Clinical Medicine Exam 3 GU Flashcards
Bladder disorders
Incontinence
Overactive bladder
Prolapse
Congenital and acquired abnormalities
Cryptochidism
Peyronies Disease
Trauma
Vesicoureteral reflux
Infectious disorders
Cystitis Epididymitis Orchitsi Prostatitis Pylonephritis urethritis
Neoplasms
Bladder cancer
Penile cancer
prostate cancer
testicular cancer
Penile disorders
Erectile dysfunction
Hypospadias/epispadias
Paraphimosis/phimosis
Prostate disorders
• Benign prostatic hyperplasia
Testicular disorders
- Hydrocele/varicocele
* Testicular torsion
Urethral disorders
- Prolapse
* Stricture
Cystitis aka
UTI
Cystitis
Uncomplicated
vs
complicated
Complicated is infection above bladder
Complicated has fever, chills, fatigue, malaise, rigors, Flank pain, CVA angle tender,
Cystitis
Complicated
E.coli (predominates)
Gram negs- Klebsiella, proteus, pseudomonas, morganella, acinetobacter, citrobacter
Gram Positive +
Entor
Cystitis
Complicated
E.coli (predominates)
Gram negs- Klebsiella, proteus, pseudomonas, morganella, acinetobacter, citrobacter
Gram Positive +
Enterococci and S Aureus
Yeasts
Risk factors for UTI
iatrogenic / Drugs
Catheter, antibiotic use, spermicides
Behavioral
Voiding dysfunction, frequent sexual intercourse
Anatomic/physiological
vesicouretreal reflux, female sex, pregnancy
Genetic
Familial tendency
susceptible uroepithilial cells, vaginal mucous properties
UTI Path
Colonization
Uroepithlium penetration
Ascension
Pyelonephritis
AKI
UTI Comorbidities
Diabetes, urinary tract abnormalities
UTI risk factors
Women
recent sex
use of spermicides, condoms w spermicide, diaphragms
UTI world wide numbers
90% Cystitis
10%pylonephritis
UTI classic presentation
Dysuria
Frequency
Urgency
Suprapubic pain
Hematuria is often observed
Pyuria in women with cystitis
Pyuria is present in almost all women with acute cystitis;
its absence strongly suggests an alternative diagnosis.
pyuria
WBC in urine (more than 10)
UTI DDX
UTI
Vaginitis
Urethritis
PID
Most common cause of microbial UTI
E. Coli
others can be: Enterobacteriaceae Klebsiella Proteus Staph saprophyt
Fix
Urinalysis (either by microscopy or by dipstick) for evaluation of pyuria is a valuable laboratory diagnostic test for UTI. It is not indicated in women with typical symptoms of acute simple cystitis (in whom the diagnosis can reliably be made on symptoms alone), but it can be helpful in cases in which the clinical presentation is not typical.
Pyuria is present in almost all women with acute cystitis; its absence strongly suggests an alternative diagnosis.
Dipsticks are commercially available strips that detect the presence of leukocyte esterase (an enzyme released by leukocytes, reflecting pyuria) and nitrite (reflecting the presence of Enterobacteriaceae, which convert urinary nitrate to nitrite). The dipstick test is most accurate for predicting UTI when positive for either leukocyte esterase or nitrite, with a sensitivity of 75 percent and a specificity of 82 percent.
However, results of the dipstick test provide little useful information when the clinical history is strongly suggestive of UTI, since even negative results for both tests do not reliably rule out infection in such cases.
UTI Treatment
simple uncomplicated with no MDR risk factors
start nitrofurantoin, TMP-SMX, or fosfomycin.
After this, Augmentin, or some cephalosporins such as Keflex
After this fluoroquinolones, then Cipro or Levaquin
Acute complicated UTI =
Pyelonephritis
Cystitis S/S
dysuria, urinary frequency and urgency, suprapubic pain, and hematuria
may also have fever chill rigors fatigue malaise
Pyelonephritis s/s
fever, chills, flank pain, costovertebral angle tenderness, and nausea/vomiting
Acute complicated UTI can also present with
bacteremia, sepsis, multiple organ system dysfunction, shock, and/or acute renal failure
More likely with UT obstruction, physical abnormality
Pyelonephritis DX
Leukocyte left shift (CBC)
UA shows pyuria, bacteriuria, and possible hematuria
Urine Culture
If very complicated pyelonephritis, then renal U/S may show hydronephrosis secondary to obstruction
If suspect pyelonephritis on inpatient
Treat with ESBL and MRSA coverage-Imipenem or meropenem or doripenem plus vancomycin
If no risk factors for MDR gram- infection then either: ceftriaxone, piperacillin-tazobactam, ciprofloxacin, or levofloxacin with possible vancomycin
Pyelonephritis outpatient
mild to moderate and out patient
they get cipro or levoquine
Urethritis
Urethritis, or inflammation of the urethra, is a common manifestation of sexually transmitted infections among men
Gonoccocal Urethritis
bug
Neisseria gonorrhea
nonGonoccocal Urethritis
bugs
Chylamydia trachomatis m genitalium U urealyticum T vaginalis others
Urethritis risk factors
Family (genetic)
multiple sex partners
anal / risky types of sex
damaged condoms
Infectious urethritis is typically caused by
sexually transmitted pathogen;
thus, most cases are seen in young, sexually active men
2 common bugs for Infectious urethritis
Neisseria gonorrhoeaeandChlamydia trachomatisare common
also Mycoplasma genitalium
Urethritis presentation
Dysuria = chief complaint in men
others: pruritus, burning, and discharge at the urethral meatus.
can have watery or purulent or mucoid discharge
Urethritis can be diagnosed in with one of the following
Mucopurulent or purulent discharge on examination
≥2 white blood cells (WBC) on gram stain
Positive leukocyte esterase (“dipstick”) or the presence of ≥10 WBCs
If none of these findings are present, a presumptive or suspected diagnosis of urethritis can be made in sexually active men with suggestive symptoms.
Urethritis Tx gonococcal
IM 500mg Cef
if Chlamydia is suspected = also give doxy 100 BiD x 7d
Urethritis Tx nongonococcal
when gonococcal is not found, treat for suspected chylamydia
Azithromycin
Urethritis Prevention
refrain from sex x 7 days
follow treatment
testing at 3 months to rule out reinfection (chlamydia/gonorrhea)
Acute Epididymitis
Acute epididymitis is most commonly infectious in etiology but can also be from noninfectious causes such as trauma and autoimmune diseases
N. gonorrhoeaeandC. trachomatismost common in under 35
E.coli in older men
Intracellular enterococci
Gonorrhea
Epididymitis risk factors
sex with multpile partners not using condoms uncircumsized recent surgery structural problems catheter use.
Epididymitis & orchitis
Inflammatory conditions are more common in epididymis than in testes
But syphillis will begin in the testes
Most common cause of scrotal pain in adults in the outpatient setting
Acute epididymitis
epididymitis presentation
Testicular pain with tenderness and swelling on palpation of the affected epididymis, which is located posteriorly on the testis.
Prehn sign
Relief of scrotal pain after elevation
not a reliable way to distinguish between epididymitis and torsion
epididymitis dx
Dx is made presumptively based on history and physical examination after ruling out other causes requiring urgent surgical intervention
A urinalysis, urine culture, and a urine nucleic acid amplification test (NAAT) forN. gonorrhoeaeandC. trachomatisshould be performed
Id of pathogen on urine or swab testing supports the presumptive diagnosis.
Most common organisms responsible for acute epididymitis in men under the age of 35
N. gonorrhoeaeandC. trachomatis
Most common organisms responsible for acute epididymitis in older men
Escherichia coli, other coliforms, andPseudomonasspecies are more frequent in older men, often in association with obstructive uropathy from benign prostatic hyperplasia
epididymitis Tx general
Management of acute epididymitis varies according to its severity.
Most cases can be treated on an outpatient basis with oral antibiotics, nonsteroidal antiinflammatory drugs (NSAIDs), local application of ice, and scrotal elevation.
Acutely ill patients may warrant hospitalization for parenteral antibiotics and intravenous hydration.
epididymitis Tx
under 35 at risk std = coverage for Gonorrhea/chlamydia
500 IM Cef plus Doxy 100mg Bid x 10 days
Patients 35 years of age or older
low sexual risk
levofloxacin500 mg orally once daily for 10 days
insertive anal intercourse
Cef 500 mg IM, plusa fluoroquinolone (levofloxacin500 mg orally once daily for 10 days).
acute epididymitis should improve when?
within 48 to 72 hours after starting appropriate antibiotic therapy
If not better, other causes of scrotal pain should be considered. Scrotal ultrasound and referral to a urologist for consultation are advised.
Orchitis causes
Inflammation / infection of the testicles
Swelling, pain, tenderness, erythema, shininess
Viral: mumps, coxsackie, echovirus, parvovirus
Bacterial : brucellosis
Orchitis Presentation
Unilateral testicular swelling and tenderness occur.
Fever and tachycardia are common
Orchitis DX
U/A reveals pyuria and bacteriuria with infection.
Positive urine cultures.
U/S is useful if possible abscess or tumor is suspected and to rule testicular torsion
Orchitis Tx
If mumps is the cause,
symptomatic relief with ice and analgesics,
If bacteria is the cause,
see epididymitis. Evaluate any scrotal masses.
Prostatitis classes
Classified in four categories
1: Acute bacterial prostatitis
2: Chronic Bacterial Prostatitis
3: Chronic prostatitis, chronic pelvic pain syndrome
4: Asymptomatic inflammatory prostatitis
Prostatitis Risk Factors
cystitis, urethritis, or other urogenital tract infections.
anatomical anomalies (eg, urethral strictures)
Prostate infections following urogenital instrumentation, including chronic indwelling bladder catheterization, intermittent bladder catheterization, and prostate biopsy are well documented.
Bacterial prostatitis
Inflammation of prostate
Altered prostate secretory functions
(low zinc, decreased prostate antibacterial factor)
Manipulation of prostate
(catheters, instruments, prostatectomy)
Prostatitis bugs
Gram-negative infections, especially with Enterobacteriaceae, are the most common
Of Enterobacteriaceae,Escherichia coliis the most typical, followed byProteus.
E.coli 58-88%, Proteus 3-6%, Pseudo 3-7%
Other entero 3-11%
The pathogens associated with acute prostatitis reflect the spectrum of organisms causing cystitis, urethritis, and deeper genital tract infections (such as epididymitis).
Prostatits Tx
Empiric - gram negative bugs =
bactrim 1 DS Q12 or cipro/levo 500mg QD
Under 35 should be treated with regimens that cover chlamydia and gonorrhea
usually out patient unless comorbidities or bacteremia, also acute urinary retention
main function of theurinary system
eliminate the waste products ofmetabolism from the body by forming and excretingurine
Other functions included:
maintaininghomeostasisofmineralions in extracellular fluid
regulating theacid-basebalance in the body
controlling the volume of extracellular fluids, including theblood
Amount of urine produced per day
Between 1 and 2 liters
Hormones that affect urine
ADH : Conserves Water
PTH : Regulate thebalance ofmineral ions
Aldosterone : Regulates BP and causes the kidneys to excrete less sodium and water inurine
Types of UA
Complete = microscope
rapid = dipstick
24 hour collection = helps look at renal function
Urinary incontinence
leakage at inappropriate times
Stress urinary incontinence (women)
Urgency urinary incontinence (men)
Mixed urinary incontinence (both types)
Overflow incontinence (least common)(blockage)
2 types of BPH
obstructive (Crushing around the bladder)
irritative (Crushing around urethra and up into bladder)
Obstructive BPH
Swelling of prostate
Irritative BPH
Frequency
Urgency
Nocturia
Urgent urinary incontinence
TURP
transurethral resection of the prostate
TUIP
transurethral incision of the prostate
PSA
bad test
only one we have
Torsion
bell clapper
vertical testicle to horizontal testicle
twisting of testicular cord
no cremasteric reflex
Prehns sign negative (Pain may increase)
Asymmetric high riding testicle (usually left)
Torsion Time frame
Urgent 6 to 8 hours or lose testicle
Torsion Risk factors
Cryptum orchid teste (undescended teste)
Trauma (50% happen during sleep)
Bell clapper testicle deformity already present
torsion testing
no cremasteric reflex
Prehns sign negative (Pain may increase)
Doppler ultrasound
Torsion treatment
Surgery Manual detorsion (open book)
hydrocele
lumps and swelling of the scrotal sac
Fluid from the peritoneal space (into the scrotum
usually a secondary sign due to other cause)
Varicocele
lumps and swelling of the scrotal sac
swelling and twisting of the scrotal veins
*****Bag of worms
15-20% post puberty males
v-v Varicocele = veins
left internal spermatic vein (most common)
80% of cases non tender mass (varicocele)
hydrocele Tx
most do not need intervention
intervention only if extreme pain or scrotal sac integrity is compromised (incision)
hydrocele Dx
Transilluminate (75%)
Doppler Ultrasound
Varicocele Tx
Surgery
Almost all varicocele surgery will
left spermatic vein ligation
Varicocele Dx
Doppler ultrasound
Priapism
Penis/clitoris
longer than 4 hours not associated with sexual stimulation
sickle cell
ischemic vs non ischemic
ischemic is urological emergency
non-ischemic is self limiting
ischemic priapism
low flow
non ischemic
arterial high flow
Interstitial cystitis
DX of exclusion, rule out everything else
is a condition involving chronic bladder pain or discomfort
more common in women
no tests,
nsaids, kegels, elavil, botox, neuromodulation
refer to urology
Phimosis
cant roll up
circumcision
Pararphimosis
cant roll down
urological emergency
circumcision
Peyronies disease
Penile fibrosis
Crooked penis
can cause deformity, ED, pain mass
Scar tissue,
Peyronies disease Tx
Oral pentoxifylline-increases blood flow to the affected microcirculation
Surgical
Vesicoureteral reflux
the retrograde passage of urine from the bladder into the upper urinary tract.
predisposes patients to acute pyelonephritis by transporting bacteria from the bladder to the kidney
may lead to renal scarring, hypertension, and end-stage renal disease
Most common form is inadequate closure of the ureterovesical junction
second is high pressure in bladder
Vesicoureteral reflux Dx
Primary VUR is most common urologic finding in children, occurring in approximately 1 percent of newborns.
cystourethrogram (VCUG) or radionuclide cystogram.
When you don’t give IV contrast
High Creatinine
Kidney issues
VUR Tx
Vesicoureteral reflux
Cotrimoxazole /Macrobid (grade 3)
Surgical (grade 4-5)
Urethral strictures
Urethral strictures are relatively common in men
common etiology is idiopathic
Iatrogenic injuries = account for 45 percent of all cases
Urethral prolapse
Red papule at the urethral meatus that is seen in premenarchal or postmenopausal individuals.
Urethral prolapse prepubescent females Tx
prepubescent females
topical estrogen therapy
Sitz bath
Urethral prolapse Tx (nonsurgical)
pessaries
Topical Hormones (estrogen)
Kegels
Lifestyle changes
ED Risk Factors
Sedentary obesity smoking hypercholesterolemia Metabolic syndrome (h-BP, h-Chol, h-belly fat, h-BGL)) Diabetes
ED
In men, the most common sexual problem is ED
Thorough history/physical
ED Labs
CBC UA Lipids Test CMP
ED Tx
Psych
PDE5 (-afil)
inject, pump, prosthesis
Hormone replacement
Congenital or Pediatric Urinary conditions
Meatal stenosis Chordee Hypospadias/Epispadias Enuresis Cryptorchidism
Meatal stenosis
tissue over urethral opening causing “sprinkler”
in circumcised boys,
rare in uncircumcised
Chordee
Curved Penis (cosmetic) fibrous band pulls penis sideways
This condition is frequently observed in young males who have hypospadias
less than 30 degree curve ok to circumcize
greater than 30 do not circumsize
Hypospadias
Urethral opening under
Cryptorchidism
most common congenital abnormality of the genitourinary tract.
Most cryptorchid testes are undescended, but some are absent
Risk factors = premeies, low birth weight
5% of all boys have this
Orchiopexy
Orchiopexy
Surgically descend a testicle into the scrotum
Enuresis
Urinary incontinence is a common problem in children
usually potty trained by 5y/o
Usually due to developmental delay
or
Genetics
Tx desmopressin
Painless hematuria over 35 y/o
Cancer until proven otherwise
Bladder Cancer
Bladder cancer is the most common malignancy involving the urinary system
Hematuria (Most common)
If Pain, usually advanced cancer
Bladder cancer Dx
CBC, CMP
UA, Urine cytology, cystoscopy,
Bladder cancer Dx
CBC, CMP
UA, Urine cytology, cystoscopy (Cell scrape),
Prostate cancer
1 in 6 will be diagnosed
Higher in AA
Prostate cancer Exam
(DRE) may detect prostate nodules, induration, or asymmetry that can occur with prostate cancer
frequency, urgency, nocturia, and hesitancy are usually associated with BPH
Prostate cancer Risks
Elevated PSA (most common test for bladder cancer) However not completely reliable
Prostate Cancer Tx
Tumor
Nodes
Metastatsized
PSA
Prostate Cancer Tx
Tumor
Nodes
Metastatsized
PSA
Waiting Surgery External beam Radiation brachytherapy proton therapy Sterrotactic body radiation
Penile Cancer
always has skin abnormality
usually on glans
painless lump, ulcer
Inguinal adenopathy is present in 30 to 60 percent of cases at diagnosis
Testicular Cancer
Germ cell tumors (GCTs) account for 95 percent of testicular cancers
Testicular cancer is the most common solid malignancy affecting males between the ages of 15 and 35, although it accounts for only 1 percent of all cancers in men.
Testicular Cancer Dx
Ultrasound
3 markers
Alphafetoprotein
beta HcG
Lactate dehydrogenase
Nephrolithiasis/urolithiasis
Renal calculi
80% of patients form calcium stones
Risk Factors Diabetes Mellitus is a Big One
CT gold standard
More in Males than females by 2-3 times especially in 3-4th decade of life.
Reoccurrence to happen up to 50%
Radiopaque stones
Calcium
Radiolucent
Uric Acid
3 places for kidney stones
Ureteropelvic junction
Pelvic prim
Ureterovesicular junction
Stone size
5mm will pass on own
Bothtamsulosin (alpha-1 blocker) andnifedipine (calcium channel blocker)have been shown to increase the likelihood of stone passage
stone 5-10mm likely to pass
if fever, hematuria, massive pain= admit
infection = antibiotics
lithotripsy
10mm and up not likely to pass Stent, pain meds, stent, Percutaneous nephrostomy (Gold standard)
Neurogenic Bladder
Stroke Parkinson's disease Multiple sclerosis Spinal cord injuries Spinal surgeries Cerebral palsy Spinal bifida Sacral agenesis
Other causes Erectile dysfunction Trauma/accidents Central nervous system tumors Heavy metal poisoning
Pyelonephritis Treatment
Treatment with urinary tract obstruction
2. Treatment with no suspected urinary tract obstruction
Pyelonephritis-Treatment with no urinary tract obstruction
Outpatient Basis (Uncomplicated)
ciprofloxacin (Cipro) for 7 days
Or
trimethoprim/sulfamethoxazole (Bactrim) for 7 days
Outpatient but mostly Inpatient Basis (Complicated)
ciprofloxacin (Cipro) for 14 days
Or
trimethoprim/sulfamethoxazole for 14 days (Bactrim)
Stone types
Calcium Oxalate
Calcium Phosphate
Uric Acid
