Male GU

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wackojacko
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182471
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Male GU
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2012-11-08 10:26:35
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Male GU
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Male GU
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  1. common sx BPH
    • decreased FOS
    • nocturia
    • urge incontinence
    • stream= stop, start, dribble
  2. BPH sx commonly start at what age?
    50yoa
  3. BPH cz
    cz unknown
  4. testicles produce what?
    men who have testicles removed at young age avoid what?
    • testosterone
    • avoid developing BPH
  5. what happens if a pt testicles are removed after he develops BPH?
    prostate shrinks in size
  6. BPH exams
    • 1. DRE- broad, flat
    • 2. check for suprapubic fullness: PVR, bladder scan
    • 3. PSA
  7. bladder outlet obstruction of BPH has 2 components:
    1. dynamic (physiologic, reversible)
    2. fixed (structural)
    • 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
  8. TX options BPH
    Alpha blockers:
    • Alpha blockers:
    • terazosin (hytrin): 1mg-10mg
    • tamsulosin (flomax): 0.4mg-0/8mg
    • doxazosin (cardura): 1mg-8mg
    • silodosin (rapaflo): 4mg-8mg
    • alfuzosin (uroxatral): 10mg
  9. SE of BPH RX's
    education=
    • orthostatic HOTN
    • dizziness
    • syncope
    • education= take at bedtime, sit at bedside before standing
  10. classes of drugs for TX BPH:
    • alpha blockers
    • 5a-reductase inhibitors
  11. TX BPH
    5a-reductase inhibitors
    education:
    • 5a reductase inhibitors:
    • finasteride (proscar): 5mg
    • dutasteride (avodart): 0.5mg
    • education= get baseline, decrease PSA by 50%, decreased libido, liver dysfxn
  12. most common surgery for BPH
    TURP, stay 1 day
  13. surgery for very large prostates for BPH
    open prostatectomy
  14. BPH surgery, less invasive and minimal side effects
    laser therapy
  15. surgery for BPH least effective
    transurethral needle ablation w/radiofrequency: low morbidity rate, but TX failure is>80% at 10yr
  16. lifestyle changes for BPH pts
    • avoid caffeine
    • avoid meds that exacerbate sx= cold meds, allergy meds
  17. BPH pts- do not miss these possibilities...
    • acute retention
    • UTI
    • bladder stones: r/t chronic residuals, associated w/dysuria, frequency, microhematuria
  18. acute prostatitis cz
    • bacteria enter through urethra
    • gram neg= E. coli, enterobacter
  19. risk factors acute prostatitis
    trauma, horseback riding, chronic or imtermittent cath's, dehydration, sexual abstinence, caffeine, ETOH
  20. classes of prostatitis
    • 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)
  21. sx prostatitis
    • frequency, urgency, dysuria
    • pelvic/perineal pain
    • cloudy urine
    • poor FOS
    • spiking fever, chills
    • malaise, myalgias
  22. PE prostatitis
    • UA/C&S
    • bld cx
    • WBC
    • NO DRE bc painful- if have to be gentle
    • can progresss to sepsis
  23. TX acute prostatitis
    (usually gram neg)- bacterias?
    • Cipro 500mg BID x4-6wks
    • Levaquin 500QD x4-6wks

    • bacterias:
    • E. coli, Klebsiella pneumonia, Proteus mirabilis, Enterobacter, Morganella morgani
  24. acute prostatitis
    indications for IV ATB TX?
    • cannot tolerate PO meds
    • evidence of severe sepsis
    • broad spectrum should be given empirically prior to C&S results obtained
  25. IV ATB's used for acute prostatitis
    • Aminoglycoside (Gent, Tobra)
    • Fluoroquinolones (Levo, Cipro)
  26. acute prostatitis- usually gram neg but what if gram pos??
    • 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
  27. chronic prostatitis (class II)
    S?
    PE?
    DX?
    TX?
    Ed?
    • 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
  28. Chronic prostatitis/pelvic pain syndrome (class III)
    CZ?
    DX?
    TX?
    contributing factors?
    • cz- unknown
    • dx- of exclusion, cystoscopy, U/S
    • tx- 4wk trial of ATB, alpha blockers and NSAIDS
    • CF- stress, neuromuscular factors
  29. UTI male
    • low incidence
    • associated with abnormalities: BOO, BPH, instrumentation (cath's, surgery), structural (birth defects)
  30. UTI male
    asymptomatic and symptomatic
    • can have dysuria, frequency, urgency, suprapubic pain, hematuria
    • recurrence
  31. UTI male
    can be seen slong with...
    prostatitis, pyelo, epididymitis
  32. Upper UTI
    pyelo
    incidence
    risk factors
    • out of 250,000 hospitalizations only 10% are male
    • renal transplant recipients, instrumentation
  33. upper UTI
    pyelo
    sx
    • flank pain
    • N/V
    • fever (>38)
    • CVAT
    • may occur w/ or w/o cystitis
  34. source of upper and lower UTI
    • enteric gram neg rods
    • S. aureus
    • S. epi
    • pseudomonas (chronic caths, LTC facilities)
  35. UTI
    DX
    • midstream UA/C&S
    • blood culture if febrile
    • imaging if no risk factors are present
    • WBC follow w/sepsis
  36. UTI
    TX
    • TMX-SMX
    • Levaquin, Cipro
    • *if pt septic sx- must hospitalize and do IV ATB's*
  37. UTI TX
    meds to avoid
    • macrobid, avelox (moxiflox), cephalosporin
    • (d/t poor tissue concentrations in males w/occult prostatitis)
  38. urethritis
    common in...
    sx..
    dx..
    • common in sexually active males
    • sx- burning, irritative meatus
    • dx- swab, gram stain
    • gram neg rods assoc w/UTI's
    • N. gonorrheae
    • C. trichomatis
  39. testicular diseases
    acute pain
    • acute pain:
    • testicular torsion
    • epididymitis
  40. testicular diseases
    chronic pain
    • chronic pain:
    • spermatocele
    • varicocele
    • hydrocele
  41. testicular torsion
    incidence
    onset?
    risk factors?
    • common in 0-35yrs
    • sudden onset
    • risks- anatomical (poor fixation at birth), strenuous activity, cremasteric contraction during REM, HX of intermittent torsion
  42. testicular torsion
    sx
    • sx- acute unilateral pain
    • N/V
    • assymetrical high riding testis
  43. testicular torsion
    PE
    • testis oriented horizontally
    • swelling
    • short spermatic cord
    • absent cremasteric reflex
  44. testicular torsion
    DX
    • color doppler U/S if not clinically clear
    • irreversible ischemia if left untreated >6hrs
    • immediate surgical intervention
    • detorsion and fixation of testicles
  45. bacterial epididymitis
    risks
    sx
    • more rare than torsion
    • risks-
    • UTI/sepsis
    • instrumentation
    • unprotected intercourse w/infected partner
    • sx-
    • exquisite tenderness
    • swelling at epididymis
  46. bacterial epididymitis
    STD
    TX
    • Chlamydia
    • Gonococcal
    • tx-
    • Ceftraixone 250mg IMx1
    • Doxycycline 100mg BID x10days
  47. bacterial epididymitis
    typical pathogen
    TX
    • E. coli, pseudomonas
    • TX-
    • Cipro x2wks
    • Levaquin x2wks
  48. bacterial epididymitis
    F/U
    • F/U in 2-3 wks
    • hospitalize if septic
  49. varicocele
    definition
    incidence
    common spot
    • def-
    • dilatation of the pampiniform plexus of spermatic veins
    • inc-
    • 15-20% post-pubertal males
    • common spot-
    • 70% left, 30% bilateral
  50. varicocele
    sx
    PE
    • sx-
    • dull, aching, unilateral scrotal pain
    • worse standing, relieved by lying down
    • PE-
    • testicular atrophy
    • sperm concentration & motility reduced by 75%
    • poss compromised fertility
  51. varicocele
    DX
    TX
    • DX-
    • U/S if there is a question
    • semen analysis
    • TX-
    • scrotal support
    • NSAIDS
    • surgical TX ligating gonadal vein to stop retrograde blood flow
  52. varicocele
    referral warranted if...
    younger males for infertility, testicular atrophy
  53. varicocele
    DONT miss...
    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
  54. spermatocele
    definition...
    size?
    where is it?
    AKA?
    • painless, fluid filled sac
    • size varies 1-5cm
    • location- arise from epididymis, located superior to testes
    • AKA- epididymal cyst 0.5mm-1cm
  55. spermatocele
    PE
    DX
    Ed
    TX
    • PE- 1-5cm mass palpated distinct from testis
    • DX- U/S
    • Ed- assurance
    • TX- scrotum support, NSAIDS, rarely need surgery
  56. communicating hydrocele
    common when?
    secondary to...
    • 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
  57. communicating hydrocele
    which could require surgery?
    persistent communicating hydroceles and presence of bowel content within the hydrocele sac
  58. hydrocele
    • peritoneal fluid between the parietal and visceral layers of tuncia vaginalis
    • small to massive
    • idiopathic
  59. hydrocele
    HX
    SX
    • HX-
    • slow accumulation
    • trauma or infection
    • infants w/communciating patent processus vaginalis
    • SX-
    • pain and disability inc with size
    • illuminates w/penlight
  60. hydrocele
    TX
    • TX-
    • refer to urologist
    • U/S
    • surgical excision of sac
  61. testicular CA
    stats...
    • stats-
    • most common CA between 15-35yrs
    • most curable
    • 95% survival rate at 5yrs
  62. testicular CA
    risk factors...
    • cryptorchidism
    • personal, family HX
    • infertility, subfertility
    • HIV
    • White>AA   (4:1)
  63. testicular CA
    SX
    • PE-
    • painless, hard nodule
    • dull ache in groin
    • pain w/hemorrhage after trauma
  64. testicular CA
    mets common in 10%, where...
    • supraclavicular LN
    • cough
    • gynecomastia
  65. testicular CA
    PE
    • 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
  66. testicular CA
    imaging
    • imaging-
    • U/S: immediate referral to urologist; phone call to MD; educate
    • CT pelvis/abdomen
    • CXR
  67. testicular CA
    labs
    • serum beta HCG
    • alpha feta protein
    • LDH
  68. testicular CA
    pathology
    • seminoma (95%)- trophoblastic cells
    • spermatocytic seminoma- w/sarcoma
    • nonseminomatous germ cell tumors (5%)- embryonal, yolk sac
  69. testicular CA
    TX
    PX importance
    • 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
  70. prostate CA
    stats...
    • 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%
  71. prostate CA
    screening
    • 1. PSA-
    • glycoprotein produced by prostate epithelial cells
    • not as prognostic if pt has BPH
    • 2. DRE
  72. prostate CA
    PSA levels (<4 normal)
    • 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
  73. prostate CA
    other causes of elevated PSA
    • BPH
    • acute prostatitis
    • prostate BX
    • cystoscopy
    • TURP
    • urinary retention
    • DRE=minimal
    • ejaculation
  74. prostate CA
    PSA and referral
    • 1. normal 0-4 BUT if notice on DRE:
    • tissue firmness
    • nodule
    • 2. PSA >7 (7-10 is good indicator of CA)
    • 25%
  75. prostate CA
    DX
    • DX-
    • U/S guided prostate BX
    • CT staging, bone scan
    • Gleason scores- primary grade + secondary
    •                                          3 + 4=7 better
    •                                          4 + 3=7 worse
  76. prostate CA
    degree of malignancy
    • varies within the stage
    • A- confined to prostate
    • B- confined to gland
    • C- local extension
    • D- regional LN or distant mets
  77. prostate CA
    active surveillance w/selective delayed therapy
    (low risk CA)
    • stage T1b, T1c, T2a, T2b at time of DX
    • diagnostic BX Gleason score <6
    • PSA </=10
  78. prostate CA
    PSA prediction/findings
    • pathologic organ-confined dz found in:
    • 80% PSA <4
    • 66% if PSA 4-10
    • <50% if PSA >10
  79. prostate CA
    TX
    • TX-
    • DaVinci prostatectomy/open prostatectomy
    • radiation XRT
    • hormonal (LHRH, antiandrogrens)
    • orchiectomy
  80. prostate CA
    recommendations for screening
    • 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

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