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Urology Part 2

Clinical Medicine: Urology Part 2- Prostate, Masses, Cancer

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
Created by: crward88