Men's Health

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Men's Health
2011-05-05 14:54:08
DPAP2012 Men Health

Men's Health
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  1. Men’s Health History
    • Sexual Preference
    • Gender Identity
    • Relationship Status
    • Sexual Activity
    • Sexual Response/Function
    • Penile Discharge or Lesions
    • Scrotal Pain, Swelling, or Lesions
    • History of Sexually Transmitted Infections (STIs)
    • Testicular Self Examination
    • Urological Review of Systems
    • Change in Bowel Habits
    • Stool Characteristics
    • Pain with Defecation
    • Rectal Bleeding or Tenderness
    • Anal Warts or Fissures
    • Family History of Polyps
    • Family History of Colorectal Cancer
  2. Penis Evaluation
    • Patient Position: Supine or Standing
    • Inspection: Skin, Prepuce, Glans, Urethral Meatus, Shaft, & Base
    • Document: skin, discoloration, circumcision, prepuce retraction/replacement, urethral position, urethral discharge
    • Palpation: Glans to inspect for urethral discharge, Any Abnormal Areas
    • Document: induration, tenderness
  3. Scrotum Evaluation
    • Patient Position: Supine or Standing
    • Inspection: Skin & Scrotal Contours
    • Document: skin, discoloration, contours, degree of testicular descent, Transillumination of any swollen areas
    • Palpation: Testis, Epididymis, & Spermatic Cord
    • Document: size, shape, consistency, tenderness
  4. Hernia Evaluation
    • Patient Position: Standing then Supine
    • Inspection: Inguinal Regions, Genitalia
    • Document: bulging, asymmetry, changes w/ straining, changes w/ supine positioning
    • Palpation of Inguinal Canal: (External Ring) Superior & Lateral to the Pubic Tubercle; (Internal Ring) 1cm Above Midpoint of the Inguinal Ligament
    • Palpation of Femoral Canal: (Location) Inferior to Inguinal Ligament, Medial to Femoral Artery & Vein
    • Document: bulging, masses, location, changes w/ straining, changes w/ supine positioning
  5. Inguinal Lymphatics
    • Patient Position: Standing
    • Inspection
    • Palpation: Superficial Inguinal Nodes
    • Horizontal Group Location: Anterior Thigh Below Inguinal Ligament
    • Drainage: Lower Abdomen & Buttock, External Genitalia (except Testes), Anal Canal, and Perinanal Area; Lower Vagina
    • Vertical Group Location: Deeper Thigh Near Upper Part of the Saphenous Vein
    • Drainage: Portions of the Lower Extremity
  6. The Cremasteric Reflex
    • Evaluates Genitofemoral Nerve (L1-L2)
    • To Elicit: gently brush the superior medial portion of the thigh
    • Normal Response: ipsilateral contraction of the cremasteric muscle (elevation of scrotum & testes)
    • Abnormal Response: no ipsilateral contraction of the cremasteric muscle (absent). Indicates testicular torsion, L1-L2 cord injury, upper or lower motor nerve injuries, and less commonly epididymitis
    • The cremasteric reflex is almost always absent in patients with testicular torsion, and its presence may help to distinguish other causes of acute scrotal pain from testicular torsion.
    • Several studies indicate that the presence of a cremasteric reflex in the acute scrotum is unlikely to be testicular torsion.
  7. Evaluation of the Anus
    • Patient Position: Left Lateral Decubitus or Upright Forward Flexion
    • Inspection: Perianal, Sacrococcygeal Areas
    • Document: lumps, ulcers, inflammation, rashes, excoriations
    • Palpation: Any Abnormal Areas
    • Document: lumps, tenderness
  8. Evaluation of the Rectum
    • Patient Position: Left Lateral Decubitus or Upright Forward Flexion
    • Palpation
    • Process: Ask patient to strain down, Place pad of lubricated finger over the anus, When sphincter relaxes, gently insert fingertip into anal canal as far as possible, pointing toward umbilicus
    • Note: Sphincter Tone, Tenderness, Induration, Nodules
    • Tenderness: Do NOT Palpate Further, Inspect Anal Canal While Patient is Straining
    • Note: Cutaneous Lesions (fissures)
  9. Prostate Evaluation
    • Patient Position: Left Lateral Decubitus or Upright Forward Flexion
    • Palpation
    • Process: Rotate finger in the anal canal 180 degrees
    • Posterior Surface of the Prostate: Size, shape, consistency, lateral lobes and median sulcus. Most common area for prostate cancer
    • Note: Tenderness, Induration, Nodules
  10. Define erectile dysfunction (ED)
    The consistent or recurrent inability of a man to attain and/or maintain an erection sufficient for sexual performance
  11. ED Prevalence
    • (MALES) study found prevalence of 16%, 22% in US (Men ages 20-75 yrs.).
    • Affects nearly 30 million American men
  12. ED as a marker of vascular disease
    Men with ED have a greater risk of a cardiovascular event than men without ED.
  13. ED and CVD
    • ED usually precedes the onset of angina by 2-3 years.
    • ED usually precedes adverse cardiovascular events by 3-5 years.
    • Men with ED should undergo a thorough cardiovascular evaluation with investigation of cardiac risk factors.
  14. Physiology of erection
    • Neurovascular phenomenon. Sexual stimulation leads to parasympathetic nervous system enhancement of production of cyclic guanosine monophosphate (cGMP) via nitric oxide.
    • Smooth muscles relax and blood flows into the penis.
    • Filling of the penis, compresses outflow of blood via the veins.
  15. Medications that may cause ED
    • Diuretics: thiazides, spironolactone
    • Anti-HTN: CCB, BB, methyldopa, clonidine, reserpine, guanethidine
    • Cardiac or cholesterol meds: digoxin, gemfibrozil, clofibrate
    • Antidepressants: SSRI, TCA, lithim, MAOI
    • Tranquilizers: butyrophenones, phenothiazines
    • H2 agonists: ranitidine, cimetidine
    • hormones: progesterone, estrogen, corticosteroids, LHRH, 5-alpha-reductase inhibitors, ciproterone acetate
    • Cytotoxic agents: methotrexate
    • Immunomodulators: interferon-a
    • Anticholinergics: disopyramide, anticonvulsants
    • Recreational drugs: alcohol, cocaine
  16. Potential causes of ED
    • Physical Causes:
    • Vascular (leading cause) marker of endothelial dysfunction,
    • Cavernosal,
    • Neurologic,
    • Hormonal Causes.
    • Psychological Factors
  17. Lab Exam for ED
    • Consider Testosterone if decreased libido.
    • Older patients (or others where indicated) do lipid panel and fasting blood glucose.
    • Targeted tests in select patients include PSA and Prolactin.
  18. Treatment for ED
    • Identify and Treat Organic Comorbidities and other risk factors.
    • Counsel and Educate the Patient and Partner.
    • Identify and Treat any Psychosexual Dysfunctions. Medications and Devices
  19. Medications for ED
    • Phosphodiesterase Type 5 (PDE-5) Inhibitors:
    • Sildenafil (Viagra)
    • Tadalafil (Cialis)
    • Vardenafil (Levitra).
  20. Use of PDE-5 inhibitors
    • All three similarly effective. 75% of men on medications have satisfactory erection to complete intercourse.
    • Still require sexual stimulation to have erection.
    • Sildenafil’s absorption may be reduced by foods – especially fatty foods.
    • Expect maximal efficacy in 1 hour (2 hours after tadalafil).
    • First few doses may not be successful – try 6-8 times before giving up.
  21. PDE-5 inhibitors Side Effects and Contraindications
    • Side effects: Headache, Indigestion, Flushing, Nasal congestion, Blue hue to vision.
    • Contraindications: Not to use with nitrates (including amyl nitrate). Not to use if severe CV disease. Cautious use of vardenafil if has prolonged QT. Care if on alpha blocking agents – may cause significant hypotension.
  22. Yohimbe
    • From bark of the yohimbine tree in Central Africa.
    • Traditionally used to treat all forms of impotence.
    • Believed to work through the Central Nervous System.
    • An alpha2 adrenoreceptor blocker.
    • Metaanalysis shows yohimbine superior to placebo.
    • Relatively safe medication
  23. Surgery for ED
    • Implantation of prosthesis (semi-rigid and inflatable).
    • Balloon dilation of proximal arteries.
    • Bypass procedure for distal artery occlusion.
    • Ligation of veins if venous problem.
  24. Lifestyle modifications
    Weight loss, Increase Exercise, Smoking Cessation
  25. Older Treatments for ED
    • Intracavernosal Injection,
    • Vacuum Constriction Devices,
    • Intraurethral Alprostadil Suppositories,
    • Inflatable Prosthesis,
    • Vascular Surgery
  26. Why ED treatments fail
    • Food or Drug interactions,
    • Timing of Dose,
    • ?Maximal Dose,
    • Lack of Sexual Stimulation,
    • Heavy Alcohol Use,
    • Relationship Problems
  27. Classifications of prostatitis and pelvic pain syndromes.
    • Acute Bacterial Prostatitis (2-5%),
    • Chronic Bacterial Prostatitis (2-5%),
    • Chronic Prostatitis and Chronic Pelvic Pain Syndrome (CPPS) (90-95%)
    • Can be Inflammatory or Noninflammatory, Asymptomatic Inflammatory Prostatitis often found when working up men for Infertility (See WBCs in the semen).
    • Concerns of Prostate Cancer (see in biopsy).
    • No treatment needed.
  28. Acute bacterial prostatitis
    • Least common form.
    • Easiest to diagnose.
    • May be life-threatening.
    • Consider this in septic males without an obvious source of infection.
    • Risk Factors: GU Instrumentation, Anal intercourse, Immunocompromised, Other comorbid conditions (Diabetes mellitus, Neurologic disorders associated with urinary system dysfunction).
    • Pathophysiology: May be sexually acquired, May be seeded by refluxed urine, May be hematogenously spread from distant source, May be spread by the lymphatic system, May be contiguous spread from adjacent infection.
    • Signs and Symptoms: Urinary Symptoms (e.g. frequency, urgency, dysuria, nocturia, change in urinary stream). Pain (lower back, genital, abdomen of urinary retention).
    • Systemic S/S: fever, chills, nausea, vomiting, hypotension, change in LOC
  29. Organisms associated with acute bacterial prostatitis
    • Gram Negative Organisms 80% of time (E. coli, Enterobacter, Serratus, Pseudomonas, Enterococcus, and Proteus).
    • N. gonorrhea and C. trachomatis in sexually active young men
  30. Work-up for Acute Bacterial Prostatitis
    • Urinalysis and urine cultures should be obtained.
    • Can culture urethral secretions if present.
    • Testing for GC and Chlamydia as indicated.
    • If septic, blood cultures.
    • If unresponsive to Abx, consider CT for abscess.
  31. Treatment for Acute Bacterial Prostatitis
    • Does the patient need to be hospitalized for IV antibiotics? (if toxic, consider other comorbidities).
    • Pain management.
    • May need urinary diversion if retention.
    • IV Antibiotics – Broad spectrum at first.
    • Oral antibiotics – usually fluoroquinolones for 2-6 weeks.
  32. Chronic Bacterial Prostatitis
    • S/S similar but less severe than in Acute Bacterial Prostatitis.
    • Not life-threatening. Symptoms can wax and wane in the patient.
    • Think of this with recurrent UTIs in men; almost always the same organism
  33. Chronic Bacterial Prostatitis Treatment
    • Prolonged courses of Antibiotics.
    • Usually Fluoroquinolones for 4-12 weeks.
    • Some consider long term low dose fluoroquinolones in recalcitrant cases.
    • Suppressive antibiotic treatment (Consider if 3 or more recurrences each year. ¼ to ½ treatment dose given at bedtime. TMP-Sulfa, tetracycline, amoxicillin and nitrofurantoin all used.)
  34. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CPPS)
    • Pain (urinary and/or genital) with no evidence of infection.
    • Inflammatory (presence of WBCs) and Non-Inflammatory Forms (later called Prostatodynia by some).
    • Must exclude Infection, GU Cancer, Urinary Tract Disease, Urethral Stricture, Neurologic Disease affecting the bladder.
  35. Chronic Prostatitis/CPPS
    • Pathogenesis is Unclear;
    • Theories include: Nanobacteria, Elevated Prostatic Pressures, Voiding Dysfunction, Pelvic Floor Myalgia, Functional Somatic Syndrome, Emotional Disorder.
    • Work-up: includes Imaging (Ultrasound, MRI), Biopsy, Bladder Tests (Cystoscopy, Flow Dynamics), Blood Tests.
    • Treatment: NSAIDs, Alpha Blockers, Muscle Relaxants, Finasteride, Antibiotics?, Sitz Baths, Lifestyle modifications, Physical Therapy with myofascial trigger point release therapy, Counseling, Relaxation techniques, Address Comorbidities
  36. Medications that Contribute to LUTS
    • Antihistamines: decreased parasympathetic tone
    • Decongestants: increased sphincter tone via alpha-adrenergic receptor stimulation
    • Diuretics: increased urine production
    • Opiates: impaired bladder contractility
    • TCAs: anticholinergic effects
  37. Benign prostatic hyperplasia (BPH)
    • Microscopic detection of prostatic hyperplasia (benign proliferation of stroma and epithelium).
    • Palpable enlargement of the prostate (DRE or by US imaging).
    • The collection of urinary symptoms associated with prostatic hyperplasia.
    • Histologic BPH increases linearly in age.
    • Present in 50% of men at age 60 years.
    • Present in 90% of men at age 85 years.
    • Only 50% of men with microscopic findings have macroscopic findings.
    • Only 30-50% of men with macroscopic findings have symptoms.
  38. BPH Symptoms
    • Bladder Storage Problems: Urgency, Frequency, Nocturia, Urge incontinence, Stress incontinence.
    • Bladder Emptying Problems: Voiding, Hesitancy, poor flow, intermittency, straining, dysuria, Postmicturition, Terminal dribble, postvoid dribble, incomplete emptying
  39. BPH Evaluation
    • Medications,
    • DRE (est. size, shape, symmetry, consistency),
    • Abdominal exam,
    • Focused neurologic examination,
    • Post-void residual (If greater than 100 mls consider referral).
    • Labs: Glucose, Electrolytes, Urinalysis, PSA in select patients
  40. Alpha-1 Antagonists
    • Non-Selective: Terazosin (Hytrin), Doxazosin (Cardura), Prazosin (Minipres)
    • Selective: Tamulosin (Flomax), Alfuzosin (Uroxatral)
  41. Medical therapy for BPH
    • Alpha-1-adrenergic blockers: Decrease muscle tone in stroma and capsule, Address dynamic component of disease, Most rapid symptom relief.
    • Androgen hormone inhibitors (5-alpha reductase inhibitors): Reduce prostate mass, Address static component of disease
  42. Surgical Interventions for BPH
    • Indications: Renal insufficiency, Urinary retention, Recurrent UTIs, Bladder calculi, Hydronephrosis, Large postvoid residual volume.
    • Options: Transurethral resection of prostate (TURP), Transurethral incision of prostate (TUIP), Open prostatectomy, Minimally invasive surgery, Transurethral laser-induced prostatectomy (TULIP), Transurethral needle ablation (TUNA), Transurethral microwave thermotherapy, Water-induced thermotherapy, Intraprostatic stents.
    • Outcomes: Erectile dysfunction (4-10%), Urinary incontinence (0.5-1.5%), 5 year recurrence rate of 2-10%
  43. Prostate Cancer Risk Factors
    • Age, Race (AA), High Fat Diet (+/-), Family History, Genetics, Obesity.
    • Not associated with smoking, sexual activity, prior infections or BPH.
    • Risk Reduction: Well-balanced diet, Physical activity , Weight control, Chemoprevention (? Aspirin, ? statins)
  44. Signs and Symptoms of Prostate Cancer
    • None in early disease.
    • Advanced disease: Obstructive urinary symptoms (similar to BPH), hematuria, hematospermia.
    • Common sites of metastasis: Bones! Neurological symptoms from spinal cord compression, Back pain / pathologic fractures.
    • Lymph nodes –inguinal. Lower extremity lymphedema .
  45. Prostate Cancer Screening
    • DRE (digital rectal exam): Nodularity or induration. Cancer typically arises in the periphery of the prostate. Detection rate varies from 1.5 – 7% (most are more advanced tumors).
    • Serum PSA: Protein produced by healthy & malignant prostate cells. Elevated in cancer, inflammation or BPH. Not diagnostic of cancer. Will rise as men age not more than 0.75ng/mL per year. Will be elevated in 10-15% of men screened.
    • Transrectal Ultrasound: No role as first-line screening tool. Used in staging & as guidance for biopsy to improve accuracy.
  46. PSA Controversy
    • Limitations: Not yet known if it reduces mortality. False positives and false negatives.
    • Overdiagnosis: Most prostate cancers are slow-growing & can exist for decades before they are large enough to cause symptoms. Treatments aren’t without significant side effects.
  47. PSA velocity
    Serial measurement--how quickly it rises over time. >0.75 ng/mL per year = ↑ likelihood of cancer
  48. PSA density
    serum PSA/volume of prostate by US. High density = ↑ likelihood of cancer
  49. Age-specific reference ranges
    Increases sensitivity & specificity. AA men have lower age-specific reference ranges.
  50. Compare free serum and protein-bound PSA levels
    Lower % free serum PSA = ↑ likelihood of cancer
  51. Prostate Screening and the USPSTF
    • Current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men under age 75 (Grade: I).
    • Recommends against prostate cancer screening in men older than age 75 (Grade: D).
  52. Prostate Screening If men decide to be screened
    • Normal DRE and PSA < 2.5ng/mL, repeat in 2 yrs.
    • Normal DRE and PSA 2.5-4.0ng/ml, repeat in 1 yr.
    • Approx 50% will progress to >4.0.
    • General rule of thumb = refer if PSA >4.0ng/mL or abnormal DRE .
  53. Prostate Cancer Diagnosis
    • Abnormal DRE or elevated PSA.
    • Prostate biopsy by TRUS (Hypoechoic appearance, 8 – 12 cores are sampled from apex, mid-portion and base of both lobes, Most commonly adenocarcinoma).
    • MRI PPV of finding capsular extension and invasion to seminal vesicles is similar to TRUS. Can detect lymphadenopathy.
    • No role for CT scanning.
    • Radionuclide bone scan detects bone metastasis. Consider if PSA >20, high-grade histology or bone pain.
  54. Prostate Cancer Staging: Gleason system
    • Tissue graded 1 – 5, based on appearance of cells.
    • Grade 1 = well-differentiated.
    • Grade 5 = poorly-differentiated.
  55. Gleason score
    • Calculated by adding primary & secondary grades.
    • Primary grade >50% of sample.
    • Secondary grade between 5-50%.
    • Scores range 2 to 10.
    • Indicates tumor aggressiveness & prognosis.
    • 2-4 = low grade, uncommon in clinically detected ca.
    • 5-7 = intermediate grade, most common.
    • 8-10 = high grade/aggressive.
  56. Prostate Cancer Treatment
    • < 10 yr life expectancy: Active surveillance.
    • >10 yr life expectancy: Active surveillance.
    • Surgery: Radical prostatectomy. Open vs laparoscopic, Cavernosal nerve sparing, Local recurrence uncommon, 2% urinary incontinence, 10% stress incontinence, Follow PSA’s postoperatively (should be zero).
    • Radiation. External beam (associated with cystitis and proctitis and progressive impotence) or brachytherapy (radioactive seeds). Other: hormonal therapy and cryotherapy.
  57. Prostate Cancer Advanced & Metastatic Disease Tx
    • Hormone therapy is mainstay. Androgen deprivation to decrease circulating levels of androgens available to prostate cells.
    • Rapid regression in prostate size, PSA levels and Improved symptoms (bone pain).
    • Side effects: Hot flashes, Osteoporosis, Impotence, Decreased facial hair, Weight gain, Loss of muscle mass, Gynecomastia
  58. Varieties of Hormonal Therapy
    • Luteinizing hormone-releasing hormone (LHRH) analogues (Lupron) Works at level of pituitary/hypothalamus to decrease testosterone production.
    • Antiandrogens (flutamide, bicalutamide) Can be used in conjunction with LHRH agents. Blocks prostate cell metabolism of androgens.
    • Ketoconazole, steroids Function to block adrenal androgen production.
  59. Penile Cancer
    • Rare in developed countries.
    • Neonatal circumcision reduces risk.
    • Squamous cell is most common.
    • Retract foreskin on PE…you must uncover to discover!
    • Prompt urological referral for biopsy of suspicious lesions.
    • Symptoms: Painless, non-indurated, ulcerated mass. Infection of lesion is common.
    • Location: glans penis, coronal sulcus, foreskin. Inguinal adenopathy. Begins as small lesion on the glans or prepuce that is non-healing, Subtle induration. Obscured by foreskin and can grow undetected. Untreated cases may result in auto-amputation.
    • Surgery: “gold standard” for rapid definitive treatment of the primary tumor. Penile or glans-sparing procedures with low grade tumor. Range of procedures from minimally invasive to total penectomy.
  60. Testicular Cancer
    • Most common solid tumor in men age 15-34.
    • Slightly more common on right vs left. 90-95% are germ cell tumors.
    • Risk Factors: Cryptorchidism /undescended testicle (5%), 5-10% will occur in unaffected testicle, Surgery doesn’t alter risk, Highest risk for intra-abdominal testis, Lowest for inguinal testis.
    • Abnormalities in spermatogenesis and often found during work up for male-factor infertility.
    • Family history.
    • Previous personal history of testicular cancer.
  61. Testicular Cancer
    • Firm, painless mass arising from testis.
    • May present as acute scrotum-10%.
    • Tumor hemorrhage.
    • Up to 33% are treated for epididymitis.
    • 2-3% with bilateral involvement.
    • 10% asymptomatic.
  62. Testicular Cancer Advanced disease-10%
    • Cough—lung mets.
    • GI symptoms—mass.
    • Back pain—retroperitoneal mets.
    • Neurologic –brain mets.
    • Supraclavicular lymphadenopathy
  63. Testicular Cancer Diagnosis
    • Scrotal Ultrasound: Distinguishes from benign scrotal disease. Determines intra vs extratesticular. Confirmed by excisional biopsy with inguinal orchiectomy.
    • Pathology: Vast majority are germ cell tumors.
    • Staging: Serum tumor markers, B-HCG, AFP, LDH. HCG elevated in choriocarcinoma, embryonal carcinoma and 15% of seminomas. AFP elevation excludes diagnosis of seminoma. Secreted either by primary tumor or metastasis.
    • CT scans—chest, abdomen, pelvis. Retroperitoneal lymph nodes are most common site of regional metastasis. Lungs & mediastinum most common distant mets.
  64. Inguinal Orchiectomy
    • High ligation of the spermatic cord. Tumor markers are evaluated prior to orchiectomy.
    • Should decrease post-op.
    • ↑ STM post-orchiectomy requires chemotherapy.
  65. Seminomas
    • Radio-sensitive.
    • Stage I & IIa need retroperitoneal radiation.
    • Bulky Stage IIb & III need chemotherapy.
  66. Non-seminomas
    • 75% of Stage I are cured by orchiectomy alone.
    • Many can be monitored closely for recurrence.
    • Majority diagnosed at more advanced stages.
    • Platinum-based chemotherapy is standard.
  67. Testicular Cancer Prognosis
    • Testicular cancer is often curable.
    • Consider sperm banking prior to treatments.
    • Seminomas: up to 98% alive at 5 years in early stages, 55-80% in advanced disease.
    • Non-seminomas: 96-100% alive at 5 years in early stage, 90% in advanced disease.
  68. Mumps orchitis
    • Mostly in children and adolescents.
    • Paramyxoviral disease spread by respiratory droplets.
    • Spring (14-21 days incubation).
    • Abrupt/high fever accompanies orchitis.
    • Testicular swelling and tenderness (unilateral in 75% of cases).
    • Testes most common extrasalivary site of disease in adults.
    • Develops 7-10 days after the onset of parotitis in about 25-40% of postpubertal men.
    • Sterility rare. Higher with bilateral orchitis.
    • Tx: Treated symptomatically with bed rest, NSAIDs, testicular support, ice packs. Pain relief may require opioids. Injecting spermatic cord with 1% procaine solution. Admit if priapism or severe pain.
    • Etiology: Usually N. gonorrhoeae or C. Trachomatis in sexually active heterosexual men < 35 years. Enterobacteriaceae > 35 years (older men with voiding dysfunction).
  69. Epididymitis
    • Common inflammatory/infectious condition that can be acute, subacute or chronic. Subsequent to STI or urinary tract infection (UTI), irritative urine reflux in acute or chronic states.
    • Complications: oligospermia (low sperm count) and infertility.
    • Associated conditions: urethritis and hemospermia (blood in seminal fluid).
  70. Acute bacterial epididymitis
    • Relatively rare and can cause serious illness.
    • Subacute presentation is more typical.
    • Symptoms: Severe swelling, Exquisite pain involved side, High fever, Rigors, Irritative voiding symptoms.
    • Cause: Commonly seen in conjunction with acute prostatitis (in older men). Recent instrumentation is a risk factor. Prepubertal boys who present with recurrent epididymitis should be evaluated for structural abnormality of the urinary tract. Chlamydia trachomatis most common organism in men under age 35. E. coli> 35.
    • Risk factors: Sexual activity, Heavy physical exertion, Bicycle or motorcycle riding.
    • Tx: Treatment varies according to severity. Acutely febrile, septic, hospitalization for IV fluids, parenteral antibiotics. Less severe treated with oral antibiotics. Ice, scrotal elevation, NSAIDs. Prevention of sexually transmitted infections.
  71. Noninfectious epididymitis
    Thought to occur due to reflux of urine through the ejaculatory ducts and vas into epididymis producing a chemical inflammation with resultant swelling causing ductal obstruction. Typical inciting factors include prolonged periods of sitting, vigorous exercise. Treatment conservative with scrotal support, rest, NSAIDs and possibly antibiotics.
  72. Hydrocele
    • Fluid collection in scrotum or spermatic cord. Pain secondary to size.
    • CC: scrotal mass (may be asymptomatic).
    • PE: soft, painless, cystic scrotal mass usually anterior to testis, occasionally bilateral, transilluminates.
    • Tx: usually unnecessary
  73. Varicocele
    • Dilated vein of spermatic cord.
    • More common on left side.
    • Valve insufficiency in ipsilateral gonadal veins.
    • Oligospermia and/or asthenospermia (weak sperm—increased temperature).
    • Occasionally painful, dull, heavy sensation in scrotum.
    • Infertility.
    • Increased symptoms with prolonged standing and improvement when supine.
    • “Bag of worms” appearance Increases with Valsalva and decreases in supine position.
    • Symptomatic treatment with scrotal support, analgesics.
  74. Torsion of appendix testis
    • Acute onset of pain, younger boys.
    • Point tenderness early.
    • Blue dot sign diagnostic (caused by infarction and necrosis).
    • Pain lasts for several days to months.
    • Management may be operative or non-operative.
    • Rest, ice, NSAIDs.
  75. Testicular Torsion
    • Surgical emergency! Correction within 4-6 hours.
    • Pubertal boys (12-15), early adults (19-22).
    • Torsion significantly more common in cold season.
    • Cause: Rapid movement or physical trauma. Sudden twisting of spermatic cord (usually twists internally). Strangulation of vessels and infarction.
    • Symptoms: Patient presents with scrotal pain, nausea, vomiting, abdominal pain. Awaking with scrotal pain in the middle of the night (particularly in children).
    • PE: Tender testicle, may have scrotal swelling or tender epididymis. Elevated testis (high-riding testis on affected side). Scrotal edema, possible discoloration. Prehn’s sign is not reliable (elevation of testicle leading to change in pain to differentiate from epididymitis). Absent cremasteric reflex most sensitive physical finding for diagnosing testicular torsion.
    • Diagnostics: Color Doppler ultrasound useful adjunct in evaluation of acute scrotum when physical findings are equivocal.
    • Prognosis: time available for testis salvage decreases with increasing number of turns (about 6 hours with 1 turn, 2 hours with 3 turns).
  76. STIs in Males
    • Non-specific urethritis, assume chlamydia.
    • Non-gonococcal urethritis (NGU) is the most common male presentation to STI clinic.
    • Men age 25-34 years.
    • Urethral discharge, Milking urethra, Itching, Dysuria, Spontaneous discharge of fluid from urethral meatus (especially after holding urine in NGU)
  77. Lymphogranuloma venereum (LGV)
    • Chlamydia Trachomatis.
    • Most common in Asia, South America, Africa and Men who have sex with Men.
    • Three phases: Shallow painless ulcer, Painful adenopathy, Buboes
  78. Gonococcal Infections
    • Neisseria gonorrhoeae: Urethritis. Second most common notifiable infectious disease in US.
    • Can affect the Conjunctiva, Pharynx, Rectum/Anus.
    • Symptoms: Dysuria, Purulent discharge, 50% Asymptomatic, Rectal pain (proctitis), Fever (proctitis)
  79. Trichomoniasis
    Trichomonas vaginalis: Lives in male urethra. Men usually asymptomatic but 10% get urethritis
  80. Herpes Genitalis
    HSV-2 and HSV-1. Pain, pruritus, soreness, external dysuria, Inguinal adenopathy. Painful, vesicular lesions
  81. Syphilis
    Treponema pallidum: Lives in genital tract. Single painless chancre or papule
  82. Chancroid
    H. ducreyi: Multiple painful genital ulcerations. Acute always painful. Ragged red, excavated
  83. Granuloma Inguinale
    Chronic painless ulcers. Small papule quickly ulcerates to beefy-red
  84. Condyloma acuminatum
    • HPV (types 6, 11 most common but > 50 subtypes).
    • Sexual skin-to-skin contact.
    • Recurrent raised lesions usually asymptomatic-pink verrucous papules.
    • Cauliflower-like mass
  85. Testicular Pain Differential
    Torsion-EMERGENCY, Epididymitis/Orchitis, Hydrocele, Varicocele, Trauma, Tumor
  86. Varicoceles
    • Classically described as abnormal dilation of the veins of the pampiniform plexus
    • Physical examination reveals the classic bag of worms, testicular atrophy, and tender scrotal contents
    • Commonly left sided
  87. Epididymitis
    • A clinical syndrome the produces fever, acute scrotal pain, and swelling as a result of inflammation and infection of the epididymis
    • Caused by retrograde bacterial spread from bladder to urethra
    • In men < 35 most frequently caused by gonococcus and chlamydia
    • In men > 35 most frequently caused by E. coli and other coliforms
    • Differentiate between testicular torsion and epididymitis by scrotal ultrasound with Doppler flow
  88. Hydrocele
    • A serous fluid collection within the parietal and visceral layers of the tunica vaginalis of the scrotum
    • Usually present with heaviness in the scrotum, scrotal pain, and an enlarging scrotal mass
  89. What are the arteries supplying the testicles
    Testicular artery, vasal artery, cremasteric artery
  90. How are the arteries supplying the testicles transmitted to the testicles
    Via the spermatic cord
  91. Genital Herpes
    • Multiple painful vesicles on erythematous base, tender/soft adenopathy often bilateral, fever
    • Incubation period for HSV 2-7 days
    • Primary lesions of HSV last 7-14 days
    • Genital recurrence in 60% of patients
  92. Syphilis
    Incubation period 10-90 days (mean 21 days)
  93. Chancroid
    Vesicle or papule to pustule to ulcer, soft, not indurated, very painful.
  94. What is the most common extra salivary site of mumps in adults
    Testes (testicular swelling and tenderness)
  95. Signs and Symptoms of Epididymitis
    • Scrotal pain, urinary frequency/urgency/dysuria, urinary retention, nausea, fever and chills, ab or flank pain, urethral discharge
    • Edematous tender epididymis, erythematous scrotum, edematous scrotum, usually unilateral (90%)
  96. Prehn sign
    Decreased pain with scrotal elevation or support (epididymitis)
  97. Supportive care for epididymitis
    Scrotal elevation and support, ice pack, spermatic cord block
  98. Orchitis
    • Acute inflammatory reaction of the testis secondary to infection
    • Most cases of orchitis are associated with Viral mumps
    • Enlarged/indurated/tender/erythematous/edematous scrotal skin, soft boggy prostate, parotitis, fever
    • Supportive care: bed rest, scrotal support, warm or cold packs for comfort, analgesics
  99. Imaging test of choice for the evaluation of an acute scrotum
    Color Doppler ultrasound
  100. Testicular torsion
    • Sudden onset of sever pain (as if a switch had been flipped), patient appears very uncomfortable
    • Ischemia from torsion can occur as soon as 4 hrs and is almost certain after 24 hrs.
    • Salvage rate is highly dependent on speed of detorsion with a 90% salvage rate if done in < 4
    • Most cases of testicular torsion occur in boys aged 12-15yo and 19-22yo
    • With scrotal trauma if pain lasts more than 1 hr after the trauma the testicle should be evaluated for possible trauma induced torsion
    • The testis may appear higher in the affected scrotum with an abnormal transverse lie, the affected testis may also appear larger, the cremasteric reflex is absent (99% sensitive)
    • Any patient with a history and physical examination suspicious for torsion should have immediate surgery
    • Orchiopexy of other testes recommended to prevent likely future torsion
  101. Nongonococcal Urethritis (NGU)
    Incubation period 4-14 days
  102. NAATS (ligase chain reaction and PCR)
    The preferred test for Chlamydia, more sensitive than traditional culture methods
  103. Gonorrhea incubation period
    2-6 days
  104. Purulent penile discharge, dysuria, erythematous meatus
  105. Test of choice for Gonorrhea
  106. What is the most common ulcerative STD
    Genital herpes
  107. One or more painful ulcers, with painful adenopathy, with no evidence of syphilis, or herpes simplex
  108. Beefy red appearance, bleeds easily, painless, progressive ulcerative lesions without regional lymphadenopathy
    Granuloma inguinale (donovanosis)
  109. Donavan bodies
    Identify granuloma inguinale on tissue crush prep or biopsy
  110. Lymphogranuloma Venereum
    Tender inguinal and or femoral lymphadenopathy, typically unilateral, a self limited genital ulcer or papule sometimes occurs (C. trachomatis)
  111. Cause of Most Cases of ED
    • Organic rather than psychogenic
    • The gradual loss of erectile function over a period of time is more indicative of organic causes of erectile dysfunction
    • Psychogenic causes < 15%
  112. The neurotransmitters that initiate and contribute to male erection include
    Nitric oxide, vasoactive intestinal peptide, acetylcholine, and prostaglandins
  113. A loss of libido may indicate
    Androgen deficiency on the basis of either hypothalamic, pituitary, or testicular disease.
  114. Loss of erections may result from
    Arterial, venous, neurogenic, or psychogenic causes
  115. Medications Associated with ED
    • 25% may be drug related
    • Antihypertensives, Antidepressants
    • Centrally acting sympatholytics (methyldopa, clonidine, reserpine)
    • Beta blockers, and spironolactone may result in loss of libido
    • Vasodilators, alpha blockers, and diuretics rarely alter erections
  116. Delaying Ejaculation
    Clomipramine 25 mg prior to intercourse
  117. Labs to Evaluate Erectile/Sexual Dysfunction
    • CBC, U/A, lipids, serum testosterone, glucose, prolactin
    • If a patient has abnormal levels of testosterone or prolactin then test LH, and FSH to help localize the site of the disease to the hypothalamus, pituitary, or testes
  118. Initial Point in Pathway Leading to Erection
    • Sexual stimulation (psychogenic or tactile)
    • Causes release of NO by the cavernous nerves into the neuromuscular junctions.
    • To achieve an erection decreased smooth muscle Ca+ concentration leads to muscular relaxation, cavernosal artery dilation, and increased blood flow.
  119. Most Common Endocrine Disorder Associated with ED
    • Diabetes mellitus
    • Loss of function of long autonomic nerves
  120. Because of the uncommon occurrence of __ conditions in persons seeking treatment of ED, testing of theses axes is not part of the routine workup of ED
    thyroid and adrenal
  121. Atherosclerotic Arterial Narrowing and ED
    90% of patients with ED respond to injected vasodilatory agents indicating that this is not the cause of most cases of ED
  122. Afferent somatic sensory signals are carried from the penis via the __
    pudendal nerve to S2-S4
  123. The paired cavernosal nerves penetrate the corpus cavernosa and innervate the __
    Cavernous artery and veins
  124. Sympathetic innervation originates in the intermediolateral gray matter at what levels
    Thoracolumbar levels T10-L2
  125. Penile prosthesis
    Most effective long term option for impotence treatment
  126. Lower urinary tract symptoms can be divided into what two categories
    Obstructive voiding symptoms and irritative voiding symptoms
  127. Dihydrotestosterone
    Hormone is believed to be responsible for the development and maintenance of the hyperplastic cell growth characteristics of BPH
  128. The development of BPH occurs predominantly in the __
    • Periurethral prostatic tissue referred to as the transition zone
    • Tissue growth in the transition zone of the prostate leads to bladder outlet obstruction
  129. What is the American Urological Association (AUA) symptom index for BPH
    • A self administered validated questionnaire consisting of seven questions related to the symptoms of BPH and bladder outlet obstruction (BOO)
    • 0-7 is considered mild
    • 8-19 is considered moderate
    • 20-35 is considered severe
  130. Preferred 1st Line Treatment Option for Patients Diagnosed with LUTS from BPH
    Medical management
  131. What are the indications for surgery in a patient with LUTS from BPH
    Refractory urinary retention, hydronephrosis with/ without renal impairment, recurrent UTI, recurrent gross hematuria, or bladder calculi; renal insufficiency; large postvoid residual volume
  132. What is the driving factor for treatment of LUTS due to BPH
    The amount to which the patients symptoms are bothersome to him
  133. What are the most common prescribed medication for the treatment of LUTS associated with BPH
    Alpha-adrenergic antagonists (doxazosin, terazosin, tamsulosin, and extended release alfuzosin)
  134. This regimen is most effective in reducing symptoms and preventing disease progression in patients with large prostate glands (>40g)
    5a reductase inhibition (finasteride and dutasteride)
  135. What are the most widely used and studied phytotherapeutic extracts used for the treatment of LUTS associated with BPH
    Saw palmetto berry
  136. What is considered the gold standard for surgical treatment of BPH
    Transurethral Resection of the Prostate (TURP)
  137. TUMT
    Transurethral microwave thermotherapy, one of the most widely studied minimally invasive methods of treating symptomatic BPH
  138. TUNA
    Transurethral Needle Ablation
  139. What are the major benefits of the minimally invasive therapies for BPH (TUMT, TUNA) over the more invasive TURP
    The reduction in bleeding, fluid absorption, the risks associated with general or spinal anesthesia, decreased rates of incontinence, ED, bladder neck contractures, and urethral strictures, reduce hospital stay
  140. What is the success rate for the heat based minimally invasive therapies for BPH
    65-75% of patients with symptomatic reduction and flow rate improvement
  141. What procedure produces the greatest improvement in both urinary flow rates and symptom score for BPH
  142. What complications are all higher with TURP than the less invasive therapies for BPH
    Urinary incontinence, retrograde ejaculation, and urethral stricture
  143. Open surgical enucleation (prostatectomy)
    Reserved for patients with severely large prostate glands
  144. Prostatitis
    • Common clinical condition resulting in 25% of office visits to a urologist
    • Most common urologic dx in men younger than 50 years and is the third most common diagnosis in men older than 50 years
  145. Chronic Nonbacterial Prostatitis (CPPS)
    Most common symptomatic type of prostatitis and may be the most prevalent of all the prostate disorders
  146. Symptoms of Acute Bacterial Prostatitis
    Fever, chills, dysuria, perineal and low back pain
  147. Treatment of Acute Bacterial Prostatitis
  148. Symptoms of Chronic Bacterial Prostatitis
    Nonspecific but include LUTS, pelvic pain and or sexual dysfunction
  149. Treatment of Chronic Bacterial Prostatitis
    Trimethoprim-sulfamethoxazole (TMP-SMX) or a fluoroquinolone are indicated for the treatment of CBP and must be tailored to the specific organism
  150. Patients with chronic nonbacterial prostatitis usually exhibit what symptoms
    • Pain: perineal, low back, suprapubic, groin, scrotal
    • Voiding dysfunction: dysuria, week stream, frequency, urgency, or nocturia
    • Sexual dysfunction: painful ejaculation or low libido
  151. Noninflammatory Chronic Pelvic Pain Syndrome (CPPS, aka prostadynia)
    • Typically seen in males age 20-50 years
    • Usually exhibit pelvic pain and voiding symptoms but have negative urine cultures, normal EPS, and normal prostate on DRE
  152. Recurrent UTI’s
    Associated with chronic bacterial prostatitis
  153. DRE findings with chronic bacterial prostatitis
    Normal prostate exam
  154. What are the symptomatic treatments for chronic bacterial prostatitis
    NSAIDS and Sitz baths
  155. Normal Prostate Size
    20g, walnut, 2 finger breadths on DRE
  156. Meares-Stamey 4 glass test is for:
    Chronic bacterial prostatitis
  157. Prostate cancer
    Most common cancer that occurs in men and the second leading cause of cancer death
  158. There is no association with prostate cancer and
    Smoking, sexual activity, or prior history of prostatitis or BPH
  159. There is histological evidence of prostate cancer in more than __% of men over the age of 60
  160. Men with a less than __ year life expectancy may not benefit from prostate cancer screening
  161. Men younger than __ years of age and in otherwise good health are recommended to have routine screening for prostate cancer
  162. Prostate cancer typically arises from what portion of the prostate
    Peripheral portion which can be palpated on DRE
  163. __ of the prostate on DRE should be considered suggestive of prostate cancer
    Induration or nodularity
  164. Increase in PSA greater than 0.75ng/mL per year
    Probably the most important prostate cancer diagnostic piece of information
  165. Gleason system
    System most often used to grade prostate cancer
  166. What is the most useful test in determining the local tumor extent with prostate cancer
  167. __ is of limited value and usually not indicated clinically for determining either local extent or nodal metastasis (prostate ca)
    CT scanning
  168. In patients with high grade tumors or a substantially elevated PSA, __ is indicated
    A bone scan
  169. What is the most common site of distant spread for prostate cancer
  170. What treatment for prostate cancer has the most proven ability for long term cure
    Radical prostatectomy
  171. Endocrine Manipulation and Prostate Cancer
    • Primary form of treatment for patients with advanced or metastatic carcinoma of the prostate
    • Goal is to deprive the cancer cells of serum androgens
  172. Testosterone declines to castrate values within __ after surgical orchiectomy and __ after administering an LHRH analog
    A few days, a few weeks
  173. Hormonal therapy to treat prostate cancer usually causes what AE’s with long term use
    hot flushes, osteoporosis, wt gain, loss of muscle mass
  174. The prognosis for patients with prostate cancer is poor when __
    The cancer shows evidence of progression despite hormonal therapy
  175. __ can sometimes provide palliation for metastatic progressive prostate cancer, but has not been shown to increase survival
  176. __ of the penis is an uncommon tumor in the united states and the rest of the developed world
    Squamous cell carcinoma
  177. Squamous cell carcinoma of the penis is diagnosed almost exclusively in __ men
  178. __ are not routinely recommended for penile cancer b/c physical examination has been proven to be the most accurate predictor of tumor stage
    Imaging studies
  179. A diagnosis of carcinoma of the penis is confirmed by __
    Histological evaluation of an excisional biopsy
  180. The prognosis for patients with distant metastatic disease or nodal metastasis above __ is poor
    Inguinal ligament
  181. With testicular cancer, as a result of effective surgery, radiation therapy and combination chemotherapy survival approaches __% for low risk disease and __% for high risk disease
    99, 80
  182. The most common solid malignancy in men age 15-34 years
    Testicular tumors
  183. __ is a well accepted risk factor for subsequent development of testicular carcinoma
  184. What is the most common presenting sign or symptom of testis cancer
    Firm painless mass arising from the testis
  185. Up to __% of patients with testicular cancer are treated for presumed epididymitis
  186. __ is diagnostic for testicular cancer
    Scrotal ultrasonography
  187. Testicular cancer is unique in that __ play an important role in tumor staging
    Serum tumor markers
  188. Which nodes are the most common site of metastasis for testicular cancer
    Retroperitoneal lymph nodes
  189. Chest x-ray or thoracic CT scanning completes the clinical staging of what cancer, b/c the lungs and posterior mediastinum are the most common sites of distant metastatic disease
    Testicular cancer
  190. __ is the standard of treatment for patients with advanced testicular cancer
    Platinum based chemo
  191. What population groups are at highest risk for developing prostate cancer
    Blacks, those with a family history of prostate cancer, high dietary fat intake
  192. What is the standard method for detection of prostate cancer
    Transrectal ultrasound guided biopsy
  193. Detection rates for prostate cancer with DRE alone vary from __%
  194. Most prostate cancers detected with DRE are __
    Advanced (stage T3 or greater)
  195. What is the serial measurement of PSA over time
    PSA velocity
  196. A rate of change in PSA greater than __ng/mL per year is associated with an increased likelihood of cancer detection
  197. The majority of prostate cancers are __
  198. Most primary testicular tumors are __ tumors
    Germ cell (seminoma and nonseminoma)
  199. The lifetime probability of developing testicular cancer is __% for an American white male
  200. With testicular cancer, acute pain resulting from intratesticular hemorrhage occurs in approximately __% of cases
  201. __ is never elevated with pure seminomas
    Alpha fetoprotein
  202. __ is occasionally elevated in seminomas
  203. How can prostate cancer lymph node metastasis present itself
    Lower extremity lymphedema
  204. What is the clinical presentation of advanced prostate cancer
    Bone pain/pathologic fractures, hematuria, hematospermia
  205. Gleason grades for prostate cancer >__ are associated with aggressive tumors
  206. Gleason grades for prostate cancer of __ are most common
    5 or 6
  207. What do you do for a patient with prostate cancer who already has a <10 year life expectancy regardless of the cancer (significant comorbidities)
    Watchful waiting
  208. What do you do for a patient with prostate cancer who has a >10 year life expectancy
    Curative therapy (radical prostatectomy)
  209. Post radical prostatectomy consider __ if PSA levels remain detectable
  210. What kind of outcome can be expected when treating localized prostate cancer with external beam radiation
    Outcomes comparable to radical prostatectomy
  211. What are some complications of external beam radiation used to treat prostate cancer
    Cystitis, radiation proctitis, impotence
  212. What is the method of action for anti-androgen therapy
    Blocks the cellular metabolism of androgen
  213. When would cryotherapy be used to treat prostate cancer
    For cancer cells resistant to radiation and hormonal therapy
  214. What are some contraindications for prostate cancer cryotherapy
    Prior TURP, extensive disease
  215. __ is not recommended by the USPSTF
    PSA screening
  216. What is the key etiologic factor in developing penile cancer
    Chronic inflammation and irritation
  217. What are some possible risk factors for penile cancer
    Lack of neonatal circumcision, HPV 16 & 18, tobacco use, poor hygiene
  218. What are the common locations for penile cancers
    Glans penis, coronal sulcus, foreskin
  219. What is the most important diagnostic test in the evaluation of penile cancer
    Lesion biopsy
  220. What are some organ sparing procedures for the treatment of penile cancer
    5 fluorouracil (topical), external beam radiation, Moh’s microsurgery, laser ablation, circumcision
  221. Of the two types of testicular cancers which one is the pure tumor, is most common and originates in the seminal vesicles
  222. Which serum tumor marker is elevated in most testicular tumors
    Beta hCG
  223. Which serum tumor marker is elevated in non-seminomas, and excludes a diagnosis of seminoma
  224. Which serum tumor marker is very non-specific, and is useful for monitoring advanced seminoma
  225. USPSTF: prostate
    insufficient evidence for/vs in men <75; men >75: harms outweigh risks
  226. USPSTF: testicular ca
    against routine screening in Asx
  227. PSA elevations can precede clinical dz by:
    5-10 yrs
  228. PSA index
    PSA density (PSA conc divided by PSA volume); higher may be assoc w/cancer
  229. Utility of free PSA
    helps distinguish prostate cancer from BPH in DRE-negative pts with borderline-high PSA
  230. Most common formula for prostate volume
    ellipsoid formula
  231. Acid phosphatase used for:
    Dx of prostatic ca; monitor tx w/ neoplastic drugs, esp in metastatic dz
  232. Acid phosphatase elevated in prostate:
    Adenocarcinoma; Manipulation; Inflammation; Hypertrophy
  233. Do not order acid phosphatase immediately after:
    DRE, TURP, or prostatic massage
  234. Acid phosphatase: specimen
    0.5ml serum separated & added to 10µl acid phosphatase preservative (pH 5) within 2 hours of collection
  235. Cystoscopy: risks
    Infection, bleeding, tear/perf, urinary retention, scar tissue, allergy to anesthetic, epididymitis/ orchitis
  236. TRUS: utility
    not useful as screening test; US alone cannot establish /exclude the dx; used to evaluate elevated PSA (to locate suspicious area for transrectal biopsy)
  237. TRUS not accurate in:
    determining local tumor extension
  238. Prostate bx: eval men with azoospermia to:
    rule out ejaculatory duct cysts or seminal vesicular cysts
  239. Prostate bx best performed with:
    a spring-driven needle core biopsy device (or biopsy gun)
  240. Complications of prostate bx
    hematuria, rectal bleeding, hematospermia, urosepsis, & perineal pain
  241. Testosterone: indications
    Hypogonadism (loss of libido, ED, gynecomastia, osteoporosis, infertility); delayed/ precocious puberty; monitor testost replacement tx or antiandrogen tx; eval ambiguous genitalia
  242. Hgb
    3 g/dL higher in men
  243. Uric acid
    2 mg/dL higher in men
  244. Testicular U/S: utility
    Inflam scrotum; epididymitis; hydrocele; absent/ undescended testicle; torsion; abnormal blood vessels; lump or tumor; most scrotal masses
  245. If testicular mass, first do:
    dx U/S
  246. Use _____ to differentiate torsion from epididymitis
    Doppler US
  247. Male infertility: most common etiologies
    varicocele (37%); idiopathic (25%)
  248. Male factors contribute what percent to infertility cases?
  249. Male infertility analysis: start with:
    semen analysis (if abnormal, look for exposure to toxins (environment, workplace, EtOH, drugs, hypogonadism)
  250. Semen analysis: specimen
    0.5 mL, room temp, no sex 2-3 (2-5?) days prior, macro & micro analysis within 1 hr
  251. Semen analysis: normal volume
    volume >2 ml
  252. Semen analysis: normal appearance:
    beige, opalescent
  253. Semen analysis: normal liquefaction:
    liquefied within 1 hour
  254. Semen analysis: normal pH:
  255. Semen analysis: normal motility:
    ≥ 50%, >50% forward progression
  256. Semen analysis: normal sperm concentration:
    ≥ 20 x 10(6)/ml
  257. Semen analysis: normal morphology:
    ≥ 50%
  258. Low sperm motility may be due to:
    antisperm Ab or infection
  259. Abnormal sperm morphology: may be due to:
    varicocele, infection, exposure history
  260. Low semen volume: may be due to:
    retrograde ejaculation or androgen insufficiency
  261. Elevated LH: causes
    Testicular dysfn; primary testicular fail; CNS dysfn; precocious puberty; postviral orchitis
  262. Decreased LH: causes
    Testicular tumors; secondary testicular fail; hypopituitarism; hypothalamic-pituitary dysfn
  263. FSH normal range
    1.5-14.0 mIU/mL
  264. Elevated FSH causes
    primary gonadal failure, testicular agenesis, alcoholism, gonadotropin-secreting pituitary tumors
  265. Decreased FSH causes
    Anterior pituitary hypofunction, hypothalamic disorders
  266. Limitation of FSH levels
    Pulsatile secretion throughout day (physiologic variation within reference range)
  267. Primary testicular failure: labs
    increased LH/FSH, decreased testosterone
  268. Secondary testicular failure: labs
    decreased LH, FSH, testosterone
  269. Steroid tx for:
    spontaneous autoimmunity; also genital infection, testicular obstruction, & IVF
  270. Sims-Huhner test
    During female LH surge, examine cervical mucus 2-8 hrs post coitus to evaluate sperm & quality of mucus
  271. Sims-Huhner test provides info about:
    number of sperm, progressive motility, morphology & interaction of spermatozoa with the cervical mucus
  272. Seminal plasma fructose: to evaluate:
    azoospermia with ejaculate < 1 ml
  273. Seminal plasma fructose MOA
    Fructose is produced in seminal vesicles (energy source); if absent in ejaculate, implies absence or obstruction of ejaculatory ducts
  274. Seminal plasma fructose: specimen:
    frozen seminal plasma
  275. Post-vasectomy testing: check sperm counts:
    After 20 ejaculations; 8-12 weeks post-vasectomy