Clinical: Urology Flashcards by Federico Girardi

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

Asymptomatic bacteriuria

How well did you know this?

Not at all

Perfectly

WBCs in urine,

Pyuria

How well did you know this?

Not at all

Perfectly

UTI with at least 1 complicating factor

Factors: pregnancy, male, immunocompromised

Complicated UTI

How well did you know this?

Not at all

Perfectly

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

Recurrent UTI

How well did you know this?

Not at all

Perfectly

Bacterial persistence despite appropriate treatement

Unresolved UTI

How well did you know this?

Not at all

Perfectly

Immune receptor polymorphisms
Family history

Risk Factors: Genetic

UTI

How well did you know this?

Not at all

Perfectly

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

Risk Factors: Biologic

UTI

How well did you know this?

Not at all

Perfectly

Sexual intercourse
Birth control practices
Antimicrobial use

Risk Factors: Behavioral

UTI

How well did you know this?

Not at all

Perfectly

Most common pathogen in UTI

Etiology

Uropathogenic Escherichia coli (UPEC)

85% of cases

How well did you know this?

Not at all

Perfectly

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

Etiology

Staphylococcus saprophyticus

10-20% of cases

How well did you know this?

Not at all

Perfectly

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

Symptoms

UTI

How well did you know this?

Not at all

Perfectly

Hematuria
Cloudy urine
Malodorous urine
Low-grade fever

Signs

UTI

How well did you know this?

Not at all

Perfectly

UTI

Approach to Diagnosis

History
- Asymptomatic bacteriuria vs. UTI
- Uncomplicated UTI vs. complicated UTI
Physical
Diagnostic studies
- Urinalysis
- Urine microscopy
- Urine culture

How well did you know this?

Not at all

Perfectly

UTI

Approach to Therapy

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

How well did you know this?

Not at all

Perfectly

Asymptomatic bacteriuria

Approach to Therapy

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

How well did you know this?

Not at all

Perfectly

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

Pyelonephritis

How well did you know this?

Not at all

Perfectly

Septic pyelonephritis

Approach to Therapy

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

How well did you know this?

Not at all

Perfectly

Types of urinary incontinence

Urge incontinence
Stress incontinence
Mixed incontinence
Other:
- Overflow: impaired emptying; bladder overflows
- Fistula: continuous leakage of urine

How well did you know this?

Not at all

Perfectly

Urge incontinence
Urgency
Frequency
Nocturia

Symptoms

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

How well did you know this?

Not at all

Perfectly

OAB complex

Approach to Therapy

No treatment (least invasive)
Lifestyle modifications / PTx
Medications
Tibial nerve stimulation / Botox / Interstim
Bladder augmentation (most invasive)

How well did you know this?

Not at all

Perfectly

Normal bladder control

Sympathetic

Norepinephrine activates B3-adrenergic reveptor
Detrusor muscle relaxation –> storage

How well did you know this?

Not at all

Perfectly

Normal bladder control

Parasympathetic

ACh activates M3-muscarinic receptor
Detrusor muscle contraction –> emptying

How well did you know this?

Not at all

Perfectly

MoA: Antimuscarinics

OAB Tx

Antimuscarinics block M3-muscarinic receptor
Inhibits involuntary detrusor muscle contractions
Delays emptying

How well did you know this?

Not at all

Perfectly

MoA: Beta agonists (Betmiga)

OAB Tx

Agonist activates B3-adrenergic receptor
Increases detrusor muscle relaxation
Increases storage capacity, inter-void interval

How well did you know this?

Not at all

Perfectly

* Oxybutynin * Trospium chloride * Darifenacin / Solifenacin * Tolterodine / Fesoterodine

Antimuscarinics | OAB Medical Therapy

* Blurred vision * Dry eyes * Xerostomia * Tachycardia * Dyspepsia * Constipation * CNS: dizziness, somnolence, impaired memory & cognition

Anticholinergic side effects | OAB Medical Therapy

* 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

Stress incontinence (SUI)

* Anatomic defect of suburethral support & loss of urethral coaptation * Age * Parity * Weight * Vaginal delivery * Estrogen statuys * Urethral surgery | Risk Factors

Female SUI

Female SUI | Approach to Therapy

1. No treatment (least invasive) 2. Lifestyle modifications / PTx 3. Pessary Impressa tampon 4. Bulking agent 5. Surgery / Sling (most invasive)

* Radical prostatectomy * Posterior urethral injury (PFUDD) * Transurethral resection of prostate (TURP) * Myelopathy * Congenital conditions | Risk Factors

Male SUI

Most common cause of male SUI | Etiology

Radical prostatectomy

Surgical options for male SUI | Approach to Therapy

* Artificial urinary sphincter (most common) * Transurethral bulking agents * Perineal sling

* Incidence peaks between ages 40-70 * Highest incidence: white men & women * Lowest incidence: black men & asian women | Epidemiology

Kidney stones (nephrolithiasis)

* Hot, dry climates * Risk in US increases N --> S, W --> E * Occupations with exposure to excessive heat * Conditions that promote dehydration | Risk Factors: Environmental

Kidney stones

* Obesity, weight gain, metabolic syndrome * Medications * Surgeries (e.g,. gastric bypass) * Dehydration * Kidney disorders: impaired excretion of acid * T2DM | Risk Factors: Systemic

Kidney stones

Compositions of kidney stones

* Calcium stones * Uric acid stones * Cystine stones * Infection stones * Drug-induced stones

Kidney stones | Approach to Diagnosis

* CT scan (w/o contrast) * Kidney ultrasound * Basic metabolic panel: Cr & Ca levels * Urinalysis * 24-hour urine collection (recurrent stones)

* Flank pain * Hematuria * Nausea * Vomiting | Symptoms

Kidney stone passage

Presence of infection + kidney stone in ureter

Obstructive pyelonephritis

Obstructive pyelonephritis | Approach to Therapy

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

Kidney stones | Approach to Therapy

* Ureteroscopy with laser lithotripsy * ESWL: endoscopic shock wave lithotripsy * PCNL: Tx for large stones. | PCNL: percutaneous nephrolithotomy

Most common benign tumor in men | Epidemiology

BPH

BPH | Epidemiology

* 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

* Obstructive * Slow stream * Hesitancy * Having to push to void * Feeling of incomplete voiding * Irritative * Daytime frequency * Urgency * Nocturia | Symptoms

BPH

BPH | Evaluation

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

BPH | Physical Exam

* 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

BPH | Urinalysis

* 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

Most widely used urologic tumor marker

PSA

PSA | Markers

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

Age-specific PSA levels

* Age <40: < 2.0 ng/mL * Age <50: < 2.5 ng/mL * Age <60: < 3.0 ng/mL * Age <70: < 4.0 ng/mL

Indications for Prostate Biopsy | Approach to Diagnosis

* PSA above age-specific level * Suspicous finding on DRE

BPH | Approach to Therapy

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

BPH | Medical Therapy

* a-Blocker: dilate prostatic urethra * 5-a-Reductase inhibitor: shrink prostate size

"-osin": tamsulosin, terazosin, doxazosin

a-Blockers | BPH Medical Therapy

"-osin": tamsulosin, terazosin, doxazosin

a-Blockers | BPH Medical Therapy

Benefits of a-Blockers | BPH Medical Therapy

* Rapid improvement of urinary flow * Reduce BPH symptoms * Modest effects on sexual dysfunction

* Fatigue * Orthostatic hypotension * Retrograde ejaculation * Edema

a-Blocker side effects | BPH Medical Therapy

Indication for 5-a-Reductase inhibitor | BPH Medical Therapy

Prostate size: >30 g

* Erectile dysfunction * Altered libido * Gynecomastia

5-a-Reductase inhibitor side effects | BPH Medical Therapy

* Erectile dysfunction * Altered libido * Gynecomastia

5-a-Reductase inhibitor side effects | BPH Medical Therapy

BPH | Surgical Therapy

* Transurethral resection of prostate (TURP) * Monopolar system * Bipolar system * Laser * Open prostatectomy * Rezum * Urolift * Aquablation

* Urinary incontinence * Retrograde ejaculation * Bleeding

Risks of surgery | BPH Surgical Therapy

* Urinary incontinence * Retrograde ejaculation * Bleeding

Risks of surgery | BPH Surgical Therapy

* Most common cancer in men * #2nd cause of cancer death in men | Epidemiology

Prostate cancer

* Urinary incontinence * Retrograde ejaculation * Bleeding

Risks of surgery | BPH Surgical Therapy

* Age * Ethnicity: increased risk in African-Americans * Family history * Father: 2x increased risk * Brother: 4x increased risk * Father & brother: 8x increased risk

Prostate cancer | Risk Factors

* Early-stage: asymptomatic (80%) * Locally advanced: urinary symptoms (15%) * Metastatic: systemic symptoms (5-10%) | Clinical Presentation

Prostate cancer

* Early-stage: asymptomatic (80%) * Locally advanced: urinary symptoms (15%) * Metastatic: systemic symptoms (5-10%) | Clinical Presentation

Prostate cancer

Prostate cancer | Approach to Diagnosis

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

PSA | Approach to Diagnosis

* 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

* PSA: <10 ng/mL * DRE: T1c / T2a * Gleason Score: 6 * Grade Group: 1 | Risk Evaluation

Low-risk prostate cancer | Low-risk if all conditions are met

* PSA: 10-20 ng/mL * DRE: T2b / T2c * Gleason Score: 3+4=7; 4+3 =7 * Grade Group: 2; 3 | Risk Evaluation

Intermediate-risk prostate cancer | Intermediate-risk if any of conditions is met

* PSA: >20 ng/mL * DRE: T3 * Gleason Score: 8-10 * Grade Group: 4-5 | Risk Evaluation

High-risk prostate cancer | High-risk if any of conditions is met

Low-risk prostate cancer | Approach to Therapy

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

Intermediate-risk prostate cancer | Approach to Therapy

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

High-risk prostate cancer | Approach to Therapy

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

Most common cause of scrotal pain in adults | Epidemiology

Acute epididymo-orchitis

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

*N. gonorrhoeae* / *C. trachomatis*

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

*E. coli* / *Pseudomonas* | Obstruction (BPH, strictures, etc.) leads to GN UTI

* N. gonorrhoeae / C. trachomatis * E. coli / Pseudomonas * Autoimmune disease * Trauma / Torsion * Amiodarone | Etiology

Epididymo-orchitis

* Symptoms * Scrotal pain * Fever * Bacteriuria * Physical * Red, tender scrotum * Indurated epididymis on posterior scrotum * Reactive hydrocele * Scrotal wall erythema | Clinical Presentation

Epididymo-orchitis

Epididymo-orchitis | Apprioach to Diagnosis

Clinical * Labs: UA (pyuria), urine culture, NAAT | Nuclear amplification test: for chlamydia & gonorrhea

Epididymo-orchitis | Approach to Treatment

* Antibiotics * NSAIDs * Scrotal elevation

* More common in children * Usually due to inadquate adherence of testis to tunica vaginalis & rotation of spermatic cord | Epidemiology

Testicular torsion

* Symptoms * Severe scrotal pain * Nausea * Vomiting * Physical * Diffuse tenderness to palpation * Negative cremasteric reflex | Clinical Presentation

Testicular torsion

Testicular torsion | Approach to Diagnosis

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

Testicular torsion | Approach to Therapy

Urological emergency * Testicular detorsion & bilateral orchidopexy

Necrotizing fasciitis involving perineum & scrotum | Pathology

Fournier's gangrene

* 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

Fournier's gangrene | Crepitus = air under scrotum due to gas-forming organism; gas gangrene

Fournier's gangrene | Approach to Diagnosis

* Clinical * CT: air along fascial planes

Fournier's gangrene | Approach to Therapy

Urological emergency * Surgical exploration * Debridement * Antibiotics

Fluid collection within tunica vaginalis | Pathology

Hydrocele

* Idiopathic: imbalance in secretion / absorption * Acute / Reactive: secondary to acute scrotal pathology | Etiology

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

* Painless, unilateral scrotal mass * Scrotal swelling can be transilluminated | Clinical Presentation

Hydrocele

Approach to Diagnosis

* Physical * Scrotal U/S: normal testicle surrounded by fluid | U/S = confirmatory

Hydrocele | Approach to Therapy

* Asymptomatic: obseration * Symptomatic: hydrocelectomy

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

Varicocele

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

Varicocele

Most common treatable cause of male infertility | Epidemiology

Varicocele

* Sx: dull congestive pain that resolves with supine position * P/E: "bag of worms: | Clinical Presentation

Varicocele

Varicocele | Approach to Diagnosis

* Clinical: bag of worms, made more prominent with valsalva * Scrotal U/S: confirmatory

Varicocele | Approach to Therapy

* 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

Varicocele | Approach to Therapy

Most common solid tumor in men between ages 20-35 | Epidemiology

Testicular tumor

Painless solid mass | Clinical Presentation

Testicular tumor

Testicular tumor | Approach to Diagnosis

* Tumor markers: B-hCG, AFP, LDH * Testicular U/S: solid mass | U/S: confirmatory

Testicular tumor | Approach to Therapy

Initial treatment: radical orchiectomy

Testicular tumor | Approach to Therapy

Initial treatment: radical orchiectomy

Clinical: Urology Flashcards

(108 cards)