Prostrate & Scrotum/Testes Flashcards
What is BPH?
Discuss the pathphysiology
Is it common?
- Benign prostatic hyperplasia is enlargement of prostrate gland due to hyperplasia of the glandular epithelial & stromal tissue of prostate.
- Prostrate converts testosterone into DHT using 5-alpha reductase; DHT is more potent. Prostate remains responsive to testosterone throughout lifetime- unlike other organs. Androgens have a role in the hyperplasia.
- Very common:
- 40% of >50yrs have enlargement
- 90% of >80yrs have enlargement
State some risk factors for BPH
- Age
- Family history
- Afro carribean ethnicity
- Obesity
Describe clinical features of BPH
- LUTs
- Voiding: hesitancy, weak stream, terminal dribbling, incomplete emptying
- Storage: urinary frequency, noctural, nocturnal enuresis urge incontinence
- Haematuria (less common)
- Haematospermia (less common)
Before you do any investigations, alongside your history what else should you do if you suspect BPH?
- DRE
- IPSS (International prostrate symptom score)
Remind yourself of a summary of the IPSS
What investigations would you do if you suspect BPH?
For each, state why
- Urinary frequency volume chart
- Urinalysis (rule out UTI)
- Post void bladder scan (is there any retention)
- Flow rate (poor flow suggest obstruction)
- PSA (raised in malignancy- but may also be slightly raised anyway)
- USS of renal tract (volume of prostrate, retention, hydronephrosis)
- Urodynamic studies (can work out Bladder Outlet Obstruction Index using values from this. This can help diagnoses obstruttive voiding related to bPH)
Discuss the management of BPH, include:
- Conservative
- Medical
- Surgical
Conservative
- Lifestyle advice: moderating caffeine & alcohol intake, not drinking excessive fluid
- Double voiding
- Medication review
Medical
- Alpha adrenoceptor blocker e.g. tamsulosin
- Add 5-alpha-reductase inhibitors e.g. finasteride
Surgical
- TURP (transurethral resection of prostate)
- TUVP (transurethral electrovapourisation of prostate)- uses electrical current
- Holmium laser enucleation of prostate (HoLEP)
- Open prostatectomy via abdo or perineal incision
Explain how alpha-adrenoceptor blockers work
State some side effects
- Block alpha-adrenoceptors hence they relaxing the muscles in bladder and prostrate (relaxes muscles around bladder neck)- aims to reduce outflow obstruction
- Side effects:
- Hypotension (dizziness, falls etc…)
- Ejaculation problems (little or not ejaculate)
Explain how 5-alpha reductase inhibitors work in BPH
How long do they take to work?
Side effects?
Use when having intercourse with woman of child bearing age?
- 5-alpha reductase converts testosterone into DHT. Inhibits 5-alpha reductase hence decreases DHT formation. Androgens cause prosatic enlargement and DHT is more potent than tesosterone. Hence preventing DHT formation decreases prostatic volume
- 6 months
- Side effects:
- Decreased libido
- Decreased volume of ejactulate
- Can get into semen and harm unborn baby therefore if having intercourse with partner who is pregnant or may get pregnant must wear condom
For TURP, discuss:
- Procedure
- Potential complications
*complications can be remembered by FIRES HIT
- Endoscopic removal of the obstrutive prostate tissue, to increase urethral lumen size, using diathermy loop
- Potential complications:
- Failure to resolve symptoms
- Incontinence (1 in 10 have early, 1in 100have long term)
- Retrograde ejaculation (80%)
- Erectile dysfunction (10%)
- Urtethral strictures
- Haemorrhage
- Infection
- TURP syndrome
State some potential complications of BPH
- High pressure retention (which has complications such as AKI)
- Recurrent UTIs
- Significant haematuria episodes
What is TURP syndrome?
- Rare, life-threatening complications of TURP
- TURP using monopolar energy (electric current flowing in one direction) requires use of hyperosmolar irrigation
- If fluid enters circulation through exposed venous beds can cause fluid overload & hyponatraemia
- Presentation:
- Confused
- Nausea
- Agitation
- Visual cahnges
- Must reduce fluid overload and carefully corec hyponatraemia
- Increasingly rare as now use bipolar energy (energy stays in device) which uses isotonic irrigation fluids so TURP syndrome risk reduced
Prostate cancer is not the most common cancer in men; true or false?
FALSE- it is the most common cancer in men
State some risk factors for prostate cancer- highlight main ones
- Age
- Ethnicity (afrocarribean twice as likely as caucasian)
- FH of prostate Ca (only 9%)
- BRCA1 or BRCA 2 gene
- Smoking (increase risk of prostate ca related death)
- DM
- Obesity
- Degree of exercise (protective)
Discuss the pathophysiology of prostrate cancer, include:
- Hormones that influence it
- Most common type of ancer
- Which zone in prostate the cancer typically occurs
- Aetilogy unknown but agreed that growth of prostrate cancer influenced by androgens
-
Majority of adenocarcinomas (>95%):
- Acinar adenocarcinoma: originate in glandular cells- most common form
- Ductal adenocarcinoma: originates in cells that line ducts. Tends to grow & metastatise further than acinar
- Zones affected:
- 75% arise from peripheral zone
- 20% in transitional
- 5% central
- Often multifocal
Describe the clinical features of prostrate cancer
Symptoms depends on stage of disease:
- LUTs: weak stream, increased frequency, urgency, haematuria, dysuria, incontinence, haematospermia, suprapubi pain, rectal tenesmus, loin pain
- Lethargy
- Unexplained weight loss
- Boone pain
- Anorexia
What examination is KEY if you suspect prostrate cancer?
DRE
- Asymmetry
- Nodularity
- Fixed irregular mass
What investigations should you do for suspected prostate cancer?
-
PSA
- Further calculations can be done e.g. free:total PSA ratio (low= increased chance cancer), PSA density (high= increased chance cancer)
-
Biopsies:
- Transperineal
- Transrectal ultrasound guided (TRUS)
- Multi-parametric MRI
- Staging CT/CT abdo pelvis
- Isotope bone scan
- *NOTE: if first biopsy negative a repeat biopsy is reccommended if rising or elevated PSA and/or suspicious DRE*
- *NOTE: some centres do MRI prior to biopsy to identify abnormal areas and guide biopsy. Some only do if had negative biopsy for for active surveillance*
When should you do PSA test and why?
Traditionally do PSA piror to DRE to avoid stimulating release of PSA
What is the defintive investigation for diagnosing prostate cancer?
Biopsy
- Transperineal
- Transrectal US guided (TRUS)
Discuss advanatages and disadvantages of TRUS biopsies and transperineal biopsies
-
TRUS
- Quicker
- Local anaesthetic
-
Trasnperineal
- Allows more biopsies to be taken
- Higher sensitivity
- Lower infecion risk
- Takes longer
- Requires GA
What grading system is used to grade prostate cancers based on histological appearance?
Explain this grading system
- Gleason grading system
- Higher grade= worse prognosis
First number= most prevelant grade
Second number= second most prevelant grade
Total number is the above two added together but best to say Gleason grad 3+4=7 etc…
Discuss how we decide how best to manage pts with prostrate cancer
*HINT: how do we assess risk and how do we manage each level of risk
- Risk stratification using Gleason grade, TNM staging and PSA
- Low: active surveillance
- Intermediate: active surveillance or radical treatment
- High risk: radical treatment (radiotherapy or prostratectomy)
- Metastatic disease: chemotherapy & anti-hormonal agents
- Castrate resistant: further chemotherapy
*** SUMMARY: locacalised or locally advanced= radical treatment, hormones & chemo for metastatic
What is involved in active surveillance of prostate cancer?
Active surveillance:
- PSA every 3 months
- DRE every 6-12 months
- Re-biopsy every 1-3 years
- Mp-MRI (some centres)
What is meant by watchful waiting?
Who is it offered to?
- Symptom guided approach where hormonal therapy is initiated at time of symptomatic disease
- Can be offered at any stage of prostate cancer
- Typically for older pts with lower life exepetancy
- Focuses on pts wishes and quality of life
Radical therapy can be offered to pts with intermediate and high risk prostrate cancer; what are the options for radical therapy.
- Radiotherapy directed at prostate
- Brachytherapy (radioactive seeds implanted in prostrate to deliver continous radiotherapy)
-
Radical prostatectomy (resection of prostate, seminal vesicles, surrounding tissue +/- pelvic lymph nodes):
- Open approach
- Laparoscopic
- Robotic
State some side effects of radical prostatectomy
- Infertility
- Erectile dysfunction (60-90%)
- Stress incontinence
- Bladder neck stenosis
Chemotherapy and anti-hormonal agents can be used in metastataic prostate cancer; state some examples of anti-adrogen agents
- Goserelin (Luteinising hormone receptor agonist that causes chemical castration)
- Androgn receptro blockers e.g. bicalutamide
- Bilateral orchidectomy
State some complictions of radical treatment with prostatectomy and radiotherapy
- Erectile dysfunction
- Urinary incontinence
- Radiation induced enteropathy (PR bleeding pain, incontinence etc…)
- Urethral strictures
What is prostatitis?
What are main ‘types’ of prostatitis?
- Inflammation of prostrate
- Types:
- Acute bacterial
- Chronic bacterial
- Non-bacterial
- Prostodynia
What is the most common cause of acute bacterial prostatitis? Include common causative organisms
What is the cause of chronic bacterial prostatitis?
- Ascending urethral infection. Common orrgansisms:
- E-coli
- Pseudomonas aeruginosa
- Chronic bacterial prostatitis is chronic bacterial infection of prostrate with or without prostatitis symptoms thought to be due to inadequately treated acute prostatitis
State some risk factors for acute bacterial prostatitis
- Indwelling catheters
- Phimosis
- Urethral stricture
- Recent surgery e.g. cystoscopy or TRUS
- Immunocompromised
Describe clinical features of acute bacterial prostatitis
Acute bacterial prostatitis
- LUTS
- Fever
- Perineal or suprapubic pain
- Urethral discharge
- Tender, boggy prostrate
- Inguinal lymphadenopathy
*Suspect chronic prostatitis if have pelvic pain or discomfort for >3months alongise LUTs.
What investigations are required for suspected prostatitis?
For each suggest what you may find/why you do it
- Urine dipstick (leucocytes)
- Urine culture (may grow E-coli)
- STI screen (rule out STI)
- Routine bloods: FBC, CRP, U&Es
- Blood cultures (if febrile. causative organism may be found, ?sepsis)
If fail to respond to treatment and think may be abscess must do TRUS or CT
Discuss the management of acute bacterial prostatitis
- Prolonged abx
- Quinolones e.g. ciprofloxacin for 2-4 weeks
- Analgesia
- NSAIDS & paracetamol
- Consider hospital admission if unwell, immunocompromised or suspected prostatic abscess
Discuss the management of chronic prostatitis
Must explain to pt cause is not always understood and can be difficult to treat. Management focused on symptom control:
- Try abx 6 week course (if present for <6months)
- Alpha-blockers
- 5-alpha-reductase inhibitors
- Stool softners
- Referral to chronic pain specialist
When inspecting a scrotal lump what should you describe?
HINT: 6 s’s
- Site
- Size
- Shape
- Symmetry
- Skin changes
- Scars
When palpating a scrotal lump what things should you comment on?
*HINT: CAMPFIRE
- Consistency
- Attachments
- Mobility
- Pulsation
- Fluctuation
- Irreducibility
- Regional lymph nodes
- Edge
State some differential diagnoses for scrotal lumps
Remember, lumps could be testicular or extra-testicular:
Testicular
- Tumour
- Torsion
- Benign testicular
- Orchitis
Extra-testicular
- Hydrocoele
- Varicoele
- Epididymal cysts
- Epididymitis
What is the first line investigation for scrotal lumps?
- Ultrasound testes with colour doppler
- Further imaging & blood tests may be done depending on suspected underlying cause. e.g. blood tests for AFP, LDH and beta-hCG in testicular cancer*
For hydrocoele, discuss:
- What it is
- Presentation
- Causes
- Management
- Abnormal collection of fluid between parietal and visceral layers of tunica vaginalis that surrounds testis or along spermatic cord
- Presentation:
- Painless swelling
- Fluctuant
- Transilluminate
- Uni or bilateral
- Causes (note: most adult hydrocoeles are acquired):
- Congenital (due to patent processus vaginalis)
- Idiopathic
- Secondary to trauma, infection, malignancy
- Managment often involves observation and then surgery if required
For varicocoele, discuss:
- What it is
- Presentation
- Which side common on and why
- Red flags
- Managment
- Abnormal dilation of pampiniform venous plexus
- Presentation:
- Lump “like a bag of worms” with “dragging sensation”
- May disappear on lying flat
- Left side as left testicular vein drains into left renal vein
- Red flags: acute onset, right sided, remain when lying flat
- Complications: infertility and testicular atrophy
- Managment:
- Asymptomatic: no treatment
- Surgical:
- Embolisation
- Open or laparscopic ligation of spermatic veins
Why must you always examine abdomen when pt presents with varicoele?
May be renal tumour obstructing testicular or renal vein therefore causing backpressure and dilation of pampiniform plexus (as remember left testicular vein drains into right renal vein)
Why can varicocoele cause testicular atrophy and infertility?
If pampiniform plexus not functioning properly can result in increase in intra-scrotal pressure
For epididymal cysts discuss:
- What they are
- Presentation
- Who commonly seen in
- Management
- Benign fluid filled sacs arising from the epididymis (also called spermatoceles)
- Presentation:
- Smooth fluctuant nodule
- Above & separe to the testis
- Transilluminate
- Often multiple
- Middle aged men
- Management:
- Generally no treatment required
- May do surgery if painful or very large but want to avoid surgery in younger men as can cause infertility
For testicular cancer, discuss:
- Presentation
- Who common in
- Management
- Presentation:
- Painless lump (only 5% have pain)
- Firm irregular mass
- Does not transilluminate
- Men 20-40yrs
- Radical inguinal orchidectomy +/- chemotherapy post orchidectomy
For testicular torsion, discuss:
- What it is
- Presentation
- Risk factor that predisposes to testicular torsion
- Management
- Twisting of testis on the spermatic cord; can lead to ischaemia of testis.
- Presentation:
- Sudden onset severe unilateral scrotal pain
- Nausea & vomitting
- Tender
- Swollen
- Loss of cremasteric reflex
- Risk factor: Bell-clapper deformity (high attachment of tunica vaginalis allowing rotation)
- Surgical emergency:
- Scrotal exploration and fixation of both testis (orchiplexy)
- Orchiectomy is testis necrotic
*NOTE: after ~6hrs of pain salvage rates decline
For orchitis, discuss:
- What it is
- Is it common in isolation
- Main cause of orchitis
- Management
- Inflammation of testis
- Rare in isolation
- Main cause= mumps virus
- Rest & analgesia
Epididymitis and orchitis can occur together; however in most cases the cause is soley epididymitis. True or false?
True
For epididymitis, discuss:
- What it is
- Ages common in
- Presentation
*
- Inflammation of epididymis
- Bimodal distribution
- Presentation:
- Acute onset scrotal pain
- Unilateral
- Swelling
- Erythematous skin
- Fever
- Tender epididymis
- Prehn’s sign (pain relieved on elevation of testis)
State the most common cause of epididymitis in:
- Younger pts
- Older pts
- Younger= STIs
- Neisseria gonorrhoea
- Chlamydia trachomatis
- Older= enteropathic e.g. following UTI (often secondary to outflow obstruction from prostatic enlargement leading to retrograde ascent of pathogen)
- E-coli
What investigations should you do if you suspect epididymitis?
- Urine dipstick
- Urine culture for MC&S
- STI screening e.g. first void urine for NAAT
-
Routine bloods:
- FBC
- CRP
- Ultrasound doppler of testis (mainly to rule out complications or if unsure on diagnosis. Will see increased vascularity of epididymis if do doppler ultrasound)
What is the management of epididymitis? Consider:
- Conservative
- Medical
Conservative
- Avoid sexual activity until abx completed and symptoms resolve
- Bed rest & scrotal support
- Counsel on barrier contraception to reduce risk of STIs if appropriate
- Saftey net
Medical
- Analgesia
- Abx:
- Enteric organisms:
- Levofloxacin 10 days
- STI organisms:
- Single shot IM ceftriaxone
- Doxycycline 10-14 days
- Azithromycin 10-14 days (IF GONORRHOEA)
- Enteric organisms:
State some potential complications of epididymitis
- Reactive hydrocoele
- Abscess formation (rare)
- Testicular infection (rare)
If a pt presents with scrotal pain what investigations should they have?
- Urine dipstick (ALL)
- Urine MC&S (if required)
- Urethral swab (if ?STI)
- Blood tests (FBC, CRP, U&Es)
- Doppler ultrasound scrotum
HOWEVER DO NOT DELAY SCROTAL EXPLORATION IF THINK TESTICULAR TORSION
Scrotal pain can be due to referred pain as it is innervated anterolaterally by branches of genitofemoral and posteriorly by braches of pudendal nerve and posterior femoral cutaneous. State some potential causes of referred pain to scrotum
- Luminal uerteric stones
- Strangulated inguinal hernia
Summary flow chart for scrotal swelling
Summary flow chart for scrotal pain
