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Urology > Week 9 > Flashcards

Week 9 Flashcards

1
Q

what is the MC cancer in men? its ranking in morbidity? average lifetime risk of it? risk of dying from it?

A

prostate CA is MC cancer in men
2nd MC cause of morbidity related to CA
average risk of having: 16%
risk from dying from CaP: 2.9%

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2
Q

who are at higher risk for CaP and for death from CaP? what lifestyle puts men at increased risk?
why are they at increased risk? who are at a lower risk?

A 
African Americans
2x higher mortality rate
larger tumors
higher rate of METS
more frequent
possibly dt higher T levels and more 5-alpha reductase activity 
also more aggressive/spread in Western lifestyle
men in china have 20x less apparent CaP
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3
Q

RFs for CaP?

A

advancing age
ethnicity (African American)
first degree relative FHx (prostate or BrCA)
diet high in animal products, alcohol, coffee, low vegetables
cadmium exposure
vasectomy potentially
HPV infxn potentially
sxs of increased androgen exposure (early balding, early age shaving)
obesity
agent orange exposure
meds (NSAIDs, statins)

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4
Q

pros and cons of routine PSA screening?

A

pro: may improve detection of clinically important tumors
cons: may detect unimportant tumors and abn (false +’s) leading to painful bx, psychological harm, ED, infxn, discomfort, anxiety, over-dagnosis, urinary retention/infection

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5
Q

USPSTF recommendations for CaP?

A

no longer screen men >75 yo
screen q 4 yrs
screening age with average risk = start at 50 yo
earlier screening highly encouraged in populations w/higher dz prevalence and higher mortality rates (African American men, FHx, BRCA1 or 2 mutations)

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6
Q

genes responsible for CaP reside where? mutations where? potential causes of mutations?

A

on chromosome 1 (HPC1), 8 (8q24) and 17q
mutations on BRCA1 and 2
causes of mutations: radiation, carcinogens, free radicals, replication errors

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7
Q

although many prostate cells become neoplastic over time, most cancer cells don’t establish tumors for what reasons?

A

multi-stage process is required = not every pro-malignant mutation will ultimately acquire other mutations to achieve full malignant transformation
immune system surveillance and destruction
ongoing competition btw different clonal populations w/in a tumor

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8
Q

where do the majority of most CaP arise and associated %age? where do the others arise along with their %ages?

A

majority arise in the peripheral zones (70%)
10-20% arise in transition zone and periurethral glandular tissue of the prostate
5-10% arise in the central zone

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9
Q

majority of CaP is what type? other types?

A

majority of CaP is adenocarcinoma (95%), others include transitional, neuroendocrine, small cell carcinomas or sarcomas

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10
Q

what is the precursor to invasive CaP? grades? association with invasive CaP?

A

prostatic intraepithelial neoplasia
two grade: high grade and low grade
high grade associated with invasive CaP in up to 80% of cases
low grade associated with invasive CaP in 20% of cases

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11
Q

Gleason grading system #’s and association with survival?

A 
2-4= low grade, well differentiated, excellent 15 yr survival rate
5-6= moderate grade, moderately differentiated, moderate risk of death
7+= high grade, poorly differentiated, high risk fo death
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12
Q

TNM staging system? (small vs large)

A
  1. small, well-differentiated cancer are usually confined to the prostate
  2. large-volume (>4 cm) or poorly differentiated cancers are more often locally extensive or metastatic to regional nodes or bone
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13
Q

what finding is associated with high likelihood of regional or distant dz?

A

seminal vesicle invasion

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14
Q

where/how can CaP METs to?

A

spine - through valve-less venous plexis btw prostate and vertebral column, particularly in the internal vertebral plexus (straining to urinate)
via pelvic lymphatics and pelvic veins to IVC
local spread by invasion of seminal vesicles, rectum or nearby tissue

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15
Q

MC spots for CaP to METs to?

A

axial skeleton - especially the lumbar spine! presents as low back pain
followed by proximal femur, pelvic, thoracic spine, ribs, sternum, skull, humerus
can also METS to visceral organs such as lungs, liver and adrenal gland or CNS

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16
Q

what type is METS to spine of CaP?

A

osteoblastic

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17
Q

symptoms of early CaP?

A

usu asx then possibly dysuria, difficulty voiding, frequency, urinary retention, low back or flank pain, hematuria, persistent wt loss, sexual dysfxn, obstructive or irritative sxs may suggest tumor growth into the urethral or bladder neck or direct extension
METS to bone causes pain and/or cord compression

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18
Q

signs of CaP?

A

DRE: induration of prostate (f/u with PSA, TRUS, bx)
single, discrete firm/hard nodule suggests CaP (only posterior palpable)
regional LAD
lymphedema of lower extremities
cord compression can lead to weakness or spasticity of legs, hyper-reflexia in bulbocavernosus response, decreased anal sphincter tone

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19
Q

induration suggests what? diffuse enlargement suggests what?
painful DRE suggests what?

A

induration suggests CaP
diffuse enlargement of median bar = BPH
painful suggests prostatitis

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20
Q

labs to assess for CaP?

A

PSA
azotemia if B/L ureteral obstruction
sxs of METS: low RBC, inc alk phos, inc prostatic acid phosphatase

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21
Q

what will TRUS show with CaP? what is it used for?

A

hypoechoic prostate

used to measure prostate vol to calculate PSA density

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22
Q

what imaging can be done to assess for CaP?

A

TRUS
endorectal MRI (limited use)
axial CT/MRI (to see LN METS in high risk pts)
bone scan (later stages, can be excluded in newly dx, asx, PSA <10)

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23
Q

what is molecular staging?

A

reverse transcription polymerase chain reaction on peripheral blood samples, identify circulating prostate cells
clinical significance unknown

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24
Q

what is PSA?

A

kallikrien III glucoprotein: serin protease that helps to liquefy semen

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25
Q

what are some things that raise PSA levels?

A 
DRE before blood draw
ejaculation, recent sexual activity
BPH
cystitis
acute and chronic bac prostatitis 
prostate bx
exercise involving perineal P
urethral instrumentation
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26
Q

what are some things that decrease PSA levels?

A 
finasteride
saw palmetto
radical prostatectomy
withdrawal of anti-androgen drugs
regular prostatic massage
green tea
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27
Q

rise in PSA with age is thought to be dt what?

A

thought to be dt gland growth from BPH, higher incidence of subclinical prostatitis and growing prevalence of microscopic, insignificant prostate cancers

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28
Q

if PSA of >7 is found, next steps? if btw 4-7, next steps?

A

refer to urologist if >7

repeat in several weeks if btw 4-7

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29
Q

likelihood of CaP with PSA 4-10? with PSA >10?

A

25% with PSA 4-10

>50% with PSA >10, also likelihood of bone METS increased

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30
Q

what is the PSA velocity curve? does it rule out CaP?

A

rate of change of serum PSA
if increase in 0.75/yr or higher when PSA is 4-10 = highly suspicious for CaP
normal PSAV does NOT r/o CaP

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31
Q

what is PSA density? how to interpret?

A

total PSA/prostate volume
each gram of BPH is thought to raise PSA level by 0.12
should be <0.15
upper limit is 0.30
positive predictive value of PSA density is slightly higher than the use of PSA level >4

32
Q

~90% of PSA is bound to what? what is the association btw free PSA and CaP? ratio of free-total PSA in CaP?

A

~90% is bound to alpha-1-antichymotrypsin
lower the %age of free PSA = higher likelihood of CaP
ratio of free-to-total PSA is reduced in CaP

33
Q

what does following PSA #’s during tx tell you?

A

failure to decrease PSA to 0 following radiation indicates a poor sign

34
Q

other markers in research for detecting PSA?

A 
PCA3 mRNA in urine
EPCA-2 
E-cadherin
serine peptide inhibitor
PINK1
B7-H3 marker
35
Q

DDX of CaP?

A 
CRC
bladder CA
paget's dz
other causes of incr PSA
induration of prostate from TURP, needle bx, prostatic calculi
36
Q

MD tx of CaP?

A

localized dz txs based on grade and stage of tumor, life expectancy, therapy’s morbidity, therapy’s ability to ensure dz-free survival, pt and physician preference
watchful waiting

37
Q

watchful waiting pros and cons?

A

no randomized control studies demonstrate therapeutic benefit of a radical tx for early-stage CaP
surveillance alone may be appropriate for a highly selective group of pts with CaP
older pt may have concomitant illness affecting survival
small, well-differentiated CaP seen in elderly often have slow growth rates
end points for intervention in surveillance pts is unclear

38
Q

ways to complete active surveillance?

A

annual bx or annual TRUS with color doppler or PSA q 3-6 mos, DRE q 6-12 mos

39
Q

criteria for pt to undergo active surveillance?

A

undiagnosed suspected CaP w/o bx
diagnosed CaP w/2-6 Gleason score
no PSAV >2/ng/ml/yr
tPSA <10

40
Q

first line allopathic therapy for locally aggressive or highly malignant CaP? risks associated with each treatment options?

A

surgery or radiation therapy
nerve sparing radical prostatectomy - impotence, CV complications, death, increased risk of METS
radiation therapy - impotence, incontinence, hematuria, radiation ulcers
cryosurgery - short term, significant morbidity

41
Q

tx for locally advanced dz?

A

neoadjuvant hormonal therapy (androgen deprivation therapy) followed by XRT

42
Q

tx option for recurrence after radiation therapy?

A

rising PSA levels after radiotherapy is indicative of CA recurrent
bx, imaging with CT and bone scan useful
high morbidity

43
Q

allopathic tx for metastatic CaP?

A

initial endocrine therapy - androgen deprivation

44
Q

death from CaP is almost always due to what?

A

inability to control metastatic dz

70-80% of men with METS respond to various forms of androgen deprivation

45
Q

types of androgen deprivation drugs/ablation?

A

androgen receptor antagonists, LHRH, superagonist, 5-alpha-reductase-inhibitors, GnRH agonists
triple block of all 3 drugs
no clear indication for androgen ablation
B/L orchiectomy shown to be effective hormonal androgen ablation

46
Q

side effects of androgen deprivation?

A

osteopenia, impotence, low libido, hot flashes, anemia, weakness, fatigue, sarcopenia

47
Q

efficacy of chemo vs natural therapies in CaP?

A

no studies show chemo improves survival or quality of life in pts w/any type of CaP compared to supportive or alternative/natural care

48
Q

adjuncts to chemo?

A

immune and BM support and nutrition: panax, dong quai, berberis
antioxidants
melatonin and trametes versicolor helpful in combo with ablation therapy and with chemo
ginger, pyridoxine, L-glutamine and acupuncture to reduce N/V
CoQ10 reduces ill effects of chem on the heart

49
Q

additional naturopathic care for CaP?

A 
diet: low fat, broccoli, lycopene-rich foods, Ornish diet, inc fish, limit animal fats, minimize alcohol consumption with exception of 1 glass red wine/d
soy isoflavones 100 mg/d
selenium 200-400 mcg/d
vit D
vit E
honey for radiation skin healing
CT support post-surgery
crinum latifolium 
green tea
immunomodulating herbs
serenoa repens
pomegranate 230 ml/d
modified citrus pectin to reduce METS for surgery
support groups
stress management
hydro, sitz baths
constitutional HP
50
Q

what is an angiokeratoma?

A

also known as fordyce
benign vascular ectasis, very common on the penis and scrotum of adult men, 1-2 mm w/red or purple hue
usu asx, mostly a cometic concern for pts

51
Q

what is a hydrocele? RFs? clinical findings? dx? tx?

A

fluid btw tunical layers
RFs: torsion, epididymtiis, LA, intrascrotal infxn, inguinal surgery, trauma, neoplasm
clinical findings: non-tender fluid-filled sac on anterior/inferior pole of the testicle
dx via U/S
tx: surgical removal only if uncomfortable, consider HP: apis, silica, graph, pulsatilla

52
Q

clinical findings of spermatocele? dx? tx?

A

small, painless mass on superior, posterior pole of testicle (on vas deferens), may follow epididymitis, contains dead spermatozoa

dx: U/S or aspiration
tx: ignore if sm w/o sxs, aspiration vs surgical removal, HP ruta, COPs, calc fluor cell salts

53
Q

what is a varicocele? clinical findings? dx? sequellae? tx?

A

valve incompetence, leads to dilatation of pampiform plexus
clinical findings: “bag of worms” located along the spermatic cord, may extend below testicle 80% on L side, worsens with valsalva maneuver and with standing
dx: angiography most reliable
sequellae: infertility 80%, low semen count and motility
tx: ligation or sclerotherapy, radiologic embolization, aesculus, collinsonia, achillea

54
Q

if notice appearance of new varicocele or worsening of an old one in an older male what do you need to consider?

A

on L mb tumor or other mass occluding L renal or testicular vein
on R occlusion of vena cava is possible

55
Q

what is epididymitis/orchitis? two forms and causes? RFs?

A

acute - ascending LUT infxn, GC/CT; UTI MC from E. coli in children and men over 35, in teens to 35 yo STI is MC cause
chronic - sxs similar to chronic prostatitis, w/or w/o infxn
RFs: sexually active, sexual abuse, infrequent urination, urinary tract malformation

56
Q

ssxs of epididymitis/orchitis? dx?

A

painful, swollen epididymitis, overlying skin may look like pea d’orange, mb fever
dx: onset usu insidious, in acute will show Prehn’s sign (in acute, elevating the testicle eases the pain)

57
Q

tx and management of epididymitis/orchitis?

A

if GC/CT then abx tx and expedited partner therapry
ice applications initially then hot/cot
acute: immune support, digestive enzymes, probiotics, AI, anodyne botanicals
chronic: sitz baths
glandulars
bryonia, fabiana, piper, phytolacca, podophyllum, pulsatilla, serenoa, staphysagria
HP

58
Q

complications of epididymitis/orchitis?

A

if recurrent or chronic can lead to infertility

59
Q

ssxs of testicular torsion? what anatomy do most have who develop this?

A

severe scrotal pn after an episode of trauma or during intensive exercise or spontaneously in sleep
N/V, acute onset pn, affected testicle higher, pn may radiate to the abd, assume torsion until proven otherwise, swollen, tender, erythematous scrotum
prolonged elevation of the scrotum does not relieve pn!
most who develop have “bell clapper” anatomy

60
Q

labs to assess for testicular torsion? imaging?

A

UA normal
imaging: color doppler U/S is 99% specific, 85% sensitive
radionuclide scan or arteriography

61
Q

ddx of testicular torsion?

A

trauma w/o torsion, orchitis, epididymitis, torsion of appendix testis

62
Q

tx of testicular torsion?

A

EMERGENT SURGICAL INTERVENTION to de-torse and prevent testicular necrosis with orchiopexy (attach testicle to posterior wall)
do NOT attempt to manually de-torse the testicle
use high doses of oral enzymes and flavonoids to help repair tissues
reperfusion support: ginkgo, curcumin, salvia

63
Q

ssxs of acute urinary retention? causes? tx?

A

ssxs: agonizing suprapubic pn, bladder enlarged to above the umbilicus on percussion
causes: BPH, urethral stricture, blood clots, CaP, bladder neck contracture, neurogenic bladder, psychogenic, meds (antihistamines, decongestants, anticholinergics, sympathomimetics)
tx: immediate cath, determine and tx underlying cause

64
Q

what is a penile fracture? ssxs? tx?

A

rupture of tunica albuginea on one or both corpora cavernosa, caused by blunt trauma to the erect penis, most often from intercourse, less often from masturbation
ssxs: snapping sound, intense pn, detumenscence, hematoma, penile deformity
if corpus spongiosum damaged, mb hematuria or urinary retention
referral for eval and possibly surgical repair
ice in the meantime!

65
Q

what is cryptorchidism? at increased risk for what?

causes? ddx? tx?

A

failure of the testes to descend into the scrotum in infancy, MC malformation of the male reproductive tract
increased risk of torsion and infarction!
monitor until age 4 then undescended testicles usu treated w/orchiopexy
if cryptorchid testicles persist after 5 yo, significant incr risk of testicular CA and infertility

66
Q

what is megalopenis? potential causes?

A

rapid enlargement of the penis in childhood

consider abn of testosterone production - interstitial cell tumors of testicle, hyperplasia or tumors of adrenal cortex

67
Q

what is a micropenis? potential causes? what do you need to evaluate for? treatment?

A

penis is smaller than 2 standard deviations from the norm
MC: due to T deficiency, also decreased ability of the hypothalamus to secrete LHRH with intact pituitary-gonadal axis
testicles small and frequently undescended
careful eval for other endocrine and CNS anomalies - retarded bone growth, anosmia, learning disabilities, deficiencies of ACTH and thyrotropin, intersex problems
tx: may respond sluggishly to T, orally or local 5% cream, start tx at 1 yr of age and monitor, orchiopexy for undescended testes

68
Q

what are posterior urethral valves? ssxs? labs? imaging? instrumentation?

A

MC obstructive urethral lesion in male infant
located at the distal prostatic urethra
ssxs: mild, moderate or severe obstruction, dribbling urinary stream, freq urinary infxn and sepsis, severe hydronephrosis may cause palpable midline abd mass, “failure to thrive”
labs: azotemia, poor concentrating ability, UTI, anemia
imaging: voiding cystogram, urogram, U/S
instrumentation: urethroscopy and cystoscopy confirms vales at distal prostatic urethra

69
Q

tx of posterior urethral vales? prognosis?

A

tx: destruction of values - transurethral fulgeration or perineal urethrostomy, tx infxns, severe cases may require temporary diversion reconstructive surgery
prognosis: early detection best way to preserve KD fxn (in utero U/S), careful PE and observation of voiding in newborns

70
Q

ssxs of anterior urethral valve? more common or rare than posterior? dx? tx?

A

ssxs: urethral dilatation or diverticular proximal to valve, bladder outlet obstruction, post-voiding incontinence, infxn, enuresis
rare to occur
dx: urethroscopy, vioding cystourethrography
tx: endoscopic electrofulgeration

71
Q

ssxs of urethrorectal and vesicorectal fistulas? dx? tx?

A

ssxs: passage of fecal material and gas through urethra or passage of urine into the rectum
dx: cystoscopy, panendoscopy, oral administration of radiographic contrast material
tx: surgical - immediate opening of imperforate anus and closing of fistula

72
Q

what is hypospadias? how does it form? how many degrees? causes? associated with what? RFs?

A

urethral opening on ventral surface of penis, develops when fusion of urethral folds is incomplete
foru degrees: glandular, coronal, penile shaft, penoscrotal, perianal
causes: gene defects and chromosomal abn
evidence of feminization - often associated with intersexuality and cryptorchidism
RFs: FHx, low birth wt, in-utero exposure to estrogens/progestins, in-utero exposure to anti-epileptic drugs, vegetarian mother

73
Q

ssxs of hypospadias? increased incidence of what?

labs/imaging for w/u?

A

ssxs: found on inspection at birth (abn, hood appearance or ambiguous genitalia), in children see diverted urine and spraying
increased incidence of cryptorchidism
labs/imaging: buccal smear and karyotyping to establish genetic sex as well as urethroscopy, cystoscopy, excretory urogram

74
Q

tx of hypospadias? if no tx and low grade? what is C/I w/hypospadias?

A

surgical correction usu at 12 mo, may cause mild incontinence, UTIs, unsatisfactory appearance
if low grade and not repaired it may cause infertility!
circumcision is C/I

75
Q

what is chordee w/o hypospadias? tx?

A

due to short urethra, fibrous tissues surrounding corpus cavernosum, spongiosum or both; meatus at normal position in the glans, penis bows only with erection, painful erections
tx: corpus cav: injections to help achieve an erection
corrective surgeries mb helpful

76
Q

what is epispadias? RFs? dx? tx?

A

failure of midline penis fusion in embryogenesis, opening on dorsal surface of glans, penis or penopubic area
RFs: FHx, often associated w/horseshoe KD, solitary KD, hypoplastic KD or megaureter
dx: on inspection at birth and sometimes pre-natal w/U/S
tx: surgical closure usu completed w/in 48 hours after birth

77
Q

best advice to avoid hypospadias and epispadias

A

counsel mothers to avoid exposure to xenoestrogenic compounds and excessive ingestion of phytoestrogens

Urology (9 decks)

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