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CPD 3 > week 1- male > Flashcards

week 1- male Flashcards

1
Q

• What are hx Q’s for male genitalia cc?

A

o Penile Lesions (sores or growths): ask sexual hx
o Scrotal pain, swelling or lesion
o sexual function and response
o change in libido, quality of erections, timing/situational problems
o Prostate: discomfort in perianal, rectal or suprapubic areas
o Obstructive urinary sxs: hesitancy, forked stream, dribbling, straining

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2
Q

• What are the 3 parts of a male genitalia exam?

A

o External (inspect and palpate)
o Inguinal hernia exam
o Recta/prostate exam

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3
Q

• How do you perform an external male genitalia exam?

A

o Inspect: Low abd for femoral inguinal hernias; Hair distribution; Scrotum: contours, lesions; Prepuce (pt retracts foreskin); Glans penis, meatus, shaft (lesions, discharge, induration)
o Palpate: Inguinal LN (tender, swelling); Penis: start at base and move forward, d/c, induration; Glans penis (visualize meatus for redness, d/c); Scrotum: Testes for masses, Epididymis (pain, mass), Spermatic Cord (swelling)

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4
Q

• How is an inguinal hernia exam performed? Special test for scrotal mass?

A

o Pt stands; Use right hand for pt right side
o Invaginate loose scrotum with index finder
o Follow spermatic cord up to external inguinal ring
o Note any bulges with straining or cough
o Special: Transillumination to differentiate fluid vs. solid structures

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5
Q

• How is the rectal/prostate exam performed?

A

o Pt stands or LLD
o Inspect: Sacralcoccygeal area (pilonidal dimple); Perianal area: skin tags
o Palpate: Note sphincter tone; circumferentially for masses, swellings
o prostate: size (usu 4 cm wide), tender, consistency, mobility
o Normal: size of walnut, firm, central sulcus
o Prostatitis: boggy and tender
o BPH: enlarged, rubbery, nontender
o Carcinoma: hard nodules or areas

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6
Q

• What labs are done for male genitalia cc?

A

o serum hormones (T, LH, SHBG, prolactin)
o Sperm analysis (count, motility, % abn)
o Prostate specific antigen (PSA): total, free (see below)
o Urine culture and sensitivity
o UA, w Expressed Prostatic Secretion (EPS) for prostate infx (ejaculate culture more accurate)

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7
Q

• What imaging or procedures is done for male genitalia cc?

A

o Pelvic CT for staging
o Scrotal US to assess mass
o Transrectal US (TRUS), w needle bx for prostate
o Rigiscan for nighttime tumescence (erectile function)
o Uroflowmetry for obstruction (eg BPH)

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8
Q

• What are common presenting sxs for male genitalia cc?

A

o Erectile dysfxn
o Hematospermia
o Urethra d/c
o Scrotal pain

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9
Q

• What is a red flag for erectile dysfxn? Scrotal pain?

A

o ED: prolonged erection >4hrs (priapism); crucial to determine if organic cause!
o SP: acute onset, N/V, abd pain (r/o testicular torsion)

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10
Q

• What is hematospermia? Red flags?

A

o =blood in semen
o Mb from epididymis, seminal vesicle, prostate, bulbourethral glands; mb idiopathic
o Common after prostate bx. Also, BPH, urethritis, epididymitis, prostatitis, bleeding disorder, STI
o RF: sxs >1mo, palpable mass, hematuria, obstructive sx

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11
Q

• What could cause male urethra d/c? red flags?

A

o mb STI (gonococcal or non-gonococcal) or E coli
o Note: GU or NGU treated empirically
o RF: pelvic pain, fever, chills, urinary retention

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12
Q

• What are the penile conditions?

A 
o	Epispadias
o	Hypospadias
o	Balanitis, Posthitis and Balanoposthitis
o	Phimosis
o	Paraphimosis
o	Peyronie’s Dz
o	Cutaneous Penile Lesions
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13
Q

• What is epispadias? Hypospadias?

A

o E: congenital malformation of urethral meatus: upper (dorsal) side of penis; make sure urine flow is adequate - refer to urologist
o H: lower (ventral) side of the penis
o Both: mb repaired by urethroplasty → scarring/stricture → reflux

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14
Q

• What are Balanitis, Posthitis and Balanoposthitis? Variant?

A

o Balanitis: inflam of glans penis
o Posthitis: inflam foreskin
o Balanoposthitis: inflam of both
o Infx (candida, GC, Chlamydia, scabies, etc) or Non-infx (contact dermatitis, psoriasis, etc)
o Usu w poor hygiene, diabetics
o May predispose to meatal stricture, phimosis, paraphimosis, CA
o Variant: Balanitis xerotica obliterans (BXO)= lichen sclerosis of penis; indurated, white area on glans penis, from chronic inflam

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15
Q

• What is phimosis? 2 types? Risks factors? Paraphimosis?

A

o Foreskin can’t retract away from glans penis
o Physiologic: In boys, 50% of normal retractability by age 10 (or 15) Do not force retraction! St → circumcision
o Pathologic: Pain, constriction, meatus blockage dt adhesion
o Risk: Frequent diaper rash; poor hygiene; use of condom catheter, DM, aging w reduced sexual activity
o Para: Foreskin stuck in retracted position → inflamed → ↓ blood flow to glans may → gangrene, necrosis

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16
Q

• What is Peyronie’s Dz? PE?

A

o Scarring of tunica albuginea in corpora cavernosa → plaques →painful erection and dorsal curvature
o d/o of wound healing → over-expression of TGF-β1
o usu Caucasians. Up to 10% of men with ED have PD.
o Significant psychological affects!
o PE: palpable plaque on dorsal surface of penis

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17
Q

• What are the types of cutaneous penile lesions?

A

o Genital herpes: primary or recurrent infx; common ulcerative STI; usu dt HSV-2 (10-30% HSV-1)
o Genital warts (Condylomata Accuminata)
o Syphilitic Chancre
o Chancroid:
o Carcinoma in situ/Erythroplasia of Queyrat
o SCC of Penis
o Pearly Penile Papules
o Contact dermatitis: eczematous rash (red, pruritic) mb dt latex/other allergy

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18
Q

• What is a primary genital herpes infx?

A

o Usu occurs 4-7 after exposure to virus; Outbreak is more painful, prolonged and widespread than recurrent form
o Clusters of vesicles erupt and form superficial ulcers, erythematous base (on prepuce, glans, penile shaft, anus, rectum, thighs)
o Ssx: urinary hesitancy, dysuria, constipation, sacral neuralgia, flu-like discomfort, fever. Scarring may follow healing
o The virus sheds for about 3 weeks

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19
Q

• What is recurrent genital herpes infx? Dx?

A

o 80% HSV-2 and 50% HSV-1 have recurrent outbreaks, less severe
o Virus only sheds ~ 3 d
o On average, ~ 4 recurrences a year
o Men have 20% more recurrences than women
o Dx: PE lesions, Tzanck test, viral culture

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20
Q

• What are genial warts (Condylomata Accuminata)?

A

o common STI, dt HPV (> 100 types)
o ~90% dt 6 and 11, considered “low risk” cancer–causing potential.
o 16 and 18 highly associated w cervical and penile CA
o Usu ages 17–33
o highly contagious: 60% risk of infx w exposure

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21
Q

• what is pathophysiology of genital warts? Risk factors?

A

o Path: Viral particles penetrate skin and mucosal surfaces through microscopic abrasions in genital area, during sexual activity. Latency mb mos-yrs
o Risk: assoc w OCPs dt ↑ sexual contact w/o condoms, multiple sex partners, and early onset sexual activity

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22
Q

• What do genital wart lesions look like?

A

o Painless, mb bothersome dt location, size, or itching
o Size: variable < 1mm to several cm2 (if grouped)
o Soft consistency, raised, irregular surface
o Loc: mb > 1 area. urethra, penis, scrotum, rectal area
o HPV infx mb dormant or undetectable, lesions mb hidden by hair or in inner aspect of uncircumcised foreskin

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23
Q

• What is Syphilitic Chancre?

A

o contagious primary infection of Treponema pallidum
o solitary, painless (or slightly tender) ulcer
o non-exudative, indurated edge
o regional nontender LA
o Serologic testing

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24
Q

• What is Chancroid?

A

o infx of Haemophilus ducreyi
o painful, shallow non-indurated ulcers, irregular edges and red borders
o gray or yellow purulent exudate
o regional tender LA, may abscess (form buboes)
o PCR testing

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25
Q

• What is Carcinoma in situ/Erythroplasia of Queyrat?

A

o premalignant lesion: intraepithelial neoplasia
o well circumscribed area of reddish, velvety pigmentation usu on glans or at corona
o usu in intact (uncircumcised)

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26
Q

• what is SCC of penis? Dx?

A

o Mc uncircumcised, poor local hygiene habits
o HPV 16 and 18 play a role
o Fungating/exophytic or ulcerative/infiltrative types
o Non-painful “sore that does not heal”
o Dx by bx

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27
Q

• What are Pearly Penile Papules?

A

o soft papular angiofibromas around corona
o hair-like projections
o benign

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28
Q

• what are the erectile d/os?

A

o Impotency/Erectile Dysfunction (ED)

o Priapism

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29
Q

• What is ED?

A

o Very common, ↑ incidence w age

o =inability to attain or sustain erection satisfactory to perform sexual activity and ejaculation

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30
Q

• What is etio/risk factors for ED?

A

o Drugs: anti-depressants (SSRIs), NSAIDs, substance abuse, esp narcotics
o Neurogenic dos: spinal cord and brain injuries, nerve dos like stroke, PD, AD, MS
o Cavernosal dos (Peyronie’s dz)
o Psychogenic causes: performance anxiety, stress, mental health dos: depression, schizo, panic do, anxiety, personality do
o Surgery (radiation tx, surgery of colon, prostate, bladder or rectum may damage nerves and blood vessels involved in erection
o Aging: incidence ↑ linearly 40-70.
o Kidney failure
o Diabetes (affects both vascular and nervous systems)
o Smoking: → arterial narrowing
o Alcoholism
o Saddle injury: long bike rides

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31
Q

• Hx Q’s for ED? PE? Work-up?

A

o Hx: clarify pattern: time of day, circumstance, stress related, particular partner(s)
o PE: CV, neuro, MSE
o Work-up: UA, CMP, hormones

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32
Q

• What is priapism? Pathophysiology? Dx?

A

o Prolonged, painful erection >4hrs
o Emergency!!! dt ischemia/necrosis
o Path: N2O imbalance → penile vasculopathy, anoxia, oxidative stress
o Dx: Color Doppler US, assess corporal blood gases

33
Q

• What are 2 causes of priapism? 2 classifications?

A

o Idiopathic: usu dt prolonged sexual excitement
o 2nd: assoc w sickle cell dz, DM, CML, penile trauma, drugs (PDE5 inhibitors, anti-HTN, antidepressants), alcohol, cocaine, black widow spider bite
o low-flow (veno-occlusive): mc. Painful, tender penis; little intracorporal blood; “compartment syndrome” w metabolic changes, ↑ pressures → local hypoxia, acidosis by corporal blood gases.
o high flow (↑ arterial inflow w/o ↑ venous outflow resistance), NT penis

34
Q

• what are the scrotal conditions?

A

o Scrotal masses/swellings
o Epididymal conditions
o Testicular conditions

35
Q

• What are the painless scrotal masses/swellings?

A

o Tumors: e.g. adenocarcinoma
o Abscess (mb tender) - tend to drain spontaneously
o Hematocele
o Hydrocele
o Varicocele
o Sebaceous cysts- firm, cutaneous nodules
o Scrotal edema- from CHF, nephrotic syndrome, ascites, parasites, filariasis, tumor cells blocking lymphatics etc.
o Indirect inguinal hernia may extend into scrotum: Large scrotal mass, compressible, mb BS, cannot palpate above swelling. Risk bowel strangulation
o Spermatocele

36
Q

• What should you consider with scrotal masses/swellings?

A

o consider any hard swelling testicular CA until proven otherwise (esp young)
o swelling mb dt trauma, inflammatory conditions, neoplasms, etc

37
Q

• what is a hematocele? Hydrocele?

A

o Hem: blood-filled swelling usu 2nd to trauma, mb initially tender. does not transilluminate
o Hyd: NT serous fluid filled mass, bw tunical layers. Acute: mc 2-5 yrs, usu dt inflam epididymis or testis. Chronic: middle age, dt inflam, injury, usu no pn, require no tx; Transilluminates; scrotal US to confirm

38
Q

• What is a varicocele?

A

o dt gravity pull on venous valves →incompetence →dilatated pampiform plexus
o “bag of worms” appearance, along spermatic cord (80% on L)
o worse w valsalva and standing
o NT, mb “dragging” sensation
o Possible sequellae: infertility dt ↓ spermatogenesis (↑ scrotal temp)
o Dx: angiography

39
Q

• What ay cause a new varicocele or worsening one in old man?

A

o On L: mb tumor or other mass occluding L renal or testicular veins
o On R: mb occlusion of vena cava

40
Q

• What are the painful scrotal masses/swelling conditions?

A

o Epididymitis
o Testicular torsion
o Torsion of testicular appendix
o Testicular tumor: painless unless large or hemorrhage is present
o Testicular trauma: clear history of event; swelling, hematocele or hydrocele may develop
o Mumps orchitis (paramyxovirus)

41
Q

• What is testicular torsion?

A

o Emergency–assume until proven otherwise! Needs to be de-torsed <6hrs!
o Severe scrotal pain after trauma episode, during intense exercise, or spontaneous in sleep
o usu 10-25 yrs. Usu have the variant “bell clapper” anatomy (testicle freely rotates)

42
Q

• what are ssx of testicular torsion? Work-up? Ddx?

A

o Sudden, acute onset unilateral, constant pain, mb N/V
o Swollen, tender, erythematous scrotum: difficult to discern structures
o Affected testicle higher, epididymis mb anterior; reactive hydrocele possible
o Pain may radiate to abd, “acute abdomen”
o Elevation of scrotum does not relieve pain (neg Prehn’s sign)
o Cremasteric reflex absent
o Labs: UA usu normal
o Imag: Color doppler US is 99% spec, 85% sens
o Ddx: trauma w/o torsion, orchitis, epididymitis, torsion of appendix testis (Blue dot discoloration)

43
Q

• What is Torsion of testicular appendix (vestigial structure upper pole of testis)?

A

o usu 7-14 yr
o subacute onset of pain in upper pole of testis
o Cremasteric reflex present
o “blue dot” sign: discoloration seen under skin

44
Q

• What is Mumps orchitis (paramyxovirus)?

A

o 20% of post-puberty boys, onset 1-2 wks after parotitis
o UL or BL scrotal pain, erythema and swelling, Abd pain, N/V
o may → testicular atrophy (sterility rare, hormonal function intact)

45
Q

• what are the epididymal conditions?

A

o Spermatocele
o Acute epididymitis (or epididymo-orchitis if testis involved)
o Chronic epididymitis

46
Q

• What is Spermatocele?

A

o Small, painless cyst on superior, posterior pole of testicle (on vas deferens), may follow epididymitis.
o Benign. Contains dead spermatozoa
o Dx: US or aspiration

47
Q

• What are 2 types of Acute epididymitis (or epididymo-orchitis if testis involved)?

A

o Infx: dt ascending lo UTI; mc coliform bacilli in children and men > 35; mc GC or chlamydia in teens-35
o Non-infx: dt urine reflux/chemical irritation into ejaculatory ducts from heavy lifting or local trauma

48
Q

• What are risks factors for acute epididymitis? Ssx?

A

o Risk: Sexually active: sexual abuse; infrequent urination; urinary tract malformation
o Ssx: Painful, swollen epididymis; pain may radiate along spermatic cord to abd; Hydrocele may develop
o Overlying skin may look like peau d’orange; skin is movable (fixed suggests abscess)
o Mb febrile.
o D/c (if ascending infection), urinary frequency, mb dysuria
o Toxic appearance if sepsis (rare)

49
Q

• What is PE for acute epididymitis? Dx?

A

o PE: exquisitely tender, swollen epididymis, Scrotum often indurated, erythematous; elevating testicle eases pain (+ Prehn’s sign); no change in cremaster reflex
o Dx: UA reveals pyuria, Urine culture, NAAT (Nucleic Acid Amplification Test), GC/CT, Scrotal US to r/o torsion if <30

50
Q

• What is Chronic epididymitis?

A

o inflam w/o infx
o Enlarged, thickened, NT epididymis
o occurs after repeated acute epididymitis
o may find incidentally on exam

51
Q

• what are the testicular conditions?

A

o Cryptorchidism

o Testicular cancer

52
Q

• What is Cryptorchidism? 4 types?

A

o Failure of testicles to descend into scrotum during infancy (most by 3-12mos); High risk of developing infertility or testicular cancer later in life (2.5-20x risk)
o True: testis remains in abd cavity from mechanical obstruction or hormonal abnormality
o Incomplete: testis in inguinal canal, obstructed by mechanical means
o ectopic testis: outside usu course of descent
o hypermobile or retractile testis: mb in scrotum at times (e.g. hot bath) and then retract up into inguinal canal; hormonal fxn usu normal

53
Q

• what is PE for cryptorchidisms? Tx?

A

o (gloved hand and warm room). Palp for testicles
o If unpalpable, have pt squat or valsalva and repeat palp, to distinguish retractile teste from undescended testicle
o Tx: orchiopexy

54
Q

• What is testicular CA? Types?

A

o Most common solid cancer in males 15-34 yo
o =germ cell tumors
o Seminomas - 40% (arising in seminiferous tubules)
o Non-seminoma germ cell tumor (NSGCT): Embryonal 24%, Teratoma 5%, Mixed 26%, Choriocarcinoma & Yolk sac rare

55
Q

• What are risk factors for testicular CA?

A 
o	cryptorchidism (2.5- 20x ↑), exogenous estrogen exposure, trauma, gonadal dysgenesis, Klinefelter syndrome, low birth weight, environmental toxins, bisphenol A, FHx, high animal product diet, marijuana (nonseminoma risk), tobacco use
o	Ethnicity: rare among Blacks and Asians
56
Q

• What are ssx of testicular CA? work-up? Px?

A

o Ssx: painless testicular nodule, usu smooth enlargement, firm, NT. ↑ in size over time, mb dull ache, sensation of heaviness/weight. Mass does not transilluminate. Often found on self exam
o Wu: Scrotal US, Pelvic CT, ↑alpha-fetoprotein, HCG, LDH (esp. LDH1)
o Px: 5 yr. survival of seminoma > 80% w tx

57
Q

• What are the prostate gland conditions?

A 
o	Benign Prostatic Hyperplasia  BPH
o	Acute Bacterial Prostatitis
o	Chronic Bacterial Prostatitis
o	Chronic Prostatitis/Chronic Pelvic Pain Syndrome (“Prostadynia”)
o	Prostate Cancer
58
Q

• What are various sxs assoc w prostate conditions?

A

o Any condition that narrows prostatic urethra → voiding sxs: ↓force of stream, hesitancy, intermittency (starts and stops), straining to void, splitting stream, post void dribbling
o Chronic obstruction → damage bladder and storage sxs: urgency, frequency, incontinence, nocturia

59
Q

• What is PE for prostate cc?

A

o DRE to palp peripheral zone: size, consistency, symmetry, tenderness, presence of urethral secretions after exam (EPS)
o Size: ~4x4 cm; w hypertrophy, median sulcus obliterated, much of prostate not palpable!
o Consistency: Normal- like thenar eminence/tip of nose; Rubbery- BPH; Boggy- congested (infrequent ejaculation, chronic infx); Indurated- nodules (infx, mb stones); Hard- consider tumor in absence of WBC’s & infx, suspicious lesion may not be raised, distinct edge, abrupt change in consistency

60
Q

• What labs are done for prostate cc?

A

o Serum PSA: protein made in prostate epithelial cells; ↑ if damaged basement membrane; mc dt CA, bacterial infx, prostate damage by infarction. A little is normal, ↑ with prostate enlargement
o ↑ PSA: DRE (do blood draw before!), Ejaculation, Recent sexual activity, BPH, Cystitis, Acute & Chronic prostatitis (↓ w tx), Prostate bx, Exercise involving perineal pressure
o ↓ PSA: Finasteride (Proscar), Saw palmetto, Radical prostatectomy, Withdrawal of anti-androgen drugs, Regular prostatic massage, Green tea
o ↑ in 30-50% w BPH, 25-92% w prostate CA
o white males (higher is AA): 40s up to 2.5 ng/ml, 50s 3.5, 60s 4.5, 70s 6.5
o other: PSA velocity, Free/bound PSA ratio (free ↓ w CA)

61
Q

• what is BPH (hyperplasia)?

A

o Hyperplasia of prostatic stromal and epithelial cells in transitional zone →large discrete nodules in periurethral region
o Lumen of prostatic urethra narrows → urine outflow obstruction
o Urine stasis in bladder from residual urine → hypertrophy of detrusor mm, trabeculation, diverticula of bladder wall
o 8% of 31-40yrs; 50% 51-60; >80% >80
o Symptomatic effect much higher in Western world
o May co-exist with prostate CA!!

62
Q

• What causes BPH? How do you take a hx?

A

o Prostate cells stimulated by dihydrotestosterone (DHT) (made in prostate by 5α-reductase, mainly in stromal cells) →transcription of GFs → mitosis of stroma and epithelium
o ↑ androgen receptors in transitional zone are affected by ↑ DHT
o Malfunction of valves in internal spermatic veins → expose to ↑testosterone
o Hx: AUA Sx Score questionnaire to quantify extent of sx

63
Q

• What are ssx of BPH? Complications?

A

o Ssx: progressive urinary frequency, urgency, nocturia dt incomplete emptying and rapid refilling of bladder; hesitancy, intermittency of urination; ↓force of stream, initial dribbling, terminal dribbling, overflow incontinence
o Comp: UTI from urine stasis (cystitis, pyelonephritis) or Urolithiasis, Hydronephrosis w impaired renal fxn; Straining to urinate may rupture veins, hematuria, vasovagal syncope, hemorrhoids, hernias; Sudden urinary retention (catheterization needed!)

64
Q

• What is PE for BPH? Labs? Procedures?

A

o PE: DRE: usu symmetric enlarged, rubbery, smooth, loss of median furrow (sulcus), NT; mb distended bladder on abd exam
o Lab: ↑BUN, serum creatinine if obstruction backs up to kidneys; UA and urine culture to r/o causative or concomitant infx; PSA mod ↑ (depending on size and degree of obstruction)
o Procedures: Uroflowmetry to check urine flow rate and post-void residual volume; transrectal US or prostate bx to r/o CA

65
Q

• What is prostatitis?

A

o Inflam prostate mb infx or non (often poorly understood). Variable presentations of irritative/obstructive urinary sx and perineal pain

66
Q

• What are the NIDDK classifications and criteria of prostatitis?

A

o I- Acute Bacterial: symptomatic, + uropathogen urine culture and generalized sx of acute inflammation
o II- Chronic Bacterial: recurrent UTIs and uropathogens localized to prostate-specific tissues
o III- Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)/”Prostadynia”: > 3mos GU pain w/o bacteria (non-infx)
o IIIA- Inflammatory CPPS: ↑WBCs ( > 10-20/hpf) in semen, expressed prostatic secretions (EPS) or voided bladder urine-3 (VB-3)
o IIIB- Non-inflammatory CPPS: Insignificant WBCs
o IV- Asx inflammatory prostatitis (AIP): No specific CP/CPPS sxs, but WBCs found in EPS or prostate bx

67
Q

• What is acute bacterial prostatitis? Ssx?

A

o E. Coli, Klebsiella, Proteus, Pseudamonos, Enterobacter, Chlamydia
o Inflam → obstruct urethra distal to prostate
o Mc in young men and immunocompromised
o Ssx: Sudden onset spiking fever, chills, malaise, arthralgia, myalgia; LUTS: dysuria, nocturia, urgency, frequency (mb concomitant cystitis); mb acute urinary retention (inability to void, abdominal fullness); Low back/perineal/rectal pain

68
Q

• What is PE for ABP? Labs?

A

o PE: gentle DRE: exquisitely tender prostate, swollen, firm and warm; mb d/c after exam; Contraindication- no prostatic massage if acutely inflamed →bacteremia, septicemia
o Lab: CBC leukocytosis with left shift; UA has ↑ WBC’s (cloudy), bacteria, mb hematuria; Culture prostatic secretions (semen mb more accurate!) ↑bacteria; ↑CRP; Transient ↑ PSA ( normalize in~ 2 wks)

69
Q

• What is Chronic Bacterial Prostatitis? Ssx? PE? Labs?

A

o ~5% acute → chronic; only 5-10% CBP have obvious bacteria. Mb sequestered infx not tx fully or detected by traditional means
o ssx: Recurrent UTIs, Fatigue, Chronic pain (perineal, lo abd, testicular, penile), Sexual dysfunction, ejaculatory pain, Milky urethral d/c
o PE: DRE: mod tender, boggy, enlarged, soft prostate
o Lab: Post-massage urine C&S, EPS & semen culture, UA mb incidental bacteriuria, >10 WBC/hpf in EPS, Studies ongoing using RT-PCR for occult infx

70
Q

• What is Chronic Prostatitis/Chronic Pelvic Pain Syndrome (“Prostadynia”)?

A

o Poorly understood, Somatic w biopsychosocial effects, Any age, peak 35-45
o Criteria: 1) no objective explanation for sxs 2) sxs relate to anatomical area around prostate, 3) refractory to tx
o Poss etio: Psych stress ↑ local IL-10, IL-6; “Infx” of normal bacteria in prostatic fluid; AI; ↓ T → prostate inflame; ↑NGF (nerve growth factor)/ ↑sensitivity of pelvic nerves; Genetic (cytokines)

71
Q

• What are ssx of CP/CPPS?

A

o Pain in pelvic region >3mos
o disability out of proportion to PE/lab findings!
o Dysuria, urgency
o Low back/perineal pain referred to tip of penis
o Sense of rectal fullness after unsuccessful defecation
o Sexual dysfunction, post-ejaculation pain, ↓ libido
o mb hemospermia
o Fatigue, stress
o mb concurrent IBS or Chronic Fatigue Syndrome

72
Q

• What is PE for CPPS? Labs? Procedures? Ddx?

A

o PE: DRE: mild tender (variable), boggy, enlarged (rarely); Assess tenderness of pelvic floor and sidewalls, examine for hernia, testicular masses, hemorrhoids
o Lab: UA, Urine C&S, EPS cell count and culture, CBC, mb hematuria (do urine cytology), PSA <4 (though not indicated); IIIA Inflam WBCs in semen, EPS, VB3; CT/GC
o Procedures: TRUS; abd CT, uroflowmetry, IVP, cystoscopy
o Ddx: Prostate CA, obstructive uropathy, bladder CA, urethritis, neurogenic bladder

73
Q

• What is Asx Inflammatory Prostatitis?

A

o Found incidentally

o Asx but WBCs found in EPS or prostate bx

74
Q

• What is prostate CA?

A

o Mc adenocarcinoma
o Mc male cancer in men >50yrs, ~220,000 new cases/yr; 32,000 deaths
o Lifetime risk 1 in 6 white men; 1 in 5 black men
o >75% of cases dx > 65
o More men die WITH prostate cancer that FROM it!!
o BUT there are aggressive, fast growing forms

75
Q

• What are risk factors for prostate CA?

A 
o	↑age
o	Ethnicity- AA 35% ↑ than whites, larger tumors, ↑ rate mets, more freq recurrence: 2x mortality than whites.  Mb dt ↑ T, more active 5-alpha reductase; ↓ in Asian than whites
o	FHx: primary relatives
o	Hormones: ↑ androgen exposure
o	Diet- ↑ fat, ↓ fiber, alcohol, coffee
o	Obesity 
o	Vasectomy- mb, controversial
o	Occupational exposures- ↑ in farmers, mechanics, plumbers, welding, rubber 
o	manufacture, battery manufacture (Cd) 
o	Smoking- mb ↑ risk 
o	Meds—statins, NSAIDs
76
Q

• What are ssx of prostate CA? PE?

A

o Early: usu asx, slow progress depends on tumor location; Sexual dysfunction, incontinence, irritative or obstructive sx
o Late: bladder outlet obstruction, ureteral obstruction, hematuria, pyuria, mets to pelvis, ribs, vert →bone pain; tumor enlargement → cord compression and neuropathy; unintended weight loss
o PE: DRE: variable size, asymmetrical; pathognomonic: NT prostate, firm, stony hard, irregular nodule(s)

77
Q

• What labs are done for prostate CA?

A

o Total PSA: 4-10 ng/ml likelihood 25%; > 10ng > 50%
o PSA Velocity: ↑ > 0.75 ng/ml/yr or higher (based on 3 PSA measurements over 18-24 mos) w PSA 4-10 ng/ml; suspicious
o ↓ Free:total PSA ratio: < 25%
o Other markers: PCA3 mRNA in urine
o Advanced CA: CMP: ↑BUN, creatinine (if BL utereral obstruction), ↑ ALP from bone mets, ↑ acid phos; CBC: Anemia from mets

78
Q

• How is prostate CA diagnosed? Ddx?

A

o TRUS w bx (for GRADING) w Gleason Score: 2 scores, 1-5 (most aggressive), for each of 2 most seen types of histo changes (based on differentiation). Add scores: 2-4 is low grade; 5-7 intermediate; 8-10, high grade. Low score usu grow slow, mb no lifetime threat
o Axial CT or MRI (for STAGING) based on Tumor size, Node spread, Mets (often to skeletal bone)
o Ddx: colorectal CA; bladder CA; paget’s dz; other causes of ↑ PSA; induration of prostate from TURP (transurethral resection of prostate), needle bx, prostatic calculi

79
Q

• Compare characteristics of prostate in Prostatits, BPH, CA:

A

o Size: variable, var-enlarged, var
o Consistency: boggy/irregular, rubbery/firm, stony hard/irregular
o Symmetry: usu sym, usu sym/mb irregular, usu asym
o Tenderness: present, absent, absent
o Secretions: diagnostic, not helpful, no help
o PSA: usu ↑, all 3

CPD 3 (10 decks)

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