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GU2 - Urology > Clin Med - Urology > Flashcards

Clin Med - Urology Flashcards

1
Q

Define urinary incontinence

A

Involuntary loss of urine

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2
Q

What are the 5 types?

A
  1. Urge Incontinence
  2. Stress Incontinence
  3. Mixed Incontinence
  4. Total Incontinence*
  5. Overflow Incontinence*

*Not true incontinence

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3
Q

What is urge incontinence?

A
  • Most common cause of geriatric incontinence accounting for 2/3 of all cases
  • Detrusor over activity, which means uninhibited bladder contractions (not controlled by the brain) that cause leakage.
  • Women report urinary leakage after an uncontrolled “urge” to urinate.
  • Unrelated to position or activity
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4
Q

Test for urge incontinence

A

Urodynamics

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5
Q

Urge Incontinence Treatment - behavioral therapy

A
  • Timed voiding (advise patients to void every 2 hours – don’t wait on the signal)
  • Biofeedback
  • Tibial Nerve Stimulation
  • InterStim (Sacral neuromodulation)
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6
Q

Other urge incontinence tx

A

Medications & botox

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7
Q

Urge incontinence antispasmodics

A

*Myrbetriq
-Toviaz
-Enablex
-Vesicare
Detrol LA
-Ditropan
-Oxybutynin

Tricyclic antidepressants such as imipramine

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8
Q

What is stress incontinence?

A
  • Urethral Incompetence

- Usually a result of weakness of the pelvic floor muscles and dysfunction of the urethral sphincter

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9
Q

Stress incontinence characteristics

A
  • 2nd most common cause of incontinence in older women
  • Leakage of urine due to stress (increased intra-abdominal pressure), such as bearing down, sneezing, laughing, coughing or lifting heavy objects
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10
Q

When does stress incontinence generally occur?

A

During the day

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11
Q

How does urodynamics test for stress incontinence?

A

*Measure leak point pressure.

This is done by measuring the intra-abdominal pressure though a rectal transducer during the Valsalva maneuver, coughing or laughing.

  • The pressure at the first leakage is noted.
  • The severity of the degree of sphincteric weakness is indicated by a low reading.
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12
Q

Stress incontinence tx

A 
Pelvic floor muscle exercises (Kegels)
Biofeedback
Pessaries
Tampons
Surgery**
Contigen (collagen) injections
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13
Q

What does stress incontinence tx involve?

A

suspension and support of the vesicourethral segment in the normal position.
-Surgeries include MMK, TOT, TVT and sparc

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14
Q

Stress incontinence surgeries

A
  • Most common is TVT (transvaginal tape) or TOT (transobturator tape)
  • MMK is an older procedure, where periurethral tissue is attached to the back of the pubic symphysis.
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15
Q

Stress incontinence TVT procedure

A
  • TVT is placed beneath the middle of the urethra.

- Tape is inserted through the vagina to the skin.

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16
Q

Stress incontinence TOT procedure

A
  • A vaginal incision is made at the level of mid-urethra.
  • Tape is inserted through the obturator foramina from the vagina to the skin.
  • The tape is placed mid-urethra.
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17
Q

TVT vs. TOT

A

retropubic space is not entered in TOT and cystoscopy is not performed.

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18
Q

What is mixed incontinence?

A

Both stress and urge incontinence

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19
Q

What is total incontinence?

A

loss of urine at all times in all positions.

*not a true incontinence

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20
Q

What causes total incontinence?

A

Sphincteric efficiency is lost due to previous surgery (prostatectomy, TURP) nerve damage or some anatomic abnormality.

note: TURP = transurethral resection of the prostate

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21
Q

What is overflow incontinence?

A
  • due to urinary retention, small amount of urine dribbles out.
  • Usually due to obstructive or neurogenic causes.

*not a true incontinence

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22
Q

Neurogenic causes of overflow incontinence

  • what spasms
  • tx
A

External sphincteric spasms

  • In and out catheterization
  • Meds: Urecholine
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23
Q

Obstructive causes of overflow incontinence

A
  • BPH (Benign Prostatic Hypertrophy)
  • -Enlargement, doesn’t increase risk of cancer.
  • -After age of ~60, almost all men have enlarged prostate.
  • Urethral stricture
  • -Scar tissue that doesn’t allow bladder to empty.
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24
Q

Tests for retention in overflow incontinence

A

-Bladder scan (not 100%, but usually preferred by patients).

  • PVR (Post void residual)
  • -Catheterize them.
  • -Normal in an adult is less than 50 cc.
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25
Q

Treatment for retention

A
  • Double voiding
  • Medication
  • Foley catheter (MC – often needed in the beginning).
  • Surgery
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26
Q

Causes of retention

A
  • BPH

- Urethral Stricture or urethral stenosis

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27
Q

Medical Treatment for retention

A
  • Flomax (0.4 mg po QD-BID)

- Urecholine (10-50 mg po TID-QID)

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28
Q

Surgical Treatment for BPH

A
  • TURP - used to be the gold standard, but is now done less and less, high bleeding risk
  • Greenlight Laser
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29
Q

Surgical Treatment for Urethral Stricture

A
  • Dilation
  • Direct Internal Urethrotomy
  • Open Urethroplasty
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30
Q

Workup of a patient with incontinence

A
  • Urinalysis to rule in/out infection (depending on UA results: culture and sensitivity)
  • Post void residual or bladder scan
  • Urodynamic evaluation
  • Pelvic or rectal exam
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31
Q

What are 3 pelvic abnormalities?

A
  1. Cystocele
  2. Rectocele
  3. Enterocele
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32
Q

What is a cystocele?

A

Anterior vaginal prolapse

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33
Q

What is a rectocele?

A

Posterior vaginal prolapse

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34
Q

What is an enterocele?

A

Vaginal hernia s/p hysterectomy

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35
Q

MCC of hematuria

A
  • UTI
  • Stones
  • Renal cysts
  • BPH
  • Bladder cancer until proven otherwise
  • Parasite (schistosoma haematobium)
36
Q

Gold standard dx for hematuria

A

Renal U/S or CT

37
Q

Other dx for hematuria

A
  • U/A (dipstick + microscopic)
  • Cystoscopy
  • Urine cytology every 6 months - 1 year
38
Q

MC presenting symptom for bladder cancer

A

hematuria (gross or microscopic)

39
Q

Who is at greatest risk for bladder cancer?

A

SMOKERS!

40
Q

Bladder cancer tx

A

-get yearly CXR
-tx of superficial lesions via TURBT (transurethral resection of a bladder tumor)
or cystoscopies

41
Q

Bladder cancer tx - recurrent or multiple lesions

A

Bladder instillation (“chemotherapy”)

Using: thiotepa, mitomycin, or BCG (bascillus Calmette-Guerin)

42
Q

In bladder cancer, radical cystectomy is used for …

A
  • Diffuse TCCA (transitional cell carcinoma in situ)

- Muscle invasive tumors

43
Q

MCC of UTI

A
  • Baths
  • Certain foods, including carbonated beverages and acidic foods
  • Intercourse
  • Reflux in kids
44
Q

UTI Symptoms

A
  • Dysuria
  • Frequency
  • Urgency
  • Suprapubic discomfort
  • Hematuria
45
Q

Additional SX of Pyelonephritis

A
  • Fever
  • Flank pain
  • N/V and diarrhea
46
Q

Urinalysis in UTI

A
  • Leukocyte esterase positive
  • Nitrite positive
  • Heme positive
47
Q

Tests in UTI

A
  • Urinalysis-pyuria, hematuria, bacteriuria
  • Cathed C & S
  • -Most common bugs: E.coli, enterococci, Proteus, Klebsiella, Enterobacter, Pseudomonas
48
Q

When would you get renal U/S in UTI?

A

recurrent UTI’s

49
Q

What does CBC show in pyelonephritis?

A

shows leukocytosis with left shift

50
Q

Tx for acute cystitis?

A

Most commonly Fluoroquinolone, Bactrim, or Macrobid for 3-7 days.

51
Q

Tx for pyelonephritis - outpatient

A

Same as cystitis (Fluoroquinolone, Bactrim, or Macrobid), but for 7-14 days.

52
Q

Tx for pyelonephritis - inpatient

A

IV Fluoroquinolones or Ampicillin/Gentamicin for 24-48 hours after becoming afebrile, then PO Abx for 7-14 days.

53
Q

Disorders of the prostate

A
  • BPH (Benign Prostatic Hypertrophy)
  • Prostatitis
  • Prostate CA
54
Q

Prostate Evaluation

A
  • DRE (Digital rectal examination)
  • PSA (Prostate specific antigen)

Always get PSA with DRE!

55
Q

Digital Rectal Exam (DRE)

A

-Size
Normal is < 20 grams (subjective)
-Consistency and symmetry: check for nodules – they can mean prostate cancer

56
Q

PSA (prostate specific antigen)

A
  • Start in all men over the age of 50
  • Start in men over the age of 40 who are black or have a family h/o prostate cancer.
  • Less than 4 is generally considered ok in primary care.
57
Q

PSA over 4 or prostate nodule tx plan

A
  • Abx for 2 weeks to rule out Prostatitis (debatable; Cipro 500 mg #28 1 PO BID)
  • Repeat PSA in 2-3 weeks.
  • -If PSA still elevated or nodule still present, prostate bx.

-If bx negative, repeat PSA every 3 months for the next year.

58
Q

Prostate biopsy

A

Via TRUS (Transrectal Ultrasound guided)

Can be done in office or under sedation.

59
Q

BPH(Benign Prostatic Hypertrophy) Etiology

A

not completely understood, but seems to be endocrine controlled.

60
Q

Where does BPH develop? What are Sx??

A

Develops in the transition zone

Sx: incomplete bladder emptying, frequency, intermittency, urgency, weak stream, straining, nocturia

61
Q

Medical Treatment for BPH

A

5-alpha-reductase inhibitors

  • -Proscar (Finasteride) 5mg daily
  • -Avodart

Alpha-blockers
–Flomax (Tamsulosin) 0.4 mg QD-BID

62
Q

Surgical tx for BPH

A
  • TURP (Transurethral resection of prostate)

- Greenlight Laser

63
Q

Prostatitis

  • definition
  • signs & sx
A

Ascending infection of Gram-negative rods into the prostatic ducts.

  • Fever
  • Chills
  • Low back and perineal pain
  • Urgency
  • Frequency
  • Dysuria
64
Q

Dx of Prostatitis

A
  • DRE shows a “boggy” prostate that is swollen and tender
  • U/A may show pyuria
  • C & S is generally negative
65
Q

Tx of Prostatitis

A

Doxycycline or Fluoroquinolone for 14 days initially (re-evaluate pt every 2 weeks. May need 2-3 rounds of 14 day treatment.)

Supportive therapy: Rest and analgesics

66
Q

Prostate cancer

  • definition
  • metastasis
A
  • Adenocarcinoma is confirmed by bx

- Metastasis to pelvic lymph nodes, bone, lung, and liver.

67
Q

What is androgen deprivation?

A
  • given prior to prostatectomy to shrink prostate.
  • Can be used in patients that are not surgical candidates. This is not a tx  basically making them not produce testosterone.
  • we use elmiron
68
Q

Prostate cancer tx

A
  • RPP (Radical perineal prostatectomy)
  • RRP (Radical retropubic prostatectomy)
  • Brachytherapy (little seeds of radiation placed in the prostate
  • External beam radiation
  • Watchful waiting (DNA tests can tell you the probability of cancer becoming worrisome – so it’s not always treated.)
  • Cryotherapy
69
Q

Testicular findings

A
  • Testicular cancer
  • Hydrocele
  • Spermatocele
  • Varicocele
70
Q

Testicular cancer on exam

A
  • Firm, non-tender mass

- Does not transilluminate

71
Q

Testicular cancer imaging

A
  • TUS (Testicular ultrasound): 1st test ordered to differentiate between solid and cystic type mass
  • CT of abdomen and pelvis: 2nd test ordered rule out metastasis
72
Q

Testicular cancer lab

A
  • AFP (alpha-fetoprotein)

- HCG (human chorionic gonadotropin)

73
Q

What is a hydrocele?

A

Collection of serous fluid in some part of the processus vaginalis, usually the tunica.

74
Q

Hydrocele sx

A
  • Swelling of the hemiscrotum
  • Soft (vs. hard in testicular cancer)
  • Non-tender
  • May have a sensation of heaviness
75
Q

Tests & txfor hydrocele

A
  • Transilluminates
  • TUS (testicular ultrasound)
  • Can help differentiate b/w hydrocele, spermatocele and testicular tumors.

Tx: Drain in the office with a large bore needle (sometimes required surgical removal)

76
Q

Spermatocele

A
  • Cystic mass on the caput or head of the epididymis that contains fluid and sperm
  • Generally occurs in the 4th and 5th decades
77
Q

Spermatocele signs & sx

A
  • Generally painless
  • Most are less than 1 cm
  • Able to palpate the mass separate from the testis
78
Q

Spermatocele tests & tx

A
  • US
  • Transilluminates
  • TUS can demonstrate a spermatocele in the head of the epididymis

Tx: Generally none
-Elective surgery if too large

79
Q

Varicocele

  • definition
  • signs & sx
A

Dilation of the pampiniform plexus of veins in the spermatic cord most commonly on the left.

  • Nontender
  • “Bag of worms” consistency
  • Does not transilluminate*
80
Q

Varicocele imaging & tx

A
  • TUS

- Surgical repair only if pain, testicular growth retardation (in adolescents), or fertility issue.

81
Q

What are the 4 penile disorders?

A
  1. Peyronie’s Disease
  2. Priapism
  3. Phimosis
  4. Paraphimosis
82
Q

Peyronie’s disease

  • definition
  • tx
A

Curvature of the penis due to scar tissue

Tx:

  • Injection of Kenalog into scar tissue
  • Verapamil cream
  • Surgery rarely curative
83
Q

Priapism

  • definition
  • tx
A

Erection lasting longer than 4 hours - Medical emergency!

Tx:
-Draw blood from penis with butterfly needles

84
Q

Phimosis

  • definition
  • tx
A
  • Inability to retract foreskin over glans penis.

- If symptomatic, pt needs circumcision

85
Q

Paraphimosis

  • definition
  • tx
A

-Foreskin is trapped behind the glans penis.

Tx:
-Manual or surgical reduction and circumcision

GU2 - Urology (10 decks)

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