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59 Cards in this Set
- Front
- Back
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Describe pathophysiology behind BPH |
1. Testosterone converted into active metabolite dihydrotestosterone by alpha 5 reductase and causes prostate growth 2. Alpha 1 adrenergic receptors cause increased smooth muscle contraction in lower urinary tract |
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Name classes of drugs to treat BPH |
1. Alpha-5 reductase inhibitors (Finasteride) 2. Alpha-1 blockers (Prazosin, Doxazosin, Tamsulosin) 3. Anti-cholinergics (Detrol-LA) - not 1st line |
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S/Sx of BPH |
Nocturne, Frequency, Urgency, Retention, Decreased or Slow Stream, Feeling of incomplete voiding, Pushing/Forcing urine |
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What does DRE reveal for BPH? |
Enlarged, rubbery -most often |
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What is important side effect of alpha-1 blockers? |
Dizziness or syncope -especially w/ first dose. Recommend take at bedtime for 1st dose or sometimes in office first dose. Tamsulosin has less orthostatic hypotension |
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Which class of medication reduces prostate size? How long does it take to see results? |
Alpha-5 reductase inhibitors Takes 6-10 months |
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Patients w/ these conditions are not good candidates for alpha-1 blockers. |
Those w/ falls/dizziness Potentially those w/ cataract sx or intraoperative floppy iris syndrome (Tamsulosin (Flomax), in particular, is selective for the alpha-1A receptor that predominates in both the iris dilator muscle and prostatic smooth muscle. Although all alpha blockers can impair pupil dilation and cause IFIS, the bulk of available evidence(www.aaojournal.org) indicates that tamsulosin is more likely to cause severe IFIS than nonselective blockers such as terazosin (Hytrin), doxazosin (Cardura) and alfuzosin (Uroxatral), according to the release. AAFP, 2014) |
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Time from pain to intervention for torsion |
6 hours (85% survival rate if intervention within 6 hours) |
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Pertinent exam findings in torsion |
1. Absent cremaster reflex 2. Negative Prehn's sign 3. Elevated scrotum on affected side 4. Testicle may swollen and red 5. Pt c/o of extreme pain - normally writhing when I've seen them! |
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Diagnostic test for torsion |
Color doppler ultrasound |
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Diagnostic workup for BPH |
UA & Culture r/o hematuria, infxn BUN/Cr - for potential urology w/u & IVP Can do PSA but will be elevated in 30-50% of men |
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Epididymitis vs. Testicular Torsion |
Torsion: sudden onset (usually), pain not affected by position, vomiting d/t pain, testicular swelling p 12 hours, rare 4 dysuria Epididymitis: gradual onset - worse when standing, no vomiting, +testicular swelling, +dysuria |
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Main age group for epididymitis |
Men 15-35 |
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Common pathogen for epididymitis for: men < 35 men > 35 |
Men <35 = G&C Men > 35 = E-coli * consider risk factors in any age group |
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Risk factors for epididymitis |
Sexual Activity Bladder outlet obstruction Strenuous Physical activity Bicycle or motorcycle riding |
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Describe Prehn's sign |
Patient laying down, gently cup scrotum and lift up and ask if pain is better? |
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Describe S/Sx of epididymitis |
Gradual onset of scrotal or groin pain Radiates along spermatic cord, may be in lower abd Scrotum - red, slightly swollen |
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Home care for epididymitis |
Bed Rest Scrotal Support Analgesics Sits baths/ice baths |
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Treatment for epididymitis if caused by: G&C Enteric organisms |
Epididymitis Treatment if caused by G& C = Ceftriaxone 250mg IM and Doxycycline Enteric = Fluoroquinolone like Levaquin 500 BID x 10 days **F/u in 48 hr to see if SX improving = if not, consider other causes (testicular ca, TB, fungal, tumor, abscess) |
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Most common complication of epididymitis |
Infertility |
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Who should you consider for hospitalization for epididymitis? |
1. Older pt's w/ underlying urologic prob. 2. S/Sx toxicity: fever, chills, N/V 3. Can't keep fluids down... |
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Percentage of men > 50 years with Erectile Dysfxn |
33% of men > 50 have ED |
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Risk factors for Erectile Dysfunction |
Obesity, alcohol, DM, CVD, HTN, HLD, endocrine and problems with lower urinary tract |
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Medications implicated in Erectile Dysfunction |
Thiazides Beta Blockers SSRIs Venlafaxine Statins |
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Two questions to help determine if man is capable of an erection |
1. Erection in morning? 2. Erection w/ masturbation? *b/c they occur in parasympathetic state |
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Describe pathophysiology of erection |
POINT & SHOOT P = parasympathetic sys: penile smooth muscle relaxes 4 arterial blood flow to come + passive vena-occlusive sys to keep blood in S = sympathetic: shoot! ejaculation |
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Testing for Erectile dysfunction |
Chem7 TSH UA Lipid PSA Prolactin Serum Testosterone (if this is elevated, need to check LH/FSH and refer to endocrine) |
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Absolute contraindication to viagra or cialis? |
Any man with CVD & any man on nitro or nitrates |
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What is a hydrocele and diagnostic method to determine? |
Hydrocele = presence of fluid within tunica vaginals, painless If transilluminates = hydrocele |
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Reason to refer for hydrocele |
1. Hydrocele is communicating - meaning in both sacs 2. Usually resolves on own - if doesn't then should consider ddx of testicular ca |
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What condition is the most common cause of male infertility? |
Varicocele |
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Describe varicocele, where does it normally occur? |
Feels like a spongy bag of worms = dilation of veins above testes * most often occurs on left side |
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What is a one maneuver for examining varicocele? |
Have man stand up and bear down. should feel a small increase in size in area d/t increased blood flow |
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If varicocele occurs on right side, what are you concerned about? |
IVC obstruction |
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When should an infant with cryptorcidism be referred to urology? |
If testis has not descended by 6 months (AUA) |
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Prevalence of cryptorchidism in term and premature males? |
1-3% in term infants 15-30% in pre-term infants |
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Most common cancer in men aged 15-35 |
Testicular cancer |
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DDX of testicular cancer |
tumor torsion epididymitis |
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Risk factors for testicular cancer |
Family history - 1st degree relative increase risk 6-10 fold Tobacco use- doubles risk Cryptorchidism White Race Infertility |
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What is the most common presenting sx of testicular cancer? |
73% of men have testicular swelling 18-46% of men have testicular pain *Discrete painless mass on testicle *May c/o of scrotal heaviness & fullness |
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Describe how one might approach a man w/ dysuria? |
1. Risk factors (sexual history) 2. Is there pain anywhere else? low back pain radiating to groin - kidney stone 3. What does UA show? hematuria? pyuria? |
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Risk factors for prostate cancer |
African American origin Family history Advancing age |
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S/Sx of prostate ca |
Urinary complaints, retention Back pain Hematuria Nodules on prostate |
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Workup if considering prostate ca |
1. PSA level (may open door to more invasive) 2. UA 3. CMP 4. DRE - may be normal 5. Biopsy |
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PSA levels indicating increased risk |
PSA level of 1 ng/mL - 1% risk PSA level of 4-10 ng/mL - 25% risk |
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S/Sx of inguinal hernia |
1. Feeling of heaviness in groin 2. Soft, protruding mass 3. Painful when cough/urinate/lift/strain 4. Pain/swelling in scrotum if intestines descend into scrotum |
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Serious complication of hernia |
Strangulation Incarcerated - can't be reduced, gentle pressure in trendelenberg..... |
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Phimosis vs Paraphimosis |
Phimosis - can't retract foreskin over glans Paraphimosis - can't return foreskin back over glans once it is retracted |
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By this age, 50% of boys can retract foreskin By this age, 80% of boys can retrace foreskin |
At 1yo, 50% of boys will have retractible foreskin At 3 yo, 80% can retract foreskin |
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Treatment for phimosis |
0.05% betamethasone w/ daily prepuce retraction |
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Symptoms of acute bacterial prostatitis |
UTI sx Fever, chills, myalgia +perineal or suprapubic pain |
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Number one cause of urethritis |
G&C |
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Man presents with UTI SX - UA w/ leukocyte esteraces -Negative urine culture -pyuria What is likely diagnosis? |
Urethritis |
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Major cause of cystitis in men |
E-col |
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Cause of acute prostatitis |
1. Ascending infection (ecoli, klebsiella, pseudomonas) 2. Reflux of infected urine 3. Extension of infxn from blood, lymph, rectum |
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Treatment for Acute Prostatitis |
Bactrim 160/800 BID x 30 days Ciprofloxacin 500mg PO BID x 30 days *Graziano said 30 days but AFP 2010 states 6 weeks |
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Workup for Acute Prostatitis |
DRE - tender, boggy prostate UA & culture (pyuria, bacteriuria, hematuria), possible CBC w/leukocytosis w/ left shift |
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Symptoms of chronic bacterial prostatitis |
= Men generally do not appear ill = C/o irritative voiding sx, testicular/perineal or low back pain = recurrent UTI |
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Define chronic bacterial prostatitis |
Prostate infxn lasting more than 3 months often caused by e-coli (AFP, 2010) *Graziano states that it can be immunological or physiological response - which would be more of chronic prostatitis/chronic pelvic pain syndrome (AFP, 2010). |
