Prostate and Male Reproduction Flashcards
What is the most common prostate gland condition in older men?
BPH- benign prostatic hyperplasia
Most common cause of urinary outlet obstruction in men >50yo
What are the consequences of untreated BPH?
stasis –> increased risk of UTIs, bladder stones
bladder decompensation over time –> chronic urinary retention w overflow, or renal failure dt high prs urinary retention
What influences the growth of the prostate gland?
Steroid hormones
BPH doesn’t occur in men who lack DHT (active metabolite of testosterone)- castrated or pseudohermaphrodite
As men age, estrogens rise and androgen levels fall
Which part of the prostate undergoes hyperplasia?
the transitional zone, aka periurethral area.
the periurethral glandular elements undergo hyperplasia, causing increase in glandular mass- this is what compresses the urethra and causes obstruction sx
Sx of BPH
urinary hesitancy intermittency decreased force of stream sensation of incomplete bladder emptying after voiding \+secondary sx
What are the “secondary sx” of BPH?
consequence of urinary stasis:
high post void residual volumes –> bacterail growth –> UTI
Stasis –> bladder caliculi
high prs chronic retention –> bilateral hydroureteronephrosis and renal failure
PhysEx for BPH
Rectal exam- enlarged symmetric rubbery gland. (size doesn’t matter)
palpate suprapubic region to r/o distended bladder
Dx Eval for BPH
Urine- sediment analysis and culture
Serum BUN and creatinine- look for renal insufficiency
Straight catheterization or bladder US if urinary retention suspected
Urinary flow rate
US, IVP, or CT to visualize the urinary tract
Transrectal US- to eval irreg prostate or elevated PSA levels
What is a urinary flow rate test, what value indicates obstruction?
Measure volume of urine voided during 5 seconds
flow rate of <50mL in 5 seconds is evidence of bladder outlet obstruction
What information can you get from imaging with US, IVP, CT?
size of prostate
presence of bladder stones
post-void residual volume
hydronephrosis
Goal of Rx for BPH
relax smooth muscle in prostate and bladder neck
to induce regression of cellular hyperplasia –> enhancing urinary outflow from bladder to urethra
What drugs are used for BPH?
Alpha blockers (terazosin)- causes smooth musc relaxation of both prostate and bladder neck. 5-a reductase inhibitors (finasteride)- block conversion of testosterone to DHT (but don't lower serum testosterone) 5-a-reductase inhibitors are only half as efficient as alpha blockers
When is surgery indicated in BPH?
When medical therapy fails. Postvoid residual of >100mL acute urinary retention chronic urinary retention w overflow dribbling gross hematuria more than once recurrent UTI patient request dt nocturia, dribbling
What surgery is done for BPH?
TURP- transurethral resection of prostate
put resectoscpe up urethera and into bladder, ID the tsu, shave it away using wire loop
Other than TURP, what procedures can also be done for BPH?
TUNA- transurethra needle ablation
Focused US
both are less invasive than TURP and work by heating local tsu
good short term results, but long term questionable
What is the most common malignancy of the male GU tract?
Prostate cancer but most (80%) are clinically silent dt indolent tumor growth and long latency period
What kind of cancer is prostate cancer?
95% adenocarcinoma
tumors arise from glandular epithelium in the peripheral zone of the prostate
What hormones influence prostate cancer growth?
testosterone stimulates tumor growth
estrogens and antiestrogens inhibit it
What is the grading/staging system for prostate ca
TNM
Gleason system, scores from 2(well differentiated) to 10(poorly differentiated)
HPE of prostate ca
Usu asx, detected on screening exam
Obstructive sx- poor stream, imcomplete bladder emptying, nocturia (misdx’d as BPH)
Mets- bony pain, ureteric obstruction
Digital rectal exam, PSA levels
What is T1-T2 for prostate ca
localized spread within prostate
What is T3-T4 for prostate ca
local spread to seminal vesicles or pelvic wall
What is the pattern of spread of prostate ca?
Via lymphatics: to iliac and periaortic nodes
Via circulation: to bone, lung, liver
Dx eval for prostate Ca
Hard nodule on rectal exam followed but with transrectal US and needle biopsy of the prostate
CXR- look for mets
LFTs- for liver mets
if bone mets suspected, do bone scan
Rx for prostate cancer T1-T2
radical prostatectomy
external-beam radiotherapy
interstitial radiation with implants
Rx for prostate ca T3-T4
exteral-beam radiation
+hormone therapy for advanced cases
Rx for mets of prostate ca
Hormonal ablation (most prostate ca is androgen sensitive)
To ablate testosterone production: bilateral surgical orchiectomy
Or, “chemical castration” using LH-RH agonists plus antiandrogens (flutamide, cyproterone)
If hormone-refractory, give chemo w docetaxel
What testicular disorders require surgery?
congenital abn
tumors
testicular torsion
What is cryptorchidism?
Failure of testicular descent.
Do not have speratogenic fn, but may retain ability to secrete androgens.
Increased risk of testicular ca
Increased inguinal hernias
HPE for cryptorchidism
Testicle is in abd, cannot be palpated
Rx for cryptorchidism
Surgery before 2 years old
Spermatic failure is progressive.
Should place testicle in scrotum- if not possible, do orchiectomy dt high rate of ca in abd testes
What is incomplete descent of testis?
Testicle arrested in path of normal descent- usu in inguinal canal bt deep and superficial rings.
Often a/w congenital indirect hernia bc processus vaginalis doesn’t obliterate.
Rx for incomplete descent of testis
Repositioning and orchiopexy w/in scrotum. Testicular fn is less compromised than cryptorchidism
If ing hernia too, fix that at the same time.
T/F Almost all tumors of the testicle are malignant.
True.
Most common malignancy of GU in men 20-35 yo.
How are testicular tumors classified?
Germ cell tumors (90-95%)
Non-germ cell tumors
Where do non-germ cell tumors (5-10%) arise from? What do they produce?
Leydig and Sertoli cells.
Make excess androgenizing hormones.
Where do germ cell tumors (95%) arise from?
totipotential cells of the seminiferous tubules
What are the categories of germ cell tumors?
seminomas
NSGCTs (non-seminomatous germ cell tumors)
T/F seminomas are slow-growing
True.
Seminomas are slow-growing germ cell tumors that exhibit late invasion. They are usu discovered and removed before there are mets.
T/F NSGCTs are more malignant than seminomas
True.
the non-seminoma germ cell tumors are more malignant and metastasize earlier than seminoma germ cell tumors
What are the kinds of NSGCTs?
embryonal (20%)
teratoma (5%)
choriocarcinoma (<1% but highly aggressive)
mixed cell type (40%)
HPE for testicular ca
Firm, painless testicular mass
Can cause dull ache sometimes
Acute pain if there is hemorrhage into necrotic tumor after minor trauma
10% have hx of cryptorchidism
if non-germ cell (5%)- can cause precocious puberty and virilism in boys; impotence and gynecomastia in adults (bc of excess androgen production)
Dx eval for testicular ca
Serum for AFP, B-hCG, (but seminomas are often neg for these); LDH
US
Level of tumor burden directly relates to level of tumor markers, so good for followup/recurrence testing
Rx for testicular ca
Radical orchiectomy for all.
if NS-GCT, to retroperitoneal lymph node dissection
Seminomas are highly radio-sensitive.
Adjuvant rad and chemo for both local and mets gives good 5 year survival
What is torsion of the spermatic cord?
Testicle twists on its own blood supply, causing pain and ischemic strangulation.
Urologic emergency- unsalvageable after 6 hrs
Why does torsion occur?
Abnormally high attachment of the tunica vaginalis around the distal end of the cord- allows testis to hang within tunica compartment (“bell clapper deformity”). THis means it can twist easily.
HPE for testicular torsion
Young male w rapid onset severe testicular pain and swelling.
High-riding, swollen, tender testicle, horizontal orientation
Pain worse w elevation of testes
Cremasteric reflex often absent
Dx Eval for testicular torsion
Color-flow Doppler- no flow confirms Dx
DD for testicular torsion
torsion of spermatic cord
advanced epididymitis
torsion of appendix testis
appendix epididymis
Rx for testicular torsion
Surgical exploration immediately, orchiopexy.
Bell clapper deformity is usu bilateral, so do orchioplexy of unaffected testicle too.
Uncorrected torsion causes necrosis of testicle.
