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BPH, Prostate Cancer, Testicular Cancer
 

BPH, Prostate Cancer, Testicular Cancer

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    BPH, Prostate Cancer, Testicular Cancer BPH, Prostate Cancer, Testicular Cancer Presentation Transcript

    • BPH, Testicular Cancer and Prostate Cancer
      Patrick Carter MPAS, PA-C
      Clinical Medicine I
      March 4, 2011
    • 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
    • Urethral, Penile and Scrotal Injuries
    • 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
    • Phimosis
    • 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
    • Paraphimosis
    • 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
    • Penile Fracture
    • Penile Fracture
    • 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
    • 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
    • Testicular Cancer
    • 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
    • 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%
    • 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
    • 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%
    • 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
    • Testicular Cancer
      Differential Diagnosis
      Epidermoid cyst
      Laboratory Tests
      Serum human chorionic gonadotropin, alpha-fetoprotein, and lactate dehydrogenase
      Liver function tests
    • Testicular Cancer/Epidermoid Cyst
    • 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
    • Testicular Cancer
    • 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
    • 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
    • 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%
    • Prostate Disorders
    • The Prostate Gland
    • Zonal Anatomy
    • Constituents of Prostate Fluid
    • The Prostate and Aging
    • Prostate Calculi
    • X-Ray with Extensive Prostatic Calculi
    • Transrectal Ultrasound - Prostatic Calculi
    • Benign Prostatic Hyperplasia
    • Prostate Size by Age
    • Prevalence of BPH with Age
    • 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
    • Benign Prostatic Hyperplasia
      Definition = smooth, firm, elastic enlargement of the prostate
      Etiology
      Multifactorial
      Endocrine: dihydrotestosterone (DHT)
      Aging
    • 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
    • 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
    • Benign Prostatic Hyperplasia
      Irritative symptoms
      Urgency
      Frequency
      Nocturia
      American Urological Association symptom index
    • Benign Prostatic Hyperplasia
      Differential diagnosis
      Prostate cancer
      Urinary tract infection
      Neurogenic bladder
      Urethral stricture
    • 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
    • PE - Bladder Distention
    • Elevated Serum PSA
      Prostate carcinoma
      Glandular hyperplasia associated with BPH
      Acute bacterial prostatitis and prostate abscess (transitory)
      Prostatic infarction (transitory)
      Manipulation of prostate (transitory)
    • Benign Prostatic Hyperplasia
      Medications
      Alpha-blockers
      Prazosin
      Terazosin
      5 alpha-reductase inhibitors
      Finasteride
      Dutasteride
      Saw palmetto is of no benefit
      Combination therapy
    • 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
    • Benign Prostatic Hyperplasia
      Types of surgery
      Transurethral resection of the prostate (TURP)
      Postoperative complications
      Retrograde ejaculation (75%)
      Impotence (5–10%)
      Urinary incontinence (< 1%)
    • 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
    • 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
    • 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)
    • 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
    • Prostate Cancer
    • 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)
    • 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
    • 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
    • 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
    • Prostate Coronal Section - Carcinoma
    • 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
    • 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
    • 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
    • Prostate Cancer
      Medications
      Adrenal (adrenal insufficiency, nausea, rash, ataxia)
      Ketoconazole
      Aminoglutethimide
      Corticosteroids (prednisone) for gastrointestinal bleeding or fluid retention
    • Prostate Cancer
      Medications
      Pituitary, hypothalamus (gynecomastia, hot flushes, thromboembolic disease, erectile dysfunction)
      Estrogens
      Luteinizing hormone-releasing hormone (LHRH) agonists
      Antiandrogens (flutamide)
      Chemotherapy with Docetaxel
    • 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
    • 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
    • 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
    • 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
    • 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
    • Questions?