Male GU

• decreased FOS
• nocturia
• urge incontinence
• stream= stop, start, dribble

50yoa

cz unknown

• testosterone
• avoid developing BPH

prostate shrinks in size

• 1. DRE- broad, flat
• 2. check for suprapubic fullness: PVR, bladder scan
• 3. PSA

• 1. dynamic- r/t to the tension of prostatic smooth muscle in the prostate, prostate capsule, and bladder neck
• 2. r/t the bulk of the enlarged prostate impining on urethra

• Alpha blockers:
• terazosin (hytrin): 1mg-10mg
• tamsulosin (flomax): 0.4mg-0/8mg
• doxazosin (cardura): 1mg-8mg
• silodosin (rapaflo): 4mg-8mg
• alfuzosin (uroxatral): 10mg

• orthostatic HOTN
• dizziness
• syncope
• education= take at bedtime, sit at bedside before standing

• alpha blockers
• 5a-reductase inhibitors

• 5a reductase inhibitors:
• finasteride (proscar): 5mg
• dutasteride (avodart): 0.5mg
• education= get baseline, decrease PSA by 50%, decreased libido, liver dysfxn

TURP, stay 1 day

open prostatectomy

laser therapy

transurethral needle ablation w/radiofrequency: low morbidity rate, but TX failure is>80% at 10yr

• avoid caffeine
• avoid meds that exacerbate sx= cold meds, allergy meds

• acute retention
• UTI
• bladder stones: r/t chronic residuals, associated w/dysuria, frequency, microhematuria

• bacteria enter through urethra
• gram neg= E. coli, enterobacter

trauma, horseback riding, chronic or imtermittent cath's, dehydration, sexual abstinence, caffeine, ETOH

• I. acute
• II. chronic bacterial
• IIIa. chronic prostatitis/pelvic pain syndrome/inflammatory
• IIIb. chronic prostatitis/pelvic pain syndrome/non-inflammatory
• IV. asymptomatic inflammatory prostatitis (found on BX)

• frequency, urgency, dysuria
• pelvic/perineal pain
• cloudy urine
• poor FOS
• spiking fever, chills
• malaise, myalgias

• UA/C&S
• bld cx
• WBC
• NO DRE bc painful- if have to be gentle
• can progresss to sepsis

• Cipro 500mg BID x4-6wks
• Levaquin 500QD x4-6wks

• bacterias:
• E. coli, Klebsiella pneumonia, Proteus mirabilis, Enterobacter, Morganella morgani

• cannot tolerate PO meds
• evidence of severe sepsis
• broad spectrum should be given empirically prior to C&S results obtained

• Aminoglycoside (Gent, Tobra)
• Fluoroquinolones (Levo, Cipro)

• chains (enterococci):
• 1. amoxicillin 500Q8hrs x406wks
• 2. Amp IV 2G Q6hrs

• cocci (S. aureus, S. epi)
• 1. Keflex 500mg Q6hrs x4-6wks
• 2. Dicloxicillin 500mg Q6hrs x4-6wks
• 3. Kefzol IV 1G Q8hrs

• not always complication of acute prostatitis
• S: subtle clinical sx
• PE: DRE- boggy prostate
• DX: needs UA/C&S
• TX: bactrim DS BID x4-6wks, NSAIDS help
• Ed: no caffeine, no ETOH

• cz- unknown
• dx- of exclusion, cystoscopy, U/S
• tx- 4wk trial of ATB, alpha blockers and NSAIDS
• CF- stress, neuromuscular factors

• low incidence
• associated with abnormalities: BOO, BPH, instrumentation (cath's, surgery), structural (birth defects)

• can have dysuria, frequency, urgency, suprapubic pain, hematuria
• recurrence

prostatitis, pyelo, epididymitis

• out of 250,000 hospitalizations only 10% are male
• renal transplant recipients, instrumentation

• flank pain
• N/V
• fever (>38)
• CVAT
• may occur w/ or w/o cystitis

• enteric gram neg rods
• S. aureus
• S. epi
• pseudomonas (chronic caths, LTC facilities)

• midstream UA/C&S
• blood culture if febrile
• imaging if no risk factors are present
• WBC follow w/sepsis

• TMX-SMX
• Levaquin, Cipro
• *if pt septic sx- must hospitalize and do IV ATB's*

• macrobid, avelox (moxiflox), cephalosporin
• (d/t poor tissue concentrations in males w/occult prostatitis)

• common in sexually active males
• sx- burning, irritative meatus
• dx- swab, gram stain
• gram neg rods assoc w/UTI's
• N. gonorrheae
• C. trichomatis

• acute pain:
• testicular torsion
• epididymitis

• chronic pain:
• spermatocele
• varicocele
• hydrocele

• common in 0-35yrs
• sudden onset
• risks- anatomical (poor fixation at birth), strenuous activity, cremasteric contraction during REM, HX of intermittent torsion

• sx- acute unilateral pain
• N/V
• assymetrical high riding testis

• testis oriented horizontally
• swelling
• short spermatic cord
• absent cremasteric reflex

• color doppler U/S if not clinically clear
• irreversible ischemia if left untreated >6hrs
• immediate surgical intervention
• detorsion and fixation of testicles

• more rare than torsion
• risks-
• UTI/sepsis
• instrumentation
• unprotected intercourse w/infected partner
• sx-
• exquisite tenderness
• swelling at epididymis

• Chlamydia
• Gonococcal
• tx-
• Ceftraixone 250mg IMx1
• Doxycycline 100mg BID x10days

• E. coli, pseudomonas
• TX-
• Cipro x2wks
• Levaquin x2wks

• F/U in 2-3 wks
• hospitalize if septic

• def-
• dilatation of the pampiniform plexus of spermatic veins
• inc-
• 15-20% post-pubertal males
• common spot-
• 70% left, 30% bilateral

• sx-
• dull, aching, unilateral scrotal pain
• worse standing, relieved by lying down
• PE-
• testicular atrophy
• sperm concentration & motility reduced by 75%
• poss compromised fertility

• DX-
• U/S if there is a question
• semen analysis
• TX-
• scrotal support
• NSAIDS
• surgical TX ligating gonadal vein to stop retrograde blood flow

younger males for infertility, testicular atrophy

1. presence of unilateral R sided varicocele raises suspicion of poor drainage at the junction of the R testicular vein and R renal vein, could be d/t large R renal mass

2. sudden onset of varicocele in older pt raises suspicion of retroperitoneal mass leading to inadequate drainage of testicular veins

• painless, fluid filled sac
• size varies 1-5cm
• location- arise from epididymis, located superior to testes
• AKA- epididymal cyst 0.5mm-1cm

• PE- 1-5cm mass palpated distinct from testis
• DX- U/S
• Ed- assurance
• TX- scrotum support, NSAIDS, rarely need surgery

• common in infancy and childhood
• secondary to patent processus vaginalis or continuous with the peritoneal cavity
• a form of indirect inguinal hernia
• most spontaneously close by 1 year

persistent communicating hydroceles and presence of bowel content within the hydrocele sac

• peritoneal fluid between the parietal and visceral layers of tuncia vaginalis
• small to massive
• idiopathic

• HX-
• slow accumulation
• trauma or infection
• infants w/communciating patent processus vaginalis
• SX-
• pain and disability inc with size
• illuminates w/penlight

• TX-
• refer to urologist
• U/S
• surgical excision of sac

• stats-
• most common CA between 15-35yrs
• most curable
• 95% survival rate at 5yrs

• cryptorchidism
• personal, family HX
• infertility, subfertility
• HIV
• White>AA   (4:1)

• PE-
• painless, hard nodule
• dull ache in groin
• pain w/hemorrhage after trauma

• supraclavicular LN
• cough
• gynecomastia

• starting w/normal testis, pt standing
• palpate carefully between thumb and 1st two fingers
• homogenous in consistency, freely moveable, and able to seperate from epididymis
• palpate affected side; identify and measure: firm, hard, or fixed area; palpate spermatic cord, inguinal, abd, and supraclavicular nodes

• imaging-
• U/S: immediate referral to urologist; phone call to MD; educate
• CT pelvis/abdomen
• CXR

• serum beta HCG
• alpha feta protein
• LDH

• seminoma (95%)- trophoblastic cells
• spermatocytic seminoma- w/sarcoma
• nonseminomatous germ cell tumors (5%)- embryonal, yolk sac

• TX-
• radical inguinal orchiectomy- used for tumor control and to aid DX
• retroperitoneal LN dissection- identify nodal micro metastases
• PX- both # and size of involved retroperitoneal LN's

• 2nd to leading cz of CA and CA death in men; other than skin (non-melanoma) and lung CA
• avg age 72yrs
• lifetime risk of developing prostate CA 16%
• risk of dying from it= 3%

• 1. PSA-
• glycoprotein produced by prostate epithelial cells
• not as prognostic if pt has BPH
• 2. DRE

• start at age 50, 40 if family HX of it
• PSA velocity-
• 1. change of 0.35 may prompt a BX if between 2.5-4
• 2. >0.75 change within a year, may need to investigate if >4
• 3. PSA requires 3 serial readings w/same assay over 6-12-18months

• BPH
• acute prostatitis
• prostate BX
• cystoscopy
• TURP
• urinary retention
• DRE=minimal
• ejaculation

• 1. normal 0-4 BUT if notice on DRE:
• tissue firmness
• nodule
• 2. PSA >7 (7-10 is good indicator of CA)
• 25%

• DX-
• U/S guided prostate BX
• CT staging, bone scan
• Gleason scores- primary grade + secondary
•                                          3 + 4=7 better
•                                          4 + 3=7 worse

• varies within the stage
• A- confined to prostate
• B- confined to gland
• C- local extension
• D- regional LN or distant mets

• stage T1b, T1c, T2a, T2b at time of DX
• diagnostic BX Gleason score <6
• PSA </=10

• pathologic organ-confined dz found in:
• 80% PSA <4
• 66% if PSA 4-10
• <50% if PSA >10

• TX-
• DaVinci prostatectomy/open prostatectomy
• radiation XRT
• hormonal (LHRH, antiandrogrens)
• orchiectomy

• All men >50yrs (AUA rec's):
• annual PSA and DRE
• educate before screening
• USPSTF says:
• insufficient to rec for or against PSA and DRE
• screening does not benefit pt >75yrs