Men's Health - Prostate Screening PDF

Men’s Health Per Clinical Guidelines book – PROSTATE SCREENING RISK FACTORS  Family history, especially in first-degree relative  Increasing age (70% of men older than 80 years and 40% of men older than 50 years have evidence of prostate cancer)  Obesity  Black or J...

Men’s Health Per Clinical Guidelines book – PROSTATE SCREENING RISK FACTORS  Family history, especially in first-degree relative  Increasing age (70% of men older than 80 years and 40% of men older than 50 years have evidence of prostate cancer)  Obesity  Black or Jamaican ethnicity ASSESSMENT FINDINGS  Asymptomatic  Elevated PSA  Nocturia, hematuria  Abnormal prostate examination: palpable nodules, hardened prostate, asymmetry  Acute urinary retention possible  Urinary frequency, urinary hesitancy, dysuria = lower urinary tract symptoms (LUTS)  Urinary tract infection  Anemia  Weight loss, lethargy, constipation, rectal pain  Back or hip pain radiating into testicular area  Lymphedema  Lymphadenopathy DIAGNOSTIC STUDIES  PSA usually >4 ng/mL, however, PSA can be normal. Evaluate velocity of change in PSA and use in conjunction with DRE  Prostate cancer antigen 3, TMPRSS2-ERG gene fusion, and prostate health index are infrequently used by clinicians, but are adjunct tests to use with PSA  Alkaline phosphatase: elevated with metastasis  Testosterone and liver function tests if provider suspects androgen deprivation  Transrectal biopsy with transrectal ultrasound (TRUS) guidance prostate biopsy  CT, primarily to evaluate the size of prostate and assess for pelvic lymph node involvement in the preoperative period for staging purposes or evaluation of metastasis  MRI and bone scan if evidence of nodal involvement, PSA >20 ng/mLor Gleason scor >8; Gleason score >8 indicates cancer more likely to spread rapidly  Bone scan: positive if metastasis (always indicated if PSA >20) PREVENTION  Prostate screening recommendations vary. USPSTF recommends against routine screening. ACS and AUA guidelines recommend individualized approach with shared decision making on whether a digital rectal exam (DRE) and prostate-specific antigen (PSA) screening together are in the patient’s best interest   For most men, screening with PSA and DRE starting at 50 years  Consider screening at age 45 years for those at high risk (first-degree relative with prostate cancer before age 65, (Black ethnicity)  For men with more than one first-degree relative with history of prostate cancer, begin screening at age 40  Asymptomatic men with 10-year life expectancy should not be offered PSA testing  PSA 4.0-9.9 ng/mL usually is biopsied, but only 20% of these patients have prostate cancer  PSA >10 ng/mL generally necessitates biopsy REFERRAL  Refer to urologist and/or oncologist FOLLOW-UP  Clinical examination with PSA every 6 months for 5 years, then annually; DRE annually  If patient is under active surveillance, follow-up should include repeat prostate biopsies 1 year after original diagnosis, then every 2-4 years to monitor progression  Men treated with androgen deprivation therapy (ADT) require evaluation for CVD and prevention  Screen for urinary tract dysfunction and sexual dysfunction; treat symptomatically  Screen for depression, anxiety, suicidality, and caregiver distress Prostate-specific antigen (PSA) is a protein produced by cells of the prostate gland/ an elevated PSA level can be a sign of prostate cancer but also may indicate noncancerous problems such as prostate enlargement and inflammation / Men with a PSA btw 4 and 10 have about a 1 in 4 change of having prostate cancer / PSA level more than 10 indicates over a 50% change If you have advanced or metastatic prostate cancer you should:  See your healthcare provider for a physical exam and PSA every 3-6 months.  Your provider may also want to order radiology tests like CT, MRI or bone scans every 6-12 months if you have signs that your cancer has spread to your bones or your PSA is increasing Causes: A prostate cell becomes cancerous due to a change in its gene/ The exact cause for this change is unknown. The following are risk factors: Advanced age African americans are at higher risk Family history Obesity Genetic factors: inherited mutations of the BRACA1 or BRACA2 genes Early stage prostate cancer may not cause any signs or symptoms. Symptoms commonly noted during the advanced stage include:  Trouble urinating  Frequent urination  Decreased force of urination  Difficulty starting or stopping urine stream  Blood in semen  Pain or discomfort in the pelvic area  Bone Pain Common tests & procedures Digital rectal examination: Inserting a gloved finger into the rectum to check the prostate gland adjacent to it. Blood test: To check for prostate-specific antigen (PSA). Ultrasound: Uses a small-sized probe inserted into the rectum to obtain images of the prostate. Biopsy: A small sample of the prostate mass is taken for microscopic examination to assess the type and severity of cancer. Prevention: There are no definite measures to prevent prostate cancer. The risk can be reduced by following certain precautionary measures such as:  Eat a healthy diet rich in fruits and vegetables  Cut down on fatty foods  Have a regular exercise regimen  Remain physically active  Maintain a recommended weight  Avoid smoking and alcohol Per Clinical Guidelines book – TESTICULAR CANCER RISK FACTORS  History of cryptorchidism (even if repaired)  Testicular atrophy  White race, rare in Black people  Gonadal dysgenesis  Family history or previous history of testicular cancer ASSESSMENT FINDINGS  Solid, firm, non-tender unilateral testicular mass  Sensation of fullness, heaviness or dull ache in scrotum, lower abdomen, or perianal area  Previous small testicle enlarges to size of normal testicle  Hydrocele  Gynecomastia in 5% or patients with germ cell tumors  Mass does not transilluminate  Erectile dysfunction and/or loss of libido TREATMENT  Non-pharmacological management o Active surveillance o Surgical intervention: radical orchiectomy in all testicular cancers regardless of staging o Radiation therapy  Pharmacological management o Chemotherapy: cryopreservation of sperm should be discussed prior to initiation of treatment, type of chemotherapy treatment dependent on type of cancer: seminoma or nonseminoma REFERRAL  Refer to urologist or oncologist for evaluation and treatment FOLLOW-UP  Close monitoring of hCG, LDH and alpha-fetoprotein for indication of therapy response and recurrence  Periodic chest and abdominal CT for detection of metastasis  Follow-up is largely dictated by the type of cancer and treatment  Typically, initial office visits are every 1-2 months after orchiectomy with adjuvant therapy for patients with orchiectomy and adjuvant therapy, initial follow-up is every 3-4 months. Frequency tapered if no evidence of relapse Testicular cancer: growth of cells that start in the testicles/ is not a common type of cancer/ can occur at any age but it happens most often btw ages 15 and 45. The first sign of this cancer is often a bump on the testicle/ the cancer cells can grow quickly and often spread outside the testicle to other parts of the body/ highly treatable even after spreading to other parts. Risk factors: undescended testis (cryptorchidism), family history, age, ethnicity (white), infertility, HIV infection, being a young adult, abnormal testicle development Treatment include surgery and chemotherapy Signs and sxs of testicular cancer:  A lump or swelling in either testicle  A feeling of heaviness in the scrotum  A dull ache in the lower belly or groin  Sudden swelling in the scrotum  Pain or discomfort in a testicle or the scrotum  Enlargement or tenderness of the breast tissue  Back pain Causes It's not clear what causes most testicular cancers. Testicular cancer starts when something causes changes to the DNA of testicle cells. A cell's DNA holds the instructions that tell the cell what to do. The changes tell the cells to grow and multiply quickly. The cancer cells go on living when healthy cells would die as part of their natural life cycle. This causes a lot of extra cells in the testicle that can form a mass called a tumor. In time, the tumor can grow beyond the testicle. Some cells might break away and spread to other parts of the body. Testicular cancer most often spreads to the lymph nodes, liver and lungs. When testicular cancer spreads, it's called metastatic testicular cancer. Nearly all testicular cancers begin in the germ cells. The germ cells in the testicle make sperm. It's not clear what causes DNA changes in the germ cells. Testicular cancer screening: Regular testicle self-exams During a testicular self-exam, you feel your testicles for any lumps There's no research to show that self-exams can lower the risk of dying of testicular cancer Even when it is found at a late stage, testicular cancer has a high likelihood of being cured Follow-up visits for testicular cancer are usually scheduled for 5 to 10 years after the initial treatment:  every 2 to 6 months for the first 3 years  every 6 to 12 months after 3 years Per Clinical Guidelines book – CRYPTORCHIDISM RISK FACTORS  Family history of cryptorchidism  Premature birth  Hypospadias  Low birth weight  Prenatal exposure to endocrine disruptors such as pesticides  Maternal smoking or diabetes  High maternal alpha-fetoprotein levels  Klinfelter syndrome ASSESSMENT FINDINGS  Absence of one testis or both testes upon palpation of scrotum  One or both testicles in location other than scrotum  Most boys with cryptorchidism have an inguinal hernia REFERRAL   Refer for urologic evaluation if testicle(s) not descended by age 6 months or for boys >6 months (corrected for gestational age) with possible newly diagnosed (acquired) cryptorchidism  Multiple specialist consultations for evaluation of possible disorder of sex development for all phenotypic newborn boys with bilateral nonpalpable testes  Tell males to screen for condition once a month/ testicular malignancy 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.) Click to edit Master title style 3 Cryptorchidism 3 Thorough GU exam, including an attempt to "milk" inguinal 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 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 Get an ultrasound to evaluate the condition / also at a higher risk for testicular torsion Peyronie Disease: 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 Click to edit Master title style 6 Peyronie Disease 6 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 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 The bend is significant and cause severe pain and function / dx is made by hx and examination/ imaging radiograph or MRI / Per Clinical Guidelines book – ERECTILE DYSFUNCTION RISK FACTORS (ETIOLOGY)  Vascular o Cardiovascular disease o Hypertension o Diabetes o Smoking o Hyperlipidemia o Radiotherapy of the pelvis or retroperitoneum  Respiratory o COPD o Sleep apnea  Neurologic o Injuries to spinal cord/brain o Parkinson's disease o Alzheimer's disease o Multiple sclerosis o Stroke  Penile conditions o Peyronie's disease o Cavernous fibrosis o Penile fracture o Epispadias o Priapism   Hormonal o Hypogonadism o Hyper- or hypothyroidism o Hyper- or hypocortisolism o Hyperprolactinemia  Drug-induced o Antihypertensives o Antidepressants o Antipsychotics o Antiandrogens o Recreational drugs o Pain medications (especially opioids and anticholinergics) o 5-alpha reductase inhibitors o Antiulcer drugs o Alcohol use  Psychogenic o Performance-related anxiety o PTS o Relationship problems o Lack of arousal/attraction in a specific relationship o Anxiety o Depression o Stress  Surgical procedures o Radical prostatectomy o Retroperitoneal or pelvic lymph node dissection o Transurethral resection of the prostate o Postoperative disruption in neurologic function 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 Click to edit Master title style 9 Erectile dysfunction 9 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 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 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 Prostatitis 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 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! Prostatitis 14 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 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 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. Click to edit Master title style 17 Epididymitis Urinalysis and culture along with studies for GC and Chlamydia - will reveal pyuria and bacteriuria Ultrasound with Doppler studies if concern for torsion < 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) 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! 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 Per Clinical Guidelines book – TESTICULAR TORSION ASSESSMENT FINDINGS  Sudden, severe, unilateral scrotal pain  Scrotal edema and erythema  Firm, tender mass that may appear retracted upwards  No relief of pain with testicular, scrotal elevation  Lower abdominal pain  Reactive hydrocele  High-riding testicle  Horizontal lie within the scrotum  Nausea and vomiting  Testis tenderness is significant   Cremasteric reflex absent  In children, may present as sudden awakening with scrotal pain  TWIST Score (range 0-7 points) o Testicular swelling – 2 points o Hard testicle – 2 points o Absent cremasteric reflex – 1 point o Nausea and vomiting – 1 point o High riding testicle – 1 point TREATMENT  Non-pharmacological management o Manual detorsion if surgery is not performed within 6 hours o Bilateral orchiopexy o Surgical exploration and detorsion with orchidopexy or orchiectomy for nonviable testis  Pharmacologic management o Pain medication o antiemetics Testicular torsion 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 Click to edit Master title style 22 Testicular Torsion 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. Click to edit Master title style 23 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. 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 Click to edit Master title style 25 BPH 25 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 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 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 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 Inguinal hernia risk factors, assessment Risk factors for inguinal hernia include:  Being male  Being older  Having a family history of the condition  Having a congenital opening or weak spot in the abdominal wall  Having a history of abdominal surgery or radiation therapy  Having a chronic cough or sneezing  Having chronic constipation or straining to pee or poop  Being pregnant How is it diagnosed? A physical exam is usually all that's needed to diagnose an inguinal hernia. Your doctor will check for a bulge in the groin area. Because standing and coughing can make a hernia more prominent, you'll likely be asked to stand and cough or strain. If the diagnosis isn't readily apparent, your doctor might order an imaging test, such as an abdominal ultrasound, CT scan or MRI. Treatment If your hernia is small and isn't bothering you, your doctor might recommend watchful waiting. Sometimes, wearing a supportive truss may help relieve symptoms, but check with your doctor first because it's important that the truss fits properly, and is being used appropriately. In children, the doctor might try applying manual pressure to reduce the bulge before considering surgery. Enlarging or painful hernias usually require surgery to relieve discomfort and prevent serious complications. There are two general types of hernia operations — open hernia repair and minimally invasive hernia repair.  When body tissue bulges through a muscle o Indirect: A congenital hernia and will present before age one. hernia involves passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. o Direct: protrusion of abdominal contents through the transversalis fascia within Hesselbach’s triangle. The borders of Hesselbach’s triangle are the inferior epigastric vessels superolaterally, the rectus sheath medially, and inguinal ligament inferiorly. o Femoral: hernial located inferior to the inguinal ligament and protrudes through the femoral ring (more common in women and 40% and incarcerated or strangulated) o Umbilical: occur most often in newborns, and 90 percent will naturally close by the time the child reaches 5 years of age. o Ventral: protrusion of intestine or other tissue through a weakness or gap in the abdominal wall. It can also result from chronic coughing, chronic vomiting, diabetes, heavy lifting, injury, obesity, pregnancy, or prior surgery. Open hernia repair In this procedure, which might be done with local anesthesia and sedation or general anesthesia, the surgeon makes an incision in your groin and pushes the protruding tissue back into your abdomen. The surgeon then sews the weakened area, often reinforcing it with a synthetic mesh (hernioplasty). The opening is then closed with stitches, staples or surgical glue. After the surgery, you'll be encouraged to move about as soon as possible, but it might be several weeks before you're able to resume normal activities. Minimally invasive hernia repair In this procedure requiring general anesthesia, the surgeon operates through several small incisions in your abdomen. The surgeon may use laparoscopic or robotic instruments to repair your hernia. Gas is used to inflate your abdomen to make the internal organs easier to see. A small tube equipped with a tiny camera (laparoscope) is inserted into one incision. Guided by the camera, the surgeon inserts tiny instruments through other small incisions to repair the hernia using synthetic mesh. People who have a minimally invasive repair might have less discomfort and scarring after surgery and a quicker return to normal activities. Long-term results of laparoscopic and open hernia surgeries are comparable. Minimally invasive hernia surgery allows the surgeon to avoid scar tissue from an earlier hernia repair, so it might be a good choice for people whose hernias recur after open hernia surgery. It also might be a good choice for people with hernias on both sides of the body (bilateral). As with open surgery, it may be a few weeks before you can get back to your usual activity level STI and genital infections INFECTION TESTING TREATMENT SIGNS/SYMPTOMS GONORRHEA NAATs Ceftriaxone Men have 250mg IM x1 + symptoms (blood azithromycin 1g tinged urethritis, PO x1 OR dysuria, penile Cefixime 400mg edema, acute PO x1 + empididymitis, azithromycin 1g prostatitis) PO x1 Women usually do not (abnormal bleeding, dysuria, vaginal discharge HPV Diagnosis Patient- Lesions are based on administered usually clinical findings treatment: asymptomatic. Podofilox 0.5% Patients may PAP testing solution or gel report itching or applied twice pain, depending daily three times on location. per week until External warts are resolved; may flat, papular, or be repeated up pedunculated to 4 weeks lesions, single or OR multiple, and of Imiquimod various sizes. 3.75% or 5% cream applied at bedtime three times per week for 16 weeks OR Sinecatechins 15% ointment  applied three times a day for 16 weeks Provider- administered treatment: Cryotherapy with liquid nitrogen or cryoprobe, repeated every 1–2 weeks OR Surgical removal by excision, curettage, laser, or electrosurgery OR TCA or BCA 80%–90% solution applied weekly YEAST CHLAMYDIA NAATs Azithromycin 1g Asymptomatic PO x1 infection is OR common. Females Doxycycline 100mg PO BID may report dysuria x7days and mucopurulent OR vaginal discharge. Levofloxacin Males may report 500mg PO daily purulent urethral for 7 days OR discharge, dysuria, ofloxacin 300mg PO BID for 7 or pain/swelling of days testicle(s). HERPES Primary Primary: infection: Initial infection  Acyclovir may be 400mg PO TID asymptomatic 7-10 Painful ulcerations days OR Hyperesthesia  Acyclovir h/a 200mg Malaise  PO Myyalgia 5x/day Dysuria for 7-10 Lymphadenopathy days OR  Famciclo Localized pruritis vir 1g Recurrent PO BID infections: 7-10 Prodrome of pain, days burning, and/or Recurrent parasthesia over  Acyclovir area of eruption 800mg PO BID Burning genital 5 days pain OR lesions  Acyclovir 400mg PO TID 5-10 dayys  Acyclovir 800mg PO TID for 2 days  Famciclo vir 125mg PO BID for 1 day  Valacycl ovir 1g PO x1 for 5 days Suppressive  Acyclovir 400mg PO BID  Famciclo vir 250mg PO BID up to 1 year  Valacycl ovir 500mg- 1g PO daily for 1 year BV Gram stain Metronidazole Need at least 3: 500mg orally Thin white BID x7 discharge OR Clue cells Metronidazole Ph>4.5 gel 0.75%, one Fishy odor with the full applicator “whiff test” intravaginally once a dayx5 OR Clindamycin cream 2% one full applicatory intravaginally at bedtime x7days HIV Rapid test most common PID Pregnancy test Ceftriaxone Symptoms (triad): first 250mg IM in a Pelvic pain CMT single dose + Fever Uterine doxycycline Vaginal discharge tenderness 100mg PO BID Adnexal x14 days with or Pt will complain of tenderness without cervical motion Metronidazole pain 500mg PO BID x 14 days PCOS WOMEN’S HEALTH  Amenorrhea o Primary amenorrhea  No menses by age 13 in absence of secondary sex characteristics OR  Absence of menses by age 15 regardless of the development of secondary sex characteristics  Chromosome mutations  Outflow tract disorders  Ovarian disorders  Hypopituitarism  CNS disorders  Extreme weight loss/anorexia o Secondary amenorrhea  Cessation of menstruation for 3 normal cycles or for 6 months in a woman who previously experiences menstrual bleeding   Pregnancy  PCOS (90% of cases)  Endocrine disorder  Anatomical causes  Premature ovarian failure  Stress  malnutrition  irregular vaginal bleeding  menstrual cycle Day 1 First day of LH, FSH, progesterone, Ovary forms period estradiol = LOW follicle Blood and tissue (FOLLICULA shed R PHASE) Day 5-8 Period stops Estradiol = increase Follicular Uterine lining is phase rebuilding continues Day 9-13 Estradiol = increase Follicular LH = peak before ovulation phase continues Day 14 Ovulation Estradiol = peak then sharp Egg released Increase risk of drop from ovary pregnancy LH, FSH = sharp rise Day 15-24 FSH, LH = decrease Luteal phase Progesterone = starts to rise Corpus luteum Estradiol = decrease then slow forms rise Day 24-28 Premenstrual Estrogen & progesterone = drop Oocyte breaks week (when a apart if not person will feel fertilized symptoms of PMS)  PCOS o PCOS –ovaries produce an abnormal amount of androgens o Some women will not prevent with cysts and some will in the ovaries o PCOS is the most common cause of androgen excess and hirsutism o Bilaterally enlarged polycystic ovaries, amenorrhea or oligomenorrhea, and infertility o Usually, normal puberty followed by progressively longer episodes of amenorrhea o AP makes too much LH o Thought to be hypothalamic-pituitary dysfunction and insulin resistance resulting in androgen excess or can be genetically predisposed o Diagnosis in adults: evidence of 2/3 = hyperandrogenism, oligo-ovulation or anovulation, polycystic ovaries on US  o Diagnosis in adolescents: evidence of all 3 = oligomenorrhea or amenorrhea present 2 years after menarche, polycystic ovaries with increased ovarian size (US), hyperandrogenemia diagnosed via labs  Contraception  breast cancer screening  lactation  postpartum care o  Preeclampsia  Mastitis   labor  RhoGAM  UTI  care of the pregnant patient Prenatal Test Gestational Age (Weeks) Extra  Ultrasound for nuchal translucency  PAPP-A and hCG  ↑ levels are seen in chromosomal abnormalities  Low levels of PAPP-A can be associated with Down's First trimester screen 11-14 Syndrome   Analyze fetal DNA in maternal blood  Screens for trisomies of 13, 18, and 21  Positive test results should be followed by CVS or Cell free fetal DNA ~10 amniocentesis  Collect placental tissue to test for Chorionic villus sampling chromosomal and (CVS) 11-14 genetic abnormalities  AFP, hCG, estriol, inhibin  ↑ AFP = neural tube or abdominal wall defects  ↑ hCG and inhibin and ↓ AFP and estriol = Down syndrome  ↓ AFP, hCG, and estriol = Edwards Quadruple screen 16-18 syndrome  Collect amniotic fluid to diagnosis chromosomal Amniocentesis 15-20 abnormalities  1 hr glucose challenge test  If abnormal followed by glucose tolerance Glucose challenge test 24-28 test Group B strep test 35-37  Swab the lower gen  gestational diabetes o TX: Patients with gestational diabetes must check their blood glucose levels daily after fasting overnight and after each meal. At each office visit, the patient’s home glucose levels should be reviewed, and if necessary, a fasting or a 2-hour postprandial blood glucose measurement should be done during the office visit. o Patients who have fasting blood glucose measurements of greater than 105 mg/ dL or 2- hour postprandial blood sugar measurements of greater than 120 mg/ dL may require insulin. o Insulin is the treatment of choice - the goal is fasting glucose < 95 o NPH/Regular 2/3 in AM and 1/3 in PM o Glyburide (only oral hypoglycemic that doesn't cross placenta but higher risk of eclampsia) initially or insulin if needed, higher risk of eclampsia o Early delivery by c-section at 38 weeks if the child is macrosomic. o Good glucose control is described as a 2-hour glucose tolerance test 150/90 after 20 weeks into the pregnancy that resolves 12 weeks postpartum  clinically asymptomatic  elevated BP and NO PROTEIN  May withhold medications, hydralazine or labetalol are considered safe if treatment is warranted  Chronic hypertension - BP > 140/90 prior to 20 weeks of gestation that persist for > 6 weeks postpartum  symptoms of HTN include headache and visual symptoms if severe  Mild BP > 140/90, Severe >180/110 with NO PROTEINURIA  Monitor every 2-4 weeks, then weekly at 34-36 weeks gestational age and deliver at 39-40 weeks  Severe - Meds if BP > 150/100 - labetalol or intermediate-acting or extended- release nifedipine. Oral hydralazine may be added if needed to achieve and maintain target blood pressure. Methyldopa is also a safe alternative but is hard to reach BP goals and is limited by sedative effects. Avoid ACEI and diuretics o pre and post pregnancy follow up appointments o ectopic pregnancy  Symptoms   Abdominal pain  Vaginal bleeding  Amenorhea  Flulike symptoms  Vomitting  Syncope  Cardiac arrest  The presence of the following is a surgical emergency o Abdominal rigidity o Involuntary gaurding o Severe tenderness o Hypovolemic shock  Diagnosis: o Serial serum quantitative beta-hCG o If initial hCG level is 3,000 mIU/mL, expected rate of increase is 33% in 48 hours o Ultrasound o Ultrasound imaging is necessary to visually determine location of pregnancy o Although a gestational sac may be visible as early as 5 weeks, ultrasound evidence of an intrauterine pregnancy must include visualization of gestational sac with yolk sac or embryo o An hCG discriminatory level at which the landmarks of an intrauterine pregnancy would be visualized is 3,500 mIU/mL  Treatment o Medical management with intramuscular methotrexate is an option for a confirmed or high suspicion of ectopic pregnancy in women who are hemodynamically stable, without rupture and no contraindications. This is not an FDA-approved use for methotrexate, but it has been endorsed by ACOG o Medical management is more cost effective and avoids the risk of surgery and anesthesia o hCG values should be less than 1,500 mIU/mL  o group B strep screening and treatment o Naegele’srule  Use first day of the LMP  Subtract 3 from the number of months   Add 7 to the number of days  Adjust the year if the birth will occur in the next year o genetic screening, family planning, management of the pregnant patient in primary care o Hegar  Softening and compressibility of the uterine isthmus o Chadwick's sign  bluish color to the cervix, vagina and labia due to increased blood flow in pregnancy, can be seen as early as 6-8 weeks Weight gain ranges during pregnacy: Normal weight – 25-35 lb Overweight person – 15-25lb Underweight – 28-40 lb MEDICATIONS Flucanozole – not safe in pregnancy Macrolides – not safe in pregnancy Trimepothrim – not safe in pregnancy Metronidazole – SAFE Amoxicillin-clavunate – SAFE Fluoroquinolones – not safe in pregnancy Amniocentesis – 8-12 weeks AFP 14-20 weeks Gestational diabetes 24-48 A hydrocele should be reassessed after birth at 12 months HIV infection is not a risk factor for squamous cell carcinoma