Hello and welcome to Season 2, Episode 97 of the Physician Assistant Exam Review Podcast. My name is Brian Wallace. I’m the host, creator, and founder here at Physician Assistant Exam Review. And in this show, we teach core medical content in an effort to get you through PA school, teach you the best ways to get through school, and to pass your exams. Today we’re going to pick up with, actually finish up the genitourinary system with neoplasms. I’m going to ask two things of you today. Number one is I want your participation in this show.

This show is not a passive learning environment. This is an active learning environment. I want you thinking. I want you on board. I want you concentrating. I want you drawing conclusions from the material and creating the mental pictures that we talk about in order to facilitate your learning and your understanding and really taking in what we’re going to cover so that you can have it for longer. If you just let this wash over you, you’re wasting your time.

You might as well be listening to music because you’d get your runs in faster. You’d get your cleaning done faster. You’d get everything else done better. Instead of just feeling like you’re doing something, you’d actually be doing something. So I want your brain engaged. I want you participating in the show. And I hope that makes sense.

I need you thinking as we move through this. Second, the second thing I ask of you today is if you get something out of the show, if you enjoy the show, If you feel like the content has been helpful, please share it with a friend, share it with a classmate, share it with a professor, share it with your students. That’s the number one way I get to help more people in the community is through you talking about the show, not necessarily in the forums or on social media, but literally to the people in your class, literally to the person sitting next to you every day. When it comes up and you say, hey, how are you covering this? If you can say, hey, the Physician Assistant Exam Review Podcast has really been helpful. And when I get on the email list, all the amazing tips and things I get from there are super helpful and has really changed the way that I study. That would really help me out a lot and help out the people that you tell, obviously.

So those are the two things I’m asking for you, asking of you today. In return, I’m going to give you neoplastic diseases of the genitourinary system.

All right, so this is the very last day of the genitourinary system, and we’re going to be covering bladder cancer, penile cancer, prostate cancer, and testicular cancer. But first, we’re going to do our priming questions. Number one, what is the age range for most testicular cancers? What is the age range for most testicular cancers? What is the age range for prostate cancer? Age range for prostate cancer? And are males or females more likely to get bladder cancer?

Are males or females more likely to get bladder cancer?

All right, we’re going to begin with bladder cancer and move through just like I discussed earlier. One thing to note, bladder cancer is three times more likely in men than in women. Three times more likely in men than women. Also, 90% of bladder cancers are transitional cell carcinomas. Something really important, risk factors for bladder cancer, smoking is number one. I think the numbers I came across, are something like 50% of bladder cancers were linked to smoking. It’s a huge number.

So, when you come across a test question that indicates a genitourinary problem, and the patient is a smoker, I would lean toward bladder cancer. Chronic irritation is another risk factor. So, stones and things. Clinical presentation. So, what’s a patient going to look like when they come in with bladder cancer? So, bloody urine is probably the most common presenting symptom. The reason someone would come in is they’re peeing blood.

Pyuria is also possible. Dysuria is also possible. Lab studies and physical exam findings. You’re obviously going to do urinalysis, which in this case may show hematuria. You can do an ultrasound of the bladder, CAT scans, and MRIs. Of course, if we’re looking for metastasis and things, cytology from the urine, from a urine sample, cystoscopy, and biopsy. So cystoscopy is when you take a scope and actually put it up through the urethra into the bladder and look around.

I get to participate in these quite frequently because we do a lot of hysterectomies where I work. And if you do a total hysterectomy and you remove the cervix, it’s a good idea to look in the bladder after you’re done or a lot of, not everybody does it, but a lot of the surgeons I work with will do a cystoscopy at the end. And that’s to check for, efflux from the ureters to make sure that you haven’t accidentally done something to a ureter while you’re working to, ligate the uterine vessels that you haven’t done something to the ureters, that will prevent them from functioning properly. So you take a look in the bladder, make sure you haven’t done any damage, and make sure the ureters are still functioning. So cystoscopy is literally just taking a scope like you would like a laparoscopic scope, something similar to that, and you put it up through the urethra and look inside the bladder. So a way to diagnose this is going to be through biopsying. You can get a biopsy that way also.

So you can biopsy through a cystoscopy. Treatments. Largely, it’s going to be a surgical treatment. You can do a transurethral resection of the bladder tumor. You can do a partial cystectomy or a radical cystectomy. And then chemotherapy and radiation may also be necessary. And you’ll see a common theme as we move through cancers of the genitourinary system, right?

Treatments are going to be basically the same.

Now, obviously, the surgeries, the radiation, the chemo are all going to be different, right? But as far as your PANCE goes, as far as your schooling goes, I don’t believe you’re going to have to get much deeper than that. You’re not going to be expected to know the different types of surgeries, the in and outs of the surgery. Generally speaking, you know that it’s a surgical procedure. The same thing with chemotherapy and radiation. You’re not going to deal with the chemotherapy agents, right? You’re not going to deal with the different radiation treatments.

You’re going to have to know just a broader idea at this point. Penile cancer is next. This is a cancer that develops in the skin of the penis. Most penile cancers are squamous cell carcinomas. These are pretty rare in the U.S., but account for 13,000 deaths worldwide. That was in 2020. So places like South America, I can’t think of the other place.

There’s another one there. There’s more of a hotspot for penile cancer. Risk factors. Multiple sexual partners and early sexual activity are risk factors here. HPV infection is a risk factor. So the more sexual partners you have, the longer you’re sexually active, your risk for penile cancer goes up. Chronic inflammation.

So condyloma acuminata, genital warts is a risk factor. Anything that causes irritation, inflammation, and problems in this area can be a risk factor for penile cancer. And then poor hygiene, because we can get infections beneath the foreskin and things that can also cause this chronic inflammation that can at some point lead to this cancerous situation. Clinical presentation, thick and red or tender, penile skin, frank ulcers are more common, abnormal growth on the penis, bleeding from the urethra or urethral discharge. All possibilities here. So it’s kind of vague except for the skin findings may point you in a direction.

Now, how are you going to get a diagnosis here? So stop and think for a minute. What would you do? What do you think would happen? You have a patient come in and they have a thickened red skin with a little bit of an ulcer on it on their penis. Well, one way you could diagnose it is with a biopsy, right? We’re going to try to see what those cells are like.

Another thing that’s encouraged is immunostaining for HPV. Treatment. Well, first we’re going to start with prevention in this case. So good hygiene, limiting sexual partners, use of condoms, and an HPV vaccine. I like to talk about things that you don’t have to memorize. You don’t have to memorize those preventative terms, right? You don’t have to memorize that list of preventative things.

Why don’t you have to memorize it? Because if you think, if you know the risk factors, memorize the risk factors, and then then prevention is easy, right? Just don’t do those things. Avoid the risk factors, right? So I’m trying to limit what I have to remember when I try to memorize all this stuff. I hate learning lists. I hate memorizing lists.

I’m not good at it. I don’t think the human brain is designed to learn lists. It’s designed to understand stories, broader pictures, and that’s what we shoot for here on this particular show. So if you know that multiple sexual partners and early sexual activity is a risk factor for penile cancer, well, then you also know that limiting sexual partners is a preventative measure. You know that the use of condoms is a preventative measure. If you know HPV infection may cause or may lead to penile cancer, then you know that an HPV vaccine is going to be helpful, right, in preventing it.

Now, let’s say that, you know, we’re past that point, right? So what do we do? How do we treat this? Well, a wide excision of the lesion. We’re going to want to try and spare as much tissue as possible, but we also want to get as much tissue as possible, and then once again, radiation and chemotherapy. So again, we wind up with surgery, radiation, chemotherapy.

Next, we have prostate carcinoma. This is the most common cancer in men. Risk factors here. I would know these. I think they’re very relevant and easy to ask questions on. So, African American heritage, family history, a diet high in fat or high in processed meats tends to increase the risk for prostate cancer. Advancing age.

So I think I came across it was something like 99% of prostate cancers happen after the age of 50. After the age of 50. And then as you get older, the incidence goes up. But here’s the good news. So this is the most common cancer in men. And as men get older, the risk for this goes up. But the good news is it’s generally very slow growing.

In fact, you’ll see later that watchful waiting is a reasonable treatment plan. And the quote I came across that I like is that more men die with prostate cancer than from prostate cancer. More men die with prostate cancer than from prostate cancer. Clinical presentation. Generally, this will be asymptomatic. We do screening exams, right, with a digital rectal exam and a PSA. Because usually it’s going to be asymptomatic.

The symptoms you may find, well, think about it for a second. Again, this is where I want you to use your brain and not just memorize lists. Stop and think. If there was going to be a symptom from a giant nodule in a prostate, and you understand anatomy, what do you think the symptoms would be? Well, one of them would be obstructive issues with urination, right? Not being able to completely empty the bladder. So you would get overflow incontinence or you could get overflow incontinence.

You could get dribbling of urine from the penis. You could get all this stuff, right? That would be an obstructive issue. So if you have an obstructive issue in an older gentleman, you may consider that they may have prostate problem, right? They could also get hematuria. Again, just following along with where all these things are associated, where they reside anatomically, you can think through what the clinical presentations might be. Lab studies and physical exam findings, so you can feel nodules within the prostate on a digital rectal exam.

We can do screenings, PSA greater than four, although the more I read, PSA is a little bit questionable. I’m not in urology, so I’m not the person to ask about this. But from what I read researching the notes for today, the association of PSA greater than four is questionable whether the long-term data has been helpful in preventing deaths from prostate cancer. But it’s something that we still use, right? So a PSA greater than four, you should start considering alternatives and other ways to to handle this situation and think you might have a problem on your hands. A biopsy is going to get us a definitive diagnosis. You’re going to want multiple samples from each of the three zones of the prostate.

And then an MRI and a bone scan may be also useful if we’re concerned about metastasis. Treatment. Radical prostatectomy, radiation, or watchful waiting. So if we have a high-grade prostate cancer, we’re going to need to go in and get it and remove the prostate, right? And then treat with radiation if necessary. But we’re going to gauge our patient when we look at our treatments. If I have a healthy 50-year-old, I’m going to be more willing to go after the prostate, right?

And remove the cancer. If I have a demented 80-year-old with low-grade prostate cancer, I’m probably not going to do anything because they will probably outlive the diagnosis. So that’s what we’re considering a little bit here as we talk about prostate cancer. And then our last one for today is testicular carcinoma. This has one of the highest cure rates of all cancers. What kind of patient are we looking for here? Who’s coming through the door with the testicular carcinoma?

Well, with a prostate cancer, we have someone over 50, right? Generally, let’s say 60s, 70s, in their 80s who has an issue with obstruction, we’re leaning toward prostate cancer. Here with testicular cancer, we’re talking about a 15 to 35-year-old male. So picture in your head the person who comes in with this. They also may have a history of cryptorchidism, right? Cryptorchidism we talked about before leads to an increased incidence of testicular carcinoma or is linked to it. But remember, when we talked about that before, we also said that not all cryptorchidism is created equal.

Some are just slow to descend. So they’re not true cryptorchidism, although they may be diagnosed as that. So there’s a little bit of question mark in the final numbers for how related testicular carcinoma is to cryptorchidism, what that relationship is like. But if that’s in the history and you’ve got a 22-year-old male coming in, you may really be heading down that path to testicular cancer. Greater than 90% of testicular tumors are germ cell tumors, which include seminomas and non-seminomas. Clinical presentation. What is this patient going to come in like?

So now I’ve got my 22-year-old, 17-year-old, 30-year-old coming through the door with a painless lump on one testicle. That doesn’t guarantee you that it’s testicular cancer, right? But it puts you in the direction. Could it be a varicocele? Sure. But if you get that same question, and the patient has a history of cryptorchidism, now we’re really leaning in a direction, right? Acute pain in the scrotum could be another one.

A feeling of heaviness or an achiness in the scrotum. Or the patient could be completely asymptomatic, and we find this on physical exam. Lab studies and physical, I’m sorry, labs and studies. Let me just adjust my notes here. A single enlarged testicle is something we may find on that clinical presentation. I’m just going to take that out.

Okay. Ultrasound is one way we can diagnose this. And then if we’re concerned about staging we’re going to look into a CAT scan, right? So again, what are our treatments going to be now? Think about it for a second. What are our treatments for testicular cancer going to be? We’re going to take out the testicle, right?

We’re going to do an orchiectomy and then we can give chemotherapy on top of that. Once again, we kind of have the same treatment plan for all of these. Is that the same treatment plan in reality? No, it isn’t the same treatment plan in reality, right? Each of these surgeries is very specific. The chemotherapies may be very specific, but we’re not going into those details here. We know we have to take the the testicle out, and we’re probably going to give chemotherapy.

And that will take care of the genitourinary system. So we’re moving right through season two, taking out the systems one at a time. The next one we’re going to cover is infectious disease. So that should be a lot more fun. I’d say a lot more fun. That’s not fair. That should be a lot of fun going through infectious disease.

That’s a topic that obviously we haven’t covered here in a long time. So I’m looking forward to going through and sifting through some of that.

All right, let’s talk about our study tip for today. Our study tip today is really simple. Have a plan. That’s it. Think through how you’re going to spend your days, how you’re going to spend your time, how you’re going to spend your week, how you’re going to spend your month. What are you going to cover? What are you going to lean into?

Spend some time thinking. Too many times, and myself very much included in this, we jump right into our work. And I have to remind myself over and over and over about this. Jumping straight into the work is a terrible idea. It seems like such a good idea, but it’s not a good idea. Here’s why. You never feel like you got anywhere.

You never feel like you accomplished anything because you didn’t set up what you were trying to do. You didn’t set up what success looks like. You didn’t give yourself a goal to shoot for. You just jumped in and got to work. Well, you know what happens the next day? You have to jump in and get to work again. You jump in and get to work again.

And you go through a few months like this and all of a sudden you feel like you’re not making any progress, but you know that you’re working all the time. That’s one reason why jumping into work without a plan stinks. Another reason is we tend to pick the first most important thing to work on, which is good. But then there’s usually about eight other things we need to do, and we don’t stop to prioritize them. We just do what pops into our heads next. The first one tends to be big and important, so that’s easy. It’s the ones after that, right, that you sort of have to sift between.

And without a plan, we tend to spend too long on maybe numbers three and four, and we never get to seven and eight because we haven’t thought about the whole day. The plan will help keep you on track and help you to get more done. So, another thing that’s helpful about plans is that if you have a plan for how to run your day, when you’re going to study, how you’re going to get through the material, what you’re going to do between classes, what you’re going to do after class, how you’re going to take your notes, if those are all pre-planned and pre-thought out, then when something doesn’t go well, if you don’t do good on a test or you feel like you didn’t grasp something… or you’re not getting through enough material. Well, now all of a sudden you’re not a failure. What is a failure is the system, the plan, right? That’s easy.

So then what do we do? We adjust the plan. We don’t take it to heart. It doesn’t eat us up inside. We don’t think we’re a bad student or a bad person. We think, oh, my plan could use some adjusting and we fix the plan. I hope that makes sense.

Those are three very simple, very powerful reasons by having a plan will help you navigate your way through PA school. It’ll help you see to the end so you know what you’re doing and you know when you’re a success. And if you’re not a success, it’ll let you adjust to become one. Really, really important stuff here. I know it seems simple and I know we love to just jump in and get to work and we think that creating a plan is a waste of time. But if we can create a plan and execute that plan, it will save you a ton of time, and it will save you a lot of emotional turmoil. And doesn’t take very long.

And especially once you have a plan that you can reuse on a regular basis. And it takes even shorter.

Okay, let’s talk about our… stammering a lot today.

Let’s talk about our priming questions. What’s the age range for testicular cancer? Again, picture in your mind what the person coming in looks like. This is not a pediatric patient. It’s a little bit older male, right? 15 to 35. Coming in having found a painless mass on the testicle.

Or you were feeling a painless mass on the testicle during an exam. What’s the age range for prostate cancer? Greater than 50 and increasing rates with increasing age. This is an older male. Are males or females more likely to have bladder cancer? Males. And what’s our number one risk factor?

I’m just going to throw this in at the end here for bladder cancer. What’s the number one risk factor for bladder cancer? Your number one risk factor is smoking.

All right, fantastic. Now we’re going to move on to infectious disease. So glad you could join us today. That will take us out for this particular show. If you head over to physicianassistantexamreview.com/podcast, you can get every single episode of the show delivered directly to your phone, going all the way back through cardiology, all the way back through the entire season two and entire season one. So I look forward to seeing you in there.

All right, take care. Good luck on your exams and let me know how you are making out. I always love to hear from you guys. Take care. Thank you.