Urology - Details

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Shared decision making for men 55-69. Ask tell ask Do not screen if > 70 and life expectancy < 10 years, AA increase risk 1.6 x or FHx father or sibling 2-3x risk: screen 40-45. If PSA > 2.5 screen annually, and < 2.5 Q 2 years. PSA > 4 referr for bx.

When and if you screen for prostate cancer?

15 years Randomized data on men in 50-60 For every 1000 men screened, 1-2 deaths prevented and 3 avoid metastatic prostate cancer. 20-50 men will be overdiagnosed: finding small cancer which would not impact life if not found. Treating these provides not benefit only harm ( 60% incontinent/ ED, and > 20% with unnecessary bx) Controversial as 15% of men in US will be dx with but only few will die from it 2.8%. Screening reduces risk from dying prostate cancer for a small number of cases.

What is the research show about screening?

UTI, Prostatitis, BPH, ejaculation within 2 days, DRE and trauma. Decreased from Finasteride 50%

What else can elevate PSA levels? What can decrease them?

> 100,000 CFU on UA, leukocytes > 10

How do you dx UTI in men?

Instrumentation, BPH, urethral stricture, DM, uncircumcised, and anal intercourse.

What are causes of UTI in men?

Cipro 500 bid X 7-10 days of TMP/SMX.

How do you treat UTI in men?

Image with US or CTwithout contrast to r/o obstruction from BPH, or stones.

How do you manage a recurrent UIT in men?

Fever, chills, dysuria, frequency, urgency, pain and cloudy urine.

What are the sx of acute bacterial prostatitis?

Leukocytes > 10 on UA and tender prostate on exam

How do you dx bacterial prostatitis?

E. coli, Enterobacter and Proteus. If sex active, Chlamydia and GC

What are the common organisms which cause prostatitis?

TMP/SMX DS bid or Cipro 500 mg bid x 6 wks. Chronic sx > 3 mo referr to urology for eval.

How do you treat prostatitis?

Notrofurantoin 100 mg bid x 5-7 d. TMP/SMX DS bid x 3 days ( resistance increasing) Reflex 5-7 days.

How do you treat UTI in women?

Androgen deficiency, Psych (depression), Vascular, or Neurologic ETOH and drugs, metabolic, tobacco

Erectile dysfunction causes

Lack of night time erection points to vascular or neurogenic cause. Check TSH and testosterone level ( < 300 is low) Screen for DM: glucose, A1c, lipids Exam: breast for gynecomastia ( elevated prolactin), testes for mass and penis for plaque. Nocturnal Penile Tumenscence to r/o organic cause, US of penile arteries to r/o obstruction.

How do you work up?

Oral phosphodiesterase inhibitors: Viagra ( screen for CVD before) Contraindicated with Nitrates or alpha blockers. Vacuum constrictor device Penile injection Prosthesis

How do you treat ED?

Primary: Testicular problem. Decrease sperm production, low testosterone and elevated LH/FSH Secondary due to pituitary: Low FSH and LH.

Hypogonadism in men definition

Treat only if symptomatic with low testosterone levels ( am best) Sx. fatigue, low of body hair, depression and decrease muscle mass, osteoporosis, and ED)

How do you treat hypogonadism?

DM, obesity, ED, age > 62,

What are the risk factors for BPH?

UA, BG, Cr and PSA if considering starting 5alpha reductase inhibitor ( works with large prostate) Voiding diary along with DRE

What is the w/u of BPH?

Severe sx or pain, men < 45, abnormal DRE, hematuria, elevated PSA, dysuria, incontinence, neurologic, PVR > 250 Do not measure PVR unless have elevated Cr and need to look for obstruction, recurrent UTI, hydronephrosis,

When do you referr to urology for BPH?

Mild sx: Bladder training and surveillance Mod sx: bothersome Tamulosin 0.4 mg/d in am. ( alpha blocker) SE: fatigue, dizzy with postural hypotension, edema, headache. Tadalafil ( phosphodiesterase inhibitor) if have ED SE: headache, dizzy, flushing, dyspepsia Obstruction with elevated PSA > 1.5 treat with Finasteride 5 mg/d ( decrease prostate size by 50%. Works better combined with tamulosin. SE: ED, low libido, gynecomastia and increase risk of prostate cancer.

How do y ou treat BPH?

Bag of worms when upright disappearing when laying down. Common: 15% of men. Mostly on the left . If on the right consider IVC obstruction or renal cell carcinoma. Sx: Dull achy pain, testicular atrophy, infertility.

Varicocele presentation?

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