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Flashcards in GU Deck (136):
1

Any of these 7 GU emergencies in males means you've gotta send them to urology ASAP

- Bilateral hydronephrosis
- Acute urinary retention
- Fournier's gangrene
- Testicular torsion
- Priapism
- Paraphimosis
- Penile fracture

2

Male-specific causes of acute urinary retention

Prostate issue - e.g. BPH, carcinoma, abscess

3

Female specific causes of acute urinary retention

- Pelvic prolapse
- Urethral diverticulum
- Post-operative
- Pelvic mass

4

Lots of potential causes of acute urinary retention (affect men and women)... Name 6

- Urethral stricture
- Drugs (narcotics, Benadryl, Sudafed, alcohol)
- Anesthesia
- Spinal cord/sacral nerve comopression/damage
- Herpes simplex/zoster
- Radical pelvic surgery

5

First thing you gotta do for acute urinary retention pt

Catheter - urethral or suprapubic

6

Labs for acute urinary retention pt

SCr to rule out obstruction
UA/UC to rule out infection

7

What medication can you give to acute urinary retention pt with suspected BPH

Alpha-1 blocker (tamsulosin)

8

How long does it take for tamsulosin to reach therapeutic levels?

Up to 72 hours

9

ALL men with urinary retention need ______

Urology follow-up

10

Refer acute urinary retention pts to urologist for _____ in ____ days

Voiding trial in 3-7 days

11

When would you be concerned for post-obstructive diuresis in acute urinary retention pt?

>1000cc urine in bladder and increased SCr

12

Criteria for post-obstructive diuresis

>200ml/hr for 3 consecutive hrs OR 3L/24hrs

13

2 main ADRs of alpha-1 blockers

Orthostatic hypotension
Dizziness

14

_____ and _____ are more likely to cause hypotension. Take these alpha-1 blockers at bedtime.

terazosin & doxazosin

15

_____ and ______ are more likely to interact with ED meds (i.e. avoid with ED)

terazosin
doxazosin

16

These two alpha-1 blockers don't usually interact w/ ED meds.

tamsulosin
alfuzosin

17

Name 2 alpha-reductase inhibitors for BPH

finasteride
dutasteride

18

ADRs of finasteride

Decreased libido
ED
Depression

**PSA levels decrease by ~50% (affects interpretation of prostate cancer screening)

19

Gold standard for diagnosing nephrolithiasis

CT abdomen/pelvis w/out contrast

20

KUB can't diagnose these kidney stones

Uric acid stones

21

Types of stones

- Calcium oxalate
- Uric acid
- Struvite

22

Most common kidney stone

Calcium oxalate

23

Risk factors for calcium oxalate stones

Dehydration
Hypercalcuria
Hyperoxaluria

24

Risk factors for uric acid stones

- Highly acidic urine (pH<5.5)
- Persistent metabolic acidosis
- Hyperuricemia

25

Risk factors for struvite stones

UTIs w/ urease-producing bacteria (i.e. Proteus)

26

Urine is acidic in ____ stones and more basic in _____ stones

Acidic in uric acid stones (pH<5.5)
More basic in struvite stones (urease converts urea to NH4+)

27

______ stones are a/w recurrent UTIs

Staghorn calculi (struvite)

28

Struvite stones are best diagnosed via _____

KUB

29

Sx's that may indicate stone in UPJ

Deep flank pain without radiation to groin

30

Sx's that may indicate stone in ureter

finastand colicky pain in flank ipsilateral lower abd a/w vomiting - pain may radiate to testicles/vulva

31

Sx's that may indicate stone in UVJ

Pain radiates to groin and testis/labia major

32

Sx's that may indicate stone in bladder

Aha! Trick question!
Usually asx but may have cystitis-like sx's or urinary retention

33

Kidney stones can probably pass on their own unless they're greater than ______

>6mm

34

Conservative tx of kidney stones

- Alpha-blockers and analgesics
- Drink lots of fluids (2L/day)
- Strain urine (bring in for eval)
- Abx if UTI

35

Potassium citrate can help treat ____ stones

uric acid stones

36

ESWL can help treat ____ stones

<3cm

37

________ can help treat staghorn calculi

Percutaneous nephrolithotomy

38

Name 7 instances in which hospitalization is indicated for kidney stones

- Signs of infection/sepsis
- Renal deterioration
- Intractable N/V
- Pain refractory to analgesia
- Only one kidney or bilateral obstruction
- Immunocompromised
- Upper UTI

39

Why don't you want to break up an acute kidney stone? What do you do instead then?

Bacteria often housed within stone can worsen sepsis - use ureteral stent or percutaneous nephrostomy tube to decompress kidney

40

4 ways to prevent future stones

- Increase fluid intake and low-salt diet
- Moderate animal protein (less uric acid)
- Moderate Ca2+ (but still need certain amt to prevent hyperoxaluria)
- Increase dietary citrate (buffers pH, prevent calcium oxalate deposition)

41

Fournier's gangrene is polymicrobial. True or False?

True - usually see 3 on Cx

42

High suspicion of Fournier's gangrene in these 3 populations

- Alcoholic
- Diabetes
- Immunocompromised

43

Most common organism that causes Fournier's gangrene

E. coli

44

Tx for Fournier's gangrene

- Surgical consult ASAP
- IVF
- Zosyn + vanco + clindamycin

45

____° twist is required to compromise blood flow through testicular artery, resulting in ischemia in testicular torsion

720°

46

Dx testicular torsion

- Scrotal US w/ doppler
- Afebrile, no voiding sx's normal UA
- Slight leukocytosis

47

You have _____ hours to preserve the testis in testicular torsion

4-6

48

Many cases of priapism is due to _______ or _______

Intracavernosal injection of CCB or ED

49

Complications of priapism

Penile hypoxia → acidosis → penile compartment syndrome

50

Name 5 possible causes of priapism

- Sickle cell disease
- Drugs
- Neurogenic shock
- Needle injury, trauma
- Congenital arterial malformations

51

Tx priapism

- Analgesia
- Call urology for corporal aspiration followed by irrigation w/ phenylephrine
+/- Transfusion for sickle cell pts

52

Most common cause of penile fracture

Sex

53

Tx penile fracture

- Call urology
- Retrograde urethrogram to assess urethra
- Surgery to remove hematoma and suture tunica albuginea

54

Tx paraphimosis

- Topical lidocaine
- Manual reduction +/- surgical circumcision

55

Average menstrual cycle phases

Days 1-7: Menses
Days 7-13: Follicular/Proliferative phase
Day 14: Ovulation
Days 14-28: Luteal/Secretory phase

56

3 general strategies for contraception

- Prevent ovulation
- Prevent fertilization
- Prevent implantation

57

4 methods for preventing ovulation

Hormonal agents
- OCP (COC, POC)
- Nexplanon (arm implant)
- Depo-provera (injection)
- Nuvaring

58

5 methods for preventing fertilization

- Abstinence (100% effective)
- Coitus interruptus
- Fertility-awareness
- Barrier
- Sterilization

59

2 methods for preventing implantation

- IUD
- Emergency contraception

60

Category 1 contraception strategies have....

No restriction

61

Category 2 contraception strategies have....

Advantages that generally outweigh risks

62

Category 3 contraception strategies have....

Theoretical/proven risks that usually outweigh advantages

63

Category 4 contraception strategies have....

Unacceptable health risks - i.e. DO NOT use

64

Most effective contraception option (besides abstinence)

Emergency contraception

65

Least effective contraception option

Periodic abstinence (coitus interruptus, lactational amenorrhea, fertility-awareness)

66

Pros/cons of periodic abstinence for contraception

(+) Low cost, natural
(-) High failure rate, requires dedication/commitment, no protection against STIs

67

How does lactational amenorrhea prevent pregnancy?

Prolactin decreases LH and inhibits follicular maturation

68

Name the 3 criteria for lactational amenorrhea to work

<6 months postpartum
Exclusively breastfeeding
Amenorrhea

69

Cons for lactational amenorrhea

Temporary, not option for everyone

70

Fertility-awareness based methods for contraception

- Standard days → avoid sex on days 8-19
- Cervical mucous → avoid sex when mucous present (high estrogen levels, near ovulation)
- BBT → avoid sex when BBT incr.
- Symptothermal → combo of BBT + cervical mucous methods

71

Which contraceptive methods protect against STIs?

Male/female condoms

72

What mechanical contraceptive barriers can be conveniently placed in advance of sex?

Female condoms
Diaphragm/cervical cap
Sponge

73

Failure rates of _____ contraceptives depend on parity

Cervical cap and sponge

74

3 important things to note for diaphragms/cervical caps

- Must be measured/fitted via pelvic exam
- Must be used with spermicide to increase efficacy
- Must be refitted after pregnancy

75

What's important to know about sponges for contraception?

- Failure rate depends on parity
- Sulfa allergy
- One time use
- Contains spermicide

76

What's important to know about spermicides?

High failure rate when used alone

77

Noncontraceptive benefits of hormonal contraception

- Menstrual cycle regularity
- Tx menorrhagia, dysmenorrhea, PMS, acne, hirsutism, menstrual migranes
- Decrease risk of endometrial, ovarian, CRC
- Improve BMD
- Treat fibroids, endometriosis

78

MOA of progestin in contraception

Inhibits LH secretion.
Causes atrophied endometrial glands (thin lining), thickens cervical mucous, impairs peristalsis of Fallopian tubes

79

MOA of estrogen in contraception

Suppresses FSH, preventing follicular development
Stabilizes endometrium to prevent BTB, potentiates progestin action

80

ADRs of OCPs

- VTE
- Breast tenderness
- Bloating
- BTB up to 90 days
- DDIs w/ phenytoin, rifampin

81

C/I of OCPs

- Multiple CVD risks (age >35, smoking, DM, HTN)
- VTE
- Stroke hx
- Breast cancer
- Impaired liver function

82

What are the relative doses of estrogen and progestin in monophasic COCs?

Same dose estrogen and progestin in all active pills

83

What are the relative doses of estrogen and progestin in biphasic COCs?

Same amt estrogen every day
Progestin increases halfway through pack

84

What are the relative doses of estrogen and progestin in triphasic COCs?

Varying doses of estrogen +/- progestin q7 days

85

What are the relative doses of estrogen and progestin in 4-phasic COCs?

Varying doses of estrogen and progestin 4 times throughout pack

86

Examples of 24-day pack COCs with 4 days placebo

Yaz, Yasmin, Loestrin-24, Femcon (chewable)

87

Signs of excess estrogen in COCs

- Breast tenderness/cystic changes
- Dysmenorrhea
- Chloasma (skin discoloration)
- Nausea

88

Signs of estrogen deficiency in COCs

- Spotting in days 1-9
- Continuous bleeding
- Hypomenorrhea
- Atrophic vaginitis
- Acne

89

Signs of progestin excess in COCs

- Increased appetite
- Depressioin, fatigue
- Decreased libido
- Weight gain
- HTN
- Acne

90

Signs of progestin deficiency in COCs

- BTB in days 10-21
- Delayed withdrawal bleeding
- Hypermenorrhea, dysmenorrhea
- Nausea

91

Different starting methods for COCs

- Quick start (immediate, highest retention) → exclude pregnancy, use back-up for 7 days if >5d from menses
- Sunday start (Sun. after period begins) → avoid withdrawal bleed on weekend, use back-up for 7 days
- 1st day start (1st day of menses) → no back-up

92

Hormones in norethindrone

Progestin-only

93

Pros/cons of norethindrone

(+) Rapid, back-up only for 2 days, postpartum
(-) Short half-life, must be taken same time each day, irregular bleeding, doesn't suppress follicular cysts

94

A downside of Nuvaring

Increased vaginal discharge

95

Dosage of Orthoevra

Weekly dosing - new patch/wk x3 wks, 1wk patch-free (menses)

96

Where can you put Orthoevra?

Butt
Abdomen
Upper arm
Torso

97

Warnings/cautions of Orthoevra

- BBW for VTE risk in smokers
- May be less effective in obese pts

98

Dosage of Depo-provera

q90 days w/ 2wk grace period if missed 90-day mark

99

Depo-provera contents

Progestrone only

100

What should you know about Depo-provera?

- Weight gain
- Fertility may take up to 6-12 months to return
- Reversible bone loss

101

Contraceptives for postpartum/breastfeeding pts

Progestin only
- POPs
- Nexplanon
- Depo-provera
- Levonorgestrel IUD (Skyla, Kyleena, Mirena, Liletta)

102

How long is Nexplanon used for?

3 years

103

When would you put in a levonorgestrel IUD?

Bimanual exam, Cervical inspection, Immediately postpartum

If had sex yesterday, wait 2 wks to r/o pregnancy

104

Important to know about levonorgestral IUD?

Prevents ovulation. Still effective if malpositioned

105

Non-hormonal IUDs - How do they work?

TCu380A or Copper IUD (Paragrad) - prevent implantation by inflammatory response

106

C/I of IUDs

- Distortion of uterine cavity
- Active infection
- Undiagnosed uterine bleeding
- Pregnancy
- Postpartum sepsis

107

Female sterilization options

Tubal ligation or Essure

108

Pros/cons of female sterilization

(+) Highly effective, protects against ovarian cancer
(-) Permanent, surgery, if pregnancy does happen more likely to be ectopic

109

Important counseling point about vasectomy

Use back-up for 3 months s/p and f/u at 3 months for semen analysis

110

When can a postpartum pt start taking COCs?

5 wks postpartum d/t VTE risk

111

Menorrhagia

Blood loss >80mL

112

Metrorrhagia

Intermenstrual bleeding

113

Polymenorrhea

Cycles <21 days

114

Oligomenorrhea

Cycles >35 days

115

Possible causes of AUB in nonpregnant pts of reproductive age

PALM-COEIN
Polyp
Adenomyosis
Leiomyoma
Malignancy
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified

116

Is neonatal vaginal bleeding normal?

Yes, self-limited to 1wk. Caused by withdrawal of maternal estrogen.

117

How should you perform vaginal exam on prepubescent pt?

Inspection of external genitalia → vaginal exam but NOT with speculum

118

Menstrual cycles vary during first ______ years after menarche

5-7
Later menarche may take longer

119

Most common causes of AUB in reproductive-age females

Pregnancy
Structural lesions
Anovulatory cycles
Hormonal contraception
Endometrial hyperplasia

120

What is considered mild anovulatory bleeding?

>7 days menses or <24-day cycles for at least 2 months with slightly/moderately incr. menses

121

What is considered moderate anovulatory bleeding?

>7 days or frequent (q1-3wks) with moderate to heavy menses AND Hgb 10+

122

What is considered severe anovulatory bleeding?

Disruptive menstrual cycles with heavy bleeding AND Hgb <10

123

Labs for AUB in premenopausal women

CBC
HCG
TSH
Coagulation if menorrhagia
Cervical samples (cytology, cx)

124

Endometrial sampling should be performed in pts with AUB who are _____ or ______

>45 y/o
<45 y/o w/ hx of unopposed estrogen exposure or failed medical management

125

Tx for AUB

Hormonal tx
- Irregular or light → progestins
- Menorrhagia → COC
- Intractable menorrhagia → GnRH agonist (leuprolide or nafarelin) up to 6 months

COC and GnRH agonist take 2-4 wks (not for acute)

NSAIDs

126

Tx for AUB that requires hospitalization

- IV estrogens then PO plus progestin
- COC

127

What if hormonal tx of AUB doesn't work?

Endometrial ablation
Levonorgestrel IUD
Hysterectomy

128

Postmenopausal vaginal bleeding

Any bleeding 6+ months after menopause → ALWAYS needs to be investigated

129

Common causes of postmenopausal bleeding

- Atrophic endometrium
- Endometrial hyperplasia
- Endometrial/cervical ca
- Estrogens administration
- Atrophic vaginitis
- Trauma, friction ulcers
- Endometrial polyps
- Blood dyscrasia

130

Any pt with postmenopausal bleeding should get _____

Endometrial biopsy to r/o malignancy

131

Endometrial thickness of ___ on transvaginal US in postmenopause indicates low likelihood of endometrial cancer

≤4 mm

132

Tx of postmenopausal bleeding

- Simple endometrial hyperplasia → progestin or levonorgestrel IUD, repeat sampling if sx's recur
- Hyperplasia w/ atypia or malignancy → hysterectomy

133

Sx's of endometrial polyps

Asx but 50% have intermenstrual bleeding (usually w/ straining/heavy lifting)

134

Dx endometrial polyp

Histology

135

Tx endometrial plyp

- Sx → remove b/c more likely malignant
- Asx → monitor
ALWAYS remove in postmenopauseal pt regardless of sx's b/c more likely malignant

136

Why would you NOT use finasteride to immediately help with acute urinary retention?

Takes up to 6 months to be effective