GU problems of Mostly Men Notes

Transcription

1 GU problems of Mostly Men Notes I. Lower Urinary Tract Infections A. Cystitis 1. Frequency, urgency, hesitancy, back pain, nocturia, suprapubic heaviness or pain 2. E coli (80%), Staph saprophyticus (5-15%), Klebsiella, Proteus, Pseudomonas, Enterococcus 3. Incidence a. Rare in males after the age of 1 - relates to structural abnormalities b. Increases after age 50 - related to prostatic obstruction II. III. Upper Urinary Tract Infections A. Pyelonephritis 1. Incidence increases after age 65 and is equal for both genders 2. Prostatic hypertrophy primary cause in males 3. Is considered a complicated infection in males and bacteremia common Urinary Incontinence A. Overflow incontinence from an underactive or acontractile detrusor associated with: 1. Prostate gland problems 2. Urethral stricture 3. Neuro problems 4. Idiopathic detrusor failure B. Stress urinary incontinence 1. Intrinsic sphincter deficiency characterized by continuous leakage at rest or with minimal exercise 2. Risk factors a. medications b. smoking c. fecal impaction d. habitual straining during defacation e. low fluid intake C. Urge Incontinence 1. Caused by Detrusor Muscle Instability or Ineffective Sphincter Control

2 Male Urinary and Related Problems A. Epididymitis 1. The most common acute scrotal pain in post pubertal males 2. Pathogens reach the epididymis through the lumen of the vas deferens from infected urine, the posterior urethra or seminal vesicles 3. Males post puberty - 35 years a. Most commonly sexually transmitted b. Accompanied by asymptomatic urethritis, prostatitis or cystitis in c. N gonorrheae or C trachomatis causative pathogens in 75% of cases d. E coli most common in insertive gay males 4. Males >35 a. Nonsexually transmitted epididymitis more common b. Often hx of recent urinary tract surgery or instrumentation c. Commomly associated with gram neg enteric UTI 5. S&S a. Gradual onset pain, unilateral testicular pain and tenderness, fever, dysuria, frequency, urgency, urethral discharge, scrotal edema. b. N & v uncommon c. May have sx urethritis

3 6. Physical Exam a. Vital signs b. Scrotal exam for erythema, edema, torsion - usually enlarged, indurated and tender c. Prehn's sign - passive elevation of testicles relieves pain d. Suprapubic or CVA tenderness e. Rectal exam to elicit prostatic tenderness or urethral discharge 7. Diagnostic tests a. Urinalysis - Pyuria in 20-95% of cases b. Gram's stain of urethral discharge c. Urinalysis d. GC/Chlamydia cultures e. CBC f. Older males 1) culture of expressed prostatic secretions 2) assess for bladder outlet obstruction 8. Uncommon complications a. testicular necrosis b. testicular atrophy c. infertility 9. Commom complications in immunocompromised a. testicular cancer b. tuberculous epididymitis c. fungal epididymitis 10. Differential Dx a. Testicular torsion 1. Sudden onset severe pain 2. Requires emergency treatment 11. Information a. Condoms for intercourse b. Bed rest with scrotal elevation and ice packs for pain c. Scrotal support prn d. Sitz baths tid e. Refer sex partners for evaluation and treatment if STD B. Urethritis 1. Non-gonococcal (NGU) vs gonococcal (GU) 2. Most common STD syndrome 3. NGU a. C trachomatis (35-45%) b. Ureaplasma urealyticum (15-25%) c. Trichomonas, HSV, M. genitalium

4 4. S&S a. May be asymptomatic b. Mucoid or purulent discharge c. Dysuria d. Urethral itching or tingling 6. Dx a. Urethral discharge b. Presence of WBC's on gram stain (>5 WBC's/HPF) c. Gram neg intracellular dipplococci d. Asx males: urine for LET for trich 7. Treatment a. Recurrence or persistence common due to poor adherence or reinfection by untreated partner b. GU: ceftriaxone plus doxycycline or ofloxacin c. NGU: TMP-SMX; ofloxacin; cipro; third generation cephalosporin; ampicillin with sulbactam 8. Complications a. epididymitis b. Reiter's syndrome c. infertility C. Prostatitis 1. Most common male complaint - occurs in 25-50% of males at some point in time 2. Etiology a. Ascending urethral infection b. Reflux of infected urine c. direct extension or lymphatic spread of a rectal infection d. hematogenous spread 3. Bacterial prostatitis a. E. coli 75% b. Proteus, klebsiella, enterobacter, pseudomonas, serratia 4. Types a. Acute bacterial prostatitis 1) Least common and most easily diagnosed 2) Most common in young males at times of greater sexual activity 3) A systemic disease characterized by fever, chills, dysuria, frequency, urgency, retention, nocturia, low back and perineal pain, generalized malaise, arthralgia, myalgia, suprapubic discomfort 4) >10 WBC/HPF in urine specimen b. Chronic bacterial prostatitis 1) More common in older males 2) More difficult to dx

5 3) Hx recurrent UTI's by the same pathogen 4) Dysuria, urgency, dribbling, hesitency, frequency, loss of stream volume and force, pain, hematuria, hematospermia or painful ejaculation 5) Periods of exacerbation and remission 6) Dx confirmed by presence of >10-15 WBC's/HPF in urine c. Nonbacterial prostatitis 1) Occurs 8 times more frequently than bacterial prostatitis 2) Occurs in absence of UTI or hx UTI 3) Penile discharge common, vague complaints 4) >10 WBC's/HPF and macrophages containing fat in EPS 5) Neg urine cultures d, Prostadynia 1) Presenting prostatic sx without objective findings Benign Prostatic Hyperplasia a. Etiology i. Fibroadenomatous nodules form around periurethral region of prostate ii. Possible triggers 1. Circulating testosterone reduced by 5α reductase to dihydrotestosterone on prostate stromal cells where it is bound to androgen receptors a. This stimulates protein synthesis and prostate glandular growth 2. Estrogen increases as testosterone falls with aging a. Higher levels of estrogen promote BPH (correlation between estrogen/testosterone ratio and prostate size) 3. Development of autoantibodies to PSA 4. Diminished sex life and few ejaculations b. Presenting Symptoms i. Dysuria due to pressure of enlarging prostate on bladder or prostatic urethra ii. Early sx of mechanical obstruction leading to detrusor decompensation 1. difficulty starting stream 2. weak stream 3. post void dripping 4. sensation of incomplete emptying 5. overflow incontinence iii. Early irritative sx of incomplete bladder emptying due to detrusor instability 1. urinary frequency, urgency 2. urge incontinence 3. nocturia 4. painful urination

6 c. Complications i. Urethral occlusion ii. Urinary retention iii. Uremia iv. Irreversible bladder dysfunction v. Hydronephrosis vi. Hematuria vii. UTI viii. Risk increased by use of drugs such as 1. antihistamines 2. atropine 3. beta blockers 4. CCB 5. muscle relaxants ix. Risk also increased by 1. alcohol 2. cold, damp weather 3. smoking 4. emotional stress d. Diagnosis i. Presence of sx 1. Differential diagnosis of dysuria a. Urethral stricture b. Bladder neck contracture c. Neurogenic bladder d. Inflammatory disorder such as interstitial cystitis ii. DRE 1. Nl prostate size of walnut, soft and pliable 2. BPH feels larger and harder 3. Nl prostate does not R/O BPH a. Symptomatic BPH possible without enlargement b. No correlation between sx severity and prostatic enlargement 4. Differential diagnoses of prostate enlargement a. Prostatitis tender and indurated prostate b. Prostate cancer hard and nodular prostate c. Prostatic calculi d. Venereal disease in men <40 iii. Lab Tests 1. Urinalysis to R/O UTI 2. BUN/creatinine to evaluate renal function 3. PSA not helpful a. PSA >10ng/mL may indicate prostatic enlargement b. Not differentiation between BPH and prostatic cancer 4. Free PSA a. High Free PSA linked to low risk of prostate cancer b. Free PSA < 25% with total PSA 4-10ng/mL indicates higher risk for prostate cancer

7 c. Free PSA > 25% in patient with total PSA 4-10ng/mL with i. Nl prostate consistency on DRE reardless of size or patient age ii. More likely to have BPH iv. Urological Evaluation 1. Urine flow studies and measurement of residual volume 2. IV urogram to R/O a. Hydronephrosis b. Dilated or displaced ureters c. Bladder defect 3. Post-voiding cystogram determines residual urine 4. Cystoscopy to estimate gland size and evidence of obstruction 5. TRUS with biopsy to identify BPH and R/O prostate cancer a. Determines prostate volume and mass b. Separates benign from malignant lesions c. Guides biopsies when indicated. Caption: (image 1 of 2) Typical sonographic appearance of BPH. Ultrasound is used to determine prostate volume and mass, to separate benign and malignant lesions, and to guide biopsies when indicated. This scan shows a hypoechoic nodule with an echogenic surgical capsule. The surgical capsule separates the inner gland from the peripheral zone. Courtesy R.C. Hennig, MD, University of Alberta Hospital, Edmonton, Alberta, Canada.

8 (image 2 of 2) Typical sonographic appearance of BPH. Ultrasound is used to determine prostate volume and mass, to separate benign and malignant lesions, and to guide biopsies when indicated. This scan shows a hypoechoic nodule with an echogenic surgical capsule. The surgical capsule separates the inner gland from the peripheral zone. Courtesy R.C. Hennig, MD, University of Alberta Hospital, Edmonton, Alberta, Canada. e. Prompt referral to urologist for surgical intervention indicated if Hx, PE, urinalysis, blood tests indicates i. Refractory retention ii. UTI iii. Hematuria iv. Bladder stones v. Renal insufficiency vi. Urological Evaluation

9 An enlarged prostate can cause obstructive uropathy by impinging on the bladder neck and outlet. f. Medical Treatment i. If no evidence of complications, measure severity of sx 1. AUA symptom score index a. Mild </=7 b. Moderate 8-19 c. Severe ii. If AUA index score is mild and patient does not request treatment 1. annual monitoring 2. encourage lifestyle changes a. limit alcohol, table salt, caffeine, spicy foods and after dinner fluids b. avoid eating within 4 hours of bedtime iii. If age >60 and AUA score 8-19 and patient requests treatment 1. medical intervention first line of treatment a. 3 classes of meds i. antiandrogens such as 5 α-reductase inhibitors ii. long acting selective alpha 1- blockers iii. muscarinic receptor antagonists b. antiandrogens i. regulate the amount of androgen available to the prostate and slow the rate of prostate enlargement ii. Finasteride hinders conversion of testosterone to more active dihydrotestosterone by 80-90% without affecting plasma testosterone or sexual function 1. Prescribed as 5mg/day

10 2. reduces prostate volume after 3-6 months of therapy 3. the larger the prostate volume the better the response 4. 40% no response rate 5. decreases PSA after 6 months of treatment 6. to use PSA as cancer screen in patients on finasteride >6 months, double PSA value c. Selective alpha 1- blockers i. Prostatic hyperplasia takes place in stroma of prostate. ii. Smooth muscle of the stroma contains alpha adrenergic receptors and is found in the prostate and at bladder neck. But not in the body of the prostate. iii. Alpha blockers relax smooth muscle in prostate and bladder neck. Without affecting bladder contractility iv. Usual onset of action 2 weeks v. 93% symptom response rate with 44% mean improvement in urinary flow vi. Tolerance to treatment may develop after 6 months.of therapy 1. Doxazosin 4-8 mg/day maintenance, titrate up slowly, watch for orthostatic hypotension 2. Tamulosin mg qd 30 minutes after a meal, no orthostatic hypotension 3. Terazosin, start at 1mg qhs and titrate up slowly. Whatch for orthostatic hypotension and anticholinergic side effects d. Muscarinic receptor antagonists i. Effective alone or in combination with alpha1- blockers or 5αreductase inhibitors ii. Used for symptomatic relief of frequency, urgency or urge incontinence in patients with normal renal function iii. Tolerodine 2 mg bid 1. Start at 1 mg bid in patients with reduced hepatic function, taking macrolides or antifungal agents. 2. Use cautiously in patients with narrowangle glaucoma, GI obstructive disorders or clinically significant bladder outflow obstruction. g. Surgical Treatment i. Indicated when pt develops 1. renal insufficiency 2. recurrent UTI s 3. prostatitis

11 4. hematuria 5. bladder stones ii. TURP gold standard and surgical intervention of choice 1. 67% experience diminished or absent ejaculation 2. 5% become impotent 3. Urinary incontinence and hematuria also occur iii. Open prostatectomy rarely performed in US iv. Other minimally invasive techniques available but not widely performed h. Alternative therapies i. Saw Palmetto 1. has demonstrated 5α-reductase activity 2. randomized double blind trials on pts with BPH demonstrate significant improvement in decreasing lower urinary tract symptoms at a dose of 160 mg bid compared to patients taking placebo. ii. Pygeum africanum tree bark currently in multicenter testing in Europe iii. Not yet demonstrated to be effective 1. Pollen extract 2. Cucurbita pepo seeds 3. Echinacea purpurea roots E. Patient Follow-up a. Annual DRE on all male patients >40 yrs b. In patients with BPH consider semiannual DRE c. Caution patients about cold or allergy meds containing anticholinergic or sympathomimetic agents that could cause urinary retention. d. Stress the importance of an active sex life with or without masturbation regardless of age i. Avoid sexual arousal or stimulation without ejaculation e. Stress the importance of physical fitness and its impact on physical and emotional well-being

12