Lecture 22 - Men's Health Part 2

Question 1

What are the effects of testosterone?

Answer 1

increases libido 
increase lean body mass
increase grip strength 
increase self-reported physical function 
increase vertebral bone density 

no improvement in depression scores
no decrease in fracture risk
no improvement in cognitive function
no enhanced response to phosphodiesterase inhibitors

Question 2

What is evidence of low testosterone on hx or PE?

Answer 2

decreased sex drive 
decreased sexual activity 
inability to maintain erections (ED and low T typically co-exist) 
reduced beard growth 
loss of muscle mass
decreased testicular size 
gynecomastia

Question 3

What levels of T indicate possible testosterone deficiency?

Answer 3

<300 ng/dL

Question 4

What is the work up for low testosterone?

Answer 4

check LH to r/o other problems
if LH is high = primary hypogonadism (testicular problem)

if normal or low = secondary hypogonadism (HPG axis problem)

Question 5

What is the treatment for low testosterone?

Answer 5

Goal is to return testosterone level to “mid-normal” range

Testosterone Enanthat or Cypionate - IM injection once every 2 weeks

Nongenital Testosterone Patch - applied daily

Testosterone Gel - applied daily, concern for transfer of medication to others who come into contact with the pt

Buccal Adhesive testosterone

SubQ Crystalline Testosterone implants

Question 6

What is a “normal” testosterone for an 80 y/o?

Answer 6

300

a 20 year old has 1000, and it decreases about 100 per decade of life

Question 7

Testosterone Enanthate or Crypionate

Answer 7

testosterone treatment

IM injection once every 2 weeks; rise in testosterone with DHT within 24 hours; injections followed by changes in mood, sexual desire, and energy

Question 8

Nongenital Testosterone Patch

Answer 8

testosterone treatment

applied daily, usually one patch sufficient

Question 9

Testosterone Gel

Answer 9

testosterone treatment

applied to armpit –MC used today

applied daily, concern for transfer of medication to others who come in contact with the pt/get, wide variability in absorption requires frequent monitoring of serum testosterone levels; higher DHT to testosterone levels compared to normal, healthy men

Question 10

Buccal Adhesive Testosterone

Answer 10

dissolving pill help against buccal mucosa twice daily; may cause/mucosal erosion

Question 11

SubQ Crystalline Testosterone implants

Answer 11

surgical implantation; lasts 6 months; may have fibrosis around implant and scar tissue formation

Question 12

What are the CV effects of testosterone therapy?

Answer 12

trial: older men on testosterone therapy with h/o chronic disease (DM, CVD, HTN, increase lipids) had greater number of CV events compared to placebo

Retrospective analysis (x2): higher frequency of CV events in older men on testosterone therapy with preexisting heart disease

basically if the have a hx, they will have a 2x greater risk of having hx (ex. heart attack) again

Question 13

What effects does testosterone therapy have on prostate cancer?

Answer 13

no evidence connects cause and effect of exogenous testosterone therapy and prostate cancer
BUT prostate cancer tumor growth will be increased with exogenous testosterone therapy
subclinical prostate cancer will rapidly progress if the pt is on exogenous testosterone therapy
must be stopped if there is presence or suspicion of prostate cancer

“feeding the tumor”

Question 14

What screening must you do for men on testosterone therapy?

Answer 14

DRE and PSA every 3 months for the first year and then twice a year thereafter

Question 15

Should you check testosterone for all men?

Answer 15

NO

only if pt is symptomatic

Question 16

Testicular torsion

Answer 16

most commonly caused by abnormality, sometimes TRAUMA 
<25 y/o 
twisting of the testis 
block blood from spermatic cord 
sudden onset of acute scrotal pain 

90% salvage at 6 hours
50% salvage at 12 hours
10% salvage at 24 hours

PE: ABSENT CREMASTERIC REFLEX
elevated scrotum on affected side

Question 17

What is the physical exam of a pt with testicular torsion?

Answer 17

PE: ABSENT CREMASTERIC REFLEX
elevated scrotum on affected side
enlarged painful testis
abnormal testicular lie

Question 18

What is the treatment for testicular torsion?

Answer 18

confirm dx with doppler US
do not delay time to surgery
manual detorsion is a temporary fix –but surgery is required to prevent recurrence

Question 19

Epididymitis

Answer 19

acute inflammation of the epididymis
most common cause of acute scrotal pain in all age groups
typical age range 14-35 y/o

etiologies

• sexually active men <35y/o (gonorrhea, chlaymidia)
• Men >35 y/o or those who practice anal sex (E.coli)

Presentation:
gradual onset of unilateral scrotal pain
frequently accompanied by urinary sx (ex. dysuria)
epididymal and/or testicular swelling

Dx.
urethral swab for GC and chlamydia (but often negative)
may need US to r/o testicular torsion

Tx:
ABX direct at likely pathogen –Ceftriaxone + azithromycin or fluoroquinolone

Question 20

What pathogens cause epididymitis?

Answer 20

sexually active men <35y/o:
gonorrhea, chlaymidia

Men >35 y/o or those who practice anal sex: E.coli

Question 21

What is the presentation of of epididymitis?

Answer 21

gradual onset of unilateral scrotal pain
frequently accompanied by urinary sx (ex. dysuria)
epididymal and/or testicular swelling

Question 22

How do you dx epididymitis?

Answer 22

urethral swab for GC and chlamydia (but often negative)

may need US to r/o testicular torsion

Question 23

How do you tx epididymitis?

Answer 23

ABX direct at likely pathogen –Ceftriaxone + azithromycin or fluoroquinolone

Question 24

Orchitis

Answer 24

caused by mumps virus

unilateral testicular swelling and scrotal edema 4-5 days after parotitis secondary to mumps
must r/o testicular torsion (doppler US)

tx: 
symptomatic:
-bed rest
-hot or cold packs
-scrotal elevation

Question 25

What is the presentation of orchitis?

Answer 25

unilateral testicular swelling and scrotal edema 4-5 days after parotitis secondary to mumps must r/o testicular torsion (doppler US)

Question 26

What is the treatment for orchitis?

Answer 26

symptomatic: - bed rest - hot or cold packs - scrotal elevation

Question 27

Varicocele

Answer 27

dilation of testicular vein and pampiniform plexus common ~15% of adult men 40% of infertility cases have varicocele 90% occur on LEFT side "bag of worms" increases in size with standing or valsalva maneuver can try surgical repair if infertile but poor success rate of pregnancy

Question 28

Hydrocele

Answer 28

fluid collection between layers of the tunica vaginalis nearly 5% of infants incomplete or delayed closure of the processus vaginalis may have infectious or trauma etiology 10% of testicular cancer present with hydrocele tense, smooth scrotal mass that easily transilluminates usually resolve on their own in <1 year in adult men, US to r/o tumor; otherwise may require surgical drainage and repair

Question 29

Spermatocele

Answer 29

aka "epidiymal cyst" benign cystic collection of fluid arising from epidiymis smooth painless mass transilluminates may use US to confirm but usually unnecessary no tx required unless painful can surgically excise but side effect of infertility or chronic pain

Question 30

Testicular cancer epi and risk factors

Answer 30

rare ~1% of all cancers in men leading cause of cancer in men 15-35 y/o average age of dx 34 y/o RF: - cryptorchidism - family hx of testicular cancer - tobacco use - caucasian - previous h/o testicular cancer - infertility

Question 31

What is the clinical presentation of testicular cancer?

Answer 31

``` discrete PAINLESS mass on the testicle testicular swelling (73%) testicular pain in up to (46%) scrotal "heaviness" or "firmness" may look like epididymitis; if treatment failure to this, then think cancer! sx of metastatic disease --back pain ``` confirm with scrotal US

Question 32

What is the work up for testicular cancer?

Answer 32

scrotal ultrasound measure serum biomarkers pre op - AFP, hCG, LDH

Question 33

What is the treatment for testicular cancer?

Answer 33

surgery: unilateral orchiectomy with pathological evaluation post-op: CT of chest, abd, and pelvis to look for mets

Question 34

What is the prognosis of testicular cancer?

Answer 34

5 year survival - 95% distant mets: 71%

Question 35

What adjuvant therapy is used in testicular cancer?

Answer 35

treatment options depend on type (seminoma vs nonseminoma) and grade (Stage 1, 2a, 2b, 3) options include: - local irradiation (low grade seminomas) - regional lymph node irradiation - 3 drug chemo - retroperitoneal lymph node dissection

Question 36

Phimosis

Answer 36

inability to retract the foreskin over the glans penis 10% of uncircumcised males at 3 years of age 5% of uncircumcised males at 16 years of age painful erections hygiene issues may ensue d/t difficult cleansing area may require circumcision

Question 37

Paraphimosis

Answer 37

retracted foreskin of uncircumcised penis can not be returned to normal anatomic position results in venous occlusion, edema, arterial insufficiency of the distal penis requires immediate manual reduction permanent therapy/prevention requires circumcision or dorsal slit

Question 38

Priapism

Answer 38

persistent erection of at least 4 hours 3 types: ischemia - veno occlusive with little or no blood flow through the corpora cavernosa; painful, rigid erection non-ischemic - fistula formation between cavernosal artery and corpora cavernosa usually due to trauma; high flood of blood into and out of corpora cavernos; penis is not rigid and not painful Suttering - periods of painful ischemic priapism followed by periods of flaccidity and detumescence Ischemic priapism is common complications of sickle cell disease often requires drainage and irrigation with sympathomimetic (phenylephrine)

Question 39

Treatment of priapism

Answer 39

often requires drainage and irrigation with sympathomimetic (phenylephrine)

Question 40

What are the 2 types of erectile dysfunction?

Answer 40

``` Organic - 80% vascular neurogenic anatomic hormonal ``` Psychogenic depression anxiety

Question 41

What drugs can cause ED?

Answer 41

``` anti HTN - diuretics, BB, alpha blocker antidepressants - SSRIs, MAOIs, tricyclics Benzodiazepines Antipsychotics antiandrogens digoxin antihistamines niacine phenytoin ketoconazole ``` excessive EtOH

Question 42

How do you dx ED?

Answer 42

Hx | International Index of Erectile Function

Question 43

Treatment of ED

Answer 43

treat underlying conditions when possible Phosphodiesterase type 5 (PDE5) - sildenafil, tadalafil, vardenafil = FIRST LINE local injection of alprostadil

Question 44

What are the contraindications of PDE5 treatment?

Answer 44

NITRATE use alpha blockers retinitis pigmentosa conditions predisposing to priapism