OME - Male GU

Answer 1

Prostatic Hyperplasia, Benign (BPH)

Path:

Benign prostatic hyperplasia (BPH) is due to proliferation of both the smooth muscle and epithelial cell lines of the prostate which causes increased volume and may cause compression of the urethra and obstructive symptoms.

What will hypertrophy in response to increasing outlet obstruction?

Bladder detrussor muscle

S/Sx (LUTS): Clinically presents with storage and/or voiding symptoms collectively referred to as lower urinary tract symptoms (LUTS). These include difficulty initiating stream, frequency, or dysuria.

How do Symptoms correlate to prostate volume. Symptoms do not directly correlate to prostate volumeIt is estimated that half of all men with histologic evidence of BPH experience moderate to severe LUTS.

What is sequelae of untreated BPH?

Progression may result in upper and lower tract infections and may progress to direct bladder outlet obstruction and acute renal failure (ARF).

Incidence
Incidence increases with age; estimates of prevalence vary from 70% to 90% by the age of 80 years (estimated at 8–20% by age 40 years).

Risk Factors

Most significant risk factor is age.

Increased risk with higher free prostate-specific antigen (PSA) levels, heart disease, and use of β-blockers

Low androgen levels from cirrhosis/chronic alcoholism can reduce the risk of BPH.

Obesity and lack of exercise can cause LUTS to be more significant.

No evidence of increased or decreased risk with smoking, alcohol, or any dietary factors

General Prevention

The disease appears to be part of the aging process.

Symptoms can be managed through weight loss, regulation of fluid intake, decreased intake of caffeine, and increased physical activity.

Whare are Commonly Associated Conditions of BPH?

LUTS -LUTS can also be secondary to cardiovascular, respiratory, or renal disease (1).

Sexual dysfunction, including erectile dysfunction and ejaculatory disorders

What are the two divisions of LUTS?

LUTS can be divided into two groups: filling/storage symptoms and voiding symptoms.

What are the Filling/storage symptoms?

include frequency, nocturia, urgency, and urge incontinence.

What are the Voiding symptoms?

include difficulty initiating stream, need to strain or push to initiate a stream; incomplete voiding, or weak stream.

BPH can lead to acute or chronic obstructive symptoms What are the conditions of prolong obstruction?

hydronephrosis; compromised renal function including post renal azotemia.

Diagnosis: History?

• Evaluate symptom severity with the American Urological Society Symptom Index or the International Prostate Symptom Score (IPSS).
• Screen for other causes of symptoms such as infection, procedural history, or neurologic causes.
• Evaluate for comorbid conditions which may produce similar symptoms such as diabetes, congestive heart failure (CHF), or Parkinson disease.
• Review medication list. Particularly diuretics and anticholinergic medications; also, decongestants (increased sphincter tone), opiates (impaired autonomic function), or tricyclic antidepressants (anticholinergic effects)
• Review family history for BPH and prostate cancer.
• Screen for gross hematuria.
• Collect IPSS scoring of LUTS

Diagnosis: Physical Exam?

• Digital rectal exam (DRE) finding of symmetrically enlarged prostate, nodules and but size does not always correlate with symptoms
• Signs of renal failure due to obstructive uropathy (edema, pallor, pruritus, ecchymosis, nutritional deficiencies)
• If DRE is suggestive of prostate cancer, or if there is hematuria, recurrent infections, concern for stricture, or evidence of neurologic disease, the patient should be referred to urology.

What Diagnostic Tests & Interpretation

• Urinalysis (UA) in all patients presenting with LUTS can help rule out other etiologies such as bladder/kidney stones, cancer, UTI, or urethral strictures.
• PSA for men with a life expectancy of 10 years and who would be surgical candidates if prostate cancer was identified
• With bladder cancer risk factors (smoking history or hematuria), obtain urine cytology.
• If nocturia is the main concern, consider using a frequency volume chart for urine output.
• Sleep study if OSA or primary nocturnal polyuria is suspected
• Serum creatinine measurement is not recommended (AUA recommendation).

What can a PSA provide?

PSA levels also correlate with prostate volume which can help guide treatment choice.

Specialized tests when medical management doesn’t work BONUS

Uroflow: volume voided per unit time (Peak flow <10 mL/sec is abnormal.)

Postvoid residual (PVR): either with catheterization or bladder ultrasound (>100 mL = incomplete emptying)

Transrectal ultrasound: assessment of gland size; not necessary in the routine evaluation

Abdominal ultrasound: can demonstrate increased PVR or hydronephrosis; not necessary in the routine evaluation

Diagnostic Procedures/Other BONUS

Pressure-flow studies (urine flow vs. voiding pressures) to determine etiology of symptoms

Obstructive pattern shows high voiding pressures with low-flow rate.

Cystoscopy

Demonstrates presence, configuration, cause (stricture, stone), and site of obstructive tissue

May help determine therapeutic option

Not recommended in initial evaluation unless other factors, such as hematuria, are present

Treatment

Mild symptoms (score of <7) or moderate symptoms (score 8 to 15) that are nonbothersome require no treatment. Reevaluate annually.

For moderate to severe symptoms, try lifestyle interventions regulation of fluid intake, avoidance of alcohol and caffeine, exercise, diet, and eliminating/reducing contributing medications.

Medical treatment requires interval follow-up of 2 to 4 weeks for α-blockers and 3 months for 5-α-reductase inhibitors until symptoms improved and then annually.

Patients with complications including obstruction and urinary retention require bladder drainage.

Medication

Should be used as additive therapy; lifestyle modifications are still encouraged.

What are the Two main classes of medications:

α-adrenergic antagonists and 5-α-reductase inhibitors

The combination of these two medication classes is effective for long-term management of BPH and demonstrated large prostates.

What is the First-line option for moderate/severe and bothersome LUTS

α-Adrenergic antagonists

MOA and monitoring:

Affect contraction of smooth muscle in the prostatic urethra and bladder neck. Show benefit over placebo. Typically take 2 to 4 weeks to show improvement. May affect blood pressure; require dose titration and blood pressure monitoring.

What does AUA recommend?

alfuzosin (Uroxatral), doxazosin (Cardura), and tamsulosin (Flomax) because they are thought to be more selective and have less effect on blood pressure. terasosyn

Prazosin (Minipress) and phenoxybenzamine (Dibenzyline) have insufficient evidence and are not recommended.

Most common adverse effect/SE

• dizziness; may cause orthostatic hypotension
• greater than expected increase in stroke and HF. Do not use solo or as a first line HTN medications.

What are Contraindications for these meds?:

• Use caution in patients who are also using phosphodiesterase type 5 inhibitors for erectile dysfunction.
• Do not use in men pursuing cataract surgery until they are postoperative due to the risk for perioperative floppy iris syndrome

2nd line medication category? with 2 examples

• 5-α-Reductase inhibitors
• Finasteride (Proscar): 5 mg/day PO
• Dutasteride (Avodart): 0.5 mg/day PO

MOA:

Block conversion of testosterone to dihydrotestosterone, gradually reduce prostatic volume AKA size therefore are of most benefit when prostate volume exceeds 40 mL. Require 6 months to show clinical benefit.

Side effects:

include decreased libido and erectile dysfunction.

A PSA value in a patient taking a 5-α-reductase inhibitors will be artificially low by up to 50%.

Is Combination therapy of α-blocker plus 5-α-reductase inhibitor ok?

Combination therapy of α-blocker plus 5-α-reductase inhibitor is superior to monotherapy with an α-blocker BUT only in men with evidence of enlarged prostates.

Combination therapy is superior to monotherapy to prevent progression but increase risk of drug-related adverse events.

cAN anticholinerigcs ever be used?

Anticholinergic agents are appropriate for irritative LUTS without an elevated PVR (NO EVIDENCE OF OBSTRUCTION/RETENTION).

What are some options?

• Options include solifenacin (VESIcare),
• tolterodine (Detrol LA), or
• oxybutynin (Ditropan XL);
• should be avoided in patients with PVR >250 mL

If patient also experiences erectile dysfunction, phosphodiesterase-5 inhibitors have been shown to have mild improvement of LUTS; can use tadalafil (Cialis): 5 mg/day PO but avoid use in combination with α-blockers or in those with CrCl <30 mL/min

Geriatric Considerations
Use caution with anticholinergics, antihistamines, sympathomimetics, tricyclic antidepressants, and opioids.

Issues For Referral

• Moderate or severe LUTS that does not respond to medical management
• BPH-related complications such as recurrent UTIs or hematuria, renal insufficiency, and urinary retention
• Abnormal PSA or prostate exam
• Any history of urethral trauma or stricture, or neurologic disease of the bladder/urinary system
• Recurrent or persistent UTIs due to prostatic obstruction
• Recurrent gross hematuria due to enlarged prostate
• Bladder calculi

Whare some Complementary Medicines?

None currently recommended.

How do I do Patient Monitoring

• Symptom index (IPSS) monitored every 3 to 12 months
• DRE yearly in patients who choose watchful waiting
• PSA yearly in patients who choose watchful waiting: should not be checked while patient is in retention, recently catheterized, or within a week of any surgical procedure to the prostate
• Consider monitoring PVR, if elevated.

Lifestyle: Diet

Avoid large boluses of oral or IV fluids or alcohol intake; caffeine may exacerbate symptoms as well.

Patient Education

National Kidney and Urologic Diseases Information Clearinghouse, Box NKUDIC, Bethesda, MD 20893; 301-468-6345

Prognosis

Symptoms improve or stabilize in 70–80% of patients.

25% of men with LUTS will have persistent storage symptoms after prostatectomy.

Of men with BPH, 11–33% have occult prostate cancer.

Complications

Urinary retention (acute or chronic)

Bladder stones

Prostatitis

Hematuria

Answer 2

Offer STI testing for all who test positive for a single STI

Test possibilities: HIV, Hep B, syphillis; also Hep C and HSV;

Immunizations for A, Hep B; HVP

Chancroid

Causitive organism:

Haemophilius ducreyi

S/sx:

ulcer, multiple lesions, inguinal lymphadenitis

Treatment: Azithromycin 1g; ceftriaxone IM; Cipro 500 mg TID

Genital Herpes: Causative organism:

HSV 2 or less common HSV 1

S/sx:

commonly asymptomatic; painful ulcerated genital lesion, inguinal lymphadenopathy, fever, body aches.

Where is the virus found?

intact skin, lesions, mucosal surfaces, genital secretions and oral secretions.

How frequent is virus shed in asymptomatic pt?

10%

how is it detected?

PCR of a genital lesion;

Purpose of serology?

AB in the blood; detect a new infection from a recurrent infection

Percentage of people with HSV-2? and % of these with a clinically evident disease?

15%; 10-20%

Treatment:

acyclovir

Nongonococcla urethritis

Causitive organism:

C. trachomatis and mycoplasma genitalium

S/sx:

irritative voiding symptoms; occasional mucopurlent discharge

treatment:

Azithromycin

gonococcal urethritis

Causitive organism:

N. gonorrhoeae usu with beta lactamase activity

S/sx:

irritative voiding symptoms; occasional mucopurlent discharge with occasional blood contains large numbers of WBCs. but most men are asymptomatic

treatment

ceftriaxone IM (or cefexime- oral) plus (for coinfection with trichomatis) azithromycin

Pen allergy; azithromycin plus

Genital Warts (condyloma acuminatum -verruciform lesion). most common?

HPV 6 or 11 (16. 18. 30. 33 associated with GU malignancies)

S/sx:

verruca form lesions or subclinical

treatment:

similar to wart therapy. podofilox, imiquimod; cryotherapy,

Prevention:

Gardisil (9-45 years)

Blanitis

inflamation of the glans of the penis

Causitive: Candida, Group B Strep, gardnerella

Treatment: Oral azole; metonidazole

Trichanomniasis

Trichamonisis

usu free of symptoms

oral metroniadzole avoid alcohol for 24 hrs post therapy,

Syphilis

causative organism

treponema pallidum

The onset of symptoms?

2 to 4 weeks after contact

s/sx of primary, secondary and tertiary

Primary: Chancre (firm round painless genital or anal ulcer) localized lymphadenopathy; then resolved;

2nd state: nonpruritic diffuse skin rash esp on hands and soles of feet; gen lymphadenopathy; malaise, arthralgias and myalgia, HA

tertiary: Gumma (granulomatous lesion involving the skin, mucous membranes, bone, aortic insufficiency, aortic aneurysm,

Treatment: depends on stage:

Stage 1 and 2: penicillin G IM preferred.; doxy or tetra with Pen allergy

Stage 3: Pen G IM q week for 3 weeks

Lymphogranuloma Venereum

Causitive

chlymadia trachomatis

s/sx:

vesicular or ulcerative lesion on external genitalia iwth inguinal lymphadenitis or buboes. symptoms typically occur after 4-6 weeks.

treatment:

doxycycline

erythromycin

Answer 3

Causative organism epididymitis-orchitis M < 35

N. Gonorrhoeae C. Trachonatis

S/Sx

irritative voiding, fever, swelling of scrotum and epididymis

and treatment

Ceftriaxone IM plus doxycycline. elevate scrotum

Causative organism epididymitis-orchitis M > 35 or insertive anal.

Enterobacter (coliform)

S/Sx

irritative voiding, fever, swelling of scrotum and epididymis

and treatment

ofloxacin or levo;

Answer 4

Prostatitis Description

Painful or inflammatory condition affecting the prostate gland with or without bacterial etiology.

What are the classes with symptoms? focus on 1 & II

Class I: acute bacterial prostatitis: symptomatic with fever, perineal pain, dysuria, and obstructive symptoms; polymorphonuclear leukocytes (PMNL) and bacteria in urine

Class II: chronic bacterial prostatitis: symptomatic chronic or recurrent bacterial infection with pain and voiding disturbances; PMNL and bacteria in expressed prostatic secretions (EPS), or urine after prostate massage, or in semen

Class III: chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)

Inflammatory (subtype IIIA): chronic symptoms with PMNL in EPS/urine after prostate massage or in semen

Noninflammatory (subtype IIIB): chronic symptoms without presence of PMNL in EPS/urine after prostate massage or in semen

Class IV: asymptomatic inflammatory prostatitis: incidental finding during prostate biopsy for infertility, cancer workup; presence of PMNL and/or bacteria in EPS/urine after prostatic massage or in semen

Epidemiology

Predominant age: 30 to 50 years old, sexually active; chronic is more common in those >50 years.

Etiology and Pathophysiology of Class I

Acute bacterial prostatitis (class I)

Likely, etiology from ascending urethral infection with intraprostatic reflux of infected urine into prostatic ducts, often associated with cystitis

Most common causative organism in men over 35?

gram-negative bacteria (Escherichia coli [most common gram negative rods]; Proteus, Klebsiella, Serratia, and Enterobacter species; Pseudomonas aeruginosa)

Most common causative organism in men < 35?Consider Neisseria gonorrhoeae or C. trachomatis in sexually active men <35 years.

Chronic bacterial prostatitis (class II)

Causitive organism?

CP/CPPS (class III). (bonus material)

Unclear etiology, possibly due to difficult-to-culture infection but noninfectious etiology also proposed

Risk Factors

• Urinary tract infections
• HIV infection
• Prostatic calculi
• Urethral stricture
• Urinary catheterization: indwelling, intermittent
• Genitourinary instrumentation, including prostate biopsy (especially in patients with prior quinolone intake), transurethral resection of prostate, cystoscopy
• Urinary retention
• Benign prostatic hypertrophy
• Unprotected sexual intercourse
• Trauma (e.g., bicycle, horseback riding)

General Prevention

Antibiotic prophylaxis for genitourinary instrumentation and prostatic biopsy

Diagnosis/History/Acute prostatitis (class I):

• Acutely ill with fever, chills, malaise
• Low back pain, myalgias
• Frequency, urgency, dysuria, nocturia
• Prostatodynia, pelvic pain, perineal pain
• Cloudy urine
• Obstructive voiding symptoms: poor stream, hesitancy

Chronic prostatitis (classes II and III):

• More insidious presentation than class I
• Symptoms for 3 of 6 previous months
• Low-grade fever (class II only)
• Prostatodynia, perineal pain
• Dysuria, frequency, urgency
• Lower abdominal pain
• Low back, testicular, and/or penile pain
• Hematospermia
• Sexual dysfunction/painful ejaculation

Physical Exam

• Vital signs (Unstable vitals suggest sepsis.)
• Back exam (CVA tenderness)
• Abdominal exam (bladder distension)
• Prostate exam I, II, III

Class I: Prostate is very tender, warm, firm, and edematous.

Class II: often normal but enlarged, tender, edematous, nodular prostate also encountered

Class III: often normal prostate

ALERT??
Avoid vigorous massage of the prostate in acute bacterial prostatitis; may induce iatrogenic bacteremia; safe if done gently

• *Diagnostic Tests & Interpretation**
• *For Suspected acute prostatitis (class I)?**
• Urinalysis; urine Gram stain/culture and sensitivity
• CBC with differential; blood culture if fever, chills, or signs of sepsis are present

Suspected chronic bacterial prostatitis (class II)?

• Urinalysis; urine/EPS/semen: Gram stain/culture and sensitivity
• Review previous urine culture results.
• National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI): 9-question symptom survey

Treatment

• Analgesics/antipyretics/stool softeners
• Hydration
• Sitz baths to relieve pain and spasm
• Suprapubic catheter for urinary retention
• Anxiolytics, antidepressants if anxiety and/or depression are present

Medication

First Line
Acute bacterial (outpatient) (1)[A]

Men < 35?

ceftriaxone IM and doxycycline

Men > 35 or MSM?

gram - coverage with excellent tissue penetration

Fluoroquinolone (ciprofloxacin 500 mg PO q12h or levofloxacin 500 mg PO once daily) for 2 to 4 weeks

Trimethoprim-sulfamethoxazole 1 double-strength tablet PO q12h for 2 to 4 weeks or

If at risk for sexually transmitted infection (STI) pathogens: ceftriaxone 250 mg IM for 1 dose plus doxycycline 100 mg PO q12h daily for 1 week or azithromycin 1 g PO single dose

Chronic bacterial (class II) (1,2,3)[A],(4)[C]

Fluoroquinolone (e.g., levofloxacin 500 mg PO) once daily for 4 weeks or ciprofloxacin 500 mg PO q12h for 4 to 12 weeks Combination therapy with azithromycin may help to eradicate atypical pathogens.

Anti-inflammatory agents for pain symptoms and α-blockers for urinary symptoms

CP/CPPS (class III) (4)[C],(5,6)[A]

Heterogeneous condition with no universally effective treatment

Urology referral if antibiotic treatment fails, symptoms persist (especially obstructive voiding symptoms), hematuria, elevated PSA; or for surgical drainage if an abscess persists after ≥1 week of therapy

Answer 5

Prostate Cancer lifetime risk and clinically significant risk? chance of dying?

40% overall. 10% clinically significant. 3% risk of dying; 2nd leading cause of cancer death

Risk factors?

age, African American; family hx of prostate cancer; obesity

What is a normal PSA?

< 4 ng/ml

What PSA should prompt further investigation?

serial increases

What interval of screening?

PSA < 2.5 ng/mL. every 2 years

PSA ≥ 2.5 ng/mL. every 1 year

Testicular torsion S/SX

testicular swelling, unilateral scrotal pain, the testicle is a horizontal lie, absent cremasteric reflex, scrotal elevation has no effect on pain.

Imaging:

color flow Doppler ultrasound for blood flow

Any particular side?

left most often

treatment?

surgical detorsion and orchiopexy (tack down the testicle)

Varicocele?

dilated spermatic vein

s/sx?

bag of worms, Present when standing but disappears when supine.

Treatment options?

open surgery, laparoscopic surgery,

ED:

Any disease that causes issues with nerves or blood supply can have an effect on erections. HTN,DM

TX:

Treat underlying cause

Phosphodiesterase 5 (PDE-5) enhance nitric oxide with relaxes smooth muscle

PDE-5 with the longest half-life?

tadalafil (Cialis) can be used daily at a low dose

What drugs must be avoided?

nothing with a nitrate - severe hypotension

other options?

• drugs injected into the penis or put into the urethra; alprostadil
• mechanical vacuum devise
• prosthetic devices

Answer 6

When to screen for HIV?

Screen for HIV from 13-64

How long before antibodies to HIV are detected?

3-12 weeks

When should a test be done after exposure? What type of test?

AG/Ab test within 2-6 weeks after exposure.

This is a preliminary test. Use additional test such as western blot for confirmatory testing.