Dunphy Chapt 13 Review
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What is the rate that man develope BPH?
Typically, 50% of men older than age 50 years of BPH, and the rate increases by 10% for every 10 years of age.
When might you suspect a psychogenic origin of frequent urination?
In men with an normal bladder, the absence of nocturia while suffering from increased frequency of urination during the day suggests psychogenic origin.
What may cause urinary retention?
Symapthomimetics such as ephedrine and pseudoephedrine.
What is oliguria?
Oliguria is a decrease in urine output and can be caused by decrease in production of urine secondary to acute glomerulnephritis or other renal disease or even secondary to low cardiac output..
Urgency can be constant or intermittent in is a desire to urinate.
Hesitancy refers to difficulty initiating a urine stream.
Describe the diagnostic workup for nocturia?
A simple urinalysis is performed to urinary tract infection. A prostate specific antigen blood test and a digital rectal exam are performed to rule out a prostate problem.
What does a patent processus vaginalis predispose a patient to?
Anterior and lateral to the testes, if the processus vaginalis remains patent it will form the tunica vaginalis, which represents a detached portion of the peritoneal cavity within the scrotum.
A painful hernia can occur when evagination of the peritoneal cavity is occluded by the adult spermatic cord.
What is the typical pain pattern of prostatitis?
Prostatitis usually occurs in the lower back and radiates to the testes and it is typically accompanied by fever.
Describe the position of the prostate gland?
The prostate gland is a walnut sized gland positioned at the base of the bladder and in front of the rectum.
In which part of the prostate is BPH typically develop?
In which part of the prostate does carcinoma typically develop?
BPH develops primarily in the transition zone, whereas carcinoma of the prostate usually develops in the peripheral zone.
Describe prostate anatomy?
- 1 . Periferal Zone
- 2. Central Zone
- 3. Transitional Zone
- 4. Anterior Fibromuscular Zone
What is the key androgenic hormone contributing to the pathogenesis of BPH?
Described it to documented mechanisms of structure and in the prostate?
Static constriction is caused by the buildup of prostatic tissue, with direct obstruction bladder neck.
Dynamic constriction and is an increase in prostatic muscle tone due to andrenergic stimulation, leading to construction of the bladder neck.
Describe how obstruction can lead to bladder failure?
Obstruction of the bladder forces applied to generate higher pressures to achieve urination. Increased muscle mass in the bladder leads to reduced bladder elasticity and compliance. This manifests as reduction in bladder capacity. The bladders smooth muscle begins to be replaced by connective tissue, leading to bladder failure.
What kind of receptors are located in the prostate and bladder neck?
The prostate and bladder neck contain alpha-1 and adrenergic receptors that cause prostate and bladder neck to contract when bound. Alpha blockade decreases this affect and results in objective and subjective improvement in BPH
Describe medications used to treat BPH?
- 1. Selective alpha1-adrenergic receptor blockers:
- prazosin (mini-press) / terazosin (Hytrin) /doxazosin (cardura)
- 2. Increasingly Selective to the prostate and bladder neck are the alpha1a-andrenergic receptor blockers:
- tamsulosin (flomax) / alfuzosin (UroXatral)
- 3. Meds used to decrease DHT by blocking the converstion of testosterone to DHT are th 5-alpha-reductase inhibitors.
- finasterid (Proscar)
- dutaseride( Avodart)
How do Avodart and Proscar work?
They were to reduce DHT, thereby decreasing prostate volume. Improvement may only be seen and men with very large prostates and may take up to 6 months
At what point may have patient consider prostate surgery?
Surgery is indicated when there is urinary retention or when other symptoms are intractable due to prostate obstruction as guaged by the AUA index.
Prostate surgery may be indicated within AUA index of greater than 8.
Describe the surgical procedure for prostate resection?
- TURP (Transurethral resection of the prostate) the surgical treatment of choice for patient with BPH. TURP is performed through a cystoscope, using a diathermy loop for section of prosthetic tissue.
- Symptomatic improvement to see 90% of patients. A catheter must remain in place for 36 to 48 hours of surgery.
When is an open prostatectomy considered the only surgical option?
When patient has failed medical treatment or when carcinoma of the prostate is suspected.
What is a TUIP?
Transurethral incision of the prostate. An instrument is passed through the urethra to make one or 2 cuts in the prostate and prostate capsule reducing urethral stricture.
What is a TULIP?
Transurethral laser induced prostatectomy. A type of coagulation necrosis Ablated tissue is sloughed off over 3 weeks to 3 months.
Advantage is that it is minimmally invasive, outpatient and can be performed on patients taking anti-coagulants.
Describe other methods to of ablate prostate tissue?
1. Tranurethral electrovaporization = Diathermy engery
2. TUMT - Tranurethral microwave thermotherapy
3. TUNA - Tranurethral needle ablation = uses radiofrequency
4. HIFU - High intensity focused ultrasound.
what is considered mild erectile dysfunction?
if the patient fails to achieve satisfactory errection 2 out of 10 times
Severe is 10 out of 10
What is Priapism?
Painful erection, usually idiopathic
What test would be ordered in evaluating ED?
- 1. Blood sugar
- 2. TSH
- 3. Lipid profile
- 4. Testoserone ( if less than 300 ng /dl order a prolactin level is warranted)
- 5. PSA
A nocturnal penile tumescence and rigidity test (NPTR) and color doppler of the penis maybe the most useful in evaluating physical ability to achieve erection.
Two conditions allow a normal NPTR, but still result in dysfunction - 1. Disruption of afferent nerves - bypassed during sleep and 2. Pelvic steal syndrome - blockage of illiac blood vessels leads to loss of erection during thrusting, but not during sleep.
Which is more common , bacterial prostitits or non-bacterial prostitis?
Chronic non-bacterial prostitis is more common. 8 x more likely.
Diffentiate between bacterial prostitis and non-bacterial?
Non-bacterial has smilar symptoms however bacterial always presents with UTI. There for urine culture is alwasy pos in bacterial.
What is the clinical presentation of prostitis?
The patient may present with tenesums ( a spasmotic contration of the anal sphinchter) with pain and a persistent desire to empty the bowel or bladder accompanied by involuntary and ineffective straining efforts.
Describe the different types of prostatitis?
Patients may present with acute bacterial prostatitis, chronic bacterial prostatitis, non-bacterial prostatitis, or prostatodynia.
Prostatodynia-The term prostatodynia, or chronic pelvic pain syndrome (CPPS), is used to designate unexplained chronic pelvic pain in men. This pain is associated with irritative voiding symptoms and/or pain located in the groin, genitalia, or perineum in the absence of pyuria and bacteriuria (no pus cells or bacteria seen on microscopic analysis of the urine).
How is bacterial prostatitis diagnosed via lab work?
WBCs and colonies are sought. A sample of urine and prostate secretions is taken.
Urethritis is diagnosed if 1st 10ml of urine expressed has highest number of WBCs and colonies of the three samples.
Cystitis is diagnosed if 2nd 10ml of urine expressed has highest number of WBCs and colonies of the three samples.
If prostatic sample is highest of the three, then chronic prostitis is confirmed.
T/F Chronic prostatitis, rectal exam may reveal a tender prostate, it is usually not swollen or boggy.
Differentiate a urine sample from a patient with non-bacterial prostatitis and with bacterial prostatitis?
The patient with nonbacterial prostatitis, will have wbc's in the urine of the culture will be negative.
Describe the management of a patient with acute prostatitis, and chronic prostatitis.
The main principle of mythical prostatitis is to treat the patient an outpatient basis if he does not have a fever.
Men with a turtle prostatitis will be treated for 4 to 6 weeks with quinolones as first line.
The best cure rates and chronic bacterial prostatitis are associated with treatment with Bactrim.
What is the primary treatment for prostatodynia?
The patient with prostatodynia is usually treated with alpha blockers to reduce bladder neck spasms.
Describe the major complaint of patients with epididymitis?
The major complaint of patients with epididymitis is scrotal pain often radiates along spermatic cord or to the flank.
A physical exam will reveal scrotal swelling and the testes may be indistinguishable from the epididymis. The scrotal wall will be thickened and indurated and a reactive Hydrocele may occur.
What is the peak age for testicular torsion?
14 years, most common ages between 10 and 20 years
What is the most common clinical sign of testicular torsion?
Abscence of the cremesteric reflex
The "bell clapper deformity" describes what?
A transverse lie of the testical, a variant from the normal longitudinal lie.
T/F Elevation of the testies relieves pain in testicular torsion?
False. Elevation of the testies relieves pain in epididymitis. This clinical finding is known as Prehn's sign.
What is the "blue dot sign"?
The blue dot sign describes the tightly pulled skin over over a small lump that is palpable over the superior pole of the testis. The lump may appear blue during torsion of the appendices of the testies and is the result of necrosis and infarction.
How is testicular torsion typically resolved?
Gentle manual reduction. Typically by EXTERNALLY rotating toward the thigh for 2/3 of cases.
Must be relieved in less than 6 hours to be 85-90% effective, although salvaged, 2/3s go on to atrophy
Releif of pain, resolution of the bell clapper deformity and restoration of blood flow are used as indicators of effective reduction.
Is infertility a risk if torsion of the tesicluar appendix leads to necrosis and re-absorbtion?
No, fertility is preserved.
How are hydroceles diagnosed?
Diagnosed by transillumination, testes and hemotomas do not transillluminate.
No treatment necessary unless fairly large and painful.
Describe the surgical procedures used to treat a hydrocele.
The Jaboulay-Wnkelmann surgical procedure is for thick hydrocele sacs.
The Lord procedure is used for a thin hydrocele sac.
The Radial suture is used to gather hydrocele posteriorly to the testes and epididymis.
The Tunica Vaginallis can be resected, or filled with a sclerosising agent to close.
Where are most vericoceles found?
Left Side. Right sided varicoceles may indicate seroius pathology.
What would you expect on physical exam of a varicocele?
In a recumbant position, venous dilitation will increase when performing a Valsalva manuver. Dilitation will also abate when recumbant and relaxed.
Describe the grading of a varicocelele?
- Grade I - Palpable only when performing valsalva
- Grade II- Palpable only when patient is standing
- Grade III - Assessed only with light palpation and inspection.
True/ False Varicoceles do not influence fertility?
False. 65-75% of the time, patients with varicoceles have decreased sperm counts.
What is a vericocele?
Abnormal venous dilitation of the Pampiniform plexus above the testes, which ususally results in pain and engorgement of the testes.
Bag of worms feel.
Should have surgical consultation, although surgery is rare because most varicoceles are minor. Surgical treatment of a varicocele involves ligation of the internal spermatic vein.
What type of carcinoma represent 95% of all prostate cancer?
acinar adenocarcinoma represents 95 percent of all prostate cancer.
Describe the rating system for measuring an enlarged prostate.
The prostate is 2-3 cm across and is roughly twice the width of the examining finger.
A slightly enlarged prostate is documented as +1 and is considered three finger-breadths across.
+2 = Twice the normal breadth.
+3 or 4 involves marked encroachment of the posterior rectal wall.
What does the Gleason score measure?
A Gleason score describes the architectural pattern of prostate CA.
Gleason score 1-4: Indicates a well-differentiated CA that is likely to be slow growing.
Gleason score 5-7: Indicates a moderately differentiated CA.
Gleason score 8-10: Indicates poorly differentiated CA cells that are likely to be agrresive and rapidly growing.
What are the standard treatment options for prostatet CA?
The standard treatment options for prostate CA include radical prostatectomy, radiation therapy, and wathful waiting.
If the patient is younger than 70, aggressive surgery is recomended for a prostate CA cure.
What is the main management for testicular CA?
The main principle management for testicular CA is radical orchidectomy, which is also the main diagnostic tool.
Describe staging of testicular carcinomas.
Staging is divided up into two catagories. non-seminomas and seminomas.
- Non-seminomas Germ Cell Tumor Staging:
- Stage A Lesion confined to testes
- Stabe B Regional lymph node involvement in retroperitoneum
- Stage C Distant METS
- *75% are cured with orchiectomy alone
- MD Anderson System for Seminomas
- Stage I Lesion confined to the testes
- Stage II Spread to retroperitoneal lymph nodes
- Stage III Supradiaphragmatic nodal or visceral involvement.
- Must have chemo and radiation, typically responds well
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