Urology Flashcards by Maya Birchler

Irritative voiding symptoms (frequency, urgency, dysuria), suprapubic discomfort, gross hematuria
Women = following intercourse

acute cystitis

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what are RF for acute cystitis

Women (sexual intercourse), spermicidal use, pregnancy, infants, indwelling catheter, elderly

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Infection of bladder mostly from e.coli, gram + bacteria (enterococci)
Route = ascending from urethra

Cystitis-like symptoms can also be caused by: pelvic irradiation, chemo, cancer, interstitial cystitis, voiding dysfunction, bladder irritants, psychosomatic disorders

acute cystitis

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PE: suprapubic tenderness
UA: pyuria >10 WBCs, bacteriuria, hematuria
Culture = + for offending organism, definitive diagnosis (those who are asymptomatic with + urine cultures do not require treatment unless pregnant)
Imaging: uncomplicated cystitis is RARE in men; warrants further eval → abdominal US, postvoid residual testing, cystoscopy
→ follow-up if pyelonephritis, recurrent infection, anatomic abnormalities

acute cystitis

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how do you prevent acute cystitis?

hydration + complete emptying bladder, women void after intercourse, postcoital single dose antibiotic, postmenopausal women with recurrent UTI (3+/year) – vaginal estrogen, daily cranberry tablets
(Prophylactic antibiotics discouraged

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how do you treat acute cystitis?

Uncomplicated cystitis in non-pregnant women:
– single dose or 1-7 days of therapy: fosfomycin, nitrofurantoin, bactrim
Restrict FQ use for uncomplicated infections; resistance
Pregnant females: 5-7 days of nitrofurantoin, cephalexin, fosfomycin, augmentin, ampicillin
Refer for any suspicion of abnormality, evidence of urolithiasis, recurrent

Uncomplicated males = doxycycline, ciprofloxacin
Get urine culture first

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Fever, flank pain, shaking chills, irritative voiding symptoms, nausea/vomiting/diarrhea - uncommon but suggestive

acute pyelonephritis

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Infectious inflammatory disease of the upper GU tract with kidney parenchyma and renal pelvis with gram - bacteria most common: E.coli, proteus, klebsiella, enterobacter, pseudomonas, ascending from lower urinary tract

acute pyelonephritis

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PE: fever, tachycardia, CVA tenderness pronounced
LABS: leukocytosis, pyuria (>10 WBCs), bacteriuria, hematuria, white cell casts, urine culture, blood culture
Renal US - hydronephrosis from stone or obstruction
CT - decreased perfusion of kidney, nonspecific perinephric fat stranding

acute pyelonephritis

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how do you treat acute pyelonephritis?

Outpatient: IV of ceftriaxone, ciprofloxacin, gentamicin
Orally: ciprofloxacin, levofloxacin, or bactrim
Inpatient: IV ampicillin + AGs for 24 hours after fever resolves → oral antibiotics

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Pain, pressure, discomfort, with bladder filling relieved with urination
Urgency, frequency, nocturia

interstitial cystitis

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interstitial cystitis is ass w

Severe allergies
IBS
IBD

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“Painful bladder syndrome”, “chronic pain syndrome”, unknown etiology

interstitial cystitis

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Diagnosis of exclusion – negative urine culture, cytology, without obvious other causes
Urodynamic testing to exclude detrusor instability
Cystoscopy: glomerulations (hemorrhage) with hydrodistention of bladder
Biopsy = may have submucosal mast cells but NOT needed to make diagnosis (Hunner’s ulcers)

interstitial cystitis

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how do you treat interstitial cystitis?

No cure – symptomatic relief:
Amitriptyline, nifedipine
Pentosan polysulfate sodium (Elmiron) to restore integrity to bladder
Intravesical instillation of dimethyl sulfoxide and heparin
Electric nerve stimulation
Acupuncture
Stress reduction
Exercise
Surgical therapy last resort - cystouretherectomy w/ urinary diversion

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Perineal, sacral, suprapubic pain with fever, irritative voiding, urinary retention, chills (acute)

acute bacterial prostatitis

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Gram negative rods → e.coli and pseudomonas that ascends from urethra and reflex of infected urine into prostatic ducts
Lymphatic and hematogenous = rare
<35 = chlamydia + gonorrhea MCC
>35 = e.coli MCC

acute bacterial prostatitis

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PE: high fever, warm/tender BOGGY prostate (note, prostate massage is CI)

LABS: leukocytosis and left shift, pyuria, bacteriuria, hematuria, urine culture
IMAGING: can progress to abscess - pelvic CT/transrectal US is indicated if not responsive to antibiotics in 24-48 hours

acute bacterial prostatitis

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how do you treat acute bacterial prostatitis?

Hospitalize → IV ampicillin + aminoglycoside
After patient is afebrile for 24-48 hours -> oral
Ciprofloxacin or bactrim

If urinary retention develops = straight cath to relieve initial obstruction OR short term catheter

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Irritative voiding symptoms, urethral pain, obstructive urinary symptoms, low back and perineal pain, history of UTIs

chronic bacterial prostatitis

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Gram negative rods commonly cause

chronic bacterial prostatitis

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PE: often unremarkable, prostate boggy/indurated, postvoid residual volume, NONTENDER
LABS: normal unless secondary cystitis
Expressed prostatic secretions/post-prostatic massage with urine → increased leukocytes, bacterial growth when cultured
NO organisms = nonbacterial prostatitis, chronic pelvic pain, interstitial cystitis

chronic bacterial prostatitis

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how do you treat chronic bacterial prostatitis?

Repeated courses of antibiotics, if febrile or systemically ill = admission and initial IV therapy → ampicillin + gentamicin, 3rd gen ceph, or FQ

Then oral FQ, bactrim, or extended beta-lactamase

Symptoms = anti-inflammatory agents, hot sitz baths, alpha blockers

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Gradual onset of localized pain and swelling

Chronic dysfunctional voiding, urinary retention, sexual activity, trauma → urethritis, cystitis, pain at scrotum radiating along spermatic cord or flank

acute epididymitis

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<35 = STI + urethritis >35 = UTIs + prostatitis, gram -

acute epididymitis

Most cases infectious – urethra → ejaculatory duct → vas deferens → epididymis

acute epididymitis

PE: scrotal swelling and tenderness, fever, reactive hydrocele, prostate tenderness + Phren’s sign (relief of pain with elevation of scrotum) + Cremasteric reflex LABS: leukocytosis with a left shift Sexually transmitted = gram stain is positive for gonorrhea, urethral stain is positive for nongonococcal, trachomatis Non sexually transmitted = pyuria, bacteriuria, hematuria, urine culture IMAGING: scrotal ultrasound with enlarged epididymis, increased blood flow

acute epididymitis

how do you treat acute epididymitis?

Acutely = bed rest, ice, scrotal elevation STI → IM ceftriaxone + levofloxacin Non-STI = levofloxacin

Scrotal pain, swelling, tenderness, most commonly unilateral Inflammation of testicle + common with other infections such as mumps, coxsackie, EBV, varicella, echovirus, bacterial (ass w/ epididymitis)

orchitis

orchitis has the same treatment of

epididymitis

Urethral discharge or pruritus, dysuria Gonococcal = abrupt onset of opaque, yellow-white, clear thick discharge Non-gonococcal= purulent or mucopurulent discharge, hematuria, pain with intercourse

urethritis

how do you treat urethritis

IM ceftriaxone Doxycycline Allergy to cephalosporins = gentamicin + azithromycin Alternative for chlamydia = azithromycin or levofloxacin

genital or peritoneal pain, pruritus, prodrome of lethargy and fever → swelling and erythema → crepitus and ecchymosis of inflamed tissues

fournier gangrene

Diabetes, alcohol use Polymicrobial, synergistic, infective necrotizing fasciitis of the perineal, genital, perianal Benign infection/abscess → virulent in immunocompromised host → microthrombosis of subcutaneous vessels → gangrene of the skin

fournier gangrene

Bedside US: scrotal wall thickening, “Dirty shadowing” CT

fournier gangrene

how do you treat fournier gangrene?

Fluid resuscitation Full coverage of G+, G-, anaerobic: –pip/taz, imipenem, meropenem + vancomycin Urgent urologic consultation Admit to ICU

Pain: acute, unremitting, and severe colic, typically localized to flank Proximal ureter = flank/CVA tenderness Mid-ureter = mid-abdominal Distal ureter = groin pain N/V, constantly moving, urinary frequency and urgency

urinary stone disease

what are RF for urinary stone disease?

Men 30s-50s Recurrence Decreased fluid intake, medications (carbonic anhydrase inhibitors, steroids, antiretroviral protease inhibitors, gout, diuretics, decongestants, laxatives, calcium), gout, hypercalcemia, polycystic kidney disease, UTIs Stress

what are the types of urinary stones?

Calcium oxalate/phosphate (MC) - radiopaque on XR, increased protein and salt inhibit calcium reabsorption Struvite - urea-splitting organisms Uric acid - pure → radiolucent, from high protein foods Cystine - smooth-edged ground-glass appearance, faintly radiolucent

PE: CVA tenderness LABS: microscopic or gross hematuria Persistent urinary pH <5.5 = uric acid/cystine stone Persistent pH >7.2 = struvite Normal pH + calcium New = consider dietary counseling, sodium/animal protein intake, fluids, PTH, kidney stones IMAGING: non-contrast CT CI: US KUB = only calcium + struvite seen IV pyelography - extent

kidney stone disease

you should monitor renal calculi

with serial abdominal XRs or renal US or every 3-12 m

how do you treat kidney stone disease?

Obstruction + infection (fever, tachycardia, HOTN, elevated WBC – suspect UTI with it): ~~ medical emergency - consult, ureteral stent or percutaneous nephrostomy tube (abx alone are not adequate) Ureteral stones <5mm: → pass spontaneously, expulsive therapy with alpha-blocker (tamsulosin), ibuprofen, low dose prednisone Pain meds + follow up Fail to pass w/n 4 weeks with fever, pain, persistent N/V = surgery >7mm: alkalize urine to pH >6.5 for uric acid stones, stone extraction (stent), extracorporeal shock wave lithotripsy (breaks up stones into fragments, but NO in pregnant women and with UTI) >10mm, struvite, less invasive modalities: percutaneous nephrolithotomy

fibrotic disorder causing penile pain, curvature, deformity, multifactorial

peyronie disease

prolonged, painful erections w/o sexual stimulation low venous flow (compartment syndrome, MC), high arterial flow (trauma), commonly from idiopathic, SCD, infection, trauma

priapism

Loss of libido = androgen deficiency/depression ED = neurological, vascular, hormonal, psychological (MCC = low arterial flow from vascular disease), commonly from medications like anti-HTN, antidepressants, anti-psych, opioids Nitric oxide

sexual dysfunction in males

in sexual dysfunction, the most improtant is

History and PE! – document severity, intermittency, timing, other disease etiologies PE: vitals, 2ndary sexual characteristics, cardio/neuro, genitalia LABS: testosterone – look for hypothalamic-pituitary dysfunction, carnevosal blood gas

use a doppler when concerned about

priapism

how do you treat male dysfunction?

Priapism: Low flow: phenylephrine injection Terbutaline Needle aspiration Shunt surgery High flow: observation ED: phosphodiesterase-5 inhibitors, injectable or suppository meds (prostaglandin E2, alpradostil), hormone replacement, devices, prosthetic Peyronie’s: refer to urologist

Obstructive: hesitancy, decreased force/caliber of stream, sensation of incomplete emptying, double voiding, straining to urinate, post void dribbling Irritative: urgency, frequency, nocturia

BPH

→ bladder outlet obstruction, dependent on increased dihydrotestosterone production

BPH

PE: DRE – smooth, firm, enlarged, rubbery (if induration, concern for cancer), lower abdominal exam to assess for distended bladder PSA elevation IMAGING: cystoscopy, transrectal/abdominal US, cross-sectional imaging of pelvis

BPH

how do you treat BPH

American urological association symptom index to evaluate before therapy Mild (0-7): watchful waiting, alpha blockers - terazosin, doxazosin, tamsulosin (symptom relief, but no slowing disease) 5-alpha-reductase - finasteride (slows growth), phosphodiesterase 5-inhibitor - tadalafil (symptoms and signs) Surgery - TURP, TUIP, TUVP, TUMT

Emergency - abrupt onset of scrotal, inguinal, lower abdominal pain with N/V Teenagers, 10-20, neonates Spermatic cord twists + cuts off blood supply

testicular torsion

PE: swollen, tender, retracted testicle -Phren’s sign -Cremasteric reflex +Blue dot sign at upper pole (torsion) Doppler US, surgical exploration if not

testicular torsion

how do you treat testicular torsion

Detorsion + orchiopexy within 7 hours Orchiectomy if testicle not salvageable

Empty, small scrotum, inguinal fullness (inguinal canal) Premature infants, low birth rate Undescended testicle (right MC) – can lead to cancer, subfertility, torsion, hernia by 4 months of age

cryptochordism

how do you treat cryptochoridsm

Orchiopexy (as early as 6 months of age) Observation if <6 months

Painless scrotal swelling, dull ache or heavy sensation, worsening with Valsalva Cystic testicular fluid collection MCC of painless scrotal swelling either congenital or acquired (injury, infection, trauma)

hydrocele

PE: transillumination, ruling out testicular tumor

hydrocele

how do you treat a hydrocele?

Treatment typically not needed >1 year, complications = surgical repair

“Bag of worms”, painless, but dullness/ache, worsens with upright or valsalva, decreases with supine or testicular elevation

varicocele

Testicular mass of varicose veins, MC on left side Right may be retroperitoneal/abdominal malignancy Left may be due to renal malignancy

varicocele

Foreskin cannot be pulled forward → impairs blood/lymphatic flow → gangrene/auto-amputation

paraphimosis

Infants and young boys adolescents/adults - after inflammation foreskin becomes trapped behind corona of glans and forms tight band, constricting penile tissues

paraphimosis

Inability to retract foreskin over glans MC penile abnormality, congenital or inflammatory

phimosis

how do you treat paraphimosis/phimosis?

pp: Emergency! Manual reduction, incision, cool compresses p: NON emergent → circumcision, topical steroids, gentle stretching

Ventral foreskin lacking, dorsal portion gives appearance of a hood

hypospadias

hypospadias is a risk in

Infants Advanced maternal age, pre-existing maternal DM, family Hx, prenatal exposure to smoking/pesticides, placental insufficiency, prematurity, fetal growth restriction, in-vitro fertilization

Urethral folds fail to fuse over urethral groove, changing urethral meatus location – genetic and environmental factors VENTRAL placement of urethra Epispadias = dorsal

hypospadias

how do you differentiate hypospadias and epispadias?

Can be associated with CHORDEE Hypospadias: Glandular/near the head of the penis - severe Epispadias: Glandular Penile Penopubic (base of abdominal pelvis) >severe PE: inguinal hernias common

how do you treat hypospadias?

Surgical treatment before the age of 2 Do not circumcise because you may need foreskin for later repair!!

Painless enlargement of testis, heavy sensation, acute testicular pain from intratesticular hemorrhage Some may be asymptomatic Metastatic symptoms: back pain, cough, lower extremity edema

testicular cancer

testicular cancer is the MCC ---

neoplasm in men 20-35 yrs crytochordism is a risk

what are the two types of testicular cancer?

Nonseminomas: embryonal cell carcinoma, teratoma, choriocarcinoma (worst), mixed Seminomas (MC in 30-40): 4S: simple (lack tumor markers), sensitive to radiation, slower growing, ass w/ stepwise spread Leydig cell, Sertoli cell, gonadoblastoma are benign

PE: discrete, firm/hard mass, diffuse testicular enlargement, secondary hydrocele, supraclavicular adenopathy, gynecomastia NO transillumination LABS: Nonseminomas: elevated hCG, alpha-fetoprotein Liver tests Advanced anemia IMAGING: scrotal US CT for TMN staging

testicular cancer

4S in seminomas:

Simple Sensitive to radiation Slow growing Stepwise spread

how do you treat seminomas?

Stage 1: candidates for surveillance, single agent carboplatin, radiotherapy Stage 2: radial orchiectomy + retroperitoneal irradiation or primary systemic chemotherapy Stage 3: primary systemic chemotherapy + surgical resection of residual retroperitoneal nodes

how do you treat nonseminomas?

Stage 1: orchiectomy followed by surveillance, adjuvant chemotherapy, lymph node dissection – post operative active surveillance: follow-up every 2-6 months for the first 2 years, every 4-6 months in the 3rd year Tumor markers at each vest, CXR, CT scans every 3-6 months

Mostly asymptomatic, but may cause obstructive voiding symptoms - urinary retention, lymph node involvement - lower extremity edema Increased risk of bone metastases - back pain, pathologic fractures

prostate cancer

prostate cancer has a correlation with

family history of breast and ovarian cancer

MC noncutaneous cancer in American men Majority of men > 50 have it

prostate cancer

LABS: elevated PSA, elevated BUN or Cr, ALP, Ca DRE: hard, nodular, enlarged asymmetrical prostate US biopsy IMAGING: mpMRI, CT/MRI of abdomen/pelvis and bone scans Note PSA is not specific

prostate cancer

how do you treat prostate cancer?

Risk stratified based on PSA level at diagnosis, DRE, and Gleason score Active surveillance for low-risk clinical features, avoid treatment if possible + watchful waiting Radical prostatectomy, radiation therapy, focal therapy Local and regional advanced disease = adjuvant therapy of radiation + orchiectomy + chemo Metastatic disease = androgen deprivation (hit at multiple levels)

Hematuria, irritative voiding symptoms Men>women ~73 years Cigarette smoking Exposure to industrial dyes and solvents - leather, rubber White

bladder cancer

2nd most common urologic cancer – epithelial malignancies - transitional cell or urothelial tumors Non-urothelial cell tumors (SCC, adenocarcinoma, SCC), non-epithelial

bladder cancer

Urinalysis: hematuria, pyuria Azotemia if urethral obstruction Anemia with chronic blood loss or bone marrow metastases Urine cytology w/ biopsy = detecting cancers of higher grade + stage-less IMAGING: US, CT, MRI

bladder cancer

bladder cancer tx

Localized or superficial → transurethral resection Invasive disease – radical cystectomy Recurrent → BCG vaccine intravesical

Triad: hematuria, flank/abdominal pain + palpable mass HTN, left sided varicocele

renal cell cancer

60s Male > female Physical inactivity, obesity, diabetes, smoking Originating from proximal tubule cells - several types

renal cancer

LABS: hematuria, erythrocytosis, anemia, hypercalcemia IMAGING: CT, renal US, MRI, CXR, bone scans, brain imaging

renal cancer

how do you treat renal cancer

Radical nephrectomy Single kidney, bilateral lesions, significant disease – partial Radiofrequency and cryosurgical ablation - alternative options with tumors <3-4cm Active surveillance NO CHEMO Palliative care, immunomodulatory therapy

WAGR syndrome (Wilms tumor, aniridia, GU malformation - cryptorchidism - mental retardation) Increasing size of abdomen - mass usually smooth, firm, and rarely crossing midline HTN Microscopic hematuria, fever

wilms tumor

3-3.5 years Sporadic aniridia Hemihypertrophy (Beckwith-Wiedemann syndrome) GU abnormalities (ambiguous genitalia) Nephroblastoma – MC malignant renal tumor in childhood

wilms tumor

Abdominal US - bilateral involvement, hydronephrosis CT of abdomen with contrast CBC, UA, liver and renal function, CXR, CT Biopsy for diagnosis

wilms tumor

How do you treat wilms tumor?

Nephrectomy Surgical exploration and inspection of liver and lymph nodes Chemotherapy Radiation if at high stage

topiramate zonisamide acetazolamide prednisone indinavir probenecid furosemide bumetanide torsemide triameterene guafinesan edephrine laxatives calcium supplements >2000mg

can cause kidney stones

Urology Flashcards

(96 cards)