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PHA 522 > Men's Health/Urology > Flashcards

Men's Health/Urology Flashcards

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1
Q

Hydrocele: what is it

A

collection of fluid around the testicle

forms between the parietal and visceral tunica vaginalis

benign

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2
Q

Hydrocele: etiology

A

idiopathic
OR
reactive (assc w/ inflammatory process)

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3
Q

Hydrocele: presentation

A

unilateral scrotal enlargement

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4
Q

Hydrocele: evaluation/diagnostics

A

palpation
transillumination
scrotal US

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5
Q

Hydrocele: treatment

A

asymptomatic:
- reassurance, monitoring

bothersome:
- needle aspiration w/ sclerosing agent
- hydrocelectomy

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6
Q

Hydrocele: Which treatment option has an increased risk of recurrence?

A

needle aspiration w/ sclerosing agent

hydrolcelectomy: not likely to recur

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7
Q

Varicocele: what is it

A

dilated veins of the pampiniform plexus

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8
Q

Varicocele: effects (can lead to…)

A

pain
testis damage (fibrosis, dec spermatogenesis)
testis atrophy
infertility (dec sperm count, dec sperm motility, inc abnormal sperm)

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9
Q

Varicocele: physical exam

  • which positions to we exam the patient in
  • what is the hallmark finding
A

supine, standing, valsalva w/ standing

feels like a BAG OF WORMS

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10
Q

Varicocele: Grade I

A

small size
not grossly visible
only palpable w/ valsalva

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11
Q

Varicocele: Grade II

A

med size
not grossly visible
palpable w/ standing

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12
Q

Varicocele: Grade III

A

large size

grossly visible

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13
Q

What is the MC location for a varicocele?

A

typically on the left

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14
Q

What is the potential significance of a right sided, rapid onset varicocele?

A

can signal renal malignancy

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15
Q

Varicocele: treatment

A

surveillance (semen analysis, measure testicular size)

surgery (ligation of vein to redirect venous outflow, percutaneous embolization)

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16
Q

Varicocele: indications for surgery

A

symptomatic

palpable w/ abnormal semen analysis

w/ small testis

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17
Q

Phimosis: what is it

A

prepuce stuck distal to glans

“muzzle”

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18
Q

Phimosis: presentation

A

difficulty voiding

balanitis

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19
Q

Phimosis: treatment

A

circumcision

hygiene

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20
Q

Paraphimosis: what is it

A

prepuce stuck proximal to the glans – unable to be reduced

emergency!

preventable!

constriction of venous outflow, normal arterial flow –> swelling –> prepuce gets tighter (positive feedback loop)

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21
Q

Paraphimosis: treatment

A

reduction (prepuce pulled back over glans)

if manual reduction not successful:

  • dorsal slit
  • circumcision
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22
Q

Paraphimosis: complications

A

Fournier’s gangrene in IM

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23
Q

Testicular Torsion: risk factors

A

undescended testis (cryptorchidism)

bell clapper deformity

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24
Q

Testicular Torsion: presentation, MC age group

A

acute onset
severe intensity
absent swelling

tender, firm testis
high riding testis
horizontal lie
ABSENT CREMASTERIC REFLEX
no relief w/ elevation
thick/knotted sperm cord
misplaced epididymis (not posterior)

MC age group: 12-18yo

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25
Testicular Torsion: diagnosis
clinical doppler US (minimal blood flow) nuclear testicular scan (dec radiotracer activity)
26
Testicular Torsion: treatment
manual detorsion if viable: B orchiopexy if not viable: orchiectomy + orchiopexy of contralateral testis
27
What is the timeline for viability with testicular torsion?
detorsion <6hrs: most viable detorsion >24hrs most non-viable
28
Cystitis: what is it
urinary infection involving the bladder aka bladder infx, lower UTI
29
Cystitis: risk factors
``` immunocompromised urinary stasis/obstruction congenital abn sexual activity spermicide use diaphragm use urinary incontinence cystocele, pelvic prolapse ```
30
Cystitis: presentation
``` dysuria, urgency, frequency suprapubic discomfort cloudy malodorous urine fever mental status change SCI ```
31
Cystitis: diagnosis
urinalysis: - leukocyte esterase positive - nitrite positive - pyuria >5 - bacteria urine culture: - > 100,000 - monoculture
32
What is the MC pathogen for cystitis?
E coli Other common: Klebsiella, Enterobacter, Proteus, Pseudomonas, Staphylococcus saprophyticus, Enterococcus, Candida
33
Cystitis: treatment
antibiotics - TMP/SMZ DS bid x 3d - nitrofurantoin 100mg bid x 5-7d
34
Cystitis: persistent symptoms post treatment: prevent re-infection
avoid spermicides/diaphragm topical vaginal estrogen prophylactic abx self start abx therapy
35
Cystitis in the presence of a chronic indwelling catheter: what do you do
remove catheter replace catheter and obtain urine culture abx **colonization does NOT equal infection!
36
Urethritis: what is it
inflammation of the urethra
37
Urethritis: causes (infectious and non infectious)
non infectious: - trauma - reiter's - urethral stricture - urethral stone - urethral lesions infectious: - gonorrhea - chlamydia, mycoplasma, etc
38
Urethritis: presentation
``` dysuria urethral pruritis urethral discharge -gonorrhea: profuse, purulent -chlamydia: clear/purulent/absent ```
39
Urethritis: labs
first void urinalysis - leukocyte esterase positive - >10 wbc gram stain - >5 wbc culture/NAAT for gonorrhea/chlamydia
40
Urethritis: treatment
gonorrhea: ceftriaxone 250mg IM x 1 chlamydia: azithromycin 1g PO x 1 OR doxycycline 100mg PO bid x 7d abstain from sex until 7d after tx initiated
41
Urethritis: follow up
gonorrhea: test of cure in 3mo (1wk if alt tx) chlamydia: if pregnant -- test of cure in 3-4wks
42
Epididymitis: causes
``` behcet's disease accumulation of amiodarone in epididymis testis/epididymal tumor acute bacterial infx viral granulomatous (TB) fungus, ureaplasma, trichomonas ```
43
Epididymitis: What are the MC pathogens for which age groups?
< 35yo: neisseria gonorrhoeae, chlamydia trachomatous >35yo: E coli
44
Epididymitis: presentation
testicular pain edematous tender testicle, epididymis, spermatic cord fever hydrocele
45
Epididymitis: diagnosis
clinical urine culture STD test (if suspected) scrotal US w/ doppler
46
Epididymitis: treatment
scrotal support analgesia cold antibiotics (levofloxacin)
47
Chronic Epididymitis: what is it
epididymitis for 3+ months
48
Chronic Epididymitis: diagnosis
clinical UA, urine C&S, other cultures scrotal US w/ doppler CT
49
Chronic Epididymitis: treatment
``` analgesics pain clinic scrotal support activity modification moist heat spermatic cord block antibiotics ``` ``` testicular denervation removal of granuloma vasovasostomy/epididymectomy orchiopexy inguinal orchiectomy ```
50
Prostatitis: what is the hallmark
prostatic pain
51
Acute Bacterial Prostatitis: presentation
fever irritative, poss obstructive voiding sx warm, boggy, tender prostate "they look septic"
52
Acute Bacterial Prostatitis: MC population MC pathogen
young men | E coli
53
Acute Bacterial Prostatitis: diagnosis
clinical (NO vigous prostate exam) urine culture (NO post prostate massage) CBC, blood cultures
54
Acute Bacterial Prostatitis: treatment
may need to admit for IV abx PO abx x 4-6wks *if persistently febrile: CT pelvis (r/o abscess)
55
Chronic Bacterial Prostatitis: presentation
``` recurrent prostatic infx pain in genitals, urinary tract, perineum, low back dysuria, urgency, frequency pain w/ ejaculation tender, boggy prostate ```
56
Chronic Bacterial Prostatitis: MC population MC pathogen
older men E coli other organisms: Klebsiella, Pseudomonas, Proteus, Enterococcus, Staphylococcus saprophyticus, Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis
57
Chronic Bacterial Prostatitis: diagnosis
clinical labs: - expressed prostatic secretion - post prostate massage urine culture - meares stamey 4 glass test
58
Chronic Bacterial Prostatitis: treatment
antibiotics (TMP/SMZ) x 8-16wks NSAIDs alpha blockers anticholinergics/antimuscarinics ``` phytotherapy zinc diet stress management prostate massage, ejaculation sitz baths ```
59
Inflammatory Chronic Pelvic Pain Syndrome: what is it
nonbacterial prostatitis
60
Inflammatory Chronic Pelvic Pain Syndrome: presentation
``` recurrent prostatic infx pain in genitals, urinary tract, perineum, low back dysuria, urgency, frequency pain w/ ejaculation tender prostate ```
61
Inflammatory Chronic Pelvic Pain Syndrome: diagnosis
clinical labs: - prostatic fluid w/ leukocytes - no bacteria on culture
62
Inflammatory Chronic Pelvic Pain Syndrome: treatment
FQ or SMX-TMP x 6-8wks (not responsive: doxycycline 4-6wks) mycoplasma genitalium (NAAT test) palliative measures
63
Noninflammatory Chronic Pelvic Pain Syndrome: presentation
``` recurrent prostatic infx pain in genitals, urinary tract, perineum, low back dysuria, urgency, frequency pain w/ ejaculation tender prostate ```
64
Noninflammatory Chronic Pelvic Pain Syndrome: diagnosis
clinical labs: - no bacteria on culture - no leukocytes in prostatic fluid
65
Noninflammatory Chronic Pelvic Pain Syndrome: treatment
palliative measures
66
What are the palliative measures in the treatment of prostatitis?
NSAIDs Anticholinergics for urinary urgency Alpha blockers Sitz baths Stress reduction, biofeedback, counselling Can try zinc, nickel, saw palmetto, quercitin Prostate massage Dietary (caffeine, alcohol, spicy acidic food) Benzodiazepine Tricyclic antidepressant Analgesics, Pain specialist consult
67
Pyelonephritis: what is it
upper tract urinary infx involving kidney's renal parenchyma
68
Pyelonephritis: presentation
``` fevers chills flank pain abdominal pain N/V ``` ``` ascending infx: dysuria frequency urgency hematuria ``` ``` hematogenous spread (IVDA, cutaneous infx) no urinary sx ```
69
Pyelonephritis: diagnosis
UA: WBC, WBC casts urine culture CBC: leukocytosis w/ L shift CT urogram: - perinephric stranding - kidney enlargement - dec nephrogram - dilated renal collecting system Renal US: - kidney enlargement - abn echogenicity
70
Pyelonephritis: indications for imaging
``` very ill unstable septic DM IM structural abnormality obstruction stones unresponsive to abx ```
71
Pyelonephritis: treatment: mild illness
FQ PO x 7d
72
Pyelonephritis: treatment: mod-sev illness
(high fever, high wbc, vomiting, dehydration, sepsis) admit: - cultures - IV abx - imaging - f/u C&S after tx
73
What GU infections is part of a spectrum? | What else does the spectrum include?
pyelonephritis acute bacterial nephritis and renal abscess
74
Acute Bacterial Nephritis: what is it
bacterial interstitial nephritis of the renal cortex causes renal mass but NO liquefaction aka acute lobar nephronia
75
Renal Abscess: what is it MC population MC pathogen
purulent fluid collection of kidney DM, IM gram negatives (hematogenous route: gram positives)
76
Renal Abscess: treatment
IV abx percutaneous drainage surgical drainage
77
Chronic Pyelonephritis: what is it
scarred atrophic poorly functioning kidney result of prior infx low flow, high renin
78
Chronic Pyelonephritis: presentation
``` HTN anemia proteinuria renal insufficiency recurrent UTIs ```
79
Chronic Pyelonephritis: diagnosis
radiography: caliceal blunting
80
Chronic Pyelonephritis: treatment
manage UTI risk factors control HTN nephrectomy
81
Benign Prostatic Hyperplasia: what is it
enlarged prostate in the absence of malignancy impedes urine leaving bladder by: - growth of prostatic glandular tissue - inc smooth muscle of prostatic stroma
82
BPH: presentation
``` (LUTS) weak urinary stream urinary hesitancy stream intermittency post void dribbling nocturia ``` urinary retention recurrent UTIs hx of cystolithiasis, urolithiasis
83
What is the questionnaire used to assess patients with BPH?
AUA symptom score 7 questions score: 0-7: mild sx 8-19: moderate sx 20-35: severe sx
84
BPH: diagnosis
GU exam w/ DRE (note size, consistency, tenderness) UA PSA if indicated ``` uroflow study (low flow rate) PVR (high residual) cytoscopy (trabeculation, obstructive prostate, kissing lobes) urodynamic study (low flow, elevated intravesical pressures) ```
85
BPH: treatment
watchful waiting lifestyle modification medication surgery
86
BPH: treatment: lifestyle modifications
``` avoid fluid intake and diuretics in evening elevate legs in evening (if edema) avoid food/drinks that exacerbate sx double void avoid pseudoephedrine/alpha agonists caution w/ anticholinergics ```
87
BPH: treatment: medication
phytotherapy (saw palmetto) alpha blockers (1: terazosin, doxazosin)(1A: tamsulosin, silodosin, alfuzosin) 5 alpha reductase inhibitors (finasteride, dutasteride) PDE 5 inhibitors (tadalafil)
88
BPH: treatment: alpha blockers - action - 1A vs 1 - ADEs
relax smooth muscle --> freer urine passage 1A: more specific, less ADEs than 1 ADEs: dizziness, asthenia, nasal congestion, orthostatic hypotension/syncope, retrograde ejaculation, IFIS (no cataract surgery)
89
BPH: treatment: 5 alpha reductase inhibitors - action - time to effect - indication - ADEs
``` dec glandular vol inc flow rates improve sx score dec risk of progression dec PSA readings by 50% ``` can take 6 mo to see effect most beneficial in large prostates (>40cc, PSA > 1.4) ADEs: impotence, dec libido, lower ejaculatory vol, gynecomastia
90
BPH: treatment: medication plan
combination alpha blocker + 5 ARI alpha blocker: early response until 5 ARI takes effect
91
BPH: treatment: PDE5-I | -indication
patients w/ BPH + ED
92
BPH: treatment: surgery
Transurethral Microwave Thermotherapy (TUMT) Transurethral Incision of Prostate (TUIP) Urolift Transurethral Resection of Prostate (TURP) Photoselective Vaporization of Prostate (PVP) Open simple prostatectomy Holmium Laser Enucleation of Prostate (HoLEP)
93
BPH: when is TUIP indicated?
smaller collar type prostates
94
BPH: treatment: urolift | -what is it
permanent implant into prostate compresses prostatic tissue --> widened urethral lumen
95
What is the gold standard surgical treatment for BPH?
Transurethral Resection of Prostate (TURP)
96
BPH: treatment: TURP: complications
``` retrograde ejaculation hematuria TUR syndrome -hyponatremia -mental confusion -HTN -visual changes ```
97
BPH: what is an advantage of PVP treatment?
can be done on an anticoagulated pt
98
BPH: when is open simple prostatectomy indicated?
very large prostate >80cc
99
BPH: when is HoLEP indicated?
For large prostates (>80g, >100g, >200g…)
100
Urinary Incontinence: what is it, classification
involuntary loss of urine classified based on: - symptoms (stress, urge) - underlying pathology (sphincter def, detrusor overactivity, urinary retention)
101
Urinary Incontinence: Transient Causes
``` DIAPPERS delirium infection atrophic vaginitis pharmaceuticals/polypharmacy psychological excessive urine production restricted mobility stool impaction/constipation ```
102
Urinary Incontinence: precipitating factors
``` cough/laugh/strain movement EtOH, caffeine constipation immobility ```
103
Urinary Incontinence: treatment (DIAPPERS)
``` D: treat underlying cause I: abx A: topical vaginal estrogens P: elimination/adjustments P: psych referral E: treat cause, alter timing of fluid intake/diuretics, elevate LE R: bedside commode S: bowel management ```
104
Urinary Incontinent: treatment (urinary retention)
avoid certain meds catheterization BPH meds, surgery
105
Urinary Incontinence: treatment (continuous incontinence/fistula)
surgery
106
Urinary Incontinence: Female SUI Treatment (noninvasive)
behavioral therapy medication continence devices
107
Urinary Incontinence: Female SUI Treatment (minimally invasive)
bulking agents (collagen, graphite, calcium hydroxyapatite, silicone)
108
Urinary Incontinence: Female SUI Treatment (surgical)
anterior repair suspension artificial urinary sphincter sling
109
Urinary Incontinence: Female SUI Treatment: behavioral therapy
``` Activity modification Voiding diary Timed voiding Bladder training Pelvic floor muscle training (PFMT) Fluid intake modification Dietary modification Weight loss Avoidance of constipation Elevation of edematous lower extremities ```
110
Urinary Incontinence: Female SUI Treatment: medications
alpha agonists | duloxetine
111
Urinary Incontinence: Female SUI Treatment: continence devices
pessary indwelling urinary catheter urethral occlusive device
112
Urinary Incontinence: Artificial Urinary Sphincter: complications
infection - pain, edema, erythema, leukocytosis, fever - tx: explantation, abx erosion - dysuria, hematuria, recurrent infx - tx: explantation, re-implant 3 months later - prevention: avoid harsh perineal pressure
113
Urinary Incontinence: Urge Incontinence: what is it
episodic involuntary loss of urine immediately preceded by/associated w/ urgency
114
Urinary Incontinence: Overactive Bladder: what is it
urinary urgency usually associated w/ frequency
115
Urinary Incontinence: Urge Incontinence and Overactive Bladder: treatment (non invasive)
behavioral therapy estrogen (postmenopausal females) anticholinergic meds (oxybutynin, tolterodine, fesoterodine, darifenacin, solifenacin, trospium) bet adrenergic medication (mirabegron)
116
Urinary Incontinence: Urge Incontinence and Overactive Bladder: treatment (min invasive)
neuromodulation (sacral, posterior tibialis) | botulinum
117
Urinary Incontinence: Urge Incontinence and Overactive Bladder: treatment (surgical)
augmentation enterocystoplasty autoaugmentation urinary diversion
118
When treating patients with Mirabegron, what do you need to monitor for?
increased blood pressure
119
Prostate Cancer: risk factors
FAMILY HISTORY possible: - environmental - diet (mediterranean = protective) - high serum T
120
What is the relationship between prostate cancer and castrated men?
castrated before puberty --> do NOT develop prostate cancer prostate cancer responds to hormonal deprivation
121
Prostate Cancer: early signs and symptoms
none
122
Prostate Cancer: late signs and symptoms
obstructive sx
123
Prostate Cancer: later signs and symptoms
metastatic sx
124
Prostate Cancer: DRE general principles
any hard nodule needs to be biopsied any questionable nodule needs to be correlated with PSA
125
What are the indications for checking PSA when screening for prostate cancer?
positive FH African American symptomatic
126
Is it appropriate to check PSA after a DRE?
yes inc in serum PSA after DRE is clinically insignificant
127
PSA velocity: definition, usefulness
change in PSA concentration over a period of time may detect early prostate cancer
128
PSA density: definition, usefulness
serum PSA concentration divided by prostate volume significant >0.15 helps differentiate prostate cancer from BPH
129
Is PSA specific to prostate cancer?
NO ``` can also be elevated by: -acute urinary retention -BPH -prostatitis -prostatic infarction -prostatic intraepithelial neoplasia instrumentation/catheterization ```
130
Aside from PSA and DRE, what are other tools used in diagnosis of prostate cancer?
genomic testing (PCA 3, 4K score) multiparametric MRI (PI RADS score) targeted fusion biopsy transrectal US/biopsy
131
What is the Gleason score?
histologic grading of prostate cancer
132
Prostate Cancer: symptoms of metastasis
``` bone pain weight loss anemia azotemia fatigue dyspnea lymphedema ureteral obstruction ```
133
Prostate Cancer: metastatic evaluation
nuclear medicine bone scan CT abdomen and pelvis PET
134
Prostate Cancer: treatment
``` surgical (radical prostatectomy) radiation (external beam, seed implantation) hormonal manipulation observation/active surveillance new options ```
135
Prostate Cancer: indication for radical prostatectomy
lesions clinically confined to prostate
136
Prostate Cancer: radical prostatectomy complications
IMPOTENCE bladder neck contracture incontinence
137
Prostate Cancer: what is the result of hormonal manipulation treatment?
tumor regression
138
Prostate Cancer: hormonal manipulation
B orchiectomy LH RH analogs (leuprolide, goserelin) anti androgens
139
Prostate Cancer: common ADEs of LH RH analogs
``` diarrhea N/V peripheral edema gynecomastia HOT FLASHES ```
140
Prostate Cancer: castrate resistant treatments
``` Abiraterone (Zytiga) Enzalutamide (Xtandi) Sipuleucel-T (Provenge) Docetaxel (Taxotere) Cabazitaxel (Jevtana) Radium-223 ```
141
Most Common causes of cancer death in US males
1. lung 2. prostate 3. colorectal 4. bladder
142
MC type of bladder cancer
urothelial carcinoma
143
MC etiology of urothelial carcinoma
smoking
144
MC population for bladder cancer Race with the lowest rate of bladder cancer
caucasian males asian
145
Bladder Cancer: treatment
transurethral resection of bladder tumor (TURBT) cystoscopy, biopsy, fulguration (CBF) intravesicle therapy (BCG, mitomycin, thiotepa, valrubicin) cystectomy (robot assist, open)
146
Bladder Cancer: when is a cystectomy indicated?
if the tumor is muscle invasive **SF vs muscle invasive
147
Bladder Cancer: urine pathway
ileal conduit neobladder mainz II catheterizable pouch
148
Noncancerous reasons to do a cystectomy
urinary incontinence | interstitial cystitis
149
Bladder cancer is a disease of the ...
urothelium
150
What is the MC type of testicular tumor?
germ cell tumors (seminoma and non seminomas) **5-10%: stromal tumors (leydig cell, sertoli cell, granulosa cell)
151
Testicular Tumor: risk factors
cryptorchidism FH personal hx HIV infx
152
Testicular Tumor: presentation
PAINLESS mass/swelling R>L back pain, abdominal mass
153
Testicular Tumor: locations of metastasis
contralateral testis retroperitoneal LN lung, liver, brain, bone, kidney, adrenal, GI, spleen
154
Testicular Tumor: diagnostics
``` H&P US tumor markers (alpha fetoprotein, beta HCG, lactate dehydrogenase) LFTs, CBC, creatinine CXR ```
155
Testicular Tumor: treatment
refer to oncology (lymphoma) radical inguinal orchiectomy
156
Testicular Tumor: post orchiectomy evaluation
wait 5 half lives to assess tumor markers - AFP: 5wks - B HCG: 1-2wks - LDH: 3wks CT chest/abd/pelvis
157
Testicular Tumors: staging is based on...
tumor lymph nodes distant metastasis serum tumor markers
158
Testicular Tumor: post orchiectomy management
surveillance chemotherapy radiation retroperitoneal LN dissection (RPLND)
159
Testicular Tumor: post orchiectomy: surveillance
H&P, tumor markers - q3-4mo x 2yr - q6-12mo x 2 yr - annually CT abd/pelvis - q6mo x 2yr - q6-12mo x 1yr - annually CXR PRN
160
Testicular Tumor: post orchiectomy: chemotherapy (agents, ADEs)
carboplatin, bleomycin, etoposide, cisplatin ADEs: - myelosuppression - nausea - fatigue - infertility
161
Testicular Tumor: post orchiectomy: radiation (side effects)
Acute: - nausea - vomiting, fatigue, myelosuppresion Later: - PUD, gastritis - inc risk of CV death - inc risk of secondary cancer
162
Testicular Tumor: follow up
tumor markers physical exam imaging lifelong
163
What is the most common stone composition in urolithiasis? (features, MCC)
calcium oxalate - radio opaque - resistant to dissolution - MCC: dehyrdation
164
Urolithiasis: other stone compositions
uric acid (radiolucent, dissolves in alkaline urine) magnesium ammonium phosphate (MCC: uti, dissolved in acidic urine, staghorn) cystine (genetic defect, MCC: cystinuria, dissolves in alkaline) matrix (proteus uti, radiolucent) ammonium acid urate (uti/laxative abuse, radiolucent) proteus inhibitor stone (drug/indinavir, radiolucent, not visible on stone protocol CT)
165
Urolithiasis: etiology
anatomy (obstruction, stasis) urine characteristics (pH, citrate, urea) volume status (vol depletion, low UO, supersaturation) diet metabolic (hypercalciuria, hypocitraturia, hyperoxaluria, hyperuricosuria) disease state UTI medication
166
Urolithiasis: etiology: disease states
``` obesity metabolic acidosis renal tubular acidosis sarcoidosis chronic diarrhea (--> vol dep) cystinuria inflammatory bowel disease hyperparathyroidism medullary sponge kidney adult polycystic kidney disease ```
167
Urolithiasis: etiology: medications
``` vitamin C vitamin D triamterene precipitation protease inhibitors (indinavir) furosemide acetazolamide uricosuric agents (probenecid, salicyclates) ```
168
Urolithiasis: presentation
pain (flank, radiating, colic) N/V hematuria hyperkinetic fever --> emergency CVA tenderness
169
Urolithiasis: is it worse when you drink?
yes | making more urine --> pressing against stone --> worse pain
170
Urolithiasis: is it worse with twisting/bending?
no | yes would be more indicative of MSK issue
171
Urolithiasis: diagnostics
UA CBC creatinine, BUN, electrolytes ``` KUB US IV urogram **CT STONE PROTOCOL CT urogram ```
172
Urolithiasis: indications for acute intervention
``` complete/high grade obs bilateral obs obs w/ infx obs in solitary kidney obs w/ rising creatinine sev N/V sev pain ```
173
Urolithiasis: acute treatment
antibiotics | ureteral stent/nephrostomy tube
174
Urolithiasis: lower tract stone treatment
cystourethroscopy,cystolitholapaxy extracorporeal shock wave lithotripsy (ESWL) open stone removal dissolution
175
Urolithiasis: upper tract stone treatment
``` trial of passage dissolution extracorporeal shock wave lithotripsy (ESWL) ureteroscopy w/ stone manipulation percutaneous nephrolithotomy (PCNL) open/laparoscopic surgery ```
176
Urolithiasis: candidates for trial of passage
``` renal function pain control PO intake no infx stone size (5mm or less) ```
177
Urolithiasis: which stones are dissolved in alkaline urine?
uric acid | cystine
178
Urolithiasis: which stones are dissolved in acidic solution?
struvite | calcium phosphate
179
Urolithiasis: ESWL contraindications
pregnancy coagulopathy UTI renal artery aneurysm, AAA relative: - cystine stone, matrix stone - pancreatitis - distal obs
180
Urolithiasis: what are the requirements for ESWL?
stone <2cm | visible on fluoroscopy
181
Urolithiasis: ESWL complications
``` renal/retroperitoneal hematoma ecchymosis UTI, sepsis steinstrasse ureteral stricture pain ```
182
Urolithiasis: ureteroscopy w/ manipulation complications
``` ureteral avulsion ureteral perforation submucosal tunneling ureteral stricture extrusion of stone outside ureter UTI bleeding pain ```
183
Urolithiasis: PCNL indications
large stone burden (>2cm) | staghorn calculus
184
Urolithiasis: PCNL: contraindications
UTI coagulopathy no percutaneous renal access
185
Urolithiasis: PCNL: complications
bleeding sepsis renal pelvis perforation pneumothorax/hydrothorax
186
Urolithiasis: high risk for recurrent stones
``` Pediatric stone formers Solitary kidney Staghorn/multiple stones Cystine, uric acid, struvite stones Nephrocalcinosis Gout Chronic UTI FH Stones GI diseases w/ higher incidences of stones (Crohn’s) Bone diseases (path fx, osteoporosis) Professions where stone pain can endanger others ```
187
Urolithiasis: prevention of future stones
``` inc fluid intake (esp w/ citrate, no soda) low Na low animal protein low oxalate mod Ca avoid high dose vitamin C and D reduce PRAL medications ```
188
Urolithiasis: prevention of future stones: medications
``` potassium citrate thiazide allopurinol pyridoxine (B6) cholestyramine thiols ```
189
What are the 6 things to not miss in urology?
``` obstructive stone w/ fever testicular torsion fournier's gangrene acute urinary retention priapism paraphimosis ```
190
Obstructive Stone w/ Fever: what is it
infected urine upstream of obstruction unable to drain infx abscess
191
Obstructive Stone w/ Fever: treatment
drainage (nephrostomy tube, ureteral stent) IV abx
192
Fournier's Gangrene: what is it
necrotizing fasciitis of male genitalia and perineum infx advances RAPIDLY, over minutes
193
Fournier's Gangrene: risk factors
diabetes alcohol abuse IM
194
Fournier's Gangrene: presentation
``` painful swelling/induration of penis, scrotum, perineum cellulitis eschar necrosis ecchymosis crepitus cutaneous anesthesia foul odor fever ```
195
Fournier's Gangrene: finding on imaging
gas in subcutaneous tissues
196
Fournier's Gangrene: treatment
``` IV abx surgical debridement wet to dry dressings whirlpool therapy HBO ```
197
Acute Urinary Retention: etiology
BPH | anticholinergic meds
198
Acute Urinary Retention: diagnosis, treatment
``` Normal bladder capacity Bladder scan (Ultrasound) Lidocaine gel/ Lubrication Foley catheter Coude catheter Suprapubic tube ```
199
Priapism: what is it
Persistent penile erection that continues hours beyond, or is unrelated to sexual strimulation and lasts greater than 4 hours duration
200
Priapism: etiology
sickle cell trazodone cocaine ED treatments
201
Priapism: sequelae
ischemia/hypoxia progressive cavernosal fibrosis ED
202
Priapism: treatment
aspiration instillation of phenylephrine shunts
203
Erectile Dysfunction: definition
inability to attain/maintain penile erection sufficient for satisfactory sexual performance
204
Erectile Dysfunction: etiology
vasculogenic neurogenic (prostatectomy) psychogenic (depression, stress, anxiety, psych d/o) endocrine (hyperPRL, thyroid d/o, SHBG, hypogonadism) medication induced (antihypertensives - beta blockers, antidepressants, antipsychotics, etc)(alcohol, smoking) disease states (renal/hepatic disease, DM, atheroscelrotic, neurologic, endocrine disease, surgery, pelvic/penile fx)
205
Erectile Dysfunction: diagnostics
if indicated: T, PRL nocturnal penile tumescence penile duplex doppler sonography (arterial insufficiency) cavernosometry/cavernosography (venous leak)
206
Erectile Dysfunction: treatment
PDE 5 I yohimbine ``` vacuum erection device (VED) medicated urethral system for erection (MUSE) penile injection constriction ring penile spint penile prosthesis penile revascularization ```
207
Erectile Dysfunction: when are PDE 5 inhibitors contraindicated?
with nitrate use
208
Erectile Dysfunction: PDE 5 I: ADEs
``` nasal congestions facial flushing headache dyspepsia back pain/myalgia visual changes (blue halo/NAION) priapism ```
209
Erectile Dysfunction: PDE 5 I: instructions for use
30-60min before sex avoid taking after meal (not tadalafil) PHYSICAL STIMULATION NEEDED tadalafil stays in system for 36hrs (more likely to have back pain)
210
Erectile Dysfunction: penile injection: risks
``` pain infx bleeding fibrosis (curvature) priapism ```
211
Erectile Dysfunction: penile revascularization surgery: indication, grafted artery
focal arterial occlusion of cavernosal artery inferior epigastric

PHA 522 (2 decks)

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