E3: Miscellaneous male GU diseases 2

How large is the normal prostate?

2 fingerbreadths in width (walnut)

When do testicles typically begin their descent in utero?

28 weeks gestation

How long do you have to give ABX for with prostatitis?

4 weeks

What are patients with cryptorchidism at higher risk for?

40X more likely to develop testicular cancer 10% of all testicular cancers involve undescended testicles

What is hydrocele?

Abnormal fluid collection between the parietal & visceral layers of the tunica vaginalis

What demographic is at risk for more severe and progressive BPH?

African Americans

When should you refer a child to urology for cryptorchidism?

After 6 months of age (highly unlikely to descend after this time)

When should someone take Tamsulosin?

At bedtime (orthostatic hypotension) Educate pt about this as well (sit when you pee)

How can you differentiate prostatitis and BPH?

BPH is more gradual, prostatitis is more acute BPH also doesn't have symptoms like malaise and myalgias, fevers/chills, dysuria, low back pain

What are indications for TURP?

BPH surgical management if... •Acute urinary retention + failed voiding trials •Recurrent UTI's •Recurrent gross hematuria •AKI/CKD •Failed medical therapy associated with intolerable QOL issues

What is the #1 cause of urethritis?

Chlamydia trachomatis

What are the most common bugs that cause urethritis?

Chlamydia trachomatis & Neisseria gonorrhea are the most common bugs

What is the #1 congenital genital problem in pediatrics?

Cryptorchidism Therefore it is critical to palpate testicles on ALL well child visits

When would a biopsy of the undescended testicle be done?

Cryptorchidism in adults

How is BPH treated?

Dynamic effects: alpha-adrenergic antagonists Fixed effects: 5-alpha-reductase inhibitors Surgery is reserved for pts who are unresponsive to medical management

When are pediatric hydroceles usually repaired?

First 1-2 years of age

What are fixed effects of BPH?

Hesitancy Straining Sensation of incomplete emptying Weakening of the force of the urinary stream (inability to use the urinal) May progress to acute urinary retention

Why might varicocele result in decreased fertility?

Hypothesized that resultant elevation in temperature may contribute to ↓ fertility(but fertility is usually normal) •May result in ↓ sperm count, poor motility & predominance of abnormal sperm forms •But, studies reveal that a vast majority of men with varicoceles managed with observation alone had normal fertility rates

What are the dynamic effects of BPH?

Increased frequency, urgency, and nocturia

What is urethritis?

Infection of the urethra secondary to an STI

What is the #1 location of an undescended testicle with cryptorchidism?

Inguinal canal

How does doxycycline work against chlamydia?

Inhibits bacterial protein synthesis (chlamydia has no cell wall)

How does ceftriaxone work against GC?

Inhibits bacterial wall synthesis

If you did a PSA test on someone with BPH, how would it come back?

It might come back positive (falsely) if they have not been treated

Varicoceles are more common on what side?

Left (d/t high pressure of left renal vein and absence of anti-reflux valves)

How should the prostate feel?

Like the thenar eminence or tip of your nose •If the consistency is like your knuckle or the bridge of your nose, this is abnormal •Document the presence of any nodules or tenderness (not just "discomfort")

What increases the likelihood that a child will develop cryptorchidism?

Low birth weight #1 Premature births Twin births Maternal exposure to estrogen during first trimester Siblings Family history of cryptorchidism, hypospadias, or infertility

What might cause a right-sided varicocele?

May be due to cancer or an acute DVT

When is urethritis most common?

Men < 25 years old

When do testicles most commonly descend?

Most commonly occurs by 4 months of age

Is BPH a risk factor for prostate cancer?

NO

What is the pampiniform plexus?

Network of small veins that drain into the testicular vein and help cool the testes

Does chlamydia trachomatis have a cell wall?

No

What is the pathophysiology of cryptorchidism?

Not well understood •Usually 2° to incomplete descent from the abdomen into the scrotum •Testis may occasionally be absent (2° to an intrauterine ischemic event)

How common are varicoceles?

Occur in up to 20% of males

What do you need to do when you palpate the testicles?

Patient needs to be warm otherwise the testes will go up

What does the prostate gland do?

Produces the majority of the ejaculatory fluid

What should you always consider when searching for the source of sepsis in immunocompromised patients, dialysis patients, and patients who recently underwent lower HU tract instrumentation?

Prostatitis

What is the #1 concern if someone has a R-sided varicocele? Why?

Renal cell carcinoma or DVT-IVC thrombosis R sided varicoceles are rare because the right testicular vein is not high pressure like the left is. The left testicular vein drains directly into the L renal vein which is high pressure. The R testicular vein empties directly into the IVC

What dietary supplements might be used for BPH?

Saw palmetto (no proof to help, no harm)

How do you treat cryptorchidism? Consults?

Surgery (prepubertal orchiopexy decreases the risk of cancer) •Requires pediatric urologic consultation if not descended by 6 months of age •May also require consultation with a pediatric endocrinologist

How do we treat varicocele?

Surgery (varicocelectomy) (although, the vast majority do not require surgical intervention)

You have a patient presenting with typical urethritis symptoms. What would increase your suspicion of something like disseminated GC or pyelonephritis?

Systemic symptoms

What are examples of alpha antagonists? What do they do?

Tamsulosin (Flomax) Teraxosin (Hytrin) Doxazosin (Cardura) Relaxes the prostate and bladder smooth muscle (dynamic symptoms of BPH)

Cryptorchidism increases the risk of _______

Testicular cancer

You have a patient with typical urethritis symptoms. What would increase your suspicion of something like epididymitis/prostatitis/cystitis?

The presence of urgency or frequency

Where does benign prostatic hyperplasia occur?

Transitional zone of prostate (which surrounds the urethra)

What ABX can be used for the treatment of prostatitis? Side effects?

Trimethoprim-sulfamethoxazole (Bactrim, Septra) for 4 weeks Interferes with bacterial folate (vitamin B9) synthesis (so supplement) Ciprofoxacin (Cipro) for 4 weeks Avoid if pt is on warfarin or under 18

How do varicocele's present?

Usually asymptomatic

What is a varicocele?

Varicose veins of the pampiniform plexus of the spermatic cord

How common is BPH?

Very common > 50% of men aged 60 > 90% of men aged 85

Can a hydrocele ever be life threatening?

Yes, it could be secondary to cancer

What might you need to do if you find a cryptorchidism?

You may need to "milk down" from the iliac crest to the scrotum

What is prostatitis?

inflammation of the prostate

What is cryptorchidism?

undescended testes

How do primary hydroceles present?

•"1°" = not due to an underlying problem •Soft nontender (usually) fullness within the hemiscrotum •Large hydroceles may be painful •Degree of swelling ranges from minimal to dramatic •Testis is generally palpable along the posterior aspect of the fluid collection •Transillumination reveals a red glow at the anterior aspect of the abnormal testicle

What are the locations of cryptorchid testicles?

•1 = intraabdominal •2 = inguinal canal (more likely under hormonal control) •3,4 = suprascrotal •5 = femoral •6 = perineal •7 = contralateral hemiscrotum (extremely rare)

What is the difference between primary and secondary hydrocele?

•1° hydroceles present with nontender, gradual swelling with no other symptoms •2° (reactive) hydroceles may develop as a result of acute testicular pathology (10% of testicular tumors have an associated reactive hydrocele)

What are the different classifications of Cryptorchidism?

•Absent •Undescended- pathway into scrotum stopped in utero •Retractile - cremaster reflex has pulled the testicle to a suprascrotal location •Ectopic- testis located at an abnormal position not along its normal path

What are risk factors for prostatitis?

•Anatomic abnormalities •Recent urologic instrumentation (e.g. cystoscopy, prostate biopsy) •Chronic indwelling Foley •Underlying epididymitis/orchitis/urethritis •Unprotected receptive anal intercourse

What are complications of BPH?

•Chronic bladder outlet obstruction may lead to ↑ post-void residuals (> 200 mL) & multiple complications: •Urinary retention •AKI/CKD •Recurrent UTI's •Bladder calculi •Gross hematuria

What are the lobes of the prostate?

•Composed of several lobes & a median sulcus & enclosed by an outer capsule •Contains several zones including a transitional zone & a peripheral zone

How is cryptorchidism diagnosed?

•Cryptorchidism is primarily a clinical diagnosis •Ultrasonography is occasionally useful: •Significant underlying obesity •May identify ovaries & uterus in the presence of a suspected sexual development disorder

How do you transilluminate the scrotum? What will cause transillumination?

•Darken the room & shine a bright light thru the posterior aspect of the scrotum •In the presence of a hydrocele, transmission through the scrotum will generate a red glow •Testicular tumors, torsion, & epididymitis/orchitis will transilluminate if there is an associated reactive hydrocele •Hernias will not transilluminate

What are post-surgical considerations after orchiopexy?

•Despite successful scrotal repositioning of the testis, there is still some ↑ risk of testicular cancer (necessitates self-exams) •Appropriate counseling & follow-up are critical •Re-ascent can occur in up to 25%

What historical questions are pertinent to cryptorchidism?

•Did the mother receive hormonal therapy during pregnancy? •Were there multiple gestations? •Was the patient low birth weight or born prematurely? •Any family history of cryptorchidism, hypospadias, or infertility?

What are indications for varicocele surgery?

•Documented infertility in a couple + the male partner has at least one abnormal semen parameter + the female has normal fertility •Adolescents with progressive failure of testicular development documented by serial examinations •In addition, any patient with a palpable varicocele & abnormal findings on semen analysis should be offered varicocele repair

How is TURP done?

•Done under general or spinal anesthesia •Shaves away small amounts of the prostate piece by piece •Moderate risk of post-op bleeding

What causes hydrocele in infants?

•Due to patency of the processus vaginalis (embryonic developmental outpouching of the parietal peritoneum) •Patent processus allows peritoneal fluid to flow into the scrotum •Referred to as a communicating hydrocele

How does urethritis present?

•Dysuria is the #1 complaint •Unprotected intercourse is the 1° risk factor •Urethral discharge- may be clear or purulent (may only notice underwear staining) •Urethral pruritus •Hematuria or hematospermia (may finally get the patient's attention) •Painful intercourse or ejaculation •Associated arthritis & conjunctivitis (reactive arthritis) or accompanying sore throat or proctitis

What is the prognosis after varicocelectomy?

•Extremely low incidence of postoperative complications •70% have improved semen analysis results after surgery •Up to 60% have increased conception rates

How is urethritis treated?

•GC- ceftriaxone (Rocephin) one dose IM •Chlamydia- doxycycline po X 7 days

How does varicocele present?

•Generally complain of an asymptomatic mass •Feels like a "bag of worms" •Easily distinguished from the testis •Valsalva maneuver results in enlargement(or identification) Usually easy to distinguish from other causes of scrotal swelling (hydrocele, torsion, epididymitis, tumor, hernia, etc)

What might you find on PE with urethritis?

•Generally well-appearing with normal vitals •Examine the meatus for skin lesions, stricture, or obvious discharge •Meatus may be erythematous, tender, & swollen •Palpate along the urethra for areas of fluctuance, tenderness, or warmth suggestive of an abscess •Note any firmness of the urethra suggestive of a foreign body- will not respond to antibiotics until it is removed •May need to "milk" the urethra outwards to express discharge

What is on your ddx for scrotal swelling?

•Hydrocele (1° or 2°) •Testicular tumor** •Testicular torsion** •Epididymitis/orchitis** •Inguinal hernia •Scrotal abscess •Varicocele (up next) **May present with a cystic mass that transilluminates (reactive hydrocele)

What causes hydrocele in adults?

•In adults: 2° to an imbalance between the secretion & absorption of fluid from the tunica vaginalis •Adult hydroceles may be 1° or 2° •1° hydroceles often due to minor unrecognized injury or may be idiopathic (little impact to the testes) •2° (reactive) hydroceles may occur 2° to inflammation from testicular cancer, testicular torsion, or epididymitis ("the underlying process") •Referred to as non-communicating hydroceles

What are indications for surgery in adults with hydroceles?

•Inability to distinguish from an inguinal hernia •Inability to clearly examine the testis •Suspect underlying pathology (tumor, torsion) •Persistent pain •Infertility •Patient request (failure to resolve spontaneously after an appropriate period of observation)

What are examples of 5-alpha-reductase inhibitors? What do they do? Side effects?

•Inhibit the conversion of testosterone to dihydrotestosterone •Choices include finasteride (Propecia, Proscar) & dutasteride (Avodart) •Result in ↓ in prostatic size •Reduce the incidence of urinary retention •May result in ↓ libido & erectile dysfunction (etiology unclear)

How does urethritis caused by chlamydia present?

•Insidious onset, often minimal dysuria •Scant, mucoid or clear discharge •May be asymptomatic in > 10%

How does urethritis caused by GC present?

•More abrupt onset than Chlamydia •Significant dysuria (vs. Chlamydia urethritis) •Thick yellow or green urethral discharge •More likely to have systemic signs & symptoms •May also result in epididymitis, prostatitis, proctitis, pharyngitis, pustular skin lesions, conjunctivitis, septic arthritis, & osteomyelitis

What are the causes of prostatitis?

•Most commonly 2° to reflux of urine into the prostatic (ejaculatory) duct •May also be caused by ascending infection thru the urethra or direct extension from a local infection

What are the bugs that might cause prostatitis?

•Most infections are caused by gram negative rods including E. coli (#1), Proteus, Enterobacter, Serratia, & Pseudomonas •May also be due to an STI (Neisseria gonorrhea & Chlamydia trachomatis)

What might prostatitis do to PSA test results?

•PEARL: prostatitis results in temporary elevation of the prostate-specific antigen (PSA) test; must wait one month after resolution of infection before prostate cancer screening can be completed

How do you treat hydroceles?

•Pediatric hydroceles are usually repaired at 1-2 years of age •Asymptomatic adults with 1° hydroceles can be observed indefinitely or until they become symptomatic •Adult 1° hydroceles generally will resolve without therapy •Adult 2° hydroceles- treat the underlying cause •NSAID's & scrotal support offer symptomatic relief ("supportive care") •PEARL: always consider underlying causes including testicular cancer, testicular torsion, & epididymitis/orchitis (all may cause reactive hydroceles)

What are complications of prostatitis?

•Pyelonephritis •Sepsis •Abscess formation •Infertility 2° to scarring of the urethra or ejaculatory ducts •Bladder outlet obstruction resulting in urinary retention •Renal damage

When you test for urethritis, what do you need to do?

•STI's are reportable to the state health dept. ("public health- ethics contextual feature") •Urethral swab obtained by inserting a Dacron swab into the urethra & "gently" twisting (testing of the discharge itself is less sensitive) •Gram stain usually not necessary as treating empirically (both bugs) •Urine leukocyte esterase + (also + for epididymitis, prostatitis, & UTI's)

What might you find on PE with hydrocele?

•Soft cystic mass palpable anterior to the testis •Mass will transilluminate

What might you find on PE with prostatitis?

•Suprapubic abdominal tenderness (clue to DDX) •Prostate is hot & "boggy" (spongy/mushy) (necessitate completion of a DRE) •Prostate is severely tender (necessitates completion of a DRE) •May have enlarged tender bladder 2° to urine retention •Prostatic massage should be avoided in patients with acute prostatitis (may result in bacteremia)

How does prostatitis present?

•Suprapubic tenderness •DRE- tender, hot, & "boggy" prostate •"Dynamic symptoms"- frequency, urgency, nocturia (FUN) •"Fixed symptoms"- hesitancy, weak stream, incomplete emptying •Additional symptoms- malaise & myalgias; fevers/chills; dysuria; suprapubic & low back pain

What historical factors can increase the risk of urethritis?

•Surgical history- recent urethral catheterization or other GU tract instrumentation (including self-induced) •Social history - # & sex of partners, condom use, prior STI's

How does BPH present?

•Symptoms develop gradually over years •Dynamic effects: urinary frequency, urgency, & increasing nocturia •Fixed effects: hesitancy, straining, sensation of incomplete emptying, weakening of the force of the urinary stream (inability to use the urinal); may progress to acute urinary retention +/- hematuria

What is involved in the prostate exam?

•Tell the patient EXACTLY what you are going to do •Warn the patient that they may feel the need to urinate •Identify the two lateral lobes & the median sulcus •Extend your finger above the prostate to the region of the seminal vesicles (not normally palpable) & the peritoneal cavity •Sweep your finger along the anterior rectal wall •Gently withdraw your finger •Note the size, shape, & consistency

What causes BPH?

•Testosterone is normally metabolized to dihydrotestosterone (DHT) by 5-alpha-reductase •Theorized that metabolism ↑ with age •↑ DHT binds to androgen receptors in prostatic smooth muscle cells resulting in ↑ smooth muscle tone & prostate cell hyperplasia •↑ smooth muscle tone results in lower urinary tract irritative symptoms & "dynamic effects" •Prostatic enlargement results in narrowing of the urethra & "fixed effects" of BPH

How do you inspect for cryptorchidism on physical exam? What would you find?

•The patient should be warmed & relaxed •The examiner should be warm (hands) & relaxed •Patient placed in the frog-leg position •Inspection precedes palpation: may reveal an empty hemi-scrotum or scrotum •#1 location of the undescended testicle is in the inguinal canal •Milk down, palpating from the iliac crest to the scrotum •Body habitus, testicular position, & compliance of the child are all factors in obtaining an accurate exam

How do you treat prostatitis?

•Treat empirically for gram negative rods unless strong suspicion for an STI •Acceptable regimens include trimethoprim-sulfamethoxazole (Bactrim) or ciprofloxacin (Cipro)- consider side effects, costs, drug interactions •Tx required for 4 weeks as antibiotic penetration into prostatic tissue is poor •Prostatitis may lead to urosepsis & significant mortality in immunocompromised patients, dialysis patients, & patients who have recentlyundergone lower GU tract instrumentation

What labs/imaging might you want with BPH? Why?

•UA to assess for leukocytes, bacteria, blood & glucose •Urine culture to exclude infectious causes •BPH results in false (+) PSA (Prostatic-specific antigen) testing •BMP or CMP if concerns for post-renal AKI (rare) •Bladder scan evaluates for post-void residual (> 200 mL is significant)

What labs may be indicated for prostatitis?

•Urine studies indicating infection still support the diagnosis (but remember the DDX-UTI) •CBC, CMP, & blood cultures only if patient is ill-appearing

Where is the prostate?

•Walnut-sized gland (2 finger widths) •Anterior to the rectum (DRE) & just distal to the urinary bladder •Surrounds the proximal ("prostatic") urethra

What might you find on PE with BPH?

•With BPH, the prostate will be symmetrically enlarged, of normal consistency, & nontender •Median sulcus will be obliterated •Identify any exam findings suggestive of malignancy or prostatitis •The normal prostate is 2 fingerbreadths in width

What are causes of secondary (reactive) hydroceles?

•testicular tumor, testicular torsion, epididymitis, or orchitis