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60 Cards in this Set
- Front
- Back
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Prostate cancer RF
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urban blacks
FHx 1° → 2x risk 1° & 2° → 9x risk high dietary fat → 2x risk cigarettes |
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Prostate ca pathology
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>95% adeno ca
often multifocal transitional cell ca 4.5% - assoc/w TCC of bladder - not hormone responsive endometrial ca - rare - ca of utricle |
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Prostate ca location
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peripheral zone - 60-70%
transition zone - 10-20% central zone - 5-10% |
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Prostate ca clinical features
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usually asymp
most commonly detected by DRE, ↑PSA, or incidental with TURP locally advanced dz - obst/irritative symp (uncommon w/o spread) suspect with prostatism +/- back pain |
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Prostate ca Mets
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bony to axial skeleton (osteoblastic)
visceral less common - liver, lung, adrenal local invasion LN obturator>iliac>presacral/para-aortic hematogenous early |
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Prostate ca investigations
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DRE
PSA TRUS → local staging, size TRUS guided bx can omit bone scan if PSA <10 lymphanigiogram + CT for mets |
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DDx of prostate nodule
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prostate ca (30%)
BPH prostatitis prostatic infarct prostatic calculus TB prostatitis |
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Prostate ca grading
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Gleason score = aggregate score of 2 most prominent histo patterns
1-4 well diff 5-6 mod diff 8-10 poorly diff |
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Rx of prostate ca - T1
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T1 = small well diff associated w slow growth rate
Young - consider radical prostatectomy, brachytherapy/ XRT Elderly - f/u (cancer death rate ≤10% |
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Rx of prostate ca - T2
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radical prostatectomy or XRT (70-85% 10yr S) or brachytherapy
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Rx of prostate ca - T3, 4
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staging lymphadenectomy and XRT or hormonal Rx
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Rx of prostate ca - N>0 or M>0
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hormone therapy or palliative XRT to mets
Options: b/l orchiectomy - removes 90% testosterone LHRH agonists - leuprolide, goserelin DES antiandrogens - steroidal and non-steroidal - inhibitors of steroidogenesis chemo - docetaxel (may ↑survival in advanced prostate ca no longer responsive to H therapy) |
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LHRH agonists
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leuprolide, goserelin
- initially stim LH → ctestosterone & cause "flare" →→ ↓testosterone S/E "hot flashes" |
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Estrogens in prostate ca
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DES
- inhibits LH - cytotoxic effects on tumor cells ↑risk CVS S/E |
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antiandrogens in prostate ca
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Steroidal - cyproterone acetate
Non-steroidal - flutamide - both compete w DHT for cytosolic receptors - testosterone ↔/↑ Inhibitors of steroidogenesis Ketoconazole, spironolactone - block multiple enzymes in pathway including adrenal androgens - ↑androgen blockade by combining antiandrogen w LHRH agonist or orchiectomy |
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PSA may be ↑ with
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prostate ca
BPH prostatitis prostate ischemia/infarct acute urinary retention prostate bx/Sx prostatic massage urethral catheterization TRUS strenuous exercise ejaculation ARF CABG XRT after DRE |
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free-to-total PSA
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complexed PSA ↑s in prostate ca → ↓%age free PSA
<10% free suggestive of ca >20% free suggest benign cause |
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Testicular tumors
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most common solid malignancy in males 15-34y/o
95% germ cell (all malignant) Seminoma 35% NSGCT embryonal cell ca 20% teratoma 5% mixed cell type 40% choriocarcinoma <1% yolk sace <<1% Nongerm cell tumors (~benign) 5% Leydig Sertoli |
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Seminomas
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classic
anaplastic spermatocytic |
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NonSeminomatous germ cell tumors
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embryonal cell ca (20%)
teratoma 5% choriocarcinoma <1% yolk sac <<1% mixed cell 40% |
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Non-germ cell tumors (testicular ca)
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usually benign
Leydig - testosterone - precocious puberty Sertoli - gynecomastia - ↓libido |
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Clinical features of testicular tumors
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painless testicular enlargement (painful if hemorrhage/infarction)
firm, nontender mass dull heavy ache in ↓er abd, anal area, scrotum associated hydrocele 10% supraclavicular & inguinal LN |
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Investigations of testicular ca
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Dx established by radical orchiectomy
tumor markers βhCG & AFP +ve in 85% NSGCT βhCG +ve in 7% seminomas AFP NEVER ↑ in seminomas testicular U/S |
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testicular U/S findings suggestive of Ca
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hypoechoic area within tunica albuginea
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Causes of acute and reversible urinary incontinence
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"DRRIIPP"
Delerium Restricted mobility/Retention Inflammation/Infection Pharmaceuticals/Polyuria |
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Urinary Incontinence ♂ Etiologies
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Bladder
- detrusor overactivity - ↓compliance of bladder wall Spincter/urethra - urethral hypermobility - intrinsic sphincter dysfunction (most common - 2° to Sx disruption of outlet) |
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Classification of urinary incontinence
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Stress
- urine loss with sudden ↑ intra-abd pressure (uretral hypermobility/intrinsic sphincter dysfunction/both) Urge - urine loss precede by strong, sudden urge to void - assoc/w inflam/neuro disorder Overflow - urine loss when intravesical pressure > urethral pressure - obstructive - hypotonic bladder Total - constant loss of urine s warning Functional - urine loss caused by inability to reach toilet in time |
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Rx of stress incontinence
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Kegel's
topical estrogen cream injectable agents to prox urethra - Sx - reinforce bladder neck/urethra with cystourethropexy or slings to prevent urethral descent or kink hypermobile urethra |
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Rx of urge incontinence
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antispasmodics
- oxybutynin anticholinergics - propanthaline - tolterodine TCAs - imipramine Botox injection |
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Rx of retention associated urinary incontinence
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catheterization to prevent bladder/kidney damage
Rx underlying cause |
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Urinary retetion causes:
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Outflow obstruction
Loss of bladder innervation pharmacologic |
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Urinary retention d/t outflow obstruction
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Prostate
- BPH - prostate ca - prostatitis Urethra - stricture - traumatic disruption Bladder neck/urethra - calculus - FB - clot |
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Urinary retention d/t meds
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anticholinergics
narcotics anti-HTN - ganglionic blockers - methyldopa OTC cold meds with ephedrine/pseudoephedrine Antihistamines |
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Clinical features of urinary retention
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palpable/percussable bladder
+/- purulent/bloody meatal d/c DRE - prostate size, anal tone Neuro - DTRs, "anal wink", normal sensation |
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BPH definition
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hyperpasia of stroma & epithelium in periurethral area of prostate (transition zone)
also ↑tone of smooth muscle 25% require Rx |
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Clinical features of BPH
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result from outlet obstruction & compensatory changes in detrusor function
obstructive - d/t outflow obstruction & impaire detrusor contractility Irritative - d/t detrusor instability, ↓compliance prostate - smooth, rubbery, symmetrically enlarged on DRE |
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Complications of BPH
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retention
incontinence hydronephrosis renal compromise infection gross hematuria |
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Investigations for BPH
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hx
DRE U/A to r/o UTI PSA to r/o malignancy (if life expectancy >10yrs) +/- uroflowmetry +/- bladder U/S for residual volume cystoscopy for potential Sx mngt |
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Rx for BPH
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Mild
watchful waiting - 50% improve spontaneously lifestyle changes - pm fluid restriction, activity planning Meds α-blockers ↓sm.m tone (terazosin, doxazosin, tamsulosin, alfuzosin) 5α-reductase inhbitors - blocks testosterone → DHT conversion (acts on epithelial component of prostate) - finesteride TURP |
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Renal Colic DDx
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acute urethral obstruction by other causes
- UPJ obstruction - sloughed papillae - clot colic from gross hematuria Acute abd crisis - biliary, bowel, pancreas, AAA Gyne - ectopic - torsion/rupture of ovarian cyst pyelo L1 radiculitis |
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Location of renal calculi
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calyx
+/- flank discomfort, recurrent infection, persistent hematuria pelvis - tend to obstruct at UPJ - staghorn calculi = renal pelvis + ≥1 calyx - often assoc/w infection that doesn't resolve until stone clears Ureter <5mm pass spontaneously in 75% |
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Renal calculi pathogenesis
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supersaturation of stone constituents
stasis, ↓flow/V urine crystal formation & stone nidus Loss of Inhibitory factors citrate - forms soluble complex w Ca Mg - forms soluble complex w oxalate Pyrophosphate Tamm-Horsfall glycoprotein |
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4 narrowest passage points for upper GUT stone
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1. UPJ
2. pelvic brim 3. under vas deferens/broad lig 4. UVJ |
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Renal caliculi - Ca stones etiology
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75-85% all stones
Ca oxalate > Ca phosphate/mixed Hypercalciuria Hyperuricosuria (25%) Hyperoxaluria (<5%) Hypocitraturia (12%) Other hypomagnesemia (assoc/w hyperoxaluria, hypocitraturia) high diet Na - ↑Ca excretion, ↓urinary citrate ↓urinary proteins - Tamm-Horsfall glycoprotein, uropontin |
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Hypercalciuria etiology
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↑intestinal absorption
- ↑ingestion (Ca, VitD) - renal PO₄leak → ↓PO₄→ ↑1,25(OH)₂VitD - idiopathic Resorption Ca from bone - HyperPTH - immobilization - malignancy - steroids Other - sarcoidosis - distal RTA |
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Hyperuricosuria and renal caliculi
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25% of pts with Ca stones
- uric acid crystals can act as nidus for Ca stone formation, independent of uric acid stone formation - acid urine (pH<5.8) - dehydration |
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Hyperoxaluria
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<5% pts with Ca stones
↑intestinal absorption (most common) Has large effect on stone formation with small ∆ urinary [] - pts with SI resection, IBD, malabsorption - ↑intestinal fat binds dietary Ca → unavailable to bind oxalate → ↑oxalate absorption in LI + ↑urinary excretion Endogenous overproduction - end production of AbN metabolism of glycine, ascorbic acid, hydroxyproline & serine ↑ingested oxalate (tea, coffee, beer, leafy veggies, chocolate, ethylene glycol) |
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Hypocitraturia
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citrate usuall complexs w Ca → inhibits stone formation
↓ d/t systemic acidosis (includes distal RTA) hypokalemia - thiazides, chronic diarrhea high animal protein diet |
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Struvite stones
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5-10% renal stones
Mg ammonium phosphate (MAP) alkaline urine pH d/t infection w urea-splitting organisms precipitates MAP - proteus, psudomonas, klebsiella, mycoplasma, serratia, S. aureus (NOT E. coli) perpetuate UTI b/c stone itself harbours organism - must remove stone to cure infection - assoc/w staghorn calculi |
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Uric acid stones
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5-10%
Not seen on plain Xray precipitate in ↓V, acidic urine with ↑uric acid [] Hyperuricosuria alone - ↓urine pH, ↓V (eg GI H2O loss) - ASA, thiazides - purine rich diet (red meats) Hyperuricosuria w hyperuricemia Gout high cell turnover/death |
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Cystine stones
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AR defect in SI mucosal absorption and renal tubular absorption of dibasic a.a.'s
→ "COLA" in urine (cystine, ornithine, lysine, arginine) Aggressive stone dz in children/young adults (recurrent stones, FHx) aggregation in acidic urine Dx - +ve urine Na nitroprusside test - urine chromatography for cystine |
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Indinavir stones
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only stones radiolucent on spiral CT AND plain film
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Investigations of renal calculi
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CBC, SMA7, U/A, urine C&S
Imaging KUB - DDx opaque vs non (90% opaque) Spiral CT - no contrast DDx - radiolucent stone from soft tissue defect uric acid stones visible Abd U/S +/- shows stones (difficult in ureter) +/- shows hydronephrosis cystoscopy - for suspected bladder stone Metabolic studies for recurrences Ca, PO4, urate, PTH if hypercalcemic 24h urine x2 for Cr, Ca, PO4, uric acid, Mg, oxalate, citrate |
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Indications for admission for renal caliculi
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intractable pain
fever single kidney w ureteral obstruction b/l obstructing stones compromised renal fxn |
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Rx of renal caliculi
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analgesics +/- antiemetics
NSAIDs - ↓intra-ureteral P +/- Abx for UTI IV fluids if vomiting Conservative if <5mm |
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Specific Rx of Calcium oxalate stones
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thiazides
+/- K+ citrate +/- allopurinol, Ca |
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Specific Rx of uric acid stones
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alkalinize urine - HCO3, K+citrate
+/- allopurinol |
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Specific Rx of struvite stones
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Abx
remove stone |
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Specific Rx of cystine stones
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alkalinize urine
penicillamine/α-MPG captopril |
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Indications for ESWL and percutaneous nephrolithotomy
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ESWL
stone <2.5cm (unless cystine) nephrolithotomy stone >2.5cm staghorn UPJ obstruction calyceal diverticulum cystine stones |
