Male GU Health + SDM Schema Flashcards

Question

Varicocele pharm + nonpharm mangement

Answer 1

* NSAIDs * Scrotal support * R-sided → surgical plan * < 21 → eval for testicular atrophy → if have it → Surgery * > 21 → Monitor w/semen analysis Q1-2yrs

Answer 2

* Rare cancer; survivable * Most common cancer 15-35yrs * ↑ risk w/ chrytorchidism (undescended testicle) * ↑ incidence in whites * FMHx of cancer * Peak age 20-39/40

Answer 3

**Hard lump on testicle** Feels **Heavy,** dull, swelling, fulllness **Painless** Can have hydrocele, gynecomastia, epididymitis too - Metastasis: SOB, cough, LBP, LE swelling

Answer 4

Palpate scrotal/testicular mass Transilluminate area → Look for **darkened area**

Answer 5

U/S MRI + CT for mets CXR for staging CBC - infxn sx Tumor markers: AFR, beta-hCG, LDH

Answer 6

* Epididymitis * Hydrocele * Prostatitis * Testicular cancer * Testicular torsion * Varicocele

Answer 7

Chemo + radiation therapy Surgery - orchiectomy * Depend on type of testicular cancer, if mets occured

Answer 8

USPSTF + AHRQ **DO NOT RECOMMEND** screening d/t potential harms + likelihood of finding malignancy - Can do self-exams Q2mos in shower

Answer 9

* For all solid, firm masses w/in testis, investigate, even if painless * Testicular cancer must be considered as DX until proven otherwise * If pt w/scrotal pain is tx for epididymitis that does not resolve, consider testicular cancer * For young men, consider fertility options such as sperm banking

Answer 10

* Persistent inability to achieve + maintain penile erection sufficient for satisfactory sex * Most common sexual problem in men - Causes them to seek medical attention they might now otherwise seek; HCP can discuss lifestyle changes

Answer 11

* Vasculogenic (HTN, PVD, DM: uncontrolled) * Neurogenic (Parkinson’s, CVA, MS, inury) * Endocrine (hypogonadism, thyroid diseases) * Urologic (malignancy)/ Penile (Peyronies – penis curve) * Meds (BBs, SNRIs) * Substance use (tobacco, EtOH, illicits) * Injuries (trauma, surgery, radiation) * Psychogenic

Answer 12

Ask about sx of hypogonadism - ↓ libido - ↓ erectile quality + frequency incl. nocturnal erections - Mood changes, ↓ intellectual activity + cognitive fx, spatial orientation, fatigue, depressed mood, irritability - Sleep disturbance - ↓ lean body mass - ↑ visceral fat – overweight - ↓ body hair + skin changes - ↓ BMD

Answer 13

- Men > 50 - RFs of ED (DM, HTN, CVD, MS, depression, anxiety, smoking, drug or EtOH abuse, or sedentary lifestyle) - Taking meds affecting ED

Answer 14

* PE includes genitourinary + full neuro exam * Are you aroused by your partner? IF NO → consider hypogonadism * Use International index of ED (IIEF) - On scale of 0-5 in past 4wks

Answer 15

* Glucose, TSH, lipid profiles (if not assessed in last 12 mos), CBC, CMP * Total testosterone (AM x 2); if indicated, free testosterone - **check hormone levels 8a-10a** * Testing done to exclude underlying disease as DX made from detailed medical + sexual Hx

Answer 16

* Testosterone replacement (1° hypogonadal state) * PDE5 inhibitors - Cialis – Tadalafil; Levitra – Vardenafil; Stendra – Avanafil; Viagra – Sildenafil * Give lowest full dose 1st – can cut in ½ * These meds do not work W/O SEX STIMULATION * Do not take w/ nitrates → fatal HoTN * Anxiety reduction (psychogenic) * Lifestyle modification (exercise, wt. loss, quit smoking) * Encourage use of film, vids, etc → desire * Lubricants

Answer 17

* Alprostadil (Caverject) available as INJ sol or urethral suppository * Surgical + procedural therapy - constriction band/ vacuum pump devices noninvasive * If this fails → surgical implantation of inflatable penile prosthesis

Answer 18

* Assess therapeutic outcome: - Erectile response - SEs - Treatment satisfaction * TREAT UNDERLYING CAUSE - Vasculogenic: Prevent or tx HTN to ↓ ED - SA: Refer to tobacco, drug tx - Meds: If AE on sexual functioning, change if possible * 2° hypogonadal state → endocrine

Answer 19

* Certain diseases (MS, uncontrolled DM) * Suspected urologic problem * Failure to improve w/standard therapy * Severe depression Sexuality + aging can affect ED * Physiological changes * Older W less likely to be sexually active vs. M * Elders in poor health less likely * W: lack of desire, vag dryness, + inability to achieve orgasm * Men’s concerns – erection issues * Always ask about their perceived issues surrounding sexual dysfunction

Answer 20

produce the fluid that nourishes and transports sperm (seminal fluid).

Answer 21

* Acute bacterial prostatitis - prostage gland acute infection * Chronic bacterial prostatitis - "" Chronic infection * Chronic pelvic pain syndrome - Pelvic pain w/o bacteria in prostate * Inflammatory - HIGH WBC * Noninflammatory - LOW WBC * Asymptomatic prostatitis - WBC count +/or bacteria in EPS, VB3, semen, or histologic specimens in asymptomatic patients

Answer 22

* Ascending UTI; reflux of infected urine; extension of rectal infxn * **E. coli**

Answer 23

Urinary * Straining, urgency, dysuria, hesitancy, frequency, obstruction, irritation Systemic * fever, malaise, arthralgia, myalgia, intense suprapubic pain, chills, nausea, emesis, low back pain, abdominal, pelvic or perineal pain

Answer 24

Chills, Nausea, Urinary frequency + hesitancy

Answer 25

* Check temp - fever * MS – back, joint swelling, inflamm * Neuro – other etiology * Abd – (bladder distension, discomfort) * CVA tenderness * GU – inspect + palpate * Rectal to assess prostate enlargement, bogginess, tenderness

Answer 26

* Signs of sepsis (↑ HR + HoTN) * Distended bladder * DRE: Warm, tender, boggy, enlarged prostate * DO NOT MASSAGE!!

Answer 27

* BPH * Neurogenic bladder * Pyelonephritis * Renal calculi * Prostate abscess

Answer 28

* **UA + C & S** (Pyuria, Bacteriuria) - > 10 WBC per hpf - **Urine gram stain** * **CBC w/diff **(optional) * In pts < 35 or > 35 w/ multiple partners - **Urine GC/CHL** * In pts w/fever > 101°F: **Blood cultures**

Answer 29

* Initial tx is empiric based on chief complaint, ROS + Gram (-) bacteria being usual cause * **Bactrim – good prostate penetration** * Cipro * Levaquin * In sexually active men < 35 w/multiple partners → tx to cover GC/CHL - Ceftriaxone + Azithromycin or Doxycycline (STI cocktail) * **Nitrofurantoin NOT B/C d/t poor prostate penetration + risk of AEs for long term use** * Prophylactic ABX for recurrent bacterial prostatitis Don't forget to check for med interactions! Pts on these meds for weeks

Answer 30

* Return for urgent tx should sxx return * Complete 4-6 wks of abxs * Completely better at 4wks – stop * If not, keep going to 6wks * Should see improvement in symptoms in 2-6ds * Infxn deep in gland

Answer 31

Acute: Cured by prompt abx tx Chronic: Same, but therapeutic filaures/recurrence common Pelvic: POOR PROGNOSIS - urology referral

Answer 32

* Pyelonephritis * Sepsis * Prostatic abscess * Chronic prostatitis – A/w STI

Answer 33

Severe bact prostatitis Not respondinig to initial tx Pts w/obstructive sxs

Answer 34

* ID histologically – cells * BOO – Bladder outlet obstruction * mLUTS (male lower urinary tract sxs) – irritative sxs

Answer 35

* BOO - Urinary hesitance - ↓ caliber + force of stream - Post-void dribbling * mLUTS - Urinary frequency - Urgency - Nocturia

Answer 36

Irritative: **FUN** - **F**requency - **U**rgency - **N**octuria Obstructive: **WISE** - **W**eak stream, - **I**ntermittent flow, - **S**training to urinate, - Incomplete **E**mptying

Answer 37

* DRE: should be nontender, smooth, rubbery – feel squishy, not hard * Lower ABD for bladder distension * Neuro exam to include: general mental status, ambulatory status, LE NM fx + sphincter tone

Answer 38

* Abnormal sphincter tone – neurogenic bladder * Fever – Prostatitis * Hematuria – Bladder Cancer * Prostate nodule or induration – Prostate Cancer * Tenderness – Prostatitis

Answer 39

Irritative + Obstructive sx mixed for questions Over the past month, how often have you . . . * Had a sensation of incomplete emptying * Had to urinate again less than 2 hours after the last void * Found you stopped and started again several times * Found it difficult to postpone urination * Had a weak urinary stream * to push or strain to begin urination * How many times did you typically get up in the night to urinate Treatment is based on the symptom score: 0-7 = mild; 8-19 = moderate; 20-35 = severe

Answer 40

**UA for all men presenting w/LUTS; likely only test** Helps r/o bladder cancer, bladder stones, UTI, urethral strictures

Answer 41

- Life expectancy > 10yrs: candidate for treatment for prostate cancer - 5-alpha reductase INH therapy is planned: (because it will lower PSA) - Physical findings suggestive: (abnormal DRE)

Answer 42

* Anticholinergics incl. Diphenhydramine (Benadryl) Antihistamines * Decongestants * Diuretics incl. HCTZ, furosemide * Opiates * TCAs

Answer 43

Alpha blocker alone * Doxazosin, Terazosin – older, longer acting, required dose titration – start at bedtime to avoid dizziness * Alfuzosin, **Tamsulosin** – long acting –** Less risk for HoTN – risk of Floppy iris syndrome** - Relaxes smooth mm, 2-4 wks for improvement - SE: HoTN, don’t use alone for HTN; HF risk

Answer 44

5 alpha-reductase INH * Finasteride + Dutasteride – take 6-12mos to work - Mech: shrinks prostate; works better w/prostate vol over 40mL; normal is 20-30mL - **Main SE: sexual dysfunctio**n - Reduction of PSA, must take into account - Warning of **male breast cancer w/finasterid**e

Answer 45

monitor + annual monitoring

Answer 46

* Refer after trying alpha blocker * Any pt w/upper tract injury such as hydronephrosis or renal dysfunction, or lower tract injury such as urinary retention, recurrent infection, bladder decompensation; these all require invasive therapy

Answer 47

* Sxs in setting of autonomic or severe peripheral neuropathy * Sxs following invasive tx of urethra or prostate * Men < 45 years old * Abnormality on exam such as nodule, induration, asymmetry * Presence of hematuria in absence of infxn * Incontinence * Severe symptoms, AUA Symptom Score > 20

Answer 48

* Most common malignant neoplasm after skin cancer in US men * Most commonly DX visceral cancer in US * Leading cause of cancer death in men > 55, + 2nd leading cause of cancer death in men overall **Risk of dying is 2.9%**

Answer 49

Early (1st 1-2 mos): * **Hesitancy** * **Urgency** * **Frequency ** * **Nocturia** Later * Back pain * Impotence * Bone pain * Weight loss * Constipation * Malaise * Hematuria * Rectal pain * Paresthesias w/LE weakness d/t nerve root compression

Answer 50

* Early on, exam normal * **Firm nodule** * **Induration** * **Stony, asymmetric prostate**

Answer 51

* BPH * Prostatitis * UTI * Prostate Calculi * Bladder Outlet Obstruction

Answer 52

* DRE – less sensitive vs. PSA – staging * PSA – can be normal even w/cancer; not specific for cancer – prostate - Can be ↑ w/benign conditions, BPH, prostatitis, + prostate massage or ejaculation * CBC w/diff * Genomic assays (little data)

Answer 53

* **TR-U/S w/biopsy – GOLD STANDARD** Transrectal * Transperineal biopsy * Multiparametric MRI guided biopsy * MRI U/S fusion guided biopsy - (+) biopsy + Gleason score > 7 → radionuclide lymph nodes for mets * Abd/pelvis CT for regional lymph nodes + mets

Answer 54

* Grade 1 = well differentiated; Grade 5 = poorly differentiated * Gleason score is the sum of the most common and the next most common findings * Score ranges 2-10 * 2-4, well differentiated, favorable prognosis * 5-7, moderate differentiation; most clinically detected tumors are in this range * 8-10, poor differentiation, unfavorable prognosis * New WHO grading system: Grade Group 1; Gleason Score

Answer 55

TNM: Tumor, regional node, metastasis system * PSA level * DRE findings * TR U/S * Gleason score

Answer 56

* Watchful waiting * Active surveillance * Radical prostatectomy * External bean radiation therapy * Brachytherapy

Answer 57

* Androgen deprivation * Radiation therapy

Answer 58

* Complete androgen ablation * Antiandrogens (inhibit binding of androgen to receptor) * LHRH agonists (chemical castration) * Chemo w/Docetaxel – inhibits cell division * Orchiectomy (surgical castration)

Answer 59

* Advancing Age * African American race – SDOH * FMHx – one 1st degree relative doubles risk * Geography – Caribbean men of African ancestry, men living in northwestern Europe, NA, Australia

Answer 60

* Anxiety * Discomfort of serial testing * ED + Loss of libido * Incontinence * Proctitis, Urethritis * Bowel dysfunction including diarrhea, urgency, soiling * Loss of stamina * Hot flashes * Decreased muscle mass * Premature osteoporosis * Fatigue

Answer 61

* Incidence of prostate cancer rose rapidly when the PSA test began use as a screening tool * However, w/time we have seen that screening **can reduce mortality but the overall risk reduction is very small**. * **Harms of screening, including invasive testing such as transrectal ultrasound with biopsy and its attendant risk, are substantial** * Overdiagnosis can lead to invasive treatments which negatively affect quality of life

Answer 62

1. **Get consent** for prostate cancer screening, preferably using the “Simple Schema” decision aid. 2. PSA screening is only for healthy men aged **45 to 70**. 3. **Tailor screening frequency based on PSA level** and cease screening for men older than 60 unless PSA is higher than median (1 ng/mL). 4. For men with **elevated PSA (3 ng/mL), repeat** PSA. 5. Use secondary tests, such as marker or imaging before biopsy, or only refer to urologists who do so. 6. Only refer to urologists who recommend active surveillance to almost all patients with low grade cancer. 7. Preferably refer to urologists at major academic centers.

Answer 63

* **Describe**: goal of SDM tool is to initiate a conversation about options – PURPOSE * **Check**: ask if patients wish to read it themselves or to they prefer the comparisons to be vocalized * **Handover**: give the SDM handout tool to the patient with writing implement so they can mark their copy and jot down questions * **Create space**: ask permission to do other tasks if the patient wishes to read the information * **Ask**: encourage questions and discussion * **Gift**: patients should be told they may take the handout with them

Answer 64

* Lack of tools * Shortage of time * Challenge of integrating into clinical pathways * More demanding to practice SDM than to recommend a treatment

Male GU Health + SDM Schema Flashcards

(97 cards)