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Urology Part 2
Clinical Medicine: Urology Part 2- Prostate, Masses, Cancer
| Term | Definition |
|---|---|
| Phimosis: Definition and Cause | cannot pull foreskin back; congenital or infx causes |
| Paraphimosis: Definition and Cause (5) | cannot push foreskin back up (more detrimental); in uncircumsized males, 50 will have retraction of skin by age 10, 99% of skin by age 17. Retraction due to 1) cleaning, 2) sexual encounters, 3) masterbation, 4) trauma (piercing), 5) catheterization |
| Phimosis/Paraphimosis: Sx (4) | 1) Swelling and pain in uncircumsized male 2) Dysuria/decreased urine flow 3) blanching 4) Later stages: necrosis/firmness of glans penis |
| Phimosis/Paraphimosis: DD (4) | 1) Tourniquet syndrome 2) Balanoposthitis: inflammation/swelling of glans penis and foreskin usually w/ discharge 3) insect bites 4) zipper trauma |
| Phimosis/Paraphimosis: Tx (6) | 1) Pain control (lidocaine/penis anesthesia; oral) 2) reduction of swelling (ice, anti-inflammatories) 3) Adson/Babcock forceps 4) Dundee procedure (multiple puncture wounds to decompress swelling 5) Aspiration (10cc) 6) Dorsal-slit procedure (urologist) |
| Consult to Urology (in ED and in clinic) | ED: 1) Suspect necrosis of glans penis 2) after successful invasive reduction of paraphimosis. 3) Suspect of ischemia, infarction, gangrene. Clinic: 1) After successful, minimally-invasive procedure for reduction (routine) 2) phimosis after reduction |
| Peyronie's Disease: Definition and Progression (untreated) | Fibrotic disorder of the tunica albuginea; contains excessive collagen -> fragmented elastic fibers -> calcified (permanent penile dysfn; alters penile anatomy compromising erectile fn. |
| T/F: You cannot see Peyronie's with a flaccid penis; Hx | T: Mostly true, rare exception. Think of it as true. Increased use Viagra (PDE-5 inhibitors) has more men presenting w/Peyronie's |
| Peyronie's Disease: Prognosis | 1 study: 94% resolved w/in 18 months w/o pain. 40-48% have worsening curvature w/in 12 months |
| Peyronie's Disease: Sx (6) and Dx | 1) Penile pain w/erection 2) Induration (hard to touch/stiff) 3) Nodules 4) Curvature 5) Sexual dysfn 6) Difficulties w/ coitus, but this isn't classic. Dx: May have to pharmacologically stimulate erection. |
| T/F: Most Peyronie's is dorsal curvature | True 1) Dorsal 2) lateral 3) ventral |
| Peyronie's Disease: Imaging | U/S of penile shaft (can determine calcification of plaque and blood flow to penis); Others used but not as beneficial. |
| Peyronie's Disease: Main Tx (3) | 1) Watchful waiting for mild. 2) Pentoxifylline reserved for moderate to severe (400 mg po bid) 3) Intralesional injection: Verapamil can increase collagenase activity OR Collagenase directly |
| Peyronie's Disease: Other Tx/Surgeries (4) | 1) Penile traction possible. 2) Plication: (longer shaft) shortening opposite side of plaque to promote straighter penis 3) Graft (shorter shaft) plaque excised and replaced w/ graft 4) Penile prosthesis (TOC) (ruptures and breaks down fibrous plaque) |
| Prostatitis: Acute Sx, Chronic Sx (3 each) | Acute: 1) fever/chills 2) Pain in lower back/rectum 3) Tenesmus/Dysuria; Chronic: 1) Relapsing UTIs 2) Irritative urinary Sx 3) Genital pain |
| Acute Prostatitis: DD, main Sx, PE, Dx, Tx | DD: prostatic abscess, acute cystits. Sx: Irritative voiding Sx, sick looking, intense suprapubic pain, N/V, signs of sepsis. PE: tender, boggy, enlarged on DRE. Dx: Urine Cx, postvoid residual. Tx: ABX 10-14 days |
| Chronic Prostatits: DD, main Sx, PE, Dx, Tx | DD: BPH, stones, prostatic abscess. Sx: Irritative voiding Sx, testicular, low back, perineal pain, recurrent UTIs. PE: prostatic massage, normal, tender, or boggy on DRE. Dx: 2-glass pre and post prostatic massage test. Tx: ABX 4-12 WEEKS |
| Clinical Presentation of BPH (6) | 1) Urinary frequency 2) urgency 3) nocturia 4) slowed initiation of micturition 5) decreased force of stream 6) Tenesmus |
| Complications of BPH (6) | 1) Urinary retention 2) Bladder stones 3) Recurrent UTIs 4) Overflow incontinence 5) Renal failure 6) Hematuria (straining) |
| T/F: Testosterone causes prostate to enlarge. | False, at least directly: Dihydrotestosterone (DHT) stimulates prostate growth. (also slows hair production) |
| Patient Evaluation of BPH | 1) Urinalysis, Blood Chemistry, PSA if Hx of prostate cancer. 2) DRE 3) Urological consult if PSA is elevated AND DRE positive 4) Rectal U/S and prostate Bx, urine flow study, cystoscopy. |
| T/F: Prostate Specific Antigen (PSA) specific for prostate cancer | FALSE; DD: increasing age, bladder cath, acute urinary retention, prostatitis or BPH; plus, prostate Ca can have occur w/normal PSA |
| PSA Testing: General and Use | 1) approved by FDA for annual screening of prostate Ca in 50yo+. 2) Naturally higher in Blacks, MEastern, Asians. 3) USPSTF gave it a C rating which is why it is important to couple it w/ Hx, PE, DRE. 4) D rating in 75yo+. |
| T/F: A substantial proportion of PSA-detected cancers are considered overdiagnosed because they would not cause clinical problems during a man's life. | True |
| BPH: Tx | Moderate to severe: Alpha blockers: doxazosin, tamsulosin etc. 5a-reductase inhibitors: Finasteride, Dutasteride. Surgery: indicated if reccurent UTIs, retention, hematuria, azotemia (nitrogen in blood): TURP (TransUrethral Resection of Prostate). |
| Bladder Outlet Obstruction: 2 components | 1) Dynamic (moving): due to smooth muscle tone, regulated by Alpha mechanisms, relieved by Alpha blockers. 2) Static (pushing against something): due to mechanical compression from increased prostate size, Sx relieved by 5a-reductase inhibitors. |
| Prostate Ca: Epidemiology | Most common Ca in US males, AA 1.6 > Whites 1; 1st degree relative 2x risk. Risk increases overall after age 50 (40 in blacks). 200,000 new cases/year and 27,000 deaths/year. DON'T correlate w/ socioeconomic status |
| Prostate Bx warranted if: | 3 PSA specimens w/in 18 months change >.75ng/mL/year |
| T/F: You can miss prostate cancer, even w/ a Bx | True, Bx doesn't reach the anterior lobe |
| Prostate Ca: Tx and Prognosis | 1) Radical prostatectomy: Life expectancy should be >10 years to warrant this procedure. So you might reconsider if they are 85 yo. 2) Radiation therapy. Prog: 5 year survival is 60-70%, follow up PSA q6 months w/ DRE annually. |
| Another possibility for early Prostate Ca Tx | Brachytherapy: only can be considered in standard therapeutic option in men w/ low risk disease (no mets, no BPH) |
| T/F: External Beam Radiation has less of a cure rate than Radical Prostatectomy | GOT YA, False and True, they are comparable in first 5-8 years, but after 10 years, results are not as favorable as RP |
| Brachytherapy: Low Dose Radiation | Permanent seed implantation requires 1 time insertion in an outpatient setting |
| Brachytherapy: High Dose Radiation | temporary brachytherapy using a computer-controlled machine. Pushes single highly radioactive iridium seed into the catheters one by one and removes it after a period of time |
| Tx for metastatic prostate Ca | Orchiectomy (castration) or LHRH agonist such as Lupron block DHT AND testosterone production. |
| What do you look for on Physical Exam with a painful scrotum? (4) | 1) Size, location, tenderness of both testes 2) lack of transillumination 3) edematous/erythematous scrotal skin 4) positive cremasteric reflex (normal finding of pudendal nerve) |
| T/F: Epididymus is posteriorly-inferior in relation to the testis. | False, posteriorly-superior. |
| Lab testings and other Dx testing for scrotal pain (3) | 1) Urinalysis (for bacteria, WBCs, crystals) present in torsions/tumors, epididymitis 2) Urine Cx 3) Ultrasonography |
| DDs of scrotal pain (5) | 1) torsion of testes 2) Infx/inflammation (epididymitis/orchitis, Fournier's Gangrene, Mumps Orchitis) 3) systemic disease: Henoch-Schonlein purpura 4) Trauma 5) Hernia/hydrocele |
| Testicular Torsion: Hx, PE, General | Hx: sudden onset (often from trauma/riding bike etc). PE: Absent Cremasteric reflex, Prehn's Sign (elevation of testes doesn't relieve pain). Gen: twisting of spermatic cord cutting off blood; medical emergency. Comps: High risk of loss due to infarction |
| Testicular Torsion: Management/Tx; Dx/Testing | Refer emergently: 90% can be salvaged w/in 6 hours. Attempt manual detorsion (open the book). Surgery still required even w/torsion. U/S studies can assess blood flow of testicular artery and indicate necrosis. Nuclear Scintigraphy documents blood flow. |
| Who gets extravaginal torsion? Intravaginal? | Extravaginal: neonates/babies; Intravaginal: adolescents |
| Testicular Torsion: Appendix Testis: | Usually more gradually w/ severe pain localizes to the superior aspect of testis. Classic BLUE DOT SIGN indicates infarcted appendix. |
| 4 diseases causing inflammation of the testes | 1) Gonorrhea 2) Mumps (unilateral in 70%) 3) Tuberculosis 4) Syphilis (histology will show gummas or obliterative endarteitis) |
| Hydrocele | incomplete obliteration of the processus vaginalis – Fluid accumulates in scrotum. Hematocele: blood is fluid. |
| Varicocele | enlargement of the veins draining the testicle (pampiniform plexus) (bag of worms feeling). Caused by incompetence of valves of spermatic veins; can cause oligospermia (infertility) |
| Spermatocele | collection of sperm and fluid in the head of the epididymis |
| Hernia | large opening of the processus vaginalis which may allow abdominal contents to enter scrotal sac. |
| Epididymitis: Age of onset, Onset, Sx, Epidemiology of organisms, DD | most common acute-scrotum problem post-pubertal. Gradual onset (differentiating it from Ca). Sx: Fever, dysuria, pyuria. Often STD in <35yo, E.coli in >35yo. DD: Rule out torsion. Tx: scrotal elevation, ABX. Orchitis is viral and also be present w/this. |
| Fournier's Gangrene | Necrotizing fasciitis of the perineum w/ 20-50% mortality rate. Polymicrobial infx. Tx: Gentamicin, Penicillin G, Flagyl, surgical debridement. |
| Idiopathic Scrotal Edema: DD, Age of Onset, Onset, Tx. | DD: torsion/tumor. Age of onset: 2-11yo. Onset: sudden, uni/bilateral. Self limiting. |
| Henoch-Schonlein Purpura | diffuse vasculitis involving skin, joints, Gi, kidneys. Sx: purpura, hematuria, proteinuria, 33% scrotal/testicular involvement.. Etiology: complement/IgA involvment. Age of Onset: 75% <7yo. |
| Testicular Trauma: Etiology, Management | Etiology: blunt trauma (penetrating trauma requires surgical repair. Early exploration (<72 hours) ideal. Refer to urology for definitive evaluation. |
| Penetrating Testiuclar Trauma Dx/Management decisions (Tunica vaginalis disrupted? U/S helpful?) | Exam: tunical vaginalis usually not disrupted. U/S: not helpful. Exploration: local repair in ED vs debridement in main OR. |
| young age, sudden onset, clean UA= | torsion |
| older age, insidious onset, pyuria= | epididymitis |
| older age, mass, clean UA= | tumor |
| Cell cycle to cancer (4 steps of cell differentiation) Which is(are) irreversible? | Normal Cell -> hyperplasia -> metaplasia -> dysplasia -> neoplasia. Neoplasia is the only one irreversible, dysplasia "somewhat reversible" |
| T/F: Neoplasms can be benign. | True! They are localized w/ well defined borders and may even have normal function. They don't invade and often have a CT "capsule". |
| Malignant Neoplasms: General | grow more rapidly than benign and are "cancerous". Cell mass not compacted/cohesive, seldom have CT. Cell may have irregular shape and invade surrounding cells with metastasis. |
| Oncogenesis | complex process of developing a tumor where cell division leaves change in daughter cells. |
| Steps to Ca formation | 1) Initiation: substantial and important change introduced into cell (initiator referred to as carcinogen), caused by DNA damage inducing gene modification w/o repair or apoptosis. 2) Promotion: sets transformed cell up for uncontrolled replication/growth |
| T/F: Initiation and Promotion are both required for all cancerous formations | False, MOST THOUGH |
| Proto-oncogenes | code for proteins that initiates cell division |
| Onocogenes | unregulated versions of proto-oncogenes, mutated and over-expressed leading to Ca. Single copy significant to result in malignant transformation (20% of tumors show oncogenes) |
| Tumor suppressor genes | these, in general, code for proteins that inhibit cell division (thereby inhibiting neoplastic growth). Under-expressed in Ca |
| Apoptosis | active process of cellular self-destruction affecting single, scattered cells. Pathway activated by proteins like p53 which is mutated and no longer functioning in 50% cancers. |
| Necrosis vs Apoptosis | Necrosis is a completely different process which cells swell and lyse causing damage and inflammation of neighboring cells. |
| Cancer cells in general (3) | 1) Limitless replicative potential (loss of negative feedback loop). 2) Sustained angiogenesis (ability to stimulate growth of their own blood supply. 3) Tissue invasion/metastasis (can break off and seed other tissues). [Not all metastasize, but all can] |
| Anti-cancer drugs are: | anti-proliferative; active on fast dividing cells, most effective during the S phase of the cell cycle causing DNA damage and are anti-metabolic initiating apoptosis. Some target angiogenesis. Adverse: greatest in fast-dividing cells (hair, marrow etc) |
| Testicular Cancer: Epidemiology, Risk Factors | Most common in 20-35yo, Whites 5x> Blacks 1; RF: Cryptorchidism, testicles must be removed from abdomen, can lead to germ cell cancer, smoking, sibling w/testicular cancer. |
| T/F: USPSTF recommends screenings every year during annual Physician visits. | False: the USPSTF doesn't recommend physician screening nor self-examination. |
| Testicular Cancer: Presentation | painless, testicular mass is PATHOGNOMONIC for testicular malignancy; may have fullness/discomfort/swelling. 5% metastasize. Sx: Mass typically hard, won't transillumina. |
| Testicular Cancer: Management | NEVER Bx, U/S can help determine intra or extracellular, AFP elevated, need CT of chest/abdomen/pelvis and a CXR as it tends to metastazie to the lungs. |
| Tumor Markers | HCG NOT detectable in healthy males and is secreted by nonseminoma tumors...single screening would cause worry. AFP only detectable in minute amounts in healthy men. |
| T/F: Doubling time of testicular tumors is 3 months | False, 10-30 days!!! Early detection is EXTREMELY important. |
| S1 | LDH <1.5xN AFP<1000 |
| S2 | LDH 1.5-10xN AFP 1000-10,000 |
| S3 | LDH >10xN AFP >10,000 |
| Non-seminoma germ cell tumors: General, Tx | 3rd decade of life, metastasize early. Tx: POST ORCHIECTOMY: surveilence, RPLND (lymph node dissection) |
| Seminoma germ cell tumors: General, Tx | 50% of all germ-cell tumors. 4th decade of life. More indolent clinical course. Tx: POST ORCHIECTOMY: surveilance, chemo, radiation therapy |
| T/F: Cure rate for germ cell tumors is great, even for disseminated disease. | True; good education, early detection, and aggressive surgical removal/chemo/radiation |
| T/F: High rate of decreased or infertility after germ cell cancer | True, encourage banking of sperm before any treatment. Seen in 60%. The issue is Tx starts so quick after the discovery of GCTs that it can be hard to do anything in that time. |
| Testicular Cancer: Follow up | CXR and tumor markers (AFP, BetaHCG, LDH) every month for 2 years, then 6 month intervals for the next 2 years. |
| T/F: 10 year recurrence rate for testicular cancer is 93% | True. 12x increased risk to contralateral testicle. Highest risk is w/in 5 years post-Tx |
| Secondary Malignancy of Testicular Ca | Leukemia as a complication of radiation and chemotherapy. |
| Bladder Cancer: Epidemiology | Men>women 3:1; 2nd most common GU cancer, most common in older (60yo+ 80% of Dx); White>Blacks, but delayed Dx in blacks -> higher mortality rate. Tobacco smoking accounts for 50% of cases. |
| Bladder Cancer: Risk Factors | Cigarette smoking (50% cases), occupational exposures (dyes, paints, textiles, combustion products; chronic infxs/inflammation: bladder calculi, cystitis; long-term catheter. |
| Bladder Cancer: Pathology | 90-95% of epithelial bladder tumors are urothelial carcinomas (transitional cells). Remaining 10% are mesenchymal/non-urothelial (squamous, adenocarcinoma, benign). Multiple tumors foundon 30% of cases. Most are superficial |
| Bladder Cancer: Presentation/Sx | Painless hematuria (85-90% gross and microscopic). Non-dysmorphic RBCs. Irritative urinary Sx (MORE typical of cystitis though). Obstruction, if near bladder neck/urethra. METASTATIC: hepatomegaly and lower extremity edema (if spread to lymph nodes) |
| T/F: Dysmorphic RBCs in hematuria is pathognumonic for glomerular disease | True! |
| Hematuria: General, Epidemiology | Both gross and microscopic hematuria require eval and work up! ASx screening increases Dx of tumors, but doesn't prolong life. Pts w/anti-coags require THOROUGH eval, don't assume it is secondary to anti-coags. Most common: BPH in males. |
| Hematuria: Evaluation (Tests, Hx) | Obvious first step is Urinalysis (dysmorphic RBCs=glomerular, WBCs=infx, proteinuria=renal orgin); Hx: renal colic, irritative voiding Sx, constitutional Sx, anti-coags; cytology (+) suggests bladder neoplasm (not great for renal detection) |
| Hematuria: Evaluation (Imaging) | Abdominal and pelvic CT for neoplasms, urolithiasis, obstructive uropathy; U/S: avoids constrast if chronic renal disease present...adequate kidney info for stones, not great for Ca) |
| Bladder Cancer: Dx | Urine cytology: (IDs high-grade tumors and monitors pts for persistent disease), high specificity, low sensitivity; Imaging: CT, U/S, MRI; Cystocopy/Bx confirms tumor location, appearance, size. |
| T/F: Look for metastasis if bone scan reveals lowered Alkalkine Phosphatase | False, look for mets if bone scan reveals ELEVATED alkaline phosphatase |
| Bladder Cancer: Tx | Non-muscle invasive disease: TURB (TransUrethral Resection of Bladder tumor) and BCG (Bacille Calmette-Guerin). Muscle invasive disease: radical cystectomy w/ pelvic lymphadenectomy (prostectomy in men, hysterectomy in women. Chemo in high risk. |
| BCG | Bacille Calmette-Guerin; delays recurrence and progression, decreasing need for immediate cystectomy. |
| Intravesical installation process | 1) Pt empties bladder 2) medication instilled via catheter 3) pts retains medication for 2 hours changing position every 20 minutes to fully expose bladder (given 6 weeks) |
| What IS a radical cystecomy? | removal of the bladder |
| Bladder Cancer: Tx for metastasis | Bone, liver, lungs. Chemothrapy based on comorbidties such as cardiac/renal dysfunction. Radical cystectomy and pelvic lymphadenectomy. |
| Renal Cell Carcinoma: Epidemiology | Peak btwn 50-70yo, Males:Females 2:1; strong association w/ smoking. Von Hippel-Lindau disease (rare autosomal dominant cancer syndrome) |
| Renal Cell Carcinoma: Pathology of clear cell cases | distinct histopathologic, genetic, and clinical features; >60% of cases arise from epithelial cells of proximal tubles. Chromosomes 3p deletions- which encode tumor-suppresor gene; |
| Characteristics of Renal Ca Papillary tumor | 5-10% bilateral and multifocal |
| Characteristics of Renal Ca Chromophobic tumors | 5-10% indolent |
| Characteristics of Renal Ca Oncocytomas | 5-10% considered benign |
| Characteristics of Renal Ca Collecting duct tumors | <1% very aggressive |
| Renal Cell Carcinoma: Presentation | CLASSIC TRIAD (10-15% seen together): Hematuria 60%, abdominal mass (30%), flank pain (30%). May also have a fever. |
| Paraneoplastic syndromes | rare disorders triggered by aberrant immune response to Ca. Fever, wt loss present first. Erythrocytosis (increased EPO ->anemia of chronic disease late in course), hypercalcemia, Stauffer syndrome (hepatic dysfn), HTN resistant to Rx |
| Incidental renal mass: Evaluation | >1/3 adults 50+ have 1+ renal mass on CT scan 1) Cyst 2) Tumors 3) Inflammatory (infx, infarction, trauma). Often seen w/ U/S |
| Renal Cyst | if CT/MRI doesn't lead to definitive Dx, renal angiography or needle aspiration of cyst may be necessary. Once Dx, no Tx required...rare for cyst to harm kidney. Simple cysts Dxed w/ great accuracy w/ U/S |
| Renal Cyst: Class I | Simple benign cyst: no further workup needed |
| Renal Cyst: Class II | Cystic lesions w/ abnormal radiologic features |
| Renal Cyst: Class III | Indeterminant, malignancy rate of 50%. Surgical excision recommended |
| Renal Cyst: Class IV | Cystic lesions & solid renal masses that enhance with contrast are presumed to be malignant . Surgical excision recommended |
| Renal Cell Carcinoma: Evaluation | CT scan of abdomen/pelvis, CXR, Urinaylysis, Urine cytology (primarily for bladder cancer), MRI to evaluate IVC, Fine Needle Bx (choice in those w/ clinically apparent mets |
| Renal Staging and Prognosis: Stage 1 | tumor <7cm, limited to kidney, 5 year: 95% |
| Renal Staging and Prognosis: Stage 2 | tumor >7cm, limited to kidney, 5 year: 88% |
| Renal Staging and Prognosis: Stage 3 | tumor in major veins or adrenal gland, w/in Gerota's fascia 1 regional lymph node involved, 5 year: 59% |
| Renal Staging and Prognosis: Stage 4 | tumor beyond Gerota's fascia or >1 regional lymph node involved, 5 year: 20% |
| Renal Cell Carcinoma: Tx | tumors <4cm: partial nephrectomy. Tumors 4-7cm: radical nephrectomy and resection of adjacent organs, possible thrombectomy from renal vein and IVC. |
| Advanced Renal Cell Carcinoma: Tx | cytoreductive nephrectomy +/- metastasectomy if solitary metastasis, local radiation, systemic therapy, palative. No effective chemo available for metastatic renal cell carcinoma. CYTOKINE therapy (interferon alpha) 15% improved survival. |
| Prognosis for Renal Cell Carcinoma | T1-T2: 5 year 90-100%; T3: 5 year 50-60%; T4: 5 year 0-15% |
| Memorial Sloan Kettering Prognostic Criteria | Risk Factors: Poor Karnofsky performance status, ^LDH, ^ corrected Calcium, low hemoglobin, time from Dx to interferon alpha therapy; Prognosis: 0 risk factors: 30 months median survival 1-2 RF; 14 months; 3-5 RF, 5 months. |
| Wilm's Tumor | nephroblastoma, most common solid renal tumor of childhood (5% childhood cancers). 650 cases/year. Peak presentation: 3 yo. Commonly unicentric, either kidney. Genetic pathogenesis. Dx by asymptomatic mass. Sx constitutional and abdominal, esp mass |
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crward88
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