BPH, Prostate Cancer, Testicular Cancer

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BPH, Prostate Cancer, Testicular Cancer

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

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