BPH, Prostate Cancer, Testicular Cancer

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  • 1. BPH, Testicular Cancer and Prostate Cancer
    Patrick Carter MPAS, PA-C
    Clinical Medicine I
    March 4, 2011
  • 2. Objectives
    For each of the following diseases describe the etiology, epidemiology, pathophysiology, risk factors, signs and symptoms, diagnostic work-up, and treatment:
    Urethral, penile and scrotal injuries
    Benign prostatic hyperplasia (BPH)
    Testicular cancer
    Prostate cancer
    Compare and contrast the pathophysiology, clinical presentation, diagnostic work-up and treatment of BPH and prostate cancer
  • 3. Urethral, Penile and Scrotal Injuries
  • 4. Phimosis
    Inability to retract the foreskin
    Physiologic at birth
    In 90% of uncircumcised males the foreskin becomes retractable by the age of 3 years
    May become pathologic from inflammation and scarring at the tip of the foreskin
    Treatment
    Corticosteroid cream to the foreskin three times daily for 1 month
    After age 10, circumcision is recommended
  • 5. Phimosis
  • 6. Paraphimosis
    Foreskin is retracted behind the coronal sulcus and cannot be pulled back over the glans
    Leads to painful venous stasis in the retracted foreskin results, with edema leading to severe pain
    Treatment
    Lubrication of the foreskin and glans and then compressing the glans and simultaneously placing distal traction on the foreskin
    In rare cases, emergency circumcision under general anesthesia is necessary
  • 7. Paraphimosis
  • 8. Penile Fracture
    Traumatic rupture of the corpus cavernosum, occurs when the tunica albuginea is torn
    Usually associated with sexual activity
    Patient may hear a snapping sound and experience localized pain, detumescence, and a slowly progressive penile hematoma
  • 9. Penile Fracture
  • 10. Penile Fracture
  • 11. Penile Fracture
    Treatment
    Nonsurgical – bed rest and ice packs for 24 to 48 hours followed by local heat and a pressure dressing
    Surgical (most common) – hematoma is evacuated, torn tunica albuginea is sutured, and a pressure dressing is applied
    Prognosis – 10% will experience a permanent deformity, suboptimal coitus, or impaired erections, especially if managed nonoperatively
  • 12. Peyronie’s Disease
    Acute phase – pain and inflammation as the plaque is forming
    Medical therapy with p-aminobenzoic acid, vitamin E, colchicines, or tamoxifen may be modestly successful
    Chronic phase – pain subsides and the plaque is stable
    Surgical correction if the curvature interferes with sexual intercourse
  • 13. Testicular Cancer
  • 14. Testicular Cancer
    Essentials of diagnosis
    Most common neoplasm in men aged 20–35
    Typical presentation as a patient-identified painless nodule
    Orchiectomy necessary for diagnosis
  • 15. Testicular Cancer
    General Considerations
    Rare (2–3 new cases per 100,000 males in the United States each year)
    90–95% of all primary testicular tumors are germ cell tumors
    Slightly more common on the right than on the left, bilateral in 1–2%
  • 16. Testicular Cancer
    General Considerations
    Cause unknown, but increased risk with a history of unilateral or bilateral cryptorchism
    Risk of malignancy is highest for an intra-abdominal testis (1:20) and 1:80 for an inguinal testis
    Orchiopexy does not alter the risk in the cryptorchid testis; it does help examination and tumor detection
    5–10% of testicular tumors occur in the contralateral, normally descended testis
  • 17. Testicular Cancer
    Signs and symptoms
    Most common symptom is painless enlargement of the testis
    Sensation of heaviness
    Acute testicular pain from intratesticular hemorrhage in ~10%
    Symptoms relating to metastatic disease in 10%
    Asymptomatic at presentation in 10%
  • 18. Testicular Cancer
    Physical examination findings
    Testicular mass or diffuse enlargement of the testis most common
    Secondary hydroceles in 5–10%
    Supraclavicular adenopathy
    Retroperitoneal mass
    Gynecomastia in 5% of germ cell tumors
  • 19. Testicular Cancer
    Differential Diagnosis
    Epidermoid cyst
    Laboratory Tests
    Serum human chorionic gonadotropin, alpha-fetoprotein, and lactate dehydrogenase
    Liver function tests
  • 20. Testicular Cancer/Epidermoid Cyst
  • 21. Testicular Cancer
    Imaging Studies
    Scrotal ultrasound
    CT scan of abdomen and pelvis
    Surgical treatment
    Radical orchiectomy by inguinal exploration with early vascular control of the spermatic cord structures
    Scrotal approaches and open testicular biopsies should be avoided
  • 22. Testicular Cancer
  • 23. Testicular Cancer
    Seminomas
    Stage I and IIa seminomas treated by radical orchiectomy and retroperitoneal irradiation have 5-year disease-free survival rates of 92 - 98%
    Stage IIb and III seminomas are treated with primary chemotherapy
    Among stage III patients, 95% will attain a complete response following orchiectomy and chemotherapy
  • 24. Testicular Cancer
    Nonseminomas
    Up to 75% of stage A nonseminomas are cured by orchiectomy alone
    Modified retroperitoneal lymph node dissections have been designed to preserve the sympathetic innervation required for ejaculation
  • 25. Testicular Cancer
    Prognosis
    Patients with bulky retroperitoneal or disseminated disease treated with primary chemotherapy followed by surgery have a 5-year disease-free survival rate of 55–80%
  • 26. Prostate Disorders
  • 27. The Prostate Gland
  • 28. Zonal Anatomy
  • 29. Constituents of Prostate Fluid
  • 30. The Prostate and Aging
  • 31. Prostate Calculi
  • 32. X-Ray with Extensive Prostatic Calculi
  • 33. Transrectal Ultrasound - Prostatic Calculi
  • 34. Benign Prostatic Hyperplasia
  • 35. Prostate Size by Age
  • 36. Prevalence of BPH with Age
  • 37. Benign Prostatic Hyperplasia
    Essentials of diagnosis
    Obstructive or irritative voiding symptoms
    May have enlarged prostate on rectal examination
    Absence of urinary tract infection, neurologic disorder, urethral stricture disease, prostatic or bladder malignancy
  • 38. Benign Prostatic Hyperplasia
    Definition = smooth, firm, elastic enlargement of the prostate
    Etiology
    Multifactorial
    Endocrine: dihydrotestosterone (DHT)
    Aging
  • 39. Benign Prostatic Hyperplasia
    Epidemiology
    The most common benign tumor in men
    Incidence increases with age
    Prevalence
    ~20% in men aged 41–50
    ~50% in men aged 51–60
    > 90% in men aged 80 and older
    Symptoms are also age related: at age 55, ~25% of men report obstructive voiding symptoms
  • 40. Benign Prostatic Hyperplasia
    Obstructive symptoms
    Hesitancy
    Decreased force and caliber of stream
    Sensation of incomplete bladder emptying
    Double voiding (urinating a second time within 2 hours)
    Straining to urinate
    Postvoid dribbling
  • 41. Benign Prostatic Hyperplasia
    Irritative symptoms
    Urgency
    Frequency
    Nocturia
    American Urological Association symptom index
  • 42. Benign Prostatic Hyperplasia
    Differential diagnosis
    Prostate cancer
    Urinary tract infection
    Neurogenic bladder
    Urethral stricture
  • 43. Benign Prostatic Hyperplasia
    Diagnosis
    Physical examination
    DRE to note size and consistency
    Focused neurologic examination
    Examine lower abdomen for a distended bladder
    Renal insufficiency from BPH
    If possibility of cancer, do serum prostate-specific antigen (PSA), transrectal ultrasound, and biopsy
  • 44. PE - Bladder Distention
  • 45. Elevated Serum PSA
    Prostate carcinoma
    Glandular hyperplasia associated with BPH
    Acute bacterial prostatitis and prostate abscess (transitory)
    Prostatic infarction (transitory)
    Manipulation of prostate (transitory)
  • 46. Benign Prostatic Hyperplasia
    Medications
    Alpha-blockers
    Prazosin
    Terazosin
    5 alpha-reductase inhibitors
    Finasteride
    Dutasteride
    Saw palmetto is of no benefit
    Combination therapy
  • 47. Benign Prostatic Hyperplasia
    Indications for surgery
    Refractory urinary retention (failing at least one attempt at catheter removal)
    Large bladder diverticula
    Recurrent urinary tract infection
    Recurrent gross hematuria
    Bladder stones
    Renal insufficiency
  • 48. Benign Prostatic Hyperplasia
    Types of surgery
    Transurethral resection of the prostate (TURP)
    Postoperative complications
    Retrograde ejaculation (75%)
    Impotence (5–10%)
    Urinary incontinence (< 1%)
  • 49. Benign Prostatic Hyperplasia
    Types of surgery
    Transurethral incision of the prostate (TUIP)
    Removes the zone of the prostate around the urethra leaving the peripheral portion of the prostate and prostate capsule
    Lower rate of retrograde ejaculation reported (25%)
    Open simple prostatectomy when
    Prostate is too big to remove endoscopically (> 100 g)
    Bladder stone is present
  • 50. Benign Prostatic Hyperplasia
    Minimally invasive approaches
    TULIP (transurethral laser-induced prostatectomy) under transrectal ultrasound guidance
    Advantages of laser surgery include
    Outpatient surgery
    Minimal blood loss
    Ability to treat patients while they are receiving anticoagulation therapy
  • 51. Benign Prostatic Hyperplasia
    Minimally invasive approaches
    TULIP
    Disadvantages of laser surgery include
    Lack of tissue for pathologic examination
    Longer postoperative catheterization time
    More frequent irritative voiding complaints
    Expense of laser fibers and generators
    Transurethral needle ablation of the prostate (TUNA)
  • 52. Benign Prostatic Hyperplasia
    Other options
    Watchful waiting: only for patients with mild symptoms (AUA scores 0–7)
    With watchful waiting, ~10% progress to urinary retention, and half demonstrate marked improvement or resolution of symptoms
    Follow-Up
    Follow AUA Symptom Index for BPH
  • 53. Prostate Cancer
  • 54. Prostate Cancer
    Essentials of Diagnosis
    Prostatic induration on digital rectal examination (DRE) or elevated level of serum prostate-specific antigen (PSA)
    Most often asymptomatic
    Rarely, systemic symptoms (weight loss, bone pain)
  • 55. Prostate Cancer
    General Considerations
    Most common cancer in American men
    Second leading cause of cancer-related death in men
    About 234,500 new cases of prostate cancer, about 27,350 deaths in 2006
    At autopsy, > 40% of men aged > 50 years have prostate carcinoma, most often occult
  • 56. Prostate Cancer
    Incidence increases with age
    Risk factors
    Black race
    Family history of prostate cancer
    History of high dietary fat intake
    Majority of prostate cancers are adenocarcinomas
  • 57. Prostate Cancer
    Signs and symptoms
    Focal nodules or areas of induration on DRE
    Obstructive voiding symptoms
    Lymph node metastases
    Lower extremity lymphedema
    Back pain or pathologic fractures
    Rarely, signs of urinary retention or neurologic symptoms as a result of epidural metastases and cord compression
  • 58. Prostate Coronal Section - Carcinoma
  • 59. Prostate Cancer
    Laboratory tests
    Elevations in serum PSA (normal < 4 ng/mL)
    PSA correlates with the volume of both benign and malignant prostate tissue
    18–30% of men with PSA 4.1–10.0 ng/mL have prostate cancer
    Elevations in serum BUN or creatinine in patients with urinary retention or ureteral obstruction
    Elevations in alkaline phosphatase or hypercalcemia in patients with bony metastases
  • 60. Prostate Cancer
    Imaging Studies
    Transrectal ultrasound (TRUS)
    MRI of the prostate
    CT imaging to detect regional lymphatic and intra-abdominal metastases
    Radionuclide bone scan for PSA level > 20 ng/mL
  • 61. Prostate Cancer
    Diagnostic procedures
    TRUS-guided biopsy from the apex, mid portion, and base of the prostate
    Fine-needle aspiration biopsies should be considered in patients at increased risk for bleeding
  • 62. Prostate Cancer
    Medications
    Adrenal (adrenal insufficiency, nausea, rash, ataxia)
    Ketoconazole
    Aminoglutethimide
    Corticosteroids (prednisone) for gastrointestinal bleeding or fluid retention
  • 63. Prostate Cancer
    Medications
    Pituitary, hypothalamus (gynecomastia, hot flushes, thromboembolic disease, erectile dysfunction)
    Estrogens
    Luteinizing hormone-releasing hormone (LHRH) agonists
    Antiandrogens (flutamide)
    Chemotherapy with Docetaxel
  • 64. Prostate Cancer
    Therapeutic procedures
    Surveillance
    For minimal capsular penetration, standard irradiation or surgery
    For locally extensive cancers, combination therapy (androgen deprivation combined with surgery or irradiation)
    For metastatic disease, androgen deprivation
  • 65. Prostate Cancer
    Therapeutic procedures
    Radical prostatectomy
    For stages T1 and T2 prostatic cancers, local recurrence is uncommon after radical prostatectomy
    Adjuvant therapy (radiation for patients with positive surgical margins or androgen deprivation for lymph node metastases)
    Radiation therapy
    External beam radiotherapy
    Transperineal implantation of radioisotopes
  • 66. Prostate Cancer
    Screening for prostate cancer
    Screening tests currently available include DRE, serum PSA, TRUS
    Detection rates with DRE are low, varying from 1.5% to 7.0%
    TRUS has low specificity (and therefore high biopsy rate)
    Elevation of PSA is not specific for cancer, occurs in BPH
  • 67. Prostate Cancer
    Age-specific reference ranges for PSA increase specificity
    For men aged 40–49 years, range is < 2.5 ng/mL
    For men 50–59, < 3.5 ng/mL
    For men 60–69, < 4.5 ng/mL
    For men 70–79, < 6.5 ng/mL
    Lower Ranges for Black Males
  • 68. Prostate Cancer
    PSA testing
    Annually in men with a normal DRE and a PSA > 2.5 ng/mL
    Biennially in men with a normal DRE and serum PSA < 2.5 ng/mL
  • 69. Questions?