repro test 3 : 2nd set of ppts (4-6)

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Questions and Answers

What is the primary risk factor leading to testicular torsion known as 'bellclapper's deformity'?

Absence of the inguinal canal

Presence of hydrocele

Weakness or absence of the scrotal ligament (correct)

History of testicular cancer

Which of the following pathogens is primarily associated with sexually transmitted testicular inflammation?

Chlamydia (correct)

Staphylococcus aureus

Escherichia coli

Coxsackie virus

What symptom is commonly absent in a testicle affected by torsion?

Severe local pain

Swelling of the scrotum

Cremasteric reflex (correct)

Transverse lie of the testis

Which complication may result from testicular torsion if left untreated?

Testicular necrosis Signup and view all the answers

In which anatomical structure does the gubernaculum persist in connection with the testis?

Scrotum Signup and view all the answers

What is a common symptom indicating testicular inflammation (orchitis)?

Rapid onset of localized pain in one or both testicles Signup and view all the answers

Which condition involves undescended testicles and must be distinguished from testicular torsion?

Cryptorchidism Signup and view all the answers

What happens to pain in the swollen testicle during physical examination that suggests inflammation?

It improves when the scrotum is lifted Signup and view all the answers

What is a primary characteristic of pathologic phimosis?

The glans can never be exposed Signup and view all the answers

Which condition can escalate to a medical emergency due to blood flow issues?

Paraphimosis Signup and view all the answers

What factor is most commonly thought to contribute to the development of Peyronie’s disease?

Minor penile trauma Signup and view all the answers

Which HPV serotypes are primarily associated with squamous carcinoma of the penis?

16 and 18 Signup and view all the answers

What is a typical manifestation of Peyronie’s disease?

Development of a plague Signup and view all the answers

What is priapism commonly defined as?

A painful erection lasting more than 4 hours Signup and view all the answers

What contributes to the mechanism of erection in the penis?

Relaxation of penile smooth muscle Signup and view all the answers

In priapism, what type is characterized by increased arterial flow?

Nonischemic (high-flow) Signup and view all the answers

What is a potential complication of severe Peyronie’s disease?

Calcification of the plaques Signup and view all the answers

Which of the following is NOT a recommended approach for treating foreskin-related conditions?

Aggressive physical therapy Signup and view all the answers

What is the primary reason fertility may be affected in cases of bilateral orchitis?

Damage to Leydig cells and seminiferous tubules Signup and view all the answers

What is the most common type of testicular cancer diagnosed in young individuals?

Seminoma Signup and view all the answers

Which chromosome is commonly associated with genetic abnormalities in testicular cancer?

Chromosome 12 Signup and view all the answers

What type of hydrocele occurs when the tunica vaginalis is open to the peritoneal cavity?

Communicating hydrocele Signup and view all the answers

Which event is most closely associated with intraperitoneal bleeding leading to scrotal swelling?

Abdominal cancer Signup and view all the answers

How does BPH primarily cause urinary retention?

By compressing the pelvic plexus branches Signup and view all the answers

Which statement correctly describes the relationship between age and DHT in prostate health?

DHT remains high in the prostate region despite decreasing testosterone Signup and view all the answers

What is the potential consequence of having a patent funicular process in males?

Higher likelihood of developing a communicating hydrocele Signup and view all the answers

Which statement is true regarding the lymphatic spread of testicular cancer?

It seldom spreads contralaterally Signup and view all the answers

Which factor is NOT considered a risk factor for prostate cancer?

Family history of diabetes Signup and view all the answers

In the context of the penis, what does phimosis refer to?

Inability to retract the foreskin completely Signup and view all the answers

Which condition is characterized by the accumulation of fluid in the tunica vaginalis without an open connection to the peritoneal cavity?

Non-communicating hydrocele Signup and view all the answers

What role do androgens play in the development of prostate cancer?

They can increase mitotic events and cellular immortality Signup and view all the answers

What is the primary role of the detrusor muscle in the urinary system?

To increase pressure in the bladder Signup and view all the answers

Which of the following conditions is least likely to result in a positive urinalysis for glucose?

Excessive hydration Signup and view all the answers

Which crystal type is most commonly associated with kidney stones?

Calcium oxalate Signup and view all the answers

What factor does NOT contribute to the formation of urinary stones?

Excessive fluid intake Signup and view all the answers

In a urinalysis, a positive nitrite result is most commonly indicative of which condition?

Urinary tract infection Signup and view all the answers

Which statement about the urethra is true?

The male urethra can be up to eight inches long Signup and view all the answers

What is a potential reason for false positives in a urinalysis for protein?

Exercise Signup and view all the answers

Which of the following refers specifically to the grouping of three structures within the urinary system?

Trigone Signup and view all the answers

Which risk factor is most commonly associated with the formation of urinary stones?

Excessive vitamin C consumption Signup and view all the answers

What is the most common symptom presented by patients with bladder cancer?

Hematuria Signup and view all the answers

Which treatment option is generally not recommended for low-grade stage I bladder cancer?

Radical cystectomy Signup and view all the answers

What method is primarily used for the diagnosis of renal stones?

Non-contrast helical CT scan Signup and view all the answers

Which one of the following medications is known to relax the bladder in the management of overactive bladder?

Tolterodine Signup and view all the answers

What is the typical treatment approach for uncomplicated lower urinary tract infections?

Outpatient antibiotics such as fluoroquinolones Signup and view all the answers

Which of the following is a characteristic symptom of pyelonephritis?

Flank pain and fever Signup and view all the answers

What is the most common causative organism of lower urinary tract infections (UTIs)?

Escherichia coli Signup and view all the answers

Which symptom is least likely to indicate a urinary tract infection (UTI)?

Unexplained vomiting Signup and view all the answers

In patients with urinary stones, which size is generally indicated as likely to pass naturally?

5 mm to 10 mm Signup and view all the answers

Which imaging technique provides rapid results for assessing urinary tract infection while waiting for culture results?

Gram stain of urine Signup and view all the answers

Which of the following risk factors is primarily associated with bladder cancer?

Smoking cigarettes Signup and view all the answers

What is a common adverse effect of medications used to treat overactive bladder?

Dry mouth and constipation Signup and view all the answers

In the presence of upper urinary tract infection, which systemic symptom should alert healthcare providers?

Systemic fever Signup and view all the answers

What is the lifetime risk of a 50-year-old American man developing clinically apparent prostate cancer?

16% Signup and view all the answers

Which age group shows the highest prevalence of prostate cancer according to autopsy studies?

80–89 years Signup and view all the answers

What is the primary method through which most prostate cancer patients are diagnosed?

Elevated serum PSA levels Signup and view all the answers

Which factor is NOT considered a risk factor for developing prostate cancer?

Low dietary fat intake Signup and view all the answers

Lymph node metastases from prostate cancer may lead to which of the following rare complications?

Lower extremity lymphedema Signup and view all the answers

At what age should clinicians begin regular prostate cancer screening for individuals at increased risk?

Age 40 to 45 years Signup and view all the answers

Which method is preferred for prostate cancer detection due to decreased infection rates?

Transperineal biopsy Signup and view all the answers

What is a typical range for PSA levels in patients with localized prostate cancer?

Less than 10 ng/mL Signup and view all the answers

Which Gleason score indicates the worst prognosis?

Score of 9 Signup and view all the answers

What is the primary goal of active surveillance in prostate cancer management?

Monitoring while avoiding unnecessary treatment Signup and view all the answers

What is the recommended frequency for a PSA test during active surveillance?

Every three to six months Signup and view all the answers

In which scenario would watchful waiting be preferred over active surveillance?

Men with limited life expectancy Signup and view all the answers

What is the common imaging modality used for localized prostate cancer detection?

Multiparametric MRI (mpMRI) Signup and view all the answers

What is the standard procedure for prostate cancer diagnosis?

Ultrasound-guided biopsy Signup and view all the answers

What defines the Gleason grading system in prostate cancer?

Architectural criteria of cancer cells Signup and view all the answers

Which medication has proven to significantly lower the risk of clinical progression of BPH when used in combination with doxazosin?

Finasteride Signup and view all the answers

What is often the first-line surgical option for patients with BPH who require surgical intervention?

Transurethral resection of the prostate (TURP) Signup and view all the answers

Which symptom is a hallmark of acute bacterial prostatitis?

Sudden onset of fever Signup and view all the answers

What is a common risk factor associated with the development of prostatitis?

Bicycle riding Signup and view all the answers

What type of prostatitis is most prevalent and can occur without identifiable bacterial causes?

Chronic pelvic pain syndrome Signup and view all the answers

What is a key diagnostic criterion for acute bacterial prostatitis?

Exquisite tenderness on digital rectal examination (DRE) Signup and view all the answers

Which treatment is typically administered to patients with acute bacterial prostatitis?

Intravenous aminoglycosides Signup and view all the answers

What symptom is least likely to be associated with chronic prostatitis?

Fever Signup and view all the answers

When is surgery recommended for chronic prostatitis?

In cases of severe pain unresponsive to medication Signup and view all the answers

What condition may occur after bacterial prostatitis, leading to persistent symptoms?

Chronic pelvic pain syndrome Signup and view all the answers

Which α-blocker is commonly prescribed to alleviate voiding symptoms in chronic prostatitis management?

Silodosin Signup and view all the answers

Which blood test finding indicates a positive diagnosis of acute bacterial prostatitis?

Leukocytosis with a left shift Signup and view all the answers

Which chronic prostatitis symptom might indicate complications involving pelvic floor dysfunction?

Erectile dysfunction Signup and view all the answers

What does an undetectable PSA level after surgery indicate about a patient's condition?

The patient is in full remission. Signup and view all the answers

What role does androgen deprivation therapy (ADT) play in treating high-risk prostate cancer patients?

It reduces testosterone levels to help manage the disease. Signup and view all the answers

Which factor is essential for assessing a patient's risk for developing Benign Prostate Hypertrophy (BPH)?

Genetic and hereditary factors. Signup and view all the answers

How do obstructive symptoms of BPH commonly manifest?

Weak urine flow and straining during voiding. Signup and view all the answers

Why might PSA levels rise temporarily after brachytherapy?

Because of prostate inflammation and necrosis. Signup and view all the answers

What is a significant challenge in the management of metastatic prostate cancer?

Failure to control distant metastatic disease. Signup and view all the answers

Which statement accurately reflects the relationship between age and development of BPH?

The incidence of BPH increases with aging. Signup and view all the answers

What commonly indicated procedure can help determine the appropriate surgical intervention for BPH?

Cystoscopy. Signup and view all the answers

Which treatment is characteristic for low-grade prostate cancer patients?

Watchful waiting or active surveillance. Signup and view all the answers

What is the most common approach to achieving medical castration in advanced prostate cancer management?

Use of LHRH agonists. Signup and view all the answers

Which statement correctly describes the symptoms of BPH?

Can present both obstructive and irritative symptoms. Signup and view all the answers

Why is it essential to evaluate a patient's life expectancy before deciding on treatment for prostate cancer?

To determine if immediate treatment is beneficial. Signup and view all the answers

What indicates a significant potential issue when a patient presenting with BPH has nodules or induration during examination?

It raises suspicion for prostate cancer. Signup and view all the answers

What percentage of men report decreased urinary stream at age 75 due to BPH?

50% Signup and view all the answers

Study Notes

Penis/Scrotum Pathology

Inflammation (Orchitis, Orchitis-Epididymitis): Usually caused by infection, often combined with epididymal inflammation. Two possible paths for infection: bloodstream or retrograde via vas deferens.
- Bacterial (non-sexually transmitted): Staph, Strep, E.Coli
- Sexually transmitted: Gonorrhea, Chlamydia, Syphilis
- Viral: Mumps, coxsackie, parvovirus
Symptoms: Rapid onset of pain in one or both testicles, often radiating to groin. Pain may decrease when scrotum is lifted. Swelling, redness, tenderness, "heavy feeling" in the swollen testicles. Possible blood in ejaculate, urethral discharge, pain with urination, intercourse, or increased abdominal pressure. Systemic symptoms may include fever, nausea, vomiting, and malaise.
Torsion: Twisting of the spermatic cord compromising blood supply.
- Cause: Often due to "bell-clapper's deformity" - weakness or absence of scrotal ligament, leading to poor testicular positioning.
- Symptoms: Acute and significant pain, absent cremasteric reflex, swollen, tender, high-lying testis with abnormal transverse orientation.
- Diagnosis: Ultrasound
Cryptorchidism: Undescended testicle.
Hydrocele: Fluid collection within the scrotum.
- Communicating Hydrocele: Fluid travels from peritoneal cavity through patent funicular process (embryonic remnant) into scrotal sac.
  - Can be caused by intra-abdominal processes: bleeding, ascites, cancer
- Non-communicating Hydrocele: Fluid accumulates within the tunica vaginalis after the processus vaginalis closes, either before birth or later due to infection, cancer, or fluid production.
Varicocele: Dilation of veins in the spermatic cord.
- Cause: Poor blood return through pampiniform plexus, testicular vein, and into central circulation.
- Prevalence: More common on the left side due to drainage pattern into the renal vein on that side.
Testicular Cancer:
- Common: Seminoma, affecting young men (highest incidence between ages 20-34)
- High Cure Rate: 90% survival at 5 years
- Tumor Markers: Some germ cell cancers release β-HCG, AFP, or LDH, used to monitor treatment.
- Lymphatic Spread: Follows venous drainage of testes, primarily superiorly along the IVC and renal veins.
Genetics: 80% of testicular cancer patients have an extra copy of chromosome 12p. Most tumor cells are triploid or tetraploid, suggesting a defect in chromosomal proofreading.

Prostate

Benign Prostatic Hyperplasia (BPH): Increased number of gland and muscle cells, not just enlargement.
- Cause: Increased cell division possibly driven by high testosterone levels.
- Symptoms: Urinary retention due to pressure on the prostate capsule, potential nerve dysfunction within the pelvic plexus.
- Hormonal Impact: While testosterone levels decline with age, DHT levels remain high in the prostate, leading to a paracrine effect on cell division.
Prostate Cancer:
- Location: Most common in the peripheral zone of the prostate.
- Risk Factors: Multiple sexual partners, history of HSV or HPV, positive serology for HPV 16 and 18.
- Oncology: Cancer cells often eliminate apoptosis (increasing immortality) and may have decreased tumor suppressor gene activity. Androgens can also stimulate cell turnover.
- Note: BPH is not a risk factor for prostate cancer.

Penis

Phimosis: Inability to retract the foreskin.
- Physiologic Phimosis: Tight foreskin at birth, separation typically occurs naturally by age 7.
- Pathologic Phimosis: Secondary condition due to adhesions and scar tissue, often caused by recurrent balanitis or poor hygiene.
Paraphimosis: Foreskin is retracted but stuck, constricting penile tissue, potentially causing medical emergency.
- Treatment: Good hygiene, gentle manipulation (avoiding force in children), circumcission if required.
Penile Tumors:
- Papillomas: Caused by HPV, some serotypes are high risk (16, 18, 31, 33).
- Squamous Carcinoma of the Penis: In situ, invasive, ulcerative. Linked to HPV 16 and 18.
Peyronie's Disease: Acquired penile inflammation resulting in plaque formation within the connective tissue.
- Cause: Possibly related to minor penile trauma, vigorous sexual activity, sports injuries, or accidents.
- Impact: Plaques reduce penile elasticity, leading to curvature, pain, and shortening during erection.
Priapism: Painful erection lasting over 4 hours, unrelated to sexual stimulation.
- Cause: Increased inflow or decreased outflow of blood in the penile erectile tissue.
- Types:
  - High Flow (non-ischemic): High arterial flow.
  - Low Flow (ischemic): Decreased venous drainage due to vaso-occlusion.

Urinary System Anatomy

Kidneys are paired organs located posteriorly and retroperitoneally.
Ureters connect the renal pelvis to the bladder.
Bladder stores urine and is connected to the ureters.
Trigone, located in the bladder, is the triangular area between the ureter openings and urethra.
Transitional epithelium lining bladder allows for stretching.
Detrusor muscle contracts to increase bladder pressure, while internal and external urethral sphincters need to relax for urination.
Urethra conducts urine from the bladder out; female urethra is approximately 1.5 inches long, while male urethra is up to 8 inches.

Urinalysis Findings

Specific gravity indicates hydration status (normal range: 1.005-1.030).
pH (normal 5.0-8.0) can indicate urea-splitting organisms (Proteus) if above 7.5.
Positive nitrites suggest urinary tract infection (specificity ~90%).
Protein presence in urine could signal kidney issues.
Glucose in urine is abnormal except during pregnancy or SGLT1 inhibitor use.
Ketones indicate hunger or diabetes mellitus.
Leukocytes in urine (e.g., 3+) suggest a possible infection, but also could indicate contamination.

Urinary Calculi (Stones)

These solid crystals form within the urinary system.
Most commonly form in kidneys and travel through ureters for excretion.
4 main types: calcium oxalate (~85%), uric acid, magnesium ammonium phosphate (struvite), and cystine.
Stones form due to salt crystallization in concentrated urine with excess salts and minimal flow.

Urinary Calculi Risk Factors

Hypercalciuria
Excess vitamin C intake
High purine diet (proteins)
Hyperuricosuria
Increased urine acidity
Medications (loop diuretics, prednisone, decongestants, probenecid, anti-acids)
Family history of renal stones
Dehydration

Urinary Calculi Signs and Symptoms

Usually asymptomatic if contained within kidneys.
Become symptomatic if they obstruct, cause infection, or travel through narrow spaces (ureters, urethra).
Common symptoms include nausea, vomiting, severe pain (renal colic), flank pain radiating into abdomen, CVA tenderness, fever, chills (with infection), suprapubic pain, hematuria, and dysuria.

Urinary Calculi Diagnosis and Evaluation

Diagnosis relies on clinical suspicion, urinalysis, and imaging (renal ultrasound, x-ray, non-contrast helical CT scan).

Urinary Calculi Treatment and Management

Identify stone type by analyzing strained urine.
Pain management with analgesics, nausea and vomiting relief with antiemetics.
Stones under 10 mm often pass independently.
Treatment for non-passing stones includes potassium citrate (for uric acid stones), shockwave lithotripsy, or endoscopic removal after 6-8 weeks.
If kidney obstruction occurs, stenting might be necessary.

Overactive Bladder (OAB)

Characterized by excessive detrusor muscle contraction leading to frequent and uncontrollable urination (urge incontinence).
Diagnostic criteria include 8 or more urinations per 24 hours and 2 or more episodes of nocturia.

Overactive Bladder Workup and Diagnosis

Involves a thorough medical history, physical exam, urinalysis, and blood tests to rule out systemic causes.

Overactive Bladder Treatment and Management

Pelvic floor exercises (Kegel) to strengthen muscles.
Bladder training and scheduling to control urination.
Absorbent pads for accidents.
Medications to relax bladder (anti-parasympathetics) like tolterodine, oxybutynin, solifenacin, and mirabegron.
Common adverse effects of these medications include dry eyes and mouth, constipation.

Bladder Cancer

Fourth most common cancer in men and seventh in women in the US.
More common in men (3:1 ratio).
Affects mainly older individuals (average onset at age 73).
Risk factors include cigarette smoking (~60%) and industrial dye exposure.

Bladder Cancer Symptoms and Signs

Hematuria is the primary symptom (85% of patients).
Less common symptoms include urinary urgency, frequency, and nocturia.
Metastatic bladder cancer may present as lymphadenopathy, hepatomegaly, or lymphedema.

Bladder Cancer Workup and Diagnosis

Suspect bladder cancer with painless hematuria.
Evaluation includes a complete blood count, urinary cytology, and imaging with CT, MRI, or cystoscopy for lesion assessment.
Confirmed by cystoscopy and biopsies.

Bladder Cancer Treatment and Management

Refer to a urologist or oncologist.
Low-grade stage I can be treated with transurethral resection and intravesical chemo.
Stage 2 and higher usually require neoadjuvant chemo followed by radical cystectomy and/or lymphadenectomy if the patient is healthy enough for surgery.
Advanced stage, localized lesions, or end-of-life cases may involve radiotherapy and chemotherapy.

Urinary Tract Infections (UTIs)

Lower tract UTIs involve the urethra and bladder (urethritis, cystitis).
Upper tract UTIs involve the kidneys (pyelonephritis).

Lower Tract Infections (Bladder Infection)

Etiology: bacteria (usually fecal or skin flora), most commonly E. coli (80%).
More prevalent in women (50-60% lifetime prevalence).
Presentation: urinary tract symptoms (dysuria, suprapubic pressure, frequency, urgency, cloudy or malodorous urine) and systemic symptoms (fever, malaise, flank pain) that may indicate upper tract infection.
Workup: thorough medical history, physical exam, urinalysis, and culture (especially for repeat UTIs, kidney disease, and pregnancy).

Upper Tract Infections (Pyelonephritis)

Usually ascends from lower tract, less commonly hematogenous spread.
Predominantly bacterial, but viral infections are possible.
Requires special attention in pediatric patients, renal transplant recipients, chronic renal failure patients, and pregnant women.
Symptoms and signs: fever, chills, flank pain, nausea, vomiting, CVA tenderness, dysuria, and irritative voiding symptoms.
Workup: urine culture, urinalysis, and gram stain for quick management until culture results available.

Upper Tract Infections Treatment

Outpatient antibiotics (fluoroquinolone is common and effective for ~90%).
Inpatient antibiotics for complicated patients (initially inpatient and transitioned to oral medication).

UTI Hospitalization Indications

Absolute: persistent vomiting, failed treatment of uncomplicated UTI, suspected sepsis, uncertain diagnosis, urinary tract obstruction, pregnancy.
Relative: age over 60 years, anatomic urinary tract abnormalities, immunocompromised status, inadequate follow-up, frailty, and poor social support.

Prostate Cancer

Most common non-cutaneous cancer in men.
Second leading cause of cancer-related death in American men.
Most cancers are small, slow-growing, and confined to the prostate.
Prevalence increases with age.
Autopsy studies show over 40% of men over 50 have prostate cancer.
A 50-year-old American man has a 40% lifetime risk of latent cancer, a 16% risk of developing clinically apparent cancer, and a 2.9% risk of death due to prostate cancer.

Prostate Cancer Risk Factors

Black race
Family history
Hormone replacement therapy (testosterone)
Aging
History of high dietary fat intake

Prostate Cancer Signs & Symptoms

Most patients are asymptomatic and diagnosed due to elevated PSA levels.
Some are diagnosed based on nodules or areas of hardening in the prostate on a DRE (digital rectal exam).
Obstructive voiding symptoms are more often due to benign prostatic hyperplasia.
Large or extensive prostate cancers can cause obstructive voiding symptoms, including urinary retention.
Lymph node metastases can lead to lower extremity lymphedema (rare).
Axial skeleton is the most common site of metastases, leading to back pain and pathologic fractures.
Rarely, neurologic symptoms from epidural metastases and cord compression occur.

Prostate Cancer Screening Guidelines

Shared decision-making with patients regarding screening.
PSA as the first screening test.
Repeat PSA before secondary biomarkers, imaging, or biopsy for newly elevated PSA.
Clinicians may start prostate cancer screening with a baseline PSA test between ages 45 and 50.
Screen for prostate cancer starting at age 40 to 45 for increased risk patients.
Regular prostate cancer screening every 2 to 4 years for people aged 50 to 69.
Digital rectal exam (DRE) can be used with PSA to assess risk.

Prostate Cancer Lab Assessment & Work-Up

PSA (prostate-specific antigen) is a glycoprotein produced only by prostate cells.
Serum PSA is non-specific but useful for detecting and staging prostate cancer, monitoring treatment response, and identifying recurrence.
No PSA threshold excludes the diagnosis of prostate cancer.
Gleason scores help with staging via microscopic examination of biopsy cells. Higher scores indicate a worse prognosis.
Untreated patients have PSA levels correlating with cancer volume and stage.
PSA levels less than 10 ng/mL usually indicate localized disease.
PSA levels greater than 40 ng/mL are more likely to have advanced disease.
A rising PSA after therapy suggests progressive disease, either locally recurrent or metastatic.

Prostate Cancer Procedures & Imaging Modalities

Ultrasound-guided biopsy is the standard for prostate cancer detection.
Transperineal approach increasing over transrectal due to lower infection and sepsis rates.
Multiparametric MRI (mpMRI) is the imaging study of choice for localized prostate cancer detection and characterization.
Imaging for staging depends on the likelihood of advanced disease metastases.
Asymptomatic patients with low to intermediate-grade cancer and modest PSA elevations, deemed localized, generally need no further imaging.
Cross-sectional imaging with CT or MRI of the abdomen and pelvis and radionuclide bone scans are first-line staging studies for nodal and bony metastases assessment.

Staging Prostate Cancer

Most prostate cancers are adenocarcinomas.
Majority arise in the peripheral zone, with a smaller percentage in the central (5-10%) and transition zones (20%).
Gleason grading system is used by pathologists.
Gleason score correlates with tumor volume, pathologic stage, and prognosis.
Grading is based on architectural rather than histologic criteria, with five possible "grades."

Prostate Cancer Treatment & Management

Active surveillance is preferred for men with well-differentiated prostate cancer and low-risk features.
Aims to avoid treatment for those who may never need it, while treating higher-risk disease.
Treatment decisions are made based on stage, PSA, cancer grade (Gleason score), age, and patient health.
Watchful waiting is preferred for men with limited life expectancy who can be followed with PSA alone in the absence of metastases signs or symptoms.
A rising PSA after therapy is usually consistent with progressive disease, either locally recurrent or metastatic.
Refer all patients to a urologist for localized disease management or active surveillance.

Active Surveillance per the American Society of Clinical Oncology

PSA test: Every three to six months
Digital rectal exam (DRE): At least once a year
Prostate biopsy: At least every two to five years
Active surveillance is an option for slow-growing prostate cancer.
Helps patients avoid surgery and radiation therapy side effects.
Differs from watchful waiting, usually reserved for elderly men with reduced life expectancy.

Radical Prostatectomy

Seminal vesicles, prostate, and ampullae of the vas deferens are removed.
Ideal candidates are healthy patients with stages T1 and T2.
Patients with advanced local tumors (T4) or lymph node metastases are rarely candidates for prostatectomy alone.
Undetectable PSA (less than 0.1 ng/mL) after surgery suggests no residual or recurrent disease, no further imaging required, "Full remission."
Local recurrence is uncommon after radical prostatectomy.
Patients should have an assessment of life expectancy prior to treatment decision-making, as low-risk and many intermediate-risk patients with less than 10-year life expectancy will not benefit from immediate treatment.

Brachytherapy

Procedure involving placing radioactive material ("seeds") in the prostate, delivering radiation therapy.
Allows for higher doses of radiation to specific body areas.
Can be used as monotherapy for low-grade or low-volume cancers or combined with external beam radiation for higher-grade or higher-volume disease.
PSA may rise initially due to inflammation and necrosis of the prostate.
Patients with intermediate- and high-risk disease benefit from concomitant androgen deprivation therapy (ADT) for a specified period, reducing testosterone, "medication castration."

Metastatic Disease

Death from prostate carcinoma is almost always due to uncontrolled metastatic disease.
Research emphasizes improving control of distant disease.
Most prostate carcinomas are hormone-dependent.
70-80% of men with metastatic prostate carcinoma respond to various forms of androgen deprivation.
LH-releasing hormone (LHRH) agonists (leuprolide, goserelin) achieve medical castration without orchiectomy, being the most common method for reducing testosterone levels.
Advanced prostate cancer management is rapidly evolving, now based on the volume of metastatic disease at diagnosis.

Benign Prostatic Hypertrophy (BPH)

Common hyperplastic process, resulting from increased cell numbers.
Occurs as men age.
Can cause uncomfortable urinary symptoms (obstructive or irritative).
Can also cause bladder, urinary tract, or kidney problems.

BPH Epidemiology & Risk Factors

Most common benign tumor in men over age 50.
At age 55, ~25% of men report obstructive voiding symptoms.
At age 75, 50% report a decrease in urinary stream force and caliber.
Studies indicate genetic and hereditary factors play a role.
Insulin resistance and metabolic syndrome are independent risk factors.
Two factors are necessary for BPH development: endocrine compounds (ie., dihydrotestosterone [DHT]) effect on prostate growth and impact of aging.

BPH Signs & Symptoms

Voiding (OBSTRUCTIVE) symptoms: hesitancy, straining, weak flow, terminal dribbling, prolonged voiding, retention, overflow incontinence.
Storage (IRRITATIVE) symptoms: frequency, urgency, nocturia, urge incontinence, small voided volume, pain.

BPH Assessment & Work-Up

Physical exam, including DRE, and focused neurologic exam should be performed.
Size does not correlate well with symptom severity or obstruction degree.
BPH typically results in a smooth, firm, elastic enlargement of the prostate.
Nodules or induration suggest possible prostate cancer and further evaluation is needed (PSA testing, transrectal ultrasound, or biopsy).
Urinalysis to assess infection or hematuria.
Consider serum PSA in those of screening age, especially if life expectancy is > 10 years.
Consider prostate volume assessment before surgical intervention to determine the most appropriate approach (TURP versus simple prostatectomy for large glands).
Can be done with cystoscopy, transrectal or abdominal ultrasound, or cross-sectional imaging of the pelvis.
Simple prostatectomy removes the inner parts of the gland, while radical removes the entire prostate gland.

Cystoscopy & Uroflowmetry Procedures

Cystoscopy is not required to determine treatment need but can help decide the surgical approach for those opting for invasive therapy.
Uroflowmetry and postvoid residual should be assessed before prostate surgical treatment and can track treatment response.

BPH Treatment & Management

Patients with mild symptoms (AUA score index 0-7) and low bother scores can be managed by watchful waiting only.
Medical therapy for those with significant bother attributed to symptoms.
Surgery considered for moderate to severe symptoms or failed medical therapies.

Transurethral Surgical Therapy

Most BPH cases requiring surgery can be managed with transurethral or minimally invasive techniques.
TURP is the gold standard for surgical treatment of BPH.

Alpha-blockers "OZINS"

Tamsulosin (Alpha-1-blockade): Blocking these receptors relaxes smooth muscle, reducing resistance at the bladder outlet.

5-Alpha-reductase Inhibitors

Finasteride & Dutasteride: Block the conversion of testosterone to dihydrotestosterone.
Long-term combination therapy with doxazosin and finasteride is safe and reduces BPH clinical progression risk significantly more than either medication alone.

Phosphodiesterase-5 Inhibitor

Tadalafil (Cialis): Approved as first-line treatment for urinary symptoms and erectile dysfunction in men.

When to Consider Referring Patients

Urinary retention
Patient dissatisfaction with medical therapy
Need for further evaluation (cystoscopy) or surgical intervention

Prostatitis

Inflammation of the prostate causing pain.
Can be bacterial or non-bacterial in etiology.
Occurs in approximately 1 out of 3 men.

Prostatitis Etiology & Risk Factors

STDs like chlamydia and gonorrhea
E. coli infection
UTI, catheter placement
Past prostate biopsy
Past prostatitis infection
Anal sex
Avid bicycle riding
Trauma
Lower urinary tract nerve problems
HIV/AIDS
Pelvic floor injury or problem
Unknown etiology (especially in chronic prostatitis)

Chronic Prostatitis (Non-bacterial)

Chronic pelvic pain syndrome is most common.
Symptoms for at least 3 months, may be episodic.
Can take months to years to resolve but may recur.

Essentials of Diagnosis for Chronic Prostatitis

Irritative voiding symptoms
Perineal or suprapubic discomfort similar to chronic bacterial prostatitis
Positive white blood cells from expressed prostatic secretions, but negative culture

Chronic Prostatitis Symptoms & Signs

Chronic perineal, suprapubic, or pelvic pain is the most common symptom.
Men may complain of pain in the testes, penis, groin, anus, and/or lower back, pain during or after ejaculation.

Chronic Prostatitis Treatment & Management

Multimodal therapy is recommended.
Painkillers like Tylenol and/or NSAIDs.
Voiding symptoms managed with α-blockers (tamsulosin, silodosin, alfuzosin).
Pelvic floor muscle dysfunction (Kegel exercise, diazepam, etc.).
Sexual dysfunction with pain symptoms (sexual therapy and phosphodiesterase-5 inhibitors).
Surgery is not recommended for chronic prostatitis.

Acute Bacterial Prostatitis

Usually caused by common bacterial strains.
Infection may spread from other urinary or reproductive systems.
Usual causative organisms: Escherichia coli (> 50% of cases) and Pseudomonas.
Less common: Enterococcus.

Acute Bacterial Prostatitis Signs & Symptoms

Sudden onset of symptoms.
Exquisitely tender prostate (per DRE).
Perineal, sacral, or suprapubic pain.
Pain in the testes, penis, groin, anus, and/or lower back.
Fever typically present.
Irritative or obstructive voiding complaints.
Hematuria possible.

Acute Bacterial Prostatitis Diagnosis

Laboratory Tests:
- Complete blood count: Leukocytosis and a left shift (immature cells).
- Urinalysis: Pyuria, bacteriuria, hematuria.
- Urine culture: Positive.
- Blood cultures if fever > 101°F, lasts longer than 36 hours, or in immunocompromised patients.
- No PSA is needed, though it may be elevated.
Imaging:
- Pelvic CT or transrectal ultrasound is indicated in patients who do not respond to antibiotics within 24-48 hours, as rare abscesses may occur within the prostate.

Acute Bacterial Prostatitis Diagnosis Criteria

Fever
Irritative voiding symptoms
Perineal or suprapubic pain
Exquisite tenderness on rectal examination (DRE)
Positive urine culture

Acute Bacterial Prostatitis Treatment

Ampicillin and an aminoglycoside IV until afebrile for 24-48 hours, then PO quinolone for 4-6 weeks.
Ampicillin, 1 g IV q6h, and gentamicin, 1 mg/kg IV q8h for 21 days.
Ciprofloxacin, 400 mg IV q12h.
Levofloxacin, 500-750 mg IV q24h.
Ciprofloxacin, 500 mg PO BID x 10-14 days (first-line outpatient).
Levofloxacin, 500-750 mg PO QD x 10-14 days (first-line outpatient).
Ofloxacin, 200-400 mg PO BID x 21 days.
Trimethoprim-sulfamethoxazole, 160/800 mg PO BID x 10-14 days (alternative regimen outpatient).
Ceftriaxone 250 mg IM x 1, then doxycycline 100 mg PO BID x 10 days.

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Description

Ppt 4: Male Reproductive Pathophysiology ppt, Ppt 5: Urinary System Concerns ppt, ppt 6:Prostate Disorders