Male GU Flashcards
(150 cards)
1
Q
Anatomy
A
2
Q
Scrotal/Testicular Pain
(3)
A
Testicular Torsion
Torsion of Testicular Appendices
Epididymitis/Orchitis
3
Q
What is the most common cause of acute scrotal pain?
A
Epididymitis/Orchitis
4
Q
Testicular Torsion
=
A
Testicle twists spontaneously on spermatic cord, cutting off blood flow to testicle
5
Q
Testicular Torsion Prevalence
- Generally, a ____-degree twist is required to compromise blood flow through the testicular artery and cause ischemia
- More common in ____ testicle 1:4000 incidence in males < ___ years old
- Most common in adolescents between ages of __-__
- Older men too, so should be in ________ for every male with testicular pain
A
- Generally, a 720-degree twist is required to compromise blood flow through the testicular artery and cause ischemia
- More common in left testicle 1:4000 incidence in males < 25 years old
- Most common in adolescents between ages of 12-18
- Older men too, so should be in differential for every male with testicular pain
6
Q
Testicular Torsion Risk Factors
(1)*
A
Bell Clapper Deformity
Inappropriately high attachment of the tunica vaginalis, allowing testis to rotate more freely on the spermatic cord within the tunica vaginalis
7
Q
Testicular Torsion S/S
-
______ onset, ______ testicular pain and s_______
- Usually _/_ dt severe pain
- ____lateral testicular swelling, exquisitely ______
- ____ riding testicle with transverse/_____ lie
- Usually, absence of ______ reflex on ipsilateral side
A
-
Rapid onset, severe testicular pain and swelling
- Usually N/V dt severe pain
- Unilateral testicular swelling, exquisitely tender
- High riding testicle with transverse/horizontal lie
- Usually, absence of cremasteric reflex on ipsilateral side
8
Q
Testicular Torsion S/S
Usually absence of s/s of (1) → pt typically a_____, denies dys____, would have normal (2) labs if were able to check
Unless in later stage torsion where you could see (1) r/t inflammation
A
Usually absence of s/s of infection → pt typically afebrile, denies dysuria, would have normal UA/WBC labs if were able to check
Unless in later stage torsion where you could see leukocytosis r/t inflammation
9
Q
Testicular Torsion Diagnostic Test
A
Scrotal US + HP
10
Q
Intermittent Testicular Torsion
Pt may report similar pain that previously resolved
- (1) present but normal (2)
- Reasonable to (1) prior to “full fledged torsion”
A
- Pain present but normal PE and scrotal US
- Reasonable to treat with elective procedure prior to “full fledged torsion”
11
Q
Testicular Torsion Treatment
(1)*
Important to “fix” the _____ testis as well
“Bell clapper usually exists __laterally if present”
A
Refer immediately to ED if suspected → Surgical detorsion
Important to “fix” the unaffected testis as well
“Bell clapper usually exists bilaterally if present”
12
Q
Testicular Salvage Rate
Time is Testicle
- 90-100% if < __ hours
- 20-50% if ___ - ___ hours
- 0-10% if > ___ hours
A
- 90-100% if < 6 hours
- 20-50% if 12 - 24 hours
- 0-10% if > 24 hours
13
Q
Torsion of Testicular Appendices
=
A
Twisting of testicular or epididymal appendix/appendices
14
Q
Torsion of Testicular Appendices S/S
____lateral testicular ___, possible s______
(1) sign (ecchymotic appendix)
Testicle ___ high riding or in transverse lie, __febrile
A
Unilateral testicular pain, possible swelling
Blue dot sign (ecchymotic appendix)
Testicle not high riding or in transverse lie, afebrile
15
Q
Torsion of Testicular Appendices Diagnostics
(1) + (1)
First test is used to confirm what?
A
Scrotal US + UA
US to confirm vascular flow to testicle (hypervascular at appendix)
16
Q
Torsion of Testicular Appendices Treatment
A
Self-Limiting
Appendix atrophies over time
17
Q
Epididymitis/Orchitis
(3) Defintions
A
Inflammation of Epididymis
Inflammation of Testicle
Combo - Epididymo-orchitis
18
Q
Epididymitis/Orchitis Etiologies
(2)-(3),(1)
A
- STIs N.gonorrhoeae, C. trachomatis, M.genitalium
- Non-STD enteric organisms E.coli
19
Q
Epididymitis/Orchitis Other Etiologies
- Other infectious etiologies
- v_____ (m___, cox_____)
- gran_____ (T__, B___)
- Non infectious etiologies (rare)
- Beh____ disease (auto____, painful ul____)
- am____
A
- Other infectious etiologies
- viral (mumps, coxsackie)
- granulomatous (TB, BCG)
- Non infectious etiologies (rare)
- Behcet’s disease (autoimmune, painful ulcers)
- amiodarone
20
Q
Epididymitis/Orchitis S/S
____lateral testicular pain and s_____, possibly f____ or ___uria
- ____ing and ______ness of epididymis, testicle, or both. May be hard to distinguish during acute infection
- May be able to _____ thickened spermatic cord
- Possible scrotal er____ and ed____ on affected side. Could also develop a reactive ______
A
Unilateral testicular pain and swelling, possibly fever or dysuria
- Swelling and tenderness of epididymis, testicle, or both.
- May be hard to distinguish during acute infection May be able to palpate thickened spermatic cord
- Possible scrotal erythema and edema on affected side. Could also develop a reactive hydrocele
21
Q
Epididymitis/Orchitis Diagnostics
Imaging (1)
Labs (3)
A
Scrotal US (potentially confirms hypervascularity, but usually)
UA/Ucx, STI testing (more common)
22
Q
Epididymitis/Orchitis Treatment
A
Empirically treat most likely cause → adjust abx PRN based on culture sensitivities
23
Q
Epididymitis/Orchitis Treatment
For men?
Most likely cause?
A
Ceftriaxone 500mg* IM x1 AND Doxycycline 100mg PO BID x10 d
STIs - N.gonorrhoeae or C.trachomatis
24
Q
Epididymitis/Orchitis Treatment
For men who practice insertive anal sex?
What are the most likely causes?
A
- *Ceftriaxone 500mg* IM**
- *x1 AND Levofloxacin**
- *500mg PO QD x10d**
N.gonorrhoea or
C.trachomatis or enteric
organisms
25
Epididymitis/Orchitis Treatment
For men who's most likely cause is not STIs, most commonly (1)
**Levofloxacin 500mg PO QDx10d-** most commonly *E.coli*
26
Epididymitis/Orchitis Symptom Management
If ceftriaxone not available? (3)
Symptom management (3)
Gentamicin 240mg IMx1 or
Azithromycin 2g POx1 or
Cefixime 800mg POx1
**NSAIDs, Scrotal elevation/support, Ice**
27
Scrotal/Testicular Masses
(5)
**Varicocele**
**Spermatocele**
**Hydrocele**
**Groin Hernias**
**Testicular Cancer**
28
Varicocele Definition
* \_\_% prevalence in men overall
* 40% with _____ have varicocele
* *Benign-Enlargement of**
* *pampiniform plexus veins**
* *in scrotum**
* 15% prevalence in men overall
* 40% with infertility have varicocele
29
Varicocele S/S
**(1)\*** - increases with (1)
pain?
More common on what side? why?
**“bag of worms”** - increases with valsalva
mild, achy pain sometimes
Left side, r/t angle at which left testicle vein connects to left renal vein
30
Varicocele Treatment
**(2)** only if (2)
**Surgery or Embolization**
if pain is bothersome or pt is struggling with infertility
31
Spermatocele
=
* *Benign-Small, smooth, firm**
* *mass filled with old sperm,**
* *on epididymis anywhere**
* *from epididymal head to**
* *tail**
32
Spermatocele S/S
May be \_\_\_\_\_\_, (1) to touch, but noted along the ______ not the \_\_\_\_\_
Diagnostic
**(1)**
May be palpable, usually
nontender, but noted along
the epididymis (not the
testicle)
## Footnote
**Scrotal US**
33
Spermatocele Treatment
=
No intervention unless significant pain/bothersome
34
Hydrocele
=
(2) types
* *Benign- Fluid filled sac**
* *surrounding testicle**
communicating vs.
non-communicating
35
Hydrocele Causes
**(4)**
Fourth cause (2)
Which is most common?
* *Inguinal Hernia** (most common cause of secondary hydrocele)
* *Trauma**
**Infection**
**Tumor** (rhabdomyosarcoma, mesothelioma)
36
Hydrocele S/S
**(1)\***
Diagnostic
**(1)**
**Transilluminates**
**Scrotal US** (to r/o other causes
37
Hydrocele Treatment
=
* Repair ____ if cause of communicating hydrocele
* As\_\_\_\_ + S\_\_\_\_therapy or hydrocel\_\_\_\_ if large or bothersome/recurrence
No intervention typically, fluid may be reabsorbed or self-limiting in some cases
* Repair hernia if cause of communicating hydrocele
* Aspiration + Sclerotherapy or hydrocelectomy if large or bothersome/recurrence
38
Groin Hernias Risk Factors
(Inguinal and Femoral Hernias)
* Femoral hernias more common in (1)
* Risk Factors
* P\_\_\_\_\_\_\_/F\_\_\_ Hx Chronic cough
* Condition with chronic cough (1)
* Chronic con\_\_\_\_\_/st\_\_\_\_\_\_\_
* Sm\_\_\_\_\_\_
* Frequent heavy _____ (occupational)
* ________ birth (more likely indirect inguinal hernia)
* Femoral hernias more common in women
* Risk Factors
* Personal/Fam Hx Chronic cough
* Condition with chronic cough (cystic fibrosis)
* Chronic constipation/straining
* Smoking
* Frequent heavy lifting (occupational)
* Premature birth (more likely indirect inguinal hernia)
39
Direct Inguinal Hernia
* More common in (1) gender \>\_\_\_yo
* ____ or ___ protruding into inguinal canal through ____ abdominal _____ wall
* ______ to inferior epigastric vessels
* More common in men \>50yo
* Intestine or fat protruding into inguinal canal through weak abdominal muscle wall
* Medial to inferior epigastric vessels
40
Indirect Inguinal Hernia
* _____ COMMON TYPE OF GROIN HERNIA
* Usual cause (1)
* Intestine or fat protrude down (1) and possibly into scrotum
* ______ to inferior epigastric vessels
* MOST COMMON TYPE OF GROIN HERNIA
* Usually congenital - inguinal ring fails to close
* Intestine or fat protrude down inguinal canal and possibly into scrotum
* Lateral to inferior epigastric vessels
41
Benign Groin Hernia
What can we do to the hernia to help determine if intervention is needed?
\_\_\_\_ if pain/bothersome
\_\_\_\_\_ if no pain/reducible
Reducible either when supine (direct) or with exam (potentially direct or indirect)
Imaging if pain/bothersome
Monitor if no pain/reducible
42
Groin Hernia Complications
**(2)**
Diagnostic (1) if pain/bothersome
Treatment if needed (1)
**Incarceration:** not easily manually reproducible
**Strangulation****:** SURGICAL EMERGENCY! incarcerated hernia where blood supply is cut off and cause necrosis of hernia content
Imaging
Surgical repair (laparoscopic or open) by general surgeon
43
Testicular Cancer
**Most common cancer in men between ___ - \_\_\_**
* Ave age of diagnosis =
* Every 1/\_\_\_ males
* Only \_\_% of testis tumors in adults are benign\*
* Most common _secondary_ testicular cancer = \_\_\_\_\_\_
**Most common cancer in men between 15-34**
* Ave age of diagnosis 33
* Every 1/250 males
* Only 1% of testis tumors in adults are benign\*
* Most common _secondary_ testicular cancer = lymphoma
44
Testicular Cancer Risk Factors
* Ethnicity (1)
* P\_\_\_\_\_ hx (3-4% risk in contralateral side)
* F\_\_\_ hx (father or brother)
* **(1)\***
* **More common on what side, therefore testicular CA is more common on that side?**
* _____ the testis, higher the risk
* \_\_\_lateral → still increased risk in contralateral descended testicle
* ______ syndrome
* In\_\_\_\_
* H\_ \_
* Body size (1)
* Caucasian Personal hx (3-4% risk in contralateral side)
* Fam hx (father or brother)
* Cryptorchidism - undescended testicle
* \>right side → testicular CA \>right side
* Higher the testis, higher the risk
* Unilateral → still increased risk in contralateral descended testicle
* Klinefelter’s syndrome
* Infertility
* HIV
* Body size (height, not weight)
45
Testicular Cancer S/S
Most common sign **(1)**
* \_\_\_, _____ pain in testicles 10%
* \_\_\_\_cele 5-10%
* ____ pain (metastatic)
**Hard, nontender, painless lump/bump on testicle**
* dull, aching pain in testicles 10%
* Hydrocele 5-10%
* Back pain (metastatic)
46
Testicular Cancer Diagnostics
**Imaging (1)**
* (1) (AFP, b-HCG, LDH)
* (2) labs
* (1) Additional imaging
**Scrotal US**
* Serum tumor markers (AFP, b-HCG, LDH)
* CBC, CMP (check LFTs and Creatinine)
* CXR
47
Testicular Cancer Treatment
(2)
Excellent prognosis with?
**Refer to Urology**
**Radical Inguinal Orchiectomy** (then based on pathology, staging, imaging/labs will decide between surveillance, chemo, RT, or RPLND, or a combo of these)
**Early detection and tx**
(95% 5y survival, 99% if localized vs. 73% metastasized at dx)
48
Testicular Self Exam
1. Best done when?
2. How to examine?
3. Find what structure?
49
Penile/Urethral Conditions
(5)
**Hypospadias/Epispadias**
**Urethral Stricture**
**Priapism**
**Peyronie's Disease**
**Phimosis/Paraphimosis**
50
Hypospadias =
Epispadias =
**Hypospadias =** Urethral opening on bottom of penis
**Epispadias** = Urethral opening on top of penis
51
Hypo/Epispadias Treatment
=
Surgically repaired in childhood
52
**Narrowing of portion of urethra dt scar tissue/collagen formation**
Urethral Stricture
53
Urethral Stricture Causes
(1) major cause (rt f\_\_\_\_, gon\_\_\_\_\_ risk)
(1) (pelvic __ **,** str\_\_\_ injury, traumatic catheterization)
(1) TURP, RT for prostate CA
Infection major cause (rt foley, gonococcal risk)
Trauma (pelvic fx, straddle injury, traumatic catheterization)
Post Procedure Scarring (TURP, RT for prostate CA)
54
Urethral Stricture S/S
* Stream =
* Urinating =
* Recurrent (1)
* \_\_\_\_\_/\_\_\_\_\_ that can damage bladder or kidney function
* Weak/Split stream
* Difficulty urinating
* Recurrent infections
* Obstruction/Retention that can damage bladder or kidney function
55
Urethral Stricture Treatment
(2)
Dilation
Surgical incised or repair
56
Priapism
=
**2 types**
**Persistent penile erection \>4h, hours beyond or unrelated to sexual stimulation**
1. **Ischemic** (low flow/veno-occlusive)
2. **Non-Ischemic** (high flow/arterial) -Most common type
57
Rare form of ischemic, recurrent over extended period of time
Most common cause: sickle cell disease
Manage each episode, include prevention strategies
**Stuttering Priapism**
58
Priapism Causes
* \_\_\_\_pathic
* (1) trait/disease
* M\_\_\_\_\_ infiltration of corpora (ie leukemia)
* M\_\_\_\_\_\_\_ (ED tx, testosterone, alpha agonists, trazodone, bupropion, cocaine)
* T\_\_\_ (esp after 20% lipid infusion - increases platelet activity)
* (1) injury
* Spinal or general an\_\_\_\_\_\_
* Idiopathic
* Sickle cell trait/disease
* Malignant infiltration of corpora (ie leukemia)
* Medications (ED tx, testosterone, alpha agonists, trazodone, bupropion, cocaine)
* TPN (esp after 20% lipid infusion - increases platelet activity)
* Spinal cord injury
* Spinal or general anesthesia
59
Priapism S/S
* Corpora cavernosa will fully \_\_\_\_, r\_\_\_\_, t\_\_\_\_
* Glans penis and corpus spongiosum will be \_\_\_\_\_
* Color of the blood aspirated from corpora will be?
* Corpora cavernosa will fully erect, rigid, tender
* Glans penis and corpus spongiosum will be soft
* Color of the blood aspirated from corpora will be very dark red
60
Priapism Treatment
=
**EMERGENCY → SEND TO ER!**
61
Priapism Goals
1. **D\_\_\_\_\_\_** using (2)
2. **Preservation of erectile \_\_\_\_\_**
3. **Prevention of further \_\_\_\_\_\_\_**
Longer duration = Increased rate of \_\_\_
* * \_\_-\_\_ 65-90%
* \>\_\_h 100%
1. **Detumescence** using (phenylephrine injections or corporal aspiration with or without irrigation)
2. **Preservation of erectile function**
3. **Prevention of further episodes**
Longer duration = Increased rate of ED
* \<12h 50%
* 24-36 65-90%
* \>36h 100%
62
**Dense fibrous plaque that forms on penile shaft causing penile curvature and often painful/poor erections**
Peyronie's Disease
63
Peyronie's Disease Causes
* Often \_\_\_\_\_, however microscopically is c/w severe vasculitis
* Possible association with **(1)** of the hand
* May develop as a SE of (1) given for ED
* Often unclear, however microscopically is c/w severe vasculitis
* Possible association with Dupuytren’s contracture of tendons in hand
* May develop as a SE of intracavernosal injections given for ED
64
Peyronie's S/S and Tx
Not painful when \_\_\_\_\_
50% _____ resolve
Options for Tx often poor success
* PO pent\_\_\_\_\_\_, Intralesional coll\_\_\_\_\_\_ (Xiaflex) + modeling
* Penile tr\_\_\_\_\_ device
* Ex\_\_\_\_\_ of plaque/skin graft and penile pros\_\_\_\_ have been more successful
Not painful when flaccid
50% spontaneously resolve
Options for Tx often poor success
* PO pentoxifylline, Intralesional collagenase (Xiaflex) + modeling
* Penile traction device
* Excision of plaque/skin graft and penile prosthesis have been more successful
65
Phimosis/Paraphimosis Definitions
1. **(1):** inability to retract or pull back the foreskin/prepuce covering the glans
2. **(1)**: Infection/inflammation of glans, usually fungal
3. **(1):** foreskin/prepuce that has been retracted/pulled back cannot be returned to normal
1. **Phimosis:** inability to retract or pull back the foreskin/prepuce covering the glans
2. **Balanitis**: Infection/inflammation of glans, usually fungal
3. **Paraphimosis:** foreskin/prepuce that has been retracted/pulled back cannot be returned to normal
66
Phimosis/Paraphimosis Causes
1. **Phimosis:** usually r/t chronic _____ d/t poor \_\_\_\_\_
2. **Paraphimosis:** R/t chronic ______ and formation of tight ___ of skin behind glans
1. **Phimosis:** usually r/t chronic infection d/t poor hygiene
2. **Paraphimosis:** R/t chronic inflammation and formation of tight ring of skin behind glans
67
Phimosis Treatment
Treat any _____ first
Trial topical ______ to soften skin
Then consider dorsal foreskin sl\_\_\_ vs. circ\_\_\_\_\_
* Risk for (2) formation under prepuce (esp older men with ___ who get recurrent balanitis)
Treat any infection first
Trial topical betamethasone to soften skin
Then consider dorsal foreskin slit vs. circumcision
* Risk for calculi and squamous cell carcinoma formation under prepuce (esp older men with DM who get recurrent balanitis)
68
Balanitis Treatment
=
Start with topical clotrimazole
69
Paraphimosis Treatment
UROLOGIC \_\_\_\_\_\_\_
Can lead to swelling of glans, arterial \_\_\_\_\_, and possibly tissue \_\_\_\_\_\_
1. Firm _______ glans for 5 min to reduce tissue edema to then return foreskin to normal position
2. Then treat any \_\_\_\_\_\_
3. Then consider (1) vs. (1)
UROLOGIC EMERGENCY
Can lead to swelling of glans, arterial occlusion, and possibly tissue necrosis
1. Firm squeeze glans for 5 min to reduce tissue edema to then return foreskin to normal position
2. Then treat any infection
3. Then consider incision vs. circumcision
70
Urination Issues/Benign Prostate Conditions
(4)
LUTS
BPH
Acute Prostatitis
Chronic Prostatitis
71
Lower Urinary Tract Symptoms
**(2)** main phases of bladder function
Detailed Hx
* What s\_\_\_, how se\_\_\_\_\_?
* How both\_\_\_\_ is pt, impact on \_\_\_?
* Co\_\_\_\_\_ conditions that may impact LUTS or other t\_\_\_\_ options?
Then taking that info to decide further testing/determine etiology
**Storage (filling), Voiding (emptying)**
Detailed Hx
* What sx, how severe?
* How bothered is pt, impact on QOL?
* Comorbid conditions that may impact LUTS or other treatment options?
Then taking that info to decide further testing/determine etiology
72
Storage (Filling)
1. Normal function requires
1. lack of (1)
2. (1) to allow filling
3. ____ outlet
2. Storage related symptoms
1. ur\_\_\_\_
2. fr\_\_\_\_\_\_
3. noc\_\_\_\_
4. urge in\_\_\_\_\_\_
1. Normal function requires
1. Lack of involuntary contraction
2. Compliance to allow filling
3. Closed outlet
2. Storage related symptoms
1. urgency
2. frequency
3. nocturia
4. urge incontinence
73
Voiding (Emptying)
1. Normal function requires
1. lack of \_\_\_\_\_\_\_
2. ____ bladder outlet (relaxation of pelvic muscles)
3. coordinated detrusor \_\_\_\_\_
2. Voiding related symptoms
1. ____ stream
2. \_\_\_\_mittency
3. \_\_\_tancy
4. str\_\_\_\_\_
5. terminal dr\_\_\_\_\_
6. \_\_\_uria
1. Normal function requires
1. lack of obstruction
2. open bladder outlet (relaxation of pelvic muscles)
3. coordinated detrusor contraction
2. Voiding related symptoms
1. weak stream
2. intermittency
3. hesitancy
4. straining
5. terminal dribble
6. dysuria
74
IPSS
=
(7)
Score of **\_\_- __ =** Mildly symptomatic
Score of \_\_**-**\_\_ = Moderately symptomatic
Score of \_\_**-**\_\_ = Severely symptomatic
**International Prostatism Symptom Score**
Incomplete emptying, Frequency, Intermittency, Urgency, Weak stream, Straining, Nocturia
0-7 = mildly symptomatic
8-19 = moderately symptomatic
20-35 = severely symptomatic (MUST see medical help and begin tx immediately)
75
Uroflow
76
LUTS Diff Dx
**Causes of Obstruction**
* B\_\_\_
* Urethral st\_\_\_\_\_\_
* Ph\_\_\_\_
* Bladder neck or detrusor sphincter ______ (DSD), often noted in (1) injuries above S2
* Idiopathic
* BPH
* Urethral stricture
* Phimosis
* Bladder neck or detrusor sphincter (DSD), dyssynergia often noted in spinal cord injuries above S2
* Idiopathic
77
LUTS Diff Dx
**Bladder Storage Disorders**
* ______ bladder (OAB)
* _______ detrusor
* Sc\_\_\_\_\_ in bladder causing decreased c\_\_\_\_\_\_
* Overactive bladder (OAB)
* Underactive detrusor
* Scarring in bladder causing decreased compliance
78
LUTS Diff Dx
**Neurologic Conditions**
* MS, NPH, Stroke, CVA → (1)
* Cauda equina syndrome, sacral spinal cord injury → (1)
**Inflammatory Conditions**
* U\_\_, prost\_\_\_\_\_, interstitial \_\_\_\_\_\_, bladder st\_\_\_\_
* Neoplastic (2) CA
**Other Causes of polyuria**
* (2) chronic illnesses
**Neurologic Conditions**
* MS, NPH, Stroke, CVA → detrusor overactivity
* Cauda equina syndrome, sacral spinal cord injury → acontractile detrusor
**Inflammatory Conditions**
* UTI, prostatitis, interstitial cystitis, bladder stone
* Neoplastic bladder or prostate CA
**Other Causes of polyuria**
* DM, CHF chronic illnesses
79
Benign Prostatic Hypertrophy (BPH)
*Most likely etiology of?*
* 50% of men by age \_\_\_
* Nearly \_\_**%** of all men will develop BPH - with \_\_% receiving treatment for it
*Most likely etiology of gradually worsening voiding symptoms in aging men is BPH, so often is most likely diagnosis based on H&P, and other conditions are ruled out with further testing*
* 50% of men by age 50
* Nearly 80% of all men will develop BPH - with 30% receiving treatment for it
80
BPH Diagnosis
The key with evaluating BPH is evaluating the need for treatment/intervention
* \_\_&\_\_
* Voiding symptom questionnaire, like (1)
* (1) exam
* (1) lab value
* (1) Could consider imaging to evaluate size
* H&P
* Voiding symptom questionnaire, like IPSS
* DRE
* PSA
* Could consider imaging to evaluate size - US
81
BPH Treatment
_Lifestyle Modifications_
* **Avoid or caution with ______ that can increase risk for urinary \_\_\_\_\_** by increasing flow resistance and relaxing bladder contraction
* **Decrease bladder \_\_\_\_\_\_** (caffeine, alcohol, carbonated drinks, spicy foods, acidic foods)
* **(1):** decrease evening fluids, don’t take diuretic in evening, if LE edema - elevate for 1 hour in early evening to recirculate prior to sleep
* **Avoid or caution with medications that can increase risk for urinary retention** by increasing flow resistance and relaxing bladder contraction
* **Decrease bladder irritants** (caffeine, alcohol, carbonated drinks, spicy foods, acidic foods)
* **Nocturia:** decrease evening fluids, don’t take diuretic in evening, if LE edema - elevate for 1 hour in early evening to recirculate prior to sleep
82
Meds that increase urinary retention by increasing flow resistance and relaxing bladder contraction in BPH
* **\_\_\_\_\_\_ agonists** (decongestants with pseudoephedrine)
* **(1)** (esp benadryl) and hydroxyzine (atarax/vistaril) → if older male pt needs -
* **Anti\_\_\_\_\_\_**/beta 3 agonists for OAB -
* **Anti\_\_\_\_\_\_** like amitriptyline (Elavil) -
* **Anti\_\_\_\_\_\_** agents (levodopa) -
* **Anti\_\_\_\_\_\_** (haloperidol)
* **\_\_\_\_\_ relaxants** (diazepam) and cyclobenzaprine (flexeril)
* **O\_\_\_\_\_**
* **Amph\_\_\_\_\_\_**
* **Alpha agonists** (decongestants with pseudoephedrine)
* **Antihistamines** (esp benadryl) and hydroxyzine (atarax/vistaril) → if older male pt needs -
* **Anticholinergics**/beta 3 agonists for OAB -
* **Antidepressants** like amitriptyline (Elavil) -
* **Antiparkinsonian** agents (levodopa) -
* **Antipsychotics** (haloperidol)
* **Muscle relaxants** (diazepam) and cyclobenzaprine (flexeril)
* **Opioids**
* **Amphetamines**
83
BPH Pharm Therapy
(4)
Which is 1st line?
**Alpha Blockers (alpha adrenergic receptor blockers)- 1st line**
**5 alpha reductase inhibitors**
**Combo of alpha blocker + 5 alpha reductase inhibitor**
**PDE5 inhibitor**
84
Alpha Blockers
**(4)**
Which has the best CV SE profile/best option to start with?
Which one is least likely to have bothersome RGE?
Which ones are also used for HTN?
1. **Tamsulosin \***best CV SE profile, is best option to start with
2. **Silodosin (Rapaflo)**
3. **Alfuzosin (Uroxatral)** \*least likely to have bothersome RGE
4. **Doxazosin (Cardura) or Terazosin (Hytrin)** also used for HTN
85
Alpha Blockers Pharmacokinetics
MOA
Onset
SE (4) + (1)\*
Upcoming cataract surgery?
Relaxes smooth muscle in prostate/prostatic urethra to reduce outflow resistance
Rapid onset 48hr - often symptomatic improvement immediately
Lightheadedness, Dizziness, Postural hypotension, somnolence, **retrograde ejaculation**
Wait to start alpha blocker until **after** cataract surgery, risk for **intraoperative floppy iris syndrome (IFIS)**
86
BPH Alternative Therapies
(3)
Recommendations?
Saw palmetto, Pumpkin seed, Super beta prostate
DO NOT RECOMMEND, no proven benefit in literature (also no proven harm)
87
5 Alpha Reductase Inhibitors
(2)
MOA
Indication
Onset
SE (4)
**Effects on PSA?**
**Finasteride (proscar), Dutasteride (avodart)**
Reduces production of dihydrotestosterone, arrests prostatic hyperplasia ("shrinks prostate")
Better for larger volume prostates/more progressive BPH
Up to 6m for symptomatic benefit
Decrease libido, retrograde ejaculation, gynecomastia, breast tenderness/CA
**Falsely decreases PSA by 50%, so imp to double PSA if on 5-alpha red (ie PSA 3.0 on 5-alpha is really PSA of 6.0)**
88
Alpha Blocker + 5 Alpha Reductase Inhibitor Combo
(1)
\_\_ capsule/s a day, but often \_\_\_\_
**Dutasteride-Tamsulosin (Jalyn)**
1 capsule a day, but often expensive
89
PDE5 Inhibitor
(1)
MOA
FDA approved for tx of BPH with (1) + (1)
CI **(1)\***
**Tadalafil (Cialis) 5mg daily**
blocks reuptake of PDE5, increasing cGMP and smooth muscle relaxation
BPH with LUTS +ED
**X Nitrates\* X**
90
BPH Minimally Invasive Treatments
TUMT =
TUNA =
TUIP =
PVP, HoLEP =
Transurethral microwave thermotherapy (TUMT)
Transurethral needle ablation (TUNA)
Transurethral incision of prostate (TUIP)
“Laser Turp” options - Greenlight laser photoselective vaporization of the prostate (PVP), Holmium laser enucleation of the prostate (HoLEP)
91
BPH Newer Minimally Invasive Treatments
(2)
**Urolift:** tiny implants to hold prostate lobes apart
**Rezum:** radiofrequency generated thermal water vapor injections
92
BPH Surgical Options
(2)
Which is the **Gold Standard?**
**Transurethral resection of the prostate (TURP)- GOLD STANDARD**
**Simple prostatectomy** (either open or robotic laparoscopic)
93
Acute Prostatitis
=
Most common cause **(1)**
**Bacterial infection of prostate**
**E.coli** most common cause
94
Acute Prostatitis S/S
* F\_\_\_\_\_
* Irr\_\_\_\_\_ and/or ob\_\_\_\_\_ voiding symptoms
* Pelvic/perineal soreness/”\_\_\_\_\_\_”
* Fever
* Irritative and/or obstructive voiding symptoms
* Pelvic/perineal soreness/”heaviness”
95
Acute Prostatitis Diagnosis
**(1)\*** will show a t\_\_\_\_, w\_\_\_, b\_\_\_\_ prostate
(3) labs
**DRE** (tender, warm, boggy prostate)
UA/Ucx, CBC, blood cx if indicated
96
Acute Prostatitis Treatment
=
(2) Rx
Supportive therapy: N\_\_\_\_\_, Stool \_\_\_\_\_, (1) for pain/fever
**Empiric abx treatment** (then adjust per Ucx)
1. TMP-SMX **(Bactrim DS)** BID x 4-6 wks OR
2. **Fluoroquinolone** (Cipro 500mg BID or Levaquin 500mg QD) x 4-6 weeks
Supportive therapy: NSAIDs, Stool softeners, Antipyretics for pain/fever
97
Acute Prostatitis When to Refer
1. If not improving in 24-48 hrs OR
2. If worsens or suspecting sepsis or acute urinary retention
1. Refer to Urology
2. Send to ED/admit
98
Chronic Prostatitis
_2 Types_
10% of cases
90% of cases
**Chronic Bacterial Prostatitis**
**Chronic Pelvic Pain Syndrome (inflammatory/non bacterial)**
99
Chronic Bacterial Prostatitis
Most common cause of (1) in adult men
Perineal p\_\_\_/h\_\_\_\_\_, s\_\_\_pubic pain, LUTS, painful ej\_\_\_\_\_
Consider _____ course (\_-\_m) abx + NSAIDs OR Suppressive abx/consider involving (1)
Most common cause of recurrent UTIs in adult men
Perineal pain/heaviness, suprapubic pain, LUTS, painful ejaculation
Consider longer course (3-4m) abx + NSAIDs OR Suppressive abx/consider involving ID
100
Chronic Pelvic Pain Syndrome
* Prostate inflammation without (1), but similar sx
* Component of (1)?
* Prostate inflammation without infection, but similar sx
* Component of interstitial cystitis (IC)?
101
Chronic Pelvic Pain Syndrome Treatment
=
+ Refer to \_\_\_\_\_
Trial and error of many options
(Abx (bactrim, FQ, doxy) NSAIDS, Alpha blockers, 5 alpha reductase inhibitors, Dietary changes, Frequent ejaction (could also worsen for some) Acupuncture, Sitz baths, Pelvic floor PT/biofeedback, PTNS, OAB medications, Elmiron, Cymbalta, Muscle relaxants for pelvic floor muscles, Antianxiolytics, Zinc etc)
Refer to Urology (both can be difficult and frustrating to treat)
102
Prostate CA Prevalence
* ___ most common cancer in men (after skin cancer)
* ___ leading cause of cancer death in men (after lung cancer)
* Every 1/\_\_ men will die of prostate CA (lifetime risk of dying 3%)
* 2nd most common cancer in men (after skin cancer)
* 2nd leading cause of cancer death in men (after lung cancer)
* Every 1/8 men will die of prostate CA (lifetime risk of dying 3%)
103
Prostate CA Risk Factors
* (1) (over 2 fold increase in risk if first degree relative)
* (1) Ethnicity
* \>\_\_\_ yo
* Family Hx (over 2 fold increase in risk if first degree relative)
* African/African American
* Higher age \>65yo
104
Prostate CA 5 Year Survival
Localized/regional disease at diagnosis ~ \_\_\_% Distant metastases at diagnosis \_\_\_%
Localized/regional disease at diagnosis ~ 100% Distant metastases at diagnosis \<30%
105
Prostate CA Screening Tests
(3)
Which is the most definitive test?
*Consider risk factors (ethnicity, fam hx)*
**PSA**
**DRE**
**Prostate Biopsy (most definitive 100%)**
106
PSA Background
* Prostate Cancer screening is \_\_\_\_\_\_\_
* Screen w PSA blood test - specific to prostate but not prostate \_\_\_
* PSA is a glyco\_\_\_\_ produced by prostate ep\_\_\_\_ cells
* PSA blood test does ____ diagnose prostate CA, nor can it tell ____ form from _____ cancer
* PSA can be _____ by many things, like BPH, inflammation, infection, irritation, and recent instrumentation
* Be sure not to have ___ at time of test -
* ____ DRE, ejaculation, bicycle riding/vigorous exercise, or enema 48hrs prior to test
* Wait at least \_\_m after prostate biopsy before re-checking PSA
* Prostate Cancer screening controversial
* Screen w PSA blood test - specific to prostate but not prostate CA
* PSA is a glycoprotein produced by prostate epithelial cells
* PSA blood test does NOT diagnose prostate CA, nor can it tell aggressive from nonaggressive cancer
* PSA can be altered by many things, like BPH, inflammation, infection, irritation, and recent instrumentation
* Be sure not to have UTI at time of test -
* Avoid DRE, ejaculation, bicycle riding/vigorous exercise, or enema 48hrs prior to test
* Wait at least 3m after prostate biopsy before re-checking PSA
107
PSA USPSTF 2018 Update
* \_\_-\_\_ yo = now Grade __ rec
* (previously grade D) - *individual decision making*
* \>\_\_ yo = remains Grade D rec =
* 55-69 yo = now Grade C rec
* (previously grade D) - *individual decision making*
* \>70 yo = remains Grade D rec **do not screen**
108
PSA AUA recommendations
* \<40 =
* 40-54 ave risk =
* 40-54 high risk =
* 55-69 =
* \<40 = against screening
* 40-54 ave risk = does not recommend routine screening for ave risk men
* 40-54 high risk = *individual decision making*
* 55-69 = *shared decision making* strongly recommend
109
PSA Normal Level
=
* However this can be broken down by ___ group/decade
* If PSA found to be elevated?
* Data point for interpretation, often to be \_\_\_\_
0-4 ng/mL
* However this can be broken down by age group/decade
* **If PSA found to be elevated, refer to urology** for further workup
* Data point for interpretation, often to be repeated
110
DRE
What finding on DRE is concerning? What should you do if this is found?
Urology may order other lab work such as (2) and imaging such as (2)
**Firm nodule** → refer to urology
4K blood test, PCA3 urine, prostate MRI or TRUS
111
**What is the most definitive test for Prostate Ca?**
It is done trans\_\_\_\_ via ___ guidance or transperineally
MRI ____ biopsies possible when indicated
**Prostate Biopsy** (most definitive test - 100%)
transrectally via US guidance or transperineally
MRI-fusion biopsies when indicated
112
Prostate CA Grading
What Gleason scores correlate with low, intermediate and high risk?
low risk _\<_ 6
intermediate risk 7
high risk 8-10
113
Treatment of Prostate CA
**Varies based on aggressiveness of cancer**
1. Active \_\_\_\_\_\_\_\_
2. F\_\_\_\_\_ treatments
3. W\_\_\_\_\_ gland or s\_\_\_\_\_\_ treatments
1. Active surveillance
2. Focal treatments
3. Whole gland or systemic treatments
114
Prostate CA Active Surveillance
* Indicated for what type of prostate CA?
* (4) surveillance
* G\_\_\_\_\_ testing now available/used to help estimate risk for progression (even an epigenomic test on negative biopsies)
* Typically, low volume, low risk prostate cancer
* **PSA** surveillance at some interval, **DRE** surveillance, **imaging** surveillance if possible, surveillance **biopsies**
* Genomic testing now available/used to help estimate risk for progression (even an epigenomic test on negative biopsies)
115
Prostate CA Focal Treatments
(2)
* For what type of prostate CA?
* Often a good alternative for pts who may no be a good candidate for whole gland tx dt co\_\_\_\_\_\_\_
High intensity focused US (HIFU)
Cryotherapy
* Low volume, unilateral, low-intermediate risk prostate CA
* Often a good alternative for pts who may no be a good candidate for whole gland tx dt comorbidities
116
Prostate CA Whole Gland or Systemic Treatments
1. Radical \_\_\_\_\_\_\_
2. R\_\_\_\_\_\_
3. H\_\_\_\_\_\_ therapy (anti-androgen)
4. Ch\_\_\_\_\_\_
5. Im\_\_\_\_\_\_
1. Radical Prostatectomy
2. Radiation
3. Hormone therapy (anti-androgen)
4. Chemotherapy
5. Immunotherapy
117
Radical Prostatectomy
(either robotic, assisted laparoscopic, or open)
(2) Main post-op side effects/risks
Risks with surgery: an\_\_\_\_\_ risks, injury to surrounding ____ (2)
Urinary incontinence, Erectile dysfunction
Risks with surgery: anesthesia risks, injury to surrounding organs (bladder, bowel/rectum)
118
Radiation for Prostate CA
Types (4)
Relatively similar risks of (2), also (1) symptoms, radiation cy\_\_\_\_/proct\_\_\_\_\_, rectal bl\_\_\_\_\_\_, secondary c\_\_\_\_\_
External beam (EBRT), intensity modulated (IMRT), brachytherapy seeds, Cyberknife
Relatively similar risks of incontinence and ED, also LUTS, radiation cystitis/proctitis, rectal bleeding, secondary cancers
119
Hormone Therapy for Prostate CA (anti-androgen)
Usually part of \_\_\_\_-modality treatment, or on its own if patient wouldn’t tolerate anything else/more p\_\_\_\_\_\_
Usually part of multi-modality treatment, or on its own if patient wouldn’t tolerate anything else/more palliative
120
Chemotherapy for Prostate CA
Indicated for what stage of Prostate CA
(2) Regimens
Late stage, sometimes first line for metastatic
CHAARTED, STAMPEDE
121
Immunotherapy for Prostate CA
(1) T (Provenge) = first commercially available, very expensive
(1) = PDI inhibitor, many other immune checkpoint inhibitors being researched
Sipuleucel T (Provenge) = first commercially available, very expensive
Pembrolizumab (Keytruda) = PDI inhibitor, many other immune checkpoint inhibitors being researched
122
Erectile Dysfunction/Decreased Libido Definitions
* **(1)**: a neurovascular event subject to psychological and hormonal modulation
* **(1)**: Difficulty either achieving or maintaining (or both) an erection firm enough for intercourse
* **(1)**: Psychogenic, neurogenic, hormonal, vasculogenic, and medication induced
* **(1)**: erectile failure more than 75% of the time
* **Penile erection**: a neurovascular event subject to psychological and hormonal modulation
* **ED**: Difficulty either achieving or maintaining (or both) an erection firm enough for intercourse
* **5 main categories of ED**: Psychogenic, neurogenic, hormonal, vasculogenic, and medication induced
* **Impotence**: erectile failure more than 75% of the time
123
ED Risk Factors
* **A\_\_\_**: some progressive worsening
* **Conditions**: Endocrine/D\_\_ (decreased blood flow), psychologic, h\_\_\_\_tension, neurologic (st\_\_\_\_, spinal cord injury), ob\_\_\_\_, OSA, t\_\_\_\_ use, al\_\_\_\_\_ use
* **(1)**?: prelim data suggests yes - vasculogenic/endothelial dysfunction, also consider psychological impact
* **Medication SE:** diu\_\_\_\_, antihy\_\_\_\_\_\_, antihis\_\_\_\_\_\_, antid\_\_\_\_\_\_, P\_\_\_\_\_\_’s disease drugs, tranquilizers, muscle relaxants, NSAIDs, h\_\_\_\_\_\_/prostate cancer drugs, ch\_\_\_\_therapies, anti-seizure meds
* **(1) disease**: can cause new onset ED (rf for CV disease as smoking and fam hx of heart disease)
* **Age**: some progressive worsening
* **Conditions**: Endocrine/DM (decreased blood flow), psychologic, hypertension, neurologic (stroke, spinal cord injury), obesity, OSA, tobacco use, alcohol use
* **Covid 19**?: prelim data suggests yes - vasculogenic/endothelial dysfunction, also consider psychological impact
* **Medication SE:** diuretics, antihypertensives, antihistamines, antidepressants, Parkinson’s disease drugs, tranquilizers, muscle relaxants, NSAIDs, hormones/prostate cancer drugs, chemotherapies, anti-seizure meds
* **Life threatening CV disease**: can cause new onset ED (rf for CV disease as smoking and fam hx of heart disease)
124
Diagnosing ED
* **(1) :** a good sexual history helps to determine if issue r/t l\_\_\_\_\_, er\_\_\_\_\_ function, or ej\_\_\_\_\_ function
* **Bloodwork**
* AM \_\_\_\_\_\_\_
* P\_\_\_\_
* L\_\_, F\_\_\_, es\_\_\_\_\_
* Pr\_\_\_\_\_ (if low T and low LH)
* Other non-urologic causes: A1c, BMP, lipid panel, TSH
* **Penile (1)** to assess for adequate blood flow (if indicated)
* **(1) testing**, but now only used in rare cases
* **History:** a good sexual history helps to determine if issue r/t libido, erectile function, or ejaculatory function
* **Bloodwork**
* AM testosterone
* PSA
* LH, FSH, estradiol
* Prolactin (if low T and low LH)
* Other non-urologic causes: A1c, BMP, lipid panel, TSH
* **Penile doppler US** to assess for adequate blood flow (if indicated)
* **Nocturnal penile tumescence (NPT) testing**, but now only used in rare cases
125
ED Treatment 1st line
(1)-(3)
**PDE Inhibitors**
Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra)
126
PDE Inhibitors for ED
* MOA =
* CI (1)
* SE
* All of them can cause (3)
* Viagra/Levitra can cause con\_\_\_\_, fl\_\_\_\_, h\_\_\_\_\_\_
* Viagra can cause ____ spots
* Cialis can cause ___ and ___ pain
* MOA = blocks reuptake of PDE5, increasing cGMP and smooth muscle relaxation, which leads to vasodilation
* CI = nitrates
* SE
* All of them can cause hypotension, priapism, dyspepsia
* Viagra/Levitra can cause congestion, flushing, headaches
* Viagra can cause blue spots
* Cialis can cause leg and back pain
127
ED other Treatment
* **(3) devices**
* **(1)** urethral suppository (Muse, intrac injectsion system - Caverject, Edex)
* **Med combos for intra\_\_\_\_\_\_ injections (ICI):** Bimix, Trimix, Quadmix
* **(1):** (usually try to promote vasodilation/blood flow) - Edox, L-arginine, ginseng, gingko biloba, maca, etc
* **Experimental newer therapies (4):** little data yet, some may be commercially available but expensive
* **Vacuum erection device (VED), Penile constriction ring, Penile implant**
* **Alprostadil** (urethral suppository)
* **Intracavernosal injections**
* **Supplements**
* **Stem cell therapy, plasma rich plasma (PRP), hyperbaric oxygen, low intensity shockwave therapy (LIST)**
128
**Premature Ejaculation**
**=**
* \_\_**-**\_\_ % of men
* Management
* **(1)** low daily dose or PRN
* (1) either alone or combo with above - tends to be more effective with concomittant ED
* (1) creams or sprays
* (1) therapies
* (1) possible short course (3rd line)
**Ejaculatory latency time (ELT) of \<1-2 minutes**
* 20-30 % of men
* Management
* **SSRI's** low daily dose or PRN
* PDE5i either alone or combo with above - tends to be more effective with concomittant ED
* Topical anesthetic creams or sprays
* Behavioral/psych therapies
* Tramadol possible short course (3rd line)
129
SSRI options for Premature Ejaculation
**(1) 10-20mg daily** (possible most effective)
(1) (Prozac) 20mg daily or
(1) (Zoloft) 50-100mg daily
**Paroxetine (Paxil) 10-20mg daily** (possible most effective)
Fluoxetine (Prozac) 20mg daily or
Sertraline (Zoloft) 50-100mg daily
130
**Retrograde Ejaculation**
Cause
Frequently r/t BPH med SE
131
Testosterone Deficiency
=
(consideration for testosterone supplementation)
Low serum testosterone **AND** clinical symptoms of low testosterone
132
Primary Hypogonadism
=
Levels of T and LH?
* **(1) syndrome:** extra X chromosome (small firm testes, gynecomastia, azoospermia)
* **(1) syndrome:** short stature, webbed neck, low set ears, undescended testes
* **(1) testes:** (s/p orchiectomy for testicular cancer)
* **(1)** **testes:** (cryptorchidism, torsion, atrophy)
**Testicular Failure**
**Low T, elevated LH**
* **Klinefelter’s syndrome** - extra X chromosome (small firm testes, gynecomastia, azoospermia) -
* **Noonan’s syndrome** - short stature, webbed neck, low set ears, undescended testes
* **Absent testes** (s/p orchiectomy for testicular cancer)
* **Poor functioning testes** (cryptorchidism, torsion, atrophy)
133
Secondary Hypogonadism
=
**Levels of T and LH?**
* **(1) syndrome** = X linked, absent puberty
* **(1) syndrome** = small hands and feet, obesity, mental retardation, hypotonic musculature -
* **\_\_\_\_\_\_ prolactin** = (d/t prolactinoma, renal failure, hypothyroidism, meds, stress)
* **Pituitary or hypothalamic \_\_\_\_\_** d/t tumor or surgery
**Hypothalamic pituitary disruption (normal testes)**
**Low T, normal or low LH**
* **Kallman’s syndrome** = X linked, absent puberty
* **Prader - Willi syndrome** = small hands and feet, obesity, mental retardation, hypotonic musculature -
* **Elevated prolactin** = (d/t prolactinoma, renal failure, hypothyroidism, meds, stress)
* **Pituitary or hypothalamic damage** d/t tumor or surgery
134
Other Clinical Conditions
(that cause testosterone deficiency)
Usually some degree of impact on HPG axis
* OPIAD =
* nonsurgical c\_\_\_\_\_\_ treatments
* ____ (multifactorial: AIDs wasting syndrome, testicular atrophy 2/2 opportunistic infection, anti-mitotic medications)
* (1) Virus
* osteo\_\_\_\_/osteo\_\_\_\_\_
* Opioid-induced androgen deficiency (OPIAD)
* nonsurgical cancer treatments
* HIV (multifactorial: AIDs wasting syndrome, testicular atrophy 2/2 opportunistic infection, anti-mitotic medications)
* HCV
* osteoporosis/osteopenia
135
Prolactinoma
(causing testosterone deficiency)
=
* **If T \< \_\_\_\_, and confirmed secondary hypogonadism (normal or low LH/FSH) and serum ______ elevated**
* S/S c/f a tumor or mass (2)
* Dx imaging =
* Tx =
**Prolactin secreting pituitary tumor**
* **If T \< 150, and confirmed secondary hypogonadism (normal or low LH/FSH) and serum prolactin elevated**
* S/S c/f a tumor or mass = HA, visual/field defect
* Dx imaging = brain/pituitary MRI
* Tx = **refer to endocrine/neuroendocrine**, Rx prolactin antagonist (1st line) then surgery or RT if med fails
135
Prolactinoma
(causing testosterone deficiency)
=
* **If T \< \_\_\_\_, and confirmed secondary hypogonadism (normal or low LH/FSH) and serum ______ elevated**
* S/S c/f a tumor or mass (2)
* Dx imaging =
* Tx =
**Prolactin secreting pituitary tumor**
* **If T \< 150, and confirmed secondary hypogonadism (normal or low LH/FSH) and serum prolactin elevated**
* S/S c/f a tumor or mass = HA, visual/field defect
* Dx imaging = brain/pituitary MRI
* Tx = **refer to endocrine/neuroendocrine**, Rx prolactin antagonist (1st line) then surgery or RT if med fails
136
S/S of Testosterone Deficiency
* **(1) - most common symptom**
* E \_
* In\_\_\_\_\_\_\_\_
* Fat\_\_\_\_\_
* Altered masculine features (gynec\_\_\_\_\_, decreased facial and body h\_\_\_\_, reduced _____ mass)
* _____ body fat
* _______ bone mineral density
* M\_\_\_\_ disturbances
* **Low libido - most common symptom**
* ED
* Infertility
* Fatigue
* Altered masculine features (gynecomastia, decreased facial and body hair, reduced muscle mass)
* Increased body fat
* Decreased bone mineral density
* Mood disturbances
137
Testosterone Deficiency Diagnosis
=
**2 separate AM testosterone values \<300 ng/dL**
Also check hormones involved in HPG axis: LH and FSH, estradiol, prolactin
138
Testosterone Replacement Indications
For men with (1) **AND** (1) after evaluating for any underlying causes of ED
For men with documented/consistently low T (\<300ng/dL) **AND** clinically significant symptoms of low T
139
Testosterone Replacement Considerations and CI
* **Considerations**
* long term impact of exogenous testosterone on \_\_\_\_genesis
* C\_\_\_ risk
* \_\_\_\_themia
* **CI**
* (2) CA
* abnormal (1) exam
* (1) \>3 that has not yet been evaluated
* untreated O\_\_
* severe ___ failure
* Erythro\_\_\_ (Hct \>50%)
* **Considerations**
* long term impact of exogenous testosterone on spermatogenesis
* CV risk
* polycythemia
* **CI**
* prostate or breast CA
* abnormal DRE exam
* PSA \>3 that has not yet been evaluated
* untreated OSA
* severe heart failure
* Erythrocytosis (Hct \>50%)
140
Testosterone Replacement Dosing
Start with standard dose and set therapeutic target to **\_\_\_ or ___ range**
1. **(1) (Androderm)**
1. Nightly to back, thigh, or upper arm, mimics normal diurnal rhythm
2. **(1) (Androgel, Testim)**
1. Number of pumps nightly to upper arm - risk of transference
3. **(1) (Enanthate, Cypionate)**
1. T levels peak and valley, so could moods - also higher risk of erythrocytosis
2. Short-acting (patient - administered) vs long-acting (provider-administered)
4. **(1) (Striant)**
1. BID, gum irritation
5. **(1) (Testopel)**
1. Implanted subq with surgical incision q3-6m
Start with standard dose and set therapeutic target to **low or mid range**
1. **Transdermal patch (Androderm)**
1. Nightly to back, thigh, or upper arm, mimics normal diurnal rhythm
2. **Transdermal gel (Androgel, Testim)**
1. Number of pumps nightly to upper arm - risk of transference 3)
3. **Testosterone IM/SQ injections** (Enanthate, Cypionate)
1. T levels peak and valley, so could moods - also higher risk of erythrocytosis
2. Short-acting (patient - administered) vs long-acting (provider-administered)
4. **Buccal sustained release bioadhesive (Striant)**
1. BID, gum irritation
5. **SQ Pellets (Testopel)**
1. Implanted subq with surgical incision q3-6m
141
Testosterone Replacement Monitoring
* Baseline labs before starting treatment, including ___ testosterone, H\_\_\_, P\_\_\_ (and DRE)
* Repeat labs above and DRE \_\_m after starting, then q\_-\_\_m, along with assessing for ______ improvement
* If Hct \>\_\_% stop T until returns to safe level
* Eval for hyp\_\_\_\_ and O\_\_\_
* When restarting - restart at _____ dose
* Advise _______ cessation if indicated
* TRT and PSA?
* Baseline labs before starting treatment, including AM testosterone, Hct, PSA (and DRE)
* Repeat labs above and DRE 3m after starting, then q6-12m, along with assessing for symptom improvement
* If Hct \>54% stop T until returns to safe level
* Eval for hypoxia and OSA -
* When restarting - restart at lower dose
* Advise smoking cessation if indicated
* TRT does not alter PSA or PSA velocity beyond established norms, so any abnormalities in PSA while on TRY should not be attributed to T and should be referred to urology for eval
142
Alternatives to Testosterone
(3)
Examples of each and MOA
**SERMS**
* Clomiphene, tamoxifen
* Increase LH and FSH via negative feedback loop (reduces negative feedback)
**Aromatase Inhibitors**
* Anastrozole
* Inhibits conversion of testosterone into estradiol
**Human chorionic gonadotropic**
* same activity as LH
143
When to Refer to ER
1. Suspected testicular t\_\_\_\_\_\_
2. Incarcerated/strangulated inguinal \_\_\_\_\_
3. Acute (or chronic/recurrent) urinary _____ (inability to void) - Especially if acute urinary retention in setting of acute prostatitis - May need suprapubic tube placement instead of foley catheter
4. Concern for s\_\_\_\_\_ r/t acute prostatitis, pyelo, or concern for sepsis s/p prostate biopsy
5. Concern for acute renal \_\_\_\_\_, or U\_\_\_/sepsis in setting of solitary kidney
6. Concern for septic or obstructing kidney \_\_\_\_\_\_
7. Pr\_\_\_\_\_\_ lasting longer than 4 hours
8. Para\_\_\_\_\_\_ - if concern for possible disruption of blood supply
9. Concern for Fournier’s \_\_\_\_\_\_
1. Suspected testicular torsion
2. Incarcerated/strangulated inguinal hernia
3. Acute (or chronic/recurrent) urinary retention (inability to void) - Especially if acute urinary retention in setting of acute prostatitis - May need suprapubic tube placement instead of foley catheter
4. Concern for sepsis r/t acute prostatitis, pyelo, or concern for sepsis s/p prostate biopsy
5. Concern for acute renal failure, or UTI/sepsis in setting of solitary kidney
6. Concern for septic or obstructing kidney stone
7. Priapism lasting longer than 4 hours
8. Paraphimosis - if concern for possible disruption of blood supply
9. Concern for Fournier’s gangrene
144
When to Refer to Outpatient Urology
1. Concern for testicular _____ (or any GU malignancy)
2. Pain\_\_\_ scrotal mass for consideration for surgical intervention (hydro\_\_\_\_\_, etc)
3. Bothersome v\_\_\_\_\_ symptoms - especially if unclear etiology or if neurologic involvement
4. Re\_\_\_\_\_\_ UTI
5. H\_\_\_\_\_\_ (microscopic or gross)
6. Elevated PSA \>\_\_\_, or fast PSA r\_\_\_/d\_\_\_\_\_ time
7. Abnormal (1) exam, or any other concern for prostate CA
8. Ch\_\_\_\_\_\_ prostatitis
9. Kidney or bladder s\_\_\_\_\_\_
10. Hypog\_\_\_\_\_/in\_\_\_\_\_/persistent E\_\_
1. Concern for testicular cancer (or any GU malignancy)
2. Painful scrotal mass for consideration for surgical intervention (hydrocele, etc)
3. Bothersome voiding symptoms - especially if unclear etiology or if neurologic involvement
4. Recurrent UTI
5. HEMATURIA (microscopic or gross)
6. Elevated PSA \>4, or fast PSA rise/doubling time
7. Abnormal DRE, or any other concern for prostate CA
8. Chronic prostatitis
9. Kidney or bladder stones
10. Hypogonadism/infertility/persistent ED
145
Practice Question
* A 15yo male is added to your schedule today as a telehealth visit with his mother. On video, the patient looks visibly in pain. His mother reports that about 2 hours ago he was throwing a football outside with his friend and then he came inside ℅ left “groin pain”.
* Initially he was too embarrassed to tell her anything else, but since then pain became so bad he started crying, felt nauseous, and vomited. He won’t let his mom look at the area, but when you ask him over video, he says the left testicle is swollen and very painful. It could be higher than normal, but he can’t tell.
* He denies fever, chills, or dysuria. He says he didn’t get injured while playing outside. He has a girlfriend, but he doesn’t want to talk about sexual activity since his mom is on the telehealth visit. What should you do (SATA)?
1. Advise him to ice, elevate, try NSAIDs, and monitor.
2. Order urine testing and STI testing at a local lab
3. Order scrotal ultrasound, and schedule telehealth follow up tomorrow for results.
4. Treat empirically for STI
5. Refer to emergency room
**5. Refer to emergency room (concern for testicular torsion - esp with young male intense, new pain)**
146
Practice Question
* A 26 yo male is added to your schedule today as a telehealth visit. He is by himself on the video call. On video, the patient looks visibly in pain. He also ℅ left “groin pain” that started 4 days ago.
* Initially the pain was too severe, just a soreness. Gradually the pain is worsening and is now 8/10. The testicle is now swollen and tender to touch. It does feel warm to him. It could be higher than normal, but he can’t tell. He also feels a burning sensation with urinating.
* He denies fever, chills, nausea, vomiting. No recent groin injuries. He has had 3 new sexual partners in the last month. No history of STI. What should you do (SATA)
1. Advise him to ice, elevate, try NSAIDs, and monitor
2. Order urine testing and STI testing at a local lab
3. Order scrotal ultrasound, and schedule telehealth follow up tomorrow for results.
4. Treat empirically for STI
5. Refer to emergency room
1. **Advise him to ice, elevate, try NSAIDs, and monitor**
2. **Order urine testing and STI testing at a local lab**
3. Order scrotal ultrasound, and schedule telehealth follow up tomorrow for results.
4. **Treat empirically for STI Take home message: this one we can try to treat – treat empirically and symptom management**
5. Refer to emergency room
147
Practice Question
Which of these patients with the same chief complaint of “testicular mass” are you most concerned about?
1. 53 yo M with painless right testicular swelling x 3 months
2. 23 yo M with painless hard bump on right testicle x 2 weeks
3. 33 yo M with painless soft bump on top of right testicle x 4 weeks
4. 13 yo M with painless long bump on back and bottom of testicle x 2 months
5. 43 yo M with painless swelling of “tubes” above right testicle x 3 years
**23 yo M with painless hard bump on right testicle x 2 weeks Hard\*, young, 2 weeks – concern for testicular ca**
148
Practice Question
(Urology in primary care)
* A 38 yo M with no known PMH presents to establish primary care ℅ gradually worsening difficulty retracting foreskin x6m. Foreskin feels dry and gets painful cracks when he tries to fully retract. Intercourse is uncomfortable
* As his new PCP, what underlying undiagnosed chronic medical condition are you most concerned about?
**Phimosis → major cause = diabetes – get a BMP, A1C**
149
Practice Question
* 62yo M with h/o well-controlled HTN presents C/O gradually increasing noctruia x6m. Used to not get up at night, now gets up 2-3 times to urinate
* Urinary stream is gradually getting weaker - “not as strong as when I was younger.”
* Needs to know where bathrooms are when going out, as urgency to void is becoming mroe urgent - “when i gotta go, I GOTTA go
* Usually feels like he empties his bladder, but occasionally needs to go back to the bathroom a few minutes after urinating to “go a little more.
* Dribbles a little after urinating, sometimes gets on his underwear.
* You WILL see this patient frequently in primary care.
* Important to feel comfortable asking these questions, and either starting the workup to evaluate for **(1) vs. (1)** vs. other underlying medical conditions, and/or referring to urology
BPH vs. Prostate CA
Gradual change = benign, slow growth
