Module 7: Male Reproductive Issues Flashcards
Benign Prostatic Hyperplasia
(BPH)
Enlargement of prostate gland leading to disruption
of urine outflow from bladder through urethra
Almost 50% of men will have signs of BPH by age
50; 70% by ages 60 to 69
Lower urinary tract symptoms (LUTS)
Difficulty starting a urine stream
Decreased/weaker flow of urine
Urinary frequency
Hormonal changes from aging process may
contribute
Excessive accumulation of DHT in prostate cells that
can stimulate overgrowth of prostate tissue
Increased proportion of estrogen over testosterone in blood
Develops in inner part of prostate—“transition zone”
As enlarges, leads to compression of urethra resulting in partial or complete obstruction
No direct relationship between overall size of prostate and severity of obstruction or symptoms; location is significant
Risk Factors
Risk factors for BPH
Aging
Obesity—increased waist circumference
Lack of physical activity
High intake of red meat and animal fat
Alcohol use
Erectile dysfunction (ED)
Smoking
Diabetes
Family history—first-degree relative
BPH Clinical Manifestations
Manifestations occur gradually
Early: bladder may initially compensate for small
amounts of resistance to urine flow
Symptoms worsen as obstruction increases
Lower urinary tract symptoms (LUTS)
Two groups
1. Irritative symptoms
2. Obstructive symptoms
Irritative symptoms
Inflammation or infection
* Nocturia—often first
* Urinary frequency
* Urgency
* Dysuria
* Bladder pain
* Incontinence
Obstructive symptoms
Caused by prostate enlargement— diameter of
urethra
* Decrease in caliber and force of urinary stream
* Difficulty initiating a stream
* Intermittency
Starting and stopping stream several times while
voiding
* Dribbling at end of urination
Symptom Index for BPH
The American Urological Association (AUA) uses
this tool to assess voiding symptoms
Symptom index (AUA-SI) for BPH
Not diagnostic but provides guidelines for treatment
High score = Increased symptom severity
Complications of BPH
Relatively rare
Acute urinary retention
* Sudden and painful inability to urinate
Treatment involves:
Catheter insertion
Surgery if severe
* Bladder damage can occur if treatment delayed
UTI
Incomplete bladder emptying/residual urine allows for
bacterial growth
If severe:
Pyelonephritis
Sepsis
Bladder calculi
Renal failure
Caused by hydronephrosis
Bladder damage
Diagnosing BPH
History and PE
Digital rectal exam (DRE)
Size, symmetry, and consistency
Urinalysis, urine culture and sensitivities
Prostate-specific antigen (PSA) level
Serum creatinine
Renal ultrasound
Neurologic exam
Postvoid residual (bladder scan)
Transrectal ultrasound (TRUS)
Biopsy
MRI of pelvis
Targeted biopsy
Uroflowmetry
Cystoscopy
Urodynamic/pressure flow studies
BPH Treatment
Goals
Restore bladder drainage
Relieve symptoms
Prevent/treat complications
Treatment based on
How bothersome are the symptoms
Presence of complications
Options: surveillance, drug therapy, or minimally
invasive procedures
BPH Conservative Therapy
Conservative therapy
Active surveillance—watchful waiting
* Mild symptoms (AUA score of 0-7)
* Lifestyle changes
Decrease bladder irritants
Restrict evening fluid intake
* Timed voiding schedule—bladder retraining
Get annual PSA and DRE
BPH Drug Therapy
Drug therapy—2 main classes
5α-Reductase inhibitors
α-adrenergic receptor blockers
More effective when used in combination
Treatment guided by AUA symptom index
5α-Reductase inhibitors
Blocks enzyme necessary for conversion of
testosterone to DHT
Decreased size of prostate gland
More effective for larger prostates with bothersome
symptoms
* Finasteride (Proscar)
* Dutasteride (Avodart)
* Jalyn (finasteride plus tamsulosin
5α-Reductase inhibitors
May lower risk of prostate cancer
Not recommended in prevention of prostate cancer
Discuss prostate cancer screening with HCP
α-Adrenergic receptor blockers
Promote smooth muscle relaxation and facilitate urinary
flow through urethra
Do not decrease size of the prostate
* Alfuzosin (Uroxatral)
* Doxazosin (Cardura)
* Prazosin (Minipress)
* Terazosin (Hytrin)
* Tamsulosin (Flomax)
* Silodosin (Rapaflo)
Side effect: retrograde ejaculation
Erectogenic drugs
Tadalifil (Cialis) effectively reduces symptoms of both
BPH and ED
Herbal therapy (Saw palmetto)
Research does not support beneficial effects
Discuss use of herbal therapy with HCP
BPH Minimally Invasive Therapy
Minimally invasive therapies
Becoming more common than surveillance and
invasive treatment
Few adverse events
Outcomes comparable to invasive technique
Photoselective vaporization of the prostate (PVP)—
laser light, with visual or ultrasound guidance, used
to vaporize prostate tissue
Works well for larger prostate glands
Increased urine flow and decreased symptoms
immediate
Irritative voiding symptoms persist for several weeks
Laser enucleation of the prostate
Transurethral laser beam used for rapid coagulation
and vaporization of prostatic tissue
* Holmium laser enucleation of the prostate (HoLEP)
* Thulium laser enucleation of the prostate (ThuLEP)
Doesn’t penetrate deep tissues leads to decreased
side effects
Prostatic urethral lift (PUL)
Permanent transprostatic implants or tension sutures
delivered through the urethra via cystoscope
Compresses prostate tissue to mechanically open the
prostatic urethra; no ablation
Newer procedure- Lack of data on
* Long-term durability
Rates of needing repeat treatment of TURP
Transurethral microwave therapy (TUMT)
Outpatient procedure; hold anticoagulants for 10 days before procedure; ~90 minutes
Delivers heat via microwaves directly to prostate
through a transurethral probe
Heat (113° F or 45° C) causes death of tissue, relief
of obstruction
* Rectal probe monitors temperature to prevent rectal
tissue damage
Common complication: postprocedure urinary
retention
* Patients go home with indwelling catheter for 2 to 7
days to maintain urinary flow
Antibiotics, pain medication, and bladder
antispasmodic medications are used to treat
symptoms and prevent problems
Transurethral needle ablation (TUNA)
Heat delivered from low-wave radiofrequency via
needle to prostatic tissue leads to localized necrosis
* Only tissue in direct contact with needle affected
Outpatient procedure; ~30 minutes
* Local anesthesia and IV or oral sedation
* Very little pain
Transurethral vaporization of the prostate (TUVP)
Electrosurgical modification of TURP
Vaporization and desiccation destroy obstructive
prostatic tissue
Results, side effects, and long-term outcomes are the
same as TURP
Uses bipolar energy deliver surface
Saline used for irrigation results in decreased risk for TUR syndrome
Water vapor thermal therapy
Water vapor/steam destroys obstructive prostate tissue
Transurethral delivery of steam by handheld device with retractable needle; 9 second doses
Minimizes risk of postprocedure ED
Newer procedure; long-term durability data pendin
Invasive Therapy: Surgery
Invasive treatment of BPH involves surgery
Factors for choice of treatment depend on:
* Size and location of prostatic enlargement
* Age and surgical risk
Indications:
Decreased urine flow causes discomfort
Persistent residual urine
Acute urinary retention
Hydronephrosis
ransurethral incision of the prostate (TUIP)
Several small incisions made into the prostate gland
to expand the urethra
* Relieves pressure and improves urine flow
* Local anesthesia used
Indication: moderate to severe symptoms with a small or moderately enlarged prostate gland
Transurethral resection of the prostate (TURP)
* Gold standard for obstructing BPH
* Surgical removal of prostate tissue through urethra
using a resectoscope
* Large 3-way indwelling catheter inserted
Provides post-op hemostasis
Facilitates urinary drainage
Transurethral resection (TURP)
Excellent outcome for most; decreased symptoms,
increased urine flow
Low risk- assess for
* TUR or TURP syndrome:
Nausea, vomiting, confusion, bradycardia, HTN
* Other postoperative complications
Bleeding and clot retention
Prostate Cancer
Most common cancer among males, excluding
skin cancer; second leading cause of cancer
death
ACS estimates 248,530 men will be diagnosed
and 34,130 will die in 2021
1 in 8 men have a risk of developing prostate
cancer in his lifetime
In United States, more than 3.1 million survivors
Postate Cancer Etiology
Slow-growing, androgen-dependent cancer
Most likely to develop in outer, peripheral zone
Can spread by 3 routes
Direct extension- seminal vesicles, urethral mucosa,
bladder wall, and external sphincter
Through lymph system- regional lymph nodes
Through bloodstream- to axial skeleton, liver, and
lungs
Known risk factors
Age, ethnicity, family history
Cultural and ethnic health disparities
Incidence rises markedly after age 50
Median age at diagnosis is 66 years old
Black men have highest rate but mortality rate is
declining
Asian Americans have lower incidence and mortality
than white men
Possible risk factors
Diet
* High red and processed meat intake
* High-fat dairy products
* Diet low in vegetables and fruits
Obesity
Environment
* Chemical pesticides
Smoking—unclear
Prostate Cancer Genetics
No single gene is known cause
Some genes or gene mutations are more common in
men with prostate cancer
Classified into 3 categories:
Sporadic (75%)
* Damage to genes occurs by chance
Familial (20%)
* Combination of genes and environment or lifestyle
factors
Hereditary (5% to 10%)
* Passed down through generations
Hereditary: a family with an inherited form of
prostate cancer has any of the following
characteristics
Three or more first-degree relatives with prostate
cancer
Prostate cancer in 3 generations on same side of
family
2 or more close relatives on same side of family
diagnosed with prostate cancer before age 55
Father, brother, son, grandfather, uncle, nephew
Hereditary breast and ovarian cancer syndrome
(HBOC)
Associated with mutations in BRCA1 and BRCA2
genes
Males with HBOC have an increased risk of breast
cancer and prostate cancer
Cause only a small percentage of familial prostate
cancers
Genetic testing may be appropriate
Prostate Cancer: Clinical
Manifestations and Complications
Asymptomatic in early stages
Eventually patient may have LUTS symptoms similar to BPH
Symptoms of metastasis
Pain in lumbosacral area that radiates down to hips or legs that is combine with urinary symptoms
Metastasis
Tumor can spread to pelvic lymph nodes, bones,
bladder, lungs, and liver
* Pain management is a major problem
Bone metastasis results in severe pain especially in
the back and legs due to spinal cord compression and
bone destruction
Diagnostics: PSA
Most males in United States are diagnosed by PSA
screening
Smaller cancers are being found in older men
Most slow-growing cancers probably do not need to
be treated
Many men live and die with prostate cancer—most
will not die from it
The American Urological Association (AUA) states
that males ages 55 to 69 years have the greatest
potential benefit from PSA screening
Recommend shared decision making and potential
screening every 2 years
Males at higher risk should have more personalized
screening schedule
High PSA levels do not always indicate prostate
cancer
Mild increases may occur with aging, BPH, recent
ejaculation, constipation, prostatitis, or after long bike
rides
Transient increases occur with cystoscopy, indwelling
urethral catheters, and prostate biopsies
Biopsy of the prostate tissue is usually indicated
when:
PSA levels are continually high
DRE is abnormal
Biopsy can confirm diagnosis of prostate cancer
Transrectal ultrasound procedure (TRUS)
* Transperineal—alternate approach to infection
MRI/ultrasound fusion biopsy
PSA is used to monitor treatment success
Levels should be undetectable with successful
prostatectomy, hormone therapy or radiation therapy
Regular measurement of PSA levels after treatment
important to
* Evaluate effectiveness of treatment
* Possible recurrence of prostate cancer
Indicators of advanced prostate cancer with bone
metastasis
serum alkaline phosphatase
Other tests used to determine location and extent of
metastasis
Whole body bone scan
CT scan of the abdomen and pelvis
MRI of pelvis
