Clinical: Urology Flashcards
Presence of bacteria in the urine that causes no illness or symptoms
Asymptomatic bacteriuria
WBCs in urine,
Pyuria
UTI with at least 1 complicating factor
Factors: pregnancy, male, immunocompromised
Complicated UTI
2 culture-proven UTIs in 6 months or 3 in 1 year
Recurrent UTI
Bacterial persistence despite appropriate treatement
Unresolved UTI
- Immune receptor polymorphisms
- Family history
Risk Factors: Genetic
UTI
- Urinary calculi
- Urinary stasis / obstruction
- Congenital anomalies of lower urinary tract
- Microbiologic change: atrophic vaginitis, pH alkalinization
- Diabetes / neurologic disorders
- Immunosuppression
Risk Factors: Biologic
UTI
- Sexual intercourse
- Birth control practices
- Antimicrobial use
Risk Factors: Behavioral
UTI
Most common pathogen in UTI
Etiology
Uropathogenic Escherichia coli (UPEC)
85% of cases
2nd most common pathogen in UTI; mainly in reproductive age women
Etiology
Staphylococcus saprophyticus
10-20% of cases
- Pain with urination (dysuria)
- Frequency
- Urgency
- Incontinence
- Mild back pain
- Suprapubic pain (very common)
Symptoms
UTI
- Hematuria
- Cloudy urine
- Malodorous urine
- Low-grade fever
Signs
UTI
UTI
Approach to Diagnosis
- History
- Asymptomatic bacteriuria vs. UTI
- Uncomplicated UTI vs. complicated UTI
- Physical
- Diagnostic studies
- Urinalysis
- Urine microscopy
- Urine culture
UTI
Approach to Therapy
- Supportive measures to treat dysuria
- Hydration
- Acetaminophen
- NSAIDs
- Phenazopyridine (urinary analgesic)
- Empiric vs. culture-directed antibiotics
- Shortest duration, no longer than 7 days
- Escalate based on patients status
Asymptomatic bacteriuria
Approach to Therapy
No treatment except in:
* Pregnant women
* Patients scheduled for GU instrumentation
- Ascending GU tract infection
- Bladder UTI (cystitis) ascends through ureter to kidney
- Clinical diagnosis:
- UTI symptoms
- Flank pain: CVA tenderness on physical exam
- Fever
- Leukocytosis
CVA = costovertebral angle
Pyelonephritis
Septic pyelonephritis
Approach to Therapy
- Treatment duration: 7-14 days
- IV broad-spectrum antibiotics
- Imaging for perinephritic abscess / structural abnormality
Types of urinary incontinence
- Urge incontinence
- Stress incontinence
- Mixed incontinence
- Other:
- Overflow: impaired emptying; bladder overflows
- Fistula: continuous leakage of urine
- Urge incontinence
- Urgency
- Frequency
- Nocturia
Symptoms
Overactive bladder (OAB) complex
* Extremely common; prevalence increases w/ age
OAB complex
Approach to Therapy
- No treatment (least invasive)
- Lifestyle modifications / PTx
- Medications
- Tibial nerve stimulation / Botox / Interstim
- Bladder augmentation (most invasive)
Normal bladder control
Sympathetic
- Norepinephrine activates B3-adrenergic reveptor
- Detrusor muscle relaxation –> storage
Normal bladder control
Parasympathetic
- ACh activates M3-muscarinic receptor
- Detrusor muscle contraction –> emptying
MoA: Antimuscarinics
OAB Tx
- Antimuscarinics block M3-muscarinic receptor
- Inhibits involuntary detrusor muscle contractions
- Delays emptying
MoA: Beta agonists (Betmiga)
OAB Tx
- Agonist activates B3-adrenergic receptor
- Increases detrusor muscle relaxation
- Increases storage capacity, inter-void interval
- Oxybutynin
- Trospium chloride
- Darifenacin / Solifenacin
- Tolterodine / Fesoterodine
Antimuscarinics
OAB Medical Therapy
- Blurred vision
- Dry eyes
- Xerostomia
- Tachycardia
- Dyspepsia
- Constipation
- CNS: dizziness, somnolence, impaired memory & cognition
Anticholinergic side effects
OAB Medical Therapy
- Urine leakage due to increase in abdominal pressure
- Involuntary leakage of urine secondary to insufficient bladder outlet resistence
- Outlet resistence provided by: internal & external sphincters
- Internal: bladder neck; involuntary
- External: rhabdosphincter; voluntary
Stress incontinence (SUI)
- Anatomic defect of suburethral support & loss of urethral coaptation
- Age
- Parity
- Weight
- Vaginal delivery
- Estrogen statuys
- Urethral surgery
Risk Factors
Female SUI
Female SUI
Approach to Therapy
- No treatment (least invasive)
- Lifestyle modifications / PTx
- Pessary Impressa tampon
- Bulking agent
- Surgery / Sling (most invasive)
- Radical prostatectomy
- Posterior urethral injury (PFUDD)
- Transurethral resection of prostate (TURP)
- Myelopathy
- Congenital conditions
Risk Factors
Male SUI
Most common cause of male SUI
Etiology
Radical prostatectomy
Surgical options for male SUI
Approach to Therapy
- Artificial urinary sphincter (most common)
- Transurethral bulking agents
- Perineal sling
- Incidence peaks between ages 40-70
- Highest incidence: white men & women
- Lowest incidence: black men & asian women
Epidemiology
Kidney stones (nephrolithiasis)
- Hot, dry climates
- Risk in US increases N –> S, W –> E
- Occupations with exposure to excessive heat
- Conditions that promote dehydration
Risk Factors: Environmental
Kidney stones
- Obesity, weight gain, metabolic syndrome
- Medications
- Surgeries (e.g,. gastric bypass)
- Dehydration
- Kidney disorders: impaired excretion of acid
- T2DM
Risk Factors: Systemic
Kidney stones
Compositions of kidney stones
- Calcium stones
- Uric acid stones
- Cystine stones
- Infection stones
- Drug-induced stones
Kidney stones
Approach to Diagnosis
- CT scan (w/o contrast)
- Kidney ultrasound
- Basic metabolic panel: Cr & Ca levels
- Urinalysis
- 24-hour urine collection (recurrent stones)
- Flank pain
- Hematuria
- Nausea
- Vomiting
Symptoms
Kidney stone passage
Presence of infection + kidney stone in ureter
Obstructive pyelonephritis
Obstructive pyelonephritis
Approach to Therapy
Urological emergency
* Immediate decompression with ureteral stent or nephrostomy tube
* Antibiotics
Kidney stones
Approach to Therapy
- Ureteroscopy with laser lithotripsy
- ESWL: endoscopic shock wave lithotripsy
- PCNL: Tx for large stones.
PCNL: percutaneous nephrolithotomy
Most common benign tumor in men
Epidemiology
BPH
BPH
Epidemiology
- Incidence is age-related
- Age 41-50: 20%
- Age 51-60: 50%
- Age >80: 90%
- 25% of cases are symptomatic at age 55
- 50% of cases are symptomatic at age 75
- Obstructive
- Slow stream
- Hesitancy
- Having to push to void
- Feeling of incomplete voiding
- Irritative
- Daytime frequency
- Urgency
- Nocturia
Symptoms
BPH
BPH
Evaluation
- History
- AUA symptom score
- Physical
- Urinalysis
- PSA (select patients)
BPH
Physical Exam
- Abdominal exam: rule out bladder distension
- Digital rectal exam (DRE):
- Prostate size
- Nodule / induration
- Focused neurological exam
- Mental status
- Ambulatory status
- Anal sphincter tone
- Lower extremity neuromuscular functions
BPH
Urinalysis
- Micro hematuria: >3 RBC/hpf; needs full workup
- Micro hematuria: blood not visible
- Gross hematuria: blood visible
- Pyuria: >3 WBC/hpf; needs urine culture
- Glycosuria: glucose > 25 mg/dL; rule out diabetes
Most widely used urologic tumor marker
PSA
PSA
Markers
BPH
* PSA = glycoprotein produced by prostate epithelium
* Primarily secreted in semen or lost in urine
* Significant amounts found in serum only if prostate is traumatized, diseases or enlarged
Age-specific PSA levels
- Age <40: < 2.0 ng/mL
- Age <50: < 2.5 ng/mL
- Age <60: < 3.0 ng/mL
- Age <70: < 4.0 ng/mL
Indications for Prostate Biopsy
Approach to Diagnosis
- PSA above age-specific level
- Suspicous finding on DRE
BPH
Approach to Therapy
Treatment is based on severity of symptoms & presence of complications
* Mild symptoms: conservative treatment
* Moderate symptoms: medical therapy
* Severe symptoms: surgery if medical Tx fails
BPH
Medical Therapy
- a-Blocker: dilate prostatic urethra
- 5-a-Reductase inhibitor: shrink prostate size
“-osin”: tamsulosin, terazosin, doxazosin
a-Blockers
BPH Medical Therapy
“-osin”: tamsulosin, terazosin, doxazosin
a-Blockers
BPH Medical Therapy
Benefits of a-Blockers
BPH Medical Therapy
- Rapid improvement of urinary flow
- Reduce BPH symptoms
- Modest effects on sexual dysfunction
- Fatigue
- Orthostatic hypotension
- Retrograde ejaculation
- Edema
a-Blocker side effects
BPH Medical Therapy
Indication for 5-a-Reductase inhibitor
BPH Medical Therapy
Prostate size: >30 g
- Erectile dysfunction
- Altered libido
- Gynecomastia
5-a-Reductase inhibitor side effects
BPH Medical Therapy
- Erectile dysfunction
- Altered libido
- Gynecomastia
5-a-Reductase inhibitor side effects
BPH Medical Therapy
BPH
Surgical Therapy
- Transurethral resection of prostate (TURP)
- Monopolar system
- Bipolar system
- Laser
- Open prostatectomy
- Rezum
- Urolift
- Aquablation
- Urinary incontinence
- Retrograde ejaculation
- Bleeding
Risks of surgery
BPH Surgical Therapy
- Urinary incontinence
- Retrograde ejaculation
- Bleeding
Risks of surgery
BPH Surgical Therapy
- Most common cancer in men
- # 2nd cause of cancer death in men
Epidemiology
Prostate cancer
- Urinary incontinence
- Retrograde ejaculation
- Bleeding
Risks of surgery
BPH Surgical Therapy
- Age
- Ethnicity: increased risk in African-Americans
- Family history
- Father: 2x increased risk
- Brother: 4x increased risk
- Father & brother: 8x increased risk
Prostate cancer
Risk Factors
- Early-stage: asymptomatic (80%)
- Locally advanced: urinary symptoms (15%)
- Metastatic: systemic symptoms (5-10%)
Clinical Presentation
Prostate cancer
- Early-stage: asymptomatic (80%)
- Locally advanced: urinary symptoms (15%)
- Metastatic: systemic symptoms (5-10%)
Clinical Presentation
Prostate cancer
Prostate cancer
Approach to Diagnosis
- PSA
- DRE
- Multi-parametric prostate MRI
- Prostate biopsy
PSA
Approach to Diagnosis
- 1/3 of pts w/ PSA >4.0 ng/mL have cancer
- Over 1/2 of pts w/ PSA >10.0 ng/mL have cancer
- PSA: <10 ng/mL
- DRE: T1c / T2a
- Gleason Score: 6
- Grade Group: 1
Risk Evaluation
Low-risk prostate cancer
Low-risk if all conditions are met
- PSA: 10-20 ng/mL
- DRE: T2b / T2c
- Gleason Score: 3+4=7; 4+3 =7
- Grade Group: 2; 3
Risk Evaluation
Intermediate-risk prostate cancer
Intermediate-risk if any of conditions is met
- PSA: >20 ng/mL
- DRE: T3
- Gleason Score: 8-10
- Grade Group: 4-5
Risk Evaluation
High-risk prostate cancer
High-risk if any of conditions is met
Low-risk prostate cancer
Approach to Therapy
Surveillance
* Monitor via PSA, DRE
* Repeat biopsy within 1 year
Intermediate-risk prostate cancer
Approach to Therapy
Unimodal treatment
* Radical prostatectomy
* Radiotherapy +/- hormonal therapy
High-risk prostate cancer
Approach to Therapy
Multimodal treatment
* Radical prostatectomy +/- radiation
* External beam radiation +/- hormonal therapy
Most common cause of scrotal pain in adults
Epidemiology
Acute epididymo-orchitis
Most common cause of epididymo-orchitis in men age <35
Etiology
N. gonorrhoeae / C. trachomatis
Most common cause of epididymo-orchitis in men age >35
Etiology
E. coli / Pseudomonas
Obstruction (BPH, strictures, etc.) leads to GN UTI
- N. gonorrhoeae / C. trachomatis
- E. coli / Pseudomonas
- Autoimmune disease
- Trauma / Torsion
- Amiodarone
Etiology
Epididymo-orchitis
- Symptoms
- Scrotal pain
- Fever
- Bacteriuria
- Physical
- Red, tender scrotum
- Indurated epididymis on posterior scrotum
- Reactive hydrocele
- Scrotal wall erythema
Clinical Presentation
Epididymo-orchitis
Epididymo-orchitis
Apprioach to Diagnosis
Clinical
* Labs: UA (pyuria), urine culture, NAAT
Nuclear amplification test: for chlamydia & gonorrhea
Epididymo-orchitis
Approach to Treatment
- Antibiotics
- NSAIDs
- Scrotal elevation
- More common in children
- Usually due to inadquate adherence of testis to tunica vaginalis & rotation of spermatic cord
Epidemiology
Testicular torsion
- Symptoms
- Severe scrotal pain
- Nausea
- Vomiting
- Physical
- Diffuse tenderness to palpation
- Negative cremasteric reflex
Clinical Presentation
Testicular torsion
Testicular torsion
Approach to Diagnosis
Scrotal ultrasound (Doppler): absence of blood flow into testicle
Testicular torsion
Approach to Therapy
Urological emergency
* Testicular detorsion & bilateral orchidopexy
Necrotizing fasciitis involving perineum & scrotum
Pathology
Fournier’s gangrene
- Male age 60-80 with multiple comorbidities (e.g., diabetes, obesity)
- Symptoms
- Severe lower abdominal pain
- Pain, redness, swelling in scrotum or perineum
- Physical
- Bullae
- Crepitus
Clinical Presentation
Fournier’s gangrene
Crepitus = air under scrotum due to gas-forming organism; gas gangrene
Fournier’s gangrene
Approach to Diagnosis
- Clinical
- CT: air along fascial planes
Fournier’s gangrene
Approach to Therapy
Urological emergency
* Surgical exploration
* Debridement
* Antibiotics
Fluid collection within tunica vaginalis
Pathology
Hydrocele
- Idiopathic: imbalance in secretion / absorption
- Acute / Reactive: secondary to acute scrotal pathology
Etiology
Hydrocele
Acute scrotal pathology: torsion, infection, trauma, etc.
- Painless, unilateral scrotal mass
- Scrotal swelling can be transilluminated
Clinical Presentation
Hydrocele
Approach to Diagnosis
- Physical
- Scrotal U/S: normal testicle surrounded by fluid
U/S = confirmatory
Hydrocele
Approach to Therapy
- Asymptomatic: obseration
- Symptomatic: hydrocelectomy
Dilation of spermatic vein due to impaired drainage; L:R = 9:1
Pathology
Varicocele
Abnormal dilation / tortuosity of pampiniform plexus secondary to blood flow reversal in gonadal (internal spermatic) vein
Etiology
Varicocele
Most common treatable cause of male infertility
Epidemiology
Varicocele
- Sx: dull congestive pain that resolves with supine position
- P/E: “bag of worms:
Clinical Presentation
Varicocele
Varicocele
Approach to Diagnosis
- Clinical: bag of worms, made more prominent with valsalva
- Scrotal U/S: confirmatory
Varicocele
Approach to Therapy
- Most cases: observationq
- Indications for surgery:
- Chronic scrotal pain
- Male factor infertility >1 year
- Ipsilateral testicular atrophy
Palomo procedure: ligation of spermatic vein at retroperitoneal level
Varicocele
Approach to Therapy
- Most cases: observationq
- Indications for surgery:
- Chronic scrotal pain
- Male factor infertility >1 year
- Ipsilateral testicular atrophy
Palomo procedure: ligation of spermatic vein at retroperitoneal level
Most common solid tumor in men between ages 20-35
Epidemiology
Testicular tumor
Painless solid mass
Clinical Presentation
Testicular tumor
Testicular tumor
Approach to Diagnosis
- Tumor markers: B-hCG, AFP, LDH
- Testicular U/S: solid mass
U/S: confirmatory
Testicular tumor
Approach to Therapy
Initial treatment: radical orchiectomy
Testicular tumor
Approach to Therapy
Initial treatment: radical orchiectomy
