Week 5 pt 2

Question 1

Urgency Urinary Incontinence:
What causes this? Explain

Answer 1

Detrusor Overactivity: Uninhibited detrusor contractions; raise bladder pressure

Question 2

Overflow Incontinence: What 2 things can cause it?

Answer 2

Obstruction or neurologic deficit

Question 3

Define the following fistulas:
1) Vesicovaginal
2) Urethrovaginal
3) Ureterovaginal

Answer 3

1) Vagina & Bladder
2) Vagina & Urethra
3) Ureterovaginal

Question 4

Define the following fistulas:
1) Vesicouterine
2) Rectovaginal

Answer 4

1) Bladder & Uterus
2) Rectum & Vagina

Question 5

Incontinence eval:
1) What may History, PE, and direct observation of urine loss help you figure out?
2) What is urodynamic testing?
3) What are the 2 different types?

Answer 5

1) Postvoid residual volume (PVR)
2) Measure the pressures, volumes and function of the bladder with a catheter
3) Single-channel: bladder only
Multi-channel: bladder and vagina or rectum

Question 6

List and describe the 3 nonsurgical Tx options for incontinence

Answer 6

1) Lifestyle: weightless, caffeine reduction, fluid management, smoking cessation, constipation management
2) Kegel Exercises
3) Pharmacology:
Anticholinergic agents
Beta-3 agonists
Tricyclic antidepressants
Antimuscarinics

Question 7

List the surgical Tx options for incontinence

Answer 7

1) Midurethral Slings
2) Retropubic colposuspension
3) Pubovaginal Sling

Question 8

Give the epidemiology and etiology of UTIs

Answer 8

1) 11% of women report at least one diagnosed UTI per year
Lifetime probability: 60%
2) Most common cause: fecal flora (E. coli)

Question 9

Differentiate between lower and upper UTIs

Answer 9

1) Lower Urinary Tract: Acute Simple Cystitis
-Dysuria, frequency, urgency, nocturia, suprapubic pain
-Fever Uncommon
2) Upper Urinary Tract: Acute Pyelonephritis
-Fever, chills, flank pain, dysuria, urgency and frequency

Question 10

Describe the Diagnostics and Laboratory Evaluation for UTIs

Answer 10

1) History: >1 symptoms of UTI = 50% probability of UTI
-Ask about fever, chills and flank pain
2) PE: CVAT, Abd tenderness
-Pelvic exam (when indicated)
3) Lab: Urinalysis (U/A; “clean-catch”)
-+ Leukocytes esterase or + Nitrite
-Culture if no improvement within 48 hours, h/o recurrence, or concern for pyelo

Question 11

UTIs: Who needs cultures?

Answer 11

1) Advanced age
2) Chronic renal disease
3) Diabetes Mellitus
4) Immunodeficiency
5) Pregnancy
6) Recent Urinary Tract Instrumentation
7) Urologic abnormalities
8) Repeat infections

Question 12

How do you Tx UTIs?

Answer 12

1) Typically, 3-5 days of abx
*Look at local resistance rates
2) Rule out kidney stone
3) Admit if high risk or unable to take oral medication

Question 13

What abx have the highest resistant rates?

Answer 13

1) Gentamicin
2) Amicasin
3) Cefepime and nitrofurantoin

Question 14

What abx can you use for Uncomplicated cystitis?

Answer 14

1) Nitrofurantoin (Macrobid)100mg po BID X 5 days or
2) Trimethoprim-sulfamethoxazole (Bactrim) DS 800mg po BID x 3 days 0r
3) Cephalexin (Keflex) 500mg BID x 5 days or
4) Fosfomycin (Monurol) single dose 3 gm x 1

Question 15

What are the second line abx options for uncomplicated cystitis?

Answer 15

1) Cipro 250 mg po BID X 3 days or
2) Levaquin 250 po daily X 3 days or
3) Ofloxacin 200mg po BID X 3 days

Question 16

What abx can you use for complicated UTI?

Answer 16

1) Use Cipro 500 mg for 7-14 days or
2) Levaquin 250-750 (bacteria-dependent) for 5-10 days

Question 17

Describe Trimethoprim-Sulfamethoxazole (Bactrim) for UTIs in pregnancy

Answer 17

1) Higher risk medication; risks/benefits must be weighed especially in 1st and close to term.
2) Sulfamethoxazole: risk of kernicterus near-term
3) Trimethoprim: risk of spontaneous abortion in 1st trimester; risk of congenial neural tube defects

Question 18

How do you Tx recurrent UTIs?

Answer 18

1) > 2 UTIs in 6 months or 3 in one year
2) Risk factors?
3) Increase fluids
4) Consider:
-Vaginal estrogen in postmenopausal women
-Change contraception method
5) Not evidenced-based but:
-Education on wiping anterior-to-posterior
-Voiding after sex
-Cranberry extract
-Probiotics

Question 19

Asymptomatic Bacteriuria: Who should you Tx?

Answer 19

1) Pregnant
2) Undergoing a urologic procedure
3) Catheter-acquired bacteriuria persists 48hrs after removal
4) Recent transplant patients

Question 20

Fecal Incontinence:
1) What is it?
2) What is it assoc. with?

Answer 20

1) Inability to control the passage of stool
2) Muscle or nerve damage from childbirth
-Neuromuscular disease: spinal cord injury, MS, or CVA
-Aging
-Chronic diarrhea

Question 21

A 64 y/o multiparous woman presents with urinary incontinence. She describes losing small amounts of urine when she coughs or lifts heavy objects. These symptoms began several months ago and have resulted in her now wearing a pad to avoid wetting her clothes.
What kind of urinary incontinence is this?

Answer 21

Stress urinary incontinence
Tx: Kegels BID for 6 wks

Question 22

Describe the roles of estrogen and progesterone in breasts

Answer 22

1) Estrogen: responsible for the growth of adipose tissue and lactiferous ducts
2) Progesterone: leads to lobular growth and alveolar budding

Question 23

What are the most common presenting breast concerns?

Answer 23

Pain and a mass

Question 24

What kinds of Hx questions should you ask regarding a breast mass?

Answer 24

1) Location?
2) Duration?
3) How was the mass discovered?
4) Presence or absence of nipple discharge?
5) Any changes in size?
6) Association with menstrual cycle?
7) Any risk factors?

Question 25

Risk Factors for Breast Cancer include what?

Answer 25

-Age -Personal history of breast cancer -History of atypical hyperplasia on past biopsies -Inherited genetic mutations (BRCA 1 and BRCA 2) -High breast tissue density -First-degree relatives with breast or ovarian CA diagnosed at an early age -Early menarche (<12) or late cessation of menses (>55) -No term pregnancies -Radiation exposure (chest) -Recent and long-term oral contraceptive use -Postmenopausal obesity -Personal history of endometrial or ovarian CA -Ashkenazi Jewish heritage -Caucasian>African American -Late age at first live birth (>30) -`Never breastfed

Question 26

What should breast self awareness include?

Answer 26

Include a visual inspection.

Question 27

Clinical Breast Examination (CBE): What parts should you examine?

Answer 27

Axillae and entire chest wall

Question 28

List the symptoms concerning for malignancy of the breast

Answer 28

-Rapid change in the appearance of one breast -Thickness, heaviness or visible enlargement of one breast -Discoloration, giving the breast a red, purple, pink or bruised appearance -Unusual warmth of the affected breast -Dimpling or ridges on the skin of the affected breast, similar to an orange peel -Itching -Enlarged lymph nodes under the arm, above the collarbone or below the collarbone -Flattening or nipple inversion

Question 29

Describe Mammography

Answer 29

1) Can detect lesions approximately 2 years before they become palpable 2) Lobular carcinoma is more difficult to detect with routine screening mammography 3) >40 y/o first-line study

Question 30

Describe Ultrasonography for breast cancer screening

Answer 30

1) For “Inconclusive” mammogram findings -Differentiate between a solid and cystic mass -Guide tissue core-needle biopsies 2) More commonly used in women <30 as initial modality

Question 31

Describe MRIs for screening for breast cancer

Answer 31

1) Useful as an adjunct 2) Limited due to cost 3) Used for very high risk or recently dx

Question 32

Describe the 2 diagnostic tests for breast cancer

Answer 32

1) **Fine-Needle Aspiration**: Useful to determine if lump is simple cyst -Clear fluid reassuring -Bloody fluid needs cytology **Core-Needle Aspiration**: Large bore needle (8-16g) -Helpful for solid or calcified masses -3 to 6 samples taken

Question 33

Give some examples of Benign Breast Diseases

Answer 33

1) Sclerosis Adenosis 2) Radial Scars 3) Fibroadenoma 4) Fibrocystic Changes 5) Fat Necrosis 6) Breast Abscess 7) Lipoma

Question 34

Describe Sclerosing adenosis

Answer 34

1) Composed of small breast lumps caused by enlarged lobules 2) Small, firm, tender, palpable nodules 3) May be found on a mammogram and may be mistaken for breast cancer. 4) Benign condition and does not need treatment.

Question 35

Describe Radial scars (complex sclerosing lesions)

Answer 35

1) Core of connective tissue fibers with ducts and lobules growing out from it. 2) Can look like breast cancer on a mammogram, found most often during a biopsy. 3) No consensus on whether they increase risk of breast cancer

Question 36

Give the clinical features and management for fibroadenomas

Answer 36

1) Firm, smooth, rubbery and defined -Highly mobile -Painless 2) Observe and provide reassurance -Biopsy if dx in doubt -Consider surgical excision

Question 37

Fibrocystic Changes: 1) What are they? 2) Who are they common in? 3) What does FNA usually demonstrate?

Answer 37

1) Consists of fibrous and cystic changes of the breast 2) Women 30-50 3) Green/brown fluid

Question 38

Fibrocystic Changes: 1) What are the clinical features? 2) How do you manage them?

Answer 38

1) Smooth, mobile, lumpy texture; Cyclical mastalgia 2) No tx required; Manage pain with simple analgesics and properly-fitted bra

Question 39

Define fat necrosis [of the breast]

Answer 39

Fibrosis and calcification of fat cells after trauma to breast

Question 40

Fat necrosis: 1) What are the features? 2) How do you Tx/ manage it?

Answer 40

1) Painless firm lump -May have area of bruising/erythema/sign of trauma 2) Should be referred for assessment -No treatment required once dx is confirmed

Question 41

Breast Abscess: 1) Define these 2) What are the clinical features?

Answer 41

1) Collection of pus just under skin 2) Hot, painful swelling; +/- fever

Question 42

How do you manage breast abcesses?

Answer 42

1) U/S guided aspiration for small abscesses (overlying skin normal) 2) Surgical I&D 3) Antibiotics 4) Against S. aureus unless gram stain +culture results available 5) Analgesics prn

Question 43

Lipomas: 1) What are the clinical features? 2) How do you manage them?

Answer 43

1) Solitary, soft, non-tender, well-circumscribed mass 2) Biopsy may be needed -Consider surgical excision if growing rapidly/continue to enlarge

Question 44

Describe the following forms of mastalgia: 1) Cyclical 2) Noncyclical 3) Extramammary

Answer 44

1) Associated with luteal phase. B/L. Upper outer quadrants 2) Tumors, mastitis, cysts, or trauma. Some idiopathic. Medication side effects: sertraline, amitriptyline, hormones 3) Chest wall trauma, rib fractures, shingles and fibromyalgia. R/O myocardial infarction

Question 45

List some medical therapies for mastalgia

Answer 45

1) Danazol: side effect-hirsutism 2) Selective estrogen receptor modulators (SERMs): -Tamoxifen (off label use) -Raloxifene: Lower risk of endometrial hyperplasia

Question 46

List some non-medical therapies for mastalgia

Answer 46

1) Proper fitting bras 2) Weight Reduction 3) Regular Exercise 4) Decrease caffeine

Question 47

Mastitis: 1) Define it 2) What are 2 types? 3) What can cause it?

Answer 47

1) Infection of the breast 2) Infectious vs non-infectious (per WBCs on CBC) 3) Bacteria (MRSA, strep, e.coli)

Question 48

Mastitis: How do you Tx it?

Answer 48

1) CONTINUE breastfeeding! -Breasts need to be emptied, and that is the best way 2) Dicloxacillin 1st line treatment (after culturing breast milk) -+ MRSA risk factors: Bactrim 3) U/S if not improving to ensure not breast abscess

Question 49

Ductal Ectasia: Define and describe it

Answer 49

1) Dilation of the mammary ducts, walls thicken, and fluid builds up 2) Usually non-bloody discharge Green, yellow or brown sticky d/c 3) Attributed to fibrocystic changes

Question 50

Unilateral bloody discharge may be due to what?

Answer 50

Intraductal Papilloma

Question 51

Define galactorrhea

Answer 51

Physiologic nipple discharge, nonpathologic nipple discharge unrelated to pregnancy or breastfeeding

Question 52

Intraductal Papilloma: 1) What are they and who are they found in? 2) Where do they occur? 3) What is the etiology and risk factors?

Answer 52

1) Small, benign, usually in women 35-55 2) Grows in a milk duct of the breast 3) Causes and risk factors unknown

Question 53

Intraductal Papilloma: 1) What are the Sx? (CC or PE findings) 2) How is it treated?

Answer 53

1) Breast enlargement, lump, and/or pain -Nipple discharge (Clear or Bloody) 2) Observation or possible duct excision

Question 54

Intraductal Papilloma: How is it diagnosed?

Answer 54

1) H&P 2) Can do cytology of the nipple discharge 3) MRI or ductography

Question 55

Medications that may cause Galactorrhea include what?

Answer 55

1) Anti-hypertensives: Aldomet, Atenolol, Verapamil 2) Anti-depressants: Fluoxetine, Paroxetine, Sertraline, etc 3) Anti-psychotics & phenothiazines: chlorpromazine, prochlorperazine 4) H2-receptor blockers: Famotidine, Ranitidine, Cimetidine 5) Hormones: Prempro (menopause tx), Depo Provera and OCPs 6) Herbs: anise, blessed thistle, red clover, red raspberry, nettle 7) Other drugs: Isoniazid, Cyclobenzaprine, Sumatriptan, Valproic Acid, Amphetamines

Question 56

How uncommon or common is breast CA?

Answer 56

1) 2nd most common malignancy in women 2) 2nd leading cause of cancer-related death 3) Lifetime risk in developing breast CA is 1 in 8 4) Lifetime risk of dying from breast CA is 1 in 37

Question 57

List & explain the risk factors for breast cancer

Answer 57

1) Age: Single largest risk factor 2) Family history and Genetics 3) Early age of menstrual onset (<12yo) and late menopause (>55yo) 4) Delayed childbearing, nulliparity 5) Radiation Exposure: Large doses (treating Hodgkin dx or thymus gland) 6) Breast Changes: Dense breast tissue at increased risk. -Atypical hyperplasia 7) Other: Overweight after menopause; Alcohol

Question 58

Breast Cancer Risk Assessment Tool: The Gail Model does what?

Answer 58

Estimates risk of developing invasive breast CA over the next 5 years (and in their lifetime up to 90yo) using 7 risk factors

Question 59

American Joint Committee on Cancer (AJCC) classifies most malignancies into one of three histologic categories; what are they?

Answer 59

1) Ductal 2) Lobar 3) Nipple

Question 60

Describe some skin changes that can happen around/ on the breasts

Answer 60

1) Redness suggests infection or inflammation In women who have not recently nursed a baby, worrisome for IBC 2) "Peau d'orange" quality 3) Dimpling: often a sign there is a tumor beneath. 4) Asymmetry 5) Nipple retraction: if new, often a sign there is a tumor beneath. -Carefully palpate around and under the nipple

Question 61

Define Inflammatory Breast Cancer, its Sx, and the prognosis

Answer 61

1) A rare type of breast cancer (1-4% of breast cancers) that develops rapidly, making the affected breast red, swollen and tender. 2) Most patients have signs of advanced cancer at the time of diagnosis, including lymphadenopathy and metastasis. 3) Five-year rate of survival for IBC patients: 25-50%

Question 62

Paget’s Disease of the Breast: 1) Define it. Is it cancerous? 2) What is the main Sx? Who does it occur in usually? 3) How common/ uncommon is it? 4) Describe where it is

Answer 62

1) Intraductal carcinoma that involves the skin of the nipple and areola. 2) Eczema-like appearance to the nipple USUALLY women > 40yo 3) Approximately 3% of total # of annual breast cancers 4) Nearly always unilateral There IS a mass underneath the nipple, but it is only clinically palpable 70% of the time.

Question 63

The seriousness of invasive breast cancer is strongly influenced by the stage of the disease; what does The American Joint Committee on Cancer (AJCC) classification of tumors use?

Answer 63

1) Tumor size and spread to nearby organs (T) 2) Lymph node involvement (N) 3) Presence or absence of distant metastases (M)

Question 64

List the stages Primary Tumors (T)

Answer 64

-TX: Primary tumor cannot be assessed. -T0: No evidence of primary tumor. -TIS: Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass) -T1: Tumor is 2 cm (3/4 of an inch) or less across. -T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across. -T3: Tumor is more than 5 cm across. -T4: Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.

Question 65

List the different stages of Metastasis (M)

Answer 65

MX: Presence of distant spread cannot be assessed. M0: No distant spread is found on x-rays (or other imaging procedures) or by physical exam. M0(i +): Small numbers of cancer cells are found in blood or bone marrow (found only by special tests), or tiny areas of cancer spread (no larger than 0.2 mm) are found in lymph nodes away from the breast. M1: Spread to distant organs is present. (The most common sites are bone, lung, brain, and liver.)

Question 66

Endocrine receptor positive breast CA: 1) 75% of breast cancers are ___+; 65% are ____+. 2) What kind tend to be very aggressive and fast-growing tumors?

Answer 66

1) ER+; PR+ 2) HER2 positive (20-25% of breast cancers)

Question 67

Treatment of ER+ patients: What should you begin after surgery, chemo, and radiation? How does it work?

Answer 67

Anti-estrogen therapy works by blocking the hormone receptors, so they can't signal cancer cells to grow.

Question 68

Some of the drugs that are widely used to treat hormone-receptor positive cancers are what?

Answer 68

1) Tamoxifen 2) Raloxifene (Evista) 3) Arimidex (chemical name: anastrozole) 4) Aromasin (chemical name: exemestane) 5) Femara (chemical name: letrozole) 6) Faslodex (chemical name: fulvestrant)

Question 69

Breast cancer surgical Tx: 1) Define and describe Lumpectomy 2) Define and describe mastectomy

Answer 69

1) Breast conservation therapy. Need negative margins Followed by radiation 2) Removes breast tissue with preservation of the pectoralis muscles +/- followed by radiation and reconstruction for those who desire it

Question 70

slides 60-77

Question 71

List some Alternatives to Hormone Therapy

Answer 71

Phytoestrogens (soy) Acupuncture Black cohosh Exercise Relaxation techniques Chinese herbal medicines Evening primrose oil

Question 72

True or false: “Natural” does not always mean safe.

Answer 72

True

Question 73

1) Define Pelvic Floor Disorders 2) What are their Sx?

Answer 73

1) Conditions that result from weaking or injury to the muscles that supports the pelvic area 2) Vaginal bulging, urinary frequency or incontinence, trouble defecating

Question 74

What are some risk factors for pelvic organ prolapse?

Answer 74

1) Childbirth 2) increasing age 3) chronically increased intra-abdominal pressure 4) connective tissue disorders 5) surgery

Question 75

What can happen to the 4 supports of the pelvic organs?

Answer 75

Can be compromised (see risks) and create tears of site-specific tissues

Question 76

What are 3 important Hx questions to consider when evaluating POP?

Answer 76

1) Has there been a change in intra-abdominal pressure? 2) Does the patient have a chronic cough or constipation that has precipitated her symptoms? 3) Is a neurologic process complicating the patient’s presenting symptoms?

Question 77

Describe the classification (POP-Q) of pelvic organ prolapses

Answer 77

Stage 0: No prolapse Stage I: The leading edge of the prolapse >1 cm above the hymen. Stage II: The leading edge of the prolapse < 1cm above or below the hymen. Stage III: The leading edge of the prolapse >1cm beyond the hymen but less than or equal to the total vaginal length minus 2cm Stage IV: Complete eversion

Question 78

Describe how to Tx POPs

Answer 78

1) Asymptomatic or mild: Observation 2) Nonsurgical: Pessaries, pelvic floor exercises, sx-directed tx 3) Surgery: Compartment-specific reconstruction vs obliterative If uterus associated with prolapse: Hysterectomy or Colpoclesis