GU Flashcards
(86 cards)
1
Q
What is BPH
A
Enlarged prostate . 1st growth at puberty, 2nd growth = BPH.
Common (24% if aged 40-64)
2
Q
Symptoms of BPH
A
• Nocturia • Frequency • Urgency • Post-micturition dribbling • Poor stream/flow • Hesitancy • Overflow • Incontinence • Over flow incontinence • Haematuria UTI
3
Q
investigations for BPH
A
- PR exam
- Bloods:
• MSU
• U&E
PSA (prior to PR exam) - Transrectal US + biopsy
4
Q
lifestyle management of BPH
A
• Avoid caffeine/ alcohol (to reduce urgency, post micturition)
• Relax when voiding, void twice in a row to aid emptying
Train bladder i.e. increase holding on time.
5
Q
Drug treatment for BPH
A
1st line: Alpha-blockers (Tamsulosin 400mcg/d/PO) (Alfuzosin, Doxazosin, Terazosin)
2- 5 a reductase inhibitors:Finasteride 5mg/d PO.
6
Q
What examples of alpha blockers are there for BPH
A
Tamsulosin, alfuzosin, doxazosin, terazosin
7
Q
How do alpha blockers work in BPH
A
Reduces smooth muscle tone. (Prostate and Bladder)as well as anywhere else you can find alpha receptors, like the ureter
8
Q
Side effects of alpha blockers
A
Drowsiness, depression, dizziness, Low BP, Dry mouth, ejaculatory failure
9
Q
Give an example of a 5 alpha reductase inhibitor for BPH treatment
A
Finasteride
10
Q
How do 5 alpha reductase inhibitors work
A
It reduces testosterone to a more potent androgen, dihydro-testosterone excreted in Semen.
11
Q
Side effects of alpha reductase inhibitors
A
Impotence, Reduced libido, reduced Prostate size over 3-6 months
12
Q
how can 5 alpha reductase inhibitors be used
A
they can be used either alone or added to alpha blockers
13
Q
What surgical interventions are there for BPH
A
- Transurethral resection of prostate (TURP) (High risk of impotency)
- Transurethral Incision of the prostate (TUIP) (less destruction than TURP and less risk of sexual dysfunction.
Retropubic Prostectomy: open op for a very large Prostate.
14
Q
Main side effect of TURP?
A
impotence
15
Q
Causes of acute urinary retention in men
A
BPH, meatal stenosis, paraphimosis, phimosis, prostate cancer
16
Q
Causes of urinary retention in women
A
Prolapse (cystocele, rectocele, uterine),
pelvic mass (gynaecological malignancy, uterine fibroid, ovarian cyst),
retroverted gravid uterus
17
Q
Causes of cute urinary retention for both men and women
A
Bladder calculi, bladder cancer, faecal impaction, gastrointestinal or retroperitoneal malignancy, urethral strictures, foreign bodies, stones
18
Q
Infectious and inflammatory Causes of acute urinary retention
A
- In men - balanitis, prostatitis and prostatic abscess.
- In women - acute vulvovaginitis, vaginal lichen planus and lichen sclerosis, vaginal pemphigus.
In both - cystitis, herpes simplex virus (particularly primary infection), peri-urethral abscess, varicella-zoster virus.
19
Q
Drug-related causes of AUR
A
- Anticholinergics (e.g., antipsychotic drugs, antidepressant agents, anticholinergic respiratory agents).
- Opioids and anaesthetics.
- Alpha-adrenoceptor agonists.
- Benzodiazepines.
- Non-steroidal anti-inflammatory drugs.
- Detrusor relaxants.
- Calcium-channel blockers.
- Antihistamines.
- Alcohol
20
Q
Presentation of acute urinary retention
A
- Self-evident
- Pt is unable to pass urine and is very uncomfortable
- Bladder is distended and tender
- Associated symptoms can include: fever, weight loss, sensory loss, weakness
- However, take care to diagnose pts who are unable to describe symptoms, e.g. pts who are unconscious
History and examination should be directed towards finding a cause. Although BPH is common, other causes like cord compression and cauda equina MUST NOT be missed.
21
Q
Investigations for acute urinary retention
A
• Urinalysis - check for infection, haematuria, proteinuria, glucosuria
• MSU
• Blood tests:
○ FBC
○ U&E, creatinine, estimated glomerular filtration rate (eGFR).
○ Blood glucose
○ Prostate-specific antigen (PSA). NB: this is elevated in the setting of AUR so is of limited use at this stage
22
Q
Imaging studies for acute urinary retention
A
○ Ultrasound - commonly used
○ CT scan - used to look for pelvic, abdominal or retroperitoneal mass causing extrinsic bladder neck compression
○ MRI/CT brain scan - used to look for intracranial lesions (e.g. tumour, stroke, MS)
○ MRI scan of the spine - used to look for disc prolapse, cauda equina syndrome, spinal tumours, spinal cord compression, MS
○ Investigations such as cystoscopy, retrograde cystourethrography or urodynamic studies may also be undertaken depending on the suspected cause of retention
23
Q
What is Cystitis
A
inflammation of the bladder caused by a lower UTI
24
Q
Which bacteria causes cystitis
A
• Ecoli
Staphylococcus saprophyticus
25
Risk factors for cystitis
* Bacterial inoculation: Sexual Activity , Urinary/ Faecal incontinence. Constipation.
* Reduced urine flow: Dehydration, obstructed urinary tract.
Bacterial growth: DM, Immunosuppressed, obstruction, stones, catheter, pregnancy
26
Symptoms of cystitis
* Frequency
* Dysuria
* Urgency
* Suprapubic pain
* Offensive smell, cloudy urine.
* Polyuria
* Haematuria
27
Treatment of Cystitis in non pregnant women
• If three or more symptoms (or one severe) of cystitis and no vaginal discharge treat empirically with 3day course of:
• Nitrofurantoin 50mg four times daily orally or 100mg twice daily (if eGfR >45ml/m, or treated with trimethoprim already in the last year)
OR
• Trimethoprim 200mg twice daily. (if women has been treated previously up to a year with Trimethoprim give Nitrofurantoin.
• 5-10 day course if women has:
• Impaired Renal function
• Abnormal urinary tract
• Immunosuppressed
28
Treating cystitis in pregnant women
1. Symptomatic relief with Paracetamol
2. Nitrofurantoin 50mg four times days or 100mg twice daily for 7 days
This is preferred over Trimethoprim
3. Trimethoprim 200mg twice daily for 7 days
• Give FOLIC ACID 5mg = if in first trimester of pregnancy.
• Do not give Trimethoprim to women if folate deficient, taking a folate antagonist or has been treated with Trimethoprim in past year. Give CEFALEXIN 500mg BD or 250mg 6 hr for 7 days.
4. Repeat urine culture seven days after finishing treatment
If group B Streptococcus (inform antenatal as prophylactic Abx will be needed during labour)
29
Treating cystitis men
1. Symptomatic relief = Paracetamol/ NSAIDs.
2. Nitrofurantoin 100 mg twice for 7 days (if eGFR >45ml) or
3. Trimethoprim 200mg twice daily for 7 days.
4. Ciprofloxacin 4 weeks if Prostitis (Pain in Pelvis, Genitals, lower back, buttocks)
Arrange follow up, after 48 hrs depending on clinical judgement to check response to treatment and urine culture results.
-If Urine Culture shows the micro-organism is resistant to the current antibiotic, change to
Antibiotics the micro-organism is sensitive to.
30
When to refer for bladder cancer fast track
• Aged 45 and over and have:
• Unexplained visible haematuria without UTI or
• Visible haematuria that persists or recurs after successful treatment of UTI.
Or
• Aged 60 and over and have unexplained non-visible haematuria either dysuria or Raised White Cell count on a blood test.
31
How is nitrofurantoin cleared
Through the kidneys, therefore it is contraindicated in patients with an egfr of less than 45
32
when is trimethoprim contraindicated
in patients that have anemia, or folate acid deficiency or other blood disorders
33
when is nitrofurantoin contraindicated
when the egfr is less than 45
34
what is prostatitis
Acute bacterial prostatitis is a potentially serious non-sexually transmitted bacterial infection of the prostate- it could lead to sepsis, which may be associated with epididymitis or urethritis
35
How long does it usually take to be treated for acute prostatitis
Most men treated appropriately for acute prostatitis will recover completely within 2 weeks, although it can take up to 4 weeks
36
When should Acute prostatitis be suspected?
* A feverish illness of sudden onset.
* Irritative urinary voiding symptoms (dysuria, frequency, urgency), or acute urinary retention.
* Perineal or suprapubic pain.
* Tender prostate on rectal examination (BPH is not tender)
Urine dipstick test showing white blood cells, and urine culture confirming urinary infection.
37
What other differential diagnosis of acute prostatitis are there
* Prostatic abscess or chronic prostatitis.
* Cystitis, urethritis, or upper urinary tract infection.
* Acute epididymo-orchitis.
* Prostate, bladder or rectal cancer
38
How to diagnose acute prostatitis
• Confirm urinary infection with a urine culture
39
What conditions do you need to rule out when diagnosing acute prostatitis
* Chronic prostatitis — consider this if the symptoms have been present for several weeks or months.
* Cystitis, urethritis, or upper urinary tract infection — consider these if there are no symptoms suggesting that the prostate is affected.
* Acute unilateral or bilateral epididymo-orchitis — consider these if the scrotum, testis, or epididymis are painful or swollen.
Local invasion from cancer of the prostate, bladder, or rectum
40
Symptoms of acute prostatitis
* Pain: perineum, rectum, scrotum, penis, bladder,
* Lower back pain
* Fever/malaise
* Nausea
* Swollen or tender prostate on PR.
* Fever
* Abdominal or loin tenderness
* Check for distended bladder; enlarged prostate.
* PID
41
What tests do you do when you suspect acute prostatitis
```
1. Urine Dip: showing white blood cells and urine culture confirming urinary infection
2. MSU
3. Bloods: (if systemically unwell)
• FBC
• U&E
• CRP
•Blood Culture
```
4.Imaging: Consider USS and referral to urology
42
general non drug Management of Acute prostatitis
• A patient with acute prostatitis may be acutely ill and require admission to hospital.
* They may also be in septic shock and require resuscitation.
* Adequate analgesia may also be required.
* If there is retention of urine, a suprapubic catheter may be required.
* Avoid repeated rectal examination for fear of seeding infection and give parenteral antibiotic to cover Gram-negative organisms.
* If the disease is sexually transmitted, a genitourinary clinic may be valuable, both in terms of accurate diagnosis and of contact tracing.
43
Drug management of prostatitis
• Flouroquinolones are first-line (eg, ciprofloxacin or ofloxacin) and should be prescribed for four weeks.
Severely ill patients may require parenteral aminoglycosides in addition to flouroquinolones.
• Second-line agents include trimethoprim-sulfamethoxazole and macrolides.
44
What is Balanitis
Inflammation of the foreskin and glans of penis.
45
What causes balanitis
* Associated with Strep and Staph infection.
* More common in diabetics.
•Poor hygiene not washing under foreskin.
46
What infections is balanitis associated with
Strep and Staph infection.
47
Symptoms of balanitis
* Penile Soreness and itch
* Bleeding from the Skin/ odour which develops over a few days
* Dysuria
* Redness and swelling of the glans of (often foreskin) with exudate
* Tightening of the foreskin or
* Inability to retract the foreskin (phimosis)
48
What would you see on examination in balanitis
* Redness and swelling of the glans of (often foreskin) with exudate
* Tightening of the foreskin or Inability to retract the foreskin (phimosis)
49
Assessments for balanitis, what to ask
• Symptoms: Onset and duration: Dysuria, pain, itch, bleeding, splitting, dyspareunia and sexual dysfunction. Urethral discharge or exudate.
• Other symptoms: Joint problem or eye involvement (Reiters syndrome or Chlamydia)
50
What examinations would you do for balanitis
1. Examine the penile skin and genital area and extra genital area.
2. STI Screen
3. Arrange HbA1c - Underlying DM.
51
lifestyle management of balanitis
1. Advise the person to clean under foreskin daily with lukewarm and dry gently.
• Do not use soap or bubble bath
• Consider emollient
52
Treatment for balanitis caused by candida
1. Imidazole cream 14 days until symptoms settle
| 2. Oral Fluconazole 150mg single dose
53
Treatment for bacterial balanitis
Flucloxacillin 500mg four times a day for 7 days or Clarithromycin 250mg twice daily for 7 days.
54
Balanitis due to allergic dermatitis/ irritant
Irritant or allergic dermatitis
• Advise person to stop any triggers (soap, bubble bath, latex condoms)
Prescribe: Hydrocortisone 1% cream or Ointment once daily until symptoms settle.
55
What is epididymitis
• Inflammation of the epididymis.
Which is a tube located at the back of the testicles that stores and carries sperm
56
What causes epididymitis
* STI (14-35 years) Chlamydia trachomatis or Neisseria Gonorrhoea.
* E coli or Enterococcus faecalis that cause UTI for men aged 35 years and older.
* Pre-pubertal : Usually non-infective and self limiting Cause: Reflux of urine into the ejaculatory ducts. Or Ecoli.
57
causes of epididymitis
* STI (14-35 years) Chlamydia trachomatis or Neisseria Gonorrhoea.
* E coli or Enterococcus faecalis that cause UTI for men aged 35 years and older.
* Pre-pubertal : Usually non-infective and self limiting Cause: Reflux of urine into the ejaculatory ducts. Or Ecoli.
58
Symptoms of epididymitis
```
low-grade fever
chills
pain in the pelvic area
pressure in the testicles
pain and tenderness in the testicles
redness and warmth in the scrotum
enlarged lymph nodes in the groin
pain during sexual intercourse and ejaculation
pain during urination or bowel movements
urgent and frequent urination
abnormal penile discharge
blood in the semen
```
59
main Risk factors of epididymitis
STI's especially gonorrhea and chlamydia
UTI
Prostate infection
60
Other risk factors that increase your chances of getting epidiymitis
```
Youre uncircumcised
Have structural problems with the urinary tract
Have TB
Have an enlarged prostate causing a blockage in the bladder
Recent urinary tract injury
Recent groin injury
Catheter
Use of amiodarone
```
61
Management of sexually transmitted epididymitis
Gonorrhoea
• Ceftriaxone 500mg IM + Doxycycline 100mg orally twice daily 10-14days.
*Oral Cefixime 400mg if IM Ceftriaxone cannot be given.
* if gonorrhoea = add Azithromycin to Ceftriaxone and Doxycycline.
• Refer to Sexual Health Clinic
Advise man not to have any sexual contact
62
management of Organismal causes of epididymitis
* Ofloxacin 200mg Orally twice daily for 14 days or Levofloxacin 500mg by mouth once daily 10days.
* Advise: Bed Rest, Scrotal elevation (supportive underwear) and analgesia until inflammation or fever.
If symptoms worsen or do not begin to improve within 3 days: return for reassessment.
63
what is Epdidymo-orchitis
• is inflammation of the epididymis (the coiled tube on top of the testis that provides the space and environment for sperm to mature),
64
causes of Epdidymo-orchitis
* Chlamydia
* E.coli
* Mumps
* Gonorrhoea.
65
Symptoms Epdidymo-orchitis
* Onset gradual over hours to days
* Dysuria
* Sweats/fever
* Urethral discharge
* Painful and tender, relieved. Maybe relieved by elevation of testis. (Painless and non-tender if tuberculous)
* Palpable swelling of the epididymis and or testies
* Difficult to distinguish from torsion. (Torsion most likely; if person presents less than 6 hours after onset;
66
Investigation of Epdidymo-orchitis
* 1st catch urine sample (check for ureteral discharge )
| * STI Check
67
Management of Epdidymo-orchitis
* If <35 years, doxycycline 100mg/12h (cover chlamydia) + Ceftriazone 500mg IM stat.
* If <35 (mostly non STI) associated with UTI so Ciprofloxacin 500mg/12h or Ofloaxacin 200mg/12h. USE 2-4 Weeks.
68
what is Urethritis
Inflammation of the urethra usually (but not always) caused by a sexually
Transmitted infection
69
Classifications of urethritis
* Gonococcal urethritis (Neisseria gonorrhoeae)
* Non-gonococcal urethritis (NGU) (Chlamydia trachomatis and (Mycoplasma genitalium)
Persistent/recurrent urethritis (urethritis which occurs 30-90days after treatment for acute NGU)
70
Causes of urethritis
* STI
* Trauma
* Irritation (soaps, lotions etc.)
* Urethral stricture
* Urinary calculi
71
Investigations for urethritis
* Refer all men with suspected urethritis to a GUM clinic.
* If they refuse: working diagnosis of should be made if:
1. The man has mucopurulent or purulent urethral discharge.
2. First void urine sample tests positive for leucocyte esterase.
72
Management of urethritis
1. Doxycycline 100mg twice a day for 7 days or
| 2. Azithromycin 1g single dose
73
Advice for patients that have urethritis
* Most likely cause of urethritis is STI
| * Abstaining from sex (including oral/)
74
What is Haematuria
Blood in urine can come from anywhere in the renal tract.
Causes such as UIT and menstruation should be excluded.
Visible Haematuria = Macroscopic
Non visible: found on dipstick, microscopy, frank.
Non visible Haematuria = subdivided into Symptomatic (sNVH) and Asymptomatic (aNVH)
75
Causes of Haematuria
* Malignancy (Kidney, Ureter, bladder)
* Calculi
* IgA nephropathy
* Glomerulonephritis
* Polycystic kidney disease
* Schistosomiasis
76
Management of Haematuria
```
2 WEEK REF: Bladder CA.
• Aged 45 years with:
• Unexplained haematuria without UTI or
• Haematuria persisting or recurs after successful treatment of UTI or
• Aged 60 and over with unexplained non-visible haematuria with dysuria or raised WCC
Renal causes should be excluded/ and referral made if NVH with:
• eGFR <60
• Coexistent proteinuria >140/90mmHg
• Family history of renal disease
```
77
What is Acute Renal Failure
Acute Renal Failure (AKI) = reduced renal function
Measured by serum Creatinine or Urine output
Definition of AKI
• Rise in creatinine >26umol/L within 48h
• Rise in creatinine >1.5 x baseline (i.e. before AKI) within 7 days
• Urine output <0.5ml/kg/h for 6 consecutive hours
78
Prerenal causes of AKI
* Hypovolemia
* Reduced cardiac output
Drugs (reducing blood pressure, circulating volume or renal flow)
79
Intrinsic causes (damage to the glomeruli, renal tubules or interstitium of the kidney themselves)
• Glomerulonephritis
• Rhabdomyolysis
Tumour lysis syndrome
80
Post-renal causes of AKI
* Obstruction to the urine coming from the kidneys resulting in things backing up.
* Kidney stone (ureter or bladder)
* Benign prostatic hyperplasia
* External compression of the ureter.
81
Risk factors of AKI
* CKD
* Other organ failure: Heart Failure, Liver disease, Diabetes.
* Hx of Kidney Injury
* Use of Nephrotoxic drug: NSAIDs, Aminoglycosides, ACE inhibitors, ARBs and diuretics within the past week
* Use of iodinated contrast agents in the past week.
* Age 65 years or over
82
Investigations for AKI
* U&Es
* Renal US (If no cause found and obstruction may be the reason)
* Urine dipstick (proteinuria/ Haematuria)
* LFT
83
Management of AKI
1. Pulmonary oedema = Early referral to renal as may need dialysis
2. Treat K+ >6.5mmol/L or ECG changes.
3. Treat Hypovolaemia = Bolus Fluid 250-500ml crystalloid (normal saline or Hartmann's). Further 250-500ml. Stop at 2L if no response and seek help.
Other:
1. If sepsis, Treat sepsis
2. Stop Nephrotoxic medication: NSAID, ACE, ARB, Aminoglycosides
Stop drugs increasing complication: Metformin, antihypertensive, diuretics
3. Avoid radiological contrast
84
What is CKD?
* Abnormal kidney structure or function for >3 months
* US = bilateral; small kidneys
* eGFR persistently = less than 60mL/min/1.73m
85
Causes of CKD
* Diabetes
* Glomerulonephritis
* High BP
* Renovascular disease
86
Investigations of CKD
* Serum creatinine
* Early morning urine sample: albumin: creatinine ratio.
* Dip the urine for haematuria
