(3.1) Nocturia [DSA-Tyler] Flashcards
Getting up to urinate more than 2x a night can be defined as ___
Nocturia
What are the main causes of nocturnal polyuria? (3)
Age-related delay in urine excretion (time and volume of fluid intake, caffeine, ETOH)
Peripheral edema
Medications (gabapentin, NSAIDs, nifedipine)
How long must dysuria occur to be considered acute?
<1 week
What structures may be involved in internal dysuria?
Internal genital structures:
Bladder
Urethra
Suprapubic area
What structures may be involved in external dysuria?
External genital structures:
Labia minora/majora
What are the main voiding symptoms?
Slow/intermittent stream
Hesitancy
Dribbling
Dysuria
Complicated UTI may occur in what population?
Individuals with functional/strucutral abnormalities of urinary tract
Transient causes of urinary incontinence?
DIAPPERS
Delirium
Infection
Atrophic urethritis and vaginitis
Pharmaceuticals (diuretics, anticholinergics, CCBs, a-blockers in men, a-agonists in women, opioids)
Psychological factors
Excess urinary output caused by: diuretics, excess fluid
Restricted mobility
Stool impaction
Established causes of urinary incontinence? (3)
Detrusor overactivity (urge incontinence)
Urethral incompetence (stress incontinence)
Detrusor underactivity (overflow incontinence)
What is the most common cause of established geriatric incontinence?
Detrusor overactivity (urge incontinence)
Uninhibited bladder contractions that cause leakage
What population is urethral incompetence (stress incontinence) more common in?
Most common in women (not older women?)
Older men following prostatectomy
Urethral obstruction due to prostatic enlargement, urethral stricture, bladder neck contracture, or prostatic CA
What may cause urethral incompetence (stress incontinence) in older women?
Cystoceles or other anatomic problems
What distinguishes detrusor underactivity from detrusor overactivity and stress incontinence?
Elevated postvoid residual (>450 mL)
Via ultrasonography
What distinguishes detrusor underactivity from urethral obstruction in men?
Urodynamic testing
What is the standing full bladder stress test? What do the results indicate?
Test for stress incontinence
Have pt relax perineum and cough 1x while standing with full bladder
Instant leakage = + stress incontinence if retention excluded using US
Delay several sec or persistent leakage = uninhibited bladder contraction
What are the obstructive LUTS of BPH?
Urinary hesitancy
Straining
Weak stream
Terminal dribbling
Prolonged voiding, encomplete emptying
What are the irritative LUTS of BPH?
Urinary frequency
Urgency
Nocturia
Urge incontinence
Small voided volumes
The American Urological Association Symptom Index (AUASI) is used to measure what? What do the ranges indicate?
Lower urinary tract symptoms (LUTS)
0-7: Mild
8-19: Moderate
20-35: Severe
What is the most common reason men seek treatment for BPH?
Symptomatic relief
Also usually the goal of therapy for BPH
What drugs treat the dynamic aspect of BPH?
Static aspect?
Dynamic: a-adrenergic receptor antagonists - reduce sympathetic tone
Static: 5 ARIs - reduce prostate volume
May be used in combination with variable success
What drugs may treat the LUTS of BPH?
PDE5 inhibitors
Sildenafil, vardenafil, tadalafil, avanafil
What are the most common drugs for treating overactive bladder sx?
Anticholinergics
When is surgical therapy considered for pts with BPH?
Second-line therapy after a trial of medical therpay has failed
What ethnic group has a higher incidence of prostate CA and present at a more advance stage?
African Americans
What is the risk of being diagnosed with prostate CA if first degree relatives are affected?
2.5x if 1 relative affected
5x if >2 relatives are affected
How are the clinical states of prostate cancer defined?
- If CA diagnosis has been established
- If metastases are detectable on imaging studies and testosterone levels in blood
What are the 3 guidelines for administering the PSA test?
- Avoid in men with little to no gain (i.e. asymptomatic men with short life expectancy)
- Do not treat those who do not need treatment (can be managed by active surveillance, phases of prostate CA)
- Refer who do need treatment to a urologist - PSA 4-7 ng/ml
Why is DRE and PSA for prostatic CA detection controversial?
Low specificity and sensitivity with low rates of detection
What is the difference between asymptomatic bacteriuria (ASB) and UTI?
ASB occurs in the absence of sx attributable to the bacteria in the urinary tract
Detected incidentally, does not usually require tx (i.e. old people with chronic indwelling catheters do NOT need abx)
What distinguishes cystitis and pyelonephritis?
Mild fever - mild pyelonephritis
High fever - severe pyelonephritis
Elderly pts with cystitis may not be able to mount a fever response
What sx in cystitis may indicate upper urinary tract involvement?
Unilateral back/flank pain
Fever in a patient with cystitis may indicate involvement of what organs?
Invasive infection of kidney or prostate
How long does a fever in pyelonephritis take to resolve?
72 hours of therapy
Pt w/ hx of diabetes presents with pyelonephritis. What renal pathology might you be concerned about?
Obstructive uropathy associated with acute papillary necrosis when sloughed papillae enter the ureter
What form of pyelonephritis is often found on ultrasound in diabetic patients?
Emphysematous pyelonephritis
Production of gas in renal and perinephric tissues
What form of pyelonephritis may occur when chronic urinary obstruction and chronic infection leads to suppurative destruction of renal tissue?
Xanthogranulomatous pyelonephritis
Infiltration by lipid-laden macrophages
When would an intraparenchymal abscess be suspected in a patient with pyelonephritis?
Pt has continued fever and/or bacteremia despite antibacterial therapy
Infectious prostatitis is almost always ___ in nature
Bacterial
How might a complicated UTI present?
Symptomatic episode of cystitis or pyelonephritis in pt with anatomic disposition to infection
FB in urinary tract
Factors predisposing to a delayed response to therapy
What sx most commonly present in a patient with L ventricular failure?
Dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
(May have hemoptysis)
Typical PE findings on a patient with LV heart failure?
Pulsus alternans
Rales
Lung bases dull to percussion
S3 and S4
What population is most effected by urinary stone diseases?
Males
Age: 30s-40s
What genetic/environmental factors may increase risk of urinary stone formation?
Cystinuria
Distal RTA
High protein/salt intake
Sedentary occupations
What type of urinary stone is radiolucent?
Uric acid
What form of nephrolithiasis can be caused by absorptive, resorptive, and renal disorders?
Hypercalciuric calcium nephrolithiasis
What form of nephrolithiasis is secondary to dietary excess or uric acid metabolic defects?
Hyperuricosuric calcium nephrolithiasis
What form of nephrolithiasis is due to primary intestinal disorders (chronic diarrhea, IBS, steatorrhea)?
Hyperoxaluric calcium nephrolithiasis
A patient on long term hydrochlorothiazide treatment is at risk for what form of nephrolithiasis? What are the other risk factors?
Hypocitraturic calcium nephrolithiasis
Risk factors: disorders associated with metabolic acidosis (chronic diarrhea, Type 1 RTA)
Urease-producing organisms produce what kind of calculi?
Struvite (magnesium-ammonium-phosphate “staghorn” calculi)
What bacteria is associated with recurrent UTI but does not produce urease?
E. Coli
A patient presents with colicky flank pain and is unable to get comfortable. What pathology might they have?
Urinary stone formation
Persistent urinary pH <5.5 is suggestive of ____ stones
Uric acid or cystine
Persistent urinary pH > 7.2 is suggestive of ___ stones
Struvite infection
Urinary pH in what range suggests calcium-based stones?
5.5 - 6.8
What kind of metabolic evaluation is done for urinary stone formation?
Stone analysis
Serum Ca++, electrolytes, uric acid
Reduce Na+ and ptn intake
Fluid intake
What imaging studies will detect most stones?
KUB
Renal US
Most ED physicians go for CT because it is most accurate
When would you admit a patient with a urinary stone?
Intractable nausea/vomiting or pain (manage sx)
Obstructing stone with signs of infection
What diagnostic criteria are found in a patient with acute bacterial prostatitis?
Fever
Irritative voiding sx
Perineal/suprapubic pain
Exquisite tenderness on rectal exam
+ Urine culture
Most common organisms causing acute bacterial prostatitis?
E. Coli and Pseudomonas
What lab results would be foundon a pt for suspected acute bacterial prostatitis?
CBC: leukocytosis, left shift
UA: pyuria, bacteriuria, hematuria
+ Urine culture
When would you admit a patient with acute bacterial prostatitis?
Signs of sepsis
Need for surgical drainage of the bladder or prostatic abscess
Medications for acute bacterial prostatitis?
IV ampicillin + aminoglycoside until afebrile
Ampicillin and gentramicin
Ciprofloxacin
Ofloxacin
TMP-SMX
When would you refer a patient with acute bacterial prostatitis?
Evidence of urinary retention or chronic prostatitis
Why might a diabetic patient have nocturia?
Diabetic patients tend to be hyperglycemic which may cause osmotic diuresis
