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Lecture Three—March 6 th, 2012. “Painful Bladder Syndrome” Diagnosis of Exclusion Negative culture and cystology No other obvious cause (radiation,

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Presentation on theme: "Lecture Three—March 6 th, 2012. “Painful Bladder Syndrome” Diagnosis of Exclusion Negative culture and cystology No other obvious cause (radiation,"— Presentation transcript:

1 Lecture Three—March 6 th, 2012

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3 “Painful Bladder Syndrome” Diagnosis of Exclusion Negative culture and cystology No other obvious cause (radiation, chemical, vaginitis, herpes, urethral diverticulum) people per 100,000 Affects both genders but most patients are women Higher prevalence in white and Jewish average age 40 years Bladder problems in childhood Up to 50% spontaneous remission (average 8 months)

4 Etiology unknown Most likely several diseases with similar symptoms Multiple theories as to possible cause Increased epithelial permeability sensory nervous system abnormalities autoimmunity Associated with severe allergies, IBS, IBD

5 Pain with bladder filling, relieved by urination Urgency, frequency, nocturia Labs – urinalysis, urine culture, urine cytology, urodynamic testing Cystoscopy – distend bladder with fluid (hydrodistention) Glomerulations (submucosal hemorrhage) Hunner’s Ulcers Thinned bladder epithelium Differential Diagnosis – radiation, chemical, bacterial cystitis, herpes, vaginitis, bladder carcinoma, eosinophillic cystitis, tuberculous cystitis, urethral diverticulum, urethral carcinoma

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9 No cure – goal is symptomatic relief Hydrodistention – done as part of work-up – 20-30% see improvement Oral medications Amitryptyline (10-75 mg/day orally) Nifedipine (30-60 mg/day orally) and other CCBs Elmiron (100 mg 3x/day orally) – helps restore integrity to bladder epithelium Intravesical instillation of DMSO and heparin TENS units Acupuncture Surgery – last resort—cystourethrectomy

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11 Phimosis – inability to retract the distal foreskin over the glans penis Physiologic – occurs naturally in newborn males Pathologic – inability to retract foreskin when it was previously retractable or after puberty Paraphimosis – foreskin cannot be pulled back over the head of the penis – uncircumcised or partially circumcised males

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13 Phimosis – Poor hygiene, recurrent inflammation or infection of glans or foreskin, forceful retraction of foreskin, elderly Patients with phimosis are at risk for developing paraphimosis when the foreskin is forcibly retracted past the glans and/or the patient or caretaker forgets to replace the foreskin after retraction. Penile piercings increase the risk of developing paraphimosis Impairment of venous/lymphatic flow to the glans leads to venous engorgement and worsening swelling  arterial supply is compromised  penile infarction/necrosis, gangrene

14 Physiologic – inability to retract the foreskin during routine cleaning or bathing; "ballooning" of the prepuce during urination Pathologic – painful erections, hematuria, recurrent UTIs, preputial pain, weakened urinary stream The foreskin cannot be retracted proximally over the glans penis. Physiologic – preputial orifice is unscarred and healthy appearing. Pathologic – contracted white fibrous ring may be visible around the preputial orifice

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16 Painful, swollen glans penis Uncircumcised or partially circumcised patient Foreskin retracted behind glans penis and cannot be replaced to its normal position Tight, restricting ring around the glans Flaccidity of penile shaft proximal to constriction Glans – initially its normal pink hue and soft, becomes increasingly erythematous/edematous, becomes firm and blue or black with necrosis Preverbal infant may present only with irritability or may be an incidental finding in a debilitated patient.

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18 Phimosis – rarely require emergency intervention – outpatient urology referral Paraphimosis – urologic emergency – immediate intervention with goal of reducing foreskin to naturally occuring position over the glans penis Manual reduction Osmotic reduction Puncture reduction Hyaluronidase method Aspiration Vertical incision Surgery (emergency circumcision)

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22 2 nd most common urologic cancer 2.7 : 1 male-to-female; average age at diagnosis – 65 Risk factors – cigarette smoking and industrial dye/solvent 98% are epithelial malignancies 90% - urothelial cell carcinomas 7% - squamous cell cancers 2% - adenocarcinomas

23 Hematuria is presenting symptom in 85-90% Irritative voiding (frequency and urgency) Many with no symptoms at all Abdominal masses – if large or deeply infiltrating Hepatomegaly or lymphadenopathy (if metastasis) Lymphedema of lower extremities – if locally advanced or metastasis to pelvic lymph nodes

24 Urinalysis – microscopic or gross hematuria, pyuria Azotemia may be present on labs Cytology – 80-90% sensitive in detecting higher grade/stage cancers but less so in superficial or well-differentiated lesions (50%) Anemia—chronic blood loss or metastasis to marrow Urinary tumor markers – under investigation Imaging – Ultrasound, CT, or MRI may show filling defects Cystourethroscopy/Biopsy – cystoscopy confirms diagnosis; pt then undergoes transurethral resection and random biopsies Grading (cellular features) and staging (wall penetration and metastasis)

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26 Superficial – (Ta, T1) – complete transurethral resection and intravesical chemotherapy Invasive, Localized – (T2, T3) – risk of nodal metastases and progression – radical cystectomy, radiation, or combination of chemotherapy and selective surgery or radiation Muscle invasive (T2 or greater) transitional cell carcinoma requires systemic chemotherapy READ – Specific forms of treatment (p. 1592)

27 Initially, 50-80% are superficial (Ta, Tis, T1) With proper treatment, metastasis/progression are low and survival is excellent (81%) T2, T3 – 5 year survival ranges from 50-75% Long-term survival for pts with metastasis at initial presentation is rare

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29 2-3 new cases per 100,000 males in US each year 90-95% of primary testicular tumors are germ cell tumors Nonseminomas – mixed cell types (40%) embryonal cell carcinoma (20%), teratoma (5%), choriocarcinoma (<1%) Seminomas – 35% Non-germinal neoplasms 5% of testicular tumors occur in pts with history of cryptorchidism but 15-10% of these occur in normal testis Testicular cancer is slightly more common on right than left

30 Painless enlargement of the testis Sensations of heaviness Acute testicular pain 2 o intratesticular hemorrhage – 10% Asymptomatic – 10% Metatstatic symptoms – 10% (back pain, cough, lower extremity edema) Discrete mass or diffuse testicular enlargement Secondary hydrocele – 5-10% Supraclaviuclar adenopathy Abdominal mass Gynecomastia – 5% (germ cell tumors)

31 Labs – hCG, α- fetoprofen, LDH Liver transaminases (metastasis) or anemia Imaging – scrotal ultrasound (extratesticular / intratesticular) Diagnosis – confirmed by inguinal orchectomy Staging – chest/abdominal/pelvic CT scanning Nonseminomas – Stage A – confined to testicle; Stage B – retroperitoneal lymph node involvement; Stage C – distant metastasis Seminomas – Stage I – confined to testicle; Stage II – retroperitoneal lymph node involvement

32 Initial Intervention – inguinal exploration with early vascular control of spermatic cord structures Examine testis for cancer – if unable to exclude cancer, radical orchiectomy 75% of stage I nonseminomas are cured by orchiectomy alone Stage I and II a/b seminomas – radical orchiectomy and retroperitoneal irradiation IIc and Stage III seminomas – chemotherapy

33 Surveillance – monthly for first 2 years after diagnosis/treatment then bimonthly for 3 rd year tumor markers at each visit CXR/CT scans every 3 months 80% of relapses in first 2 years Nonseminoma prognosis – stage A with % 5 yr survival rate, stage B with 90% disease-free survival 5 yrs Stage I seminoma – 98%, Stage IIa seminomas – 92-94% Stage III seminoma – 95% Disseminated disease – 55-80%

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35 Most common noncutaneous cancer in US men 2 nd most common cause of cancer-related death 218,000 new cases/yr and 27,000 deaths/yr Clinical incidence does not equal prevalence on autopsy Over 40% of men over 50 y/o have prostatic carcinoma Incidence increases with age Autopsy prevalence is similar world-wide, but clinical incidence varies and is high in North America/Europe, intermediate in South America, low in Far East Black race, + family history, high dietary fat intake

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37 Most are associated with palpably normal prostates and detected solely by elevated PSA May have focal nodules or indurated areas on DRE Urinary retention or neurologic symptoms – epidural metastasis and cord compression Obstructive voiding – usually due to BPH, but large or locally extensive prostatic cancers may cause Lower extremity edema – lymph node metastasis Back pain or pathologic fractures – skeletal metastasis Axial skeleton – most common site of metastasis

38 PSA – glycoprotein made only by prostate cells (benign or malignant) – corresponds with prostate volume 10-15% of men will have elevated PSA on screening 18-30% of men with PSA will have prostate cancer 50-70% of pts with PSA > 10 will have cancer If not treated, PSA level correlates with volume and stage of disease Organ confined – usually PSA <10 Advanced disease (seminal vesicle invasion, lymph node involvement, occult metastases) – PSA >40 98% of pts with metastatic cancer have elevated PSA 20% of pts who undergo radical prostatectomy have normal PSA Rising PSA after therapy = progressive disease PSA increase of over 0.75 ng/mL per year is suspicious

39 PSA – glycoprotein made only by prostate cells (benign or malignant) – corresponds with prostate volume 10-15% of men will have elevated PSA on screening 18-30% of men with PSA will have prostate cancer 50-70% of pts with PSA > 10 will have cancer If not treated, PSA level correlates with volume and stage of disease Organ confined – usually PSA <10 Advanced disease (seminal vesicle invasion, lymph node involvement, occult metastases) – PSA >40 98% of pts with metastatic cancer have elevated PSA 20% of pts who undergo radical prostatectomy have normal PSA Rising PSA after therapy = progressive disease PSA increase of over 0.75 ng/mL per year is suspicious

40 Urinary retention/urethral obstruction – BUN/CR elevation Bony metastasis – alkaline phosphatase, calcium DIC (disseminated intravascular coagulation) – advanced Biopsy – transrectal ultrasound guided biopsy Spring-loaded 18-gauge biopsy needle Transrectal US – staging (hypoechoic areas) MRI – evaluate prostate and lymph nodes Radionuclide bone scan – superior to plain skeletal films Most metastases are multiple and usually in axial skeleton Advanced local lesion, metastasis symptoms, high grade disease, PSA >20 FNA (lymphadenopathy), plain films (bone scan) CT is of limited use

41 DRE alone – %, usually advanced cancers Transrectal US – not appropriate for screening; expensive, low specificity (high biopsy) PSA combined with DRE – increased detection rate Serial PSA – increases specificity (>0.75 ng/yr increase is increased likelihood of cancer) PSA density – in normal DRE and transrectal US – serum PSA divided by volume of the prostate Free serum PSA vs. protein-bound (lower free PSA = increased odds of cancer) Benefit of screening for prostate cancer is controversial

42 Localized—active surveillance is an option, but pts with life expectancy > 10 years should get treatment – radiation vs. radical prostatectomy Radical Prostatectomy – seminal vesicles, prostate, ampulla of vas deferens removed Modern surgery – usually preserves urinary continence and may also preserve erectile function Healthy patients with T1 and T2 cancers are ideal candidates Advanced – rarely candidates for prostatectomy alone Radiation – external beam or implantation of radioisotopes Surveillance – older pts with small volume, well-differentiated cancers

43 Cryosurgery – less invasive, positive biopsy rate 7-23% Metastatic – death is almost invariably due to uncontrolled metastatic disease Most prostate carcinomas are androgen-dependent and 70-80% of metastatic disease will respond to androgen deprivation (table 39-7) Prognosis – varies with stage, grade of cancer, PSA level, number and extent of + biopsies Tables 39-8 and 39-9

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