarrassment or low self esteem
Relationship problems
Inability to get partner pregnant
What is epididymo-orchitis?
Inflammation of the epididymis and testicle - normally due to infection
What is the route of sperm from the testicles?
Released from the testicle into the head of the epididymis. Then into the body then tail. It is stored in the epididymis to mature before being released into the vas defernes (sperm duct)
What are the main causative organisms of epidiymo-orchitis?
Escherichia coli (e.coli)
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps
How does epididymo-orchitis present?
Gradual onset over mins to hours of unilateral
- testicular pain
- dragging or heavy sensation
- swelling or testicle and epididymis
- urethral discharge (think of STIs)
- systemic symptoms such as sepsis
What investigations can be done to help diagnose epidiymo-orchitis?
Urine microscopy and culture
Chlamydia and gonorrhoea testing
Saliva swab - testing for mumps
Ultrasound - assessing for torsion or tumours
How is epipidymo-orchitis managed?
Analgesia
Antibiotics - e.g. ciprofloxacin (broad spectrum)
If suggestive of STIs, refer to GUM clinic for treatment
Admit to hospital if any signs of sepsis.
What are some complications for epididymo-orchitis?
Chronic pain
Chronic epididymitis
Testicular atrophy
Sub fertility or infertility
Scrotal abscess
