��Men’s Health �Clustered Didactic

Round 1

12/15/21�

Jared Dubey, DO

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Disclosures

• No financial disclosures.

Objectives

• At the end of this seminar the learners will be able to diagnose and manage
• Acute scrotal pain
• Benign prostatic hypertrophy
• Erectile dysfunction
• Low testosterone
• Prostate cancer
• Prostatitis and urethritis
• Testicular masses
• Undescended testes

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Schedule

9 - 9:30 Cases Round 1 (small group work time)

9:30 - 10:25 Cases round 1 review as big group

10:25 - 10:35 Break

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10:35 - 11:10 Cases Round 2 (small group work time)

11:10 - 12 Cases round 2 review as big group

12 Wrap - up/overflow time

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CASES ROUND 1

• Small group work time 20-30 minutes.
• Read the cases and answer the questions as you read the cases using evidence-based resources.
• Be prepared to present/discuss your case with the group.

Cases

• Case 1
• A 53 year old man with history of seasonal allergies and obesity who has not been to the doctor for 5 years presents with urinary frequency. Since turning 50 he has been getting up to urinate 3 times per night and is not getting good sleep. He often feels like he is unable fully empty his bladder at night. He favors natural remedies.

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Question 1

• What is the most likely diagnosis?
• What are the classic symptoms of this condition?

BPH

• Symptoms
• Obstructive symptoms
• Weak stream
• Dribbling
• Urinary hesitancy
• Irritative symptoms
• Urinary urgency
• Urinary frequency
• Nocturia

Question 2

• What work-up would you do?
• Should you get a PSA?
• What management options would you offer to the patient?

AUA Symptom Score

• 6 questions, each rated on 1-5 and then total score classified as mild, moderate, or severe (treat BPH if moderate to severe sx). AUA symptoms index doesn’t distinguish BPH from other causes of voiding dysfunction (DynaMed Plus)
• Sensation of bladder not emptying
• Need to urinate again within 2 hr after urinating
• Stop and start several times when urinating
• Difficulty postponing urination
• Weak stream
• Push or strain to begin urine stream

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BPH Management

• Behavioral measures (fluid intake, caffeine)

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• Alpha -1 blockers (tamsulosin)

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• Phosphodiesterase-5 inhibitors (sildenafil, tadalafil)
• 5-alpha reductase inhibitors (finasteride)
• May take 3-6 months to be effective
• Combo of alpha blocker plus 5-ARI may be more effective than either alone
• Anticholinergics (oxybutynin)
• Use when sx are irritative

• Saw palmetto
• A weak 5-alpha reductase inhibitor
• Inconsistent effect across studies
• AUA recommends against using it
• 2012 Cochrane found that it did not improve urinary flow or reduce prostate size in med with lower urinary tract symptoms
• When should you refer to urology?

Indications for Urology referral

• hematuria
• retention
• incontinence
• young patient (<45)
• abnormal DRE

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Question 3

• As you are about to leave the room, the patient tells you that his father had prostate cancer at age 78 and asks you about prostate cancer screening.
• What do the USPSTF, AAFP, and AAU recommend for prostate cancer screening?

Prostate cancer screening

Question 4

• How would you counsel this patient about prostate cancer screening based on his history?
• Can you find a shared decision making tool to help him make an informed decision?

n= 1782

Question 5

• The patient decides to get a PSA checked. It comes back at 4.9. There are no other PSAs for comparison. You did a prostate exam at his appointment and it felt enlarged without masses.
• What would you next steps be?
• What is the normal range and expected increase with age for PSA?

PSA values

• 40s: 0-2.5 ng/mL
• 50s: 0-3.5 ng/mL
• 60s: 0-4.5 ng/mL
• 70s: 0-6.5 ng/mL
• It may be normal for PSA to increase by 3-10% annually.
• Different ranges are generally not used for different races.

n = 4350 men aged 55–70 yr

Free/T PSA

<15% is currently thought to be associated with cancer; an index above 20–25% with benign

Case 2

• A 40 year old man with history of hypothyroidism presents with burning with urination for 1 week.

Question 1

• What questions would you want to ask him (burning with urination)?

Question 2

• Upon further questioning you learn that he feels a shooting pain down the urethra after urinating and after ejaculation. He is sexually active with one female and one male partner. He always uses condoms. He has no urethral discharge, no blood in the urine, no sexual dysfunction. He has mild chills and no measured fevers.
• How do the clinical presentations of urethritis and prostatitis differ? What are the potential etiologies of both (microorganisms and modes of transmission)?

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Clinical Presentation: Prostatitis vs Urethritis

Etiology: Prostatitis vs Urethritis

Question 3

• How would you proceed with exam and work-up for this case?

Work-up prostatitis and urethritis

• Physical exam: prostate exam, genital exam if needed
• Labs:
• Urinalysis
• STI panel
• Possibly CBC

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Case continued

• On exam, vitals are normal, there is no tenderness to palpation of testes, no penile discharge or erythema at urethral meatus. Prostate examination reveals tenderness to palpation and shooting pain down the urethra. UA reveals 20 WBCs, 2+ leukocyte esterase, zero nitrites, occasional RBCs, few squamous epithelial cells and CBC is normal. STI panel (HIV, chlamydia, gonorrhea, RPR) is negative.

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Question 4

• Discuss management of urethritis and prostatitis. For this case, what is your most likely diagnosis and what treatment/follow-up would you recommend?

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Management: Prostatitis and Urethritis

Case 3

• A 25 year old man with history of depression comes to the office with concern of a left testicular pain. It started intermittently 2 weeks ago and he noticed that his left testicle feels more “full” than the right.

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Question 1

• What is your differential diagnosis for a testicular mass?

DDx testicular mass

• Cyst
• Epididymis (or epididymitis)
• Hematoma-prior trauma
• Hydrocele
• Malignancy
• Varicocele

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Case continued

• The patient mentions that his cousin was diagnosed with testicular cancer 5 years ago at age 32, and he is wondering about screening for testicular cancer.

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Question 2

• What would you recommend to the patient for testicular cancer screening?
• What does the USPSTF recommend?
• What would be the expected findings on exam for a testicular cancer?

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Testicular cancer screening

• USPSTF recommendations
• Grade D: The USPSTF recommends against testicular cancer screening in adolescent and adult males
• American Cancer Society
• Recommends that asymptomatic males >20 years old should have periodic health examinations that include examination of testicles and discussion of self-exams
• Concerning findings: firm, immobile mass on testicular body (like a marble); if the testicular body is hard like a rock

Case continued

• On exam, the right testicle is normal with no masses. The left testicle has no masses on the testicular body but you do palpate a fullness in the scrotum superior to the testicle that feels like a bag of worms. There is no tenderness to palpation.
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Question 3

• What is the most likely diagnosis?

Question 4

• What is a hydrocele and varicocele?
• How do you distinguish between a hydrocele and varicocele on exam?
• What are the potential adverse effects of both?

Hydrocele vs Varicocele

Hydrocele

Varicocele

Adverse effects: hydrocele vs varicocele

Question 5

• Discuss work-up and management for both hydrocele and varicocele.
• Would you be more concerned about a left varicocele or right varicocele and why?
• What would you recommend to this patient for work-up and management?

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Management: hydrocele vs varicocele

Varicocele

• More common on left b/c left testicular vein→renal vein @ 90 degrees. Right testicular vein→ IVC @<90 degrees
• Right varicocele in man >40: consider abdominal/pelvic malignancy-ultrasound