What type of tissue comprises 30% of the prostate?
What comprises the other 70%?
30%: Glandular tissue
70%: Stroma
What is the smallest structural component of glandular prostate?
Acini
T/F: Proliferation of the acini results in BPH
True
Proliferation of the ________ (Acini/Basement Membrane) of the prostate leads to prostate cancer
Basement Membrane
What are the three zones of the prostate?
Central Zone
Transitional Zone
Peripheral Zone
Which zone of the prostate contains mucosal and submucosal glands?
Changes in this zone often lead to urethral pressure.
Periurethral Zone
Which zone of the prostate contains the majority of prostatic glandular tissue and is the origin site for most adenocarcinomas of the prostate?
Peripheral Zone
Which zone of the prostate is often described of as the “cone shaped” portion of the prostate?
Central Zone
T/F: The transitional zone of the prostate does NOT surround the urethra
False
It does surround the urethra
What percentage of men have BPH by the age of 60?
80?
60: 50%
80: 90%
What is the mechanism for BPH development?
Testosterone is broken down by 5alpha-reductase to form DHT
DHT then binds to nuclear receptors in the prostate leading to BPH
What receptors in the prostate (near the bladder neck) result in smooth muscle contraction leading to LUTS associated with BPH?
A1-Adrenergic Receptors
What are examples of obstructive LUTS?
Weal Stream
Hesitancy
Incomplete Emptying
Double voiding
What are examples of irritative LUTS?
Urgency
Frequency
Nocturia
What are FOUR key components to a BPH work-up?
DRE
UA
BMP
Baseline PSA
What ‘imaging’ study can be obtained to see if a patient is retaining urine?
PVR (Post-Void Residual)
What is the name of the ‘imaging study’ used to measure how strong a patient’s urine stream is?
Uroflow
What is the name of the procedure used to visual the inside of the bladder?
Cystoscopy
What may the appearance of the bladder be described as if it has been squeezing hard against the prostate?
Trabeculated
What medications used in BPH management “open up” the prostate through smooth muscle relaxation?
Alpha Blockers…..
Non-Selective: Terazosin (Hytrin), Doxazosin
Selective: Tamsulosin (Flomax), Silodosin (Rapaflo)
What medications used in BPH management “shrink” the prostatic glands?
%-alpha reductase inhibitors…..
Finasteride
Dutasteride
What is an antimuscarinic used in BPH management?
Oxybutynin
What are examples of surgical procedures used to manage BPH?
TURP
TUNA
TUMT
PVP
T/F: Recurrent UTIs attributable to BPH is NOT an indication for surgical management
False
It is an indication
T/F: Prostate CA is the 2nd leading cause of cancer death in US men
True
What are two crucial screening tools for prostate cancer?
PSA
DRE
What is the normal PSA range?
0.0 - 4.0
What are three examples of things that lead to a benign elevation in PSA?
Trauma
Instrumentation
Ejaculation
T/F: You should always trend PSA values prior to jumping to conclusions or management decisions (ie: Biopsy)
True
A 75 y.o. male presents for annual screening. He denied any urinary symptoms but has been noticing himself get sweaty at night. His exam is unremarkable other than an enlarged nodular prostate on DRE. Upon review of his annual labs you notice that his PSA is trending up and most recently is at 8.9.
What is your most concerning diagnosis and how is this diagnosed?
Prostate Cancer
Diagnosed through a prostate biopsy with transrectal US guidance
How many samples of prostate tissue are taken during a prostate biopsy?
12
What is the name of the ‘grading score’ used in staging prostate cancer?
Gleason Score
Where are the first two places prostate cancer is likely to metastasize?
Lymph Nodes
Bones
What is the name of the surgical procedure used in prostate cancer treatment?
What is the most common and concerning ‘side effect’ of this procedure?
Radical Prostatectomy
Most Common Complication is ED and Impotence
_________ is the name of the prostate cancer therapy in which radioactive seeds are implanted in the prostate….this works best for localized contained prostate cancers.
Brachytherapy
_________ is pain or burning with urination
Dysuria
What is hematuria?
Blood in the urine
________ is the a sudden, strong urge to pass urine
Urgency
What is urinary frequency?
Voiding too often
A ______ UTI occurs frequently with different or similar organisms for each infection
Recurrent UTI
How is a persistent UTI described?
Same organism never clears often with the same susceptibility profile
A _______ UTI results from inadequate treatment
Unresolved
A _________ UTI may occur in the presence of features that may result in therapy failure
Complicated UTI
What is Asymptomatic bacteriuria?
Bacteria present in the urine without host response of symptoms
What is the most common pathogen associated with an acute UTI?
E coli (80%)
*Staph, Klebsiella, Proteus are also common
A 39 y.o male presents with complaints of burning with urination, feeling like he has to pee all the time, and a cloudy appearance to his urine over the last two days. He denied any fever or fatigue. This has happened to him as a child she remembers and he was diagnosed with a bladder infection.
What is you most likely diagnosis at this time?
Acute UTI
A 39 y.o male presents with complaints of burning with urination, feeling like he has to pee all the time, and a cloudy appearance to his urine over the last two days. He is febrile and appears very fatigued in the examination room. He also describes a vague back pain over the last 24 hours, but is unable to localize it.
What would be the most concerning at this time?
What physical examination finding may support this diagnosis?
Pyelonephritis
+ CVA Tenderness
How should a urine sample be collected when working up a UTI?
It need to be a “Clean Catch”
Positive nitrites in a urine sample would indicate what?
Infection
WBC Casts on a microscopic urinalysis would indicate what?
Pyleonephritis
Glomerulonephritis
T/F: Urine samples don’t need to be cultured
False
They do!
T/F: All urine samples from men dont need cultured
False
All urine samples from men should be cultured!
What is the cheapest and most effective ABx in UTI management?
TMP/SMX (Bactrim)
Why arent fluoroquinoones used as much in UTI management?
Resistance
Renal Dosing
Avoid with Warfarin
What is a drawback to using nitrofurantonin (Macrobid) in UTI treatment?
Longer Course (~7 days) GI Upset
How long do patients take ABx if they’re on them for UTI prophylaxis?
6 Months!
Examples:
TMP/SMX 100 mg
TMP 100 mg
NItrofurantonin 100 mg
What is an example of a common hospital procedure/treatment that is associated with a high UTI rate?
Urinary Catheters
Catheterization longer than __ days greatly increases a patients risk for catheter associated UTIs
6 Days
What is the most common pathogen associated with pyelonephritis?
E Coli
*Proteus, Pseudomonas, and Klebsiella are also common
T/F: A patient with a renal calculi is at a higher risk of developing pyelonephritis
True
A patient with suspected pyelonephritis and a history of renal stones should get what imaging study and why?
Renal US
To exclude obstructing stone and hydronephrosis
How is pyelonephritis managed?
IV Abx
IVF
Glucose control
What procedure can be to relieve pressure on the kidneys if the urinary outflow tract is obstructed?
Percutaneous Nephrostomy Tube Placement
What are the most common types of urinary lithiasis?
Ca-Containing Stones (Calcium-Oxalate, Calcium-Phosphate)
What is another name for a struvite stone?
Infectious Stone
A 25 y.o. male presents to the ED with right flank pain. He notes that yesterday he had this waxing and waning pain in his lower back, but this morning it became a harp stabbing pain. He is visibly uncomfortable in the exam room and moves around throughout. He denied any fever or chills, but he has noticed some difficulty and discomfort with urination. He denied any gross hematuria.
What is the most likely Dx at this time?
Urinary Lithiasis
A 25 y.o. male presents to the ED with right flank pain. He notes that yesterday he had this waxing and waning pain in his lower back, but this morning it became a harp stabbing pain. He is visibly uncomfortable in the exam room and moves around throughout. He denied any fever or chills, but he has noticed some difficulty and discomfort with urination. He denied any gross hematuria
You decide to start his work up with a CBC with is unremarkable, CMP that shows slightly elevated BUN and sCr from the patients normal, and a UA that has microscopic hematuria.
Does this support the diagnosis of Urinary lithaisis? What diagnosis might these labs rule out?
The labs support the diagnosis of urinary lithiasis and make pyelonephritis less likely at this time.
A 25 y.o. male presents to the ED with right flank pain. He notes that yesterday he had this waxing and waning pain in his lower back, but this morning it became a harp stabbing pain. He is visibly uncomfortable in the exam room and moves around throughout. He denied any fever or chills, but he has noticed some difficulty and discomfort with urination. He denied any gross hematuria
What imaging study is 100% sensitive in diagnosing your most likely diagnosis?
CT Abdomen/Pelvis w/o contrast
Where are the THREE most common places for stones to “get stuck” or become symptomatic?
UPJ
Illiac Vessels/Pelvic Brim
UVj
____% of stones in the distal ureter that are less than 4 mm will pass spontaneously
90%
What alpha-blocker is often given to stone patients to help stones pass easier?
Tamsulosin (Flomax)
What are examples of surgical procedures used in urinary lithiasis management?
Shock-Wave Lithotripsy (ESWL)
Ureteroscopy + Laser Lithrotripsy
Percutaneous Nephrolithotripsy
What work up do patients with recurrent stones need?
Meatbolic Work-Up to include……
Serum Uric Acid, Calcium, Magnesium, Phosphate, PTH, and 24-Hour urine collection
What medication is indicated in a recurrent stone patient with hypercalciuria?
HCTZ
What medication can be given to a recurrent stone patient with uric acid stones?
Allopurinol
____________ is described as inflammation of the glans penis or foreskin.
Symptoms include….
Glossy flat lesions on the penis or foreskin with blotchy erythema, smega, and possibly phimosis
Balantitis (Glans)
Posthitis (Foreskin)
What medication is used to treat balantitis/posthitis?
Clotrimazole (Lotrimin)
What is phimosis?
The inability to retract the foreskin
T/F: Yeast are a common cause of phimosis or posthitis in patients especially with poorly controlled DM
True
How can phimosis be managed pharmacologically?
Nystatin +/- Topical Steroid
If phimosis is refractory to pharmacological or conservative management…..
What would be recommended?
Circumcision
__________ is described as the foreskin being stuck in a retracted position and cannot be reduced
Paraphimosis
What are two ways paraphimosis is managed?
Manual Compression/Reduction
Dorsal Silt
_____ is described as inflammation of the urethra commonly associated with STIs.
Sx include…..
Diffuse purulent discharge with dysuria
Urethritis
How is Urethritis treated?
remember it is usually due to a STI
Ceftriaxone + Azithromycin
________ ________ is the inability to obtain or maintain an erection
Erectile Dysfunction
What are two classes of medications that are associated with erectile dysfunction?
Pyschotropics
Anti-Hypertensives
What are co-morbid conditions associated with ED?
DM HTN CAD HLD Smoking
T/F: A radical prostatectomy is associated with ED
True
Up to ___% of patients with undiagnosed vascular disease will present with ED
20%
What labs should be obtained when working up erectile dysfunction?
Total and free testosterone
Lipid Panel
What medication class is indicated for ED treatment?
PDE-5 Inhibitors
Sildenafil - Viagra
What are penile condylomas?
Genital Warts
What pathogen is typically the cause of genital warts?
HPV
If there are warts on the penis where else should be inspected for warts?
The Anus
T/F: Penile Condylomas are a clinical diagnosis
True
Is there a cure for penile condylomas?
No, this is a chronic disease
What ‘strains’ of HPV are associated with penile cancer?
16
18
31
33
How is penile cancer managed?
Surgery
What is a good preventative measure to take for penile cancer prevention?
HPV Vaccine
What medication classes are associated with priapism?
Psychotropics (Trazadone)
PDE5-Inhibitors
What systemic diseases are associated with priapism?
Sickle Cell
Disseminated CA
_________ _______ results in plaque deposits in the tunica albugenia eventually resulting in penile fibrosis
Peyronies Disease
Are there proven therapies for peyronies disease?
No, there has not been proven therapies for this disease. There are surgical options but not proven effective long term.
___________ is low testosterone levels that presents with symptoms of fatigue, ED, decrease ejaculatory force, and decreased libido.
Hypogonadism
A primary cause of hypogonadism is testicular failure…..
What is a common cause of this?
Mumps Orchitis
How is hypogonadism treated?
Androgen (Testosterone) Supplementation
After initiating androgen supplementation for hypogonadism…..
What should you monitor and for how long?
Monitor PSA, H&H, Testosterone, DRE
Evaluate at 3, 6, and 12 months and then annually
What is the name of the questionnaire used to assess men for hypogonadism?
ADAM Questionnaire
What is cryptorchidism?
Failure of the testis to descend into the scrotum
How is is cryptorchidism treated?
Hormonal Manipulation (GnRH Injections)
Orchidopexy
If cryptorchidism is present……
Most testis descend by what age?
3 months
If they are still undescended by 6 months old then descent is unlikely
T/F: Being a twin increases the risk for cryptorchidism
True
What are three common sequelea/consequences of cryptorchidism?
- Increased CA Risk
- Decreased Fertility
- Torsion
A ________ is a benign accumulation of serous fluid between layers of tunica vaginalis
Hydrocele
What is the most common cause of a hydrocele in infants?
Patent process vaginalis
What are common causes of a hydrocele in adults?
Idiopathic
Post-Traumatic
Post-Infectious
If conservative management of a hydrocele (ie; aspiration) fails what can be done?
Scrotal excision (Hydrocelectomy)
A ________ results from congestion in the veins around the testis due to a valvular anomaly
Does this condition typically occur in patient older than 40 y.o.?
Varicocele
No, these occurtypically in patients 15 - 30 years old
Is a varicocele more common in the right of left testis?
Left
What physical examination finding would help clinically diagnose a varicocele?
“Bag of worms” presentation to the veins in the pampiniform plexus
T/F: Imaging is required to work up a varicocele
False
How are varicoceles managed?
Varicocelectomy
Embolization
T/F: Infertility is associated with varicoceles
True
This typically improves with surgical treatment
A 21 y.o. male presents to the ED with complaints of sudden right testicular pain that began about 1 hour ago. He denied any traumatic injury prior to the onset of the pain.
What is the most concerning diagnosis?
What physical examination findings are consistent with this diagnosis?
Testicular Torsion
Physical Examination….
Negative ipsilateral cremasteric reflex
Scrotal Edema
Negative Phren;s Sign
A 21 y.o. male presents to the ED with complaints of sudden right testicular pain that began about 1 hour ago. He denied any traumatic injury prior to the onset of the pain. On examination, he is afebrile, there is no cremasteric reflex on the right, and his pain is not relieved with scrotal elevation.
What is the most diagnostic imaging study?
How should this condition be managed?
Scrotal US
Surgery ASAP!
What ‘deformity’ is commonly associated with an increased risk of testicular torsion?
Bell-Clapper Deformity
_______ is the inflammation or infection of the epididymis
Epididymitis
What are the common pathogens in epipidymitis in patients…..
<35 y.o.?
> 35 y.o.?
<35: C. Trachomatis, N. gonorrhoeae
> 35: E Coli
If a patient has scrotal pain relieved with elevation, what diagnosis would this be consistent with?
What is the name of the physical examination sign described above?
Epididymitis
Phrens Sign
How is epididymitis treated?
ABx (Doxycycline or Ciprofloxacin)
___________ is an acute inflammatory reaction of the testis secondary to an infection
Orchitis
What is the most common etiology of orchitis?
Mumps Orchitis
T/F: Bacterial Orchitis is most common associated with epididymitis in sexually active males and men >50 with BPH
True
Is testicular cancer highly curable?
Yes
What is the most common type of testicular cancer?
95% are Germ Cell
Seminoma, Non-seminoma, Mixed
How would testicular CA present?
Painless Testicular Mass Incidentally Found
What tumor markers are typically present in testicular cancer?
AFP
Beta-HCG
LDH
in a Bell’Clapper’s Deformity there is an absence or weakness in the ______ ligament, which is a remnant of the gubernaculum
Scrotal ligament
80% of people with testicular cancer have an extra copy of a portion of chromosome ___
Chromosome 12
T/F: Most testicular cancers are triploid or tetraploid
True
Why are varicoceles more common on the left rather than on the right?
The left drains to the renal vein instead of the IVC
Patients with a patent funicular process may increase the risk for what?
Indirect Hernia
What intra-abdominal disease processes could cause this person to have scrotal swelling?
Intraperitoneal Bleeding
Ascites
Abdominal CA
A __________ (Non-Communicating/Communicating) hydrocele occurs when the process vaginalis has closed.
What are two ways this can occur?
Non-communicating
- Fluid accumulates in the tunica vaginalis before birth, and just doesn’t get reabsorbed.
- A process inside the scrotum (infection, cancer, or fluid production by the tunica itself) causes fluid to build up there.
What is the name of the plexus that supplies the prostate and bladder?
Pelvic (Hypogastric) Plexus
T/F: DHT can activate proto-oncogenes in the prostate
True
Which zone is the most common site of prostate cancer?
A. Transitional Zone
B. Peripheral Zone
C. Central Zone
B. Peripheral Zone
T/F: Many prostate cancers are known to increase production of transcription factors that eliminate apoptosis
True
Prostate cancer is also associated with androgens that _______ (increase/decrease) cell turnover
Increase
Physiologic phimosis typically resolves by what age?
7 y.o.
What are THREE risk factors that increase the risk of developing Peyronie’s Disease?
Diabetes
Tobacco Use
Pelvic Trauma
Erections are mediated by NO and ___________ (paracrine/endocrine) signaling
Paracrine
What are the TWO types of priapism?
High-Flow (non-ischemic): Abundance of arterial flow
Low-Flow (ischemic): Decreased venous drainage, vaso-occlusion
The average temperature of the penis is __ degrees lower than the body
4 degrees