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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
- 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
- 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
- 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
- Patient Position: Standing
- 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
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.
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
Evaluation of the Rectum
- Patient Position: Left Lateral Decubitus or Upright Forward Flexion
- 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)
- Patient Position: Left Lateral Decubitus or Upright Forward Flexion
- 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
Define erectile dysfunction (ED)
The consistent or recurrent inability of a man to attain and/or maintain an erection sufficient for sexual performance
- (MALES) study found prevalence of 16%, 22% in US (Men ages 20-75 yrs.).
- Affects nearly 30 million American men
ED as a marker of vascular disease
Men with ED have a greater risk of a cardiovascular event than men without ED.
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.
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.
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
Potential causes of ED
- Physical Causes:
- Vascular (leading cause) marker of endothelial dysfunction,
- Hormonal Causes.
- Psychological Factors
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.
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
Medications for ED
- Phosphodiesterase Type 5 (PDE-5) Inhibitors:
- Sildenafil (Viagra)
- Tadalafil (Cialis)
- Vardenafil (Levitra).
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.
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.
- 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
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.
Weight loss, Increase Exercise, Smoking Cessation
Older Treatments for ED
- Intracavernosal Injection,
- Vacuum Constriction Devices,
- Intraurethral Alprostadil Suppositories,
- Inflatable Prosthesis,
- Vascular Surgery
Why ED treatments fail
- Food or Drug interactions,
- Timing of Dose,
- ?Maximal Dose,
- Lack of Sexual Stimulation,
- Heavy Alcohol Use,
- Relationship Problems
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.
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
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
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.
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.
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
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.)
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.
- 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
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
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.
- 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
- 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
- Non-Selective: Terazosin (Hytrin), Doxazosin (Cardura), Prazosin (Minipres)
- Selective: Tamulosin (Flomax), Alfuzosin (Uroxatral)
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
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%
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)
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 .
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.
- 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.
Serial measurement--how quickly it rises over time. >0.75 ng/mL per year = ↑ likelihood of cancer
serum PSA/volume of prostate by US. High density = ↑ likelihood of cancer
Age-specific reference ranges
Increases sensitivity & specificity. AA men have lower age-specific reference ranges.
Compare free serum and protein-bound PSA levels
Lower % free serum PSA = ↑ likelihood of cancer
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).
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 .
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.
Prostate Cancer Staging: Gleason system
- Tissue graded 1 – 5, based on appearance of cells.
- Grade 1 = well-differentiated.
- Grade 5 = poorly-differentiated.
- 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.
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.
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
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.
- 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.
- 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.
- 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.
Testicular Cancer Advanced disease-10%
- Cough—lung mets.
- GI symptoms—mass.
- Back pain—retroperitoneal mets.
- Neurologic –brain mets.
- Supraclavicular lymphadenopathy
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.
- High ligation of the spermatic cord. Tumor markers are evaluated prior to orchiectomy.
- Should decrease post-op.
- ↑ STM post-orchiectomy requires chemotherapy.
- Stage I & IIa need retroperitoneal radiation.
- Bulky Stage IIb & III need chemotherapy.
- 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.
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.
- 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).
- 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).
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.
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.
- 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
- 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.
- 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.
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.
- 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).
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)
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
- 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)
Trichomonas vaginalis: Lives in male urethra. Men usually asymptomatic but 10% get urethritis
HSV-2 and HSV-1. Pain, pruritus, soreness, external dysuria, Inguinal adenopathy. Painful, vesicular lesions
Treponema pallidum: Lives in genital tract. Single painless chancre or papule
H. ducreyi: Multiple painful genital ulcerations. Acute always painful. Ragged red, excavated
Chronic painless ulcers. Small papule quickly ulcerates to beefy-red
- 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
Testicular Pain Differential
Torsion-EMERGENCY, Epididymitis/Orchitis, Hydrocele, Varicocele, Trauma, Tumor
- 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
- 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
- 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
What are the arteries supplying the testicles
Testicular artery, vasal artery, cremasteric artery
How are the arteries supplying the testicles transmitted to the testicles
Via the spermatic cord
- 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
Incubation period 10-90 days (mean 21 days)
Vesicle or papule to pustule to ulcer, soft, not indurated, very painful.
What is the most common extra salivary site of mumps in adults
Testes (testicular swelling and tenderness)
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%)
Decreased pain with scrotal elevation or support (epididymitis)
Supportive care for epididymitis
Scrotal elevation and support, ice pack, spermatic cord block
- 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
Imaging test of choice for the evaluation of an acute scrotum
Color Doppler ultrasound
- 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
Nongonococcal Urethritis (NGU)
Incubation period 4-14 days
NAATS (ligase chain reaction and PCR)
The preferred test for Chlamydia, more sensitive than traditional culture methods
Gonorrhea incubation period
Purulent penile discharge, dysuria, erythematous meatus
Test of choice for Gonorrhea
What is the most common ulcerative STD
One or more painful ulcers, with painful adenopathy, with no evidence of syphilis, or herpes simplex
Beefy red appearance, bleeds easily, painless, progressive ulcerative lesions without regional lymphadenopathy
Granuloma inguinale (donovanosis)
Identify granuloma inguinale on tissue crush prep or biopsy
Tender inguinal and or femoral lymphadenopathy, typically unilateral, a self limited genital ulcer or papule sometimes occurs (C. trachomatis)
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%
The neurotransmitters that initiate and contribute to male erection include
Nitric oxide, vasoactive intestinal peptide, acetylcholine, and prostaglandins
A loss of libido may indicate
Androgen deficiency on the basis of either hypothalamic, pituitary, or testicular disease.
Loss of erections may result from
Arterial, venous, neurogenic, or psychogenic causes
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
Clomipramine 25 mg prior to intercourse
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
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.
Most Common Endocrine Disorder Associated with ED
- Diabetes mellitus
- Loss of function of long autonomic nerves
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
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
Afferent somatic sensory signals are carried from the penis via the __
pudendal nerve to S2-S4
The paired cavernosal nerves penetrate the corpus cavernosa and innervate the __
Cavernous artery and veins
Sympathetic innervation originates in the intermediolateral gray matter at what levels
Thoracolumbar levels T10-L2
Most effective long term option for impotence treatment
Lower urinary tract symptoms can be divided into what two categories
Obstructive voiding symptoms and irritative voiding symptoms
Hormone is believed to be responsible for the development and maintenance of the hyperplastic cell growth characteristics of BPH
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
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
Preferred 1st Line Treatment Option for Patients Diagnosed with LUTS from BPH
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
What is the driving factor for treatment of LUTS due to BPH
The amount to which the patients symptoms are bothersome to him
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)
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)
What are the most widely used and studied phytotherapeutic extracts used for the treatment of LUTS associated with BPH
Saw palmetto berry
What is considered the gold standard for surgical treatment of BPH
Transurethral Resection of the Prostate (TURP)
Transurethral microwave thermotherapy, one of the most widely studied minimally invasive methods of treating symptomatic BPH
Transurethral Needle Ablation
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
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
What procedure produces the greatest improvement in both urinary flow rates and symptom score for BPH
What complications are all higher with TURP than the less invasive therapies for BPH
Urinary incontinence, retrograde ejaculation, and urethral stricture
Open surgical enucleation (prostatectomy)
Reserved for patients with severely large prostate glands
- 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
Chronic Nonbacterial Prostatitis (CPPS)
Most common symptomatic type of prostatitis and may be the most prevalent of all the prostate disorders
Symptoms of Acute Bacterial Prostatitis
Fever, chills, dysuria, perineal and low back pain
Treatment of Acute Bacterial Prostatitis
Symptoms of Chronic Bacterial Prostatitis
Nonspecific but include LUTS, pelvic pain and or sexual dysfunction
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
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
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
Associated with chronic bacterial prostatitis
DRE findings with chronic bacterial prostatitis
Normal prostate exam
What are the symptomatic treatments for chronic bacterial prostatitis
NSAIDS and Sitz baths
Normal Prostate Size
20g, walnut, 2 finger breadths on DRE
Meares-Stamey 4 glass test is for:
Chronic bacterial prostatitis
Most common cancer that occurs in men and the second leading cause of cancer death
There is no association with prostate cancer and
Smoking, sexual activity, or prior history of prostatitis or BPH
There is histological evidence of prostate cancer in more than __% of men over the age of 60
Men with a less than __ year life expectancy may not benefit from prostate cancer screening
Men younger than __ years of age and in otherwise good health are recommended to have routine screening for prostate cancer
Prostate cancer typically arises from what portion of the prostate
Peripheral portion which can be palpated on DRE
__ of the prostate on DRE should be considered suggestive of prostate cancer
Induration or nodularity
Increase in PSA greater than 0.75ng/mL per year
Probably the most important prostate cancer diagnostic piece of information
System most often used to grade prostate cancer
What is the most useful test in determining the local tumor extent with prostate cancer
__ is of limited value and usually not indicated clinically for determining either local extent or nodal metastasis (prostate ca)
In patients with high grade tumors or a substantially elevated PSA, __ is indicated
A bone scan
What is the most common site of distant spread for prostate cancer
What treatment for prostate cancer has the most proven ability for long term cure
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
Testosterone declines to castrate values within __ after surgical orchiectomy and __ after administering an LHRH analog
A few days, a few weeks
Hormonal therapy to treat prostate cancer usually causes what AE’s with long term use
hot flushes, osteoporosis, wt gain, loss of muscle mass
The prognosis for patients with prostate cancer is poor when __
The cancer shows evidence of progression despite hormonal therapy
__ can sometimes provide palliation for metastatic progressive prostate cancer, but has not been shown to increase survival
__ of the penis is an uncommon tumor in the united states and the rest of the developed world
Squamous cell carcinoma
Squamous cell carcinoma of the penis is diagnosed almost exclusively in __ men
__ are not routinely recommended for penile cancer b/c physical examination has been proven to be the most accurate predictor of tumor stage
A diagnosis of carcinoma of the penis is confirmed by __
Histological evaluation of an excisional biopsy
The prognosis for patients with distant metastatic disease or nodal metastasis above __ is poor
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
The most common solid malignancy in men age 15-34 years
__ is a well accepted risk factor for subsequent development of testicular carcinoma
What is the most common presenting sign or symptom of testis cancer
Firm painless mass arising from the testis
Up to __% of patients with testicular cancer are treated for presumed epididymitis
__ is diagnostic for testicular cancer
Testicular cancer is unique in that __ play an important role in tumor staging
Serum tumor markers
Which nodes are the most common site of metastasis for testicular cancer
Retroperitoneal lymph nodes
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
__ is the standard of treatment for patients with advanced testicular cancer
Platinum based chemo
What population groups are at highest risk for developing prostate cancer
Blacks, those with a family history of prostate cancer, high dietary fat intake
What is the standard method for detection of prostate cancer
Transrectal ultrasound guided biopsy
Detection rates for prostate cancer with DRE alone vary from __%
Most prostate cancers detected with DRE are __
Advanced (stage T3 or greater)
What is the serial measurement of PSA over time
A rate of change in PSA greater than __ng/mL per year is associated with an increased likelihood of cancer detection
The majority of prostate cancers are __
Most primary testicular tumors are __ tumors
Germ cell (seminoma and nonseminoma)
The lifetime probability of developing testicular cancer is __% for an American white male
With testicular cancer, acute pain resulting from intratesticular hemorrhage occurs in approximately __% of cases
__ is never elevated with pure seminomas
__ is occasionally elevated in seminomas
How can prostate cancer lymph node metastasis present itself
Lower extremity lymphedema
What is the clinical presentation of advanced prostate cancer
Bone pain/pathologic fractures, hematuria, hematospermia
Gleason grades for prostate cancer >__ are associated with aggressive tumors
Gleason grades for prostate cancer of __ are most common
5 or 6
What do you do for a patient with prostate cancer who already has a <10 year life expectancy regardless of the cancer (significant comorbidities)
What do you do for a patient with prostate cancer who has a >10 year life expectancy
Curative therapy (radical prostatectomy)
Post radical prostatectomy consider __ if PSA levels remain detectable
What kind of outcome can be expected when treating localized prostate cancer with external beam radiation
Outcomes comparable to radical prostatectomy
What are some complications of external beam radiation used to treat prostate cancer
Cystitis, radiation proctitis, impotence
What is the method of action for anti-androgen therapy
Blocks the cellular metabolism of androgen
When would cryotherapy be used to treat prostate cancer
For cancer cells resistant to radiation and hormonal therapy
What are some contraindications for prostate cancer cryotherapy
Prior TURP, extensive disease
__ is not recommended by the USPSTF
What is the key etiologic factor in developing penile cancer
Chronic inflammation and irritation
What are some possible risk factors for penile cancer
Lack of neonatal circumcision, HPV 16 & 18, tobacco use, poor hygiene
What are the common locations for penile cancers
Glans penis, coronal sulcus, foreskin
What is the most important diagnostic test in the evaluation of penile cancer
What are some organ sparing procedures for the treatment of penile cancer
5 fluorouracil (topical), external beam radiation, Moh’s microsurgery, laser ablation, circumcision
Of the two types of testicular cancers which one is the pure tumor, is most common and originates in the seminal vesicles
Which serum tumor marker is elevated in most testicular tumors
Which serum tumor marker is elevated in non-seminomas, and excludes a diagnosis of seminoma
Which serum tumor marker is very non-specific, and is useful for monitoring advanced seminoma
insufficient evidence for/vs in men <75; men >75: harms outweigh risks
USPSTF: testicular ca
against routine screening in Asx
PSA elevations can precede clinical dz by:
PSA density (PSA conc divided by PSA volume); higher may be assoc w/cancer
Utility of free PSA
helps distinguish prostate cancer from BPH in DRE-negative pts with borderline-high PSA
Most common formula for prostate volume
Acid phosphatase used for:
Dx of prostatic ca; monitor tx w/ neoplastic drugs, esp in metastatic dz
Acid phosphatase elevated in prostate:
Adenocarcinoma; Manipulation; Inflammation; Hypertrophy
Do not order acid phosphatase immediately after:
DRE, TURP, or prostatic massage
Acid phosphatase: specimen
0.5ml serum separated & added to 10µl acid phosphatase preservative (pH 5) within 2 hours of collection
Infection, bleeding, tear/perf, urinary retention, scar tissue, allergy to anesthetic, epididymitis/ orchitis
not useful as screening test; US alone cannot establish /exclude the dx; used to evaluate elevated PSA (to locate suspicious area for transrectal biopsy)
TRUS not accurate in:
determining local tumor extension
Prostate bx: eval men with azoospermia to:
rule out ejaculatory duct cysts or seminal vesicular cysts
Prostate bx best performed with:
a spring-driven needle core biopsy device (or biopsy gun)
Complications of prostate bx
hematuria, rectal bleeding, hematospermia, urosepsis, & perineal pain
Hypogonadism (loss of libido, ED, gynecomastia, osteoporosis, infertility); delayed/ precocious puberty; monitor testost replacement tx or antiandrogen tx; eval ambiguous genitalia
2 mg/dL higher in men
Testicular U/S: utility
Inflam scrotum; epididymitis; hydrocele; absent/ undescended testicle; torsion; abnormal blood vessels; lump or tumor; most scrotal masses
If testicular mass, first do:
Use _____ to differentiate torsion from epididymitis
Male infertility: most common etiologies
varicocele (37%); idiopathic (25%)
Male factors contribute what percent to infertility cases?
Male infertility analysis: start with:
semen analysis (if abnormal, look for exposure to toxins (environment, workplace, EtOH, drugs, hypogonadism)
Semen analysis: specimen
0.5 mL, room temp, no sex 2-3 (2-5?) days prior, macro & micro analysis within 1 hr
Semen analysis: normal volume
volume >2 ml
Semen analysis: normal appearance:
Semen analysis: normal liquefaction:
liquefied within 1 hour
Semen analysis: normal pH:
Semen analysis: normal motility:
≥ 50%, >50% forward progression
Semen analysis: normal sperm concentration:
≥ 20 x 10(6)/ml
Semen analysis: normal morphology:
Low sperm motility may be due to:
antisperm Ab or infection
Abnormal sperm morphology: may be due to:
varicocele, infection, exposure history
Low semen volume: may be due to:
retrograde ejaculation or androgen insufficiency
Elevated LH: causes
Testicular dysfn; primary testicular fail; CNS dysfn; precocious puberty; postviral orchitis
Decreased LH: causes
Testicular tumors; secondary testicular fail; hypopituitarism; hypothalamic-pituitary dysfn
FSH normal range
Elevated FSH causes
primary gonadal failure, testicular agenesis, alcoholism, gonadotropin-secreting pituitary tumors
Decreased FSH causes
Anterior pituitary hypofunction, hypothalamic disorders
Limitation of FSH levels
Pulsatile secretion throughout day (physiologic variation within reference range)
Primary testicular failure: labs
increased LH/FSH, decreased testosterone
Secondary testicular failure: labs
decreased LH, FSH, testosterone
Steroid tx for:
spontaneous autoimmunity; also genital infection, testicular obstruction, & IVF
During female LH surge, examine cervical mucus 2-8 hrs post coitus to evaluate sperm & quality of mucus
Sims-Huhner test provides info about:
number of sperm, progressive motility, morphology & interaction of spermatozoa with the cervical mucus
Seminal plasma fructose: to evaluate:
azoospermia with ejaculate < 1 ml
Seminal plasma fructose MOA
Fructose is produced in seminal vesicles (energy source); if absent in ejaculate, implies absence or obstruction of ejaculatory ducts
Seminal plasma fructose: specimen:
frozen seminal plasma
Post-vasectomy testing: check sperm counts:
After 20 ejaculations; 8-12 weeks post-vasectomy
What would you like to do?
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