Download Men`s Health 2016

MEN’S HEALTH
NURS 870
MEN’S HEALTH
Objectives: Class participants will be able to address,
diagnose and/or treat common men’s health
complaints in primary care
1.
2.
3.
4.
5.
6.
Urethritis
Benign Prostatic Hyperplasia
Acute Prostatitis
Scrotal pain & masses
Erectile dysfunction
Current prostate CA screening guidelines
1. URETHRITIS
Pathophysiology:
• Uncomplicated UTI rare in healthy men ages 15-50
• Most common causes:
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Hx of unprotected, insertive anal sex – E. coli
STI: gonorrhea or chlamydia
If STI is not the cause, need to do workup for prostatitis
OR, need to consider possible structural abnormalities
1. URETHRITIS
Signs & symptoms:
• Dysuria – burning with urination
• Purulent discharge – may or may not be present
1. URETHRITIS
Etiology:
• STIs: gonorrhea or chlamydia
• Prostatitis:
• Most Common: enteric, gram negative organisms
• Escherichia coli, Klebsiella or Proteus mirabilis, and
occasionally Pseudomonas aeruginosa
• Less common: gram positive organisms
• Staphylococcus saprophyticusis isolated in 5 to 10% of bacterial UTIs.
• Enterococcus faecalis (group D streptococci) and
• Streptococcus agalactiae (group B streptococci), which may be
contaminants, particularly if they were isolated from patients with
uncomplicated cystitis.
1. URETHRITIS
Diagnosis:
• Urinalysis with microscopic evaluation & reflex to
culture
• Urine for GC/CT DNA amplification (not culture)
• Patient should not have urinated for at least 1 hour.
Collect the specimen in sterile, preservative-free
collection cup. The patient should collect the first 20-60
mL of voided urine (the first part of the stream - Not
Midstream) into a urine collection cup.
1. URETHRITIS
Treatment:
• Sexually Active with urethritis:
• Sexually active patients with symptoms are usually treated
presumptively for STDs pending test results. A typical
regimen is ceftriaxone 250 mg IM plus either azithromycin 1
g po once or doxycycline 100 mg po bid for 7 days.
• If prostatitis suspected, Rx for prostatitis
(stay tuned…)
2. BPH
• Benign prostatic hyperplasia (BPH) is nonmalignant adenomatous overgrowth
of the periurethral prostate gland.
• Symptoms are those of bladder outlet obstruction—weak stream, hesitancy,
urinary frequency, urgency, nocturia, incomplete emptying, terminal
dribbling, overflow or urge incontinence, and complete urinary retention.
• Using the criteria of a prostate volume > 30 mL and a moderate or high
American Urological Association Symptom Score:
• the prevalence of BPH in men aged 55 to 74 without prostate cancer is
19%.
• But if voiding criteria of a maximal urinary flow rate < 10 mL/sec and a
postvoid residual urine volume > 50 mL are included, the prevalence is only
4%.
• Based on autopsy studies, the prevalence of BPH increases from
• 8% in men aged 31 to 40
• 40 to 50% in men aged 51 to 60
• > 80% in men > 80
2. BPH
Pathophysiology:
• Multiple fibroadenomatous nodules develop in the periurethral region of
the prostate, causing the prostate to enlarge over time
• As the lumen of the prostatic urethra narrows and lengthens, urine
outflow is progressively obstructed.
• Increased pressure associated with micturition and bladder distention
can progress to hypertrophy of the bladder detrusor and trabeculation
(increased post-void residuals)
• Incomplete bladder emptying causes stasis and predisposes to calculus
formation and infection.
• Prolonged obstruction, even if incomplete, can cause hydronephrosis
and compromise renal function
2. BPH
"Benign Prostatic Hyperplasia nci-vol-7137-300" by Unknown - National Cancer Institute, AV Number: CDR462221. Licensed under Public
Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Benign_Prostatic_Hyperplasia_nci-vol-7137300.jpg#/media/File:Benign_Prostatic_Hyperplasia_nci-vol-7137-300.jpg
2. BPH
Symptoms:
• Symptoms include progressive urinary frequency, urgency, and nocturia
due to incomplete emptying and rapid refilling of the bladder.
• Decreased size and force of the urinary stream cause hesitancy and
intermittency.
• Pain and dysuria are usually not present.
• Sensations of incomplete emptying, terminal dribbling, overflow
incontinence, or complete urinary retention may ensue.
• Straining to void can cause congestion of superficial veins of the prostatic
urethra and trigone, which may rupture and cause hematuria. Straining
also may acutely cause vasovagal syncope and, over the long term,
may cause dilation of hemorrhoidal veins or inguinal hernias.
2. BPH
2. BPH
Diagnosis:
• Digital rectal examination (prostatitis? Prostate CA?)
• Urinalysis and urine culture
• Prostate-specific antigen level
• PSA interpretation is complex
• PSA level is moderately elevated in 30 to 50% of patients with BPH, depending on
prostate size and degree of obstruction
• PSA is elevated in 25 to 92% of patients with prostate cancer, depending on the tumor
volume.
• In patients without cancer, serum PSA levels > 1.5 ng/mL usually indicate a prostate
volume ≥ 30 mL.
• Typically, if the PSA level is > 4 ng/mL or if the digital rectal examination indicates an
abnormality (other than smooth, symmetric enlargement), then a transrectal biopsy is
recommended. For men < 50 or those at high risk of prostate cancer, a lower cutoff
(PSA > 2.5 ng/mL) may be used.
• Sometimes uroflowmetry and bladder ultrasonography
2. BPH
Treatment:
• In men with BPH, avoid use of anticholinergics,
sympathomimetics, and opioids.
• Consider relieving troublesome obstructive symptoms with αadrenergic blockers
(eg, terazosin, doxazosin, tamsulosin, alfuzosin), 5α-reductase
inhibitors (finasteride, dutasteride), or, if there is concomitant
erectile dysfunction, tadalafil.
• Consider TURP or ablation if BPH causes complications (eg,
recurrent calculi, bladder dysfunction, upper tract dilation) or if
bothersome symptoms are drug resistant.
3. ACUTE PROSTATITIS
• Prostatitis refers to a disparate group of disorders that manifests with a
combination of predominantly irritative or obstructive urinary
symptoms and perineal pain.
• Some cases result from bacterial infection of the prostate gland and
others, which are more common, from a poorly understood
combination of:
• noninfectious inflammatory factors,
• spasm of the muscles of the urogenital diaphragm
• or both
3. ACUTE PROSTATITIS
Prostatitis can be bacterial or, more commonly, nonbacterial. However,
differentiating bacterial and nonbacterial causes can be difficult,
particularly in chronic prostatitis.
• Bacterial prostatitis
• can be acute or chronic and is usually caused by typical urinary pathogens
(eg, Klebsiella,Proteus, Escherichia coli) and possibly by Chlamydia.
• How these pathogens enter and infect the prostate is unknown.
• Chronic infections may be caused by sequestered bacteria that antibiotics have not
eradicated.
• Nonbacterial prostatitis
• can be inflammatory or noninflammatory. The mechanism is unknown but may
involve incomplete relaxation of the urinary sphincter and dyssynergic voiding.
• The resultant elevated urinary pressure may cause urine reflux into the prostate
(triggering an inflammatory response) or increased pelvic autonomic activity leading
to chronic pain without inflammation.
3. ACUTE PROSTATITIS
3. ACUTE PROSTATITIS
Signs & Symptoms
• Acute bacterial prostatitis often causes such systemic symptoms as fever, chills,
malaise, and myalgias. The prostate is exquisitely tender and focally or diffusely
swollen, boggy, indurated, or a combination. A generalized sepsis syndrome may
result, characterized by tachycardia, tachypnea, and sometimes hypotension.
• Chronic bacterial prostatitis manifests with recurrent episodes of infection with or
without complete resolution between bouts. Symptoms and signs tend to be milder
than in acute prostatitis.
• Chronic prostatitis/chronic pelvic pain syndrome typically has pain as the
predominant symptom, often including pain with ejaculation. The discomfort can
be significant and often markedly interferes with quality of life. Symptoms of urinary
irritation or obstruction also may be present. On examination, the prostate may be
tender but usually is not boggy or swollen. Clinically, inflammatory and
noninflammatory types of chronic prostatitis/chronic pelvic pain syndrome are
similar.
• Asymptomatic inflammatory prostatitis causes no symptoms and is discovered
incidentally during evaluation for other prostate diseases when WBCs are present in
the urine.
3. ACUTE PROSTATITIS
Diagnosis:
• Urinalysis
• Prostate massage except possibly in acute bacterial prostatitis
• Diagnosis of type I, II, or III prostatitis is suspected clinically.
• Febrile patients with typical symptoms and signs of acute bacterial
prostatitis:
• usually have WBCs and bacteria in a midstream urine sample
• prostate massage to obtain a postmassage urine sample unnecessary (concern for
causing bacteremia)
• rectal exam should be done gently
• blood cultures should be obtained in patients who have fever and severe weakness,
confusion, disorientation, hypotension, or cool extremities. transrectal ultrasonography
and sometimes cystoscopy may be necessary to rule out prostatic abscess in patients
who do not respond to antibiotics
• additional tests that can be considered are cystoscopy and urine
cytology (if hematuria is also present) and urodynamic studies
3. ACUTE PROSTATITIS
Treatment:
• < 35 years of age with risk for STD: Ceftriaxone 250 mg IM
then Doxycycline 100 mg po bid x 10 days
• Low risk for STD: Cipro or Bactrim po bid x 14-28 days
• Hospitalize patients who have acute bacterial prostatitis
and systemic symptoms that suggest sepsis
• For men with chronic prostatitis or chronic pelvic pain
syndrome, consider anxiolytics (eg, SSRIs,
benzodiazepines), sacral nerve stimulation,
biofeedback, prostatic massage, and minimally invasive
prostatic procedures (eg, microwave thermotherapy).
4. SCROTAL PAIN & MASSES
• Epididymitis and Orchitis
• Benign masses
• Hernia
4. SCROTAL PAIN & MASSES
Epididymitis and Orchitis
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1 in 144 outpatient visits in 2002
Most between ages 18-50
Epididymitis is more common than Orchitis
In one study 58% of men with epididymitis also had Orchitis
Isolated Orchitis associated with viral illnesses such as
mumps
4. SCROTAL PAIN & MASSES
Epididymitis and Orchitis
Etiology:
retrograde of pathogens
Ages 14-35: usually gonorrhea or chlamydia
Ages > 35: usually E. coli
Risk factors: sexual activity, strenuous physical activity,
bicycle or motorcycle riding, sitting (sedentary job)
• Risk factors in men > 35: urinary tract surgery, anatomic
abnormalities (BPH) or instrumentation
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4. SCROTAL PAIN & MASSES
Epididymitis and Orchitis
Symptoms:
• Gradual onset of pain that radiates to lower abdomen
• May radiate to non-affected testis
• May have UTI symptoms: fever, frequency, urgency,
hematuria, dysuria
• RED FLAGS:
• Severe pain with nausea vomiting could be testicular torsion
• Viral Orchitis from mumps may begin 4-7 days after swelling of
parotids
4. SCROTAL PAIN & MASSES
Epididymitis and Orchitis
4. SCROTAL PAIN & MASSES
Epididymitis and Orchitis
Diagnosis:
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urinalysis with micro, C&S
Urine for GC/CT DNA amp
Ultrasound
If torsion suspected: STAT ultrasound and urology consult –
surgery needed within 6 hrs to save the testis
4. SCROTAL PAIN & MASSES
Epididymitis and Orchitis
Treatment:
• If < 35 years or STD: Rx for GC/CT
• If > 35 years: Levofloxacin 750 mg po daily x 10-14 days
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Analgesics
Scrotal elevation
Limitation of activity
Use of cold packs
4. SCROTAL PAIN & MASSES
Benign
Masses
4. SCROTAL PAIN & MASSES
4. SCROTAL PAIN & MASSES
Treatment:
ultrasound – to confirm clinical diagnosis
urology referral is prudent for masses
5. ERECTILE DYSFUNCTION
Epidemiology
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ED affects 1/3 of men at some point in life
12% prevalence in those < 59 years
22% in those 60-69
30% in those > 69
• Those with DM have three fold greater risk
• Depression increases the risk (which comes first?)
5. ERECTILE DYSFUNCTION
Pathophysiology
• Organic Causes: vascular, neurogenic, hormonal, anatomic, druginduced
• Psychological Causes: mental health, poor relationship with partner
• Normal erectile response
• interaction between neurotransmitter, biochemical and vascular smooth
muscle responses initiated by parasympathetic and sympathetic neuronal
triggers that integrate physiologic stimuli of the penis with sexual perception
& desire.
• Nitric oxide produced form endothelial cells after parasympathetic stimuli
triggers a molecular cascade that results in smooth muscle relaxation and
arterial influx of blood into the corpus cavernosum
• This causes compression of venous return which produces an erection
5. ERECTILE DYSFUNCTION
Risk Factors
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Advancing age
Cardiovascular disease
Cigarette smoking
Diabetes mellitus
History of pelvic irradiation or
surgery, including radical
prostatectomy
Hormonal disorders (e.g.,
hypogonadism, hypothyroidism,
hyperprolactinemia)
Hypercholesterolemia
Hypertension
Illicit drug use (e.g., cocaine,
methamphetamine)
• Medications (e.g., antihistamines,
benzodiazepines, selective
• serotonin reuptake inhibitors)
• Neurologic conditions (e.g.,
Alzheimer disease, multiple
• sclerosis, Parkinson disease,
paraplegia, quadriplegia, stroke)
• Obesity
• Peyronie disease
• Psychological conditions (e.g.,
anxiety, depression, guilt, history
• of sexual abuse, marital or
relationship problems, stress)
• Sedentary lifestyle
• Venous leakage
5. ERECTILE DYSFUNCTION
Medications that May Cause or Contribute to ED:
Medication class
Examples
Analgesics
Anticholinergics
Anticonvulsants
Antidepressants
Antihistamines
Opiates
Tricyclic antidepressants
Phenytoin (Dilantin), phenobarbital
Lithium, monoamine oxidase inhibitors, SSRIs, tricyclic antidepressants
Dimenhydrinate, diphenhydramine (Benadryl), hydroxyzine (Vistaril),
meclizine (Antivert), promethazine (Phenergan)
Alpha blockers, beta blockers, calcium channel blockers, clonidine
(Catapres), methyldopa, reserpine
Bromocriptine (Parlodel), levodopa, trihexyphenidyl
Digoxin, disopyramide (Norpace), gemfibrozil (Lopid)
Methotrexate
Spironolactone (Aldactone), thiazides
5-alpha reductase inhibitors, corticosteroids, estrogens, luteinizing
releasing hormone agonists, progesterone
Antihypertensives
Anti-Parkinson agents
Cardiovascular agents
Cytotoxic agents
Diuretics
Hormones
hormoneIllicit drugs, alcohol,
and nicotine
Immunomodulators
Tranquilizers
Amphetamines, barbiturates, cocaine, heroin, marijuana
Interferon-alfa
Benzodiazepines, butyrophenones, phenothiazines
5. ERECTILE DYSFUNCTION
5. ERECTILE DYSFUNCTION
5. ERECTILE DYSFUNCTION
5. ERECTILE DYSFUNCTION
Link to Cardiovascular Disease!
Men with ED should be considered for cardiovascular risk screening.
ED rates differ significantly in patients with established CAD
On average, ED symptoms present three years earlier than CAD symptoms
Men with ED have a 75 percent increased risk of PVD
The Prostate Cancer Prevention Trial determined that
men with ED have a significantly greater likelihood of having
angina, myocardial infarction, stroke, transient ischemic
attack, congestive heart failure, or cardiac arrhythmia
compared with men without ED.
• Because most men are asymptomatic before an acute coronary syndrome,
ED may serve as a sentinel marker for prompting discussions
centered on promotion of cardiovascular risk stratification and
modification.
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6. PROSTATE CA SCREENING
• The American Cancer Society recommends that men make an informed
decision with their doctor about whether to be tested for prostate
cancer. Research has not yet proven that the potential benefits of testing
outweigh the harms of testing and treatment.
• The American Cancer Society believes that men should not be tested
without learning about what we know and don’t know about the risks
and possible benefits of testing and treatment.
• Age 50 for men who are at average risk of prostate cancer and are
expected to live at least 10 more years.
• Age 45 for men at high risk of developing prostate cancer. This includes
African Americans and men who have a first-degree relative (father,
brother, or son) diagnosed with prostate cancer at an early age
(younger than age 65).
• Age 40 for men at even higher risk (those with more than one first-degree
relative who had prostate cancer at an early age).
6. PROSTATE CA SCREENING
• After this discussion, men who want to be screened should be tested with the
prostate-specific antigen (PSA) blood test. The digital rectal exam (DRE) may also
be done as a part of screening.
• If, after this discussion, a man is unable to decide if testing is right for him, the
screening decision can be made by the health care provider, who should take into
account the man’s general health preferences and values.
• If no prostate cancer is found as a result of screening, the time between future
screenings depends on the results of the PSA blood test:
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Men who choose to be tested who have a PSA of less than 2.5 ng/mL may only need to be
retested every 2 years.
Screening should be done yearly for men whose PSA level is 2.5 ng/mL or higher.
• Because prostate cancer often grows slowly, men without symptoms of prostate
cancer who do not have a 10-year life expectancy should not be offered testing
since they are not likely to benefit. Overall health status, and not age alone, is
important when making decisions about screening.
• Even after a decision about testing has been made, the discussion about the pros
and cons of testing should be repeated as new information about the benefits and
risks of testing becomes available. Further discussions are also needed to take into
account changes in a man’s health, values, and preferences.
Title
Screening for Prostate Cancer - USPSTF
Population
Adult males
Recommendation
Do not use prostate-specific antigen (PSA)-based screening for prostate cancer.
Grade: D
Screening Tests
Contemporary recommendations for prostate cancer screening all incorporate the measurement of
serum PSA levels; other methods of detection, such as digital rectal examination or ultrasonography, may
be included. There is convincing evidence that PSA-based screening programs result in the detection of
many cases of asymptomatic prostate cancer, and that a substantial percentage of men who have
asymptomatic cancer detected by PSA screening have a tumor that either will not progress or will
progress so slowly that it would have remained asymptomatic for the man's lifetime (i.e., PSA-based
screening results in considerable overdiagnosis).
Interventions
Management strategies for localized prostate cancer include watchful waiting, active surveillance,
surgery, and radiation therapy. There is no consensus regarding optimal treatment.
Balance of harms and
benefits
The reduction in prostate cancer mortality 10 to 14 years after PSA-based screening is, at most, very small,
even for men in the optimal age range of 55 to 69 years. The harms of screening include pain, fever,
bleeding, infection, and transient urinary difficulties associated with prostate biopsy, psychological harm
of false-positive test results, and overdiagnosis.
Harms of treatment include erectile dysfunction, urinary incontinence, bowel dysfunction, and a small risk
for premature death.
Because of the current inability to reliably distinguish tumors that will remain indolent from those destined
to be lethal, many men are being subjected to the harms of treatment for prostate cancer that will never
become symptomatic.
The benefits of PSA-based screening for prostate cancer do not outweigh the harms.
Relevant USPSTF
Recommendations
Recommendations on screening for other types of cancer can be found
athttp://www.uspreventiveservicestaskforce.org .