It’s a non malignant enlargement of the prostate glandIt’s nearly a universal condition in men as they age.About 90% of men had BPH on autopsy data.
The prostate gland surrounds the urethra , the tube that carries urine from the bladder out of the body. As the prostate gets bigger, it may squeeze or partly block the urethra. This often causes problems urinating.The prostate is a doughnut-shaped gland with two lobes, and it is located below the bladder about halfway between the rectum and the base of the penis. It encircles the urethra,In young men it is normally about the size of a walnut. The prostate produces most of the fluid that makes up semen.
Causes: Benign prostatic hyperplasia is probably a normal part of the aging process in men. May involve aging associated hormonal changes that stimulate hyperplasia.SXS: (usually progressive)Starting/stoping stream of urineFeeling of incomplete voidIn a small number of cases, BPH may cause the bladder to be blocked. This backed-up of urine (urinary retention), leads to bladder infections or stones or kidney damage.
Although BPH is found in many pt’s with BPH, no causative association has been identified. These apppear to be 2 common coincident conditions associated with aging.NOTCancerFertilitySexual function
Historyfor sxs, which may be progressive constant or even remit for a while. TestsUA – infection, renal involvementDRE – most helpful. (DRE), which lets your doctor feel the size of your prostate. Blood tests: renal function assessment . PSA usually not helpful, maybe normal or elevated, unless CA is a concern. In some cases, a prostate-specific antigen (PSA) test is done to help rule out prostate cancer. (Prostate cancer and BPH are not related, but they can cause some of the same symptoms.)
Treatment Watchfull waiting. Those with mild sxsMedical therapy (alpha blockers are first line) Relax smooth muscle in the prostate and bladder neck. (pt respond within days)Alpha reductase inhibitors: shrink prostate by 24% (full response take months)Herbal preparations: Saw Palmetto is widely used by without clinical evidence.
Malignancy arising from the prostate gland
High prevalence in older menHighest risk with African-American race (275/100k vs 172/100k)Also tend to be more malignantdzLowest incidence in Asian Americansfamily history2 fold if one 1st degree relative4fold if 2 1st degree relativeGenetics5 fold increase if BRCA2 mutation carrier. Possible risck factorsObesity hormones: leptin
Sxssimilar and indistinguishable to BPH, but most people with such sxs likely have BPH over prostate cancer. Exception Dysuria, ED, back/hip pain due to mets and or wt loss. Nodular Prostate Vs enlarged but smooth with BPH.
Tests for Prostate CancerScreenings for healthy men may include both (DRE) and a (PSA). Nodular Prostate Vs enlarged but smooth with BPH. Around 1/3 of those with prost CA have a normal PSA. At what age do you stop: US preventive task force says around 75. The American Urological Association recommends a first-time PSA test at age 40, with follow-ups per doctor's orders.__________PSA Sensitivity 57-79%Specificity 59-68%Positive predictive value 40-49%
TRUS: (trans rectal ultra sound) often done for guided biopsyMRI: more sensitive at detecting dz outside of capsuleBone Scans: used to eval spread to bonesAbdominal CT: main value is to plan for radiation tx. Also detect nodal metsTreatment obvioulsy depends on stage of dz: Varies from active surveillance to radical prostatectom to radiation therapy to brachytherapy
Abnolmal DRE and PSA f/u via biopsy. Those going for surgery often have an MRI
1% of all cancers in manMost cases curable350 deaths per year (spread and result in death. may spread slowly or rapidly through the lymphatics or blood vessels)Peak age 20-404 x more common in whites
No one cause has been determined but there are know links between testicular cancer and other factors. Cryptochidism: 10% of test cancers:orchiopexydoes not reduce a man's risk for developing cancer. The normal position simply allows for better and closer examination.Personal history of testicular cancer:strongest risk factor - 500 times that of the normal populationThe incidence of developing cancer in the opposite testicle is 1 to 2%.Infertilify> test ca and test can> infertilityA few genetic disorders, including Klinefelter’s syndrome and Down’s syndrome, are associated with a risk of testicular cancer.
Aches only present about 30% of the time.Ie: back pain from mets to the retroperitoneal region. Dyspnea from pulmmetsTumor markers
Testicular self exam has yet to improve outcome, but it is the only preventive technique we got. Excellent prognosis: among the most curable of cancers, even in an advanced stagerarely fatal. Over 90% of patients are diagnosed with small, localized cancers that are highly treatable5 yr. survival rate close to 95%
Cancers affecting either of these organs also may be called colorectal cancer.Polyps: grossly visible protrusion from mucosal surface.2008 >148 k new cases, close to 50k deaths. 15% higher incidence and 40% higher mortality in AASex: 35% higher in manMortality is 43% higher in males
Enviromental: upper class in urban areasDiet: Colon cancer may be associated with a high-fat, low-fiber diet and red meat. Tobacco use: particularly > 35yr oldFmHx: 25% of colorectal CaPmHx of DM
Many asymptomaticIf Sxs, they vary depending on the physiologic location.Ceccum and ascending colon, may become large w/o obstruction (pt present with fatigue, palpitations, angina from lesions hemmoraging)Transverse and descending: obstruction (cramping, perforations)Rectosigmoid: hematochezia, tenesmus, rectal bleeding
PE: abdominal mass, rectal mass on DRE,rectal bleedingA rectal exam may reveal a mass in patients with rectal cancer, but not colon cancer.FOBT: may detect small amounts of blood in the stool, which could suggest colon cancer. However, this test is often negative in patients with colon cancer. Thus done with colonoscopyalso important: a positive FOBT doesn't necessarily mean you have cancer.Colonoscopy with bx as the gold standard for dxingLabsCBC helps dx anemiacarcinoembryonicantigen (CEA) and CA 19-9, help track progressafter treatment.
TxChemotherapy to kill cancer cellsSurgery (most often a partial colectomy) to remove cancer cellsRadiation therapy to destroy cancerous tissuePrevention: The death rate for colon cahas dropped in the last 15 years. Screening (american cancer society recs)Men and women >50 colonoscopy earlier if Fmhx of sxs) or annual FOBT with 6 samples from 3 diff BMDRE age > 40precancerous polyps. Removing these polyps may prevent colon cancer.NSAIDs (aspirin, ibuprofen, naproxen, celecoxib), Several studies, However, the U.S. Preventive Services Task Force and the American Cancer Society recommends against taking aspirin or other anti-inflammatory medicines to prevent colon cancer if you have an average risk of the diseaseAlthough low-dose aspirin, does not lower the rate of colon cancerStatin’s associated with a 50% reductionsSupplementation: shown promised in case controlled trials
Topics in men's health
TOPICS INMEN’S HEALTH Marcos Pienasola PA-S
LEARNING OBJECTIVES Outline some of the health problems specific to men. Common terminology pertinent to caring for such problems. Basic anatomy, physiology and pathophysiology of common conditions affecting men. Diagnostic studies and treatments available.
TOPICS INMEN’S HEALTH Across a broad range of indicators, men report poorer health than women. Although men in all socioeconomic groups are doing poorly in terms of health, some especially high-risk groups include men of low socioeconomic status (SES) of all racial/ ethnic backgrounds, low-SES minority men, and middle-class African American men.” —David Williams, PhD, MPH
WHY MEN’S HEALTH? Life expectancy shorter than women (75.6 years vs. 80.8.1 years) More likely to die at earlier ages from: Chronic diseases (heart disease, CA, stroke) Communicable diseases Injuries (both accidents and homicides) Highest-income men have mortality rates equal to those of the poorest women (Rieker and Bird 2000)
DIAGNOSIS ADDRESSED TODAYBPHProstate cancerTesticular cancerColorectal cancer
BPH – WHAT IS IT? Benign prostatic hyperplasia (BPH) is an enlarged prostate gland. BPH occurs in almost all men as they age. BPH is not cancer . An enlarged prostate can be a nuisance, but it is usually not a serious problem. About half of all men older than 75 have some symptoms. Benign prostatic hyperplasia is also known as benign prostatic hypertrophy.
CAUSES AND SYMPTOMS Causes: Not really sure. Better understanding of risk factors Advanced age Obesity FmHx of BPHSymptoms: Obstructive Irritative Hesitancy Intermittent voiding Urgency Diminished stream Frequency Incomplete bladder Nocturia emptying Postvoid leakage
WHAT BPH DOES NOT DO: does not cause prostate cancer does not affect a mans ability to father children. does not cause erectile dysfunction.
BPH – DIAGNOSIS AND TREATMENT How is BPH diagnosed? Present + past health history and a physical exam. Tests may include Urine test (urinalysis) Blood tests Digital rectal exam How is it treated? Treatment may not be necessary unless the symptoms are bothersome enough or there are other problems such as backed-up urine, bladder infections or bladder stones.
PROSTATE CANCERMost common cancer found in American menafter skin cancer.It tends to be a slow-growing cancer, butthere are also aggressive, fast-growing types.Highly treatable with early detection.
RISK FACTORS Advancing age African Americans FmHx of Prostate cancer Geneticfs Possible risk factors Obesity Fatty diet Red meats
SYMPTOMS AND SIGNS Very similar to BPH, including asymptomatic. Signs Nodular posterior prostate Hard in consistency Irregular shape Other associated with CA Coagulopathy Spinal cord compression
PROSTATE CANCER - TESTINGDRE - digital rectal examPSA - prostate specific antigenDiscussions at age: 50 for average-risk men 45 for men at high risk. This includes African-Americans. 40 for men with a strong family history of prostate cancer.
PROSTATE CANCER - + PSA F/U TRUS Abdominal MRI CT Bone Scans
ELEVATED PSA DDX BPH Post Prostate biopsies Prostatitis Post DRE Prostate Cancer
TESTICULAR CANCER Uncommon cancer Usually curable Most occurrences between ages 15 and 35. Whites > African american
TESTICULAR CANCER RISK FACTORS No one cause has been determined but there are know links between testicular cancer and other factors. Undescended testicle (cryptorchidism). Personal history of testicular cancer. Infertility Klinefelter’s syndrome and Down’s syndrome. Smoking Suspected risk factors: sedentary lifestyle, early puberty, previous mumps, testicular injury, elevated scrotal temperature, and overexposure to pesticides or radiation.
SIGNS,SYMPTOMS AND WORKUP Classic presentation: Painless testicular mass. Other sxs occur in special circumstances A testicular mass should be considered cancer until proven otherwise. Testicular exam during CPE US recommended for any suspicious masses or persistent painful testicular swelling . Lab work you may come across hCG, LDH, AFP
PREVENTION Noncancerous growths in the testicle are rare, so all masses should be assumed to be a cancer until proven otherwise.
WHAT IS COLORECTAL CANCER? Colon cancer vs rectal cancer. Most arise from polyps 2nd highest cause of cancer death. Generally > 50 y/o More common and more morbid amongst African Americans Higher mortality in males (43%)
RISK FACTORS Older than 60 African American and eastern European descent History of cancer Colorectal polyps Have inflammatory bowel disease Family history of colon cancer Genetic syndromes: hereditary nonpolyposis colorectal cancer (HNPCC) Familial adenomatous polyposis (FAP). Diet: animal fat Obesity, smoking cigarettes and drinking alcohol.
SYMPTONS Many asymptomatic Abdominal pain and tenderness in the lower abdomen Blood in the stool (hematochezia) Dark, tarry stools (melena) Diarrhea, constipation, or other change in bowel habits Intestinal obstruction Narrow stools Unexplained anemia Weight loss w/o other identifiable cause
TESTS AND DIAGNOSISPhysical exam May reveal abdominal mass DREFOBT: Fecal occult blood testColonoscopy vs Sigmoidoscopy biopsyBlood tests: Complete blood count (CBC) Liver function tests CEA, CA19-9 (tumor markers)CT or MRI scans of the abdomen, pelvic area, chest, or brain may beused to stage the cancer.
TREATMENT AND PREVENTION Treatment Treatment depends partly on the stage of the cancer. In general, treatments may include: Chemotherapy Surgery Radiation Prevention: Screening: Statins Colonoscopy >50 y/o Dietary and lifestyle modifications DRE age 40 are important. Removal of precancerous polyps Folic acid, Calcium, fiber NSAIDs may help reduce the risk of colorectal cancer.
TEN LEADING CAUSES OF DEATH IN MEN Heart disease Cancer (lung, prostate, colorectal, skin) Stroke Accidents and unintentional injuries Lung disease Diabetes Pneumonia and influenza Suicide Chronic liver disease and cirrhosis Kidney disease
References American Cancer Society MerkMedicus www.emedicine.com Harrison’s Medicine Practice Manual Epocrates Prostate Cancer Foundation www. mayoclinic.org