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Repro med test 2 > BPH, Urinary tract disorders, and prostate ca > Flashcards

BPH, Urinary tract disorders, and prostate ca Flashcards

1
Q

______ tissue comprises 30% of the prostate.

A

glandular

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2
Q

______ comprises 70% of the prostate.

A

stroma, it supports the glandular tissue

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3
Q

What is the smallest structure in the glandular component?

A

Acini

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4
Q

Proliferation of the Acini is what condition?

A

BPH

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5
Q

What influences BPH?

A

-testosterone decrease, estrogen and adipose increase deposition

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6
Q

Proliferation of what 2 cell types leads to BPH?

A

epithelial and stroll

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7
Q

Proliferation of what = cancer?

A

basement membrane

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8
Q

Peripheral zone info:

A
  • majority of prostatic glandular tissue (70%)

- Origin of 70% or prostate adenocarcinomas

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9
Q

Epidemiology of BPH:

A
  • *normal part of aging
  • Present in 50% of men by age 60 and 90% by 80
  • More progressive and more sever in blacks, but prevalence rates are similar
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10
Q

Pathophys of BPH:

A

Testosterone -> 5 reductase -> DHT: binds to nuclear receptors in the prostate leading to hyperplasia
A1- adrenergic receptors in:
-Muscle of stroma
-Capsule of Prostate
-Bladder neck responds causing smooth muscle contraction and contribute by worsening urinary symptoms (LUTS)

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11
Q

Prostate areas involved in BPH:

A

Transition and periurethral zones:

  • epithelium proliferation (divides forms nodular cells
  • Acini proliferation (“sitting in the sauce”)
  • Smooth muscle proliferation
  • Stromal support changes
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12
Q

What does growth of the transitional zone cause?

A

urethral obstruction

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13
Q

LUTS=

A
  • Lower Urinary Tract Symptoms

- Symptoms are classified as voiding (obstructive) or Storage (irritative)

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14
Q

What are the obstructive urinary symptoms?

A
  • weak stream
  • hesitancy
  • incomplete emptying
  • double voiding
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15
Q

what are the irritative urinary symptoms?

A
  • urgency
  • frequency
  • nocturia
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16
Q

Urinary incontinence:

A
  • paradoxical or overflow incontinence
  • urge-related
  • Hx or uti
  • symptoms exacerbated by cold meds
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17
Q

American Urological Association’s BPH symptom score:

A
  • how often have you had a sensation of not emptying your bladder completely after you finish urinating?
  • how often have you had to urinate again less than two hours after you finished urinating?
  • How often have you stopped and started again several times when you urinated?
  • how often have you found it difficult to urinate?
  • How often have you had a weak stream?
  • how often do you have to push or strain to begin urinating?
  • How many times did you most typically get up to urinate form the time you went to bed at night until the time you got up in the morning?
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18
Q

Normal BPH work-up:

A
  • scent of urine
  • soiling of undergarments
  • DRE
  • UA
  • BMP
  • Baseline PSA
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19
Q

Specialty BPH work-up:

A
  • Bladder sonogram with measurement of post-void urinary residue (PVR)
  • Measurement of urine flow rate/ pattern (Uroflow)
  • Transrectal ultrasound
  • Cystoscopy (determine best surgical approach, if indicated)
  • Upper tract imaging (renal sono or ct if s/s of stones, CKD, hematuria)
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20
Q

How do medications of BPH work?

A
  • either they open up the gland by relaxing smooth muscle
  • or they shrink the gland
  • or antimuscarinics
  • or combo
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21
Q

Meds that open of the gland in BPH tx:

A
  • Non-selective alpha-blockers: doxazosin (Cardura), terazosin (Hytrin)
  • Selective alpha-blockers: tamsulosin (Flomax, now available as a generic), silodosin (Rapaflo)
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22
Q

Meds that shrink the gland in BPH:

A

5-alpha reductase inhibitors: finasteride, dutasteride

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23
Q

Antimuscarinics:

A

Oxybutynin

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24
Q

How Finasteride shrinks the prostate:

A

Finasteride inhibits the enzyme 5alphareductase (5ARI)
Thus, testo in the prostate not converted to DHT
Prostate shrinks over time

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25
Q

indications for surgical tx of BPH:

A
  • symptoms refectory to meds
  • urinary retention
  • pt can’t tolerate meds
  • pt prefers surgery
  • recurrent UTI attributable to BPH
  • Impaired renal function attributed to BPH
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26
Q

Confounders of BPH:

A 
UTI
Prostatitis
Neurologic disease (CVA/TIA, Parkinson’s, MS)
Dietary indiscretion (caffeine, alcohol, etc.)
Diabetes (polyuria)
Timing of diuretics
OSA (“Does he snore?”)
Advanced cancer of the prostate (rare)
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27
Q

Prostate Ca epidemiology:

A

Most common non-skin cancer in men in the U.S.
2nd leading cause of cancer death in men in the U.S.
241,000 new cases annually
28,100 deaths in 2012
Survival – excellent if detected early

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28
Q

Prostate cancer screening types:

A
  • PSA

- DRE

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29
Q

PSA-

A

“prostate specific antigen”

  • Enzyme that liquefies ejaculate-sperm swim free
  • May have a role in reproduction*
  • Sensitivity 21% for any cancer (threshold of 4.0 ng/mL), 50% for high-grade cancer
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30
Q

DRE-

A

digital rectal exam

  • Should be smooth, symmetric, no nodules/induration
  • Sensitivity 59%, specificity 94%
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31
Q

Annual prostate screening:

A

PSA + DRE

  • Tries to answer the question: “Does he need a biopsy??”
  • Men < age 50 only if positive family history in 1st degree relative or African American (then age 40)
  • “Normal” PSA range: 0.0-4.0
  • If positive family history, many lower biopsy threshold to 2.5
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32
Q

PSA limitations:

A
  • Non-specific: elevated in benign conditions (BPH, prostatitis), trauma, instrumentation, ejaculation (48 hours)
  • DRE has minimal effect on -PSA value (increases 0.26-0.4 ng/mL)
  • Altered by 5ARI (finasteride/dutasteride, lower PSA value)

Further refinements:

  • Serial measurements
  • PSA free percentage (lower = higher risk of cancer)
  • Age and race-specific reference ranges
  • Take time to retrieve/compare past values!
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33
Q

DRE limitations:

A

-only 85% of cancers arise peripherally (palpable)

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34
Q

PSA interpretation:

A

Know that there are age- and ethnicity-related norms for PSA that range from 1-6.5. Don’t memorize the table.

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35
Q

Presentation of Prostate Ca:

A

-Prostate screening – elevated PSA, nodular prostate, etc.
-Urinary symptoms are rare, usually only when advanced
-Constitutional symptoms:
Weight loss, night sweats
-Bony metastatic symptoms

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36
Q

Working up prostate ca:

A
  • prostate needle biopsy (PNB)
  • Patient awake
  • Topical and injected local anesthetic
  • Low but significant risk of prostatitis
  • Predictable self-limited bleeding (urine, stool, semen)
  • Transrectal ultrasound (TRUS) guidance
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37
Q

Prostate Needle Biopsy (PNB):

A

Sextant sample:

  • Right apex, mid, base
  • Left apex, mid, base

Variable number of cores depending on size of gland, results of past biopsy, etc.

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38
Q

Prostate Cancer grading/ scoring:

A

Know that Gleason scoring exists and that low numbers are better (indicate low-grade, low-stage tumors)
score= 1-10

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39
Q

Staging work-up of prostate ca includes:

A

Chest X-ray
Comprehensive labs – CBC, LFT’s (alk phos)
Bone scan if PSA >20 ng/mL
CT of pelvis if high risk

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40
Q

Tx options of prostate ca:

A 
Radical retropubic* prostatectomy (RRP)
Radiotherapy
Brachytherapy “seed” implant 
External beam (3-D conformal, IMRT)
Androgen suppressive therapy (AST) 
Active Surveillance
41
Q

Selection prostate ca tx:

A

Is the patient treatable at all?
Which modality is likely to give best result?
What does your patient value most?** (incontinence, erectile function, etc.)

42
Q
  • Quality of life is determined by….
A

the person living the life

43
Q

Brachytherapy is best for what?

A
  • localized, contained ca
44
Q

what is brachytherapy?

A

Brachytherapy seeds are radiated and implanted in prostate They remain in prostate even after radiation has degraded about 60 days.

45
Q

Dyuria:

A

-pain/burning with urination

46
Q

Hematuria:

A

-blood in urine

47
Q

urgency:

A

sudden, strong urge to pass urine

48
Q

frequency:

A

-complaint of voiding too often

49
Q

UTI:

A

UTI

you should probably know this by now

50
Q

Recurrent UTI:

A

recurrent infection, generally with different organisms or same organism but different susceptibilities

51
Q

Asymptomatic bacteriuria:

A

-bacteria in urine, w/o significant host response/ symptoms

52
Q

UTI etiology:

A
  • begins with inoculation of the urinary tract (usually from fecal reservoir)
  • E. coli (80% of acute cystitis)
  • Staph species, Klebsiella, Proteus
53
Q

UTI epidemiology:

A

50-60% of women have reported having an UTI

54
Q

UTI presentation:

A
  • variable
  • Local urinary symptoms – dysuria, SP pressure, frequency, urgency, cloudy/malodorous urine
  • Systemic symptoms – fever, malaise, flank pain
55
Q

UTI work up:

A
  • Good history
  • Good exam with vitals, check for CVAT, +/- genital exam
  • UA +/- culture
56
Q

UA:

A

Evaluation of mid-stream urine (“clean catch”)
Male: retract foreskin if present, cleanse glans
Female: cleanse perimeatus, separate labia
Begin voiding, sweep under to collect mid-stream

57
Q

Gross exam:

A

Color – food (beets), infection, medications, blood
Clarity/turbidity – infection, post-prandial, phosphaturia
-Pyridium turns urine orange and can make dipstick unreliable

58
Q

What does dipstick analysis look at?

A
  • Specific gravity
  • pH
  • Blood
  • protein
  • glucose
  • ketones
  • nitrate
  • Leukocytes
59
Q

specific gravity:

A

-hydration status

60
Q

pH:

A

ranges from 5.0-8.0
>7.5 can be indicative of urea-splitting organisms (Proteus)
<6.0, think uric acid stones

61
Q

blood:

A

ranges from none to 3+ (large)
Sensitivity is >90%; specificity is lower
False positives: menses, highly-concentrated urine, exercise
Should be confirmed with microscopic analysis

62
Q

Protein:

A

ranges from none to 4+

63
Q

Glucose:

A

always abnormal if positive

Renal threshold corresponds to serum glucose of ~180 mg/dL

64
Q

Ketones:

A

-sign or hunger or DM

65
Q

Nitrite:

A

negative or positive

If positive, likely infection (specificity of ~90%, lower sensitivity)

66
Q

Leukocytes:

A

ranges from none to 3+ (large); presence of WBC in urine

Often positive with infection, can also be positive with contamination

67
Q

What does microscopic UA look at?

A
  • RBCs
  • WBCs
  • Epithelial cells
  • Casts
  • Crystals
  • Bacteria
68
Q

Bacteria in UA:

A

5 bacteria/hpf reflects 100,000 cfu/mL

Any bacteria found in male sample should be cultured

69
Q

technique in urine culture:

A

-freshly voided/catheterizations

70
Q

Who needs urine culture?

A 
All men 
Women
Recent antibiotic treatment
Early recurrence
DM
Pregnancy or recent pregnancy
Suspect surgical or other anatomic complexity
Symptoms > 7 days
71
Q

Some RFs or UTI’s (anatomy, behaviors, environment)

A

Anatomy - female v. male urethra; VUR; incomplete bladder emptying from functional obstruction (neurogenic bladder, diabetic bladder) or anatomic obstruction (BPH, stricture, meatal stenosis), phimosis, kidney/bladder stones

Behaviors - sexual activity, spermicidal use, ?post-coital voiding, ?wiping technique, ?condoms, ?baths instead of showers

Environment - increased host exposure to pathogen
Repeated introduction of contaminated FB (intermittent catheter)
Colonization of chronic FB (indwelling catheter, pessary)
Overgrowth of pathogens due to alteration of host native flora (post-menopausal female)

72
Q

Tx of UTIs

A

ANTIBIOTICS APPROPRIATE TO THE INFECTION- AND IT’S USUALLY E COLI, but don’t hesitate to culture!

73
Q

UTI prophylaxis:

A

Reasonable to attempt if infection is recurrent in otherwise straightforward female patient
Usual duration of six months; 50% recur 3 months after stopping

First-line:
TMP/SMX SS qHS
TMP 100mg qHS
Nitrofurantoin non-monohydrate 100mg qHS
Second-line: (if allergic, or if recurrent despite first-line agent)
Ciprofloxacin 125mg qHS
Cephalexin 250mg qHS

Non-antimicrobial strategies:
Cranberry or lingonberry juice, 20 -30% effective
Vaginal estrogen, 30% effective
Probiotics

74
Q

What percent of open system catheterized pts are bacteriuria by 4 days?

A

95%

75
Q

Catheter-associated UTI:

A

Catheters are a problem due inevitable colonization of the bag or tubing, with subsequent extraluminal migration (66%) or intraluminal migration (33%) into the bladder

Open system: 95% of patients are bacteriuric by 4 days

Closed system: rate as low as 5% per day of catheterization, but as high as 50% at 7 days

76
Q

Prolonged catheterization >6 days relative risk?

A

5.1-6.8

77
Q

Pyelonephritis:

A

infection of renal parenchyma and collecting system (upper UTI)

78
Q

Pyelonephritis Etiology:

A

E. coli most common
Also Proteus, Pseudomonas, and Klebsiella
Ascending spread most common, rare hematogenous spread

79
Q

Predisposing factors of Pyeloneophritis:

A

Obstruction, renal calculi, DM, immunosuppression, congenital anomalies, prolonged catheter, pregnancy

80
Q

Clinical presentation of pyelonephritis:

A

Fever, chills, malaise, flank +/-radiation (upper tract sxs)
Dysuria, urgency, frequency (lower tract sxs)
N/V
CVAT on affected side is hallmark PE finding

81
Q

Pyelonephritis work up:

A

UA, urine culture, blood culture, CBC, chem-8

Renal sonogram to exclude obstruction, especially if history of stones

82
Q

Tx of Pyelonephritis:

A

IV antibiotics, hydration, blood glucose monitoring, etc.

Low threshold for hospital admission, especially in at-risk individuals (elderly, DM, immunocompromised, pregnant, potentially non-compliant patients)

If urinary tract obstruction, should be decompressed via placement of percutaneous tube or ureteral stent

83
Q

Urinary lithiasis:

A

calculi within the urinary tract, anywhere from renal calyces to the urinary bladder

84
Q

Urinanary lithiasis Etiology:

A

chemistry!! (pH, urine concentration/supersaturation)
Ca-stones – hypercalciuria, hyperoxaluria (gastric bypass patient), hypocitraturia (important stone inhibitor), low urine volume
HyperPTH, dietary indiscretion (sodium, oxalate, animal protein), medullary sponge kidney
Uric acid stones – acidic urine (pH < 5.5), elevated serum uric acid
Gout, chronic diarrhea (bicarb loss), DM/metabolic syndrome (low urine pH), dietary indiscretion (animal protein)
Struvite stones – chronic upper tract infection, urease positive organisms (Proteus, Klebsiella); can develop into “staghorn calculi”
Cystine stones – autosomal recessive disorder (leads to cystinuria)
Mucinex stones/HIV drug stones

85
Q

Predisposing factors of urinary lithiasis:

A 
Environmental factors (chronic foreign body, factory worker)
Functional abnormalities (high-pressure neurogenic bladder)
Anatomic abnormalities (horseshoe kidney, congenital UPJ obstruction, stenosed infundibulum)
86
Q

Epidemiology of Urinary Lithiasis:

A
  • 12% of men and 5% of women will have at least 1 symptomatic stone by age 70
  • appears to be increases in US especially SE US
87
Q

Types of calculi:

A

80% ca- containing (ca oxalate, ca phosphate or mixed)

  • 15-20 infection stones
  • 5-10 uric acid stones
  • 1-5 cystine stones
88
Q

Presentation of 1st time urinary lithiasis:

A

-renal colic (waxing and waning)
-Location- specific (pain, urinary symptoms
Kidney – often asymptomatic
Proximal ureter – flank pain (sharp, intermittent, severe)
Distal ureter – groin/inguinal pain, can radiate to ipsilateral testicle/labium
UVJ – urinary hesitancy, urgency
Bladder – frequently asymptomatic

Other complaints:
Hematuria
Nausea, vomiting
Symptoms of associated illness:
-UTI symptoms, fever, etc.
89
Q

Urinary lithiasis work-up:

A

UA and culture:

  • Hematuria (absence does not exclude stone)
  • pH <5.5 suggests uric acid stone
  • pH >8 suggests infection (struvite) stone

Chem-8:
-assess renal function (creatinine)

CBC:
-if pt appears ill/ febrile

Imaging:
- CT abd and pelvis w/o contrast is nearly 100% sensitive

90
Q

3 tight spots ;) to look for ureteral calculi:

A
  • Ureteropelvic junction (UPJ)
  • Iliac vessels / pelvic brim
  • UreteroVESICAL junction (UVJ)
91
Q

Likelihood of stones passing:

A
  • 90% in distal ureter and <4 mm will pass spontaneously
  • 50% 4-5.9 will pass without surgery
  • 20% >6 mm will pass w/o surgery
92
Q

Urinary lithiasis conservative tx:

A
  • a-blocker (flomax), not fad approved for stones but widely used. Contra indicated in infection
  • 40-65% more likely to pass stone w/ flomax on board
  • strain all urine in anticipation of stone passage
  • pain control- narcotics, NSAIDs
  • Urology referral if illness, renal failure, unyielding pain n/v
93
Q

Indications for kidney stone surgery:

A
  • Ureteral stone too large to pass
  • Persistent/severe pain
  • Recurrent urinary tract infection
  • High risk non-compliance with expectant management
  • Staghorn calculi
94
Q

kidney stone procedures:

A

ESWL (extracorporeal shock wave lithotripsy)
Ureteroscopy + laser lithotripsy
Percutaneous nephrolithotripsy
Open stone surgery (rare)

95
Q

if stone is retrieved what should you lo0ok at?

A

composition

96
Q

when do you do metabolic work up on someone who has had a kidney stone?

A
  • recurrent stone formers
  • Blood work- serum uric ac id, calcium, magnesium, phosphorus, PTH
  • 24 hour UA
97
Q

general recommendations for someone who’s had a kidney stone:

A
  • increased hydration, decreased dietary sodium/ oxalate/ animal protein
  • no need to avoid dietary calcium. pursue normal calcium diet
98
Q

ESWL

A

KNOW THAT THIS EXISTS AND WORKS WELL

Repro med test 2 (7 decks)

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