MENNONITE COLLEGE OF NURSING

AT

ILLINOIS STATE UNIVERSITY

Family Nurse Practitioner III 475

Common Genitourinary Problems

Hematuria

Definition: > 3 RBC/HPF (although 3-5 RBC/HPF = normal in Peds)

History:

· Clots usually indicate lower urinary tract bleeding.

· Relationship to exercise may indicate runner’s hematuria

· Pain?

· Association with flank pain suggests infection, calculus, or obstruction

· Painless bleeding is associated with cancer or glomerulonephritis

· Association with hesitancy, frequency, or decreased force of stream is suggestive of prostatic hypertrophy

Determine type of hematuria:

Initial Hematuria

Arises from a lesion within the penile or bulbous portions of the urethra

Causes may include:

· cancer

· infection

· trauma

· excessive masturbation

· foreign body such as a calculi

Total Hematuria

Present throughout the entire voiding, must have a source higher than the bladder neck in order for the blood to thoroughly mix with the urine prior to the onset of voiding.

Such conditions may be:

· bladder, ureters, or kidney cancer

· infection,

· inflammation

· trauma of the bladder, kidney, or ureters

· TB of the bladder or kidney,

· stones in the bladder or kidney.

Terminal Hematuria

Exists when the urinary stream is visibly clear until the end of voiding, at which time the last part of the urine becomes grossly bloody, or when blood is passed from the meatus after the patient thinks that urination has ceased.

This is usually from:

· BPH

· prostatitis,

· bladder cancer (rarely)

Most common causes:

For men:

· < age 40: STDs

· > age 40: bladder cancer, BPH

For women:

· bacterial cystitis

· < age 40: UTI

· age 40-60: bladder tumors, UTI, calculi

· > age 60: bladder tumors, UTI

Consider child abuse

False-positive results from foods such as beets and blackberries, vaginal bleeding, myoglobin (exercise), drugs, and factitious sources.

Exam: VS, CV, CVA tenderness, abdomen, GU, skin (check for coagulopathy)

Diagnostic Tests:

· microscopic urinalysis

· screening lab tests (may need ANA, ASO antibody, RPR, CBC, PPD, urine for acid-fast bacilli, PSA)

· urine cytology

· Bladder tumor antigen

· Abdominal x-ray

· IVP

· Renal sonogram

· Cystoscopy

Follow-up

In many patients, despite a thorough workup, the cause is still unknown. Studies of 5-year follow-up of patients who have undergone a previously negative workup have shown that the future incidence of serious disease is low.

· Those > age 50 or with risk factors for urologic cancer should have a urine cytology every 6 months and yearly cystoscopy and IVP for 3 years.

· Those < age 50 who are asymptomatic and have no risk factors only require observation.

Acute Urinary Tract Infection

Etiology:

· Largely a disease of sexually active females

· Female to male incidence ratio of UTI is 2:1 after age 60

· UTIs are the most common bacterial infection in the elderly and are a common source for bacteremia

· Gram-negative coliforms are responsible for the majority of bacterial infections, with Escherichia coli predominating.

Symptoms:

Lower Urinary Tract:

· Dysuria

· Frequency

· Nocturia

· Suprapubic pain

· Hematuria

· Malodorous urine

· incontinence

Upper Urinary Tract:

· flank pain

· fever

· nausea and vomiting

· mental changes (in the elderly)

NOTE: Atypical presentations such as loss of appetite, nocturia, difficulty urinating, and new incontinence are common symptoms of UTI in elderly patients.

Clinical findings (Key signs):

Lower UTI:

· suprapubic tenderness

Upper UTI:

· flank tenderness

· fever

· tachypnea

· tachycardia

· mental status changes (in the elderly)

· vomiting

Diagnostic Tests:

Urine dip (screening test)

· biochemical screening tests include nitrite reduction and leukocyte esterase tests

· These screening methods are insensitive at bacterial counts < 100,000 colony-forming units/ml.

Microscopic examination & culture of clean midstream urine

· pyuria: 10 or more WBC/ml

· In absence of a (+) culture (< 100 uropathogens/ml), pyuria suggests infection by chlamydia or Neisseria gonorrhoeae, or tuberculosis

· WBC casts noted on microscopy strongly suggest pyelonephritis (upper UTI) in patients with UTI symptoms

Blood culture (in toxic or elderly patients with signs of upper UTI)

Differential Diagnosis:

· Acute bacterial lower UTIs in females may be mimicked by urethritis caused by C. trachomatis, N. gonorrhoeae, and herpes simplex virus.

· Vaginitis from Candida albicans and Trichomonas vaginalis or bacterial vaginosis also may cause dysuria.

· Acute upper UTI can be mimicked by diverticulitis, appendicitis, pneumonia, intestinal obstruction, and nephrolithiasis.

Treatment:

· Acute bacterial uncomplicated lower UTIs in females

· 3-5 days of oral outpatient therapy

· Uncomplicated bacterial upper UTIs in females and males: 14 days of oral or parenteral antibiotics; may need hospitalization (hospitalize if pregnant)

· Uncomplicated bacterial lower UTI in males: 14 days

NOTE: Elderly patients with asymptomatic bacteriuria aren’t at risk for developing a UTI or renal damage. Treatment is necessary only when the patient has a symptomatic UTI or is at risk for developing a more significant complication, such as if the patient has diabetes or is immunocompromised.

· Recurrent infections that cannot be eradicated can sometimes be suppressed by antibiotics. This should be avoided, however, unless the patient is symptomatic or developing complications, because it can often lead to infection with resistant organisms.

Factors that would designate a UTI as complicated include:

· Age > 65 years

· Indwelling catheter

· Recent GU instrumentation

· Urinary calculi

· Renal impairment

· Prostatic involvement

· DM

· Renal transplant

· Neutropenia

· Recent antibiotic therapy

· Recurrent UTI

· Pregnancy (cannot use quinolones during pregnancy or sulfonamides near delivery date; cephalexin is a reasonable 1^st choice)

· Steroid therapy

· Immunocompromising disease

· Known structural or functional impairment

Patient Education

· Stay well hydrated

· In female patient: voiding after intercourse for prophylaxis

· Alternate contraception if recurrent UTI is associated with use of diaphragm

· Consider chemoprophylaxis with recurrent lower UTI

Follow-up:

· UTI in men and complicated UTI require initial culture, and repeat culture after completion of therapy

· Thorough GU examination needed with:

· UTI in men

· Recurrent and complicated UTIs in females

Interstitial Cystitis (IC)

Definition/Cause

· A chronic inflammatory condition of the bladder.

· Its cause is unknown.

· Unlike common cystitis, which is caused by bacteria and usually successfully treated with antibiotics, IC is believe not to be caused by bacteria and does not respond to conventional ABT therapy.

· It is not a psychosomatic disorder nor is it caused by stress.

· It is not associated with bladder cancer.

Symptoms

· Frequency

o Day and/or night frequency of urination (up to 60 times/day in severe cases)

o In early or very mild cases, frequency is sometimes the only symptom

· Urgency

o May also be accompanied by pain, pressure or spasms

· Pain

o Can be in the lower abdominal, urethra, or vaginal area

o Pain also frequently associated with sexual intercourse

o Men with IC may experience testicular, scrotal and/or perineal pain, and painful ejaculation

· Other disorders

o Muscle and joint pain

o Migraines

o Allergic reactions

o GI problems

o IC sometimes associated with certain other chronic diseases and pain syndromes such as vulvar vestibulitis, fibromyalgia and IBS

Diagnosis

· Urine culture to rule out bacterial infection

· Rule out other diseases and/or conditions that have symptoms resembling IC

o Bladder cancer

o Kidney problems

o Tuberculosis

o Vaginal infections

o STDs

o Endometriosis

o Radiation cystitis

o Neurological disorders

· Cystoscopy with hydrodistention under general anesthesia

o Done if no infection present and no other disorder is discovered

o If distention under anesthesia is not performed, diagnosis of IC may be missed

o Cystoscopy during a routine office visit may not reveal the characteristic abnormalities of IC and can be painful for those who have IC

o Necessary to distend the bladder under general or regional anesthesia in order to see the pinpoint hemorrhages on the bladder wall that are the hallmark of this disease

o A biopsy of the bladder wall may be necessary at this time to rule out other diseases such as bladder cancer and to assist in the diagnosis of IC

Treatments

· Oral medications

o Elmiron (pentosan polysulfate sodium)

§ FDA approval in 1996

§ Only oral medicaiotn approved specifically for use in IC

§ Believed to work by repairing a thin or damaged bladder lining

o Antidepressants

§ Tricyclic antidepressants such as Elavil (amitriptyline)

§ Help with both the pain and frequency of IC

§ Used for their anti-pain properties, not as a treatment for depression

o Other oral meds

§ Anti-inflammatory agents

§ Antispasmodics

§ Bladder analgesics (such as Urimax)

§ Antihistamines

§ Muscle relaxants

· Bladder installations

o Bladder distention with water under general anesthesia (diagnostic and may be therapeutic as well)

o DMSO (dimethyl sulfoxide) as anti-inflammatory

o BCG (bacillus Calmette-Guerin) experimental; to boost immune system

o Cystistat (hyaluronic acid) in clinical trial; replace defective lining of bladder

· Other treatments

o Diet

§ Eliminating acidic, spicy foods may decrease severity of IC

§ Smoking, drinking coffee or tea, and alcoholic beverages may aggravate IC

o Self-help

§ Stress reduction, visualization, biofeedback, bladder retraining and exercise

o Electronic nerve stimulators

o Surgery (only if severe symptoms); cystectomy, urinary diversion

Pyelonephritis

Definition: Acute pyelonephritis (APN) is an acute infection of the upper urinary tract (collection system and renal parenchyma)

· Usually occurs when colonic bacteria ascend through the urinary tract to invade the renal parenchyma

· More common in females due to short length and position of urethra

· E. Coli most common cause (others include Proteus, Klebsiella, Staphylcoccus saprophyticus, and Enterococcus

Key Symptoms:

· Fever (101-105 degrees)

· Chills

· Dysuria, frequency, or urgency

· Back or flank pain

· Nausea or vomiting

Key Signs:

· Fever

· CVA tenderness

(Note: Cystitis: no fever, no CVA tenderness)

Conditions that can be confused with APN include:

· PID

· Acute appendicitis

· Acute cholecystitis

· nephrolithiasis

Treatment:

· Factors favoring hospitalization include:

· Geriatric age group

· Underlying medical condition such as DM or pregnancy

· Male gender (higher frequency of anatomic abnormality)

· Known GU tract abnormality

· Uncontrolled N & V

· Signs of possible sepsis (hypotension, altered mentation)

· Pregnancy

· Consider outpatient management for otherwise healthy young females who are reliable and who are tolerating oral intake.

Drug of choice (for outpts.): trimethoprim-sulfamethoxazole

Alternative drugs: fluoroquinolones, amoxicillin-clavulanate

Treat 10 days (in less ill patients) to 14 days (in more ill or pregnant patients).

Follow-Up:

· Brief visit (or at least phone follow-up) after 1-2 days to document clinical improvement

· Failure to improve or worsening symptoms after 48-72 hours of outpatient treatment may represent obstruction or abscess (will need ultrasound or IVP).

· A “test of cure” urine culture should be obtained approximately 2 weeks after the completion of antibiotic therapy.

Glomerulonephritis (GN)

Etiology: either idiopathic (due to primary kidney disease) or secondary (associated with a systemic disease such as lupus or infectious such as poststreptococcal GN (80% of these cases occur in children)

Key Symptoms:

· SOB, leg or facial edema

· Dark urine (“Coke-colored”)

· Symptoms suggesting secondary GN:

· Pharyngitis or skin infection 2-3 weeks earlier (suggests poststreptococcal GN)

· Joint pain (suggests lupus nephritis, cryoglobulinemia, or polyarteritis nodosa)

· Hemoptysis (suggests Wegener’s granulomatosis, Goodpasture’s syndrome)

· Sinusitis (suggests Wegener’s granulomatosis)

· Fever (suggests endocarditis, lupus nephritis)

· Heart murmur (suggests endocarditis)

Diagnostic Tests:

· Dipstick (proteinuria +/-)

· U/A (asymptomatic hematuria, especially RBC casts)

· BUN, creatinine (GN frequently causes renal failure)

· CBC (anemia seen in many cases of GN; thrombocytopenia suggests lupus nephritis)

· 24-hour urine for creatinine clearance and protein (protein excretion is usually < 3 gm, but a minority of patients may be nephrotic)

· Blood cultures (to screen for endocarditis)

· Antistreptolysin O (ASO) titer, streptozyme titer (if elevated, suggests poststreptococcal GN)

· Serum antinuclear antibody (ANA) (positive at high titer in lupus nephritis)

· Serum complement (C3, C4, CH50) (low in poststreptococcal GN, endocarditis-associated GN, lupus nephritis)

· Kidney biopsy (helps to define the etiology)

Treatment:

· No specific medical therapy indicated for poststreptococcal GN

· Appropriate antibiotic therapy required in endocarditis

· Prolonged treatment with corticosteroids and cyclophosphamide for lupus nephritis

· Diuretics often needed to treat volume overload and hypertension

· Dialysis may be required in patients with GN accompanied by severe renal failure

· Diet: Dietary sodium restriction (2 gm/day) to prevent volume overload and hypertension

· If patient is hyperkalemic, potassium restriction is also indicated

Follow-Up:

· Long-term follow-up as outpatients for adjustment of medications to produce and maintain a clinical remission and monitor for med side effects

· Labs: U/A, BUN, creatinine, lytes, serum complement

Urinary Incontinence

Definition, Prevalence, & Significance:

· Defined as “involuntary loss of urine sufficient to be a problem”

· Because it is frequent and embarrassing, it is often accepted, underreported and undertreated (about 50% of individuals with UI have not reported their symptoms to an MD or NP.

· Incidence and prevalence increase with age and are related to cognitive and functional impairments

· Affects approximately 15-30% of noninstitutionalized older persons, (19% of men, 39% of women)

· In nursing facilities between 50-70% of the 1.5 million residents are incontinent (30% of this group also experience fecal incontinence) due to functional dependency

· Social and psychological impacts of UI:

· Significant changes in social activities outside of the home

· Depression

· Social isolation

· Anxiety about potential disclosure to friends that UI is a problem

· Embarrassment about accidents in public

· Enforced changes in sexual activity

What is needed to maintain continence?

· Integrity of the bladder and urethra

· Intact neurological system that provides voluntary and coordinated control of voiding

· Pattern of urine production

· Desire and physical capability of the person to perform the activities associated with normal toileting

Spinal reflex contraction impulses are continually generated between the spinal column and the bladder. Continuous inhibitory signals from the brain (in the pons) normally prevent these contraction signals from causing bladder contractions.

· In older persons suffering progressive brain failure or other cerebral change, the loss of these inhibitory signals can, when combined with other predisposing factors, result in enough of a bladder contraction to provoke leakage.

· Some apparent “stress incontinence,” in which the individual experiences urine leakage after coughing or some other sharp increase in intraabdominal pressure, is in fact caused by uninhibited bladder contractions.

** An important factor in women is loss of the vesicourethral angle (the angle at the juncture of the bladder and the urethra) as a result of overstretching of pelvic muscles during childbirth and relaxation of pelvic muscles after menopause related to estrogen deficiency.

Predisposing and Age-Related Factors in Urinary Incontinence:

· Increased residual urine

· Diminished bladder capacity

· Decreased bladder sensitivity

· Detrusor instability

· Prostatic hypertrophy

· Increased nocturnal urinary output

· Prior childbirth

· Obesity

· Smoking

· Estrogen withdrawal and menopause

· Brain failure

· Dysmobility

Factors Precipitating Urinary Incontinence:

· Relocation

· Inappropriate environment

· UTI

· Other acute illness

· Intravesical lesions

· Medications

· Urinary obstruction

· Neurological lesions

· Atonic bladder (as with diabetic autonomic neuropathy)

· Reflex neurogenic bladder

· Uninhibited neurogenic bladder

· Detrusor-sphincter dyssynergia

Common Causes of Transient Incontinence (fairly sudden or recent onset of symptoms):

· Delirium or confusional state

· Symptomatic urinary infection

· Atrophic urethritis or vaginitis

· Drugs

· Sedatives or hypnotics, especially long-acting agents

· Loop diuretics

· Anticholinergic agents

· Alpha agonists/antagonist

· Calcium channel blockers

· Psychological problems, including depression

· Endocrine disorders (hypercalcemia, hyperglycemia)

· Restricted mobility

· Stool impaction

Types of Persistent Urinary Incontinence:

· Stress incontinence

· Leakage with physical activity or increased intraabdominal pressure

· Small to moderate volume leaks

· Usually in daytime only; infrequently nocturnal

· Due to sphincter incompetence; urethral instability

· Causes: pelvic prolapse in women, sphincter weakness or damage (such as following prostatectomy)

· Urge incontinence

· Leakage following a strong uncontrollable urge to void or inability to delay voiding

· Moderate to large volume – a “gush”

· Urinary frequency, nocturia, possible suprapubic discomfort

· Due to detrusor overactivity (instability or hyperreflexia)

· Causes: CNS damage (stroke, Alzheimer’s, brain tumor, Parkinson’s disease), interference with spinal inhibitory pathways, local bladder disorder

· Overflow incontinence

· Leakage without the urge to void, from a distended or obstructed bladder; intermittent or continuous

· Volume varies

· Hesitancy, straining to void, weak or interrupted urine stream; occurs day or night

· Due to outlet obstruction or underactive detrusor

· Causes: Obstruction (BPH, bladder neck obstruction, urethral stricture), underactive detrusor (as with herniated disk, diabetic neuropathy), anticholinergic/antispasmodic drugs

· Functional incontinence

· Factors outside the urinary tract cause the loss of urine: mobility problems, cognitive deficit, sedatives, environmental barriers, etc.

Diagnostic Tests:

· U/A

· Postvoid residual measurement

· Three measurements between 50 and 200 ml is normal, but consistently above 100 ml should be closely monitored

· Simple cystometry to evaluate bladder filling, storage, and emptying

· Abnormal findings include first desire to void at < 100 ml, pain or incontinence during filling, a bladder capacity of < 400 or > 650 ml

· Uroflowmetry (listen while the patient voids)

· Should be smooth, uninterrupted, and initially strong

· Urodynamic studies (reserved for those unresponsive to a trial of treatment for the type of UI diagnosed or where surgery is anticipated)

Treatment for Urinary Incontinence:

Behavioral Treatment (educating the patient about UI to change the individual’s response to UI symptoms)

· Maintain a bladder schedule (fixed interval, e.g., every 2-3 hours -- voiding too often or too little can cause deconditioning of the bladder)

· Bladder training (progressively longer intervals)

· Promote fluid intake (many patients deliberately restrict their intake to reduce “accidents.”) – concentrated urine can produce debris or in itself can be a bladder irritant.

· ½ the body weight in pounds is the number of ounces of liquid needed per day

· Avoid bladder irritants such as caffeine, tomatoes, citrus fruits, Equal

· Promote bowel regularity (constipation makes bladder symptoms worse)

· Practice urge control (urges are not a command to void, just a reminder that the bladder is filling)

· Do pelvic muscle exercise (30-80/day)

· Electrical simulation treatment (with implants)

· “Double voiding” can reduce residual volume, decreasing the reservoir for infection and the constant presence of urine available for leakage

· Most elderly men should sit down to urinate; it is safer, and it ensures the bladder is more fully emptied each time.

Pharmacological Treatment

· For bladder wall: anticholinergics (Pro-Banthine, Bentyl, Ditropan), tricyclics (imipramine), calcium channel blockers (nifedipine), antimuscurinic (tolterodine [Detrol])

· For urethra: alpha-adrenergics (pseudoephedrine), estrogen, alpha-blockers (Minipress, Hytrin), central relaxants (baclofen [Lioresal], dantrolene [Dantrium], diazepam [Valium])

Surgical

· Artificial urinary sphincters

· Prostatectomy or TURP

· Dilation of urethral stricture

· Circumcision

· Penile reconstruction

· Urinary diversion

· Suprapubic catheter

Equipment and Devices

· Absorbent products

· Skin care

· Devices and urinals

· External catheters

· Indwelling urethral catheters

· Intermittent catheterization

Disorders Involving Scrotal Contents

Testicular Torsion

· Most common cause of acute scrotum

· With scrotal pain/masses, this is the first diagnosis to rule out

· Differentiate from other scrotal problems

· Testicular torsion presents abruptly with pain

· Epididymitis incarcerated hernia, and viral orchitis present gradually with scrotal pain

· Hydrocele, testicular tumor, varicocele, and epididymal cyst are typically painless unless there is a rapid increase in size

· Clinical findings

· Initially, the testicle is diffusely tender with hemiscrotal edema and erythema. Eventually, the entire scrotum becomes tender, edematous, and erythematous.

· The testicle is elevated in the scrotum and lies in a horizontal position.

· Elevation of the testicle above the pubic symphysis does not relieve the pain (negative Prehn’s sign)

· Abdominal pain, nausea, and vomiting

· Absent cremasteric reflex

· Usually in teenagers and men in their 20s

· If found, REFER IMMEDIATELY! This is a surgical emergency.

· Testicular loss can occur 2-12 hours after torsion.

Epididymitis

· Two major forms: bacterial and sexually transmitted

· Sexually transmitted (usually < 35 years of age)

· Chlamydia, gonorrhoeae, ureaplasma, gram-negative rods

· Bacterial (seen with anatomic abnormalities)

· Usually > 35 year after prostatectomy, prostatitis, BPH

· E. coli, Pseudomonas

· Can also occur in children from pathologic connection from the GI or urinary tract to the genital duct system

· Amiodarone (Cardarone) – usually associated with bilateral epididymitis

Symptoms

· Scrotal pain/swelling

· Dysuria

· Urethral discharge

· Abdominal pain

Key signs

· Epididymal tenderness and swelling

· Scrotal erythema and edema

· Fever

· Urethral discharge

WARNING: Massaging the prostate may exacerbate epididymitis.

Diagnostic Tests

· CBC – increased WBC count with shift to left

· Gonorrhea and Chlamydia culture

· Urethral smear (collect before collecting urine)

· U/A, C&S

· Ultrasound of scrotum—very important, but operator-dependent)

· Radionuclide scanning

Treatment

· Chlamydia: Floxin, doxycycline, or erythromycin X 10 days

· Gonorrhea: Rocephin IM X 1 dose or ampicillin po for 10 days

· Combination therapy: Suprax 400 (or Cipro 500) plus Zithromax 1 gram

· Bacterial: Cipro, Bactrim DS

· NOTE: If unsure of etiology, treat with Rocephin and doxycycline while awaiting culture results.

· Treat partner for STDs

· Oral NSAID

· Bed rest for 3-4 days with scrotal elevation on towel until pain is gone

· Roomy athletic supporter

· Ice in early phase, heat in later phase

· Avoid sexual activity and physical strain

Complications

· Testicular atrophy (occurs in 2/3) possibly due to partial vascular thrombosis of the testicular artery

· Infertility (50% in bilateral epididymitis)

· Abscess and infarction (5% of cases)

· Chronic epididymitis

Varicocele

· Definition: an abnormal degree of venous dilatation in the pampiniform vascular plexus of the scrotum

· Cause unknown but possibly due to valvular incompetence in the internal spermatic veins

· Often asymptomatic

· May experience heaviness in the scrotum and/or rarely a dull ache

· Patient may be concerned about many dilated and engorged veins in the scrotum

· Examine patient while standing (to accentuate the dilated veins)

· Valsalva maneuver or coughing may help identify the veins

· > 90% of varicoceles occur on the left

· If sudden appearance of a right-sided varicocele, rule out obstruction of right spermatic vein due to retroperitoneal neoplasm

· On palpation a varicocele often feels like a “bag of worms”

· Tests: scrotal ultrasonography, spermatic venography “gold standard”

· Treatment: surgical ligation, laparoscopic varicocelectomy, percutaneous varicocele occlusion

· No medication, diet, or activity changes needed

Hydrocele

· A cystic fluid accumulation in the tunica or processus vaginalis

· May be congenital or occur after epididymitis, orchitis, testicular trauma, radiation therapy, or unknown etiology

· Symptoms: usually none, may have “heaviness” in the scrotum

· Clinical findings: nontender, rounded scrotal mass that transilluminates

· Usually more prominent anteriorly and may surround the testis

· Mass may be soft and cystic or large and tense

· Diagnostic tests:

· Aspiration of fluid may result in infection – avoid if possible

· Testicular sonography – to differentiate cyst from solid mass (to exclude cancer)

WARNING:

· An intratesticular mass or a mass adherent to the testicle is cancer until proven otherwise.

· If a hydrocele develops spontaneously between the ages of 18 and 35, careful evaluation should be made to exclude cancer.

· Treatment: If very tense, large – may require surgical repair. Otherwise, active therapy is not required. An athletic supporter may relieve symptoms.

Testicular Cancer

Prevalence

· Approximately 3 of every 100,000 US males develop testicular cancer

· Accounts for 1% of all male cancers

· When diagnosed early, has a cure rate approaching 100%

Risk Factors

· Ages 20-34

· White males affected 4.5 times more frequently than black males

· History of cryptorchidism increases risk for testicular cancer 3-17 fold

· Relative risk can be reduced by surgical repair (orchiopexy) before puberty

· Risk back to normal if corrected before age 8

· Inguinal hernia (frequently exists with a cryptorchid testis)

· Klinefelter’s syndrome

· Degeneration and atrophy of the testes (due to infection, trauma, or torsion)

Clinical Presentation

· Testicular nodule or thickening

· Increased size or heaviness of the scrotum

· May be asymptomatic

· Usually painless

· 10% present with symptoms of epididymitis

· 5% present with gynecomastia

· May have supraclavicular lymphadenopathy, abdominal, groin or flank masses

Self-Examination

· 90% of testicular cancer is identified by the patient

· Study of college students: 87% of the men had never heard of TSE. Of these 89% stated that if they were given information about TSE, they would practice it monthly.

· Mnemonic:

· T = timing, once a month for 3 minutes

· S = shower, where the warmth of the shower relaxes the scrotal sac

· E = examine, check for changes and report them immediately

Balanitis

Definition: Inflammation of the skin covering the glans penis

Signs/symptoms: penile pain, dysuria, drainage at site of infection, erythema, prepuce swelling, ulceration, plaques

Most common causes:

· Allergic reaction (condom latex, contraceptive jelly)

· Fungal (Candida albicans) and bacterial infections

· Fixed drug eruption (sulfa, tetracycline, barbital)

Risk factors: presence of foreskin; oral antibiotics in male infants

Treatment:

· Fungal: Lotrimin 1% bid or nystatin bid to qid to affected area

· Bacterial: bacitracin qid or Neosporin qid to affected area

· Dermatitis: topical steroids qid to affected area

Follow-up: Every 1-2 weeks until etiology has been established. Persistent balanitis may require biopsy to rule out malignancy.

Prevention/Avoidance: proper hygiene, avoidance of allergens, circumcision

Possible complications: meatal stenosis, premalignant changes from chronic irritations, UTIs

Erectile Dysfunction

Definition

The persistent inability to attain or maintain penile erection sufficient for sexual intercourse

Demographics

An estimated 10-20 million American men have some degree of erectile dysfunction

Causes

· Organic (80% of cases)

o Vasculogenic (arterial or inflow disorders most common)

§ Atherosclerosis

§ Hypertension

§ Hyperlipidemia

§ Long-term smoking

o Neurogenic

§ Stroke

§ Spinal cord injury

§ Complication of prostate surgery

§ Diabetes

§ Long-term heavy alcohol use

o Hormonal

§ Low testosterone

o Medications

§ Antihypertensives

§ Psych meds

§ Antiandrogenic meds (digoxin, Histamine 2-receptor blockers)

§ Others (alcohol, ketoconazole, niacin, phenobarbital, phenytoin)

· Psychogenic (20% of cases)

o Depression

o Anxiety

o Social stressors

Treatment

· Lifestyle changes

o Smoking cessation

o Decreased alcohol intake

o Stress reduction

o Strengthening of relationships

· Adjustment of regularly used medications

· Identification and treatment of underlying medical conditions

· Oral medications

o Sildenafil (Viagra)

o Tadalafil (Cialis)

o Vardenafil (Levitra)

· Vacuum devices

· Intrapenile or intracavernosal medication

Prostatitis

Etiology

· Most common and important causes of UTI in adult males

· Most common causative agents include gram-negative bacilli (E. coli), enterococci, Chlamydia, ureaplasma

Symptoms

Acute bacterial prostatitis

· Fever, chills, malaise, myalgias

· Decreased urine flow, dysuria, perineal and back pain, nocturia, urinary outlet flow obstruction

Chronic prostatitis

· Dysuria

· Decreased flow

· Hesitancy

· Dribbling

· Possibly a low-grade fever

Nonbacterial prostatitis

· Similar clinical presentation to chronic prostatitis, but no evidence of UTI despite presence of leukocytes in prostatic secretions

Clinical Findings/Key Signs

· Gentle rectal examination (do not massage the gland) reveals a swollen, exquisitely tender, and boggy prostate gland

· Often bladder distention is noted on abdominal examination

· “Appears ill” with acute prostatitis

Diagnostic Tests

· U/A, C&S

· Expressed prostatic secretions when diagnosis is in doubt

· Possibility of bacteremia with acute bacterial prostatitis

Differential Diagnosis

· Acute prostatitis is straight-forward and readily evident with the findings of fever, dysuria, and tender prostate

· Chronic prostatitis may be more difficult and should include differential diagnoses of:

· BPH

· Prostatic Ca

· Urethral stricture

· Bladder Ca

· Neurogenic bladder

· Interstitial cystitis

Treatment

· Some require hospitalization

· Commonly used: Cipro 500 mg bid

· Some studies indicate that fluoroquinolones may have better cure rates in chronic prostatitis

· Continue treatment at least 3-4 weeks

· Some authors suggest suppression therapy to last approximately 3 months, using Bactrim DS , Cipro 500 mg, or doxycycline 100 mg only once a day

· Diet: avoid irritative substances: caffeine, spicy foods, OTC decongestants

· Warm sitz baths may help if having difficulty voiding

· No activity restriction; normal sexual activity

Follow-Up

· Acute prostatitis: re-evaluate 48-72 hours after initial evaluation or after discharge from hospital

· Subsequent follow-up evaluations in 2-3 weeks, and then 1 month after discontinuing antibiotics

Benign Prostatic Hyperplasia (BPH)

Definition: Benign adenomatous growth of prostate which may result in bladder outlet obstruction

· The prostate grows from 1 g at birth to a usual adult weight of about 20 g.

Predominant age:

· Rarely seen in men < 40

· Seen in 50% of men > 50; 80% of men > 70

Causes:

Exact etiology unknown, but evidence suggests BPH arises from a systemic hormonal alteration which may or may not act in combination with growth factors stimulating glandular hyperplasia

Signs/Symptoms:

· Obstructive symptoms due to mechanical obstruction and/or detrusor muscle decompensation

· Decrease force or caliber of stream

· Hesitancy

· Post-void dribbling

· Sensation of incomplete bladder emptying

· Overflow incontinence

· Inability to voluntarily strop stream

· Urinary retention

· Irritative symptoms due to incomplete bladder emptying and/or detrusor muscle instability

· Frequency

· Nocturia

· Urgency

· Urge incontinence

· Others

· Gross hematuria

· Observation of weak stream

· Distended bladder (> 150 cc in order to detect by percussion)

· Increased post-void residual (> 100 cc)

· Prostate enlarged (normal 20 gram prostate – size of horse chestnut)

· Clinical clues suggesting renal failure due to obstructive uropathy (edema, pallor, pruritus, ecchymoses, nutritional deficiencies, etc.)

· American Urological Association (AUA) symptom index score > 7 (test attached)

· Mild symptoms (score 0-7)

· Moderate symptoms (score 8-19)

· Severe symptoms (score 20-35)

Diagnostic Tests:

· BPH is a pathologic diagnosis – lab data is only suggestive

· U/A – pyuria, pH changes due to chronic residual urine

· Elevated serum creatinine (if obstructive uropathy present)

· C&S may be positive (chronic residual urine)

· PSA may be elevated but usually < 10 ng/ml

· Increased post-void residual

· Transrectal prostate ultrasound

· Confirmation obtained by biopsy, resection

Treatment:

· Medications (when no strong indications of surgery exist or patient refuses surgery)

· Alpha adrenergic antagonist: terazosin [Hytrin], doxazosin [Cardura], tamsulosin [Flomax]

· Caution in patients with cardiac or cerebrovascular disease or those who operate machinery

· Hormonal (anti-androgens) agents: finasteride [Proscar] works best for larger prostates; turosteride , flutamide [Eulexin], and leuprolide [Lupron] are rarely used; saw palmetto weak

· Hormones may cause impotence (except flutamide)

· The semen of men taking finasteride may cause effects on the fetus of pregnant sex partners

· Surgery

· Transurethral resection of prostate (TURP)

· Transurethral incision of prostate (TUIP)

· Open prostatectomy (glands > 40 grams)

· Transurethral microwave thermotherapy (TUMT)

· Transrectal prostatic hyperthermia

· Transurethral laser induced prostatectomy (TULIP)

· Visual laser assisted prostatectomy (VLAP)

· Prostatic urethral stenting

· Transurethral electrovaporization of prostate (TVAP)

· Transurethral needle aspiration ablation of prostate (TUNA)

· Diet: avoid caffeinated or alcoholic beverages, excessively spiced foods

Follow-Up:

· AUA Symptom Index every 1-6 months

· Urodynamics every 3-12 months

· DRE yearly

· PSA yearly

Prostate Test (for urinary activities)

Adapted from the American Urological Association (AUA)

Symptom Index for BPH

Circle the numerical score for each question below:

1. Over the last month or so, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

· None (0)

· 1 time (1)

· 2 times (2)

· 3 times (3)

· 4 times (4)

· 5 or more (5)

2. Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

· Not at all (0)

· Less than 1 time in 5 (1)

· Less than half the time (2)

· About half the time (3)

· More than half the time (4)

· Almost always (5)

3. Over the past month or so, how often have you have to urinate again less than two hours after you finished urinating?

· Not at all (0)

· Less than 1 time in 5 (1)

· Less than half the time (2)

· About half the time (3)

· More than half the time (4)

· Almost always (5)

4. Over the past month or so, how often have you found that you stopped and started again several times when you urinate?

· Not at all (0)

· Less than 1 time in 5 (1)

· Less than half the time (2)

· About half the time (3)

· More than half the time (4)

· Almost always (5)

5. Over the past month or so, how often have you found it difficult to postpone urination?

· Not at all (0)

· Less than 1 time in 5 (1)

· Less than half the time (2)

· About half the time (3)

· More than half the time (4)

· Almost always (5)

6. Over the past month or so, how often have you had a weak urinary stream?

· Not at all (0)

· Less than 1 time in 5 (1)

· Less than half the time (2)

· About half the time (3)

· More than half the time (4)

· Almost always (5)

7. Over the past month or so, how often have you had to push or strain to begin urination?

· Not at all (0)

· Less than 1 time in 5 (1)

· Less than half the time (2)

· About half the time (3)

· More than half the time (4)

· Almost always (5)

Total Score: _______

Score of 0-7: Mild symptoms

Score of 8-19: Moderate symptoms

Score of 20-35: Severe symptoms

Prostate Cancer

Description:

The prostate is composed of acinar glands and their ducts arranged in a radial fashion with the stroma containing blood vessels, lymphatics and nerves.

· 95% of prostate cancers are acinar adenocarcinomas

· Degree of malignancy based on grading various stages:

· A1 A2, and B1, B2 = confinement within the capsule

· C1 = extension beyond the capsule

· C2 = involving the seminal vesicles

· D1 = metastatic disease in regional lymph nodes

· D2 = metastatic disease in bone or other organs

Signs/symptoms:

· May be asymptomatic early or late in the course of disease

· Induration of the prostate on DRE

· Hard prostate, localized or diffuse

· Bladder outlet symptoms

· Acute urinary retention

· Hematuria (rare)

· UTI

· Bone pain

· Weight loss

· Anemia

· SOB

· Lymphedema

· Neurologic symptoms

· Lymphadenopathy

Risk Factors:

· Genetic predisposition

· Endogenous hormonal influences

· Exposure to chemical carcinogens

· STDs

· Male > age 60

Diagnostic Tests:

· PSA elevated

· Free PSA – low in cancer

· Alkaline phosphatase, elevated with metastasis

· Biopsy

· Bone scan to check for mets

Treatment:

· Over age 70: conservative or palliative treatment

· Radiation, external beam or brachytherapy with implants

· Total androgen ablation

· Flutamide (Eulexin) 250 mg. Tid

· Leuprolide (Lupron) 1 mg subcu daily or 7.5 mg IM depot monthly or goserelin (Zoladex) 3.6 mg q 28 days

· Under age 70: aggressive surgery for cure

· Stages A-B and selected C under age 70

· Orchiectomy

Follow-Up:

· Routine clinical examination every 3 months X 1 year

· Routine clinical examination every 6 months X 1 year

· Annual examinations indefinitely

· PSA q 3 months X 1 year, q 6 months X 1 year, then yearly

· CXR, bone scan q 6 months X 1 year, then yearly

PSA (Prostate-Specific Antigen)

Efficacy of PSA

· USPSTF Strength of Recommendation: D

· Test Sensitivity

o Overall: 79-82%

o Cancers >1 cm: 90%

o More sensitive than Rectal Exam (30% for 1 cm tumor)

o Much more sensitive than Acid Phosphatase

· Test Specificity = 59%

o High false positive rate

o Benign Prostatic Hyperplasia often increases PSA

· Positive Predictive Value (PPV) 32-40%

· Much more cost-effective than Mammography

· Outcomes uncertain despite effective screening

o Detection may not impact morbidity and mortality

Causes of elevated PSA

· Prostate Cancer

· Benign Prostatic Hyperplasia (BPH)

· Prostatitis

· Prostate inflammation, trauma, or manipulation

· Prostatic infarction

· Recent sexual activity

· Urologic procedures

o Cystoscopy

o Urinary Catheterization

Screening recommendations

· Most organizations do not recommend routine screening

o See Efficacy above

o US Preventive Task Force

o American College of Physicians

o American Society of Internal Medicine

o National Cancer Institute

o Centers for Disease Control and Prevention (CDC)

o American Academy of Family Physicians

o American College of Preventive Medicine

· Organizations advocating screening

o American Cancer Society

o American Urological Association

o National Comprehensive Cancer Network

· Screening (if performed)

o Men without risk factors: Age over 50 years

§ Digital Rectal Exam yearly

§ Prostate Specific Antigen (PSA) yearly

o Men with risk factors: Age over 45 years

§ Indications

· See Prostate Cancer for risks factors

· African Americans

· Young first degree relative with Prostate Cancer

§ Digital Rectal Exam yearly

§ Prostate Specific Antigen (PSA) yearly

o Age over 70 to 75 years

§ Discontinue PSA screening

Informed Consent Discussion with Patient

· Blood Test improves detection of Prostate Cancer

o PSA is twice as effective as rectal exam

· Early detection, however may not save more lives

o Small Prostate Cancer exists in 30% of men your age

o Only 3% of men die from Prostate Cancer

o Most Prostate Cancers do not affect men who have them

o Prostate Cancer most often affects those over age 70

· Not all PSA number increases are due to Prostate Cancer

· Increased PSA number requires evaluation

o Urology consultation

o Transrectal ultrasound with prostate biopsies

· Treatment for Prostate Cancer requires prostate removal

o Prostate removal is extensive surgery

§ Death: 2%

§ Impotence: 25%

§ Urethral stricture: 18%

§ Incontinence: 6%

o Prevents death in only 10% men with Prostate Cancer

Age specific Normal PSA values

Age	Normal PSA Values
	White	African-American	Asian
40 to 49 years	PSA ≤ 2.5	PSA < 2.0	PSA < 2.0
50 to 59 years	PSA ≤ 3.5	PSA < 4.0	PSA < 3.0
60 to 69 years	PSA ≤ 4.5	PSA < 4.5	PSA < 4.0
70 to 79 years	PSA ≤ 6.5	PSA < 5.5	PSA < 5.0

Algorithm to evaluate PSA results

· PSA < 2 ng/ml

o Repeat PSA in 2 years

o Chance that PSA > 5 mg/ml in 2 years is <4%

· PSA 2.6 to 4.0 ng/ml

o Unclear guidelines as to approach this range of PSAs

o Age over 50 years should be considered for evaluation

· PSA 4.0 to 5.0 ng/ml

o Prostate Cancer "Curable" Range

· PSA >5.0 ng/ml

o Lower likelihood of Prostate Cancer "Cure"

Prognostic Predictive Value of PSA

PSA with associated Prostatectomy findings
PSA ≤ 4.0 ng/ml	Organ limited Prostate Cancer in 64%
PSA 4.0-10.0 ng/ml	Organ limited Prostate Cancer in 50%
PSA 10.0 to 20.0 ng/ml	Organ limited Prostate Cancer in 35%
PSA >100 ng/ml	Predicts bone metastases in 74% of cases
PSA in combination with Rectal Exam and Biopsy
PSA < 10 ng/ml (Non-palpable, Low Gleason grade)	Organ limited disease in 60%
PSA >20 ng/ml (Palpable, Gleason poor-moderate diff)	Organ limited disease in 10%

Free PSA

(Free Prostate Specific Antigen)

Mechanism

• Free PSA increases more in Benign Prostatic Hypertrophy
• PSA associated with cancer is more protein bound

Indication

• Detection of Prostate Cancer when PSA 2.5 to 10 ng/ml

Efficacy

• Improved Specificity when combined with PSA

Interpretation

• Free PSA >27% with lower likelihood of Prostate Cancer
• Values suggestive of Prostate Cancer
• Total PSA 3.0 to 4.0 with Free PSA <19%
• Total PSA 4.0 to 10.0 with Free PSA < 17 to 24%