Men's Health Flashcards
(88 cards)
1
Q
Describe the location of the prostate
A
- Below the bladder
- Above the urogenital diaphragm
- Behind the pubic symphysis
- In front of the rectum
- Around the urethra
*anterior disease is hard to detect w/ rectal exam
2
Q
Describe the structure of the prostate
A
- Stromal (fibromuscular) and glandular (epithelial) components
- Three lobes (Left & Right, Median)
- Surrounded by a capsule (expands inward and can compress the urethra)
*Produces seminal fluid
3
Q
How do you estimate the weight/size of the prostate
A
20 g: 2 finger widths (normal prostate)
30 g: 3 finger widths
40 g: 3 finger widths ++
>40 g: bigger
4
Q
What should you document a prostate DRE
A
- note size/estimate weight
- Texture: Firm, nodular, boggy
- Asymmetry
- Tenderness
5
Q
Types of prostatitis
A
- Common inflammatory condition of the prostate gland
- Acute bacterial prostatitis (ABP)
- Chronic bacterial prostatitis (CBP)
- Nonbacterial prostatitis (NBP)/prostatodynia
- Other (rare) e.g. gonococcal prostatitis
6
Q
Symptoms of ABP
A
- Fever and chills
- Malaise
- Perineal and low back pain
- Irritative voiding symptoms: burning, frequency, urgency, nocturia
- Obstructive voiding symptoms: difficulty initiating stream, retention
**ACUTELY ILL– needs to be taken seriously!
7
Q
What is the most common cause of ABP and what is the tx
A
- Ascending infection - gram negative rods (e. coli, klebsiella)
- Uncommon, potentially serious
- Treatment is generally with IV antibiotics
8
Q
What are sx of CBP
A
- Generally less severe than ABP
- Some patients are asymptomatic
May have some or all of the following: - Irritative voiding symptoms: burning, frequency, urgency, nocturia
- Pelvic and/or perineal pain
- Postejaculatory pain (occasionally)
- Hematospermia (occasionally)
*Common, often persistent and frustrating
9
Q
What is the most common type of prostatisis
A
NBP/prostatodynia
10
Q
Describe the presentation of NBP/prostatodynia
A
- Typically afebrile
- No bacteria on culture, no response to antibiotics
- DRE can be normal or mildly tender
- Symptoms similar to CBP
- *Undetermined cause
- *Urinary tract disease must be excluded
11
Q
Prostatitis DDX
A
- UTI
- BPH
- Prostate cancer
- Bladder cancer
- Urethral stricture
- Neurogenic bladder
- Interstitial cystitis
- Hernia
- Musculoskeletal
12
Q
Describe the evaluation of prostatitis
A
- PE -attention to abdominal and genital exam, hernias
- DRE - prostate typically swollen and tender
- UA - pyuria (WBCs) usually seen in ABP
- Prostatic fluid culture via prostatic massage*
- EPS (expressed prostatic secretions)
*Contraindicated in ABP
13
Q
When is prostatic message contraindicated
A
in ABP
*high risk of urosepsis in elderly
14
Q
how Do you dx NBP/prostatodynia
A
- Need 2 rounds of abx (different classes) bc you need to exclude Urinary tract disease/bacterial process
- often refer to urology
15
Q
What is the tx of CBP
A
- FQ (cipro, levofloxacin)- Abx of choice!
- SMX-TMP-less effective but still an option
*tx for 4 weeks minimum
16
Q
What is the tx of NBP
A
- NSAIDS*
- alpha– blockers (relax prostate and bladder neck)
- 5 alpha-reductase inhibitors – helpful if patient also has BPH
- Dietary restriction - avoidance of alcohol*, caffeine, pseudoephedrine, other irritants
- Sitz baths
- Prostatic massage
- Counseling
- Surgery (see BPH)
OR…how about the Dila-Therm?
17
Q
What signifies an abnormal DRE for prostatiis
A
boggy
tender
stimulates urge to pee
18
Q
What is the most common benign tumor in men over 60
A
Benign Prostatic Hyperplasia (BPH)
*Affects roughly 50% at age 60, 90% at age 85
19
Q
What is Benign Prostatic Hyperplasia (BPH) characterized by?
A
- prostatic enlargement,
- obstruction of bladder outlet,
- voiding symptoms
**Prostate size does not correlate with degree of obstruction
20
Q
Only __% of men with anatomical BPH will ever need treatment, however…
__% of American males over 50 have moderate to severe symptoms…ASK ABOUT IT!!
A
50%
30%
21
Q
Describe the basic pathophysiology of BPH
A
- Increase in cell number
- Capsule limits outward growth, urethra obstructed
- Etiology not well understood but androgens play a necessary role
22
Q
BPH can lead to:
A
- severe bladder dysfunction
- recurrent UIT
- bladder stones
23
Q
Most BPH involves ___ tissue, some cases have a ___ component
A
stromal
glandular
24
Q
What are obstructive sx of BPH
A
- Hesitancy (delay/difficulty in initiating stream)
- Weak urinary stream
- Feeling of incomplete bladder emptying
- Intermittency (stopping and starting several times during voiding)
25
What are irritative sx of BPH
1. Urgency (feeling of little warning when urge develops)
2. Frequency (frequent urination with short intervals)
3. Nocturia
4. Dysuria
5. Feeling of incomplete bladder emptying
26
Describe the evaluation of suspected BPH
1. PE -attention to abdominal and genital exam, hernias
2. DRE - size, texture
3. Urinalysis - pyuria or hematuria
4. Serum creatinine-- long standing could cause VUR renal scarring
5. May consider: Uroflowmetry, pressure-flow studies, cystoscopy, ultrasound, biopsy
27
Describe the scoring of AUA symptoms score
*good to assess symptom changes (response to meds, progression)
0-7: mild
8-19: moderate
20-35: severe
*opens door for discussion
28
What are management strategies for BPH
1. Watchful waiting
2. Correction of aggravating factors
3. Medical treatment
4. Minimally invasive therapies: fluid restriction
5. Surgical therapies
6. Other (laser, stents)
7. Beer?
29
Who is the ideal candidate for watchful waiting with BPH
1. Mild symptoms (AUA symptom score 7 or less)
2. No recurrent UTI
3. No gross hematuria
4. No bladder stones
5. No urinary retention
6. No renal insufficiency
30
What are ways for correction of aggravating factors in BPH
1. Fluid restriction, particularly before bedtime
2. Avoidance of caffeine, alcohol
3. Tight control of diabetes
4. Medications (diuretics, decongestants, anti-cholinergics-- PSEUDOPHED)
5. Treatable neurologic conditions
6. Recurrent UTIs or prostatitis
7. Coexisting urologic conditions
31
In men over 50, always ask about
1. sexual function
2. concerns about urination
*30% of males over 50 have moderate-severe symptoms of BPH
32
What medications can be used to treat BPh
1. Alpha-blockers
2. 5-alpha reductase inhibitors (5aRI)
3. Phytotherapy-- saw palmetto berry and Trinovin (soy isoflavone extract)
33
How do alpha-blockers work to treat BPH
1. Prostatic smooth muscle cells have type a1-adrenoceptors (a1-AR) - norepinephrine
2. Bind to and block a-adrenoceptors on smooth muscle
3. Binding to a1-AR on smooth muscle of fibromuscular stroma causes relaxation of the prostate, greater urine flow
34
What are side effects of alpha-blockers (used to tx BPH)
* Side effects related to binding to non-prostatic receptors
1. dizziness
2. fatigue
3. somnolence
4. postural hypotension
5. flu-like symptoms
6. retrograde ejaculation
7. others (nausea, erectile dysfunction, etc)
35
Selective long-acting a-blockers medications used in BPH:
* No significant difference in efficacy among these
1. a1-AR blockers: terazosin (Hytrin), doxazosin (Cardura)
2. a1a-AR blockers: tamsulosin (Flomax), alfuzosin (Uroxatral) - more selective for prostate receptors, FEWER side effects
36
How do you choose an alpha-blocker for BPH
1. Cost: Significant differences in price, terazosin (Hytrin) and doxazosin (Cardura) are cheaper
2. Side effects: 90% of patients tolerate these well
3. Try terazosin or doxazosin first line and switch to tamsulosin (Flomax) or alfuzosin (Uroxatral) if poorly-tolerated
4. alfuzosin has most favorable side-effect profile, particularly re: ejaculatory and erectile dysfunction
37
How do 5-alpha Reductase Inhibitors (5aRI) help manage BPH
- Androgen suppression, targets epithelial (glandular) component, decreasing prostatic size via cellular regression
- Unlike a-blockers, take time to work…1 to 6 months
* Lower PSA values…Be careful! Double measured values
38
Examples of 5-alpha Reductase Inhibitors (5aRI) help manage BPH
finasteride (Proscar) and dutasteride (Avodart)
*Both are expensive, dutasteride has slightly better side effect (decreased libido, ejaculatory/erectile dysfunction) profile
39
Describe the use of phytotherapy for BPH
1. Saw palmetto berry (Serenoa repens) - many small studies with conflicting results. One decent study (STEP study) showed no benefit.
- No significant adverse events.
- Most common side effect: GI distress Unregulated - poor quality control
2. Trinovin - soy isoflavone extract. No convincing data.
40
What are minimally invasive ways to manage BPH
1. thermal ablations, various heat sources
2. Transurethral needle ablation of the prostate (TUNA)
3. Interstitial laser thermal therapy (ILTT)
4. Transurethral microwave therapy (TUMT)
41
When is minimally invasive management appropriate for BPH
1. Safer than surgical approaches though not as successful
2. Outpatient, minimal anesthesia, lower complication rate
3. Appropriate for patients who fail or are unable to tolerate medical therapy, poor surgical candidates
4. Not appropriate for men with severe symptoms, greatly enlarged prostates
5. Long-term outcomes unknown
* Can not biopsy tissue
42
What is transurethral resection of the prostate (TURP) a good choice
* Treatment of choice for moderate to severe symptoms
- Consider for patients who:
1. fail medical treatment,
2. have refractory urinary retention,
3. recurrent UTI,
4. persistent hematuria,
5. bladder stones,
6. renal failure
43
What are long term complications of transurethral resection of the prostate (TURP)
1. retrograde ejaculation (70%),
2. impotence (14%),
3. partial incontinence (6 %),
4. total incontinence (1%)
5. Risky with large (>50g) prostates
44
What are complications of TURP surgery
1. bleeding
2. clot retention
3. infection
4. capsular perforation
45
Surgeon is able to directly visualize procedure
| Uses radiofrequency loop to generate prostatic chips
TURP
46
Surgical removal of the inner portion of the prostate
| Suprapubic or retropubic approach
Simple open prostatectomy
47
When is Simple open prostatectomy indicated
1. Indicated for prostates larger than 50-75g, for which TURP is considered risky
2. Still most effective treatment with low retreatment rates but high morbidity (e.g. retrograde ejaculation approaches 100%)
48
Complications of Simple open prostatectomy
1. Open surgery with potential complications (e.g. post-op ileus, DVT, wound infection)
49
What is the most common CA in males
prostate CA (1 in 6 lifetime)
* Most common non-skin malignancy
* Second to lung cancer in cancer mortality in men
50
What are risk factors for prostate cancer
1. age
2. fhx (2-10x)
3. race (AA) (1.3x)
4. high dietary fat (1.6-1.9x)
5. No specific genes identified but BRCA genes do increase risk
6. Unproven: vitamin D,E, selenium deficiency, cadmium exposure (welding), STD, high calcium intake
51
__ and __ do not have a significant risk factor for prostate cancer
BPH and vasectomy
52
Symptoms to prostate CA
* Typically do not appear until cancer is advanced
1. Cancer usually starts in peripheral tissues and by the time urinary symptoms develop (obstructive or irritative symptoms, hematuria) it is often regionally advanced
2. May present as bone pain (with increased serum alkaline phosphatase) from metastatic disease
53
Early dx of prostate Ca is usually achieved by ___
DRE and PSA testing
*Transrectal ultrasound (TRUS)-guided needle biopsy is the standard method of confirming diagnosis
54
Is screening with PSA recommended
Routine use of PSA increases detection of cancer BUT has not been shown to reduce morbidity or mortality from prostate CA
In other words: mass screening using PSA may result in detection and invasive treatment of many cancers that might never have become a problem
55
PSA elevations can occur with
1. massage,
2. biopsy,
3. infection,
4. infarct, and
5. BPH
56
The PLCO and ERSPC studies about PSA testing concluded what
PLCO
-No mortality benefit from combined PSA and DRE testing
ERSPC
- Minimal mortality benefit from PSA testing
- Absolute reduction of 7 prostate cancer deaths per 10,000 men screened (or…1400 men needed to be screened to prevent 1 prostate cancer death)
57
What are talking points for prostate CA screening so that informed decision making
1. Prostate CA is an important health problem; it is one of the most frequently diagnosed cancers in the United States and a leading cause of cancer death in men.
2. Prostate CA screening is controversial, and men should be involved in making the decision whether or not to be screened.
3. Prostate cancer screening may reduce the chance of dying from prostate cancer. However, the evidence is mixed and the absolute benefit is small.
4. Surgery and radiation therapies are the treatments most commonly offered in an attempt to cure prostate cancer; however, they can lead to problems with urinary, bowel, and sexual function
5. Many CA detected by screening are considered "overdiagnosed", meaning that they never would have caused problems during a man's lifetime
58
What are the screening recommendations of prostate CA
1. No one recommends DRE
2. USPSTF – Recommends against screening with PSA.
3. American Cancer Society - Involve patients in informed decision making. For those who elect to be screened, start at age 50. Do not offer to men with a life expectancy of less than 10 years.
4. American Urologic Association – No screening for average-risk men ages 40 to 54, men older than 70, or men with a life expectancy of less than 10 to 15 years. Decisions should be individualized for higher-risk men ages 40 to 54, and the AUA noted that some men over age 70 in excellent health might benefit from screening. The AUA strongly recommends shared decision making.
59
What are treatment options for prostate CA
1. Watchful waiting
2. Radical prostatectomy
3. Radiotherapy/Brachytherapy
4. Hormonal (antiandrogen) therapy
60
Describe the watchful waiting management option for prostate CA
1. May be appropriate in elderly patients with life-expectancy less than 10 years
2. Patients with well-differentiated tumors (Gleason 2 to 4)
3. Patients with Gleason scores of 7 to 10 have a much higher risk of death with watchful waiting
4. Re-evaluate every 6 months
61
Complete excision of prostate and re-anastomosis of bladder and urethra
radical prostatectomy -- done for prostate CA
62
When is radical prostatectomy a good tx option for prostate CA
1. Appropriate for clinically localized cancer
2. May be most beneficial in early prostate cancer
3. Surgical morbidity correlated with surgeon experience
63
What are the different tx approaches for radical prostatectomy
Retropubic approach - avoids abdominal cavity but higher rate of impotence
Suprapubic approach - preferred method
DaVinci robotic prostatectomy - laparoscopic technique
64
Radical Prostatectomy - complications
* Surgeon’s experience important.
1. Neurovascular bundle. Supplies the penis and easily injured during surgery
2. Urinary incontinence (around 10 % in most centers)
3. Impotence
4. Lower incidence of impotence with nerve-sparing procedures (both or 1 neurovascular bundle is spared)
5. Rectal injury, uncommon
65
External source of radiation
Multiple treatments, typically over 6-8 weeks
Success approaches that of radical prostatectomy
Radiation - Electron Beam (EBRT)
66
Complications of Radiation - Electron Beam (EBRT)
1. Can have significant GI side effects and share complications of radical prostatectomy
* Urinary incontinence rates less than with radical
67
Radioactive seeds implanted in prostate
Radiation - Brachytherapy
68
Pros of Radiation Brachytherapy
Pros:
-Less impact on surrounding tissue than EBRT
Minimally invasive surgery, typically rapid recovery
69
SE of Radiation Brachytherapy
1. Side effects comparable to radical prostatectomy
| * However, in a recent NCI study, patients report better quality of life following brachytherapy
70
When is Hormonal (anti-androgen) Therapy a good option for prostate CA
Usually reserved for advanced cancer
71
Side effects of Hormonal (anti-androgen)
1. impotence,
2. hot flashes,
3. osteoporosis,
4. weight gain
72
examples of Hormonal (anti-androgen) used for prostate CA
1. LH Releasing Hormone (LHRH) agonist: Lupron
| 2. Antiandrogens: Flutamide
73
Describe the follow up of prostate CA
1. PSA every 6 months for 5 years, then every year
2. Any elevation that is detectable (>0.4ng/ml) needs to be pursued
3. DRE yearly (Debatable)
4. Clinical exam every 6 months for 5 years
74
what is erectile dysfunction
The persistent inability to attain a penile erection sufficient for intercourse
75
Who does ED effect
1. Affects 20-30 million American men
| 2. Age dependent, affects 15-25% of men over 65
76
Negative impacts of ED
1. neg. impact on quality of life,
2. self-image,
3. relationships
77
describe the mechanics of a flaccid state
-small terminal arteries leading to the cavernous sinuses are constricted, reducing inflow of blood. Venous plexus open.
78
describe the mechanics of an arousal state
1. Parasympathetic chain of events leading to release of nitric oxide (NO) in the corpora cavernosum.
2. NO activates an increase in cyclic guanosine monophosphate (cGMP), a second messenger.
3. Increased cGMP causes smooth muscle relaxation responsible for erection.
*Phosphodiesterase 5 (PDE-5) cleaves cGMP, inactivating it
79
Causes of ED
1. psychogenic- performance anxiety, relationship/marital discord, anxiety, depression
2. organic
3. iatrogenic
4. environmental: smoking, alcohol, drugs of abuse
80
What are organic causes of ED
1. Vasculogenic - arterial problems most common (DM, CAD)
2. Neurogenic - spinal cord injury, MS, etc
3. Hormonal - hypogonadism, hyperprolactinemia, thyroid dysfunction
4. Mechanical - Peyronie’s, anatomic abnormalities
81
What type of meds can cause ED
```
Antidepressants
SSRIs
Tricyclics (TCAs)
Atypicals
Antihypertensives
Beta-blockers
Diuretics
Clonidine
Antipsychotics
Anxiolytics
Benzodiazepines
Miscellaneous
Corticosteroids
Cimetidine (Tagamet)
Finasteride (Proscar)
Gemfibrozil (Lopid)
Niacin
Phenytoin (Dilantin)
```
82
Describe the PE of ED
1. CV: BP, bruits, signs of peripheral vascular disease
2. Feminization: gynecomastia, body hair changes
3. Neuro: peripheral sensory exam
4. Genital: penile abnormalities (e.g. Peyronie’s), testicular atrophy
5. Rectal: DRE, sphincter tone, “anal wink”, bulbocavernous reflex
6. Consider psychological evaluation
83
What Labs do you get for ED
CBC, BMP (glucose & electrolytes), lipids, TSH, testosterone
Urinalysis
*get color doppler US if you suspect vascular disease
84
Describe the use of testosterone for ED
*Normal levels change during the day with peak level in the am.
Decline with age
1. Age-adjusted, first-morning free testosterone levels most accurate
- If testosterone low = hypogonadism--> check prolactin, LH, FSH
- If prolactin high, get pituitary MRI
85
Treatment of ED
1. Treat secondary causes
2. Lifestyle change (smoking, exercise, EtOH, diet)
3. Oral medications
4. Urethral suppositories
5. Vacuum constriction devices
6. Penile self-injection
7. Surgical options
86
What med is used for ED
PDE-5 Inhibitors
Increase cGMP levels in corpora cavernosum
Require arousal…not an aphrodisiac!
ex. Sildenafil (Viagra)
87
What are side effects of PDE-5 Inhibitors
1. HA
2. flushing
3. dyspepsia
* *CONTRAINDICATED W/ NITRATES
88
What are surgical options for ED
1. Implants
- Inflatable, pump-assisted
- Malleable
- Most invasive option
2. Vascular reconstruction
