John Fanning D O Family Practice Ridley Park

John Fanning, D. O. Family Practice Ridley Park, Pa.

Prostate

Function adds fluid to the semen

The gland sits at the base of the bladder. The urethra goes through the center.

BPH

Diagnosis DRE

Dihydrotestosterone Causes growth of the gland Form of male hormone

Cause is not understood.

Symptoms

Hesitancy Double voiding Frequency Nocturia Straining to start Dribbling Small volume Decreased sexual functioning

BPH Treatment

Life style changes - not proved Possibly helpful changes: Decrease caffeine Decrease evening fluids Decrease alcohol Stay physically active Stay sexually active

Meds 5 A Reductase Inhibitors Avadart (Dutasteride) Proscar (Finasteride)

These meds block the conversion of testosterone to dihydrotestosterone.

This stops the prostate from growing It needs 6 months for the effect to be noticed

PSA VALUE Need to recheck this in 6 months. It will be 1/2 of the real value.

Cialis (Todalafil)

Alpha Blockers Flomax (Tamsulosin) Uroxatrol (Alfuzosin) Rapaflo (Silodosin)

Side Effects Dizziness, GI upset, hypotension, abnormal ejaculation, lethargy, headache

Surgical Tx TURP Microwave Cooled Thermo Tx

PROSTATE CA

Incidence 1 : 10 males 1 : 3 over 80 less fatal with these males

Rare under 40 y/o. The younger the man, the more lethal the disease. There are 230, ooo new cases / yr.

Second leading cause of CA death in men 2 x more fatal in Black men

Etiology Family Hx High fat intake Race

Diagnosis PSA DRE

PSA 0 - 4 used to be considered normal Unreliable 2. 5 now used to trigger a referral

PSA start checking the PSA at 50 y/o white males at 40 y/o black males at 40 y/o with significant family Hx

Symptoms Early - NO SYMPTOMS Dysuria Polyuria Pain with ejaculation Hematuria Blood with ejaculation Pain (pelvic, lumbosacral, upper thigh) LATE SIGN

Work Up Ultra sound and Bx If positive, then CT / MRI for nodes and mets Bone scan

Staging

Stage I Very early - microscopic in the prostate

Stage II Small tumor but in the prostate. It can be felt.

Stage III Spread to local areas

Stage IV Widespread: Bones, Nodes, Lung

Grading of CA Refers to the aggressiveness of the CA

Gleason Grading 2 (non-aggressive) to 10 (very aggressive)

Tx Watch and wait - ok for older men Surgery - usually for the men younger than 70 Radiation Hormone suppression Testosterone stimulates the CA Palliative

PSA Doubling Time This is the measure of time it takes to double the PSA score - the shorter the time, the worse the CA.

Velocity Refers to how rapidly the PSA value increases over time.

Real Life Examples

Prostatitis One of several inflammatory, painful conditions of the prostate

NHI Classification Class 1: Acute Bacterial Prostatitis Class 11: Chronic Bacterial Prostatitis Class 111: Chronic Abacterial Prostatitis 111 A: Inflammatory 111 B: Non-inflammatory Class 1 v: Asymptomatic Inflammatory

Class 1: Acute Bacterial Secondary to infection by gram neg. bacteria (included are E Coli, Psuedomonas, Klebsiella, Gonorrhea, Chlamydia, Trichomoniasis) Gland is swollen and tender on exam. There is perineal and low back pain, dysuria, fever, some obstructive Sx, urgency, nocturia and pain with ejaculation.

DRE with Prostatitis

Testing: physical exam, ua, urine c+s, blood cultures if they have chills Tx: Amoxicillin or Bactrim for at least 30 days. Sometimes can also use Erthromycn/ Doxy / Cipro. If ill, hospitalize - IV Ampicillin and Gentomycin

Class 11: Chronic Bacterial Prostatitis Hard to clear Tx: Usually need multiple bouts of antibiotics Use Fluroquinolones: Levaquin / Cipro for 2 - 3 months. Some pts are put on chronic meds to suppress the Sx. Sx: Can be the same but less severe than Class 1 Dx: Same as Class 1 but also “expressed prostatic secretions” show a lot of bacteria

Class 111: Chronic Abacterial Prostatitis Unknown cause Neg cultures Thought to be from spasms of internal urinary sphincter and pelvic floor striated muscles. Sx: Same as Class 11 Tx: Not effective. Don’t use antibiotics. ? Tx: Flomax, NSAIDs, decrease spices and alcohol. Try hot tubs and sedatives. Class 111 A has a lot of inflammatory cells in prostate secretion. Class 111 B has almost no inflammatory cells.

Testicular CA

Primary CA killer in men 20 - 30 y/o 7500 new cases every year More prevalent in white males

Fatalities depend on staging. Can be highly curable. Increased risk in boys with hx of undescended testicles

95% are Germ Cells 40% are Seminomas

Symptoms Lump Irregular swelling of 1 teste Not a Sudden onset Heaviness/ache/pain (may be intermittent)

Diagnosis Ultrasound If a Bx is needed - do exploratory, not needle Bx CT scan for staging

Treatment Orchiectomy Node dissection Hormone tx

Labs used to check CA Alfa fetal protein Beta human Chorionic gonadotropin (Beta-HCG) Lactate dehydrogenace LDH

Recurrence is common in first year.

HERNIA

A hernia is a tear in a muscle.

Hernia - Rupture Same thing

Acquired Wear and tear/ age/ surgical Congenital

75% hernias occur in the groin. 2/3 - Indirect 1/3 - Direct

Reducible : Incarcerated: trapped, can’t flatten the bulge, usually tender / sore / nausea Strangulated: tightly trapped, pt looks toxic - sick / blocked blood supply / emergency surg

Diagnosis Physical exam Ultrasound prn or CT scan

Symptoms Bulge - especially with standing Less when lying down Pain Tearing feeling Dull ache Pain with cough / effort No symptoms Usually worse at the end of the day

Naturally Areas Weak Umbilical Groin: Inguinal and Femoral Epigastric Incisions

Repair Usually laproscopic Open repair

Indirect Inguinal More common in woman 2: 3 Right side is more common

This type of hernia forms at the inside opening of the inguinal canal. This area is naturally prone to weakness. Age / gravity pull intestines into the canal.

Direct Inguinal Hernia

1: 3 more in males Less common than the Indirect hernias. More common in males over 40. Usually fixed with a mesh repair.

Umbilical Hernia Secondary to pregnancy Age Obesity Coughing Physical stress Usually fixed by direct repair, sometimes by mesh

Incisional Hernia Can occur months or years post op

Abdominal Hernia 30% of infants have them They usually close on their own by age 1.

Femoral Hernia More common in females

Epigastric Hernia Usually in upper abdomen in the mid line Natural weakness there

Sports Hernia Affects professional and high level athletes. It is a tear in the Oblique abdominal muscles. Occurs in a thin region of the abdominal wall.

Dx: Hx + PE MRI and CT not helpful - but R/O other causes of pain Sx: Pain lower abdomen / groin / testicles Lasts for months/ no one injury Tx: Open repair or laproscope w/ mesh

Erectile Dysfunction

Definition: Constant inability to maintain an erection for intercourse.

Etiology: Vascular disease Increased cholesterol Smoking Diabetes Neurologic Psychologic Meds Post op

Loss of orgasms: Usually psychological Premature ejaculation: anxiety

Decreased Libido: Hormone decrease Testicular, pituitary or prostate disease Depression

Get History Get Labs: CBC, UA, Lipids, FBS, Serum Testosterone, PSA, Prolactin

Treatment: Meds: Viagra (Sildenafil) / Levitra (Vardenafil) / Cialis (Todalafil) Inhibits Phosphodiesterase 5 This increases blood flow Testosterone replacement Caverject / suppositories Prosthesis / Vascular surgery Psychology for psychogenic