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Urology Flashcards

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1
Q

What are the 5 types of incontinence?

A
  • stress
  • urge
  • overflow
  • functional
  • mixed
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2
Q

What is the most common type of incontinence in ppl >75yo?

A

urge

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3
Q

S/Sx of urge incontinence? (3)

A
  • frequency
  • urgency
  • nocturia
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4
Q

Common etiologies of urge incontinence? (3)

A
  • usually idiopathic
  • overactive bladder
  • detruser hyperactivity w/impaired bladder contractility (DHIC)
    Nb. can also be d/t cystitis, tumor, stones, PD, dementia
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5
Q

Tx for urge incontinence (4)

A
  • Timed voiding
  • dietary manipulations to avoid irritants, weight loss
  • kegels
  • Meds: anticholinergics
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6
Q

What causes stress incontinence? (2)

A
  • leakage d/t lack of pelvic supports

- intrinsic sphincter deficiency

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7
Q

Describe how lack of pelvic supports leads to stress incontinenc). What would usually cause this?

A
  • usually hypermobility of the bladder neck (85%)

- 2/2 aging, hormonal changes, multiple vaginal births, pelvic surgery

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8
Q

What would cause intrinsic sphincter deficiency (stress incontinence)?

A

pelvic radiation, trauma, surgery

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9
Q

Tx for stress incontinence? (4)

A
  • pelvic floor exercises
  • Meds: alpha agonists, imipramine
  • quit smoking
  • surgery - bladder sling for support
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10
Q

What is the cause of overflow incontinence?

A
  • detrusor underactivity
  • bladder outlet obstruction
  • Elevated PRV
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11
Q

What could cause detrusor under activity (overflow incontinence)? (5)

A

DM, MS, lumbar stenosis, spinal cord injury, meds (anticholinergics)

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12
Q

What would cause bladder outlet obstruction (overflow incontinence)? (3)

A

ureteral stricture, BPH, cystocele

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13
Q

What are the s/sx of overflow incontinence

A

small but continuous urine leak

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14
Q

Tx for overflow incontinence (2)

A

TURP, or intermittent catheterization

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15
Q

functional incontinence doesn’t involve _____

A

the lower urinary tract

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16
Q

functional incontinence results from _______

A

cognitive or functional impairments

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17
Q

Mixed incontinence (stress and urge) is most common in what population?

A
  • older women (65% w/stress incontinence have urgency)
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18
Q

Tx of mixed incontinence

A

imipramine (anticholinergic and alpha agonist)

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19
Q

What are the 3 P’s you should assess for in the history of someone with incontinence? What should you also inquire about or suggest?

A
  • Position of leakage (standing, sitting, supine)
  • Protection (pads per day, wetness of pads)
  • problem (quality of life)
  • voiding diary
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20
Q

What are the different modalities you can use to diagnose incontinence? (4)

A
  • UA
  • PRV
  • pad weight
  • urodynamics
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21
Q

What other meds can be used to treat incontinence in addition to the aforementioned meds, lifestyle modifications, exercises, and bladder training?

A
  • alpha adrenergic stimulators
  • oral estrogen
  • cymbalta (duloxetine) - increases urethral sphincter contraction
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22
Q

When do you screen for prostate cancer?

A
  • high risk groups/AAs: 45 yrs
  • Others: 50 yrs
  • stop at 75 or <10 yr survival
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23
Q

RFs for prostate cancer (5)

A
  • AA>white>Asians
  • FMH
  • Diet
  • age
  • environmental exposure
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24
Q

How do you determine someone’s gleason score?

A
  • first # = majority of the tissue
  • second # = 2nd most common
    (4+3 is worse than 3+4)
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25
What gleason score is the cut off for high grade?
>6
26
PSA
- a serine protease from the prostate that breaks down products in semen
27
ULN for PSA
4
28
PSA is used mostly for _____
disease RECURRENCE more than screening
29
What things can elevate PSA? (8)
- ejaculation - infection - cancer - instrumentation - inflammation - prostatitis - BPH - irritation
30
What does PSA free:bound ratio tell us
decreased free:increased bound means a greater cancer risk
31
what is PSA velocity? How do we measure it? What is this used for?
- the change in one's PSA values over time - 3 measurements over 2 years is best - PSA 4 - threshold is 0.75 ml/yr increase
32
What is PSA density?
- density of PSA/total prostate fluid volume
33
What is the threshold for PSA density at which you'd biopsy?
>0.15
34
What is the MOST COMMON cause of PSA elevation?
- aging!!! consider BPH in older men
35
Where in the prostate does PCa occur?
peripherally
36
Why is PCa often asx?
Since it usually occurs in the periphery of the prostate it doesn't cause obstructive sx until later
37
If someone is newly dx'ed with PCa what should you look for?
BONE METS
38
When is watchful waiting indicated in PCa pts? (2) How does watchful waiting work?
- when they have <10 yr predicted survival - low grade, low volume dz - follow dz with 6 mos. PSA screening and biopsy if indicated
39
2 important outcomes after radical prostatectomy?
- nerve sparing for erections | - incontinence a major problem
40
AEs a/w Ext beam radiation tx for PCa? (2)
- 40% ED | - radiation proctitis(?)
41
AE a/w cryosurgery? How does the use of this compare with ext beam XRT in the setting of PCa?
- 50-60% incontinence rate | - used more after XRT failure
42
What hormonal drugs are used to treat PCa? (3)
- Leuprolide - GHRH agonist - Flutamide - testosterone antagonist - Ketoconazole - adrenal gland test blocker
43
SEs a/w hormonal tx for PCa? (6)
- decreased libido - hot flaslhes - impotence - increased body fat - loss of muscle - loss of bone
44
When is hormonal tx used for PCa? Why?
- in setting of metastatic dz to control growth bc tumor will eventually become hormonally resistant
45
Prevalence of BPH
50% @ 50; 80% @ 80
46
How does BPH present?
LUTS (lower UT sx) - obstruction - irritation - urethral stricture/bladder outlet obstruction
47
What are obstructive BPH sx? (5)
- weak stream - hesitancy - straining - nocturia - incomplete emptying
48
What are irritative BPH sx? (3)
- urgency - frequency - dysuria
49
What are the different types of bladder ca?
- TCC (90%) - Squamous - Adeno
50
How does BCa present?
- painless, gross hematuria
51
What is the diagnostic work up for BCa? (3)
- cytology (specific but not sensitive) - cystoscopy - TURBT
52
How does staging work for BCa?
Ta-T1: no muscle invasion | T2-T4: muscle invaded
53
Tx of BCa (localized and invasive respectively)
- localized: TURBT, then surveillance + intravescle immuno/chemotherapy - invasive: radical cystectomy +/- chemo
54
What causes BPH?
- androgens effect on periurethral (transitional) zone which constricts the urethra
55
What are the steps for a diagnostic workup of BPH? (6)
- UA - r/o infection - Cr - check renal fxn - DRE - for masses - PSA - PVR - Question survey for sx severity
56
Medical tx for BPH and their fxns? (3)
- finasteride (5-alpha reductase inhibitor) - shrinks prostate - Terazosin/doxazosin/tamsulosin/alfuzosin - alpha adrenergic blockers (latter 2 are specific) - Combination of the 2 - most effective
57
What are the SEs of alpha blockers for BPH? (4)
- orthostasis - impotence - decreased libido - retrograde ejaculation
58
What are the SEs of 5-alpha R inhibitors for BPH? (3)
- impotence - decreased libido - decreased semen ejaculatory volume
59
What is a drawback to using medications for BPH vs. surgery?
- 30-40% d/c tx w/in 12 mos. d/t unwanted SEs
60
Indications for surgery in setting of BPH? (5)
- urinary retention - recurrent UTI - persistent hematuria - bladder stones - renal insufficiency
61
What's the gold standard procedure for prostate removal d/t BPH? What does it accomplish?
- TURP | - removes just the transitional zone of the prostate
62
When would you do an open prostatectomy? (2)
- When the prostate is >100 g | - bladder stones
63
Which group most commonly has kidney stones?
white males who have previously had a stone (50% chance of recurrence at 10 yr post-stone)
64
How many kidney stones pass on their own? In what length of time?
80% | 4 wks
65
80% of stones are < ____mm
4 mm
66
What are the indications for treatment of a kidney stone?
- >5 mm - persistent pain/bleeding - chronic infection - partial/complete obstruction - causing parenchymal damage - intractable N/V - patient preference
67
Most kidney stones are _____ which form from ____ _____ _____
calcium oxalate | Randall's plaque nidus
68
Causes of ca oxalate stones (4)
- idiopathic hypercalciuria - primary hyperparathyroidism - cancer - sarcoidosis
69
Tx for pts w/ca oxalate/phosphate (4)
- thiazides - hydration - protein restriction - Na restriction
70
Describe struvite stones
form in the calyces of the renal pelvis = stag horn calculi; 2/2 urease producing bugs that alkalinize the urine
71
What are the urease producing bacteria (4)
PROTEUS klebsiella enterobacter pseudomonas
72
With what conditions do you tend to see uric acid stones? (3)
- gout - xanthine oxidase deficiency - high purine turnover states (chemo)
73
Describe the conditions (kidney/urine) that give rise to uric acid stones and how you diagnose them
- acidic urine; RTA Type I | - **CT** NOT x-ray - these are radiolucent
74
how do you treat uric acid stones
alkalinize the urine with CITRATE
75
What causes cysteine stones?
COLA transport deficiencies - cysteine, ornithine, lysine, arginine
76
What do the cysteine crystals/stones look like
- hexagonal crystals | - ground glass appearance on x-ray
77
those with cysteine stones have a positive ______ test
urinary cyanide nitroprusside test
78
cysteine stones do NOT respond to _____ tx
shockwave ****TEST QUESTION****
79
T/F - Indinavir stones are radiopaque?
False - radiolucent
80
Decreased GFR in the setting of a kidney stone leads to elevated pressures, decreased blood flow and therefore _______
ischemia
81
kidney stone presentation may mimic ____ as the stone approaches the UVJ
cystitis
82
Hematuria occurs in ___% of pts w an active kidney stone
90
83
How do you dx a kidney stone? What is they're pregnant?
CT abdomen/pelvis - KUB if no CT (75-90%) of stones are radioopaque - If pregnant: US
84
What is the medical management of kidney stones? (4)
- Analgesia: NSAIDs, narcotics - DDAVP for renal colic - metabolic stone eval for recurrent stones w/24 hr urine, serum electrolytes - facilitate passage w/alpha blockers, CCBs
85
How do you work up recurrent stones? (3)
metabolic stone eval: - 24 hr urine - serum electrolytes - stone composition
86
What are 2 modalities that can be used for stones that require removal (<3cm)?
ESWL, laser lithotripsy
87
What are the indications for stone removal vs. passage? (3)
- obstruction + infection - renal deterioration - refractory pain/nausea
88
What happens with the vasculature during an erection? (3)
- relaxation of the cavernous arteries - filling of the venous sinusoidal spaces - constriction of the subtunical venous plexus
89
What vascular conditions can give rise to ED? (5)
- HTN - HLD - DM - smoking - radiation
90
Which of the following drugs can cause ED? - antipsychotics - antidepressants - antihistamines - central anti-hypertensives - BBs - spironolactone - small amts of alcohol - large amts of alcohol
- antipsychotics: YES - antidepressants: YES - antihistamines: NO - central anti-hypertensives: YES - BBs: YES - spironolactone: YES - small amts of alcohol: NO - stimulatory! - large amts of alcohol: YES
91
What type of ED is most common - organic or psychogenic?
Mixed
92
ED could be the presenting symptom of which conditions? (6)
- DM - CAD - HLD - HTN - SC compression - pit tumor
93
What does the workup for ED involve?
- UA - fasting glu - CBC - Cr - lipids - testosterone (prolactin, LH, free test for low T)
94
What are some medical modalities (medication or otherwise) used to treat ED? (7)
- PDE5 inhibitors - psychotherapy - Testosterone (if low T) - intracavernosal injections - intraurethral injections - vacuum erection devices - penile surgery
95
What are the 3 different intracavernosal injections used for ED and what are the risks a/w this tx modality?
- papverine, phentolamine, alprostadil | - risk of scars and priapism
96
How many degrees of rotation must the spermatic cord endure to become ischemic (testicular torsion)
720
97
What is the most common cause of testis loss in the US?
testicular torsion
98
Bell clapper deformity
extended tunica vaginalis resulting in horizontal lie of the testicle - in 12% of males
99
How does testicular torsion usually present? (4)
- Negative Prehn's sign (pain stays constant with elevation of the testes) - loss of cremasteric reflex - <30 yo - intense acute onset pain
100
____ is used to dx testicular torsion; however it can distinguish between this and ______. In order to do this you must look at TESTICULAR PERFUSION
- US | - epididymitis
101
How do you treat testicular torsion?
- SURGICAL EMERGENCY (detorsion in 6 hrs = almost 100% salvage, 20% is 12 hrs) - Detorsion w/orchidoplexy of affected and unaffected testicle
102
Appendiceal torsion - what does it mimic? - natural hx? - what does duplex US show? - whats a characteristic physical finding?
mimics testicular torsion except the testis is palpable with normal lie - self limited, atrophies with time - hypervascularity to region - Blue dot sign - seen through the skin
103
(T/F) As a rule, penetrating trauma to the scrotum should be explored
T
104
What are the bugs responsible for epididymitis in the young and old?
young: GC old: gram -s (UTI bugs) - like E. coli
105
What's the presentation of epididymitis - age - which sign is + - what's tender - describe the scrotum - how is the urine affected
``` >30 yrs old + Prehn's sign epididymal tenderness scrotal thickening, erythema - pyuria ```
106
How do you dx epididymitis?
- UA - culture - duplex - increased blood to testes
107
How do you treat epididymitis?
Abx x 3 wks: textracyclines, fluoroquinolones | pain management
108
Acute orchitis | tx?
testicular inflammation/tenderness | - same as epididymitis (tetracyclines, flouros)
109
testicular abscess tx
I&D
110
Fournier's gangrene | what populations do you usually see this in?
a fasciitis leading to gangrene of the perineum - rapidly progressive, life threatening - usually see this in DM, immunocompromised
111
What are 2 inflammatory processes involving the testes/scrotum?
- Henoch-Schonlein purpura vasculitis | - fat necrosis
112
Presentation of hydrocele (2)
- usually asx | - will transilluminate
113
How do you treat hydrocele?
- you don't unless there's a hernia or if it presents beyond 12-18 mos. of age
114
Hydrocele arises from fluid in what layer of the scrotum?
- tunica vaginalis
115
Bag of worms is the nickname for _____
varicocele
116
varicocele is dilatation of the _____ plexus and it's seen in __% of men
- pampiniform | - 15%
117
varicocele usually affects which side more than the other and why?
- L | - drains into the L renal vein
118
varicocele (does/doesn't) transilluminate
doesnt
119
how do you treat varicocele?
surgically only if sx
120
What are the 2 types of hernia?
- incarcerated | - strangulated
121
What are the most common bugs that cause UTI?
SEEKS PP - Serratia - E. coli (80%) - Enterobacter - Klebsiella - S. Saprophyticus (5-15%) - Proteus mirabilis - Pseudomonas
122
What are 3 pathogenic factors of UTI bacteria
- PILI w/phase variation that allows them to avoid phagocytosis - implicated in pyelo - K antigen - hemolysin
123
What are the host defenses against UTIs? (7)
- normal flora of the periurthra - urea in urine - high osmolarity - acidity - genetic predisposition - mucosa - antibody in kidney
124
What physiologic factors affect colonization of normal flora in females? (3)
- changes in estrogen - low vaginal pH - cervical IgA
125
____ in the urine may facilitate infection
glucose
126
Bladder epithelium has _____ to recognize bacteria, recruit WBCs and induce exfoliation
TLRs
127
Uncomplicated UTI
UTI in a normal, healthy patient (acute cystitis/pyelo)
128
complicated UTI
infection in a pt w/conditions predisposing to infection (BPH, hyronephrosis, stones, neurogenic bladder, systemic illness like DM, pregnancy, anal intercourse, FB in tract)
129
recurrent UTI
occurs after a documented infection that has resolved
130
reinfection of UTI
a new event w/reintroduction of bacteria to GU
131
persistent UTI
recurrent UTI caused by same bacteria | - stones, chronic prostatitis, infected kidney, ectopic ureter, foreign body, cysts, abscess
132
UTIs are mostly from the periurethral area, but may be ______ in immunocompromised patients or neonates. In these cases the common bugs are ____(3)
- hematogenous | - staph, candida, TB
133
Generally speaking, what are 2 RFs for UTI development?
- reduced urine flow (OBSTRUCTION, VUR) | - altered defense (PREGNANCY, spinal cord injury)
134
How do you diagnose UTIs and why are the respective modalities effective? (3)
- Dipstick: LE highly sensitive and specific, nitrite specific but not very sensitive, pyuria is very sensitive (95%) - Cx: >100K colonies diagnostic - Imaging: for pets who don't respond to treatment, looking for anatomic abnormality
135
How do you treat UTIs?
hydration, relief of obstruction, foreign body (FB) removal, abx
136
``` Put the following abx in order of highest urine concentration --> lowest concentration: cipro amoxicillin bactrim cabrenicillin cephalexin nitrofurantoin ```
``` cabrenicillin cephalexin amoxicillin bactrim cipro nitrofurantoin ```
137
When and how do you treat uncomplicated UTIs? What if the person has DM, is pregnant, greater than 65 yrs, or has hx of pyelo?
- ONLY when they're symptomatic - fluoroquinolones x 3 d (use if >10-20% R to bactrim); bactrim x 3 d - DM/pregnant/>65yo/pyelo hx: 7-10 d of tx
138
When and how do you empirically treat complicated UTIs (abnormal tract, immunocompromised, MDR)
- treat even when they're asx | - parenteral ampicillin, aminoglycosides (vanc if allergic) x 14 d, switch to PO at 48 hrs
139
blood cultures are positive in ____% of people with complicated UTIs
20-40%
140
Which UTI abx are safe to use in pregnancy and which aren't?
- safe: nitrofurantoin | - not safe: fluoroquinolones - tendon malformation in infants
141
How long do you treat acute prostatitis w/abx? Chronic prostatitis?
- 4 wks | - 6-12 wks
142
In which cases would you want to repeat cultures for a UTI so you can test for the appropriate cure? (3)
- pregnancy - pyelo - relapsing UTI
143
who has a greater risk of UTI thoughout childhood, boys or girls? What is their respective prevalence? What about during the first year of life?
girls: 8% boys: 2% - in first year of life boys get them more (10x increase in uncircumcised)
144
children tend to present with UTIs w/ _____ symptoms
nonspecific - poor feeding, irritability, lethargic, vomiting, diarrhea, distension
145
_____ are the 2nd most common cause of nosocomial UTI in children and can spread systemically with the high potential to become _____ in the NICU
- Fungi | - invasive candidiasis
146
Fungi can give rise to ____ in the kidney. A renal and bladder US can diagnose these
fungus balls
147
Viral cystitis is usually caused by ____(4) and is usually self limited
- HSV - flu - adenovirus - polyoma
148
____ and ____ kids are at greater risk for viral cystitis
- transplant | - immunocompromised
149
The most common serious sequelae from pyelonephritis in a child is _____
renal scarring
150
Pyelonephrosis in a child requires _____ for treatment.
*urgent* PCNT placement and abx
151
recurrent pyelo in a child may lead to ______ and _____
reflux nephropathy | ESRD
152
how do you diagnose a UTI in children?
- dipstick - UCx - BCx (std is 10^5 colonies/ml)
153
*Under what circumstances and when do you image a child with a UTI?* What imaging modalities?
*FEBRILE infant OR child 2 mos. - 2 yrs w/1st UTI* - RBUS: anytime only for voiding cystourethrogram: as soon as the child is infection free - renal and bladder US, voiding cystourethrogram
154
In children, ____ is the most commonly isolated bug with uncomplicated cystitis and can be treated with _______
- *enterobacter* | - nitrofurantoin and bactrim
155
40% of children with UTI have ______ which is a congenital cause of UTIs - can be detected with ___ - natural hx: ____
- VUR - voiding cystourethrogram (VCUG) - generally self resolves
156
60% of children with congenital hydronephrosis have ______ - this is d/t ______ - natural hx: ____
- UPJ obstruction - poor peristalsis or anatomic abnormality - may resolve or requires pyeloplasty
157
When a child has a UTI in the first few months of life you think of _____ - you diagnose this by looking for the _____ sign on US
- ureteroceles | - drooping lily sign
158
Ectopic ureter is a congenital abnormality that may present as ___ or ___ in girls; or ____ or ____ in boys
- girls: UTI, incontinence | - boys: UTI, epididymo-orchitis
159
Neuropathic bladder in children is usually due to ____ or ____
spina bifida | trauma
160
posterior urethral valve is the most frequent cause of congenital ________ - US shows ____ - 1/3-1/2 also have ___ or ___
- bladder outlet obstruction - thick bladder, b/l hydronephrosis - VUR or renal dysplasia
161
Prune belly syndrome
deficiency of the abdominal wall, dilatation of the ureters, bladder, urethra, w/b/l cryptorchidism
162
In neonates w/a constant wet umbilicus you think of _____
urachal remnants
163
Stones occur in children who have _____ - Most of these stones are located where? - how do you treat them?
metabolic d/os - in the kidney - 50% pass spontaneously w/in 2 wks
164
What are 3 acquired causes of UTIs in children?
- stones - sexual abuse - dysfunctional voiding syndrome
165
Dysfunctional voiding syndrome
lack of coordination between detrusor and external sphincter activity in children
166
In cases of hematuria, dipstick is ____% sensitive and ___% specific. You should also confirm with _____
- 95% - 75% - microscopic examination
167
microhematuria is defined as ___ RBCs/HPF on ___ (#) specimens
>3 | 2/3
168
RFs for hematuria include: - age? - sex? - smoking hx? - exposures? which ones? - previous ____, _____ - specific sx...
- >40 - M - yes - chemicals - cyclophosph, benzenes, mitotane - pelvic radiation, urologic dz - irritative voiding
169
the likelihood of malignancy in someone with hematuria is __%. Which malignancy is most common?
10% | - TCC
170
What are the main causes of glomerular hematuria? (3)
- **IgA nephropathy/Bergers*** - thin BM disease - hereditary nephritis (alports)
171
What are the main non-glomerular causes of hematuria: - upper tract (5) - lower tract (5)
- upper: stones, pyelo, RCC, TCC, obstruction | - lower: UTI, BPH, exercise, TCC, instrumentation
172
What impact does excessive anticoagulation have on hematuria?
- does NOT lead to de novo hematuria but may worsen current hematuria
173
What is the w/u for non-high risk hematuria?
- UA | - culture if infection suspected, then treat, then repeat UA
174
What is the w/u for high risk hematuria (any of the RFs, or gross hematuria) (7)
- evaluation of upper and lower UT - US, - cytology - contrast CT - cystoscopy - retrograde ureterogram - bladder wash
175
What if the w/u for hematuria in a high risk patient turns up negative?
re-evaluate in 48-72 mos. 3% will develop malignancy
176
NO EBM RECS FOR SCREENING ASX PTS FOR HEMATURIA
-

Surgery Subspecialties (6 decks)

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