Genitourinary Flashcards
(161 cards)
1
Q
Define Bacterial Vaginosis:
A
a bacterial imbalance caused by the overgrowth of anaerobic bacteria.
2
Q
Causative Organisms of BV:
A
- Gardenella Vaginalis
- Prevotella Species
- Mycoplasma hominis
- Mobiluncus species
3
Q
What are the Risk F. of developing BV?
A
- Hygiene
- douching
- menstruation
- copper coil
- sexually active
- hormonal changes
- lack of consistent condom use
- smoking !!!
4
Q
What are the Sx of BV?
A
- increased vaginal discharge
- grey/ white watery discharge
- fishy odour
- less common: itchy/ irritation
5
Q
What are the Ix of BV?
A
AMSEL Criteria >=3:
* pH >4.5
* homogenous grey/ milky discharge
* +ive whiff test (add 10% KOH= fishy odour)
* clue cell on wet mount- gram stain
6
Q
What is the Management of BV?
A
- Metronidazole 400mg BD 5-7 days
OR
- Metronidazole 1 applicator OD for 5 days (at night)
7
Q
Define Chlamydia:
A
STI caused by obligate intracellular bacterium Chlamydia Trachomatis
8
Q
What are the risk f of Chlamydia?
A
Age <25
9
Q
What are the symptoms in men who have Chlamydia?
A
Penile/ urethral Infection:
* dysuria
* discharge
* discomfort
* painful ejaculation,
* +/- testicle pain/ swelling
Pharyngeal Infection
* sore throat
* exudates
* hypertrophy
* erythema
10
Q
What are the symptoms in women who have Chlamydia?
A
Urethral/ Cervical Infection:
* abnormal vaginal discharge
* mucopurulent cervical discharge
* dysuria
* pelvic pain
* deep dysparenunia
* post coital/ IM bleeding
* Cervical tenderness
* inflamed cervix
Anorectal Infection:
* discomfort
* discharge
* tender
11
Q
What are the Ix for Chlamydia?
A
- NAATS- cervical/vaginal swab; urethral swab in men
- Chlamydia screening
12
Q
What is the management of Chlamydia?
A
- Doxycycline 100mg BD 7/7
- Azithromycin if pregnant/ breastfeeding
Test of cure 3-6 months after treatment.
13
Q
What are the Complications of untreated Chlamydia?
A
- PID
- Epidydimo-orchitis
- sexually acquired reactive arthritis
- conjunctivitis and pneumonia in neonates
- increased risk of acquiring/ transmitting HIV
- lymphogranuloma venereum (LGV)
14
Q
Define Genital Herpes:
A
An infectious disease caused by HSV-1(oral and genital and ocular herpes); HSV-2 (anogenital sx)
15
Q
What are the risk factors of acquiring Genital Herpes?
A
- 15-24 years old
- female
- Hx of STIs
- UV light/ trauma/ stress can re-activate latent HSV
16
Q
What is the symptoms of Primary Herpes?
A
- Tingling sensation or painful before lesion appears
- clustered painful erythematous vesicles
- fever, malaise, headache
- inguinal lymphadenopathy
- urine retention
- dysuria
- discharge
- neuropathic pain
- lasting up to 3 weeks
- crusting and then healing of lesions
17
Q
What are the symptoms of recurrent Herpes?
A
- clustered painful erythematous vesicles within the same dermatome as primary outbreak.
- potential prodromal tingling/ burning up to 48 hours prior to the vesicles appearing
- less severe than primary infection
- lasting 6-12 days???
18
Q
What is the Ix of Genital Herpes?
A
- rupture the vesicles and the swab NAATs 1st line
- HSV DNA PCR = CONFIRMS
- Serology: HSV-1 IgG; HSV-2 IgG
19
Q
What is the Management of Genital herpes?
A
- oral antivirals to be started within 5 days of symptoms
- Aciclovir 400mg TDS for 5 days OR 200mg 5x daily for 5 days.
- Famciclovir 250 mg TDS for 5 days
- Valacyclovir 500mg BD for 5 days
20
Q
Define Gonorrhea:
A
STI caused by gram negative diplococci Neisseria Gonnorhoea
21
Q
What are the Risk F of Gonorrhoea?
A
- 15-24 yrs
- MSM
22
Q
What are the symptoms of Gonorrhoea in men?
A
Penile/ urethral infection
* discharge
* dysuria
* +/- testicular swelling
Anorectal Infetion:
* anal discharge
* Perianal pain
* tenesmus
* rectal bleeding
Pharyngeal Infection
* sore throat
* tonsillar exudate
* erythema
* hypertrophy
23
Q
What are the symptoms of Gonorrhoea in women?
A
Cervical Infection:
* sx within 10 days of exposure
* discharge- mucopurulent
* dysuria
* IMB
* dysparenunia
* lower abdominal pain
* friable cervix
* +/- cervical motion
* tenderness
* Bartholin’s gland
24
Q
What are the Ix of Gonorrhoea?
A
- Vaginal swab/ penile/ endocervical
- first catch urine
- rectal/ pharyngeal swab
- NAAT
- culture
- Polymorphonuclear Leukocytes- microscopy
25
What is the management of Gonorrhoea?
1st Ceftriaxone 1g IM (unknown sensitivity)
Ciprofloxacin 500mg (known sesitivity)
Test of cure at 1 week
Gonorrhoea + PID = IM Ceftriaxone + doxycycline + metronidazole
26
What are the complications of untreated Gonorrhoea?
* infertility
* PID
* epididymo-orchitis
* Prostatitis
* reactive arthritis - fever, rashes, skin sores, joint pain, swelling, stiffness
* perihepatic abscess
* increased risk if HIV susceptibility
* Miscarriage/ foetal loss/ congenital infections
27
Define Trichomoniasis:
STI caused by flagellated protozoan Trichomanas Vaginalis.
28
What are the sx in men with Trichomoniasis?
* urethritis
* asymptomatic
29
What are the sx in women with Trichomoniasis?
* offensive frothy yellow/ green discharge
* dysparenunia
* soreness
* itchy
* dysuria
* abdominal pain
* strawberry cervix
30
What are the Ix of Trichomoniasis?
* MC&S/ FCU
* vaginal swab- pH
* gram-staining
31
What is the Tx for trichomoniasis infection?
1st ORAL metronidazole 400-500 mg BD for 5-7 days OR 2g single dose
contact tracing
no sex for 1 week
screen for other STIs
32
Define Primary HIV
* this is the initial exposure to HIV-1/ HIV-2 whereby there is a surge in viral exposure
33
What are the sx of HIV infection?
* mild flu-like illness 2-6 weeks post-exposure
* lymphadenopathy
* maculopapular rash
* apthous ulcers
* myalgia/ arthralgia/ fatigue
* sx onset within 3 weeks of exposure, lasting more than 2 weeks
* CNS involvement
* progress to AIDs
34
What are the Ix for HIV?
* Serum HIV ELIZA = serum HIV antibody test
* HIV viral load (RNA PCR)
* CD4 count
* Serum combined HIV antibody and p24 antigen test (after 4 weeks from infection)
* rapid tests
35
Whom should a HIV screening be done in?
Patients with more than 1 of the following:
* severe, prolonged, recurrant, unexplained common sx/ infections
* persistant lymphadenopathy
* immunosupression
* glandular fever like illness
* unintentional weight loss >10kg
36
What is the Tx of HIV?
* systemically unwell- hospital admission
* cART - combination of 3 lifelong
* contact tracing
Monitoring:
* serum CD4 count HIV RNA PCR
* undetectable= untransmissable: when viral load >200 ??
37
What are the indications for HIV prophylaxis?
Pre- or post- exposure prophylaxis can be offered to those who may be/have been exposed to reduce transmission risk.
???
38
Who is HIV routinely tested in?
* STI
* MSM
* hx IVDU
* patients for HIV prevalent countries
* blood donors
* dialysis
* organ transplant donors
* suspected Tb, Hep B/C, lymphoma
39
What are the longstanding HIV sx?
HIV may be asymptomatic during the latent phase, but progressive immune dysfunction can give rise to the following:
* Constitutional symptoms
* Resp conditions: pneumocystis pneumonia (causes reduced SpO2 on exertion), TB/ recurrent resp infections
* Neurological sx of cryptococcal meningitis, cerebral toxoplasmosis, cerebral lymphoma, CMV retinitis
* Malignancies: lymphoma, Kaposi's sarcoma (dark purple/brown skin lesions), cervical cancer
* Skin conditions: fungal skin & nail, viral and bacterial infections
* Oral conditions: candidiasis, ulcers, oral hairy leukoplakia
* GI: oesophageal candidiasis, diarrhoea, hepatitis infections
* Genital: candida, genital herpes & warts
* Unexplained FBC abnormalities
40
What are the complications of HIV infection?
* Pneumocystis pneumonia
* Candidiasis
* Cytomegalovirus- visual changes
* Cryptococcal meningitis
* Cerebral toxoplasmosis
* Mycobacterial disease
* HIV-associated malignancies
Kaposi's sarcoma
* Lymphoma
* Cervical cancer
41
Pneumocystis pneumonia
* Fungal infection caused by Pneumocystis Jirovecii and affects immunocompromised people
* Sx: subacute onset of fever, dry cough and exertional breathlessness. Patients desaturate on walking short distances, and chest X-ray may be normal or show bilateral infiltrates.
* Definitive diagnosis requires a sputum or broncho-alveolar lavage sample with silver staining.
* Management is with co-trimoxazole, with steroids for moderate-severe cases, and supportive care. Patients may be offered prophylactic co-trimoxazole if they have very low CD4 counts or have had a previous pneumocystis pneumonia.
42
Cryptococcal meningitis
* Fungal infection
* Sx: subacute meningitis- headache, fever, altered mental status and cranial nerve deficits.
* Diagnosis is with CSF analysis cultured and stained with India ink.
* Tx = induction regime with amphotericin B alongside supportive treatment, followed by a maintenance regime of fluconazole.
43
Cerebral toxoplasmosis
* This occurs due to reactivation of a toxoplasmosis infection. PARASITE
* Sx: altered mental state, headache, seizures, focal neurology and fevers, behavioural changes
* MRI = diagnosis and will show multiple ring enhancing lesions of toxoplasma abscesses in the basal ganglia, frontal, parietal lobes.
* CSF immunofluorescence staining to confirm?
* Tx is with pyrimethamine, sulphadiazine and folinic acid for 6 weeks followed by a maintenance regime.
44
HIV-associated malignancies
Kaposi's sarcoma:
* Caused by human herpes virus 8 (HHV-8).
* Sx: multiple lesions on the skin, mucous membranes and internal organs, which may be purple, red or brown.
* It is often recognised clinically, though definitive diagnosis requires biopsy.
* Tx - combination antiretroviral therapy +/- systemic anticancer therapy may be needed.
45
Define AIDs defining illness:
* CD4 count less than 200
* advanced stage HIV
46
What are the sx of AIDs:
GI sx:
* dysphagia/ odynophagia in oseophageal candidiasis
Resp Sx:
* PCP Pneumonia sx
Neuro Sx:
* encephalopathy, toxaplasmosis, leukoencephalopathy
Skin lesions:
* kaposi's sarcoma/ lymphoma
Visual:
* CMV retinitis
47
Define Syphillis:
An STI caused by the spirochete bacterium Treponema Pallidum.
48
How is Syphilis Transmitted?
* direct contact with sores during any sex
* mother to child known as congenital syphilis.
49
What are the sx of Primary Syphilis?
* chancre- single painless lesion (ulcer)
* clean base, sharp border
* develops at site of inoculation
* heals spontaneously in 3-10 weeks
50
What are the sx of Secondary Syhpilis?
* sx appear 4-12 weeks after chancre.
* non-pruitic maculopapular rash (palm, soles, face)
& condyloma late- gray/white wart like lesions (perianal, vulva, breast, axillae)
* snail tract lesions- patchy oral mucosal lesions
* alopecia
* lymphadenopathy
* malaise, fever
* hepatitis
* glomerulonephritis
* neuro complications
51
What are the sx of Tertiary Syphilis?
* 10-30 years afte rprimary infection
* Gummatous syphilis: granulomatous lesions with nectrotic centre (shin, liver, brain, heart, bone)
* CVS syphilis: aortic regurg, aneurysm, HF
* neuro syphilis: parasteastosis, absent reflex, absent joint position/ vibration sensation, personality changes
52
What are the Ix of Syphilis:
Refer to GUM clinic
Serological testing:
* Non-treponemal test: RPR/VDRL
* treponemal test: EIA/CLIA CONFIRM which detects IgG and IgM
* dark field microscopy via swab from chancre
* CSF via lumbar puncture
53
What is the Tx of Syphilis?
* 1st IM Benzathine Benzylpeneciliin
* 3 doses BBIM for tertiary if no neurological involvement
* Neurosyphilis= IV Benzylpenecillin 10-14 days
* allergies= doxycycline/ tetracycline
54
What are the sx of Genital Warts?
* painless lump
* hard/ soft
* skin/ grey coloured growth
55
Ix of Genital warts:
* biopsy
56
What is the Tx of Genital Warts?
* Podophllotoxin (cream) 1.5%
- 5% iniquimod
- 10% sincatechins ointment
* cryotherapy (freezing warts)
* trichloroacetic acid (burn)
there is a high relapse rate
57
Define Genital Candidiasis:
Thrush- inflammation of teh vagina and vulva due to the overgrowth of the yeast fungus 'candida albicans'
58
What are the risk f of developing Genital Candidiasis:
* abx use
* DM
* immunosuppression
* pregnant
59
What are the sx in women of Genital Candidiasis?
* non-offensive white cottage cheese like discharge
* itchy
* dysuria
* soreness
* superficial dysparenunia
* tender
* burning
* red
* fissuring
* swelling
60
What are the sx of genital Candidiasis if Men?
* sore
* red
* itchy
* dry, dull, red galzed plaques and papules
61
What are the Ix of Genital Candidiasis?
* Microscopy = blastospores, pseudohyphae, neutrophils
* Culture if reocurring to identify the species.
62
What is the management of Genital Cadidiasis:
* anti-fungals
* ORAL- fluconazole 150 mg single dose
* INTRAVAGINAL- clotrimazole 500 mg single dose OR 200mg OD for 3 days
* VULVAL cream: Clotrimazole 1% / 2% TDS OR 5g/10% as singe dose
AVOID ORAL TX IN PREGNANT/ BREASTFEEDING WOMEN!!!!!!!
63
How to manage Recurring Genital Candidiasis:
* Recurrent: Fluconazole oral 150mg every 72 hrs for 3 doses max THEN maintain once weekly for 6 months.
64
Define Epididymo-orchitis:
Inflammation of the epididymus and testicle.
65
What are the causes/ risk factors of Epididymo-orchitis?
STI
* Chlamydia which is most common cause in <35 years
* Gonorrhoea
UTI
* common cause in >35 due to E.coli
Rare:
* mumps
* TB
RISK F:
* sexually active
* 19-35
* UTI complciation
66
What are the sx of Epididymo-orchitis?
* testicular swelling
* tender testicle
* fever
* dysuria
* urethral discharge
* Pehn's +ive = when lifting up the testicle relieves the pain
* cremasteric reflex intact
67
What are the Ix of Epididymo-orchitis?
* urinanalysis
* urine culture
* STI screening- NAATs
* Urethral swab with gram stain
* Scrotal USS
68
What is the Tx of Epididymo-orchitis?
Analgesia
Scrotal elevation and rest
Abx:
* STI
- IM 1g ceftriaxone + 100mg doxy BD 10-14
- Chlamydia: doxy 100mg BD 10-14 days
* UTI
- E.coli: levofloxacin 10 days/ ofloxacin 14 days
69
Define Phimosis:
When the foreskin is too tight to be retracted over the glans of penis.
70
What are the causes and risk factors of Phimosis?
Anything that lead to scarring and adhesions.
* STI
* Eczema/ psoriasis
* Lichen planus/ lichen sclerosis
* Balanitis
RISK F
* improper foreskin care
* older
71
What are the sx of Phimosis?
* unable to retract forekin
* interfere with urination/ sexual function
72
What are the Ix of Phimosis?
* clinical
* USS
* uroflowmetry
73
What are the complications of Phimosis?
* urinary retention
* penile ischaemia
74
What is the management of Phimosis?
Topical steroid creams to:
* reduce inflammation
* encourage foreskin stretching
Circumcision
75
Define Paraphimosis:
Unable to replace foreskin after retracting which in turn can lead to oedema and ischaemia of the glans penis.
76
What are the risk factors for developing Paraphimosis?
* catheter
* improper foreskin care
* elderly
77
What are the sx of Paraphimosis?
* swollen glans
* painful glans
* tight band of foreskin behind glans
78
What are the complications of Paraphimosis?
* ischaemia
79
What is the Ix of Paraphimosis?
* physical exam
* US/ uroflowmetry
80
What are the Tx of Paraphimosis?
* Reduce the oedema to glans by applying pressure
* Dorsal slit to cut foreskin and relieve constriction
81
Define Priapism:
Prolonged, typically painful erection lasting for more than 2 hours without sexual stimulus.
999
82
What are the two types of Priapism and its causes?
Ischaemic
* common
* lack of venous drainage from corpora cavernosa
* caused by hamatological disorders
Non-ischaemic:
* due to unregulated blood flow in
* trauma
83
What are the Risk F. for developing Priapism?
Most common: 5-10 years and 20-50 years
SCD, leukaemia
ED meds ??
84
What are the sx of Priapism?
* persistent erection lasting > 2 hours beyond sexual activity
* erect withous sexual stimlant
* +/- pain
85
What is the Ix of Priapism?
Labs
* FBC
* reticulocyte count
* blood gas analysis of aspirated cavernous blood
Imaging
* arteriogram- fistular
86
What is the Tx of Priapism?
1st line- apiration of blood in corpus cavernosa and irrigation with normal saline
2nd line- intracavernosal injection of alpha agonists e.g., adrenaline
3rd line- surgical shunt
87
Define Hydrocele:
The accumulation of serous fluid in sac-like cavity around testicle/
88
What are the two types of Hydrocele and its causes?
Primary Hydrocele (congenital)
* caused if the processus vaginalis doesn't obliterate after the descent of testes into the scrotum
Secondary Hydrocele
* due to excessive fluid produced in tunica vaginalis
89
What are the risk factors of hydrocele?
* newborn
* trauma
* infection
* testicular cancer
90
What are the sx of Hydrocele?
* enlarged scrotum
* scrotal swelling
* discomfort
* pain/ redness
91
What are the Ix of Hydrocele/
USS
Additional tests may be required if infection or malignancy is suspected.
This may include bloods for testicular tumour markers (i.e. AFP, LDH and HCG)
92
What is the Tx of Hydrocele?
The initial approach to managing primary hydroceles is observation as most will spontaneously resolve by 12 months of age.
If the hydrocele persists past 1 year or causes discomfort, refer to a paediatric surgeon. - Surgical correction options may include Cord’s repair or Jaboulay’s procedure - Surgery is indicated due to the significantly increased risk of an indirect inguinal hernia.
Secondary hydroceles are usually managed conservatively and self-resolve.
93
Define Varicocele:
Dilated veins of pampiniform plexus. usually affecting left and is associated with subfertility.
94
What are the sx of Varicocele?
* bag of worms
* ache
* non transilluminate swelling
* subfertility
95
What is the Tx of Varicocele:
Watchful waiting: For asymptomatic varicoceles or those not causing fertility problems.
Embolization: This minimally invasive procedure involves blocking the blood flow to the enlarged veins.
Surgery: Varicocele repair surgery can be performed through open surgery, laparoscopically, or with robotic assistance
96
What is the Ix for Varicocele?
Physical examination: Varicoceles can often be identified by palpation of the scrotum, especially while standing or during a Valsalva maneuver.
Doppler ultrasound: This imaging modality can identify the enlarged veins and assess for retrograde blood flow, confirming the diagnosis.
Hormonal assays: In cases where infertility is suspected, evaluation of testosterone, FSH, LH, and semen analysis can be useful.
97
Define Testicular Torsion:
999
Torsion occurs when an excessively mobile testis rotates on its cord structures impairing venous return which leads to venous congestion and oedema.
98
Risk F of Testicular Torsion:
* The neonatal period and at age 13-16 years
* Previous testicular torsion (suspect if history of episodes of testicular pain that self-resolved)
* Family history of testicular torsion
* Undescended testes
* Testicular tumours
* May be precipitated by trauma or exercise
This is often because of a BELL CLAPPER deformity where the testes are not attached properly to the tunica vaginalis and so they are more mobile and more liable to twist.
99
Sx of Testicular Torsion:
* Sudden onset severe pain in one testicle
* Nausea and vomiting due to pain
* Abdominal or groin pain
100
Signs of Testicular Torsion:
* Unilateral tender testicle
* Testicle may appear swollen
* The testicle may be high riding in the scrotum or lying in the horizontal plane
* Unilateral loss of cremasteric reflex (stroking the inner thigh should cause the ipsilateral testicle to elevate)
* Persistent pain despite elevation of the testicle (negative Prehn's sign)
101
What are the complications of Testicular Torsion?
* Testicular atrophy, ischaemia and necrosis
* Impaired fertility
* Chronic intermittent torsion may cause segmental ischaemia of the testicle
* Without orchidopexy of the contralateral testicle, there is a 40% risk of torsion on the other side
102
What is the Ix of Testicular Torsion:
* Clinical: all suspected cases require urgent surgical management with scrotal exploration.
* Investigations may be required in preparation for surgery, e.g. baseline blood tests including group and saves and clotting screen, ECG.
* Urinalysis may also be done to investigate for a urinary tract infection (that may precipitate epididymo-orchitis) if this is suspected.
* USS !!
103
Tx of Testicular Torsion:
- Scrotal exploration ASAP to untwist testicle (MUST be done within 6 hours)
- If testes not viable, then orchidectomy is performed.
Urgent surgical exploration is crucial to confirm the diagnosis and to attempt to salvage the testicle
If the testicle is viable, bilateral orchidopexy should be carried out
If it is not viable, it should be removed (an orchidectomy) - a prosthesis may be implanted at a later date for cosmetic reasons
Orchidopexy of the contralateral testicle should always be carried out to reduce the risk of recurrence on the other side
104
Define Fournier's Gangrene:
This is a type of necrotising fasciitis that affects the perineum and external genitalia caused by both anaerobic/aerobic bacteria.
105
Sx of Fournier's Gangrene:
- Localised infection adjacent to a portal of entry
- Pruritus and discomfort of external genitalia
- Fever, lethargy present for 2-7 days prior to gangrene.
- Pain and tenderness in groin
- Erythema
- Subcutaneous crepitation, feculent odour
- Nerve necrosis
106
Ix of Fournier's Gangrene:
- FBC, U & Es, ABG
- Blood sugar
- Blood and urine culture
- INR
- Imaging-CT
- AXR
107
Tx of Fournier's Gangrene:
- Triple therapy abx (clindamycin, ciprofloxacin, metronidazole)
- surgical
108
What are the causes of Fournier's Gangrene?
Infectious Sources:
* Perianal infections: e.g. perirectal abscess, anal fissure, hemorrhoids
* Urogenital infections: e.g. urethral strictures, urinary tract infections, infected catheterization, prostatitis
* Skin trauma: e.g. insect bites, burns, abrasions, surgical wounds
* Penile or scrotal trauma or infections
Organisms:
* Gram-negative rods: Escherichia coli, Klebsiella, Proteus
* Anaerobes: Bacteroides, Clostridium species
* Gram-positive cocci: Streptococcus, Staphylococcus aureus (including MRSA)
109
What are the Risk F of Fournier's Gangrene?
* Diabetes mellitus (most common)
* Immunosuppression: HIV, cancer, corticosteroid use
* Chronic alcoholism
* Obesity
* Poor hygiene
* Malnutrition
* Peripheral vascular disease
110
Define Penile Fracture:
Tear in the tunica albuginea of the corpus cavernosum leading to immediate penile and rapid detumescence.
111
Sx of penile fracture
Audible cracking/ popping sound
112
Tx of Penile Fracture:
- Urgent referral
- Distal circumferential penile incision following be a de-gloving of the penis fix the tear in the tunica albuginea
113
Define BPH:
BPH refers to the non-cancerous enlargement of the prostate gland, particularly the transition zone, leading to the compression of the urethra and subsequent lower urinary tract symptoms (LUTS).
114
Pathophysiology of BPH:
BPH is characterised by the nodular overgrowth of prostatic tissue, predominantly in the transition zone. This growth impinges on the prostatic urethra, causing dynamic and static obstruction, leading to urinary symptoms.
115
What are the sx of BPH?
Hesitancy
Weak stream
Frequency
Urgency
Nocturia
Sensation of incomplete emptying
116
What is the 2ww referral criteria for Prostate Cancer?
Refer for prostate cancer if their prostate feels malignant on DRE.
Consider a PSA and DRE to assess for prostate cancer in men with:
* Any LUTs sx: nocturia, urinary frequency, hesitancy, urgency or retention, or
* Erectile dysfunction, or
* Visible haematuria.
* If their PSA levels are above the age-specific reference range.
117
What the Ix for BPH?
International Prostate Symptom Score (IPSS): to assess the severity of LUTS.
DRE
Prostate-Specific Antigen (PSA) Test
USS
118
What is the management of BPH?
Watchful Waiting: For mild sx, particularly in older individuals.
Lifestyle Modifications: Fluid restriction, avoidance of caffeine and alcohol, and timed voiding.
Medical Therapy:
* Alpha-blockers: tamsulosin and 5-alpha reductase inhibitors;finasteride.
* If there is an IPSS score of 8 or more = alpha blocker.
* If the man has an enlarged prostate and is considered to be at high risk of progression, offer a 5-alpha reductase inhibitor
* If the man has bothersome moderate-to-severe voiding symptoms and prostatic enlargement, consider offering a combination of an alpha-blocker and a 5-alpha reductase inhibitor.
Minimally Invasive Therapies:
Procedures like transurethral resection of the prostate (TURP) or laser prostatectomy for moderate to severe symptoms.
Surgical Intervention
119
The most common type of Prostate cancer:
Adenocarcinomas
120
Risk factors for developing Prostate Cancer?
* African ethnicity
* BRCA gene mutations
* Family history of prostate cancer
* Age (risk increases with advancing age)
* Obesity
* Smoking
* Diet rich in animal fats and dairy products
121
What are the sx of Prostate Cancer?
* urinary sx
* poor urine stream
* blood in semen
* pelvic siconfort
* bone pain
* erectile dysfunction
122
What are the Ix of Prostate Cancer?
Initial:
* DRE
* urine dip
PSA blood test
GOLD= MRI
CT if metastases
Gleason grading
123
What can cause false ++ in a PSA?
* active UTI/ within 6 weeks
* ejaculation < 48 hrs
* vigorous exercise <48 hrs
* Biopsy <6 weeks
124
What are the PSA ranges deemed as ++ for certain age categories?
* <40 yrs and >79 yrs to use clinical judgement
* 40-49 yrs = >2.5 mg/L
* 50-59 yrs = >3.5 mg/L
* 60-69 yrs = >4.5 mg/L
* 70-79 yrs = >6.5 mg/L
125
What is the most common type of Bladder Cancer?
Transitional cell carcinomas
126
What are the risk factors for developing different types of Bladder Cancer?
Transitional call carcinoma:
* Smoking
* Use of cyclophosphamide
* Exposure to aromatic anions
Squamous cell carcinoma
* schistosomiasis
* long term catheter
Adenocarcinoma
* local bowel cancers
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What are the sx of Bladder Cancer?
* painless visible haematuria
* recurrent UTIs
* Hydronephrosis
* Infiltration of the Obturator nerve = neuropathic pain on medial thigh
* B sx
128
What are the Ix for Bladder cancer?
* urine dip
* CT urogram
* flexible cystoscopy = GOLD STANDARD
* Biopsy
* CT/ MRI
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What is the tx for Bladder Cancer?
- Cystectomy is gold standard
- Non-muscle invasive tumour: TURBT, BCG, Mitomycin
- Muscle invasive tumour: TURBT cannot remove the whole tumour so radiotherapy or cystectomy
- Robotics
130
What is the 2ww referral criteria for Bladder Cancer?
If they are aged 45 years and over and have:
* Unexplained visible haematuria without UTI, or
* Visible haematuria that persists or recurs after successful treatment of UTI
If they are aged 60 years and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
131
What is the most common type of Testicular Cancer?
Germ cell
132
What are the risk f of Testicular cancer?
* 20-40 yrs age
* caucasian
* cryptorchidism (undescended testes)
* HIV
* mumps orchitis infection
* Klinefelter's
133
What are the sx of Testicular cancer?
* painless lump in scrotum
* germ cell tumors
* gynacomastia
134
What are the Ix for Testicular Cancer?
1st line = Scrotal USS
serum tumor markers
CT TAP
135
What is the 2ww referral criteria for Testicular Cancer?
Non painful enlargement or change in shape/ texture of testes.
136
What are the sx of Renal Cancer?
* Haematuria
* Loin pain
* Flank mass
* Metastatic disease
* A left-sided varicocele
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2ww referral criteria for Renal Cancer:
2 week wait referral criteria
If they are aged 45 years and over and have:
* Unexplained visible haematuria without urinary tract infection, or
* Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
138
What are the Ix of Renal Cancer:
* USS
* CT of kidneys
* MRI Imaging
* IV Urogram
* Flex cystoscopy (to rule out bladder cancer)
* CXR - to look for cannonball secondaries in the lung
139
Define Pyelonephritis?
Pyelonephritis refers to an infection of the renal pelvis and parenchyma which is typically caused by bacteria.
140
What are the risk factors of Pyelonephritis?
* Women
* Pregnancy
* Immunosuppression
* Structural abnormalities affecting urinary flow (e.g. neuropathic bladder, obstruction due to BPH)
* Structural renal abnormalities such as polycystic kidney disease or horseshoe kidney
* Vescio-ureteric reflux
* Catheterisation or other indwelling foreign bodies (e.g. ureteric stents, nephrostomies)
* Renal stones
* Extremes of age (infancy and elderly patients)
141
What are the causes of Pyelonephritis?
* E.coli
* Klebsiella species, Proteus mirabilis, Pseudomonas or Enterobacter species
* Gram-positive causes are rarer but include Enterococcus faecalis and Staphylococcus aureus
* Immunocompromised patients may rarely develop pyelonephritis secondary to fungi (e.g. Candida albicans, aspergillosis)
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What are the sx of Pyelonephritis?
Fevers
Flank pain (usually unilateral)
Nausea and vomiting
Myalgia
Lethargy
Anorexia
Lower urinary tract symptoms:
* Urinary frequency
* Urgency
* Dysuria
143
What are the signs of Pyelonephritis?
* Renal angle tenderness
* Haematuria
* Suprapubic tenderness (without guarding)
* Rigors
* Sweating
* Signs of dehydration (e.g. dry mucous membranes, tachycardia, cool peripheries)
* Signs of sepsis (e.g. hypotension, tachypnoea, impaired level of consciousness)
144
What are the complications of Pyelonephritis?
* Sepsis
* Renal scarring
* Emphysematous pyelonephritis
* Renal abscess
* Perinephric abscesses
These are all emergencies !!
145
What are the Ix of Pyelonephritis:
Bedside:
* Urine dipstick
* Urine culture
* Pregnancy test
* Blood gas
Bloods:
* FBC- raised white cell count due to infection
* U&Es to assess renal function and look for AKI
* CRP will be raised due to infection
* Coagulation screen
* Blood cultures to look for bacteraemia
Imaging:
* Renal USS looking for obstruction (which would be a urological emergency)
* Non-contrast CT KUB (kidneys, ureters and bladder) to further characterise obstruction or in patients not improving with treatment
146
What is the Tx of Pyelonephritis?
Conservative:
* Uncomplicated pyelonephritis in low-risk patients = community with oral antibiotics
Refer a patient to hospital include:
* Signs of sepsis
* Significant dehydration
* Unable to take oral fluids and medications due to vomiting
* Pregnancy
* High risk of complications due to immunosuppression or underlying urinary tract disease
* Renal impairment (either acute or chronic)
* Recurrent pyelonephritis
* Not responding to oral antibiotics
Acutely unwell patients may require catheterisation for urine output monitoring, as well as intensive care review if there are signs of organ failure
Medical: All patients require antibiotic treatment.
* Oral cephalexin for 7-10 days- 1st line community
* IV: ceftriaxone, ciprofloxacin, co-amoxiclav
* Oral trimethoprim, ciprofloxacin if penicillin allergy
* IV fluids may be required for patients who are dehydrated and/or hypotensive, or who are not able to keep down oral fluids
* analgesia and antiemetics
147
The risk factors of developing Urinary Stones:
* Men
* 35-45 yrs
* Obesity
* Chronic dehydration
* High ambient temperatures
* Diet high in oxalate, urate, sodium and animal protein
* White ethnicity
* Family history of stone formation
* Structurally abnormal renal tract (e.g. vesicoureteric reflux, horseshoe kidney)
* Comorbidities including diabetes, gout, hyperparathyroidism, Crohn's disease, cystinuria
148
What are the sx of Urinary Stones:
*Acute severe flank pain
* Nausea, vomiting
* Urinary frequency/ urgency
* Haematuria
* Testicular pain (loin to groin)
* Asymptomatic
* Renal or ureteric colic- It may also radiate to the scrotum, labia or anterior thigh
* Renal angle tenderness
* Fever, diaphoresis, rigors and hypotension may be present if there is concurrent infection
* Dysuria
149
What are the Ix of Urinary stones?
Bedside:
* Urinalysis
* Urine MC&S
Bloods:
* FBC, U&Es, CRP
* Bone profile looking for hypercalcaemia
* Serum urate if raised may increase suspicion of uric acid stones
* VBG- acidosis and low bicarbonate if there is underlying renal tubular acidosis
* Coagulation screen
* Blood cultures in patients with suspected infection
Imaging:
* Non-contrast CT KUB should be done urgently in patients with suspected renal colic
* USS KUB is an alternative that should be offered to pregnant women and under 16 year olds
* Abdominal X-ray also has a role e.g. to follow up radio-opaque stones that are being managed conservatively
Special tests:
* Stone analysis
150
What is the management of Urinary Stones?
* Watchful waiting for asymptomatic stones
* Analgesia
* Medical expulsive therapy can be considered for patients with distal ureteric stones < 10mm: alpha blocker
* Patients with suspected infection secondary to renal stones should be treated urgently with IV antibiotics (e.g. gentamicin, co-amoxiclav)
* IV fluids
* Antiemetics
* Medical prophylaxis may be considered for recurrent stone formation
* Potassium citrate is used for recurrent calcium oxalate stones
* Thiazide diuretics may also be used for recurrent calcium oxalate stones
Surgical
- ESWL/ Ureterorenoscopy (rigid/flexible)
- PCNL- Reserved for staghorn stones (occupy multiple calyces within the kidney)
- Nephrectomy- for non-functioning kidneys
151
What are the causes of urinary incontinence?
DIAPPERS
* Delirium
* Infection
* Atrophic vaginitis
* Pharm
* psych
* endocrine
* reduced mobility
* stool impaction
152
Define Stress Incontinence:
Leakage when an increase in intra-abdominal pressure
153
Risk F. of Stress Incontinence?
* childbirth
* hysterectomy
154
Triggers of Stress Incontinence?
* laugh
* cough
* sneeze
155
Management of Stress Incontinence?
Conservative:
* avoid caffeine, fizzy, sugar, too much fluid
* pelvic floor excersise
Medical
* duloxetine
* surgical (pessaries if prolapse) (Mild urethral slings GOLD)
156
What are the causes of functional incontinence:
* sedation meds
* dementia
* etoh
157
Define Overflow Incontinence:
Small amount of urine leak with no warning
158
What are the causes of overflow incontinence?
* constipation
* prostatism
159
Define Urge Incontinence:
Sudden loss of urine associated with urgency
160
What are the risk f of Urge incontinence?
* UTI
* high BMI
* old age
* caffeine
* smoking
161
How to manage Urge Incontinence?
* avoid sugar/ caffeine
* anticholinergic medications (oxybutin; -odine; solifenacon)
* Beta3 agonist- mirabegron (!!HTN)
* bladder instillation
* sacral neuromodulation
