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GU part 1 Flashcards

1
Q

Local sx of UTI

A

Dysuria
Frequency
Low-grade fever
Hematuria

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2
Q

Systemic sx of UTI

A

Fevers
Sepsis
Advanced tissue infection

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3
Q

What is the urinary tract comprised of?

A 
Kidneys
Ureters
Bladder
Prostate
Urethra
Testicles
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4
Q

Urethritis

A

Usually associated with sexual activity

Sx- pain, urethral burning during urination, urthethral d/c

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5
Q

Organisms of urethritis

A 
Chlamydia
Pseudomonas trachomatis
Ureaplasma urealyticum
Trichomonas vaginalis
Herpes virus
Neisseria gonorrhea
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6
Q

Predisposing factors for cystitis and pyelonephritis

A

DM
Pregnancy
GU anatomic abnormalities
Instrumentation

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7
Q

Pathogenesis of cystitis and pyelonephritis

A

Ascends antegrade from urethra
Occasional hematogenous dissemination
Community acquired UTIs generally from bowel flora

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8
Q

Predispositions to kidney infection

A

Vesicoureteral reflux, stones, urinary scar

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9
Q

Organisms of cystitis and pyelonephritis

A

E. coli
K. marcescens
Enterobacter
In women- vaginal flora

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10
Q

Clinical features of cystitis

A

Suprapubic pain
Burning on urination
Urinary frequency
Low back pain

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11
Q

Clinical features of pyelonephritis

A

Flank pain
Fever >101.5
Elderly or compromised pts may have no sx or fever, AMS, hypotension

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12
Q

Nl PSA for ages 40-49

A

0-2.5

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13
Q

Nl PSA for ages 50-59

A

0-3.5

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14
Q

Nl PSA for ages 60-69

A

0-4.5

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15
Q

Nl PSA for ages 70-79

A

0-6.5

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16
Q

When should PSA testing be done?

A

Starting at age 50 and yearly until age 80

Test 5 yrs earlier if FHx, AA, or high risk

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17
Q

Additional tests for BPH

A 
Post void residual (PVR)
Uroflow imagery (VFR)
Urodynamics
Cystoscopy
Rarely indicated- renal u/s (RUS), transrectal ultrasonagraphy (TRUS)
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18
Q

Lab dx for cystitis and pyelonephritis

A

Midstream urine sample shows WBCs +/- RBCs
WBC casts indicates pyelonephritis
Bacteria seen on spun urine confirms UTI
Catheterized urine, esp in females, to confirm infection
Culture confirms UTI, 100,000 colonies/mL confirms UTI

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19
Q

Specimen collection for cystitis and pyelonephritis

A

Midstream collection plated immediately for microbiology
Consider catheterized specimen in women, particularly obese or elderly
Urine left at room temp for hours can multiply and give spuriously high results
Do not collect urine from catheter bag
Refrigerated specimens not immediately plated

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20
Q

Tx and outcome of cystitis and pyelonephritis- female uncomplicated cystitis

A

TMP-SMX DS 1 PO BID x 3 days
Cipro 250 mg PO BID x 3 days
Nitrofurantoin 100 mg PO BID x 3 days

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21
Q

Tx and outcome of cystitis and pyelonephritis- complicated urinary tracts in women

A

Get a urine culture
Cipro 500 mg PO BID x 10 days
TMP-SMX DS 1 PO BID x 10 days
Macrobid 100 mg PO BID x 10 days

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22
Q

Tx and outcome of cystitis and pyelonephritis- recurrent UTI in men

A

Requires anatomic study of urinary tract

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23
Q

Components of chronic interstitial cystitis

A 
Pelvic pain, urgency, and dyspareunia
Neg urine culture
9:1 female to male ratio
Age 20s to 50s
Associated with autoimmune conditions
Dx of exclusion. Must r/o bladder CA
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24
Q

What autoimmune conditions is chronic interstitial cystitis associated with?

A

Endometriosis
Irritable bowel
Fibromyalgia
Migraines

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25
Urethral syndrome
UTI and pyuria with no growth on culture
26
Causes of urethral syndrome
May be d/t low counts of bacteria, Chlamydia or Ureaplasma (do not grow on routine culture media) Consider urethral culture for herpes simplex infection or Neisseria gonorrhea
27
Tx of urethral syndrome
Doxy 100 mg PO BID x 10 days | Azithromycin 1 g PO x 1 day
28
Tx of pyelonephritis
Cipro 500 mg PO BID x 14 days Levo 500 mg PO qd x 14 days OR Levo 750 mg PO qd x 5 days
29
F/u of pyelonephritis
Hosp admission if toxic, poor PO intake, poor social situation, questionable f/u and compliance, complicating features such as DM, renal stones, urinary obstruction, sickle cell
30
Abx resistant pyelonephritis
Usu in hosp acquired infections or debilitative pts Hosp admission required for 3rd and 4th gen abx Admit for Imipenem, Fortaz, Gentamicin, Tobramycin or infectious dz consult Follow culture results carefully Repeat culture after tx to confirm negative
31
Upper tract imaging and pyelonephritis
Suspect if no clinical improvement in 2-3 days of abx Suspect if febrile for >7 days Suspected IC or debilitated Renal u/s- detects obstruction, abscess, small stones CT scan- detects abscess, smaller stones, perinephric stranding, anatomic abnormalities
32
Complicated UTI
Infection recurs within 3 wks of stopping tx Consider 6-12 wk course of prophylactic evening antibiotic Urologic eval for all men with recurrent UTIs and women with difficult recurrent UTIs
33
Preventative measures for recurrent UTI in women
``` Generally associated with intercourse Encourage voiding after intercourse Antibiotic around coitus -TMP-SMX DS -Cipro 250 mg -NItrofurantoin 100 mg ```
34
Asymptomatic bacteriuria in cystitis and pyelonephritis
Generally in older or middle-aged women, rarely men Urine culture >100,000 bacteria but no UTI sx Generally untreated unless pregnant female or IC pt (pyelonephritis risk high)
35
Prostatitis
Infection of prostate gland in males MC urologic dx in men <50 yo Direct invasion through urethra
36
Sx of prostatitis
Low back pain Perineal pain Fever Dyspareunia
37
Acute prostatitis
``` 95% bacterial Pos culture Toxic appearance Septic Pyuria Sx <24-72 hrs ```
38
Chronic prostatitis
``` Prostate pain Low-grade or no fever 5% pos urine culture Sx for weeks or mos before presentation and tx More common than acute ```
39
Workup for prostatitis
DRE- tender prostate or enlarged boggy prostate UA generally neg Urine culture gen neg bc it doesn't pick up pus
40
Tx for chronic prostatitis
``` 4-12 wks of abx Cipro 500 mg PO BID x 6 wks TMP-SMX DS 1 PO BID x 6 wks Levo 500 mg PO qd x 6 wks Nitrofurantoin 100 mg PO BID x 6 wks Doxy 100 mg PO BID x 6 wks Sitz baths Frequent ejaculation Prostatic massage ```
41
What is the most common category of prostatitis?
Chronic pelvic pain syndrome (CPPS) categories IIIA and IIIB are the MC types
42
Urologic eval for prostatitis
``` Refer to urologist if recurrent Prostatic u/s (TRUS) Express prostatic secretions (EPS) Cystoscopy Renal u/s ```
43
Acute bacterial prostatitis sx
``` Fever Chills Dysuria Perineal and low back pain Possible sepsis ```
44
Exam of acute bacterial prostatitis
Distended bladder | Warm, boggy, tender and enlarged prostate
45
Lab analysis for acute bacterial prostatitis
Elevated serum WBC | Pyuria
46
Tx for acute bacterial prostatitis
Urinary drainage- suprapubic tube recommended IV abx- Cipro, Genta, Ancef Hosp admission 2-4 days and then outpt abx for 30 days Prostate u/s r/o abscess or CT scan of pelvis
47
Sx of chronic bacterial prostatitis
LUTS- lower urinary tract sx Pelvic pain Sexual dysfunction Blockage when urinating
48
PE of chronic bacterial prostatitis
Abd tenderness Groin tenderness Prostate tenderness
49
Lab testing for chronic bacterial prostatitis
VB-1: 1st voided urine VB-2: Midstream urine sent for culture DRE performed, prostate massage Expressed prostatic secretions (EPS) culture VB-3: Collected for culture Chronic bacterial prostatitis means EPS or VB-3 bacteria is 10x greater than a VB-1 or a VB-2
50
Chronic pelvic pain syndrome
MC largest percentage of pts with prostatitis | Nonbacterial
51
Sx of chronic Npelvic pain syndrome
``` Perineal pain Low back pain Suprapubic pain Groin pain Scrotal pain Voiding dysfunction -Dysuria -Weak stream -Frequency -Urgency -Nocturia Sexual dysfunction -Painful ejaculation -Low libido All pts have pelvic pain ```
52
Characteristics of noninflammatory CPPS
``` Multiple positions Frequent visits Chronic pain Psychological problems Depression Anxiety ```
53
Lab dx for CPPS
Urinalysis nl | EPS nl or increased WBc
54
Tx for CPPS
``` NSAIDs Prostatic massage or physical therapy Frequent ejaculation Warm sitz baths Empiric 2-6 wk course of abx Alpha blockers for LUTs TCAs for chronic pelvic pain ```
55
BPH
Nonmalignant enlargement of prostate glands 90% of all men will develop it during lifetime Associated with ED and EjD
56
Irritative LUTS in BPH
Frequency (>8 in 24 hrs) Nocturia Urgency Urge incontinence
57
Obstructive LUTS in BPH
Hesitancy Slow stream Intermittency Incomplete emptying
58
Pathophysicology of BPH
Prostate growth under influence of testosterone converted to dihydrotestosterone 5-alpha reductase converts testosterone to dihydrotestosterone (DHT) Most BPH in transition zone of prostate
59
BPH- smooth muscle vs glandular
Glandular component enlarges- obstructive Smooth muscle tightening- obstructive Usually a combo of glandular and smooth muscle component
60
Dx of BPH
Detailed medical hx focusing on urinary sx American Urologic Association Symptom Index General PE including DRE UA PSA
61
AUA symptom index
``` Validated questionnaire of 7 questions Includes QOL question Classified -Mild (0-7) -Moderate (8-19) -Severe (20-35) ```
62
DDX of BPH
``` Prostate CA Prostatitis DM Neurologic dz CVA Urethral strictures Med SEs -Antidepressants -Anesthetics Slow stream is probably nerve condition Feeling blockage with slow stream probably indicates urethral stricture ```
63
What do alpha blockers do for BPH?
Make urination easier by relaxing smooth muscle tissue in the prostate and outlet of the bladder
64
What do 5-alpha reductase inhibitors do for BPH?
Shrinks the prostate by suppressing hormones that stimulate prostate growth
65
What are the names of the alpha-blockers for BPH
``` Doxazosin Terazosin Tamsulosin Aluzosin Silodosin ```
66
SEs of alpha adrenergic antagonists
``` Dizziness -Fall risk huge problem in elderly -Take at night to sleep through SEs Retrograde ejaculation Hypotension ```
67
5 alpha reductase inhibitors- MOA
Block intracellular conversion of testosterone to dihydrotestosterone Most effective in large prostate gland (>30-60 g) Decreases the risk of urinary retention Decreases risk of surgical intervention Takes 6-12 mos to achieve maximum response
68
Names of 5 alpha reductase inhibitors
``` Finasteride 5 mg -25% risk reduction prostate CA -Increased risk of high grade cancers Dutasteride 0.5 mg -23% reduction in all prostate CAs ```
69
SEs of 5 alpha reductase inhibitors
ED, might be permanent after stopping meds
70
Phytotherapy for BPH
Saw Palmetto berry- phytosterols African plum Flax seed oil Pumpkin seed
71
Surgical management of BPH
Transurethral resection of the prostate (TURP) -Gold standard Transurethral microwave thermotherapy (TUMT) Green light photovaporization of the prostate (PVP) Transurethral laser incision of prostate (TULIP) Simple open prostatectomy Transurethral needle ablation (TUNA) Alcohol ablation of prostate Transurethral incision of the prostate (TUIP)
72
Transurethral resection of the prostate (TURP)
A urologist passes a thin tube through the urethra into the center of the gland then scrapes away prostate tissue with an instrument inserted through the tube Wears catheter for 3-4 days afterwards, 1 night in hosp Lasts between 8 and 20 yrs
73
Surgical risks of TURP
``` Impotence Retrograde ejaculation Incontinence Infection Excessive blood loss ```
74
Cooled thermo therapy for BPH
A minimally invasive and durable tx that is an alternative to surgery or a lifetime of drugs Applies microwave energy to the prostate to continuously heat the diseased tissue Applies continuous cooling to the urethra to minimize pt discomfort and risk to the urethra
75
Advantages of cooled thermo therapy for BPH
No significant bleeding Minimal convalescent period NO associated urinary incontinence No disturbance of PSA as a diagnostic test after 6 wks
76
Interstitial laser coagulation for BPH
Transurethral procedure Heat from laser coagulates excess tissue Excess tissue absorbed by body Gradual decrease of sx
77
Photovaporization of prostate
Transurethral procedure Heat from laser melts prostate tissue Excess tissue vaporizes as gas Fast improvement...immediate
78
Transurethral needle ablation (TUNA)
Delivers low-level radio frequency energy into the middle of the prostate and relieves obstruction without causing damage to the urethra Can be performed with local anesthesia in urologist's office Takes <1 hr Catheterization, if required, is 0-2 days on average Intended for men >50
79
TUNA procedure results
``` Most pts: -Return to nl activities within 48 hrs -Have few SEs -Have low risk of sexual SEs Long-term five yr clinical data shows the durability of the procedure ```
80
Stress incontinence
Leaks with coughing, standing, sneezing, or laughing MC in females after childbirth or hysterectomy MC in males after prostate surgery
81
What is first line for stress incontinence?
Kegel exercises but hard to adhere to
82
Medical therapy for stress incontinence
Imipramine 25 mg PO BID | Pseudoephedrine 60 mg PO BID
83
Surgical therapy for stress incontinence
``` Female sling (bladder tack) Male artificial urinary bladder ```
84
Urge incontinence
Compelling urge to void quickly Cannot get to bathroom in time Day or nighttime frequency Worse with foods or drinks that irritate bladder
85
Tx for urge incontinence
Dietary mod | -Antimuscarinic anticholinergic meds
86
Surgical tx for urge incontinence
Botox bladder Interstim Bladder augmentation
87
Overflow incontinence
Weak bladder detrusor muscle | Obstructive outlet such as prostate or urethral stricture
88
Tx for overflow incontinence
Bethanethol 25 mg PO QID Interstim Intermittent catheterization 5-6 times a day
89
Functional incontinence
Does not know when voiding Does not care if voiding Common in nursing home or elderly
90
Tx for functional incontinence
Times voiding -Caretaker -Apps Diapers
91
Types of urinary calculi
Calcium oxalate Calcium phosphate Mixed calcium oxalate and calcium phosphate Struvite (infection)- magnesium ammonium phosphate hexahydrate Cystine Indinavir (5% of HIV pts receiving indinavir)
92
Urolithiasis sx
``` Renal colic N/V Hematuria Dysuria Acute onset CVA tenderness ```
93
Urolithiasis dx
``` Hx PE UA BMP, Ca KUB or CT stone study ```
94
Three premises of tx strategy for urinary calculi
Stone dz is a lifelong problem -Risk of recurrences decreases >65 yo from decreased kidney concentrating ability Surgical removal of impassable stones Medical management of each stone type
95
Factors affect urinary stone tx
``` Duration of sx Size of calculus Type of calculus Renal fxn Age and medical condition Infection Occupation Economic status ```
96
Complications of urinary calculi
``` Renal colic -As stone passes down ureter -Intense pain requiring narcotics --IV morphine --IV Toradol Obstruction -Transient of minimal consequence acutely -Can be serious if long-standing --Renal damage -Silent obstruction Infection -Combined obstruction and infection lead to urosepsis and permanent renal damage -Instumentation may infect sterile calculi or urine -Struvite calculi formation Bleeding -Not anemia -Hematuria evaluations ```
97
Etiology of urinary stones
Urinary supersaturation Insufficient crystallization inhibitors Contributors of crystallization
98
Supersaturation and urinary stones
All stones form in supersaturated urine Urine is occasionally undersaturated Urine s normally saturated or supersaturated with calcium oxalate Range of supersaturation is 1-20 times saturation concentration
99
Inhibitors of urinary stones
``` Citrate Pyrophosphate (orthophosphates) Urinary ribonucleic acid Urinary glycosaminoglycans Limited ability to influence inhibitors ```
100
Contributors to urinary stones
``` Anatomy Diet Genetics Activity Environment Dz Infection Medication ```
101
What contributes to renal calculi?
Renal calyceal diverticulum | Ureteropelvic junction obstruction
102
What contributes to bladder calculi?
BPH Neurogenic bladder Urethral stricutre
103
How does calcium contribute to calcium oxalate stones?
Calcium intestinal absorption increased by - Vit D - Protein - -56 g/day (6 oz lean meat plus other sources) - Soft drinks - Carbs - Milk products - -Lactose highly lithogenic - -Ca
104
How does oxalate contribute to calcium oxalate stones?
Absorption is increased by: - Vegetables - -Spinach and greens - -Asparagus - -Soybeans - Berries - -Cranberries - -Strawberries - Fruits - -Citrus juice - Tea and coffee - Chocolate
105
What promotes uric acid stones?
``` High purine diet High purines are in: -Meat -Vegetables -Caviar -Beer -Wine ```
106
What increases struvite stones?
``` Phosphorous High phosphorous in: -Milk -Milk products -Soft drinks -Colas ```
107
What genetic conditions contribute to urinary stone formation?
``` congenital hyperoxaluria -D/t amino acid enzyme defect -Nephrocalcinosis -Renal failure Cystinuria -Impaired transport of amino acids across intestines Gout -Altered protein metabolism -20% will develop uric acid stones ```
108
What types of activities contribute to urinary stone formation?
``` Dehydration -Vigorous physical activity -Periods of food deprivation Immobilization worsens hypercaliuria -Stones precipitate in dependent areas of kidneys -Sedentary occupations increase risk -Spinal cord injury increases stone risk ```
109
How does the environment contribute to urinary stone formatioin?
``` Hot climates promote stones Sunshine increases intestinal calcium absorption Hard water promotes stones -High in minerals and calcium -Binds oxalate in intestines -Well water 2x risk of city water ```
110
Which diseases contribute to urinary stone formation?
``` Primary hyperparathyroidism -Parathyroid adenoma -Serum calcium >10.2 -Treat with parathyroidectomy Renal tubular acidosis -Inability of distal nephron to maintain H+ ion gradient -High urinary pH >5.3 -Serum pH <7.25 Medullary sponge kidney -Dilation of ducts of Bellini -Focal or diffuse stone formation ```
111
How does infection contribute to urinary stone formation?
``` Types -Struvite -Carbonate apatite Form when: -pH >7.0 -Urease-producing infection ```
112
Meds that contribute to urinary stone formation
``` Acetazolamide- calcium phosphate stones Tiramterene- triamterene stones Chemo- uric acid stones Magnesium laxatives and antacids- struvite stones AIDS tx- indinavir stones ```
113
How to manage the first urinary stone
White adult with calcium oxalate stones - SMAC-7 - Serum Ca - UA - Urine culture - 50% chance of a second stone if no changes
114
Who gets a recurrent urinary stone workup?
Black adults Children Struvite, uric acid, and cystine stone formers
115
Management of recurrent urinary stones 1 yr after stone
``` Annual checkup 24 hr urine collection for vol UA KUB Placebo effect >50% reduction ```
116
Management of recurrent urinary stones 7 yrs stone-free
Annual checkup UA Do this until 20 yrs stone-free
117
Recurrent urinary stone management
``` Increase fluid intake Daily 3,000 cc urine output -Push pt for 1 mo -Then more automatic Even water consumption throughout the day -Postprandial -Sleep periods ```
118
How to remove impassable urinary stones
ESWL- electrohydraulic shock wave lithotripsy PUL- percutaneous ultrasonic lithotripsy EHL- ureteroscopic electrohydraulic lithotripsy Ureteroscopic ultrasonic lithotripsy Ureteroscopic laser lithotripsy Stone basket- ureteroscopic or cystoscopic (recurrent calcium oxalate)
119
Dietary modification for urinary stones
``` 24 hr urine collection -Ca, oxalate, magnesium, phosphorous, sodium, citrate, uric acid, potassium Hydration Low oxalate diet (40 mg/day) Calcium moderation (800-1000 mg/day) Low sodium diet (4-6 g/day) -Sodium increases calcium urine excretion Low phosphorous diet (1000 mg/day) Low animal proteins -Protein increases urine uric acid, oxalate, and calcium Increase high fiber -Binds calcium and oxalate in gut Low fat Add citrate ```

CAM III (12 decks)

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