Gynecologic -Urology disorders

Early findings include a single nontender, firm mass or a mammographic abnormality. • Later findings include skin or nipple retraction, axillary lymphadenopathy, breast enlargement, redness, edema, pain, and fixation of a mass to the skin or chest wall.

Next to skin cancer, breast cancer is the most common cancer, and second most common cause of death, in women. • Risk is higher with white race, advancing age, positive family history, nulliparity or late first pregnancy (after age 30 years), early menarche (before age 12 years) or late natural menopause (after age 55 years), alcoholism, high dietary fat, lack of exercise, high breast density on mammogram, fibrocystic disease when accompanied by proliferative changes, papillomatosis, or atypical epithelial hyperplasia on biopsy, history of uterine cancer. • Estimated 85% lifetime risk in women with BRCA1 gene mutations.

Fibrocystic condition of breast • Fibroadenoma • Intraductal papilloma • Lipoma • Fat necrosis

Alkaline phosphatase is increased in liver or bone metastases; hypercalcemia occurs in advanced disease. • Carcinoembryonic antigen (CEA) and CA 15-3 or CA 27-29 are tumor markers, but are not recommended for early diagnosis or for surveillance for recurrence

Mammography (plain film or full-field digital). • Tomosynthesis. • Breast ultrasound may differentiate cystic from solid masses. • MRI and ultrasound may be useful in women at high risk for breast cancer. • Chest and abdominal CT, bone scan, and PET scanning (alone or with CT) can detect metastatic disease.

Fine-needle aspiration (FNA) or core biopsy, open biopsy, or computerized stereotactic or ultrasound-guided core needle biopsy. • Cytologic examination of breast nipple discharge may be helpful on rare occasions.

Chemotherapy is used in curable disease and in metastatic disease. • CMF (cyclophosphamide, methotrexate, fluorouracil). • AC (Adriamycin [doxorubicin], cyclophosphamide) with taxanes (docetaxel or paclitaxel) • Tamoxifen or aromatase inhibitors in hormone receptor-positive patients. Young women with high-risk ER-positive cancers have fewer relapses with the aromatase inhibitor, exemestane, plus ovarian suppression compared to tamoxifen plus ovarian suppression. • Bisphosphonates are used to decrease disease recurrence and treat metastases to the bone. • Trastuzumab, lapatinib, and pertuzumab bind to HER-2/neu receptors for HER-2/neu–expressive cancers. • Neoadjuvant chemotherapy plus dual HER2-targeted therapy with trastuzumab and pertuzumab

Surgery is indicated for stage I and II cancers; breast-conserving therapy is indicated in selected patients. • Sentinel node biopsy for invasive cancer can be used as an alternative to axillary dissection.

Radiation therapy is usually used after surgical therapy.

Obstructive or irritative voiding symptoms in absence of infection, neurologic disorder, urethral stricture, or prostate or bladder malignancy. • Rectal examination may find an enlarged prostate that is smooth, firm, and elastic.

Etiology is multifactorial, related to aging prostatic dihydrotestosterone (DHT) level. • Prevalence: ~20% men ages 41 to 50 years; ~50% men ages 51 to 60 years; >90% men ages >80 years. • At age 55 years, ~25% of men report obstructive voiding symptoms. • At age 75 years, 50% of men report a decrease in the force and caliber of the urinary stream.

Prostate cancer • UTI • Neurogenic bladder • Urethral stricture

History to exclude other possible causes of symptoms. • Physical examination, DRE (note size and consistency of the prostate), and a focused neurologic examination. • Examine lower abdomen for a distended bladder. • If possibility of cancer, further evaluation is needed by serum prostate-specific antigen (PSA), transrectal ultrasonography, and biopsy.

α-Blockers such as prazosin, terazosin, doxazosin, and tamsulosin work quickly for symptoms. • 5-α-Reductase inhibitors such as finasteride require 6 months of therapy for maximum effect. • Combination therapy of an α-blocker and 5-α-reductase inhibitor is better than either one alone. • Phosphodiesterase-5 inhibitor, tadalafil, is FDA approved to treat men with both urinary symptoms of BPH and erectile dysfunction. • Saw palmetto is of no benefit.

Surgery is indicated for refractory retention, recurrent infections, kidney failure, and bladder stones. • Transurethral resection of the prostate (TURP) is effective, but complications include retrograde ejaculation (75%), erectile dysfunction (5%–10%), urinary incontinence (<1%). • Transurethral incision of the prostate (TUIP) and open prostatectomy are also available. • Minimally invasive approaches include laser surgery, needle ablation, and microwave therapy. • Implant to open prostatic urethra retracts the enlarged lobes of the prostate in BPH and improves symptoms and voiding flow while having minimal impact on ejaculation.

With watchful waiting, about 10% of patients progress to urinary retention and 50% improve.

Primary dysmenorrhea is menstrual pain associated with menstrual cycles in the absence of pathologic findings. • Secondary dysmenorrhea is menstrual pain for which an organic cause exists, such as endometriosis or uterine fibroids

Primary dysmenorrhea usually occurs in young women; begins within 1 to 2 years of menarche; and is caused by uterine vasoconstriction, anoxia, and sustained contractions mediated by prostaglandins. • Secondary dysmenorrhea usually begins well after menarche even in the third or fourth decades of life.

Low, midline, wave-like, cramping pelvic pain often radiating to the back or inner thighs. • Cramps may last for ≥1 days and may be associated with nausea, diarrhea, headache, and flushing. • No pathologic findings on pelvic examination.

The history and physical examination may suggest endometriosis or fibroids. • Other causes include PID, submucous myoma, adenomyosis, intrauterine device (IUD) use, cervical stenosis with obstruction, or blind uterine horn.

• Endometriosis • Adenomyosis • PID • Uterine leiomyomas (fibroids) • Intrauterine device (IUD) • Pelvic pain syndrome • Endometrial polyp • Cervicitis • Cervical stenosis • Cystitis • Interstitial cystitis

Pelvic imaging is useful in detecting uterine fibroids or other anomalies. • Magnetic resonance imaging (MRI) is the most reliable method to detect submucous myomas. • Ultrasonography or, preferably, MRI is useful in identifying adenomyosis.

Secondary Dysmenorrhea • Laparoscopy may be used to diagnose endometriosis or other pelvic abnormalities not visualized by imaging.

NSAIDs or cyclooxygenase-2 inhibitor started before menses. • Symptoms can be suppressed and primary dysmenorrhea usually prevented by continuous use of combined oral contraceptives, depot-medroxyprogesterone acetate, or levonorgestrel-containing IUDs. • Oral contraceptives and gonadotropin-releasing hormone agonists for endometriosis. • Levonorgestrel-releasing intrauterine system, uterine artery embolization, or hormonal approaches to treat adenomyosis.

Laparoscopy or laparotomy with or without hysterectomy is often performed.

Local heat and high-frequency transcutaneous electrical nerve stimulation

Prostatic induration on DRE or elevated level of serum PSA • Most often asymptomatic • Rarely, systemic symptoms (weight loss, bone pain)

Most common nondermatologic cancer and second leading cause of cancer-related death in American men. • Incidence increases with age: ~30% of men ages 60 to 69 versus 67% in men ages 80 to 89 years have prostate cancer. • Risk factors: African American ethnicity, family history of prostate cancer, high dietary fat intake. • Majority of prostate cancers are adenocarcinomas.

Focal nodules or areas of induration within the prostate on DRE • Lymph node metastases • Lower extremity lymphedema • Back pain or pathologic fractures • Obstructive voiding symptoms • Rarely, signs of urinary retention (palpable bladder) or neurologic symptoms as a result of epidural metastases and cord compression

Urinary obstruction (eg, urethral stricture, stone, bladder neck contracture) • Prostatitis • Benign prostatic hyperplasia • Prostatic stones • Bladder cancer

Elevated serum PSA (normal <4 ng/mL). • PSA correlates with the volume of both benign and malignant prostate tissue. • Elevated blood urea nitrogen or serum creatinine with urinary retention or urethral obstruction. • Elevated serum alkaline phosphatase or calcium in patients with bony metastases.

TRUS: most prostate cancers are hypoechoic. • Magnetic resonance imaging or transrectal ultrasonography (TRUS) can detect capsular penetration and local invasion. • CT imaging and radionuclide bone scan can be useful in detecting metastases.

TRUS-guided biopsy in men with abnormal DRE or elevated PSA. • MRI-guided biopsy may improve not only overall cancer detection but discovery of clinically relevant disease.

Androgen deprivation is used for advanced or metastatic disease via antiandrogens, surgical orchiectomy or medical orchiectomy with gonadotropin-releasing hormone agonists or antagonists. • Ketoconazole or corticosteroids also can suppress adrenally produced sex hormones. • Chemotherapy with Sipuleucel-T, denosumab, cabazitaxel, abiraterone, and enzalutamide, docetaxel or other taxanes, and radiation therapy with radium-223 dichloride may improve survival in those with castrate-resistant disease. Denosumab and radium-223 dichloride are also useful for prevention of skeletal-related events in patients with bone metastases.

Surveillance (watchful waiting) may be appropriate for low-stage or low-grade disease. • Surgery: radical prostatectomy; lower stages have lowest recurrence rates. • External beam radiation therapy or brachytherapy (transperineal implantation of radioisotopes). • Combination therapy with androgen deprivation and surgery or radiation, or both.