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

6 Men's Health Flashcards

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
Q

Clinical features of prostate cancer

A

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

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26
Q

How do you diagnose prostate cancer

A

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

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27
Q

How are prostate cancers staged?

A

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

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28
Q

How do you treat prostate cancer?

A

Choice of treatment depends on many factors

Patient specific - consider age, staging, comorbidities, lifestyle

Options include:
• Observation
• Radical prostatectomy 
• Radiation therapy
• Androgen deprivation therapy
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29
Q

What should surveillance after prostate cancer treatment look like?

A

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

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30
Q

The inability to attain or maintain a penile erection that is satisfactory for sexual performance

A

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

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31
Q

Meds that can cause ED

A 
SSRIs
Spironolactone
Clonidine, methyldopa
Thiazide diuretics
Ketoconazole
Cimetidine
And on and on
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32
Q

Lowest prevalence of ED is found in…

A

Active males without chronic medical conditions who maintain healthy lifestyle choices

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33
Q

Risk factors for ED

A 
Male gender
DM
Obesity 
HTN
HLD
CVD
Smoking 
Meds
Age
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34
Q

What ED finding is suggestive of a vascular or neurologic disease rather than a psychological one?

A

Complete loss of nocturnal erections

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35
Q

Working up some dude with ED 🍆

A

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

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36
Q

Treatment of ED

A

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

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37
Q

Urethritis is most common in…

A

Young, sexually active males

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38
Q

Gonococcal urethritis is caused by…

A

Neisseria gonorrhoeae

39
Q

Causes of non-gonococcal urethritis

A

Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, and others

40
Q

Clinical features of urethritis

A

May be asymptomatic

Male with c/o onset of dysuria and urethral discharge

May see inflamed meatus

41
Q

Diagnosing urethritis

A

Mucopurulent/purulent discharge

Gram stain of urethral secretions

First void urine (NOT clean catch) for NAAT nuclei acid amplication testing

42
Q

What will you see on the gram stain in gonococcal urethritis?

A

Polymorphonuclear cells and GRAM-NEGATIVE DIPLOCOCCI in the urethral exudate

43
Q

How do you treat gonococcal urethritis?

A

Ceftriaxone 250 mg IM + Azithromycin 1000mg (1 dose)

If PCN allergy, Gentamycin 240mg IM + Azithromycin 2 grams (1 dose)

44
Q

How do you treat non-gonococcal urethritis?

A

Azithromycin 1 gram ORALLY

Or

Doxycycline 100mg PO BID x 7 days

45
Q

What else do you need to know about treating urethritis, other than the drugs?

A

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
Q

Infection of the epididymis via the vas deferens

A

Epididymitis

Young men: associated with STDs

Old me: associated with urinary pathogens

47
Q

Clinical features of epididymitis

A

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
Q

Why do you do a scrotal U/S in epididymitis?

A

To r/o testicular torsion or an abscess

49
Q

Treatment for epididymitis

A

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
Q

Infection with involvement of the testicle by retrograde infection

A

Epididymoorchitis

51
Q

What condition is associated with mumps?

A

Epididymoorchitis (look for paroditis)

52
Q

Clinical features of epididymoorchitis

A

Acute, ipsilateral testicular swelling and tenderness

Fever

+/- bothersome urinary symptoms

53
Q

Treatment for Epididymoorchitis

A

If mumps suspected, supportive care

If bacterial pathogen suspected, treat similar to epididymitis

54
Q

Venous varicosity in the pampiniform plexus (spermatic vein)

A

Varicocele

Present in 15-20% of post-pubertal males

55
Q

Varicocele typically presents on which side of the scrotum?

A

Left, due to longer left spermatic vein

But can occur bilaterally too

RIGHT-SIDED ONLY varicocele is suspicious for pelvic/abdominal malignancy

56
Q

What are the clinical features of varicocele

A

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
Q

Varicocele increases in size with ________ and decreases in size when _________.

A

Increases with Valsalva

Decreases when supine or if the scrotum is elevated

58
Q

How do you diagnose varicocele?

A

PE - if no decompression in recumbent position, CT scan for outlet obstruction

Doppler scrotal U/S

59
Q

How do you treat varicocele?

A

Ligation of the spermatic vein if symptomatic, infertility concerns, or testicular atrophy

Supportive care if mild symptoms and no reproductive concern

60
Q

Twisting of the testis on the spermatic cord causing compromised circulation and ischemia

A

Testicular torsion

61
Q

Testicular torsion is more common in…

A

Neonates and post-pubertal boys

Often occurs after vigorous physical activity or minor trauma

62
Q

Clinical features of testicular torsion

A

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
Q

How do you diagnose testicular torsion

A

DOPPLER U/S of scrotum —> limited or loss of flow to spermatic cord and testis

64
Q

Treatment of testicular torsion

A

Manual detorsion - doesn’t really work but worth a shot while you’re waiting

Urologic emergency requiring SURGICAL DETORSION and ORCHIOPEXY

65
Q

Most common age group affected by testicular cancer

A

15-35

66
Q

Risk factors for testicular cancer

A

Personal Hx of testicular cancer

Cryptorchism

Klinefelter syndrome - risk for germ cell tumors

Family Hx

67
Q

Clinical features of testicular cancer

A

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
Q

Most common location of metastasis of testicular cancer

A

Abdomen
Lungs
Brain

69
Q

What should you do if you suspect testicular cancer?

A

Scrotal U/S

CT abdomen/pelvis

Tumor markers: Beta-HCG, lactate dehydrogenase (LDH), alpha fetoprotein (AFP)

70
Q

What are the different types of testicular tumor?

A

95% are germ cell tumors

Seminoma 35%
Nonseminoma 65%

The type determines the treatment course

71
Q

Treatment of testicular cancer

A

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
Q

What should surveillance for testicular cancer entail?

A

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
Q

A protrusion, bulge, or projection of an organ or a part of an organ through the body wall that normally contains it

A

Hernia

74
Q

______ hernias protrude through Hesselbach’s triangle

A

Direct

75
Q

_______ hernias develop at the internal inguinal ring and can travel through the inguinal canal into the scrotum

A

Indirect

76
Q

Hernia occurring at the medial aspect of the femoral canal

A

Femoral hernia

77
Q

________ hernias are due to weakness in the floor of the inguinal canal

A

Direct inguinal hernia

78
Q

________ hernias are the most common type

A

Indirect inguinal hernias

79
Q

Indirect inguinal hernias more commonly occur on the _____ side

A

Right

Most are congenital but don’t present until later in life

80
Q

Femoral hernias are the least common type but are more common in _____.

A

Women

Most likely to become incarcerated/strangulated

81
Q

Clinical features of inguinal hernias

A

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
Q

How do you diagnose hernias?

A

Hx and PE

U/S if in doubt or to r/o other conditions

83
Q

Treatment for hernias

A

Definitive treatment is always surgical

Repair is urgent for incarcerated or strangulated hernias

If reducible, elective surgery is viable

84
Q

Second most common urologic malignancy that is 7x more common in men

A

Bladder cancer

85
Q

Bladder cancer is heavily associated with…

A

Tobacco Use

Exposure to chemical dyes

86
Q

What are the most common cell types for bladder cancer?

A

Transitional cell carcinoma (90%)

Squamous cell carcinoma (7%)

Adenocarcinoma (2%)

87
Q

Clinical features of bladder cancer

A

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
Q

Gold standard for diagnosing and staging bladder cancer

A

Cystourethroscopy

Will also want to do urine cytology (bladder cells)/urine-based tumor markets, and CT with urography to evaluate upper tracts

89
Q

Treatment options for bladder cancer

A

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
Q

What are the different types of incontinence?

A

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
Q

__________ is the most common cause of stress incontinence

A

Prostate surgery

92
Q

WHich type of incontinence usually presents as nocturnal enuresis?

A

Incomplete emptying incontinence (overflow)

93
Q

What are the treatment options for incontinence?

A

Urgency incontinence:
• Antimuscarinic (tolterodine, fesoterodine, oxybutynin)
• Alpha blockers if BPH

Stress incontinence:
• Condom catheters, penile clamp
• surgical options

Overflow incontinence
• Alpha blockers

94
Q

When should you refer to urology for complicated incontinence?

A 
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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