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GU / GYN & Renal > Clinical: Urology > Flashcards

Clinical: Urology Flashcards

1
Q

Presence of bacteria in the urine that causes no illness or symptoms

A

Asymptomatic bacteriuria

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2
Q

WBCs in urine,

A

Pyuria

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3
Q

UTI with at least 1 complicating factor

Factors: pregnancy, male, immunocompromised

A

Complicated UTI

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4
Q

2 culture-proven UTIs in 6 months or 3 in 1 year

A

Recurrent UTI

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5
Q

Bacterial persistence despite appropriate treatement

A

Unresolved UTI

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6
Q
  • Immune receptor polymorphisms
  • Family history

Risk Factors: Genetic

A

UTI

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7
Q
  • Urinary calculi
  • Urinary stasis / obstruction
  • Congenital anomalies of lower urinary tract
  • Microbiologic change: atrophic vaginitis, pH alkalinization
  • Diabetes / neurologic disorders
  • Immunosuppression

Risk Factors: Biologic

A

UTI

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8
Q
  • Sexual intercourse
  • Birth control practices
  • Antimicrobial use

Risk Factors: Behavioral

A

UTI

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9
Q

Most common pathogen in UTI

Etiology

A

Uropathogenic Escherichia coli (UPEC)

85% of cases

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10
Q

2nd most common pathogen in UTI; mainly in reproductive age women

Etiology

A

Staphylococcus saprophyticus

10-20% of cases

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11
Q
  • Pain with urination (dysuria)
  • Frequency
  • Urgency
  • Incontinence
  • Mild back pain
  • Suprapubic pain (very common)

Symptoms

A

UTI

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12
Q
  • Hematuria
  • Cloudy urine
  • Malodorous urine
  • Low-grade fever

Signs

A

UTI

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13
Q

UTI

Approach to Diagnosis

A
  • History
    • Asymptomatic bacteriuria vs. UTI
    • Uncomplicated UTI vs. complicated UTI
  • Physical
  • Diagnostic studies
    • Urinalysis
    • Urine microscopy
    • Urine culture
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14
Q

UTI

Approach to Therapy

A
  • Supportive measures to treat dysuria
    • Hydration
    • Acetaminophen
    • NSAIDs
    • Phenazopyridine (urinary analgesic)
  • Empiric vs. culture-directed antibiotics
    • Shortest duration, no longer than 7 days
  • Escalate based on patients status
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15
Q

Asymptomatic bacteriuria

Approach to Therapy

A

No treatment except in:
* Pregnant women
* Patients scheduled for GU instrumentation

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16
Q
  • Ascending GU tract infection
    • Bladder UTI (cystitis) ascends through ureter to kidney
  • Clinical diagnosis:
    • UTI symptoms
    • Flank pain: CVA tenderness on physical exam
    • Fever
    • Leukocytosis

CVA = costovertebral angle

A

Pyelonephritis

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17
Q

Septic pyelonephritis

Approach to Therapy

A
  • Treatment duration: 7-14 days
  • IV broad-spectrum antibiotics
  • Imaging for perinephritic abscess / structural abnormality
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18
Q

Types of urinary incontinence

A
  • Urge incontinence
  • Stress incontinence
  • Mixed incontinence
  • Other:
    • Overflow: impaired emptying; bladder overflows
    • Fistula: continuous leakage of urine
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19
Q
  • Urge incontinence
  • Urgency
  • Frequency
  • Nocturia

Symptoms

A

Overactive bladder (OAB) complex
* Extremely common; prevalence increases w/ age

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20
Q

OAB complex

Approach to Therapy

A
  1. No treatment (least invasive)
  2. Lifestyle modifications / PTx
  3. Medications
  4. Tibial nerve stimulation / Botox / Interstim
  5. Bladder augmentation (most invasive)
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21
Q

Normal bladder control

Sympathetic

A
  • Norepinephrine activates B3-adrenergic reveptor
  • Detrusor muscle relaxation –> storage
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22
Q

Normal bladder control

Parasympathetic

A
  • ACh activates M3-muscarinic receptor
  • Detrusor muscle contraction –> emptying
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23
Q

MoA: Antimuscarinics

OAB Tx

A
  • Antimuscarinics block M3-muscarinic receptor
  • Inhibits involuntary detrusor muscle contractions
  • Delays emptying
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24
Q

MoA: Beta agonists (Betmiga)

OAB Tx

A
  • Agonist activates B3-adrenergic receptor
  • Increases detrusor muscle relaxation
  • Increases storage capacity, inter-void interval
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25
Q
  • Oxybutynin
  • Trospium chloride
  • Darifenacin / Solifenacin
  • Tolterodine / Fesoterodine
A

Antimuscarinics

OAB Medical Therapy

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26
Q
  • Blurred vision
  • Dry eyes
  • Xerostomia
  • Tachycardia
  • Dyspepsia
  • Constipation
  • CNS: dizziness, somnolence, impaired memory & cognition
A

Anticholinergic side effects

OAB Medical Therapy

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27
Q
  • Urine leakage due to increase in abdominal pressure
  • Involuntary leakage of urine secondary to insufficient bladder outlet resistence
    • Outlet resistence provided by: internal & external sphincters
    • Internal: bladder neck; involuntary
    • External: rhabdosphincter; voluntary
A

Stress incontinence (SUI)

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28
Q
  • Anatomic defect of suburethral support & loss of urethral coaptation
  • Age
  • Parity
  • Weight
  • Vaginal delivery
  • Estrogen statuys
  • Urethral surgery

Risk Factors

A

Female SUI

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29
Q

Female SUI

Approach to Therapy

A
  1. No treatment (least invasive)
  2. Lifestyle modifications / PTx
  3. Pessary Impressa tampon
  4. Bulking agent
  5. Surgery / Sling (most invasive)
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30
Q
  • Radical prostatectomy
  • Posterior urethral injury (PFUDD)
  • Transurethral resection of prostate (TURP)
  • Myelopathy
  • Congenital conditions

Risk Factors

A

Male SUI

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31
Q

Most common cause of male SUI

Etiology

A

Radical prostatectomy

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32
Q

Surgical options for male SUI

Approach to Therapy

A
  • Artificial urinary sphincter (most common)
  • Transurethral bulking agents
  • Perineal sling
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33
Q
  • Incidence peaks between ages 40-70
  • Highest incidence: white men & women
  • Lowest incidence: black men & asian women

Epidemiology

A

Kidney stones (nephrolithiasis)

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34
Q
  • Hot, dry climates
    • Risk in US increases N –> S, W –> E
  • Occupations with exposure to excessive heat
  • Conditions that promote dehydration

Risk Factors: Environmental

A

Kidney stones

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35
Q
  • Obesity, weight gain, metabolic syndrome
  • Medications
  • Surgeries (e.g,. gastric bypass)
  • Dehydration
  • Kidney disorders: impaired excretion of acid
  • T2DM

Risk Factors: Systemic

A

Kidney stones

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36
Q

Compositions of kidney stones

A
  • Calcium stones
  • Uric acid stones
  • Cystine stones
  • Infection stones
  • Drug-induced stones
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37
Q

Kidney stones

Approach to Diagnosis

A
  • CT scan (w/o contrast)
  • Kidney ultrasound
  • Basic metabolic panel: Cr & Ca levels
  • Urinalysis
  • 24-hour urine collection (recurrent stones)
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38
Q
  • Flank pain
  • Hematuria
  • Nausea
  • Vomiting

Symptoms

A

Kidney stone passage

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39
Q

Presence of infection + kidney stone in ureter

A

Obstructive pyelonephritis

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40
Q

Obstructive pyelonephritis

Approach to Therapy

A

Urological emergency
* Immediate decompression with ureteral stent or nephrostomy tube
* Antibiotics

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41
Q

Kidney stones

Approach to Therapy

A
  • Ureteroscopy with laser lithotripsy
  • ESWL: endoscopic shock wave lithotripsy
  • PCNL: Tx for large stones.

PCNL: percutaneous nephrolithotomy

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42
Q

Most common benign tumor in men

Epidemiology

A

BPH

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43
Q

BPH

Epidemiology

A
  • Incidence is age-related
    • Age 41-50: 20%
    • Age 51-60: 50%
    • Age >80: 90%
  • 25% of cases are symptomatic at age 55
    • 50% of cases are symptomatic at age 75
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44
Q
  • Obstructive
    • Slow stream
    • Hesitancy
    • Having to push to void
    • Feeling of incomplete voiding
  • Irritative
    • Daytime frequency
    • Urgency
    • Nocturia

Symptoms

A

BPH

45
Q

BPH

Evaluation

A
  1. History
  2. AUA symptom score
  3. Physical
  4. Urinalysis
  5. PSA (select patients)
46
Q

BPH

Physical Exam

A
  • Abdominal exam: rule out bladder distension
  • Digital rectal exam (DRE):
    • Prostate size
    • Nodule / induration
  • Focused neurological exam
    • Mental status
    • Ambulatory status
    • Anal sphincter tone
    • Lower extremity neuromuscular functions
47
Q

BPH

Urinalysis

A
  • Micro hematuria: >3 RBC/hpf; needs full workup
    • Micro hematuria: blood not visible
    • Gross hematuria: blood visible
  • Pyuria: >3 WBC/hpf; needs urine culture
  • Glycosuria: glucose > 25 mg/dL; rule out diabetes
48
Q

Most widely used urologic tumor marker

A

PSA

49
Q

PSA

Markers

A

BPH
* PSA = glycoprotein produced by prostate epithelium
* Primarily secreted in semen or lost in urine
* Significant amounts found in serum only if prostate is traumatized, diseases or enlarged

50
Q

Age-specific PSA levels

A
  • Age <40: < 2.0 ng/mL
  • Age <50: < 2.5 ng/mL
  • Age <60: < 3.0 ng/mL
  • Age <70: < 4.0 ng/mL
51
Q

Indications for Prostate Biopsy

Approach to Diagnosis

A
  • PSA above age-specific level
  • Suspicous finding on DRE
52
Q

BPH

Approach to Therapy

A

Treatment is based on severity of symptoms & presence of complications
* Mild symptoms: conservative treatment
* Moderate symptoms: medical therapy
* Severe symptoms: surgery if medical Tx fails

53
Q

BPH

Medical Therapy

A
  • a-Blocker: dilate prostatic urethra
  • 5-a-Reductase inhibitor: shrink prostate size
54
Q

“-osin”: tamsulosin, terazosin, doxazosin

A

a-Blockers

BPH Medical Therapy

55
Q

“-osin”: tamsulosin, terazosin, doxazosin

A

a-Blockers

BPH Medical Therapy

56
Q

Benefits of a-Blockers

BPH Medical Therapy

A
  • Rapid improvement of urinary flow
  • Reduce BPH symptoms
  • Modest effects on sexual dysfunction
57
Q
  • Fatigue
  • Orthostatic hypotension
  • Retrograde ejaculation
  • Edema
A

a-Blocker side effects

BPH Medical Therapy

58
Q

Indication for 5-a-Reductase inhibitor

BPH Medical Therapy

A

Prostate size: >30 g

59
Q
  • Erectile dysfunction
  • Altered libido
  • Gynecomastia
A

5-a-Reductase inhibitor side effects

BPH Medical Therapy

60
Q
  • Erectile dysfunction
  • Altered libido
  • Gynecomastia
A

5-a-Reductase inhibitor side effects

BPH Medical Therapy

61
Q

BPH

Surgical Therapy

A
  • Transurethral resection of prostate (TURP)
    • Monopolar system
    • Bipolar system
    • Laser
  • Open prostatectomy
    • Rezum
    • Urolift
    • Aquablation
62
Q
  • Urinary incontinence
  • Retrograde ejaculation
  • Bleeding
A

Risks of surgery

BPH Surgical Therapy

63
Q
  • Urinary incontinence
  • Retrograde ejaculation
  • Bleeding
A

Risks of surgery

BPH Surgical Therapy

64
Q
  • Most common cancer in men
  • # 2nd cause of cancer death in men

Epidemiology

A

Prostate cancer

65
Q
  • Urinary incontinence
  • Retrograde ejaculation
  • Bleeding
A

Risks of surgery

BPH Surgical Therapy

66
Q
  • Age
  • Ethnicity: increased risk in African-Americans
  • Family history
    • Father: 2x increased risk
    • Brother: 4x increased risk
    • Father & brother: 8x increased risk
A

Prostate cancer

Risk Factors

67
Q
  • Early-stage: asymptomatic (80%)
  • Locally advanced: urinary symptoms (15%)
  • Metastatic: systemic symptoms (5-10%)

Clinical Presentation

A

Prostate cancer

68
Q
  • Early-stage: asymptomatic (80%)
  • Locally advanced: urinary symptoms (15%)
  • Metastatic: systemic symptoms (5-10%)

Clinical Presentation

A

Prostate cancer

69
Q

Prostate cancer

Approach to Diagnosis

A
  1. PSA
  2. DRE
  3. Multi-parametric prostate MRI
  4. Prostate biopsy
70
Q

PSA

Approach to Diagnosis

A
  • 1/3 of pts w/ PSA >4.0 ng/mL have cancer
  • Over 1/2 of pts w/ PSA >10.0 ng/mL have cancer
71
Q
  • PSA: <10 ng/mL
  • DRE: T1c / T2a
  • Gleason Score: 6
  • Grade Group: 1

Risk Evaluation

A

Low-risk prostate cancer

Low-risk if all conditions are met

72
Q
  • PSA: 10-20 ng/mL
  • DRE: T2b / T2c
  • Gleason Score: 3+4=7; 4+3 =7
  • Grade Group: 2; 3

Risk Evaluation

A

Intermediate-risk prostate cancer

Intermediate-risk if any of conditions is met

73
Q
  • PSA: >20 ng/mL
  • DRE: T3
  • Gleason Score: 8-10
  • Grade Group: 4-5

Risk Evaluation

A

High-risk prostate cancer

High-risk if any of conditions is met

74
Q

Low-risk prostate cancer

Approach to Therapy

A

Surveillance
* Monitor via PSA, DRE
* Repeat biopsy within 1 year

75
Q

Intermediate-risk prostate cancer

Approach to Therapy

A

Unimodal treatment
* Radical prostatectomy
* Radiotherapy +/- hormonal therapy

76
Q

High-risk prostate cancer

Approach to Therapy

A

Multimodal treatment
* Radical prostatectomy +/- radiation
* External beam radiation +/- hormonal therapy

77
Q

Most common cause of scrotal pain in adults

Epidemiology

A

Acute epididymo-orchitis

78
Q

Most common cause of epididymo-orchitis in men age <35

Etiology

A

N. gonorrhoeae / C. trachomatis

79
Q

Most common cause of epididymo-orchitis in men age >35

Etiology

A

E. coli / Pseudomonas

Obstruction (BPH, strictures, etc.) leads to GN UTI

80
Q
  • N. gonorrhoeae / C. trachomatis
  • E. coli / Pseudomonas
  • Autoimmune disease
  • Trauma / Torsion
  • Amiodarone

Etiology

A

Epididymo-orchitis

81
Q
  • Symptoms
    • Scrotal pain
    • Fever
    • Bacteriuria
  • Physical
    • Red, tender scrotum
    • Indurated epididymis on posterior scrotum
    • Reactive hydrocele
    • Scrotal wall erythema

Clinical Presentation

A

Epididymo-orchitis

82
Q

Epididymo-orchitis

Apprioach to Diagnosis

A

Clinical
* Labs: UA (pyuria), urine culture, NAAT

Nuclear amplification test: for chlamydia & gonorrhea

83
Q

Epididymo-orchitis

Approach to Treatment

A
  • Antibiotics
  • NSAIDs
  • Scrotal elevation
84
Q
  • More common in children
  • Usually due to inadquate adherence of testis to tunica vaginalis & rotation of spermatic cord

Epidemiology

A

Testicular torsion

85
Q
  • Symptoms
    • Severe scrotal pain
    • Nausea
    • Vomiting
  • Physical
    • Diffuse tenderness to palpation
    • Negative cremasteric reflex

Clinical Presentation

A

Testicular torsion

86
Q

Testicular torsion

Approach to Diagnosis

A

Scrotal ultrasound (Doppler): absence of blood flow into testicle

87
Q

Testicular torsion

Approach to Therapy

A

Urological emergency
* Testicular detorsion & bilateral orchidopexy

88
Q

Necrotizing fasciitis involving perineum & scrotum

Pathology

A

Fournier’s gangrene

89
Q
  • Male age 60-80 with multiple comorbidities (e.g., diabetes, obesity)
  • Symptoms
    • Severe lower abdominal pain
    • Pain, redness, swelling in scrotum or perineum
  • Physical
    • Bullae
    • Crepitus

Clinical Presentation

A

Fournier’s gangrene

Crepitus = air under scrotum due to gas-forming organism; gas gangrene

90
Q

Fournier’s gangrene

Approach to Diagnosis

A
  • Clinical
  • CT: air along fascial planes
91
Q

Fournier’s gangrene

Approach to Therapy

A

Urological emergency
* Surgical exploration
* Debridement
* Antibiotics

92
Q

Fluid collection within tunica vaginalis

Pathology

A

Hydrocele

93
Q
  • Idiopathic: imbalance in secretion / absorption
  • Acute / Reactive: secondary to acute scrotal pathology

Etiology

A

Hydrocele

Acute scrotal pathology: torsion, infection, trauma, etc.

94
Q
  • Painless, unilateral scrotal mass
  • Scrotal swelling can be transilluminated

Clinical Presentation

A

Hydrocele

95
Q

Approach to Diagnosis

A
  • Physical
  • Scrotal U/S: normal testicle surrounded by fluid

U/S = confirmatory

96
Q

Hydrocele

Approach to Therapy

A
  • Asymptomatic: obseration
  • Symptomatic: hydrocelectomy
97
Q

Dilation of spermatic vein due to impaired drainage; L:R = 9:1

Pathology

A

Varicocele

98
Q

Abnormal dilation / tortuosity of pampiniform plexus secondary to blood flow reversal in gonadal (internal spermatic) vein

Etiology

A

Varicocele

99
Q

Most common treatable cause of male infertility

Epidemiology

A

Varicocele

100
Q
  • Sx: dull congestive pain that resolves with supine position
  • P/E: “bag of worms:

Clinical Presentation

A

Varicocele

101
Q

Varicocele

Approach to Diagnosis

A
  • Clinical: bag of worms, made more prominent with valsalva
  • Scrotal U/S: confirmatory
102
Q

Varicocele

Approach to Therapy

A
  • Most cases: observationq
  • Indications for surgery:
    • Chronic scrotal pain
    • Male factor infertility >1 year
    • Ipsilateral testicular atrophy

Palomo procedure: ligation of spermatic vein at retroperitoneal level

103
Q

Varicocele

Approach to Therapy

A
  • Most cases: observationq
  • Indications for surgery:
    • Chronic scrotal pain
    • Male factor infertility >1 year
    • Ipsilateral testicular atrophy

Palomo procedure: ligation of spermatic vein at retroperitoneal level

104
Q

Most common solid tumor in men between ages 20-35

Epidemiology

A

Testicular tumor

105
Q

Painless solid mass

Clinical Presentation

A

Testicular tumor

106
Q

Testicular tumor

Approach to Diagnosis

A
  • Tumor markers: B-hCG, AFP, LDH
  • Testicular U/S: solid mass

U/S: confirmatory

107
Q

Testicular tumor

Approach to Therapy

A

Initial treatment: radical orchiectomy

108
Q

Testicular tumor

Approach to Therapy

A

Initial treatment: radical orchiectomy

GU / GYN & Renal (23 decks)

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