Mens Health Flashcards
Proliferation of fibrostromal tissue in the transitional zone that can lead to compression of the prostatic urethra is known as what?
BPH
What is the most common benign tumor in men 40-80 yo?
BPH
What condition that can cause nocturia is a RF for BPH?
T2DM
Pt presents with at least 3 months of bothersome urinary symptoms and recurrent UTIs with gross hematuria. What are you concerned for?
BPH
What tests are used for the diagnosis of BPH?
DRE, UA, PSA (prostate specific antigen), BUN/ creatinine
What is 1st line tx for BPH?
Alpha-1-adrenergic antagonists (alpha blockers) Tamsulosin, doxazosin, terazosin
Besides alpha blockers, what other things are used for the tx of BPH? (2)
Behavior modification (decrease factors that will limit frequency of urination) 5-alpha reductase inhibitors
What are common SE’s of alpha blockers (tx of BPH)? (3)
Orthostatic hypotension, dizziness, ED
What are common SE’s of 5-alpha reductase inhibitors (tx of BPH)? (2)
↓ libido, sexual dysfunction
TURP, TUNA, TUMT, prostatic stent, suprapubic prostatectomy are all surgical tx options for what condition?
BPH
What disease is characterized as an acute infection of the prostate that typically occurs in young and middle-aged men via the urethra and is usually caused by typical urinary pathogens?
Acute bacterial prostatitis
Delay of therapy for acute bacterial prostatitis can lead to what complications?
Sepsis, abscess, metastatic infection
How can acute bacterial prostatitis be differentiated from a UTI?
Tender and edematous prostate on DRE (gentle)
What is the treatment for acute bacterial prostatitis if toxic?
Admit to hospital and start IV abx
If a pt is stable and reliable, they are treated outpatient for the tx of acute bacterial prostatitis. What meds should be prescribed?
Fluoroquinolone (levo, cipro) or Bactrim for 6 weeks
Should you receive a repeat urine culture after abx treatment of acute bacterial prostatitis?
Yes, after 7 days
What disease is classified as chronic or recurrent urogenital sxs (recurrent UTI) with evidence of bacterial infection of the prostate but generally subtle sxs?
Chronic bacterial prostatitis
What will prostate exam of a pt with chronic bacterial prostatitis reveal?
Usually normal (may reveal tenderness or hypertrophy)
What is the gold standard for dx of chronic bacterial prostatitis?
Prostatic fluid analysis (but more often dx based on hx)
What is the 1st line treatment for chronic bacterial prostatitis?
Fluoroquinolone for minimum of 6 weeks (Bactrim is alt and recurrent treated the same)
What condition is defined as chronic pelvic pain for at least 3 of the preceding 6 months in the absence of other identifiable causes?
Chronic prostatitis/ chronic pelvic pain syndrome
Prevalence of chronic prostatitis/ chronic pelvic pain syndrome?
Peaks in 5th decade
What is the etiology for chronic prostatitis/ chronic pelvic pain syndrome?
Unknown
What will be found on PE (complete genital and rectal exam) of a pt with chronic prostatitis/ chronic pelvic pain syndrome?
Prostate non-tender or mildly tender
What tests should be performed if you are suspicious for chronic prostatitis/ chronic pelvic pain syndrome?
UA, culture, imaging (to r/o other etiologies)
Chronic prostatitis/ chronic pelvic pain syndrome is typically considered a dx of what?
Dx of exclusion
Pt presents with hx of pain, blood in semen with relapsing-remitting pattern over many months. What should you be concerned for?
Chronic prostatitis/ chronic pelvic pain syndrome
Although there is no uniformly accepted treatment regimen for chronic prostatitis/ chronic pelvic pain syndrome, what is typically considered?
Alpha blockers, abx, 5-alpha-reductase inhibitors (used in combo)
What is the most common cancer diagnosed in men in the age group of 60-79 yo?
Prostate cancer
The majority of prostate cancers are diagnosed subsequent to what?
Elevated PSA or abn DRE
Who should be screened for prostate cancer?
> 10 years life expectancy, FH, black men
Sxs of urinary frequency, urgency, nocturia, and hesitancy (concomitant to BPH) are concerning for what?
Prostate caner
What are the sxs of advanced prostate cancer?
Bone pain, fatigue, weight loss
If on DRE you note a nodular prostate or asymmetric prostate, what might you be concerned about?
Prostate caner
If a pt has an abnormal prostate exam/ abnormal PSA, what should your next step be for possible dx of prostate cancer?
Prostate bx (transrectal US guided)
DRE can only detect tumors in which aspects of the gland?
Posterior and lateral
What 2 methods are used for staging of prostate cancer?
Tumor node metastases (TNM) system Gleason score (histological grading)
Although treatment of prostate cancer is patient specific, what are some of the more common options? (4)
Observation Radical prostatectomy (RP) Radiation therapy Androgen deprivation therapy
How often should surveillance be performed after treatment of prostate cancer?
Total PSA every 6-12 mos x 5 yrs then annually
If PSA rises on surveillance after treatment of prostate cancer, what should you do?
Refer
What is the procedure for recurrence of prostate cancer or for metastatic work-up?
PSA every 3-6 mos
What is defined as the inability to attain or maintain a penile erection that is satisfactory for sexual performance?
ED
The lowest prevalence of ED is found in what population?
Active males, no chronic medical conditions, healthy lifestyle
DRE, evaluation of secondary sex characteristics, femoral and peripheral pulses, breast exam and testicular volume should be included on exam for what?
ED
What additional tests can be preformed if trying to determine if ED is psychogenic or organic cause? (2)
- Nocturnal tumescence (if you get erection while asleep, ED is due psychogenic cause) 2. Duplex doppler: ID arterial obstruction or venous leak
First line treatment for ED?
Tx underlying cause (psychotherapy, T therapy, meds, lifestyle)
First line medication for ED?
PDE-5 inhibitors (sildenafil, vardenafil, tadalafil, avanafil)
What are the 2nd line txs for ED? (3)
Vacuum erection device Penile self injections Intraurethral suppository
What is 3rd line tx for ED?
Penile prosthesis/surgery
In what population is urethritis most common?
Young, sexually active males
What is the pathogen that causes Gonococcal urethritis
Neisseria gonorrhoeae
25 y/o sexually active male presents with dysuria and urethral discharge, what disease are you concerning about?
Urethritis: inflammation or infection of the urethra
What two tests do you do to DX urethritis?
Gram stain of urethral secretions (purulent discharge) –> Gram-negative diplococci First void urine for NAAT
If pt w/ gonococcal urethritis what is the tx?
Ceftriaxone 250 IM + Azithromycin 1000 mg X 1 dose (If PCN allergy, Gentamycin 240 mg IM _ Azithromycin 2 g X 1 dose) * Also tx partner
TX for non-gonococcal urethritis?
Azithromycin 1 gm orally or Doxyclycine 100 mg PO BID x 7 days * Also tx partner
Is retest needed if tx w/ 1st line regimen?
No
Infection of epididymis via vas deferens is what?
Epididymitis
In young men, what is the likely cause of epididymitis?
STD (chlamydia, gonorrhhea)
In older men, what is the likely cause of epididymitis?
Urinary pathogens
35 y/o M pt presents with acute, unilateral, severe scrotal pain radiating to ipsilateral flank what are you concerned for? What test will be positive on exam?
Epididymitis (PE: + hemi-scrotal swelling, TTP, can progress to erythematous fluctuant mass) + Prrehn’s sign
If epididymitis is NOT tx, what can result?
Orchitis (viral/bacterial inflammation of the testicles), abscess, infertility
DX test of choice for epididymitis?
Scrotal US (eval for testicular torsion, abscess)
TX for for epididymitis if suspicious for Chlamydia, N. gonorrhea?
Ceftriaxone 250 mg IM x 1 and Doxycycline 100 mg BID x 10 days
TX for for epididymitis if suspicious for enteric organism?
Levofloxacin 500 mg QD x 10 days or Ofloxacin 300 mg BID for 10 days
What adjunct therapy can you recommend for pain relief w/ epididymitis?
NSAIDS
Infection is caused by retrograde infection into the testicles?
Epidiymoorchitis
M pt presents w/ mumps, acute, ipsilateral testicular swelling and tenderness? What are concerned about?
Epidiymoorchitis
If pt with mumps, what is the tx?
Supportive care
If pt w/ bacterial epidiymoorchitis how do you treat?
SAME as epididymitis: Chlamydia, N. gonorrhea: Ceftriaxone 250 mg IM x 1 and Doxycycline 100 mg BID x 10 days Enteric organism: Levofloxacin 500 mg QD x 10 days or Ofloxacin 300 mg BID for 10 days
Varicocele is typically more common in left or right spermatic vein?
Left (b/c longer, but can occur bilaterally)
If pt w/ presents w/ varicocele only to right spermatic cord, what should you be concerned about?
Pelvic/abd malignancy
What is imaging of choice for varicocele if no decompression in recumbent position?
CT scan (evaluating for outlet obstruction) Also: Doppler Scrotal US
What is the tx for varicocele?
Ligation of spermatic vein if sx, infertility concerns, testicular atrophy Supportive care if mild sx, no reproductive concern
Testicular torsion is concerning for what with regards to the testicle?
Compromised circulation –> ischemia
What populations are at greatest right for testicular torsion?
Neonates, post-pubertal boys
2 most common precipitating factors of testicular torsion?
Vigorous physical activity, minor trauma
19 y/o M presents with acute onset of unilateral scrotal pain w/ hemi scrotal swelling what are you concerned about?
Testicular torsion
On exam of scrotum you find TTP, bell-clapper deformity, - prehn’s, and negative cremasteric reflex on left testicle. What is you suspected dx?
Testicular torsion?
What imaging is used to dx testicular torsion?
Scrotal US (limited or loss of BF to spermatic cord)
TX for testicular torsion?
Urologic emergency –> Surgery Last ditch effort: manual detorsion (if successful, pt will have pain relief)
What is the most common cancer of young men?
Testicular cancer? HINT: YMCA “Young men CA”
Hx of testicular CA, cryptorchidism, Klinefelter syndrome and + FHX are risk factors for what form of cancer?
Testicular cancer
30 y/o M presents w/ painless, solid testicular swelling/nodule. He reports dull arch/heavy sensation in lower abd and scrotum. On exam you find inguinal or para-aortic lymphadenopathy. What is your presumed DX?
Testicular CA (Always examine unaffected testicle first)
If you find a firm, hard, fixed area on testicular exam, what is your concern until proven otherwise?
Testicular CA
What lymph node locations should you check if you are concerning about testicular CA?
Inguinal, para-aortic, supraclavicular
beta HCG, LDH, and AFP are tumor markers for what?
Testicular CA
Imaging for dx of testicular CA?
Scrotal US, CT abd/pelvis
Testicular tumors are primary made of what cell type?
Germ cells
Are seminoma or nonseminoma tumors more common in testicular cancer?
Nonseminoma: 65% (radiosensitive) Seminoma 35% (radioresistant)
Are seminoma or nonseminoma tumors radiosensitive? What is this used for?
Seminatous Used w/ nerve sparing retroperitoneal lymph node dissection for tumor staging
What should you offer to a pt prior to starting tx for testicular CA?
Sperm banking
Radical inguinal ochiectomy, radiation and chemo are used in the treatment of what?
Testicular CA
What condition is characterized as involuntary leakage of urine and has an increased prevalence as age increases?
Incontinence
What are the 4 groups of incontinence?
Urge incontinence, stress incontinence, mixed, incomplete emptying incontinence (overflow)
Which group of incontinence is uncontrolled loss of urine preceded by a strong, unexpected urge to void that involves uninhibited bladder contractions?
Urge incontinence
Stress incontinence is defined as leakage with exertion (Valsalva) due to dysfunction of what structure?
Urinary sphincter
What is the most common cause of stress incontinence?
Prostate surgery
Feelings of urgency and exertional leakage is defined as what group of incontinence?
Mixed incontinence
Impaired detrusor contractility and/or bladder outlet obstruction can lead to what group of incontinence and typically present with what sx?
Incomplete emptying incontinence (overflow), nocturnal enuresis
If a pt presents with incontinence, in additional to a detailed genital and rectal exam, what other systems would you want to evaluate on PE?
CV, abdominal, neuro
The following labs/ studies would be ordered if you were suspicious of what condition? UA, culture, BUN/ creatinine, PSA, postvoid residual volume, urine flow rate, urodynamic testing, bladder diary
Incontinence
What is the treatment for urgency incontinence? With or without BPH?
No BPH = antimuscarinic (tolterodine, fesoterodine, oxybutynin) BPH = alpha blockers (tamulosin, doxazosin, terazosin)
What is the treatment for stress incontinence?
Condom catheters, penile clamp, surgery (surgical options = transurethral bulking agents, perineal sling, artificial urinary sphincter)
What is the treatment for overflow incontinence?
Alpha blockers
Incontinence with presence of any of the following is considered what and is managed how? Severe sxs, pelvic pain, hematuria, elevated PSA/ abn prostate exam, recurrent urologic infections, previous pelvic radiation/ surgery, neurologic disease
Complicated incontinence, refer to urologist
What is the second most common urologic malignancy that is most common in men and associated with tobacco use and exposure to chemical dyes?
Bladder cancer
What are the most to least common types of bladder cancer? (3)
Transitional cell carcinoma > SCC > adenocarcinoma
Why is dx of bladder cancer often delayed?
Misdx of other urinary pathology
Although PE of a pt with bladder cancer is usually unremarkable, what should be performed to look for induration of prostate?
DRE (also lymph system and abd exam)
If a pt presents with painless gross hematuria or microscopic hematuria +/- obstructive or irritative urinary sxs, what should you be concerned for?
Bladder cancer
Local advancement of bladder cancer may present with what condition?
Para-aortic lymphadenopathy
Pt with bladder cancer and hepatomegaly, supraclavicular lymphadenopathy, or periumbilical nodules is concerning for what?
Metastasis (with pain consistent with areas of invasion or metastasis)
What is the gold standard for dx and staging of bladder cancer?
Cystourethroscopy
Although cystourethroscopy is gold standard for dx of bladder cancer, what other tests can be helpful?
UA, urine cytology/ urine-based tumor markers, CT w/ urography
What is the treatment for bladder cancer? What if it is high grade? What is muscle invasive?
Transurethral resection of tumor High grade require intra-vesical chemo Neoadjuvant systemic chemo prior to radical cystectomy
What condition is defined as a protrusion, bulge, or projection of an organ or part of an organ through the body wall that normally contains it?
Hernia
What type of inguinal hernia protrudes through Hesselbach’s triangle and is due to weakness in the floor of the inguinal canal?
Direct
What type of inguinal hernia develops at the internal inguinal ring and can travel through inguinal canal into the scrotum?
Indirect
Where does a femoral hernia occur?
Medial aspect of femoral canal
What type of inguinal hernia is most common, most common the R side, and is commonly congenital (although doesn’t present until later in life)?
Indirect
What type of inguinal hernia is the least common (although more common in women) and is most likely to become incarcerated/ strangulated?
Femoral
If a pt presents with heaviness/ discomfort with straining, N/V, abd distension, pain, redness, and a painless bulge on PE, what should you be concerned for?
Inguinal hernia
Aside from typical inguinal hernia findings, what additional findings will be noted for a pt with an incarcerated/ strangulated hernia?
Fever, +/- bowel obstruction, peritonitis, toxic appearance
What should be used to help with dx of an inguinal hernia if in doubt or you are trying to r/o other conditions?
US
What is the definitive treatment for inguinal hernias?
Surgical (repair urgent if incarcerated/ strangulated)
If an inguinal hernia is reducible, what is the next step of treatment/ management?
Elective surgery is viable
When is watchful waiting appropriate for the management of an inguinal hernia?
Minimal or no sxs
