GU Flashcards

Question

when should you refer someone with UI?

Answer 1

``` Need for additional testing Abnormal U/A or culture/recurrent UTI Palpable abdominal or pelvic mass PVR > 100cc Abnormal prostate exam Vaginal bleeding; obstruction; new underlying disorder; surgical candidates ```

Answer 2

``` PME With or without biofeedback Bladder retraining Habit training; prompted voiding Other nursing measures Dietary changes Nocturia: nursing measures/new meds ```

Answer 3

Medications Anticholinergics (Block binding at M3 receptors) Actions Relax the detrusor muscle Reduce frequency, urgency and nocturia Enable better filling and delay in voiding Beta-3 Adrenergic Receptor Agonist Targets B-3 adrenergic receptor pathway to relax detrusor smooth muscle Botox injection (FDA approved 2014)

Answer 4

``` treats OAB/Urge UI Mirabegron (Myrbetriq) 25 and 50 mg PO QD First in the class SE Increased BP Nasopharyngitis UTI Headache NO Constipation or dry mouth! ```

Answer 5

Alpha-adrenergic agonist (increase outlet resistance; e.g. pseudoephedrine) No FDA approved meds

Answer 6

Stress UI New work re: autologous stem cell transplantation BPH; pelvic prolapse OAB/urgency: Interstim (implanted stimulators)

Answer 7

Products; frequent toileting; medication “rearrangement”; special clothes; avoiding public transportation; decreased or avoidance of carrying heavy objects; avoiding intercourse; locating or staying near BR Catheterization Should be the last resort

Answer 8

``` Ask about UI and evaluate prn Include prevention in routine visits Inquire about self-care strategies; assist in developing a reasonable plan Consider simple therapies first Refer prn ```

Answer 9

``` accessory male sex organ surrounds prostatic urethra function: reproduction/antibacterial pre-prostatic zone transition zone (BPH); peripheral zone (CA) ```

Answer 10

Increase: size; BPH; prostate CA; calculi; prostatitis Weight: increases with age. Embryogenesis dependent on testosterone/conversion of T-DHT via 5 α-reductase Decrease: prostatic antibacterial factor (PAF)

Answer 11

``` NIH Classification Category I: Acute Bacterial Category II: Chronic Bacterial Category III: Chronic/Chronic Pelvic Pain Syndrome Category IIIA: Inflammatory Category IIIB: Non-inflammatory Category IV: Asymptomatic Inflammatory Discovered during another evaluation *Category I and II, about 5-10% of those with prostatitis Most are CP/CPPS, non-bacterial ```

Answer 12

Acute Bacterial ProstatitisSigns and symptoms: acute chills, fever, low back/perineal pain irritative/obstructive symptoms generalized malaise; flu-like symptoms enlarged, tender prostate prostatic secretions always abnormal EPS: not recommended for ABP; rarely done by PCP

Answer 13

Pathogens: gram negative anaerobes: most common is E.coli Gram positive anaerobes: enterococcus; staph aureus Complications: prostatic abscess Treatment: Broad spectrum ABX, usually 2-4 weeks minimum Local measures Consider need for hospitalizationStart with broad spectrum ABX. Most sources suggest 2-4 week treatment regime to prevent relapse. Some pts may need hospital admission, IV fluids, etc. Sitz baths, bedrest are some of the local measures.

Answer 14

Chronic Bacterial ProstatitisIncidence is about 5% of those with chronic prostatitis Possible routes of infection: ascending urethral infection; reflux; invasion of rectal bacterial Relapsing, recurrent UTI is common

Answer 15

Clinical features: primary pathogen is e. coli Usually no fever; irritative symptoms; leukocytes in prostatic sample; often non-specific Prostate usually normal on exam, but may be boggy or tender Treatment: prolonged ABX; TURP; local measuresABX for 4-6 weeks. Fluoroquinolones may be superior to other ABX.

Answer 16

Those who require IV antibiotics: high fever, severe perineal pain Marked outflow obstruction Prostatic mass requiring I & D Refractory chronic infection Urology consult or hospitalization

Answer 17

AGE is the main determinant of BPH Other factors likely play a role, but relationship is complex ? Income, educational status, marital status, access to care, dietary factors, race

Answer 18

Asymptomatic variable many are asymptomatic, but show evidence on prostate biopsy size DOES NOT determine symptomsSymptomatic/LUTS obstructive irritative Approx.. 10% present with: retention renal failure

Answer 19

``` Irritative symptoms: UTI, prostatitis bladder CA bladder calculi radiation cystitis IC uninhibited bladder contractionObstructive symptoms: stricture atonic bladder prostate CA ``` ***Both irritative and obstructive: spinal cord injury; PD; MS; prostatitis

Answer 20

History: AUA Symptom Index** Physical exam: DRE Lab tests: to r/o other causes U/A; serum creat; PVR; ? PSA; urine cytology

Answer 21

Watchful waiting: by history, PE, patient preference; symptom score < 7 Medications: 5ARI: finasteride (Proscar); dutasteride (Avodart) Need lifetime treatment SE: sexual dysfunction; gynecomastia Alpha-blockers (non-selective): e.g., Hytrin; Caurdura Selective alpha-blocker: Flomax (tamsulosin); Uroxatral (alfluzosin) Saw palmetto: +/- effectiveness PDE-5 inhibitors/BPH & ED

Answer 22

``` Urinary retention Deteriorating renal function Hematuria PSA > 4; palpable mass Increasing symptom score Failure of pharmacologic therapy Possible surgical candidate (TURP) ```

Answer 23

Limited studies suggest a positive impact re: prevention of BPH Factors that increase risk of CV disease may be associated with increased risk of BPH: Obesity, limited physical activity, dyslipidemia, DM, HTN, heart unhealthy diet

Answer 24

Excluding skin cancer, prostate CA is the 2nd most commonly diagnosed CA in men of all ages Incidence: AA men more than 2X Caucasian men 2018 estimates: About 164,690 new cases of prostate cancer About 29,430 deaths from prostate cancer About 1 man in 9 will be diagnosed with prostate cancer during his lifetime

Answer 25

``` Age > 80 Family hx/race/genetics Less clear: Chemical exposure Agent Orange STI/prostatitis ? Vasectomy Diet ? Red meat/high dairy ? Obesity/smokingInherited mutations of the BRCA1 or BRCA2 genes raise the risk of breast and ovarian cancers in some families. Mutations in these genes (especially in BRCA2) may also increase prostate cancer risk in some men. Men with Lynch syndrome (also known as hereditary non-polyposis colorectal cancer, or HNPCC), a condition caused by inherited gene changes, have an increased risk for a number of cancers, including prostate cancer. In the future, consider BRCA testing for those with significant family history ```

Answer 26

Primarily an adenocarcinoma Multiple histologic patterns Gleason sum score: grades tumor on basis of glandular patterns observed.

Answer 27

Metastasis: spreads by local extension, vascular invasion, lymphatic invasion: e.g., regional pelvic lymph nodes, bone, lung, liver, adrenal glands Natural history: controversial clinical vs. histologic CA

Answer 28

Signs and Symptoms: may be asymptomatic; ??obstructive or irritative symptoms; ? signs of metastatic disease PSA: specific for prostate tissue, but not for prostate CA ? False + PSA: due to ABP; BPH; rectal exam ? False – PSA: Proscar; Avodart; saw palmetto*

Answer 29

``` Controversial, still! Still important to do DRE for symptomatic USPTF (2018) Ages 55 to 69 (no risk factors): Discuss benefits/harms Small potential benefit of reducing chance of death 13 deaths over 13 years/1000 3 cases/1000 metastatic disease Don’t screen men who don’t want screening (C evidence) Don’t use PSA to screen men > age 70 (D evidence) ```

Answer 30

Indicated in all men with palpable nodule or suspicion of cancer. Differential diagnosis: BPH; calculi; chronic prostatitis Prostate biopsy via transrectal ultrasound

Answer 31

``` Active surveillance Watchful waiting Radiation therapy/radioactive seeds Hormone therapy CVD; DM; osteoporosis risks Chemotherapy Surgery Complementary therapies Support pre and post treatment ```

Answer 32

Flaccid state: penile smooth muscle is contracted. Arterial resistance high. Blood outflow unopposed. 2. Onset of erection: smooth muscle relaxes. Sinusoids distended with blood. Subtunical vessels compressed against tunica abluginea.

Answer 33

``` PMH, PSH risk factors urologic symptoms? Medication hx psychosocial hx sexual hx Review slide re: etiologies to focus the history ```

Answer 34

Physical Exam vascular neuro GU

Answer 35

Labs: CBC; BUN; Cr; U/A; glucose; chol; testosterone; prolactin; PSA?, hematocrit ??TFTs; LH; FSH

Answer 36

``` International Index of Erectile Function (IEF-5) Scoring IEF-5 Scoring (Sum of all responses) 22-25: No ED 17-21: Mild ED 12-16: Mild-Moderate ED 8-11: Moderate ED 5-7: Severe ED ```

Answer 37

Counseling/behavioral sex therapy; e.g. Masters and Johnson techniques; PLISSIT model Medications: First line: PDE-5 Inhibitors (e.g., sildenafil; vardenafil; tadalafil) Second line: testosterone; vasodilators; papaverine; prostaglandin E1 Vacuum constriction devices Vascular surgery Penile prostheses

Answer 38

PDE5 inhibitors are associated with a variety of cardiovascular effects. Sildenafil has two important cardiovascular actions in patients with heart disease: It is a vasodilator that can lower the blood pressure, and it can interact with nitrates. The most data are available for sildenafil. ●PDE5 inhibitors are contraindicated in patients taking nitrates of any form, regularly or intermittently, as the combination can lead to severe hypotension. ●Nitrate treatment should be delayed if a man who has taken a PDE5 inhibitor develops chest pain. The delay should be 24 hours if he has taken sildenafil or vardenafil and 48 hours if tadalafil; the delay should be longer for each if he has renal or hepatic dysfunction. ●Myocardial infarction and sudden death have been described with and after intercourse, both in men who have and have not taken a PDE5 inhibitor. Thus, the relation to the drug is uncertain. ●Higher doses of PDE5 inhibitors are used for patients with pulmonary hypertension as monotherapy or in combination with other agents, such as guanylate cyclase stimulants (eg, riociguat). However, the US Food and Drug Administration (FDA) has issued a warning against this combination because of an excess risk of hypotension

Answer 39

Several mechanical devices have been developed that utilize vacuum pressure to encourage increases in arterial inflow and occlusive rings to limit venous egress from the penile corpora cavernosa (figure 3 and table 2B). A certain amount of mechanical dexterity is required to use these devices effectively, but once men become comfortable with using the vacuum and restraining rings many men can create an erection sufficient for vaginal penetration and sexual intercourse. The men may have difficulty ejaculating externally, however, because the occlusive rings that prevent venous drainage also compress the penile urethra sufficiently to prevent seminal fluid from reaching and traversing the urethral meatus. A number of devices are available for purchase over the counter. Although the initial dropout rate may be as high as 50 percent, long-term satisfaction of patients and partners has been reported by several groups [109]. This is especially true in patients who do not respond to penile injections. The vacuum erection device may be used with oral PDE5 inhibitors to augment an insufficiently rigid erection post-ingestion of the PDE5 inhibitor [110]. Vacuum erection devices should only be applied for a maximum for 30 minutes. These devices can also be used in patients taking blood thinners, albeit with caution. Clinical experience has suggested that these devices are most often used by couples in stable relationships. Vacuum devices successfully create erections in as many as 60 to 70 percent of patients [111]. Satisfaction with vacuum-assisted erections has varied between 25 and 49 percent. As an example, one prospective study evaluated 18 men by questionnaire at six months: 16 (89 percent) were able to attain satisfactory erections, and the overall satisfaction rate was 83 percent [112]. Sixteen of the 18 men found the device easy to use.