clin med nephro pt. 2

what zone of the prostate does most prostate cancer occur in

peripheral zone

what zone of the prostate exhibits significant growth with age and BPH

transition zone

“normal” serum PSA level

under 4

BPH

proliferation of epithelial and smooth muscle cells within the transition zone of the prostate

prostate changes with age

glandular enlargement

increased smooth muscle tone due to increase in alpha receptors

decreased compliance secondary to altered collagen deposition

obstructive urinary symptoms

hesitancy

decreased force/caliber of stream

sensation of incomplete emptying

straining to void

post void dribbling

irritative urinary symptoms

urgency

frequency

nocturia

dysuria

IPSS

used to quantify severity of LUTS and its impact on a patient’s quality of life

0-7: mild symptoms

8-19: moderate symptoms, urology referral

20-35: severe symptoms

tests for BPH

post void residual

UA, PSA

renal US if urinary retention/creatinine elevated

transrectal US of prostate to access prostate volume

BPH with mild LUTS tx

watchful waiting

avoid: pseudophedrine containing decongestants, anticholinergics, caffeine, ETOH, spicy foods

BPH medical therapy

alpha 1 blockers 1st line (tamsulosin, silodosin): promotes relaxation of smooth muscle in bladder, S/E of retrograde ejaculation, dizziness and ortho hotn

5alpha-reductase inhibitors (finasteride, dutasteride): shrinks prostate by inhibiting conversion of testosterone to DHT, usually prescribed with alpha blocker, S/E of impotence, decreased libido, gynecomastia

tadalafil: helpful for ED and BPH

BPH surgical therapy

transurethral resection of the prostate (TURP): main S/E of retrograde ejaculation, can cause transurethral syndrome where irrigation fluid is absorbed leading to fluid overload and dilutional hyponatremia

transurethral incision of the prostate (TUIP): variant of TURP, only recommended in men with smaller prostates

prostatectomy: larger prostates or other pathologies present

prostatitis classifications

acute bacterial: gram negative rods (e. coli and pseudomonas), gram positive (enterococci), gonorrhea and chlamydia (sexually active)

chronic bacterial: gram negative rods most common, enterococcus only gram positive

chronic non-bacterial (inflammatory)/chronic pelvic pain syndrome

prostatitis etiology

acute: ascent up urethra and reflux of infected urine into prostatic ducts

chronic bacterial: bacteria persist in prostatic ducts

CPPS: chronic inflammation or hypersensitivity in pelvis nerves

hallmark of CPPS

prostadynia: pelvic pain associated with voiding symptoms

prostatitis P/E

acute: very ender, swollen, warm, boggy; avoid vigorous exam

chronic: may be normal or slightly tender

when is pelvic CT or transrectal US indicated with prostatitis

pts who do not respond to abx in 24-48 hours

prostatitis tx

fluoroquinolones (1st choice), bactrim for total 4-6 weeks

frequent ejaculation to eliminate congested prostatic fluid

add alpha blocker to help with symptoms

prostate cancer facts

most common solid organ cancer in men after lung cancer

1 out of 9 men will be diagnosed

second leading cause of cancer death in men

main prostate cancer RFs

family history

black men

age over 65

prostate cancer screening

40-45 years: screening for men at higher risk

50-69 years: most likely to benefit from screening, informed decision making process

age 70+: screening generally not recommended

screening at interval of every 2-4 years

how long should PSA screening be deferred after infection or prostate manipulation

at least 4 weeks

general screening PSA cutoffs for urology referral

under 50: over 1.5

50-54: over 2

55-59: over 3

60-69: over 4

0ver 70: over 6

PSA kinetics vs free/total PSA ratio

kinetics: rapid and sustained PSA rises more indicative of cancer

ratio: lower of unbound to total suggests higher risk of cancer

prostate cancer mets

pelvic lymph nodes, bone, lung, liver

prostate cancer gold standard dx

transrectal US with biopsy with abx

for any unexplained fever within 4 weeks of biopsy should report to ED for acute prostatitis

MC pathology of prostate cancer

adenocarcinoma

grading of prostate cancer

gleason score 1 (well-differentiated) - 5 (poorly differentiated)

combines most predominant (1st number) with least predominant (2nd number)

gleason score of 7 or under tx

active surveillance

DRE and PSA every 3-6 months

repeat prostate biopsy or MRI every 1-2 years

prostate cancer tx

radical prostatectomy: younger and healthier pts

radiotherapy: older pts with lower life expectancy

ED often occurs with silent

CAD

men with ED should be considered at risk for CVD until proven otherwise

erection physiology

parasympathetic (S2-S4) activation releases NO

NO increases cGMP and promotes smooth muscle relaxation, arterial inflow filling sinusoids

venous plexuses located between sinusoids and rigid tunica covering the penia are compressed resulting in occlusion of venous outflow

detumescence

sympathetic activation (T11-L2)

norepinephrine leads to vasoconstriction

PDE5 breaks down cGMP

ED medical therapy

PDE5 inhibitors (sildenafil, tadalafil): prolong action of vasodilation mediators including nitric oxide/prevents degradation of cGMP

testosterone: can improve libido but often ineffective for erections

ED injections

intracavernosal: papaverine, hydrochloride, phentolamine

intrauretral: pellet fo alprostadil

priapism

persistent (4 or more hours) penile erection in absence of sexual stimulation

ischemic priapism

urologic emergency

MC, painful

due to impaired drainage

causes: sickle cell, malignancy, PDE5 inhibitors, trazodone, cocaine, alpha blockers

corpora cavernosa erect while glans and urethra spared

tx: aspiration and irrigation with normal saline, if fails will need distal or proximal shunt

non-ischemic priapism

painless, inflow exceeds the venous outflow

causes: post-traumatic, arteriovenous fistula formation

partially rigid

tx: observation (often self-resolves)

peyronies disease

acquired connective tissue disorder characterized by formation of fibrous plaques within the tunica albuginea of the penis

plaque usually located on dorsal penis

peyronies RFs

penile trauma or vigorous sexual activity

age

smoking

HTN

DM

cavernosal injections

genetic: dupuytrens contracture

when is penile doppler used in peyronies

when surgical intervention is planned

peyronies non-surgical tx

observation

oral meds: vitamin E, potaba, colchicine

intralesional injections: xiaflex

penile traction devices

peyronies surgical tx

plication: nesbit procedure, shortening side of penis opposite of curvature

plaque incision and grafting

penile prosthesis for concurrent ED and severe deformity

cryptorchidism

failure of one or both of the testes to descend into the scrotum

MC congenital GU anomaly in male infants

phases of testicular descent

transabdominal phase (weeks 8-15 of gestation): insulin-like hormone facilitates movement from near kidneys toward inguinal ring

inguinoscrotal phase (weeks 25-35 of gestation): testosterone influences inguinal canal to allow passage

MC location for undescended testes

inguinal canal

risks associated with cryptorchidism

infertility

testicular cancer: 4-10x higher risk

testicular torsion

inguinal hernia

cryptorchidism tx

observation: some testes descend spontaneously by 6 months

hormonal therapy: rarely used, GnRH analogs to stimulate testosterone production

surgical treatment: orchiopexy between 16-18 months, most recommend by 12 months

hydrocele

collection of serous fluid between parietal an visceral layers of the tunica vaginalis surrounding the testicle

hydrocele P/E

fluctuant, painless scrota swelling

scrotum transluminates

unable to palpate testes separate from swelling

hydrocele tx

conservative: scrotal support/elevation

surgical: hydrocelectomy or aspiration (50% recurrence with aspiration)

varicocele

group of dilated veins in pampiniform plexus due to incompetent valves

more common on left due to angle of testicular vein draining into left renal vein

right should always think right renal mass unless otherwise proven

varicocele P/E

fells like a ‘bag of worms’ and becomes more prominent with standing and valsalva

varicocele tx

varicocelectomy: laparoscopic ligation of retroperitoneal spermatic vein

epididymitis

clinical syndrome characterized by pain, swelling, and inflammation of epididymitis

non-infectious causes of epididymitis

amiodarone, behcet’s, trauma

epididymitis sxs

gradual onset testicular pain

palp tenderness and warmth over epididymis

LUTS

if caused by STD may have urethral d/c

epididymitis P/E

scrotal edema and erythema on affected side

fever/chills

pain relieved by scrotal elevation: positive Prehn’s sign

intact cremasteric reflex

scrotal US with doppler in epididymitis

increased flow to affected epididymis

epididymitis tx

STD: ceftriaxone and doxycycline

non-STD: levofloxacin with or without alpha blocker

orchitis

inflammation of one or both testes

orchitis causes

viral: mumps, develops 4-7 days after parotitis

bacterial: often occurs with epidiymitis

orchitis sxs

often bilateral in viral

sudden onset pain and swelling

fever

positive prehn’s sign

orchitis scrotal US with doppler

enlarged testicle with increased flow

orchitis tx

viral: supportive

bacterial: treat underlying infection

testicular torsion

urologic emergency

rotation of the testicle and spermatic cord with its blood vessels resulting in termination of blood flow to the testis

ischemia can cause irreversible tissue necrosis within 6 hours

testicular torsion predisposing factors

cryptorchidism

bell’clapper deformity: congenital, testis lacks posterior attachment of gubernaculum to vaginalis

testicular torsion P/E

asymmetric scrotal edema

horizontal lie of testicle

thick or knotted spermatic cord

absent cremasteric reflex

negative prehn’s sign

testicular torsion dx

clinical with history and exam

doppler US is the gold standard with minimal flow to affected side

testicular torsion tx

consult urology

immediate surgical exploration is mandatory, do not wait for imaging

if testicle salvaged, bilateral orchiopexy

if orchiectomy, orchiopexy performed on unaffected side