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Surgery > Prostate and Male Reproduction > Flashcards

Prostate and Male Reproduction Flashcards

1
Q

What is the most common prostate gland condition in older men?

A

BPH- benign prostatic hyperplasia

Most common cause of urinary outlet obstruction in men >50yo

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2
Q

What are the consequences of untreated BPH?

A

stasis –> increased risk of UTIs, bladder stones
bladder decompensation over time –> chronic urinary retention w overflow, or renal failure dt high prs urinary retention

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3
Q

What influences the growth of the prostate gland?

A

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

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4
Q

Which part of the prostate undergoes hyperplasia?

A

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

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5
Q

Sx of BPH

A 
urinary hesitancy
intermittency
decreased force of stream
sensation of incomplete bladder emptying after voiding
\+secondary sx
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6
Q

What are the “secondary sx” of BPH?

A

consequence of urinary stasis:
high post void residual volumes –> bacterail growth –> UTI
Stasis –> bladder caliculi
high prs chronic retention –> bilateral hydroureteronephrosis and renal failure

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7
Q

PhysEx for BPH

A

Rectal exam- enlarged symmetric rubbery gland. (size doesn’t matter)
palpate suprapubic region to r/o distended bladder

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8
Q

Dx Eval for BPH

A

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

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9
Q

What is a urinary flow rate test, what value indicates obstruction?

A

Measure volume of urine voided during 5 seconds

flow rate of <50mL in 5 seconds is evidence of bladder outlet obstruction

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10
Q

What information can you get from imaging with US, IVP, CT?

A

size of prostate
presence of bladder stones
post-void residual volume
hydronephrosis

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11
Q

Goal of Rx for BPH

A

relax smooth muscle in prostate and bladder neck

to induce regression of cellular hyperplasia –> enhancing urinary outflow from bladder to urethra

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12
Q

What drugs are used for BPH?

A 
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
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13
Q

When is surgery indicated in BPH?

A 
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
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14
Q

What surgery is done for BPH?

A

TURP- transurethral resection of prostate

put resectoscpe up urethera and into bladder, ID the tsu, shave it away using wire loop

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15
Q

Other than TURP, what procedures can also be done for BPH?

A

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

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16
Q

What is the most common malignancy of the male GU tract?

A 
Prostate cancer
but most (80%) are clinically silent dt indolent tumor growth and long latency period
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17
Q

What kind of cancer is prostate cancer?

A

95% adenocarcinoma

tumors arise from glandular epithelium in the peripheral zone of the prostate

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18
Q

What hormones influence prostate cancer growth?

A

testosterone stimulates tumor growth

estrogens and antiestrogens inhibit it

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19
Q

What is the grading/staging system for prostate ca

A

TNM

Gleason system, scores from 2(well differentiated) to 10(poorly differentiated)

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20
Q

HPE of prostate ca

A

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

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21
Q

What is T1-T2 for prostate ca

A

localized spread within prostate

22
Q

What is T3-T4 for prostate ca

A

local spread to seminal vesicles or pelvic wall

23
Q

What is the pattern of spread of prostate ca?

A

Via lymphatics: to iliac and periaortic nodes

Via circulation: to bone, lung, liver

24
Q

Dx eval for prostate Ca

A

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

25
Q

Rx for prostate cancer T1-T2

A

radical prostatectomy
external-beam radiotherapy
interstitial radiation with implants

26
Q

Rx for prostate ca T3-T4

A

exteral-beam radiation

+hormone therapy for advanced cases

27
Q

Rx for mets of prostate ca

A

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

28
Q

What testicular disorders require surgery?

A

congenital abn
tumors
testicular torsion

29
Q

What is cryptorchidism?

A

Failure of testicular descent.
Do not have speratogenic fn, but may retain ability to secrete androgens.
Increased risk of testicular ca
Increased inguinal hernias

30
Q

HPE for cryptorchidism

A

Testicle is in abd, cannot be palpated

31
Q

Rx for cryptorchidism

A

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

32
Q

What is incomplete descent of testis?

A

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.

33
Q

Rx for incomplete descent of testis

A

Repositioning and orchiopexy w/in scrotum. Testicular fn is less compromised than cryptorchidism
If ing hernia too, fix that at the same time.

34
Q

T/F Almost all tumors of the testicle are malignant.

A

True.

Most common malignancy of GU in men 20-35 yo.

35
Q

How are testicular tumors classified?

A

Germ cell tumors (90-95%)

Non-germ cell tumors

36
Q

Where do non-germ cell tumors (5-10%) arise from? What do they produce?

A

Leydig and Sertoli cells.

Make excess androgenizing hormones.

37
Q

Where do germ cell tumors (95%) arise from?

A

totipotential cells of the seminiferous tubules

38
Q

What are the categories of germ cell tumors?

A

seminomas

NSGCTs (non-seminomatous germ cell tumors)

39
Q

T/F seminomas are slow-growing

A

True.
Seminomas are slow-growing germ cell tumors that exhibit late invasion. They are usu discovered and removed before there are mets.

40
Q

T/F NSGCTs are more malignant than seminomas

A

True.

the non-seminoma germ cell tumors are more malignant and metastasize earlier than seminoma germ cell tumors

41
Q

What are the kinds of NSGCTs?

A

embryonal (20%)
teratoma (5%)
choriocarcinoma (<1% but highly aggressive)
mixed cell type (40%)

42
Q

HPE for testicular ca

A

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)

43
Q

Dx eval for testicular ca

A

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

44
Q

Rx for testicular ca

A

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

45
Q

What is torsion of the spermatic cord?

A

Testicle twists on its own blood supply, causing pain and ischemic strangulation.
Urologic emergency- unsalvageable after 6 hrs

46
Q

Why does torsion occur?

A

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.

47
Q

HPE for testicular torsion

A

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

48
Q

Dx Eval for testicular torsion

A

Color-flow Doppler- no flow confirms Dx

49
Q

DD for testicular torsion

A

torsion of spermatic cord
advanced epididymitis
torsion of appendix testis
appendix epididymis

50
Q

Rx for testicular torsion

A

Surgical exploration immediately, orchiopexy.
Bell clapper deformity is usu bilateral, so do orchioplexy of unaffected testicle too.
Uncorrected torsion causes necrosis of testicle.

Surgery (20 decks)

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