AUA Curriculum Flashcards
Micturition:
pelvic nerve
hypogastric nerve
pudendal nerve
pelvic nerve –> parasympathetic, activates urination, causes detrusor to contract (senses BLADDER STRETCH of detrusor muscle)
hypogastric nerve –> sympathetic, inhibits contraction of detrusor, and contracts internal sphincter = hold pee
pudendal nerve –> somatic, contract external sphincter
stones of < or equal to ____ will pass spontaneously
-stones > or equal to ____ are unlikely to pass spontaneously
< 4mm
>10 mm
ddx of acute scrotal pain (6)
- ischemia (torsion, infarct)
- Trauma
- Infectious
- Inflammatory
- Hernia
- Acute on chronic (spermatocele, hydrocele, tumor, varicocele - rupture/hemorrhage)
Testicular torsion
occurs on L>R
increased risk with bellclapper deformity
100% salvage if <6 hrs, only 20% if >12hrs
Testicular rupture
2/2 lac of tunica albuginea of testis due to blunt or penetrating trauma
tx: surgical exploration and repair
different from intratesticular hematoma because that would have an intact tunica albuginea
Epididymitis
- pain relieved by elevation of the testicle
- on US shows INCREASED blood flow
- gradual onset of pain
- <35 yrs –> gonorrhea or chlamydia
- > 35 yrs –> gram neg rods
epididymoorchitis
when epididymitis extends into the testes and causes pain and enlargement
BPH - where?
TRANSITION ZONE surrounding urethera
PCA is in peripheral zone
BPH
proliferation of epithelial and smooth muscle cells
sx: hesitance, nocturia, decreased stream force, incomplete emptying, F/U/D
BPH work up
prostate size
urinary flow rate
PVR
AUA symptom score index (aka IPSS) - mild 0-7, mod 7-15, severe >15
BPH treatment
5a-reductase inhibitors = finasteride
a1 blockers = “zosins”
surgery - TURP, prostatectomy, laser, microwaves
combined drug therapy is > than any alone
diagnosis of UTI on culture
voided urine culture –> >10^5 CFU
catheterized urine –> > 10^3 CFU
when to get imaging in pediatric UTI
febrile kid ages 2 months -2yrs at 1st UTI
-get renal US, bladder US, VCUG
treatment of pediatric UTI
ppx - TMP/SMX or Nitrofurantoin
tx - TMP/SMX, cephalosporins, ampicillin, amoxicillin, augmentin
Vesico urinary reflux (VUR)
urine flows from the bladder up the ureter
dx - VCUG
DMSA scans monitor renal cortical function
UPJ obstruction
can be due to poor peristalis of UPJ, narrow segment, aberrant vessels, high insertion of ureter into renal pelvic
sx - flank pain worse with big diuresis
dx - renal US, VCUG
ureteroceles
cystic dilation of terminal, intravesical portion of ureter
- often ureterocele drains upper pole of a duplex kidney
- sx - UTI in first few months of lige
ectopic ureters
ureter lying caudal to normal ureter insertion at trigone of bladder
-often complete ureteral duplication + contralateral duplication
sx - boys –> UTI or epididymo-orchitis
girls –> UTI or continuous incontinence
Neuropathic bladder
due to myelomeningovele or trauma to the spinal cord
Posterior uretheral valve (PUV)
obstructing membranous folds within the lumen of prostatic urethra (only in boys)
dx - antenatal US –> thick bladder + hydro + oligo
Eagle-Barrett Syndrome
aka prune belly
absence of abdominal wall musculature, dilated ureter, bladder, urethra, and bilateral undescended testes
urachus
remnant of allantoic duct connecting anterior bladder wall to umbilicus
urachal remnants
sx - wet umbilicus, leaks during crying
risks for UTI in general (3)
- decreased urine flow
- promote colonization
- facilitate ascent (e.g. catheter)
E.Coli - why is it a good UTI bug?
Pili –> facilitate adhesion to host tissues
K antigen –> capsular polysaccharide (increased resistance to bactericidal activity)
Hemolysin –> increased tissue invasiveness
Urinary tract defenses
- Normal flora (decreased with low estrogen, low vaginal pH, and cervical IgA)
- high Osm, urea concentration, and low pH in urine (ruined by high glucose in urine)
- epithelium expressed TLRs –> recognize bacteria, activate innate immune system then adaptive immune response
- Kidney IgG production
+ LE on UA –> ?
+ Nitrite on UA –> ?
>10 WBC per hpf –> ?
sensitivity and specificity
+ LE on UA –> 64-90%sensitivity and specificity
+ Nitrite on UA –> very specific, only 50% sensitive
> 10 WBC per hpf –> 95% sensitive, NOT specific
what causes pain with kidney stones
ureteral dilation and/or renal capsular distension
Progression of RBF, renal pelvic pressure (RPP), and GFR with kidney stone
1st 2 hrs –> ?
6-24 hrs –> ?
> 24 hrs –> ?
1st 2 hrs –> INCREASED RPP and INCREASED RBF –> DECREASED GFR
6-24 hrs –> increased RPP continues –> DECREASED RBF
> 24 hrs –> DECREASED RPP and significantly decreased RBF –> renal ischemia
work up of kidney stones
non-con CT
US if pregnant
KUB if CT not available
Stone evaluation includes…
24hr urine –> volume, pH, Ca, Ox, Na, uric acid, citrate, phos, Mg, sulfate, Cr, cystine
Serum –> Ca, phos, uric acid, BUN, Cr, albumin, PTH, alk phos, 1,25D
stone composition
Indications for urgent intervention in kidney stones
- Obstructed with infection
- impending renal deterioration
- pain refractory to analgesics
- intractable N/V
- patient preference
pros and cons: ESWL
not great for lower pole stones
ideal for <3cm
ureteroscopy
good for distal stones
intrcavernosal pressure during ejaculation
100 mm Hg
Nerves involved in erection/ejaculation
- Pudendal –> somatic, penile sensation, contraction/relaxation of bulbo and ischiocavernosal muscles
- Sympathetic and parasympathetic merge to form cavernous n. –> regulate blood flow
- sympathetic discharge during ejaculation aids in stopping erection
Causes of ED in general
- psychogenic
- neurogenic (DM spinal cord, stroke)
- Hormonal
- Vasculogenic
- med induced
when is a cysto recommended in hematuria
cysto rec for pts > 35 yrs with microhematuria and all patients with gross hematuria
what is microscopic hematuria?
> 3 RBCs per HPF
Urge incontinence due to…
- detrusor overactivity (neurogenic vs. non neuro)
2. poor compliance
Stress incontinence
- anatomic (due to mobility of bladder neck)
- intrinsic sphincter deficiency due to bladder neck dysfunction
- Mixed incontinence
Main types of incontinence
- Stress
- Overflow
- Urge
- mixed
high PVR indicates what?
BOO vs. poor contractility
nml PVR is < 50 mL
Tx of urgency incontinence
- behavioral - timed voiding, decreased fluids, decrease bladder irritants, bladder training
- anticholinergics/antimuscarinics vs. B3 adrenergic agonist
- botox, sacral nerve stimulators
TX of overflow incontinence
- relieve obstruction vs. clean intermittent cath
TX of stress incontinence
- pelvic floor exercises
- alpha-agonists
- pessaries
- surgery
function of the prostate
secrete fluid into the ejaculate (acid, Zn, PSA)
causes of increased PSA
- PCA
- BPH
- infection
- instrumentation
- inflammation of prostate
Age adjusted PSA
PSA 4-10 –> 70% have negative bx
age 40-49 = 2.5
age 50-59 = 3.5
age 60-69 = 4.5
age 70-79 = 6.5
PSA density
absolute PSA / prostate volume (mL)
get volume from TRUS or MRI
> 0.15 –> bx
PSA velocity
3 measures over 2 years
- 35 ng/mL/yr for PSA <4
- 75 ng/mL/yr for PSA >4
free and complexed PSA
complexed = complexed to protease inhibitors
PCA has INCREASED complexed PSA (decreased % free PSA)
> 25% free PSA –> no PCA usually
post-obstructive diuresis
if >2,000 ccs out or >200ccs/hr out for 3 hrs
most common sight of upper tract obstruction?
UPJ over iliac bifurcation OR at uretero-vesical junction
priapism - pathophys
failure of corpus cavernosum (cc) to drain due to impaired relaxation or paralysis of cavernosal smooth muscle or occlusion of venous flow
types of priapism
ischemic vs. non ischemic
ischemic priapism
increased IC pressure –> decreased arterial blood in
- -> hypoxia, acidosis, compartment syndrome
- irreversible after 24hrs, 12 hrs –> 50% w/ED
causes: sickle cell, malignant tumors (leukemia), drugs, neurologic shock
dx: penile doppler, penile blood gas
non-ischemic priapism
fistula between cavernosal artery and corpus cavernorsum
62% resolve without tx
TX of priapism
tx: corporal aspiration w/18 or 19G needle at 3 or 9’oclock
- a1 agonist (phenylephrine) 1cc Q 15-20 min (MONITOR VITALS)
penile fx
rupture of tunica albuginea of the corporal bodies
pop, pain, loss of erection, ecchymosis, swelling, “eggplant deformity”
immediate surgical repair required
paraphimosis
foreskin retracted behind glans and will not return to normal position
–> necrosis 2/2 infarction = autoamputation of glans
TX: analgesia, and manual reduction vs. dorsal slit
braided suture
sil, vicryl, ethibond
handle better, tie more securely, NOT good in presence of bacteria (harbor bacteria)
monofilament sutures
monocryl, PDS, ethilon Nylon
