Epididymitis, Testicular Torsion, Testicular Cancer, & BPH – Flashcards
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Inflammation of the Epididymis
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Epididymitis
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What causes Epididymitis?
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Infection- retrograde spread of urine or urinary bacteria from the prostate or urethra via the ejaculatory ducts and vas deferens or Noninfectious- urine (full bladder and exposed to increased intra-abdominal pressure) is pushed through internal urethral sphincter. Reflux of urine through orifice of ejaculatory ducts
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Which type of Epididymitis is more common?
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Infectious
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What is the most common age range for Epididymitis? and the bacteria?
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Men <35 and sexually active Chlamydia trachomatis or Neisseria gonorrhoeae - anal intercourse: E. coli
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What type of bacteria is likely if Epididymitis occurs in men > 35?
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Coliform bacteria (normal flora) E. coli Elderly- related to distal urinary tract obstruction
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What is the likely bacteria in prepubital boys with Epididymitis?
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usually coliform bacteria evaluate for underlying congenital abnormalities
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What is Epididymitis classified?
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Acute: sx 6 wks
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what are the risk factors for Epididymitis?
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Infection High risk sexual activity Indwelling urethral catheter Bladder obstruction Urethral or meatal stricture (narrowing, abnormal flow) Trauma
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How would a pt. with Epididymitis present?
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Scrotal pain scrotal swelling painful urination may have urethral discharge inguinal adenopathy elevation of the scrotom improves the discomfort
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What would the physical exam show on a pt. with Epididymitis?
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- Epididymis is markedly tender to palpation - Tail of epididymis is swollen - Cremasteric reflex is present
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That is the sign called when discomfort is elevated by raising the scrotum above the symphesis pubis?
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Prehn Sign
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how do you test for the cremasteric reflex?
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lightly stroke inside of thigh on the effected side using something like a tongue depressor
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What diagnostic studies would you order for a pt with suspected epididymitis?
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U/A Leukocyte Esterase- using 1st urine of the day U/A culture GC/Chlamydia testing Gram stain of discharge CBC (shows left shift) Ultrasound
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Nonpharm Tx methods for Epididymitis?
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Restrict Activity Wear athletic supporter Scrotal Elevation Cold Compresses (or hot, whatever feels best)
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Pharm Tx for Epididymitis if the Pt. has an STI
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Doxycycline 100mg PO BID x 10 days AND Ceftriaxone 250mg IM as single dose
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Pharm Tx for Epididymitis if the Pt. has a coliform infection
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Levofloxacin 500mg PO daily x 10 days or Ciprofloxacin 500mg PO BID x 10-14 days Bactrim DS is another option thats become popular
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Other Pharm Tx to help with pain caused by epididymitis?
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NSAIDS Narcotics only Rx for 1-3 days because pain should subside in that amount of time BUT...make sure pt knows they must finish the entire Tx of Antibiotics still
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Complications of Epididymitis?
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Recurrent Epididymitis (Chronic) Abscess Formation Orchitis- inflammation of adjacent testicle Infertility
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Twisting of the spermatic cord, resulting in ischemia, occludes blood flow
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Testicular Torsion
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How does the pt. present if they have testicular torsion?
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Acute onset of testicular pain Scrotal swelling Upon PE: scrotum is enlarged, erythematous exquisitely tender testicle testicle is elevated N/V Absence of Cremasteric Reflex
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What is the Difference between Testicular Torsion and Epididymitis?
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Epididymitis= Presence of Cremasteric Reflex Testicular Torsion= Absence of Cremasteric Reflex
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What diagnostic studies would you order for a pt. with testicular torsion?
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U/A *Doppler Ultrasound- demonstrates lack of blood flow to testicle
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What are the tx options for testicular torsion?
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Manual Reduction- temporary to get blood flow back Surgical Exploration - correct the torsion - allows for evaluation of testicular viability (how long has blood supply been cut off) - Orchidopexy: adhere/fix, suture it in place, wont be able to move freely to reduce risk of recurrence Orchiectomy- remove testicle if its not viable
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Complications associated with testicular torsion
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Testicular atrophy Abnormal spermatogenesis Infertility
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The most common cancerous tumor in men ages 15-34
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Testicular Cancer
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How common is testicular cancer?
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~ 2 new cases per 100,000 males in the US each year about ~ 8,400 new cases with be Dx this year
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What is the most common age range for Testicular Cancer
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15-34
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What causes Testicular Cancer?
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Most testicular tumors are germ cell tumors (90%) - Seminoma (40%) - Nonseminoma (60%) - Mixed (more rare) Nongerminal neoplasms (10%) - Leydig cells - Sertoli cells
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What are the risk factors for Testicular Cancer?
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Cryptorchidism Family Hx Prior Hx HIV AGE (any age but mainly 15-34) Race (white 5x more common) Trauma
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Testicular cancer is more common on which side?
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R>L its rare, but can be bilateral
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how does a pt. with testicular cancer present?
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Asymptomatic or Painless hard lump Enlargement of the testis Sensation of heaviness Secondary Hydrocele Sx of metastatic disease... if let go for a long time can move to other parts of the body
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Prevention Techniques for Testicular Cancer?
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Testicular Self Exam discuss this with your male pt. to help find the problem sooner
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What are the Dx studies used for Testicular Cancer?
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Order all 3: - Human Chorionic Gonadotropin (protein) HCG - Alpha-fetoprotein (protein) AF - Lactase Dehydrogenase (enzyme) LDH and Sperm Analysis
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What is the gold standard for Dx Testicular Cancer?
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Scrotal Ultrasound
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What are some other useful imaging studies for Testicular cancer?
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Chest XR Pelvic CT based on clinical judgement, if suspected to have metastisized
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Treatment Options for testicular cancer
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Radical Orchiectomy- remove testicle Retroperitoneal Lymph Node Dissection Radiation Therapy Chemotherapy
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What is the TNM System?
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T- primary tumor location N- regional lymph node involvement M- Metastasis S- Serum levels of tumor markers produced by some testicular cancers this system helps stage the cancer
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What are the clinical stages of testicular cancer?
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Stage 0- Carcinoma in site Stage I- limited to the testis and epididymis Stage II- spread to lymph nodes Stage III- spread to other areas of the body
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Complications of testicular cancer?
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Infertility (b/c of removed testicle).. sperm banking? Difficulty with ejaculations others can vary depending on action of treatment
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What is the outlook/prognosis for testicular cancer?
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5 year survival rate: - localized: 99% - regional: 96% - Distant 73% Other factors: type of cancer level of tumor markers
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Enlargement of the prostate gland?
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Benign Prostatic Hyperplasia
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What does hyperplasia mean?
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increased cell production
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What causes BPH?
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idiopathic
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What types of cells compose the prostate gland?
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stromal and epithelial cells
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Potential reasons for the development of BPH?
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Aging Family Hx Obesity/inactivity Dihydrotestosterone
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Synthesized in the prostate by ciculating testosterone by the action of the enzyme 5-alpha-reductase
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Dihydrotestosterone
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How would a pt w/ BPH present?
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enlarged prostate, interfere with normal urination lower urinary tract sx (LUTS) - obstructive (voiding) -irritative (storage)
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Obstructive Sx of BPH?
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hesitancy decreased force of stream sensation of incomplete bladder emptying straining to urinate dribbling do you need to stand closer to the urinal?
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Irritative Sx of BPH?
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Urgency Frequency Nocturia (normal voiding is 6 x per day)
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What are the Clinical Manifestations for BPH?
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Patient History PE: abd. lower back, genital DRE (Digital Rectal Exam- looks at prostate, should be smooth, walnut sized) Normal Prostate (no direct relation between prostate size and the pt's sx)
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What is the AUA Questionaire?
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questions to ask the pt. addressing sx of BPH: 1. feeling of incomplete emptying 2. urination w/in 2 hrs of voiding 3. stopped and started again when voiding 4. difficult to postpone urination 5. weak urinary system 6. trouble starting stream 7. nocturia
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How is the AUA Questionaire used?
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the symptoms are scored rated 0-5 add the scores up for all 7 sx. max score=35 0-7 = absent to mild symptoms 8-19= moderate symptoms 20 or more= severe symptoms
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What is I-PSS?
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International Prostate Symptom Score its the same as the AUA but with an additionaly 8th question Quality of Life due to Urinary Symptoms: if you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? - scored 0 to 6 (delighted to terrible)
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How do you diagnose BPH?
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UA Bun/Cr Prostate Specific Antigen- glycoprotein produced only in the cytoplasm of prostate cells Normal<4 ng/mL Postvoid Residual- Catheter or Ultrasound Upper tract Imaging: - IVP -CT -Renal US Cystoscopy- lighted scope through urethra to look at prostate and bladder
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What are the Tx options for BPH?
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Refer to Urologist as appropriate Suggest lifestyle changes - eliminate caffeine - voiding schedule - limit fluid intake right before bed Watchful waiting- if pt. is in mild category
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1st line of Tx for BPH
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Alpha Blockers - decrease symptoms by relaxing smooth muscle in the prostate and bladder neck. - most effective for men with mild to moderate enlargement of the prostate
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if alpha blockers are not working by themselves what else can be used?
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5-alpha-reductase inhibitors - inhibits the conversion of testosterone to DHT - takes 6 mos to achieve full effectiveness - most effective in men with larger prostate glands
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Side effects to Alpha-blockers
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dizziness orthostatic HTN
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what is the surgical option for BPH?
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Transurethral Resection of the Prostate (TURP) gold standard tx- cuts away excess tissue
