CAM III > GU part 2 > Flashcards

GU part 2 Flashcards

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1
Q

Components of ED

A

Impotence
Peyronie’s dz
Trauma
Ejaculatory dysfunction (EjD)

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2
Q

When does ED increase?

A

Age
Smoking
CVD
Does not correlate with testosterone levels

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3
Q

Mechanism of erection

A

Psychologic or tactile sexual stimulation initiates pathway
Parasympathetic fibers from sacrospinal cord levels S2-S4 join pelvic plexus
Nerve signals carry through pelvic plexus into cavernous nerves of penile corpora cavernosa

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4
Q

Chemical reaction of erection

A

Sexual stimulation that releases nitric oxide (NO) by cavernous nerves into neuromuscular junction
NO activates enzyme guanylyl cyclase
Guanylyl cyclase converts GTP into cGMP
cGMP activates protein kinase G enzyme
Protein kinase G activates protein kinase but decreased intracellular calcium
Decreased smooth muscle calcium causes neuromuscular relaxation and cavernosal artery dilation
Increased blood flow and penile erection occurs
Venous outflow mediates erectile detumescence

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5
Q

Causes of erectile dysfunction

A 
Neuromuscular junction d/os
Endocrine d/os
Vascular dz
Neurogenic erectile dysfunction
Medication-induced erectile dysfunction
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6
Q

Neuromuscular junction disorders that cause ED

A

Examples- MS, Parkinson’s dz
>60% of pts with ED respond to PDE-5 inhibition
Low dose medical tx successful in most cases

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7
Q

Endocrine disorders for ED- pathology

A

Testosterone metabolically inactive
Dihydrotestosterone metabolically active
Testosterone plays permissive role in ED
Testosterone affects libido
Testosterone replacement corrects ED in pts with very low serum testosterone
Testosterone replacement rarely helps ED if only mildly low

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8
Q

S/sx of ED caused by endocrine disorders

A 
Weakness
Fatigue
Lack of motivation
Lack of libido
Weight gain
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9
Q

Testosterone preparations

A 
Depo-testosterone injections 300 mg IM q 2 wks
Aveed 750 mg IM week 0, 4, then every 10 wks
AndroGel 1.62% 5 grams to skin q AM
Fortesia 40 mg (4 pumps) daily
Axiron 60 mg (2 pumps) daily
Testim 5 gms (one pack) to skin q AM
Androderm patch to skin q day
Compounded topical testosterone
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10
Q

DM and ED

A

MC endocrine d/o affecting erectile function
Causes atherosclerotic small vessel vascular dz
Also causes loss of function to autonomic nerves
DM also causes dysfunction of neuromuscular junction via arterial and smooth muscle of penile corpora cavernosa

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11
Q

Endocrine disorders that cause ED

A

Hypothyroidism
Hyperthyroidism
Adrenal dysfunction

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12
Q

Vascular dz and ED

A

ASCVD results in mechanical obstruction of vascular lumen
Endothelial dysfunction in ASCVD interrupts neural control of vascular smooth muscle function
Results in decreased corpora cavernosal arterial pressure
Treatable with PDE-5 inhibitors or vasoactive intracorporal injection
Venoocclusive dz- venous leak- initial rigidity, but quick detumescence before ejaculation

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13
Q

Neurogenic ED

A

Spinal cord injury or peripheral nerve injury may prevent initiation of erectile cascade

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14
Q

Spinal cord injury ED tx

A

Respond to tactile sensation, but require medical therapy to maintain erection

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15
Q

Psychogenic ED

A

Temporal lobe involved

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16
Q

Pelvic fx and ED

A

Causes pudendal nerve damage and ED

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17
Q

Medication-induced ED

A 
Substitution within class of meds rarely helps ED
Proceed directly to tx of ED
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18
Q

Options for medical tx of ED

A

Oral PDE-5 inhibitors
Intraurethral alprostadil
Intracavernous vasoactive injections
Yohimbine

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19
Q

What are the PDE-5 inhibitors?

A 
Cialis (tadalafil)
Levitra (vardenafil)
Staxin (vardenafil)
Viagra (sildenafil)
Stendra (avanafil)
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20
Q

MOA of PDE-5 inhibitors

A

Inhibits PDE-5 breakdown of cGMP
Increases NO and cGMP levels resulting in maintained erections
Sexual stimulation necessary for vasoactive pathways to work with PDE-5 inhibitors

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21
Q

CIs and caution for PDE-5 inhibitors

A

Generally first line therapy
CIed if used with nitrates (hypotension)
Caution when used with alpha-blockers (4-hr separation)

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22
Q

Benefits of PDE-5 inhibitor therapy

A

Can be taken orally
Well-tolerated by most pts
High success rate when used appropriately
Results in natural erection

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23
Q

Vacuum constriction device for ED (Response II, VET-CO)

A 
Vacuum plastic tube around penis
Rubber constrictive device at base of penis
May be used with PDE-5 inhibitors
Safe
Often preferred by elderly
No longer covered by Medicare
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24
Q

Soma therapy- ED

A 
Peyronie's correction therapy
Prostatectomy recovery therapy
Drug enhancement therapy
Penile implant enhancement therapy
Concomitant use with other therapies
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25
Pharmacologic injection therapy- ED
Vasoactive agents injected into corpus cavernosa Agents include PGE1, papaverine, phentolamine PGE1 used as monotherapy Papaverine and phentolamine is double mix PGE1, papaverine, phentolamine is triple mix
26
Complications of pharmacologic injection therapy for ED
Priapism Penile curvature Efficacy 90% 60% of pts stop using within 1 yr
27
Intraurethral drug therapy for ED
PGE1 intraurethral pallet Less effective than intracavernous injection Useful in pts who must be on nitrates Painful urethral irritation
28
Penile prosthesis for ED
Semi-rigid always firm Inflatable three piece prosthesis more natural 90% partner and pt satisfaction rate Most effective long-term tx for ED
29
Clinical problems associated with androgen deficiency
``` Muscle wasting Decreased body hair Decreased hematopoiesis Increased fxs Increased fat Poor concentration ability Osteoporosis Sexual dysfunction ```
30
Cause of Peyronie's dz
Scar that forms on corpus cavernosum
31
What is the MC type of prostate CA?
95% adenocarcinoma MC cancer in men Second most common cause of death in men
32
Epidemiology of prostate CA
More common in AA men, low socioeconomic groups, high-fat diet, prostatitis Selenium, Vit E and lycopene not preventative No relationship to smoking or sexual activity
33
Prostate CA detection and dx
Screening in pts with >10 yr life expectancy PSA and DRE age 50-80 Abnl DRE or PSA signals need for prostate bx
34
PSA
Produced by benign and malignant prostate tissue Can be elevated by many causes Increases with age PSA rises >0.5 nanograms/mL per yr concerning
35
Causes of increased PSA
``` BPH Prostatitis UTI Prostate trauma Prostate carcinoma Prostate infarction ```
36
Prostate cancer diagnostic study
TRUS/BX- prostate u/s transrectal with needle bx Prostate cancers have hypoechoic appearance 8-12 cores taken under Xylocaine infiltration anesthetic Abx coverage for bx 93% accuracy
37
Prostate CA and Gleason grading system
Grade tumors on a scale of 1-5 (good to bad) Grade secondary histology pattern from 1-5 Expressed as primary + secondary = total High Gleason: 6 MC Gleason total 8-10 most aggressive
38
How is the secondary score calculated on the Gleason grading system?
Calculated after the hypothetical removal of the worst tumors
39
Tx options for localized prostate CA
``` Openn Radical prostatectomy Robotic radical prostatectomy Brachytherapy (I-125 seeds) External beam radiation therapy (EBRT) Cryosurgery Hormonal therapy HIFU Watchful waiting ```
40
Radical prostatectomy
``` Can be performed by incision or robotic Pt should have a >10 yr life expectancy Overnight stay in hospital PSA goes to 0 postoperatively SEs -Incontinence -Erectile dysfunction --The better the erection before the surgery, the better it will be afterwards ```
41
Radiation therapy for prostate cancer
``` Brachytherapy (I-125 or palladium seeds) External beam radiation therapy 5 days a week x 6-8 wks -Electrons -Protons Brachytherapy +/- EBRT x 5 wks Cyberknife SEs: -ED (30-100%) -Incontinence -Bowel side effects -Often preferred in poor surgical candidates ```
42
Prostate cancer cryosurgery
5 probe freezing of prostate 2 freeze and thaw cycles Transrectal monitoring Most useful in radiation failures
43
Hormonal therapy in prostate cancer
Prostate cancer growth accelerated by testosterone Testosterone inhibition by orchiectomy or luteinizing hormone-releasing hormones (LHRH) analogs decrease testosterone Rapid tumor regression can occur Duration of response variable- yrs generally SEs occur
44
SEs of androgen deprivation therapy
``` Hot flashes Loss of libido Impotence Osteoporosis Decreased facial hair Loss of muscle mass Weight gain Mental status changes ```
45
Antiandrogens in prostate cancer
``` Use with LHRH agonist Block circulating androgen effect on prostate cancer Agents: -Casodex (bicalutamide -Nilandron (nilutamide) Eulexin (flutamide) ```
46
Advanced prostate cancer tx
Zytiga with prednisone Xtandi Chemo for advanced carcinoma
47
Vaccine therapy in prostate cancer
Provenge Use before chemo Activates pt lymphocytes against prostate cancer antigens
48
Penile carcinoma
Squamous cell carcinoma uncommon in US Neonatal circumcision has protective effect Penile cleansing has preventative effect Related to cigarette smoking and other tobacco use Related to HPV 16 and 18
49
S/sx of penile carcinoma
``` Painless mass on glans, penis or sulcus Foul-smelling d/c Inguinal lymphadenopathy Generally delayed dx d/t embarrassment Dxed by bx ```
50
Penile carcinoma tx
``` Laser ablation of tumor Partial penectomy with 2 cm margin Total penectomy Inguinal lymphadenectomy Chemotherapy, if advanced Radiation therapy, if advanced ```
51
Testicular cancer
MC solid malignancy in men age 15-34
52
Testicular cancer s/sx
``` Painless mass on testicle Painful scrotum (tumor hemorrhage) Scrotal enlargement Diagnostic studies -Scrotal u/s- shows mass -Alpha-fetoprotein, beta hCG, LDH -CT scan of abdomen and pelvis ```
53
Diagnosis of testicular cancer
AFP- elevated only in non-seminomatous tumors Beta hCG- increased with seminoma or nonseminomatous tumors Abdominal CT scan- retroperitoneal nodes in periaortic aorta CXR or CT- lung site of distant metastasis
54
Histology of testicular cancer
``` Embryonal cell carcinoma Seminoma Teratoma Yoke sac tumor Choriocarcinoma ```
55
Testicular cancer tx
``` Radical inguinal orchiectomy Chemo Radiation Retroperitoneal lymph node dissection (RPLND) Active surveillance after orchiectomy ```
56
Chemo in testicular cancer
Radiation therapy useful in advanced dz | Retroperitoneal lymph node dissection (RPLND) curative in many cases
57
RPLND and testicular cancer
``` Use for pre-chemo or to remove retroperitoneal teratoma resistant to chemo SEs -Lymphocele -Chylous ascites -Small bowel resection -Retrograde ejaculation- 20% ```
58
Chemo SEs for testicular cancer
Raynaud's phenomenon Infection Cardiac toxicity 0.55 risk of secondary malignancy
59
Varicocele
Abnormal dilation of veins of pampiniform plexus Subclinical varicocele in 30% of male population Seen in up to 505 of men with primary infertility Seen in 80% of pts with secondary infertility
60
S/sx of varicocele
Scrotal heaviness, testicular atrophy, infertility Bag of worms Semen analysis- decreased sperm counts Scrotal ultrasound/Doppler shows increased venous flow (Valsalva maneuver)
61
When should a varicocele be corrected?
Infertility Testicular atrophy Pain
62
Unilateral varicoceles have _______ effect on spermatogenesis
Bilateral
63
Surgery for varicocele
``` Open ligation Laparoscopic varicocelectomy 70% improvements in semen parameters after varicocelectomy Complications: -Hydrocele -Testis atrophy or loss ```
64
Sc of epididymitis and orchitis
Acute scrotal pain Fever Swelling
65
MC cause of epididymitis and orchitis in men <35 yo
N. gonorrhoeae | C. trachomatis
66
MC cause of epididymitis and orchitis in men >35 yo
E. coli
67
Epididymitis dx
Differentiate from acute testicular torsion (twisting) PE- epididymal swelling and tenderness WBC in urine Scrotal u/s shows increased epididymis size and blood flow
68
Epididymitis tx
``` Abx - <35 yo: Doxycycline - >35 yo: Cipro and TMP-SMX x 4 wks Orchiectomy rarely necessary Chronic epididymitis- epididymectomy ```
69
Hydrocele
Serous fluid collection within tunica vaginalis of scrotum Translucent almost clear fluid Complaint of heaviness in scrotum, scrotal pain and scrotal mass Diagnosis- transillumination of hydrocele Scrotal ultrasound definitive Causes- trauma, infection, tumor, idiopathic Tx- surgical removal, 25% recurrence
70
Testicular torsion
True urologic emergency Twisting of testicular arterial blood supply Sx- acute scrotal pain, swelling, nausea, vomiting 6-8 hour window to fix before irreversible testicular infarction and necrosis occurs Typically in pts <21 yo
71
Dx and tx of testicular torsion
Surgical exploration if index of suspicion is high Scrotal u/s with Doppler useful in differentiating from epididymitis Bilateral orchiopexy- 3 point fixation Testicular salvage rate 70% Delay in surgery- salvage rate 40%
72
Phimosis
Tightness of foreskin- cannot retract Associated with scarring and infection Common in neonates, decreases with age Tx: cirumcision
73
Paraphimosis
Edema of foreskin proximal to retracted foreskin Tx is reduction Recurrent then circumcision
74
Balanitis
Infection of foreskin More common in diabetics or immunocompromised pts Tx with Nystatin ointment or powder Recurrent balanitis: circumcision
CAM III
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