Clin Med - Urology Flashcards
Define urinary incontinence
Involuntary loss of urine
What are the 5 types?
- Urge Incontinence
- Stress Incontinence
- Mixed Incontinence
- Total Incontinence*
- Overflow Incontinence*
*Not true incontinence
What is urge incontinence?
- 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
Test for urge incontinence
Urodynamics
Urge Incontinence Treatment - behavioral therapy
- Timed voiding (advise patients to void every 2 hours – don’t wait on the signal)
- Biofeedback
- Tibial Nerve Stimulation
- InterStim (Sacral neuromodulation)
Other urge incontinence tx
Medications & botox
Urge incontinence antispasmodics
*Myrbetriq
-Toviaz
-Enablex
-Vesicare
Detrol LA
-Ditropan
-Oxybutynin
Tricyclic antidepressants such as imipramine
What is stress incontinence?
- Urethral Incompetence
- Usually a result of weakness of the pelvic floor muscles and dysfunction of the urethral sphincter
Stress incontinence characteristics
- 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
When does stress incontinence generally occur?
During the day
How does urodynamics test for stress incontinence?
*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.
Stress incontinence tx
Pelvic floor muscle exercises (Kegels) Biofeedback Pessaries Tampons Surgery** Contigen (collagen) injections
What does stress incontinence tx involve?
suspension and support of the vesicourethral segment in the normal position.
-Surgeries include MMK, TOT, TVT and sparc
Stress incontinence surgeries
- 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.
Stress incontinence TVT procedure
- TVT is placed beneath the middle of the urethra.
- Tape is inserted through the vagina to the skin.
Stress incontinence TOT procedure
- 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.
TVT vs. TOT
retropubic space is not entered in TOT and cystoscopy is not performed.
What is mixed incontinence?
Both stress and urge incontinence
What is total incontinence?
loss of urine at all times in all positions.
*not a true incontinence
What causes total incontinence?
Sphincteric efficiency is lost due to previous surgery (prostatectomy, TURP) nerve damage or some anatomic abnormality.
note: TURP = transurethral resection of the prostate
What is overflow incontinence?
- due to urinary retention, small amount of urine dribbles out.
- Usually due to obstructive or neurogenic causes.
*not a true incontinence
Neurogenic causes of overflow incontinence
- what spasms
- tx
External sphincteric spasms
- In and out catheterization
- Meds: Urecholine
Obstructive causes of overflow incontinence
- 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.
Tests for retention in overflow incontinence
-Bladder scan (not 100%, but usually preferred by patients).
- PVR (Post void residual)
- -Catheterize them.
- -Normal in an adult is less than 50 cc.
Treatment for retention
- Double voiding
- Medication
- Foley catheter (MC – often needed in the beginning).
- Surgery
Causes of retention
- BPH
- Urethral Stricture or urethral stenosis
Medical Treatment for retention
- Flomax (0.4 mg po QD-BID)
- Urecholine (10-50 mg po TID-QID)
Surgical Treatment for BPH
- TURP - used to be the gold standard, but is now done less and less, high bleeding risk
- Greenlight Laser
Surgical Treatment for Urethral Stricture
- Dilation
- Direct Internal Urethrotomy
- Open Urethroplasty
Workup of a patient with incontinence
- 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
What are 3 pelvic abnormalities?
- Cystocele
- Rectocele
- Enterocele
What is a cystocele?
Anterior vaginal prolapse
What is a rectocele?
Posterior vaginal prolapse
What is an enterocele?
Vaginal hernia s/p hysterectomy
MCC of hematuria
- UTI
- Stones
- Renal cysts
- BPH
- Bladder cancer until proven otherwise
- Parasite (schistosoma haematobium)
Gold standard dx for hematuria
Renal U/S or CT
Other dx for hematuria
- U/A (dipstick + microscopic)
- Cystoscopy
- Urine cytology every 6 months - 1 year
MC presenting symptom for bladder cancer
hematuria (gross or microscopic)
Who is at greatest risk for bladder cancer?
SMOKERS!
Bladder cancer tx
-get yearly CXR
-tx of superficial lesions via TURBT (transurethral resection of a bladder tumor)
or cystoscopies
Bladder cancer tx - recurrent or multiple lesions
Bladder instillation (“chemotherapy”)
Using: thiotepa, mitomycin, or BCG (bascillus Calmette-Guerin)
In bladder cancer, radical cystectomy is used for …
- Diffuse TCCA (transitional cell carcinoma in situ)
- Muscle invasive tumors
MCC of UTI
- Baths
- Certain foods, including carbonated beverages and acidic foods
- Intercourse
- Reflux in kids
UTI Symptoms
- Dysuria
- Frequency
- Urgency
- Suprapubic discomfort
- Hematuria
Additional SX of Pyelonephritis
- Fever
- Flank pain
- N/V and diarrhea
Urinalysis in UTI
- Leukocyte esterase positive
- Nitrite positive
- Heme positive
Tests in UTI
- Urinalysis-pyuria, hematuria, bacteriuria
- Cathed C & S
- -Most common bugs: E.coli, enterococci, Proteus, Klebsiella, Enterobacter, Pseudomonas
When would you get renal U/S in UTI?
recurrent UTI’s
What does CBC show in pyelonephritis?
shows leukocytosis with left shift
Tx for acute cystitis?
Most commonly Fluoroquinolone, Bactrim, or Macrobid for 3-7 days.
Tx for pyelonephritis - outpatient
Same as cystitis (Fluoroquinolone, Bactrim, or Macrobid), but for 7-14 days.
Tx for pyelonephritis - inpatient
IV Fluoroquinolones or Ampicillin/Gentamicin for 24-48 hours after becoming afebrile, then PO Abx for 7-14 days.
Disorders of the prostate
- BPH (Benign Prostatic Hypertrophy)
- Prostatitis
- Prostate CA
Prostate Evaluation
- DRE (Digital rectal examination)
- PSA (Prostate specific antigen)
Always get PSA with DRE!
Digital Rectal Exam (DRE)
-Size
Normal is < 20 grams (subjective)
-Consistency and symmetry: check for nodules – they can mean prostate cancer
PSA (prostate specific antigen)
- 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.
PSA over 4 or prostate nodule tx plan
- 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.
Prostate biopsy
Via TRUS (Transrectal Ultrasound guided)
Can be done in office or under sedation.
BPH(Benign Prostatic Hypertrophy) Etiology
not completely understood, but seems to be endocrine controlled.
Where does BPH develop? What are Sx??
Develops in the transition zone
Sx: incomplete bladder emptying, frequency, intermittency, urgency, weak stream, straining, nocturia
Medical Treatment for BPH
5-alpha-reductase inhibitors
- -Proscar (Finasteride) 5mg daily
- -Avodart
Alpha-blockers
–Flomax (Tamsulosin) 0.4 mg QD-BID
Surgical tx for BPH
- TURP (Transurethral resection of prostate)
- Greenlight Laser
Prostatitis
- definition
- signs & sx
Ascending infection of Gram-negative rods into the prostatic ducts.
- Fever
- Chills
- Low back and perineal pain
- Urgency
- Frequency
- Dysuria
Dx of Prostatitis
- DRE shows a “boggy” prostate that is swollen and tender
- U/A may show pyuria
- C & S is generally negative
Tx of Prostatitis
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
Prostate cancer
- definition
- metastasis
- Adenocarcinoma is confirmed by bx
- Metastasis to pelvic lymph nodes, bone, lung, and liver.
What is androgen deprivation?
- 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
Prostate cancer tx
- 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
Testicular findings
- Testicular cancer
- Hydrocele
- Spermatocele
- Varicocele
Testicular cancer on exam
- Firm, non-tender mass
- Does not transilluminate
Testicular cancer imaging
- 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
Testicular cancer lab
- AFP (alpha-fetoprotein)
- HCG (human chorionic gonadotropin)
What is a hydrocele?
Collection of serous fluid in some part of the processus vaginalis, usually the tunica.
Hydrocele sx
- Swelling of the hemiscrotum
- Soft (vs. hard in testicular cancer)
- Non-tender
- May have a sensation of heaviness
Tests & txfor hydrocele
- 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)
Spermatocele
- Cystic mass on the caput or head of the epididymis that contains fluid and sperm
- Generally occurs in the 4th and 5th decades
Spermatocele signs & sx
- Generally painless
- Most are less than 1 cm
- Able to palpate the mass separate from the testis
Spermatocele tests & tx
- US
- Transilluminates
- TUS can demonstrate a spermatocele in the head of the epididymis
Tx: Generally none
-Elective surgery if too large
Varicocele
- definition
- signs & sx
Dilation of the pampiniform plexus of veins in the spermatic cord most commonly on the left.
- Nontender
- “Bag of worms” consistency
- Does not transilluminate*
Varicocele imaging & tx
- TUS
- Surgical repair only if pain, testicular growth retardation (in adolescents), or fertility issue.
What are the 4 penile disorders?
- Peyronie’s Disease
- Priapism
- Phimosis
- Paraphimosis
Peyronie’s disease
- definition
- tx
Curvature of the penis due to scar tissue
Tx:
- Injection of Kenalog into scar tissue
- Verapamil cream
- Surgery rarely curative
Priapism
- definition
- tx
Erection lasting longer than 4 hours - Medical emergency!
Tx:
-Draw blood from penis with butterfly needles
Phimosis
- definition
- tx
- Inability to retract foreskin over glans penis.
- If symptomatic, pt needs circumcision
Paraphimosis
- definition
- tx
-Foreskin is trapped behind the glans penis.
Tx:
-Manual or surgical reduction and circumcision
