Exam 3 - GU Flashcards
Complicated vs uncomplicated UTI
Complicated: associated with condition, men, pregnant women, children
Uncomplicated: healthy, immunocompetent, non pregnant women with no significant history of UTIs or structural abnormalities
Recurrent UTI definition
UTIs at least three times in one year or twice in six months
UTI - relapse vs reinfection
- Relapse: infection caused by bacterial persistence (infection by the previously treated pathogen) which was not completely eradicated by antibiotics
- Reinfection: recurrence of infection by introduction of a new bacterial strain or regrowth of same organism after complete eradication of the same organism after complete eradication with treatment
Diagnostic studies for UTI
- Urine dipstick (leukocytes, nitrites, blood)
- Definitive → urine culture (e. coli most common pathogen)
- Urinalysis
UTI treatment for non pregnant patients
- Nitrofurantoin (macrobid)
- TMP-SMZ (bactrim)
- Alternatives → keflex, fosfomycin, ciprofloxacin
UTI treatment for pregnant patients
Treat even if patient has asymptomatic bacteruria
- Keflex
- Amoxicillin
- Augmentin
Indications for referral for UTI
- Presence of macroscopic hematuria
- Suspected malignancy
- Recurrent UTIs or infections that do not respond to standard antimicrobial therapy
- Older adults with acute, severe symptoms
- History of chronic conditions
What is interstitial cystitis?
Chronic inflammatory condition of the bladder
Interstitial cystitis symptoms
- Bladder pain
- Urinary frequency or urgency
- Nocturia
- Suprapubic pain (relieved after voiding)
UTI vs interstitial cystitis
- Urinalysis with few leukocytes, no bacteria, occasional hematuria
- Negative urine culture
What is urethritis?
- Caused by infection characterized by discharge of mucoid or purulent material
- Burning with urination
- Often caused by neisseria gonorrhea (symptomatic)
- Chlamydia often asymptomatic
Urethritis symptoms
- Men: dysuria, frequency, urethral discharge, pruritus at distal end of penis
- Women: vaginal discharge or bleeding from concomitant cervicitis, lower abdominal pain
- Women typically asymptomatic
- Pain, itching, redness
Causes of urethritis
- Infectious - gonorrhea, chlamydia
- Non infectious - enteric organisms (MSM, anal sex)
Urethritis diagnostic studies
- Chlamydia and gonorrhea
NAAT testing
- Men: first catch urine
- Women: vaginal swabs (first line), first catch urine
Gonorrhea (urethritis) treatment
Persons with gonorrhea have a coexistent chlamydia infection
- Dual ceftriaxone + azithromycin or doxycycline
Non gonococcal urethritis treatment
Doxycycline 100 mg PO bid for 7 days
OR
Azithromycin
Can providers treat for gonorrhea and chlamydia at the same time?
Treat empirically for both infections if you do not have lab evidence of just one infectious cause
What is stress incontinence?
Loss of urine associated with activities that increase intra-abdominal pressure (sneezing, coughing) → overcomes sphincter and urethral pressure
What is urge incontinence?
Involuntary loss of urine usually preceded by a strong, unexpected urge to void (aka overactive bladder)
What is mixed incontinence?
Urge and stress incontinence together
What is overflow incontinence?
An involuntary loss of urine associated with incomplete emptying
Causes of urinary incontinence?
- Detrusor overactivity
- SCI below T11 to L1
- Poor bladder compliance
What is Resnick’s Diappers mnemonic?
- Identifies pathologic conditions external to the urinary tract that cause incontinence
- D - delirium or confusional state
- I - infection (urinary)
- A - atrophic urethritis, vaginitis
- P - pharmaceuticals
- P - psychological (severe depression)
- E - excess urinary output (CHF, hyperglycemia)
- R - restricted mobility
- S - stool impaction
Urinary incontinence diagnostic studies
- Urinalysis - exclude hematuria, pyuria, glycosuria, proteinuria
- Urine cytologic studies
- Urine culture
- BUN/creatinine,glucose, calcium
- Postvoid residual (PVR)
- Ultrasound or MRI to rule out anatomical or functional abnormalities
Urinary incontinence management
- Treat underlying condition → move commode to bedside
- Voiding diaries
- Behavioral therapies
- Medications: anticholinergic, alpha adrenergic agonist, antimuscarinic
- Surgery
Acute vs chronic prostatitis
Acute and chronic prostatitis are caused by bacterial infection, but chronic prostatitis has a slower development of inflammation and duration of symptoms for 3 months
Acute prostatitis symptoms
- Fever, chills, malaise, myalgias, arthralgias
- Urinary hesitancy, frequency, urgency, nocturne, dysuria, sensation of incomplete bladder emptying
- Low back pain, perineal pain, suprapubic pain
Chronic prostatitis symptoms
- More varied than acute prostatitis
- History of recurrent UTIs
- Perineal, inguinal, suprapubic pain
- Frequency, urgency, dysuria
Prostatitis diagnostic studies
- UA and culture
- CBC
- DRE → not recommended, massage will spread the causative organism
- Abdominal exam
- Consider STI testing
Acute prostatitis management
- If severe, IV fluoroquinolone(-floxacin) in ER
- Outpatient, TMP/SMX and fluoroquinolone
- Acute for 3 weeks; chronic for 3-6 weeks to prevent chronic prostatitis
- Pain management
Causes of BPH
Bladder outlet obstruction, lower urinary tract symptoms, or a combination of the two
Symptoms associated with obstructive BPH
- Urinary hesitancy
- Decreased caliber and force of stream
- Post void dribbling
Symptoms associated with irritative causes of BPH
Frequency, urgency, nocturia, hematuria
BPH clinical presentation
- DRE → findings suggestive of prostate cancer include nodules or induration
- BPH may have a uniform or focal enlargement of the prostate, median sulcus is obliterated, non tender, rubbery and smooth in consistency
BPH diagnostic studies
- UA to exclude UTI or hematuria
- Post void ultrasound
Management for BPH (not medication)
Limiting fluids before bed, limit use of caffeine and alcohol, double voiding
Treatment for BPH
- Alpha adrenergic antagonist therapy (e.g. terazosin, doxazosin)
Relax smooth muscle in the bladder neck, prostate capsule, and prostatic urethra
Treatment for BPH
- 5 alpha reductase enzyme inhibitor therapy (e.g. finasteride, dutasteride)
- Second line if patients cannot tolerate alpha adrenergic antagonists
- Shrink prostatic glandular hyperplasia by decreasing tissue DHT levels
- Can take 6-12 months to see improvement in symptoms
Treatment for BPH
- Antimuscarinics
Help relax bladder muscle which can reduce urinary frequency, urgency, nocturia, and incontinent
Treatment for BPH
- Phosphodiesterase type 5 inhibitors (e.g. sildenafil, tadalafil)
Promote blood vessel dilation (vasodilation) and smooth muscle relaxation in certain parts of the body
Management of severe BPH
- Surgeries: transurethral resection of the prostate (TURP), transurethral incision of the prostate, open prostatectomy → for severe BPH
Prostate cancer risk factors
- Advancing age
- African American
- Positive family history (BRCA gene, first degree relative)
How to differentiate prostate cancer from BPH symptoms
Prostate cancer symptoms tend to increase in intensity during a 1-2 months period vs BPH which is slower progressing
Prostate cancer symptoms
- Urinary hesitancy, urgency, nocturia, frequency, hematuria
- Advanced disease → back pain, impotence, bone pain, weight loss
Prostate cancer screening
- No screening for men younger than 40 years or ages 40-54 years who have average risk
- Shared decision making with provider for men ages 55-69 years (if yes, screen every two years)
- Not recommended for men older than 70 years old or men with less than a 10-15 year life expectancy
DRE findings with prostate cancer
Firm nodule, induration, stony, asymmetric prostate
Prostate cancer diagnostic studies
- PSA level combined with DRE (PSA <4 ng/mL is normal)
- If PSA is high, transrectal ultrasound (TRUS) is recommended for initial biopsy
- CT scan of abdomen and pelvis important to assess regional lymph nodes and metastasis
What is paraphimosis?
Medical emergency
Retracted foreskin that cannot be reduced to the normal position → constriction of glans
Causes of paraphimosis
- Following masturbation
- Sexual activity
- Forceful retraction
- Sexual abuse
Paraphimosis management
- Manual reduction
- Surgical emergency
When should the PCP refer a pediatric patient with undescended testicles?
Referral made by six months old; if not taken care of by 2 years, will have permanent damage (infertility, malignancy)
True/false: undescended testicles normally descend by six month
True - if not, refer
Phimosis clinical presentation (history)
- Inflammation of penis
- Pain, dysuria
- Signs of urinary obstruction → ballooning due to urine collecting in foreskin
Phimosis physical exam findings
Tight, pinpoint opening of the foreskin with minimal ability to retract the foreskin; foreskin flat and effaced
Phimosis management and treatment
- Normal cleansing with gentle stretching of the foreskin until resistance is felt.
- Never forcefully retract the foreskin.
- Steroid cream
- Surgery if phimosis continues
What is a hydrocele?
Painless, gradual enlargement of scrotum with marked edema
Hydrocele clinical presentation (history)
- Bulge or lump in scrotum
- Tense overlying skin
- Bluish discoloration in area of bulge
- No distress or vomiting
Hydrocele physical examination findings
- Cremasteric reflex present
- Transllumination
Hydrocele management and treatment
- Generally self resolves
- No treatment indicated unless it is so large that it is uncomfortable or persists longer than 1 years
- If persists, refer to surgery
True/false: there is a six hour window before ischemic damage occurs with testicular torsion
True
Testicular torsion history and clinical findings
- Ill appearing
- Sudden onset of unilateral scrotal pain
- N/V
- “Blue dot” sign - painless, firm, blue scrotal mass in newborns
Testicular torsion physical examination findings
- Absent cremastueric reflex
- Scrotal swelling with redness, warmth, tenderness
- Slight elevation of testis
Testicular torsion treatment and management
Surgical emergency
- Manual reduction, but follow up within 6-12 hours to prevent retorsion, preserve fertility, prevent abscess and atrophy
