Download Training

Male Urogenital Disorders
Jeffrey T. Reisert, DO
University of New England
Physician Assistant Program
20 JAN 2010
Contact Information
Jeffrey T. Reisert, DO
Jeffrey.T.Reisert@Hitchcock.org
103 Boulder Point Rd., Suite 3
Plymouth, NH 03264
603-536-6355
603-536-6356 (fax)
Genitourinary Section-Part 1
Male urogenital disorders/Impotence
 Nephrolithiasis
 Urinary Tract Infections

Genitourinary Section-Part 2
Introduction to Renal Failure
 Acute Renal Failure
 Chronic Renal Failure
 Glomerulopathies (builds on prior topics)
 Tubular disorders (builds on prior topics)
 Hematuria (Evaluation of this entity)
 Proteinuria (Evaluation of this entity)

Agenda

Disorders of the penis
– Phimosis
– Balanitis
– Impotence

Infections
–
–
–
–
STD’s
UTI’s
Epididymis
Prostatitis
Agenda part II
Testicle cancer
 Prostate disorders

– Acute and chronic prostatitis
– Benign prostatic hypertrophy
– Prostate Cancer
Anatomy

See diagram
Phimosis
Uncircumcised male
 Cannot readily retract foreskin to the corona
of the glans
 Can get glans stuck outside of the foreskin
 Treatment: Circumcision

Balanitis
Infection of head of penis
 Typically fungal
 More often seen in uncircumcised men
 Treat with OTC antifungals like Monistat or
oral fluconazole

– Just like vaginal yeast infections in women
Circumcision

Surgery done some feel is good idea, others not
– Those opposed feel not medically necessary,
complication risk including pain, decreases stimulation
later in life.
– Those in favor feel hygienic issue, need to look like dad

Check out resources
– American Academy of Pediatrics
– www.circumcision.org
– Etc.
Penile Cancer
Can be seen on inspection
 Surgical disease

Varicocoele
Cluster of dilated veins usually on left
 “Bag of worms”

Hydrocoele
Water on the testicle
 Ultrasound
 Illumination
 Treatment usually reassurance. Sometimes
hydrocoelectomy

Other anatomical items

Hypospadius
–
–
–
–
Urethral meatus not at tip of glans
A midline defect
Sometimes requires correction
Unusual urinary stream?

Sit to pee?
– Problems with ejaculation?
Urinary obstruction
Prostate
 Stricture
 Weak detrusser muscle
 Self catheterization

Impotence/Sexual
dysfunction/Erectile
dysfunction
Failure to obtain erection, ejaculation, or
both
 Common
 Increased frequency with aging

– How old should you be to lose functioning?
– Ask Tony Randall (the late Tony Randall)
– Must be realistic
ED continued
Psychogenic (about 20% of the cases)
 Organic (up to 80% of cases)
 Other terms

– Premature ejaculation-psychological in origin

Serotonin reuptake inhibitors (SSRI’s) like Prozac
can be used to delay ejaculation
– Priapism-Persistent painful erection
Requires urology evaluation, emergently
 NOT every guy’s dream

Normal sexual functioning
Involves the desire
 Engorgement of corpora cavernosa under
control of parasympathetic nervous system
 Under sympathetic nervous system
contraction of smooth muscle occurs and if
all goes well, ejaculation can occur

Psychogenic impotence
A common cause
 The mood must be right
 Factors such as depression and anxiety
commonly affect sexual functioning
 Should include psychological review in
your evaluation
 The housekeeper story

Problems
Can’t initiate
 Can’t fill (engorge)-Usually arterial
problem

– Consider things like Diabetes, Hypertension,
and ASHD

Can’t store-Veno-occlusive dysfunction
Organic impotence




Many causes
Hormonal (loss of testosterone in testicular failure,
pituitary tumor producing prolactin, pituitary
failure)
Drugs (antihypertensives, psychological, others)
Neurological (spinal cord injury, MS)
Organic Impotence-Cont.
Vascular disease (diabetes, atherosclerosis)
 Penile diseases such as Peyronies disease
(rigid scarring of penis resulting in crooked
painful erection)

– Etiology: Unknown, or prior penile surgery.
Perhaps familial.
– Treatment: Injection verapamil, radiotherapy,
surgery, shock wave therapy
Medical evaluation for ED


History and exam
Testosterone level, prolactin level, and luteinizing
hormone (required for testes to produce
testosterone)
– Prolactinoma (pituitary origin)-MRI
– High levels prolactin result in low testosterone


Ultrasound testing
Nocturnal penile tumescence testing, or “tape
testing”
Treatments
Replace testosterone if low (next slide)
 Fix tumor if present
 Treat any other medical cause if present, or
offer counseling

Hypogonadism

Low testosterone levels
– May be due to testicular failure (or orchiectomy)
– May be due to axis problems (Hypothalamic/pituitary)

Replacement
– Testosterone is poorly absorbed orally (first pass)
– Injectable-Depo-testosterone® 1cc (100 or 200mg/cc)
qmonthly IM
– Topical


AndroGel® -Squirt gel, rub on
Patch-Androderm® transdermal patch 2.5 or 5mg
Treatments, cont.

Phosphodiesterase type 5 inhibitor-oral
–
–
–
–
Relaxes smooth muscle, allowing filling
Headache
Flushing
Can’t use with nitrates (hypotension, death may
result) or alpha blockers.
– Absorption may be affected by food, especially
higher fat containing meal
Phosphodiesterase inhibitors

Sildenafil (Viagra ®)-If Rafael Palmero can use,
so can you. Play ball!
– Visual changes possible (Blue vision, rarely loss of)
– Pfizer looking at OTC version



Vardenafil (Levitra ®)-Stay in the game!
Tadalafil (Cialis®)-The newest on the market.
Why are the couple in different bathtubs? Longer
half-life reported. 4 hour erections???
Heavily advertised
Treatment-cont.

Prostaglandin E1
– Alprostadil (Caverject)--inject into penis
80%success
 Long term adherence poor
 Penile pain
 Not as glamorous as a pill

– Alprostadil (MUSE)-Intraurethral
Penis ache
 40% success rate

Treatment-cont.


Yohimbine-Not very effective, but better than placebo
Vacuum device
–
–
–
–

Less popular
Safe
Require restrictive band
Blue penis (Smurf-like?)
Surgery-Penile prosthesis
– Semi-rigid
– Inflatable


Reservoir in abdomen or scrotum
Require dexterity
Urinary tract infections
Cystitis
 Urethritis (Some consider an STD
syndrome)
 Prostatitis
 Pyelonephritis (next slide set)
 Young males with infections should be
evaluated, urologically

Urinary defenses
Flow
 Dilution
 Prostate secretions antibacterial

Cystitis
Refers to a simple bladder infection
 Most commonly due to coliforms

– Escherichia coli (E. coli). most common (80%)
– If culture negative think Ureaplasma
ureolyticus

More later
Urethritis
Due to typical urinary tract organisms or
chlamydia (Non-gonococcal)
 Can be due to gonorrhea
 Check for urethral discharge, gram stain and
culture

Urethritis cont.
Non infectious causes include Reiter’s
syndrome (also develop arthritis following
an enteric infection)
 Treatment doxycycline 100 mg bid for 7d or
azithromycin 1000mg

Epididymitis
Can be seen in younger male (MC due to
Chlamydia)
 Can be seen in older, too (Gram negative
bacilli)
 Characteristically seen as a sudden onset of
unilateral pain
 Treatment with quinolone such as ofloxacin
or ceftriaxone and doxycycline

Prostatitis

Acute
– Often seen in young
– Usually sudden onset
– Often E. coli or Klebsiella sp.
(Enterobacteriaceae)
Prostatitis-cont.

Chronic
–
–
–
–
–
Up to 9% of men
Prostate often normal on exam
Can be due to recurrent infection or inflammation
?Autoimmune
May culture negative (Ureaplasma ureolyticus or
chlamydia). Consider prostate massage for culturing
– Alpha blockers may help
– Good review NEJM 2006….No universally accepted
best treatment
Prostatitis
Fever/chills
 Prostate tenderness (perineal or testicular
pain)
 Dysuria (usually mild)
 Urinary frequency
 Low back pain

Prostatitis-cont.
Diagnosis can be made on exam and urine
testing.
 Chronic prostatitis may require prostatic
secretion expression

– Prostate massage 
Prostatodynia
Pain without infection
 Non-steroidal anti-inflammatory drugs
(NSAIDS)

Overactive Bladder (OAB)


Urgency, incontinence (Gotta go, gotta go)
Anti-cholinergics
–
–
–
–
–
–
–
–
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Blocks muscarinic receptors, decreasing bladder contraction
Oxybutynin (Ditropan®, Oxytrol® patch)
Tolterodine (Detrol®)
Solifenacin (VESIcare®)
Trospium (Sanctura®)
Darifenacin (Enablex®)
Fesoterodine (Toviaz)
Dry mouth, constipation, blurred vision
Heavily advertised
Infection treatment
Urinary pathogens treated well with
 Trimethoprim/sulfamethoxazole,
fluoroquinolones
 3d in females, but 7-10-14d in males
 Should recheck after completing therapy

– Helps establish resistance vs. recurrence
Cure rates vary
 More later

Sexually transmitted diseases
(STD’s)
12M in USA each year
 Suggest high risk behaviors
 Social implications
 Increased incidence in lower socioeconomic
groups, unmarried, multiple partners

STD’s-Discharges
Neisseria gonorrhoeae (Gram neg.
diplococci)
 Chlamydia trachomatis (May lay dormant)

STD’s-Ulcers
Herpes simplex virus (Most common,
vesicles may be seen)
 Syphilis (Treponema pallidum, typically
painless)

STD’s-cont.

Hepatitis B
– Vaccine available
– Please be sure you are vaccinated, students!!!!
– Check titers (Vaccine not 100% successful)

HIV
– Leading cause of death in USA age 25-40
STD’s cont.-HPV

Warts (Human papilloma virus)
– Strains 6, 11 most common, least harmful
– Strains 16,18, 31, 32, 35 can cause cervical dysplasia)
– Cryosurgery or podophyllin for visible warts (less
cervical CA association)
– Vaccination



Gardasil®
9-26 y/o females (Boys too, 2009!)
Good safety and efficacy data
Testicular cancer
Also called germ cell tumors
 Can begin in testicle or elsewhere
(extragonadal)
 Typically a disease of the young (20-40)

– In older men think lymphoma

Very high cure rate (90%)
Testicular cancer
epidemiology


7000-8000 cases per year in USA
Higher risk if undescended testicle
– Cryptorchidism (undescended testicles incr risk)
– Correction may not reduce risk, but may increase ease
of detection


More common in Caucasians than men of race
Other risk factors
– Frequent UTI’s, Renal lithiasis
– Uncircumcised men, multiple sex partners
Testicular cancer-Diagnosis
Typically presents as painless lump on
testicle
 Ultrasound
 HCG may cause gynecomastia
 Self exam/Physician exam
 Must exclude infection causing similar
symptoms

Testicular cancer-Evaluation
Typically requires radical orchiopexy
through inguinal canal rather than scrotum
to prevent change in spread pattern, plus
lymph node dissection
 Tumor markers

– Beta human gonadotropic hormone (Beta HCG)
– Alpha feto protein (AFP)

Chest x-ray
Testicular cancer-Pathology
Two types
 Seminoma tumors

– Less aggressive
– Radiosensitive

Non-seminomatous tumors
– Secrete AFP, but not HCG
Testicular cancer-Treatment


Orchiopexy-Cut it out!
Chemotherapy-Etoposide + Cisplatin +/Bleomycin
– Side effects including hair loss, nausea, and
myelosuppression



Single dose carboplatin
Fix cryptorchid testes before puberty (may help,
may not)
Gotta love Lance Armstrong! Mike Lowell, too!
Prostate
Secretory gland below bladder
 Contributes about 15% of seminal fluid
 Usually 20ml sized (Chestnut or walnut)
 At 40ml enlarged (Golf ball)

Digital Rectal Exam (DRE)

Begin at age 50 if life expectancy of 10+
years
– New data 2008….Don’t screen if >75 y/o
Gently insert gloved finger, using lubricant
 Allow sphincter to relax, before insertion
 Assess for size and texture
 Top may not be palpable in large gland
 See video

Benign prostatic hypertrophy
(BPH)

Increased incidence with aging. Virtually
all men develop
– 10-20% of men in their 70’s
– 80 y/o up to 90% incidence

Begins around the urethra
BPH-cont.
Size of gland does not necessarily correlate
with severity of symptoms
 Growth probably mediated by testosterone,
although not completely understood
 Urinary obstruction most likely to play role
in symptoms
 Estrogen may play a role as well

BPH symptoms
Decrease in stream quality
 Hesitancy
 Dribbling
 Incomplete emptying/Frequency
 Retention
 Nocturia

Symptom scoring
International Prostate Symptom Score
(IPSS)
 American system (AUA)
 See attachments

BPH complications
Loss of sleep/Inconvenience
 Urinary retention may lead to obstruction,
infection
 Only need to treat if symptoms present.
 Treatment not thought to affect long term
prognosis

BPH treatments
Watchful waiting
 Medications

– Prescription
– Phytotherapy (Plants)

Surgery
BPH treatment

Alpha 1 adrenergic blockers
– Relax bladder improving symptoms
– May decrease libido, abnormal ejaculation
– Dizziness/Orthostasis
Alpha blockers

Non-selective
– Also reduce blood pressure
– Terazosin (Hytrin®)
– Doxazosin (Cardura®)

Selective
– Less orthostasis
– Tamsulosin (Flomax®)
– Alfuzosin (Uroxatral®)

Cataracts
– Surgery may result in iris softening and lens problems (Flomax
only?)
Treatment cont.

5 alpha reductase inhibitors
– Inhibit the enzyme that converts testosterone to 5 alpha
dihydrotestosterone (DHT) which decreases
testosterone stimulation of gland
– Finasteride (Proscar®)

Helps male pattern baldness (Propecia®)
– Dutasteride (Avodart®)
– Decrease gland size with some improvement in
symptoms
– Not for women, blood donors (teratogenic)
Phytotherapy

Saw palmetto (palm tree extract)
– Better than placebo (More recent data suggests not as
helpful as we once thought)
– Safe
– 80-320 mg per day

Beta sitosterol plant extract
– GI upset
– Impotence

Rye grass pollen
Treatment-cont.

Surgery
– Transurethral resection of prostate (TURP)


Not thought to increase impotence or incontinence
Bleeding, surgical morbidity
– Transurethral microwave therapy (TUMT)

Uses microwaves to burn gland
– Transurethral needle ablation (TUNA)

Uses heat to burn gland
– Transurethral ultrasound guided laser induced
prostatectomy (TULIP)


Indigo laser
Other laser treatments
Prostate Cancer
Prostate Cancer-Incidence
317K cases newly diagnosed in USA per
year
 41K deaths in USA per year (2nd or 3rd
most common cause of cancer deaths,
competing with colon CA)
 Higher incidence in African Americans

Prostate Cancer-Etiology
Is hereditary---Be sure to screen!
 Most are adenocarcinomas
 Interestingly, is often an asymptomatic
disease, early (Until bone mets…..bad)

Prostate Cancer-Grading
Gleason’s scoring
 Helps prognosticate
 Score 1 for well differentiated (favorable)
up to 5 for poorly differentiated
(unfavorable)
 Add two prostate biopsies together for score
between 2 and 10 with 10 having the worst
outlook
 Surgical staging may also be done

Prostate Cancer-Diagnosis




Digital rectal exam
– Often begins in posterior part of gland
– Hard irregularity in gland
As always, with cancer, requires biopsy
Transrectal biopsy through the lump with or
without ultrasound guidance or random sextant
biopsies
If positive, radionuclide bone scan to look for
metastatic disease
Prostate specific antigen
(PSA)
Serine protease that is involved in
liquefaction
 Elevated in 65% of cases
 35% false negative rate
 Non specific (also rises in prostate
enlargement, prostatitis)

PSA-Downfalls

May fluctuate
– Consider repeat if first elevation

If greater than 4
– Sensitivity is 57-79%
– Specificity is 59-68%
– Positive predictive value is 40-49%
Other specialized prostate blood
tests

Percent free PSA
– If low, higher likelihood of cancer

PSA velocity
– If rise >0.75ng/ml in one year

New test coming, More?
– EPCA-2 (Early prostate cancer antigen 2)
– 2008. One vendor
– More specific?
Prostate Cancer-Spread
Local
 Lymph (common in higher Gleason scores)
 Blood
 Usually to bone

Prostate Cancer-Treatment
Surgery
 Radiation
 Hormone
 Chemotherapy

– Not particularly effective
– No evidence for increased survival
Prostate Cancer-TreatmentSurgery

Removal of gland
– Radical prostatectomy
– Now being done laparoscopically and robotically




By some considered gold standard treatment
Typically cures early stage disease
High incidence of impotence (15-80%) and
incontinence (despite “nerve sparing” procedure)
Younger patients, more likely to pursue this (see
later slide)
Prostate Cancer-TreatmentRadiation
Not considered curative
 May use for local disease
 May use for palliation of bone metastasis

Prostate Radiation

External beam
– 6000-7000rads over 6 weeks
– 50% impotence
– Diarrhea/proctitis

Implantable seeds (brachytherapy)
– 10-20% impotence
– Surgery make take a few hours

Less impotence and incontinence than surgery
Prostate Cancer-TreatmentHormones
Androgen depravation
 Also considered more suppressive than
curative
 Different methods
 Hot flashes

Prostate Cancer-Hormones,
cont.
Remove testosterone production
(orchiectomy)
 Inhibit ACTH (Leuprolide (Lupron) and
also estrogen (diethylstilbestrol=DES)
 Inhibit testicular synthesis of testosterone
(Aminoglutethimide)
 Inhibit binding of androgen (flutamide
(Eulexin))

Prostate Cancer Treatment
Decision Making





Tough
What is best?
All choices have downfalls
You “may die with it, but not of it”
Younger patients do better with surgery
– More years ahead
– Better surgical risks


Older folks may be a very slow growing disease
2009 several organizations suggested NOT
screening for prostate CA
Summary
Disorders of the urogenital system can be
broadly divided into infectious and noninfectious disorders
 Testicular cancer which is very curable
contrasts with prostate cancer which isn’t
 As always, history and physical
examination lead to accurate diagnosis and
treatment
 Will discuss more on UTI’s in separate slide
set

Where to get more information
Harrison’s or Cecil’s textbook of internal
medicine
 DeVida Oncology

Questions?