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Clin Med II Unit III > 6 Men's Health > Flashcards

6 Men's Health Flashcards

(94 cards)

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1
Q

Most common benign tumor in men ages 40-80

A

BPH

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2
Q

Androgens cause proliferation of fibrostromal tissue in the transitional zone that can lead to compression of the prostatic urethra

A

Benign Prostatic Hyperplasia (BPH)

As the prostate enlarges, obstruction can occur

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3
Q

Men with BPH experience…

A

Irritative (frequency, urgency) and/or obstructive (hesitancy, weak stream, dribbling) urinary symptoms

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4
Q

What are the four zones of the prostate and which one enlarges in BPH?

A

Transitional zone** (BPH)
Central zone
Peripheral zone
Fibromuscular zone

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5
Q

DDx to rule out before attributing symptoms to BPH

A 
Urethral stricture
Bladder neck contracture
Carcinoma of the prostate
Carcinoma of the bladder
Bladder calculi
Urinary tract infection and prostatitis
Neurogenic bladder
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6
Q

Things that can be risk factors for BPH, besides just being an old man

A

T2DM (—>nocturia)
Sx of neurologic disease
Sexual dysfunction
Gross hematuria or pain (more suggestive of tumor/stone)
Urethral trauma, urethritis, or urethral instrumentation
Family Hx of BPH or prostate cancer
Meds that impair bladder function or increase outflow resistance

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7
Q

Clinical features of BPH

A

Prevalence: Age 41-50 (50%, 51-50 (50%), 60-70 (70%)

Blacks>white>Asians

Hx of at least 3 months of bothersome urinary symptoms

Hx of recurrent urinary tract infections, gross hematuria

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8
Q

How do you diagnose BPH?

A

DRE —> symmetry, firmness, nodules
UA to r/o blood, infection
Prostate specific antigen (PSA) - avoid after ejaculation, trauma, or catheterization
BUN/Cr

Optional: max urinary flow rate, post-void residual volume, urine cytology

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9
Q

Treatment options for BPH

A

Behavior modification (avoid caffeine, EtOH, meds that make it worse; fluid restriction before bed; double voiding)

Alpha1 adrenergic antagonists**
MOA - relax smooth muscle in UT and prostate
SE - orthostatic hypotension, dizziness, ejaculatory dysfunction

5-alpha reductase inhibitors (Finasteride, dutasteride)
MOA - decreases prostate size via antiandrogen effects
SE - decreased libido and sexual dysfunction

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10
Q

Surgical approaches to BPH

A

TURP - transurethral radial prostatectomy
TUNA - transurethral needle ablation
TUMT - transurethral microwave their other app
Prostatic stent
Suprapubic prostatectomy
Many more

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11
Q

Clinical features of acute bacterial prostatitis

A

ACUTE ONSET of urinary frequency, urgency, and dysuria with obstructive voiding symptoms

Perineal/pelvic pain

Fever/chills, myalgia, malaise

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12
Q

How do you diagnose acute bacterial prostatitis?

A

DRE (gentle) reveals tender and edematous prostate

Prostate exam helps differentiate from UTI

Urine gram stain/culture

Will also have leukocytosis, pyuria, elevated PSA and ESR

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13
Q

How to treat acute bacterial prostatitis

A

If toxic, admit and state IV abx
Treat outpatient if patient stable/reliable

FLUOROQUINOLONE (levofloxacin, Citroen) or Bactrim for 6 WEEKS (need a long course because prostate hard to penetrate)

Gram stain/urine culture can help guide abx with atypical pathogens

Repeat urine culture after 7 days abx - if still positive, consider alternative regimen

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14
Q

Chronic or recurrent urogenital symptoms with evidence of bacterial infection of the prostate

A

Chronic bacterial prostatitis

May follow acute bacterial prostatitis

Risk factors/epi similar to acute bacterial prostatitis

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15
Q

Clinical features of chronic bacterial prostatitis

A

Sx can be subtle

Recurrent UTI

May see pelvic pain, bladder outlet obstruction, or hematuria

Prostate exam may reveal tenderness/hypertrophy but usually is normal

Labs for infection/inflammation may be elevated but are frequently normal

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16
Q

Dx and treatment of chronic bacterial prostatitis

A

Can be made using prostatic fluid analysis (gold standard)***

More often, diagnosed presumptively based on Hx of urinary symptoms

Treat with fluoroquinolone for min of six weeks, bactrim as alternative

Recurrent episodes generally treated the same way

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17
Q

Chronic pelvic pain for AT LEAST THREE of the preceding SIX MONTHS in the absence of other identifiable causes

A

Chronic prostatitis/chronic pelvic pain syndrome

Diagnosis of exclusion, divided into inflammatory and non-inflammatory subsets

Etiology is unknown and it is unclear to what extent symptoms are due to the prostate

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18
Q

Evaluating a patient for chronic pelvic pain syndrome

A

Hx - focused on pain, urinary Sx, sexual function, overall QOL

PE - complete genital and rectal exam, with non-tender or mildly tender prostate

UA and culture

Imaging as necessary to r/o torsion, abd pain etc

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19
Q

Clinical features of chronic pelvic pain syndrome

A

Pain in perineum, lower abdomen, testicular, penis, and with ejaculation

Void difficulties

Blood in semen

Typically experience relapsing-remitting pattern over many months

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20
Q

How do you treat chronic pelvic pain syndrome?

A

No uniformly accepted regimen

Alpha blockers, abx, and 5-alpha reductase inhibitors are the most effective meds and can be used in combo

Psychological support

Urology referral

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21
Q

Most common cancer diagnosed in men in the age group 60-79

A

Prostate cancer

Slow-growing malignant neoplasm of adenomatous cells of the prostate gland - malignant but stays confined for a long time

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22
Q

80% of prostate cancer is diagnosed subsequent to…

A

An elevated PSA

20% after abnormal DRE

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23
Q

Prostate cancer is the ___________ cause of cancer death in men, but only _______ chance to die

A

Second leading cause of cancer death

2.9% chance to die

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24
Q

Prostate cancer screening should be targeted to…

A

Those with >10 years life expectancy

Family Hx of prostate cancer

Black men

Methods: DRE, PSA, PCA3 (prostate cancer antigen 3 gene)

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25
Clinical features of prostate cancer
Middle aged man, generally w/o symptoms if disease is early Urinary frequency, urgency, nocturia, and hesitancy all common but often due to concomitant BPH Advanced prostate cancer may cause bone pain, fatigue, weight loss Rarely presents with hematuria or hematospermpia DRE - modular prostate, asymmetric prostate
26
How do you diagnose prostate cancer
Abnormal prostate exam/abnormal PSA —> prostate biopsy (usually transrectal ultrasound guided) DRE can only detect tumors in the POSTERIOR and LATERAL aspects of the prostate No absolute threshold of PSA to determine when a biopsy is needed - must consider age, race, prostate volume, FHx, DRE findings, change from baseline
27
How are prostate cancers staged?
Tumor Node Metastases system Gleason Score: • Histological grading based on architectural structure • Assists with treatment and prognosis • Two scores, primary and secondary grades of tumor
28
How do you treat prostate cancer?
Choice of treatment depends on many factors Patient specific - consider age, staging, comorbidities, lifestyle ``` Options include: • Observation • Radical prostatectomy • Radiation therapy • Androgen deprivation therapy ```
29
What should surveillance after prostate cancer treatment look like?
Total PSA every 6-12 months x 5 years and then annually If PSA rises, then referral is warranted Recurrence and/or metastatic workup - physician visit and serum PSA every 3-6 months
30
The inability to attain or maintain a penile erection that is satisfactory for sexual performance
Erectile Dysfunction Primarily a vascular phenomenon, triggered by neurologic signals and facilitated only in the presence of an appropriate hormonal condition and psychological midset Most cases have an organic cause
31
Meds that can cause ED
``` SSRIs Spironolactone Clonidine, methyldopa Thiazide diuretics Ketoconazole Cimetidine And on and on ```
32
Lowest prevalence of ED is found in...
Active males without chronic medical conditions who maintain healthy lifestyle choices
33
Risk factors for ED
``` Male gender DM Obesity HTN HLD CVD Smoking Meds Age ```
34
What ED finding is suggestive of a vascular or neurologic disease rather than a psychological one?
Complete loss of nocturnal erections
35
Working up some dude with ED 🍆
Detailed Hx PE should include DRE, secondary sex characteristics, femoral and peripheral pulses, breast exam, testicular volume ``` Fasting glucose/HbA1c CBC/CMP TSH Lipids Serum testosterone ``` Nocturnal tumescence test to distinguish psychogenic/organic cause Duplex Doppler can identify arterial obstruction or venous leak
36
Treatment of ED
Address underlying cause - psychotherapy, testosterone therapy, adjust meds, lifestyle changes FIRST LINE MED: phosphodiesterase-5 inhibitors (Sildenafil, vardenafil, tadalafil, avanafil) Second line: vacuum erection device, penile self injectables, intraurethral suppository Third line: penile prosthesis/surgery
37
Urethritis is most common in...
Young, sexually active males
38
Gonococcal urethritis is caused by...
Neisseria gonorrhoeae
39
Causes of non-gonococcal urethritis
Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, and others
40
Clinical features of urethritis
May be asymptomatic Male with c/o onset of dysuria and urethral discharge May see inflamed meatus
41
Diagnosing urethritis
Mucopurulent/purulent discharge Gram stain of urethral secretions First void urine (NOT clean catch) for NAAT nuclei acid amplication testing
42
What will you see on the gram stain in gonococcal urethritis?
Polymorphonuclear cells and GRAM-NEGATIVE DIPLOCOCCI in the urethral exudate
43
How do you treat gonococcal urethritis?
Ceftriaxone 250 mg IM + Azithromycin 1000mg (1 dose) If PCN allergy, Gentamycin 240mg IM + Azithromycin 2 grams (1 dose)
44
How do you treat non-gonococcal urethritis?
Azithromycin 1 gram ORALLY Or Doxycycline 100mg PO BID x 7 days
45
What else do you need to know about treating urethritis, other than the drugs?
Treat partners if appropriate No retest needed IF TREATED WITH FIRST LINE REGIMEN Use combo treatment b/c if you have one you usually have both
46
Infection of the epididymis via the vas deferens
Epididymitis Young men: associated with STDs Old me: associated with urinary pathogens
47
Clinical features of epididymitis
Acute, unilateral dull to severe scrotal pain radiating to ipsilateral flank Hemiscrotal swelling and tenderness which may progress to erythematous, fluctuating mass Fever, chills (+) Prehn’s sign If left untreated, can result in orchitis, abscess, or infertility
48
Why do you do a scrotal U/S in epididymitis?
To r/o testicular torsion or an abscess
49
Treatment for epididymitis
If pt Hx suspicious for chlamydia or gonorrhea: Ceftriaxone 250 mg IM x1 and Doxycycline 100mg BID for 10 days If enteric organism: Levofloxacin 500mg qd x 10 days or Ofloxacin 300mg BID x 10 days Advise adjunct use of NSAIDS for pain relief
50
Infection with involvement of the testicle by retrograde infection
Epididymoorchitis
51
What condition is associated with mumps?
Epididymoorchitis (look for paroditis)
52
Clinical features of epididymoorchitis
Acute, ipsilateral testicular swelling and tenderness Fever +/- bothersome urinary symptoms
53
Treatment for Epididymoorchitis
If mumps suspected, supportive care If bacterial pathogen suspected, treat similar to epididymitis
54
Venous varicosity in the pampiniform plexus (spermatic vein)
Varicocele Present in 15-20% of post-pubertal males
55
Varicocele typically presents on which side of the scrotum?
Left, due to longer left spermatic vein But can occur bilaterally too RIGHT-SIDED ONLY varicocele is suspicious for pelvic/abdominal malignancy
56
What are the clinical features of varicocele
Post-pubertal male with reported Hx of scrotal swelling “Bag of worms” Dull, achy testicular pain relieved with support or supine Can cause testicular atrophy and infertility
57
Varicocele increases in size with ________ and decreases in size when _________.
Increases with Valsalva Decreases when supine or if the scrotum is elevated
58
How do you diagnose varicocele?
PE - if no decompression in recumbent position, CT scan for outlet obstruction Doppler scrotal U/S
59
How do you treat varicocele?
Ligation of the spermatic vein if symptomatic, infertility concerns, or testicular atrophy Supportive care if mild symptoms and no reproductive concern
60
Twisting of the testis on the spermatic cord causing compromised circulation and ischemia
Testicular torsion
61
Testicular torsion is more common in...
Neonates and post-pubertal boys Often occurs after vigorous physical activity or minor trauma
62
Clinical features of testicular torsion
Acute onset of scrotal pain, unilateral with hemiscrotal swelling Pain on palpation, without relief with elevation (-) Prehn’s sign Bell clapper deformity Absent cremasteric reflex
63
How do you diagnose testicular torsion
DOPPLER U/S of scrotum —> limited or loss of flow to spermatic cord and testis
64
Treatment of testicular torsion
Manual detorsion - doesn’t really work but worth a shot while you’re waiting Urologic emergency requiring SURGICAL DETORSION and ORCHIOPEXY
65
Most common age group affected by testicular cancer
15-35
66
Risk factors for testicular cancer
Personal Hx of testicular cancer Cryptorchism Klinefelter syndrome - risk for germ cell tumors Family Hx
67
Clinical features of testicular cancer
Painless, solid testicular swelling or nodule (consider cancer until proven otherwise) Dull ache or heavy sensation in the lower abdomen, perinatal area, or scrotum Inguinal LAD or para-aortic LAD +/- abd pain or with pulmonary symptoms or neuro defects
68
Most common location of metastasis of testicular cancer
Abdomen Lungs Brain
69
What should you do if you suspect testicular cancer?
Scrotal U/S CT abdomen/pelvis Tumor markers: Beta-HCG, lactate dehydrogenase (LDH), alpha fetoprotein (AFP)
70
What are the different types of testicular tumor?
95% are germ cell tumors Seminoma 35% Nonseminoma 65% The type determines the treatment course
71
Treatment of testicular cancer
Radical inguinal orchiectomy Radiation and chemotherapy with medical oncologist based on tumor staging Seminatous tumors are RADIOSENSITIVE Nonseminatous tumors are RADIORESISTANT Nerve sparing retroperitoneal lymph node dissection for nonseminatous tumors, stage dependent Offer sperm banking prior to treatment
72
What should surveillance for testicular cancer entail?
Office visit q 3 months for first 2 years, 6 months then yearly after 5 year mark CXR, tumor markers and CT AB/pelvis Genital exam at every visit
73
A protrusion, bulge, or projection of an organ or a part of an organ through the body wall that normally contains it
Hernia
74
______ hernias protrude through Hesselbach’s triangle
Direct
75
_______ hernias develop at the internal inguinal ring and can travel through the inguinal canal into the scrotum
Indirect
76
Hernia occurring at the medial aspect of the femoral canal
Femoral hernia
77
________ hernias are due to weakness in the floor of the inguinal canal
Direct inguinal hernia
78
________ hernias are the most common type
Indirect inguinal hernias
79
Indirect inguinal hernias more commonly occur on the _____ side
Right Most are congenital but don’t present until later in life
80
Femoral hernias are the least common type but are more common in _____.
Women Most likely to become incarcerated/strangulated
81
Clinical features of inguinal hernias
Heaviness, discomfort with straining Painless bulge N/V, abd distension and pain, redness, fever if incarcerated/strangulated Strangulated hernia can cause bowel obstruction, peritonitis, and toxic appearance
82
How do you diagnose hernias?
Hx and PE U/S if in doubt or to r/o other conditions
83
Treatment for hernias
Definitive treatment is always surgical Repair is urgent for incarcerated or strangulated hernias If reducible, elective surgery is viable
84
Second most common urologic malignancy that is 7x more common in men
Bladder cancer
85
Bladder cancer is heavily associated with...
Tobacco Use Exposure to chemical dyes
86
What are the most common cell types for bladder cancer?
Transitional cell carcinoma (90%) Squamous cell carcinoma (7%) Adenocarcinoma (2%)
87
Clinical features of bladder cancer
Painless gross hematuria or microscopic hematuria most common presenting symptom Obstructive or irritative urinary symptoms can occur Local advancement may present with para-aortic LAD Metastatic disease may present with hepatomegaly, supraclavicular LAD, or periumbilical nodules Pain consistent with the areas of invasion or metastasis
88
Gold standard for diagnosing and staging bladder cancer
Cystourethroscopy Will also want to do urine cytology (bladder cells)/urine-based tumor markets, and CT with urography to evaluate upper tracts
89
Treatment options for bladder cancer
Transurethral resection of the bladder tumor High grade tumors will require intra-vesicular chemotherapy Muscle invasive tumors - neoadjuvant systemic chemotherapy prior to radical cystectomy
90
What are the different types of incontinence?
Urge incontinence - uncontrolled loss of urine that is proceeded by a strong, unexpected urge to void Stress incontinence - leakage with exertion, valsalva due to urinary sphincter dysfunction Mixed of the above Incomplete emptying incontinence - impaired DETRUSOR contractility or bladder outlet obstruction (much less common)
91
__________ is the most common cause of stress incontinence
Prostate surgery
92
WHich type of incontinence usually presents as nocturnal enuresis?
Incomplete emptying incontinence (overflow)
93
What are the treatment options for incontinence?
Urgency incontinence: • Antimuscarinic (tolterodine, fesoterodine, oxybutynin) • Alpha blockers if BPH Stress incontinence: • Condom catheters, penile clamp • surgical options Overflow incontinence • Alpha blockers
94
When should you refer to urology for complicated incontinence?
``` Severe symptoms Pelvic pain Hematuria Elevated PSA/abnormal prostate exam Recurrent urologic infections Previous pelvic radiation or surgery Neurologic disease ```

Clin Med II Unit III (6 decks)

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