Men's Health PDF

Click to edit Master title style Men’s Health C. H a m m o n d , D N P, M S N , F N P - B C , P M H N P - B C 1 Click to edit Master title style Cryptorchidism Cryptorchidism is the failur...

Click to edit Master title style Men’s Health C. H a m m o n d , D N P, M S N , F N P - B C , P M H N P - B C 1 Click to edit Master title style Cryptorchidism Cryptorchidism is the failure of testes to descend - undescended testicle - (one or both) ↑ Risk in premature infants 30% vs. 5% in full-term infants Cryptorchidism is most common in the right testicle If not descended by 6 months and before he is 12 months old surgery (orchiopexy) should be performed. Complications of undescended testes are testicular cancer (in both descended and undescended testes) or infertility (which occurs in up to 75% of male children with bilateral cryptorchidism and in 50% of male children with unilateral cryptorchidism.) 2 2 Click Cryptorchidism to edit Master title style Thorough GU exam, including an attempt to "milk" inguinally located testes into the scrotum If one or both testes are palpable in the scrotum or inguinal canal, re-examine at the next well-child exam If neither testes are palpable at birth, obtain an ultrasound promptly 3 3 Click to edit Master title style Cryptorchidism Undescended testes can be monitored for spontaneous descent over the first 4-6 months of life If still non-palpable at 4-6 mo well-child exam, refer to urology/surgery for evaluation and possible orchiopexy For absent testes, strongly consider a consultation with a specialist Complications of undescended testes include malignancy, subfertility, and testicular torsion. Therefore, the American Urologic Association suggests that these patients should perform monthly testicular self-examinations during adolescence 4 4 Click to edit Peyronie Disease Master title style Peyronie disease (PD) is a disorder characterized by a buildup of hardened fibrous tissue in the corpus cavernosum, causing pain and a defective curvature of the penis, especially during erection Peyronie's disease is caused by repeated penile injury, typically during sex or physical activity, and genetic susceptibility The presenting symptoms of PD are penile pain, induration, curvature, shortening, and/or sexual dysfunction Penises vary in shape and size, and having a curved erection isn't necessarily a cause for concern. In Peyronie's disease, the bend is significant and may occur along with pain or interfere with sexual function 5 5 Click to edit Peyronie Disease Master title style Diagnosis is usually apparent from patient history and penile examination Various imaging modalities have been used to diagnose PD, including ultrasound, plain radiography, computed tomography, and MRI 6 6 Click to edit Peyronie Disease Master title style For men with stable, mild curvature (≤30 degrees) who have satisfactory erectile function, observation is an acceptable option In cases of worsening curvature or sexual dysfunction medical and/or surgical management (removal of plaque) Oral pentoxifylline (vasodilator and anti-inflammatory) best initial treatment within three months of onset In men who are bothered by penile deformity of >3 months’ duration may use intralesional injection with collagenase Surgical management is indicated for patients whose Peyronie's disease has persisted for more than 12 months, is refractory to medical treatment, and is associated with a penile deformity compromising sexual function. 7 7 Click to edit Erectile Dysfunction Master title style Erectile dysfunction is the recurring inability to achieve and maintain an erection sufficient for satisfactory sexual performance It is thought that up to half of all men in the United States between the ages of 40 and 70 have some form of erectile dysfunction. Prevalence increases with age Risk factors The most important risk factors are those that contribute to atherosclerosis (e.g., HTN, smoking, hyperlipidemia, diabetes) Medications—antihypertensives (may indirectly lower intracavernosal pressure by virtue of lowering systemic BP) Hematologic—sickle cell disease History of pelvic surgery or perineal trauma Alcohol abuse Any cause of hypogonadism/low testosterone state, including hypothyroidism Congenital penile curvature 8 8 Click to edit Erectile dysfunction Master title style The major organic causes of ED are Vascular disorders Neurologic disorders Psychological Hormonal Drugs The most common vascular cause is atherosclerosis of cavernous arteries of the penis, often caused by smoking and diabetes. Atherosclerosis and aging decrease the capacity for dilation of arterial blood vessels and smooth muscle relaxation, limiting the amount of blood that can enter the penis. Veno-occlusive dysfunction permits venous leakage, which results in an inability to maintain an erection. Priapism Complications of pelvic surgery Any endocrinopathy or aging associated with testosterone deficiency 9 9 Click to edit Erectile Dysfunction Master title style Detailed history and examination, including a digital rectal examination and neurologic examination. Assess for signs of PAD Laboratory tests—Obtain a CBC, chemistry panel, fasting glucose, and lipid profile If there is hypogonadism or loss of libido, order serum testosterone, prolactin levels, and thyroid profile Nocturnal penile tumescence—If normal erections occur during sleep, a psychogenic cause is likely. If not, the cause is probably organic. Consider vascular testing—Evaluate arterial inflow and venous trapping of blood. Tests include intracavernosal injection of vasoactive substances, duplex ultrasound, and arteriography Psychologic testing may be appropriate in some cases 1010 Click to edit Erectile Dysfunction Master title style Treat the underlying cause. Address atherosclerotic risk factors (weight loss and smoking cessation in all patients) First-line treatment is with phosphodiesterase inhibitors such as sildenafil citrate (Viagra), which acts by increasing cGMP levels causing increased nitric oxide release and penile smooth muscle relaxation. It can be taken 30 to 60 minutes before anticipated intercourse. It is contraindicated with the use of nitrates because together they can cause profound hypotension. Phosphodiesterase 5 inhibitors: Sildenafil (Viagra) take on empty stomach - take one hour before intercourse - can be effective 6 or 8 hours Tadalafil (Cialis) - may take two hours to work and can be effective for 24 to 36 hours Vardenafil (Levitra) - can be taken with food (avoid fatty foods) - take one hour before intercourse - can be effective 6 or 8 hours 1111 Prostatitis Click to edit Master title style Prostatitis is inflammation of the prostate gland Prostatitis is classified into acute, chronic, asymptomatic inflammatory prostatitis, and chronic pelvic pain syndrome Causes include and ascending urinary tract infection, spread from the rectum (direct/via lymphatics), hematogenous (rare) May follow catheterization, cystoscopy, urethral dilation, prostate resection procedures Acute bacterial prostatitis: Usually occurs in younger individuals and is a more serious condition Fever, chills, malaise Urinary symptoms ⇒ Frequency, urgency, dysuria Perineal/low back pain Digital rectal exam ⇒ Boggy, warm, tender, enlarged prostate Chronic prostatitis: Can be bacterial/abacterial, usually occurs in individuals aged 40–70 years; Chronic bacterial is the most common form of prostatitis 1212 Click to edit Master title style Prostatitis Can be asymptomatic Intermittent urinary symptoms History of recurrent UTIs Perineal/low back pain; suprapubic discomfort Digital rectal examination ⇒ enlarged, nontender prostate Etiology is based on the patient's age and risk factors Chlamydia and Gonorrhea in men < 35 E coli in men > 35 **If you suspect acute prostatitis, do not massage the prostate. This can lead to sepsis! 1313 Click to edit Master title style Prostatitis Urinalysis will reveal pyuria (↑ WBC in acute) +/- hematuria Urine cultures: positive in acute and negative in chronic prostatitis Prostatic fluid/secretions may show leukocytosis (↑ WBCs) with a culture typically positive for E Coli Ultrasound/CT scan/cystoscopy: For individuals with significant voiding dysfunction/suspected abscesses/neoplasms Blood tests: CBC, blood cultures if clinical findings suggestive of bacteremia Blood urea nitrogen and creatinine levels for individuals with urinary retention/obstruction Serum prostate-specific antigen (PSA) may be elevated 1414 Click to edit Master title style Prostatitis Case presentation - 24-year-old male complaining of blood in the ejaculate after intercourse with his girlfriend think prostatitis and treat appropriately In this case and in men < 35 cover chlamydia and gonorrhea - ceftriaxone and doxycycline In older men > 35, treat with fluoroquinolones or Bactrim for 4-6 weeks to ensure eradication of the infection Patients who cannot tolerate oral medication, demonstrate signs of severe sepsis or have bacteremia should be hospitalized. In such cases, intravenous levofloxacin or ciprofloxacin may be given with or without an aminoglycoside (gentamicin or tobramycin). Chronic prostatitis is treated with fluoroquinolones or Bactrim x 6- 12 weeks 1515 Click to edit Master title style Epididymitis Epididymitis is characterized by dysuria, unilateral scrotal pain, and swelling The pathogen is based on the patient's age and risk factors men < 35 chlamydia and gonorrhea men > 35 E.coli + Prehn's sign = relief with elevation is a classic sign Testicular torsion should be ruled out in all cases of new-onset testicular pain. With epididymitis, the pain is gradual in onset and the tenderness is mostly posterior to the testis. With testicular torsion, the symptoms are quite rapid in onset, the testis will be higher in the scrotum and may have a transverse lie, and the cremasteric reflex will be absent. The absence of leukocytes on urine analysis and decreased blood flow on scrotal ultrasound with Doppler will suggest torsion. 1616 Click to edit Master title style Epididymitis Urinalysis and culture along with studies for GC and Chlamydia - will reveal pyuria and bacteriuria Ultrasound with Doppler studies if concern for torsion 1717 Click to edit Master title style Epididymitis < 35 years, or suspected STD etiology Ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if patient weighs 150 kg or greater) plus doxycycline (100 mg orally twice a day for 10 days) Refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms. ≥ 35 years, with suspected enteric organism Levofloxacin (Levaquin) 500 mg/day PO for 10 days OR Trimethoprim-sulfamethoxazole (one double-strength tablet twice a day for 10 days) is a good alternative Patients of any age who practice insertive anal intercourse – coverage for N. gonorrhoeae, C. trachomatis, and enteric pathogen infections Ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if patient weighs 150 kg or greater) PLUS a fluoroquinolone (levofloxacin 500 mg orally once daily for 10 days) 1818 Click to edit Master title style Phimosis Phimosis – foreskin in normal position and cannot be retracted In adults, phimosis may result from scarring after trauma, infection (such as balanitis), or prolonged irritation Paraphimosis – is the entrapment of the foreskin in the retracted position => it is a medical emergency Paraphimosis can occur when the foreskin is left retracted (behind the glans penis) Retraction may occur during catheterization or physical examination. If the retracted foreskin is somewhat tight, it functions as a tourniquet, causing the glans to swell, both blocking the foreskin from returning to its normal position and worsening the constriction. Always remember to reduce the foreskin after urethral catheterization! 1919 Click to edit Master title style Phimosis Paraphimosis → should be regarded as an emergency because constriction leads quickly to vascular compromise and necrosis of the glans penis Firm circumferential compression of the glans with the hand may relieve edema sufficiently to allow the foreskin to be restored to its normal position. If this technique is ineffective, a dorsal slit done using a local anesthetic relieves the condition temporarily. Circumcision is then done when edema has resolved Phimosis → is normal in children and typically resolves by age 5 Treatment is not required in the absence of complications such as balanitis, UTIs, urinary outlet obstruction, unresponsive dermatologic disease, or suspicion of carcinoma 2020 Click to edit Testicular torsion Master title style Twisting of the spermatic cord that results in compromised blood flow and ischemia - this is considered a surgical emergency Often after vigorous activity or minor trauma Usually in post pubertal boys: 65% occur in boys ages 10-20 years old Asymmetric high riding testicle “bell clapper deformity” Negative Prehn's sign (lifting of testicle will not relieve pain) Loss of cremasteric reflex (elevation of the testes in response to stroking of the inner thigh) Blue dot sign: Tender nodule 2 to 3 mm in diameter on the upper pole of the testicle More common in patients with a history of cryptorchidism 2121 Click to edit Testicular Torsion Master title style Diagnosis Testicular doppler for diagnosis = best initial test Treatment Orchiopexy This is a surgical emergency - 6-hour time frame for repair with the best outcomes Emergent surgical intervention on the affected testis must be followed by elective surgery on the contralateral testes, which is also at risk for torsion. 2222 Click to edit Master title style Varicocele Varicocele "bag of worms" A varicocele is the formation of a venous varicosity within the spermatic vein Bag of worm's superior to the testicle Cystic testicular mass of varicose veins – Dilation worse when the patient is upright or with Valsalva – decreases in size with an elevation of the scrotum or supine position. (-) Transillumination – A chronic, nontender mass that does not transilluminate is seen. Management may require surgery in some cases. 2323 Click to edit Master title style Varicocele Scrotal ultrasound can be used in the diagnosis of varicocele Varicocele: surgical repair can be performed if the varicocele is painful or if it appears to be a cause of infertility 2424 Click to edit Master title style BPH BPH is part of the normal aging process but only sometimes causes symptoms (50% of men develop BPH by 60 and > 90% by age 85) Features: Decreased force of urinary stream, hesitancy (stop and start) and straining, postvoid dribbling, incomplete emptying, frequency, nocturia, urgency, recurrent UTIs Acute urinary retention can develop with exposure to cold, prolonged attempts to postpone voiding, immobilization, or use of anesthetics, anticholinergics, sympathomimetics, opioids, or alcohol In men with BPH, avoid use of anticholinergics, sympathomimetics, and opioids 2525 Click to edit Master title style BPH Digital rectal exam - will demonstrate a uniformly enlarged, firm, and rubbery prostate Although cancer may cause a stony, hard, nodular, irregularly enlarged prostate, most patients with cancer, BPH, or both have a benign feeling, enlarged prostate. Thus, testing should be considered for patients with symptoms or palpable prostate abnormalities PSA is often ↑ in BPH - correlate with risk of symptom progression PSA is considered normal < 4 PSA > 4 think BPH, prostate CA and prostatitis Urinalysis is used to rule out other conditions 2626 Click to edit Master title style BPH Observation is reasonable if mild symptoms - patients should be monitored annually Alpha-blockers cause urethral relaxation and rapid symptom relief α-1 blockers - tamsulosin (Flomax) most uroselective provides rapid symptom relief - smooth muscle relaxation of prostate and bladder neck decreases urethral resistance and obstruction which increases urinary flow can cause dizziness and orthostatic hypotension as well as retrograde ejaculation 5 ∝ reductase inhibitors (REDUCE THE SIZE) shrink an enlarged prostate 5-α reductase inhibitors - finasteride and dutasteride (androgen inhibitor - inhibits the conversion of testosterone to dihydrotestosterone suppressing prostate growth, and reducing bladder outlet obstruction) has a positive effect on the clinical course of BPH Phosphodiesterase type 5 inhibitor (PDE5 inhibitor) - tadalafil, in men with BPH-related symptoms and erectile dysfunction PDE5 inhibitors block the PDE5 enzyme to prevent it from working. This inhibition relaxes the blood vessels and increases blood flow Combination therapy with PDE5 inhibitors and alpha 1-adrenergic blockers seemed to have an additive beneficial effect on BPH/lower urinary tract symptoms compared with monotherapy 27 27 Click to edit Master title style BPH Surgery is done when patients do not respond to drug therapy or develop complications such as recurrent urinary tract infection, urinary calculi, severe bladder dysfunction, or upper tract dilation. TURP (transurethral resection of the prostate) - removes excess prostate tissue to relieve obstruction - sexual dysfunction and urinary incontinence Transurethral incision of the prostate (TUIP) - electric current to make incisions in prostate - no tissue is removed 2828