11/18- Benign Diseases of the GU system Flashcards
Describe components of the upper urinary tract
- Kidneys (retroperitoneal); collecting system begins here
- Forms the renal pelvis
- Concentrically narrows at ureteropelvic junction (UP)
- Becomes the ureter
Where do they kidneys lie? Adjacent structures?
Retroperitoneal
- Ribcage
- Retroperitoneal fat
- Perirenal fat within Gerota’s capsule
- Overlying viscera
- Right: liver, colon, duodenum, adrenal
- Left: spleen, colon, adrenal, pancreas
Describe components of the lower urinary tract
- Urinary bladder
- Male urethra begins within the pelvis and courses inferiorly through the GU diaphgram the external genitalia
What are adjacent structures of the male urethra?
- Bony pelvis
- Colon: posteriorly
- Uterus in females
- Perivesical fat
Describe the course of the urethra in male/female
The urethra begins as a funneling of the urinary bladder at the bladder neck
- Courses through the prostate
- Widens after exiting the GU diaphragm
- Male: exits through the penis
- Female: exits in the anterior vaginal wall
Describe the epidemiology of Urinary Calculus Disease
- __% in all individuals
- __% of the population during their lifetime
- Recurrence
- Ethnicity
- Gender
- 3% in all individuals
- ~ 12% of the population during their lifetime
- Recurrence rates approach 50% at 10 years
- White males have the highest incidence
What is the etiology of urinary calculus disease?
- Solutes in amounts too high to stay dissolved (supersaturated) in urine
- Solutes precipitate and aggregate to form stones
What are the 5 primary subtypes of Urinary Calculus Disease (from most -> least common)
- Calcium oxalate
- Uric acid
- Struvite (magnesium ammonium phosphate
- Calcium phosphate
- Cysteine
What is Ca oxalate?
- Describe stone formation
- Treated/inhibited by what
- Chemically may be monohydrate or dehydrate
- Thought to be initial formation of calcium phosphate
- Forms in a Randall’s plaque in the urinary collecting system
- Exposed calcium phosphate then encrusted by calcium oxalate once exposed to urine
- May be inhibited by citrate
What is uric acid?
- Produced when
- Solubility factors
- Asociated conditions
- Byproduct of purine metabolism
- Solubility determined by urine pH
- 100 X more soluble in urine pH > 6 than < 5.5
• Most common in patient with persistently acidotic urine or acidotic states
- Renal tubular acidosis
What is struvite?
- Produced when
- Solubility factors
•Result of urease producing bacterial infections
- PROTEUS followed by Klebsiella, Enterobacter, and Pseudomonas
- Urease cleaves urea into insoluble ammonium
- H+ in release reducing ammonia to ammonium further alkalinizing the urine
- Ammonium is less soluble in basic urine and binds to phosphate creating and growing stones
What is Calcium Popshate?
- Produced when
- Process of stone formation
- Phosphate metabolism and excretion is governed by parathyroid hormone
- Phosphate tends to precipitate in alkaline urine
- Initial nidus for many forms of calcium stones
What is cystine?
- Produced when
- Labs
- Solubility factors
- Recessive genetic trait involved in amino acid transport
- Amino acid of cysteine-S-S-cysteine
- Excessive excretion of cystine, > 200 mg/day vs. <100 mg/day in normal individual
- Cystine is more soluble in extremely basic urine, pH > 9.6
What are symptoms of Urinary Calculus Disease?
- Acute, colicky flank pain radiating to the groin or scrotum
- Ureter – pain may localize to the abdomen overlying the stone
- Considered among the most severe pain experienced by patients
- Female stone patients describe the pain as more intense than that of childbirth
• Ureterovesical junction – lower quadrant pain
- urinary urgency, frequency, and dysuria
- mimics bacterial cystitis
• Nausea and vomiting
What is typical history of someone with Urinary Calculus Disease?
- Family history of renal calculi - 55% of patients with recurrent stones
- 3 X more likely in men with a + family history
What are physical exam findings of Urinary Calculus Disease?
- Distressed patient, often writhing,
- Patient typically cannot get comfortable
- Acute abdomen patients lie very still
- Costovertebral angle or lower quadrant tenderness
- Vagina Exam
- Ureterovesical junction stone may be palpable on vaginal examination
What are lab/diagnostic techniques for Urinary Calculus Disease?
Laboratory exam
- Urinalysis- gross or microscopic hematuria
- Blood tests
- CBC – mild or significant leukocytosis
- Chemistries – may show electrolyte disturbances and evidence of renal injury
Imaging
• Unenhanced, helical computed tomography (CT)
- Positive and negative predictive values of CT: 100% and 91%
• Older imaging techniques include intravenous urography
What is seen here?
Unenhanced, helical CT
- Good positive and negative predictive values for CT
DDx for Urinary Calculus Disease?
- Renal or ureteral stone
- Hydronephrosis (ureteropelvic junction obstruction, sloughed papilla)
- Bacterial cystitis or pyelonephritis
- Acute abdomen (bowel, biliary, pancreas or aortic abdominal aneurysm sources)
- Gynecologic (ectopic pregnancy, ovarian cyst torsion or rupture)
- Radicular pain (L1 herpes zoster, sciatica)
- Referred pain (orchitis)
Indications for intervention in Urinary Calculus Disease?
- Obstructed upper tract with infection
- Impending renal deterioration
- Pain refractory to analgesics
- Intractable nausea/vomiting
- Patient preference
There’s a flowchart for UCD mgmt that I’m deliberately ignoring
Oops
15% of antibiotic prescriptions in US are the result of UTI; this does not account for complicated UTIs for pts with complex urologic problems. Problem?
Broad-spectrum antibiotic use is rising
- Esp fluoroquinolones and cephalosporins
- Results in “collateral damage” and co-resistance to other Abx classes
What is a UTI (def)?
- Uncomplicated
- Complicated
UTI- An inflammatory response of the urothelium to bacterial invasion that is usually associated with bacteriuria and pyuria
Uncomplicated UTI-
- An infection in a healthy patient with a structurally and functionally normal urinary tract
- Often female patients with isolated or recurrent cystitis or acute pyelonephritis
Complicated UTI-
- An infection is associated with factors that increase the chance of acquiring bacteria and decrease the efficacy of therapy
- The urinary tract is structurally or functionally abnormal, the host is compromised, and/or the bacteria have increased virulence or antimicrobial resistance
- The majority of these patients are men
What are temporal relationships of UTIs?
- First or isolated – a first time infection in a person or development of a new infection remote from a previous infection
- Unresolved – an infection that has not responded to antibiotic therapy
- Recurrent – an infection that begins after documented, successful resolution of a prior infection
What is cystitis?
- Symptoms
A clinical syndrome of dysuria, frequency, urgency, and occasionally suprapubic pain
What is acute pyelonephritis?
- Symptoms
- A clinical syndrome of chills, fever, and flank pain that is accompanied by bacteriuria and pyuria
- Must have flank pain present to be termed pyelonephritis
Describe the epidemiology of adult UTIs
- Affected population
- Nosocomial
- 150 million UTIs occur world wide annually
- Incidence 0.5-0.7 persons/annually in US
Nosocomial infections
- UTIs account for 40% infections in health care setting
- 1 million catheter associated UTIs (CAUTI) annually
What are host risk factors for adult UTIs?
- Reduced urinary flow
- Promoters of colonization
- eg. sexual activity, ↓ estrogen concentration in vaginal tissue
• Facilitate inoculation
- eg. catheterization, fecal incontinence
What are bacterial pathogenic factors for adult UTIs?
• Increased adhesion
- Pili – type I in cystitis, P in renal infections (pyelonephritis)
- Increased colonization
- Tissue invasiveness
- e.g: hemolysin
Describe the host defenses to adult UTIs
• Periurethral and urethral
- Normal flora – lactobacilli, coag ‒ staph, Corynebacterium, streptococci
• Chemical urinary factors
- Low pH
- High osmolality
- High urea concentration
• Bladder
- Toll like receptors (TLRs) – innate cellular components that initiate immune/inflammatory responses
• Kidney
- Local immunoglobulin/antibody synthesis
What are symptoms of uncomplicated UTI
- Differential diagnosis
- Risk factors
Symptoms – dysuria, frequency, and urgency
- Predict a UTI with 90% probability
- In absence of vaginal discharge
Differential Diagnosis
- Sexually transmitted infection
- Vaginitis
- Painful bladder Syndrome/interstitial cystitis
Risk factors
• Genetic, Biologic, Behavioral
Describe the history, exam, and lab of uncomplicated UTI
Historical components
• Number of past UTIs, urinary tract abnormalities or surgery, pediatric UTIs, neurogenic bladder, immunologic state
Examination
- Focused on abdominal, back, and pelvic exam
- STIs, urethral and bladder palpation
Laboratory
- Dip stick or microscopic urinalysis
- Not necessary to perform urine culture in initial or isolated UTI
What are common pathogens causing uncomplicated UTI?
- Escherichia coli (85%)
- Staphylococcus saprophyticus (10-15%)
- Klebsiella pneumoniae (4%)
- Proteus mirabilis (4%)
Treatment for uncomplicated UTI?
- TMP-SMX – caveat in population areas with resistance > 10-20%
- Nitrofurantoin
How to diagnose/evaluate uncomplicated recurrent UTI?
Must differentiate uncomplicated from complicated
Primary focus is on prevention
Evaluation
- Historical components are similar to uncomplicated isolated UTI
- Lab: urine culture is more important but not required
- Imaging: KUB and renal/bladder ultrasound may be considered to evaluate for anatomic abnormality
- Cystoscopy: considered to evaluate for sources of infection
How do you treat an uncomplicated recurrent UTI?
- Suppressive therapy
- Self-start therapy
- Urine culture obtained prior to self-initiation of antibiotics
• Post-coital prophylaxis
- Typically 1-2 pill regimen
• Non-antibiotic therapy
- Urinary acidification – Vitamin C
- Methenamine salts – Converted to formaldehyde in the urine
- Probiotics: vaginally administered vs. oral
- Cranberry: controversial with no firm data to support
What are important factors in the determination of complicated UTIs?
- Functional or anatomic abnormality of urinary tract
- Male gender
- Pregnancy
- Elderly patient
- Diabetes
- Immunosuppression
- Childhood UTI
- Recent antimicrobial agent use
- Indwelling urinary catheter
- Urinary tract instrumentation
- Hospital-acquired infection
- Symptoms for more than 7 days at presentation
Describe the presentation/evaluation/labs of a complicated UTI?
Presentation
- Must be associated with symptoms: dysuria, frequency, urgency, flank pain, fever, etc.
- Wide variability in clinical symptoms: UTI in a man with LUTS to pending sepsis from pyelonephritis
Urine cultures – Defined bacterial counts
- Women = ≥ 105 colony forming units (CFU)/mL
- Men = ≥ 104 CFU/mL
- Catheterized specimen = ≥ 104 CFU/mL
- Multiple bacterial pathogens with larger spectrum than uncomplicated UTI
- Enterobacter predominate
- Escherichia Coli are still the most common
- Non-fermenting gram negative bacteria, e.g. Pseudomonas
Microscopy
• Pyuria ≥ 10 WBC/hpf in resuspended urine
Describe evaluation of complicated UTI in a pre-menopausal woman
Urine culture is required
Imaging should be strongly considered
- KUB
- Renal Ultrasound
- CT scan in patients with suspected renal stone or obstruction
Cystoscopy
- Recent history of pelvic surgery, urinary fistula, or incontinence surgery
- Evaluate for urethral anatomic abnormalities
Adjuvant tests
- Measurement of residual urine by ultrasound
- Uroflowmetry
Describe the management of a complicated UTI
Resolve sources of urinary stasis, surgical excision of diverticulum or obstruction
Treat urolithiasis
Antibiotics
- Urinary concentration – cabrenicillin > cephalexin > ampicillin > TMP/SMX > ciprofloxacin > nitrofurantoin
- 7-14 days (Same as pyelonephritis)
- 3-5 days after defervescence or control/elimination of complicating factor (drainage, surgery)
- Fluoroquinolone
- Aminopenicillin/BLI
- Cephalosporin – parenteral
- Cefodizime, cefotaxime, ceftriaxone
- Aminoglycoside
- TMP-SMX5
- In case of initial failure (<3 days)
- Fluoroquinolone (if not initially used)
- Piperacillin/BLI
- Cephalosporin – parenteral
- Cefoperazone, ceftazidime
- Carbapenem + Aminoglycoside
- Fluconazole
- Amphotericin B
What is the definition of Benign Prostatic Hypertrophy?
Constellation of voiding symptoms that occur in aging men
• Obstructive: ↓ force of stream, hesitancy, straining to void, incomplete bladder emptying
Irritative: Frequency, urgency, dysuria
Similar set of symptoms occur in others without enlarged prostates
• More accurately termed Lower Urinary Tract Symptoms (LUTS)
Describe the epidemiology of BPH
- Age
- Percent
- Natural history
Development begins around age 30
• 10% of men by age 40 have histologic evidence
Near universal condition in older men
- 80% of men will develop benign prostatic hypertrophy (BPH)
- 30% of men will receive treatment for symptoms
Natural history of BPH
• Incidence of urinary retention or significant emptying issues is 2% per year
Describe the diagnosis of BPH
- Objective
- Subjective
Objective measures
- Prostate size on physical examination
- Measurement of urinary flow rate
- Measurement of post-void residual volume
Subjective measures
- International prostate symptom score (IPSS)
- Mild symptoms 0-7
- Moderate symptoms 7-15
- Severe symptoms > 15
What is medical therapy for BPH?
5 α reductase inhibitors
- Finasteride, Dutasteride
- Mechanism of action
- Inhibit the conversion of testosterone to dihydrotestosterone – 5X more potent
- Reduces growth or causes apoptosis of acinar glands in the prostate
- Can results in up to 50% reduction in prostate size over time
α adrenergic blockers
- Terazosin, doxazosin, tamsulosin, and alfuzosin
- Mechanism of action
- Relax smooth muscle of the prostate and bladder neck
- Reduces outflow resistance in the central prostate
Combination therapy is more effective than individual therapy in many patients
• 67% reduction in BPH progression for combined versus 30% for each drug independently
What is procedural or surgical therapy for BPH?
Minimally invasive treatments
• Transurethral microwave therapy (TUMT)
- Reduces intermittency, straining, frequency, and urgency
• Transurethral needle ablation (TUNA)
- Low-level radiofrequency energy to ablate the prostatic tissue
- Improves urinary flow. Fewer side effects than traditional therapies
Surgical therapies
• Transurethral resection of prostate
- Endoscopic treatment where the prostate is resected through a resectoscope
- Electrified wire loop is used to cut the prostatic tissue out to physically remove the obstruction
- Considered the gold standard for BPH symptom management
• Transurethral laser surgery
- Similar to TURP except laser energy is used for tissue ablation rather than resection
- Typically less blood loss than resection surgery
- Two types of lasers contact and non-contact, similar outcomes between the two
• Open prostatectomy
- Through an infraumbilical surgical incision the prostate capsule is incised and the adenoma is removed
- Reserved for patients with very large prostates or bladder stones
•Peripheral prostatic tissue and prostate capsule remain insitu
What is urinary incontinence (def)?
- Subtypes
Urinary incontinence: complaint of involuntary loss of urine
- Stress urinary incontinence (SUI): complaint of involuntary loss of urine on effort or with physical exertion or on sneezing or coughing
- Urgency urinary incontinence: complaint of involuntary loss of urine associated with urgency
- Mixed urinary incontinence: complaint of involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing
Nocturnal enuresis: complaint of involuntary loss urinary loss of urine which occurs during sleep
Continuous urinary incontinence: complaint of continuous involuntary loss of urine
Insensible urinary incontinence: complaint of involuntary loss of urine where the patient has been unaware of how it occurred
Describe the epidemiology of urinary incontinence
- Female
- Male
Females:
- Prevalence of urinary incontinence over age 20: ~50%
- Stress urinary incontinence – 49.8%
- Urge urinary incontinence – 15.9%
- Mixed urinary incontinence – 34.3%
- Estimated annual cost in 2000 was $19.5 billion
Male
- Typically the result of surgery on the prostate
- Contemporary series report incidence of 10%
- Other causes are less well reported in men
Describe the etiology of urinary incontinence
Bladder dysfunction
- Urge urinary incontinence
- Overactive blader
- Overflow incontinence
Urethral related incontinence
- Referred to as “stress incontinence”
- Urethral hypermobility
- Urethral related incontinence
What is the etiology of bladder dysfunction causing urinary incontinence?
• Urge urinary incontinence
- Occurs with increases in bladder pressure sufficient to overcome outflow resistance
- Bladder neck and urinary sphincter
- Detrusor overactivity
- Result of intermittent bladder contractions
- Non-neurogenic origin (i.e. idiopathic)
- Neurogenic origin (result of neurogenic disease)
- Result of intermittent bladder contractions
- Poor compliance of the bladderLoss of viscoelastic properties of the bladder wall
- Often the result of neural regulatory activity
- Associated with sudden, insuppressible sensation or urge to void
- Often the result of neural regulatory activity
• Overactive bladder – condition with frequency and urgency with or without incontinence
• Overflow incontinence
- Result of overwhelming the viscoelastic properties of the bladder at extreme bladder volumes
- Loss of urine is the result of inherent elevation of detrusor pressure
- Associated with urinary obstruction or poor bladder contractility
What is the etiology of Urethral Related Incontinence causing urinary incontinence?
- Referred to as stress incontinence
- Urethral hypermobility
- Proximal urethral is displaced below the pelvic floor causing loss of pressure transmission
- Results in displacement of the urethral sphincter unit
- Intrinsic Sphincteric Deficiency (ISD) – loss of resistance in the urethra resulting from poor sphincter coaptation
- Other causes – myelodysplasia, trauma, radiation
Describe the H&P evaluation of urinary incontinence?
History
- Onset, frequency, severity, pattern
- Symptoms
- Overactive bladder
- Obstruction
- Incomplete emptying, hesitancy, straining, weak stream
• Associated problems
- Neurologic symptoms, bowel function, medications/medical therapy
• Physical exam
- Abdominal, pelvic, rectal, and neurologic assessment
- Specifics pelvic exam
- Quality of the vaginal mucosa, pelvic organ prolapse, urethral hypermobility
- Rectal exam to note sphincter tone and perineal sensation
Describe the lab exam for urinary incontinence
Urinalysis and urine culture
Describe adjuvant testing for urinary incontinence
- Post void residual volume
- Voiding diary
- Urodynamic testing
- Evaluates bladder compliance, contractility, and stress incontinence
What is the treatment for urge urinary incontinence?
• Behavior modification
- Timed voids – keeping the bladder empty (voids q 1-2 hours) to prevent urge episodes
- Modification of fluid intake
- Dietary modification – limiting intake of bladder irritants, e.g. Caffeine, spices, acidic foods
• Medical Therapy
-
Anti-muscarinic agents
- Decrease bladder pressure by blocking muscarinic receptors
- Side effects – dry mouth, constipation, nausea, blurred vision, confusion, drowsiness
- Contraindicated in narrow angle glaucoma, especially untreated
• Surgical intervention
- Neuromodulation with sacral nerve stimulators
- Onabotulinumtoxin
- Bladder augmentation, urinary diversion
What is the treatment for stress incontinence?
Non-surgical therapy
• Pelvic floor exercises
- Augment closure strength of the urinary sphincter with pelvic floor musculature
- Requires intensive training sessions at specialized centers
- With adequate instruction good long term success rates
• Medical therapy
- α – agonist therapy – increases smooth muscle tone at the bladder neck/proximal urethra
- Tricyclic antidepressants – act as combined α – agonist and antimuscarinic
- Pessaries
- Surgical management
-
Sling procedures
- Restore the anatomic “hammock” of the urethra and pelvic floor/bladder neck complex
-
Pubovaginal sling
- Treats ISD and anatomic incontinence by coapting the proximal urethra and supporting the bladder neck
-
Mid urethral slings
- Retropubic and trans-obturator approach
- Functions by “kinking” or compressing the mid urethra
-
Artificial urinary sphincter
- Often used in male patients with post-prostatectomy incontinence
- Inflatable cuff surrounds the bulbar urethra (male) or proximal urethra (female)
What is the treatment for mixed urinary incontinence?
Pelvic floor physical therapy
• Biofeedback
Tricyclic antidepressants (imipramine)
Surgical treatment of stress component
• Relieves urge component in 70% of patients
What is the treatment for overflow incontinence?
Procedures to assist with emptying the bladder
- e.g.: TURP for men with BPH
Intermittent catheterization
- Ideal for patients with poor detrusor contractility
Chronic indwelling catheters are useful only in specific situations
What is acute scrotum (def)? Etiologies?
Acute onset of severe pain or swelling in the scrotum or scrotal wall
Etiology:
- Ischemia
- Trauma
- Infection
- Inflammation
- Hernia
- Acute change of chronic conditions
What are ischemic causes of acute scrotum?
Testicular torsion
What is the presentation of testicular torsion?
- Physical or lab findings consistent with infection?
- Rapid onset of severe testicular pain and swelling
- No correlation with activity or trauma
- Physical exam findings
- High lying testicle with abnormal lie
- Severe tenderness to palpation
- Initially, cord and testicle can be palpated separately
- Late presentation often has significant scrotal wall edema and confluence of intrascrotal structures
• No physical or laboratory findings consistent with infection
- Normal CBC
- Afebrile
- Normal urinalysis
Describe the diagnosis of testicular torsion
- Physical exam and history are key
- Scrotal ultrasound with Doppler flow to assist with diagnosis
- Identification of flow is key finding
What is treatment for testicular torsion?
- Surgical exploration of the scrotum
- Manual detorsion of the testicle and cord are mandatory
- Non-viable testicles are removed
• Orchiopexy to prevent reoccurrence
- Contralateral side undergoes same procedure
• Outcomes
- Salvage rage ~ 100% if caught early ( <6 hours)
- Salvage < 20 % if found at ~ 12 hours, 0 % salvage > 24 hours
What are testicular and epididymal appendages (involved in testicular torsion)
Testicular and epididymal appendages
- Mullerian and Wolffian remnants
- Testicular exam is usually normal but symptoms are similar
- Ultrasound is valuable to confirm diagnosis and demonstrate a normal testicle
Describe testicular injury leading to acute scrotum
• Penetrating and blunt mechanism
- 40-60% of genitourinary gunshot wounds involve the genitalia
• Anatomic considerations
- Rupture of the tunica albuginea is the key finding
- Absolute indication for exploration
- Collection of blood around the testicle (hematocele) may not require intervention
What is the managemetn for testicular injury causing acute scrotum?
Contusion/hematoma
- Intratesticular hematoma or small hematoceles
- Observation: compression, ice, elevation
Rupture
- Scrotal exploration with exposure of scrotal cord structures and testicle
- Debridement of non-viable tissue
- Surgical closure of the tunica albuginea
What are infectious causes of acute scrotum/
- Epididymitis and Epididymoorchitis
- Scrotal wall infections
- Acute changes of chornic conditions
What is the etiology of Epididymitis and Epididymoorchitis?
- Men < 35yr often STI – chlamydia, gonorrhea
- Men > 35yr often gram negative bacteria, similar to UTI organisms
Describe the presentation of epididymitis and epididymoorchitis leading to acute scrotum
- Diagnosis
- Management
- Gradual, progressive onset of symptoms
- Dysuria, frequency, and urgency of urination may be present
- Physical exam
- Enlarged, edematous scrotum with painful, enlarged testicle
• Diagnosis
- Scrotal ultrasound
- Urine culture
•Management
- Broad spectrum antibiotics, anti-inflammatory drugs, scrotal elevation
Describe scrotal wall infections
- PE findings
- Management
- Cellulitis, abscess, and fasciitis (Fournier’s gangrene)
- Fasciitis physical exam findings
- Crepitus in skin, edema, open, necrotic wounds
• Management
- Antibiotic therapy, surgical drainage or debridement
Describe acute changes of chronic condition
- Etiologies
- Diagnosis
- Management
Etiologies
- Neoplasms, spermatocele, hydrocele
- Neoplasms may develop necrosis and hemorrhage
Diagnosis
- Physical exam
- Ultrasonography
Management
• Antibiotics, surgical extirpation, drainage
