Male Urogenital Disorders

1. Male Urogenital Disorders Jeffrey T. Reisert, DO University of New England Physician Assistant Program 20 JAN 2010

2. Contact Information Jeffrey T. Reisert, DO Jeffrey.T.Reisert@Hitchcock.org 103 Boulder Point Rd., Suite 3 Plymouth, NH 03264 603-536-6355 603-536-6356 (fax)

3. Genitourinary Section-Part 1 • Male urogenital disorders/Impotence • Nephrolithiasis • Urinary Tract Infections

4. Genitourinary Section-Part 2 • Introduction to Renal Failure • Acute Renal Failure • Chronic Renal Failure • Glomerulopathies (builds on prior topics) • Tubular disorders (builds on prior topics) • Hematuria (Evaluation of this entity) • Proteinuria (Evaluation of this entity)

5. Agenda • Disorders of the penis • Phimosis • Balanitis • Impotence • Infections • STD’s • UTI’s • Epididymis • Prostatitis

6. Agenda part II • Testicle cancer • Prostate disorders • Acute and chronic prostatitis • Benign prostatic hypertrophy • Prostate Cancer

7. Anatomy • See diagram

8. Phimosis • Uncircumcised male • Cannot readily retract foreskin to the corona of the glans • Can get glans stuck outside of the foreskin • Treatment: Circumcision

9. Balanitis • Infection of head of penis • Typically fungal • More often seen in uncircumcised men • Treat with OTC antifungals like Monistat or oral fluconazole • Just like vaginal yeast infections in women

10. Circumcision • Surgery done some feel is good idea, others not • Those opposed feel not medically necessary, complication risk including pain, decreases stimulation later in life. • Those in favor feel hygienic issue, need to look like dad • Check out resources • American Academy of Pediatrics • www.circumcision.org • Etc.

11. Penile Cancer • Can be seen on inspection • Surgical disease

12. Varicocoele • Cluster of dilated veins usually on left • “Bag of worms”

13. Hydrocoele • Water on the testicle • Ultrasound • Illumination • Treatment usually reassurance. Sometimes hydrocoelectomy

14. Other anatomical items • Hypospadius • Urethral meatus not at tip of glans • A midline defect • Sometimes requires correction • Unusual urinary stream? • Sit to pee? • Problems with ejaculation?

15. Urinary obstruction • Prostate • Stricture • Weak detrusser muscle • Self catheterization

16. Impotence/Sexual dysfunction/Erectile dysfunction • Failure to obtain erection, ejaculation, or both • Common • Increased frequency with aging • How old should you be to lose functioning? • Ask Tony Randall (the late Tony Randall) • Must be realistic

17. ED continued • Psychogenic (about 20% of the cases) • Organic (up to 80% of cases) • Other terms • Premature ejaculation-psychological in origin • Serotonin reuptake inhibitors (SSRI’s) like Prozac can be used to delay ejaculation • Priapism-Persistent painful erection • Requires urology evaluation, emergently • NOT every guy’s dream

18. Normal sexual functioning • Involves the desire • Engorgement of corpora cavernosa under control of parasympathetic nervous system • Under sympathetic nervous system contraction of smooth muscle occurs and if all goes well, ejaculation can occur

19. Psychogenic impotence • A common cause • The mood must be right • Factors such as depression and anxiety commonly affect sexual functioning • Should include psychological review in your evaluation • The housekeeper story

20. Problems • Can’t initiate • Can’t fill (engorge)-Usually arterial problem • Consider things like Diabetes, Hypertension, and ASHD • Can’t store-Veno-occlusive dysfunction

21. Organic impotence • Many causes • Hormonal (loss of testosterone in testicular failure, pituitary tumor producing prolactin, pituitary failure) • Drugs (antihypertensives, psychological, others) • Neurological (spinal cord injury, MS)

22. Organic Impotence-Cont. • Vascular disease (diabetes, atherosclerosis) • Penile diseases such as Peyronies disease (rigid scarring of penis resulting in crooked painful erection) • Etiology: Unknown, or prior penile surgery. Perhaps familial. • Treatment: Injection verapamil, radiotherapy, surgery, shock wave therapy

23. Medical evaluation for ED • History and exam • Testosterone level, prolactin level, and luteinizing hormone (required for testes to produce testosterone) • Prolactinoma (pituitary origin)-MRI • High levels prolactin result in low testosterone • Ultrasound testing • Nocturnal penile tumescence testing, or “tape testing”

24. Treatments • Replace testosterone if low (next slide) • Fix tumor if present • Treat any other medical cause if present, or offer counseling

25. Hypogonadism • Low testosterone levels • May be due to testicular failure (or orchiectomy) • May be due to axis problems (Hypothalamic/pituitary) • Replacement • Testosterone is poorly absorbed orally (first pass) • Injectable-Depo-testosterone® 1cc (100 or 200mg/cc) qmonthly IM • Topical • AndroGel® -Squirt gel, rub on • Patch-Androderm® transdermal patch 2.5 or 5mg

26. Treatments, cont. • Phosphodiesterase type 5 inhibitor-oral • Relaxes smooth muscle, allowing filling • Headache • Flushing • Can’t use with nitrates (hypotension, death may result) or alpha blockers. • Absorption may be affected by food, especially higher fat containing meal

27. Phosphodiesterase inhibitors • Sildenafil (Viagra ®)-If Rafael Palmero can use, so can you. Play ball! • Visual changes possible (Blue vision, rarely loss of) • Pfizer looking at OTC version • Vardenafil (Levitra ®)-Stay in the game! • Tadalafil (Cialis®)-The newest on the market. Why are the couple in different bathtubs? Longer half-life reported. 4 hour erections??? • Heavily advertised

28. Treatment-cont. • Prostaglandin E1 • Alprostadil (Caverject)--inject into penis • 80%success • Long term adherence poor • Penile pain • Not as glamorous as a pill • Alprostadil (MUSE)-Intraurethral • Penis ache • 40% success rate

29. Treatment-cont. • Yohimbine-Not very effective, but better than placebo • Vacuum device • Less popular • Safe • Require restrictive band • Blue penis (Smurf-like?) • Surgery-Penile prosthesis • Semi-rigid • Inflatable • Reservoir in abdomen or scrotum • Require dexterity

30. Urinary tract infections • Cystitis • Urethritis (Some consider an STD syndrome) • Prostatitis • Pyelonephritis (next slide set) • Young males with infections should be evaluated, urologically

31. Urinary defenses • Flow • Dilution • Prostate secretions antibacterial

32. Cystitis • Refers to a simple bladder infection • Most commonly due to coliforms • Escherichia coli (E. coli). most common (80%) • If culture negative think Ureaplasma ureolyticus • More later

33. Urethritis • Due to typical urinary tract organisms or chlamydia (Non-gonococcal) • Can be due to gonorrhea • Check for urethral discharge, gram stain and culture

34. Urethritis cont. • Non infectious causes include Reiter’s syndrome (also develop arthritis following an enteric infection) • Treatment doxycycline 100 mg bid for 7d or azithromycin 1000mg

35. Epididymitis • Can be seen in younger male (MC due to Chlamydia) • Can be seen in older, too (Gram negative bacilli) • Characteristically seen as a sudden onset of unilateral pain • Treatment with quinolone such as ofloxacin or ceftriaxone and doxycycline

36. Prostatitis • Acute • Often seen in young • Usually sudden onset • Often E. coli or Klebsiella sp. (Enterobacteriaceae)

37. Prostatitis-cont. • Chronic • Up to 9% of men • Prostate often normal on exam • Can be due to recurrent infection or inflammation • ?Autoimmune • May culture negative (Ureaplasma ureolyticus or chlamydia). Consider prostate massage for culturing • Alpha blockers may help • Good review NEJM 2006….No universally accepted best treatment

38. Prostatitis • Fever/chills • Prostate tenderness (perineal or testicular pain) • Dysuria (usually mild) • Urinary frequency • Low back pain

39. Prostatitis-cont. • Diagnosis can be made on exam and urine testing. • Chronic prostatitis may require prostatic secretion expression • Prostate massage 

40. Prostatodynia • Pain without infection • Non-steroidal anti-inflammatory drugs (NSAIDS)

41. Overactive Bladder (OAB) • Urgency, incontinence (Gotta go, gotta go) • Anti-cholinergics • Blocks muscarinic receptors, decreasing bladder contraction • Oxybutynin (Ditropan®, Oxytrol® patch) • Tolterodine (Detrol®) • Solifenacin (VESIcare®) • Trospium (Sanctura®) • Darifenacin (Enablex®) • Fesoterodine (Toviaz) • Dry mouth, constipation, blurred vision • Heavily advertised

42. Infection treatment • Urinary pathogens treated well with • Trimethoprim/sulfamethoxazole, fluoroquinolones • 3d in females, but 7-10-14d in males • Should recheck after completing therapy • Helps establish resistance vs. recurrence • Cure rates vary • More later

43. Sexually transmitted diseases (STD’s) • 12M in USA each year • Suggest high risk behaviors • Social implications • Increased incidence in lower socioeconomic groups, unmarried, multiple partners

44. STD’s-Discharges • Neisseria gonorrhoeae (Gram neg. diplococci) • Chlamydia trachomatis (May lay dormant)

45. STD’s-Ulcers • Herpes simplex virus (Most common, vesicles may be seen) • Syphilis (Treponema pallidum, typically painless)

46. STD’s-cont. • Hepatitis B • Vaccine available • Please be sure you are vaccinated, students!!!! • Check titers (Vaccine not 100% successful) • HIV • Leading cause of death in USA age 25-40

47. STD’s cont.-HPV • Warts (Human papilloma virus) • Strains 6, 11 most common, least harmful • Strains 16,18, 31, 32, 35 can cause cervical dysplasia) • Cryosurgery or podophyllin for visible warts (less cervical CA association) • Vaccination • Gardasil® • 9-26 y/o females (Boys too, 2009!) • Good safety and efficacy data

48. Testicular cancer • Also called germ cell tumors • Can begin in testicle or elsewhere (extragonadal) • Typically a disease of the young (20-40) • In older men think lymphoma • Very high cure rate (90%)

49. Testicular cancer epidemiology • 7000-8000 cases per year in USA • Higher risk if undescended testicle • Cryptorchidism (undescended testicles incr risk) • Correction may not reduce risk, but may increase ease of detection • More common in Caucasians than men of race • Other risk factors • Frequent UTI’s, Renal lithiasis • Uncircumcised men, multiple sex partners

50. Testicular cancer-Diagnosis • Typically presents as painless lump on testicle • Ultrasound • HCG may cause gynecomastia • Self exam/Physician exam • Must exclude infection causing similar symptoms