Exam 3 - GU Flashcards
When do testes descend into scrotum?
4-6 weeks before birth
Etiology of Cryptorchidism
Gubernaculum is not firmly attached to the scrotum causing the testis to not be pulled into the scrotum
Complications from Cryptorchidism?
- Infertility. Worse with bilateral.
- Testicular cancer, even if corrected.
Is ultrasound in cryptorchidism warranted prior to referral?
No. Doesn’t help with decision making process.
At what point/age should surgery be used to correct cryptorchidism?
If no spontaneous descent by 6 months of age. Surgery within 1 year.
What to counsel PT with hx of cryptorchidism?
Long-term risk of infertility and cancer risk.
First step in work-up for cryptorchidism?
Consult with specialist
How to definitely diagnose and treat cryptorchidism?
Laparoscopy
What type of hernia is seen with cryptorchidism?
Inguinal hernia
Inguinal hernia due to patent…?
Patent processes vaginalis
When does the Processes Vaginalis normally close?
Within the first year of life
Who gets Acquires Hydrocele? How?
Adults. Injury, infection, or inflammation.
Are pediatric hydrocele acquired or congenital?
Congenital. Resolve within 1st year of life.
A patient Processus Vaginalis causes what type of Hydrocele?
Communicating Hydrocele
When are Communicating Hydroceles usually discovered?
Infancy
What are Noncommunicating Hydroceles due to?
Minor trauma, inflammation
Acute Reactive Hydrocele due to
Epididymitis, testicular torsion, varicocele operation, or testicular tumor
What is a Hydrocele?
Cystic collection of fluid in testicle. Main cause of painless scrotal swelling.
Can a Hydrocele be transilluminated?
Yes!
What sort of imaging for Hydrocele? What to evaluate for
Scrotal Ultrasound- to evaluate for reactive hydrocele due to testicular neoplasm or other etiology
Tx for Idiopathic Hydrocele?
Oservation only. Surgical treatment only if increase pressure, pain, or chronic irritation of scrotal skin
Tx for Communicating Hydrocele?
Surgical closure of patent Processes Vaginalis
Etiology of Varicocele?
Dilation of panpiniform plexus. Left side 95% of time.
Why left side worse in Varicocele?
Left spermatic vein enters left renal vein at 90 degree angle
How does Varicocele cause male infertility?
Increased temp from increased venous flow inhibits spermatogenesis.
PE of Varicocele?
“Bag of worms”
What positon should a PT be in when examining for Varicocele?
Upright. Will disappear when supine.
DX for Varicocele?
Scrotal ultrasound
Etiology of Epididymitis? (Hint: diff for children and adults)
Children=Viral from mumps
Adults=Chlamydia under 35; E Coli or Kleb over 35
Raped or insidious onset in Epididymitis?
Insidious
S/Sx or Epididymitis?
Gradual over few days. Unilateral scrotal pain, erythema, swelling.
Phren’s sign in Epididymitis?
Yes. Relief of pain with elevation of scrotum.
Cremasteric reflex in Epididymitis?
Yes. Normal.
Dx of Epididymitis?
UA=Pyuria or bacteruria
Scrotal US=enlarged epididymis, increased testicular flow
Etiology of Orchitis?
Viral!
What is Orthitis?
Acute inflammation of testis secondary to infection
PE of Orchitis?
Very swollen and painful testis
What important to rule out with Orthitis?
Testicular torsion
Tx for Orchitis? Abx?
Supportive. Bed rest, hot/cold packs, analgesia, scrotal elevation.
Under 35 and sex-active=Ceft+Doxy or Ceft+Azith
Over 35=Add FLQ or Bactrim for Gram Negative coverage
Etiology in Testicular Torsion?
Spermatic cord twists and cuts off testicular blood supply. 180-720 degree twist.
Which side affected more in Testicular Torsion?
Left more than right
What is Bell Clapper deformity?
Hanging testy not attached to gubernaculum. In Testicular Torsion.
How does PT with Testicular Torsion walk?
Hunched over
S/Sx of Testicular Torsion?
Severe pain, N/V; red, swollen, tender scrotum
Testicular Torsion transilluminates?
NO! Non-illuminating mass.
Tunica Vaginalis and Testicular Torsion?
inappropriately high attachment of the tunica vaginalis ->testicle rotates freely on the spermatic cord within the tunica vaginalis
Phren Sign in Testicular Torsion?
NO!!!!!
Onset of pain in Testicular Torsion?
Sudden! Severe!
Cremasteric Reflex in Testicular Torsion?
NO!
Tx of Testicular Torsion?
Surgery to detorse within 6h to save the testicle
What is Phimosis?
Foreskin can’t be retracted over glans penis
When is Phimosis treated?
Difficulty urinating or with sex
Tx for Phimosis?
Steroid creams, manual stretching, change masturbation habits, presomething, circumcision
What is Paraphimosis?
Foreskin unable to be retracted back from behind the glans penis. Causes ischemia to glans penis!
Paraphimosis only occurs in who?
Uncircumcised or partially circumcised
Is Paraphimosis a urological emergency?
YES!
What can paraphimosis cause?
Gangrene and autoamputation!
Tx options for Paraphimosis?
Conservative=gentle retraction of foreskin
Surgery=dorsal slit, then circumcision
How is kidney stone formed?
Normally soluble material (Ca, PO4, uric acid) supersaturates the urine and begins the process of crystal formation
What are 60-80% of kidney stones made of?
Calcium stones. Ca oxalate > Ca phosphate
How does dehydration cause kidney stones?
Increased urine concentration
Stuvite Stones go along with which infection
UTI
S/Sx of nephrolithiasis?
Severe unilateral flank pain radiating to groin/testicle/labia. Pacing, rocking, writhing motion and unable to find position of comfort.
Stone in kidney causes pain where?
Vague flank pain, hematuria
Stone in Prox Ureter causes pain where?
Renal colic, flank pain, upper abd pain
Stone in midureter causes pain where?
Renal colic, flank pain, anterior abdomen/groin pain
Stone in dister ureter causes pain where?
Renal colic, flank pain, dysuria, urinary frequency, urgency, hesitancy, ant abd/groin pain, testicular/labial pain,
Is ultrasound good for dx kidney stones? Who gets U/S?
Nope, only good for hydronephrosis. Patients who should avoid radiation, including children, pregnant women and woman in childbearing age.
Test of choice for kidney stones? Who not?
Noncontrast helical CT.
Not first-line for preggers, children, or gyn etiology
Tx of kidney stones?
IV hydration, analgesics (NSAIDs, Keterolac), narcotics. Admit to hosp if can’t PO meds or drink.
What should PT do with urine when passing kidney stone?
Strain urine and bring in stone for analysis
When to call urology for kidney stones?
Stone ≥6mm, multiple stones, preggers, blocking ureter (hydronephrosis), more than 2 weeks with stone
Tx for kidney stone >5mm?
Extracorporeal shock wave therapy
PT with kidney stone should be made to pee out how much?
2L/day
Tx for Staghorn Calculi?
PNL surgical then PNL and ECSW (shockwave)
What type of stone and how many calycies are Staghorn Calculi?
Struvite stone. At least 2 calycies.
When do to metabolic workup on nephrolithiasis PT?
After second stone
What test guides further dx and tx of nephrolithiasis?
24h urinalysis
Nephrolithiasis dietary counseling?
Reduce dietary sodium, Reduce dietary animal protein, Increase po fluid intake such that 2L/d urinary output
What does the Prostate do?
Secretes fluid that nourishes and protects sperm
Two most common bacteria in Acute Bacterial Prostatitis?
E coli and Pseudomonas
Route of infection in Acute Bacterial Prostatitis? Who gets the most?
Ascent of infected urine up the urethra into prostatic ducts. Occurs most in young and middle-aged men
DRE findings in Acute Bacterial Prostatitis?
Exquistely tender prostate. Warm and erythematous prostate.
UA and CBC in Acute Bacterial Prostatitis?
CBC=Leukocytosis w/left shift.
UA=pyuria, bacteruria, hematuria
When to image Acute Bacterial Prostatitis? What to think?
CT or MR if no improvement in 48h. Think prostate abscess.
When to admit Acute Bacterial Prostatitis?
Septic, can’t do PO abx, multiple comorbidities
Which abx for Acute Bacterial Prostatitis?
FLQs or Bactrim for 4-6 weeks
Which bacteria in Chronic Bacterial Prostatitis?
Most common E Coli
When does Chronic Bacterial Prostatitis develop?
After acute prostatitis infection which progresses into chronic
How does Chronic Bacterial Prostatitis present?
Some is ASx. Irritative voiding that won’t go away, dull pelvic or perianal pain.
Is prostate tender in Chronic Bacterial Prostatitis?
Not tender! Feels boggy, firm, or normal.
UA results normal in Chronic Bacterial Prostatitis?
Often normal
How to increase UA/culture yield in Chronic Bacterial Prostatitis?
Prostate massage
Tx of Chronic Bacterial Prostatitis?
Bactrim for 6-12 weeks.
What is the most common Prostatic sydrome?
Inflammatory Prostatitis
Etiology of Inflammatory Prostatitis?
Unknown
Inflammatory Prostatitis aka?
Lance Armstrong Syndrome
Inflammatory Prostatitis identical in S/Sx to what?
Chronic Prostatitis
Labs in Inflammatory Prostatitis?
Normal!
Tx of Inflammatory Prostatitis?
NSAIDS.
Trials of abx directed at ureaplasma, mycoplasma, and chlamydia.
What is most common cause of acute onset of scrotal pain in adults?
Epididymitis
Epididymitis pain unilateral or bilateral?
Unilateral
Epididymitis pain radiates to where?
Flank
Does Epididymitis alter the Cremasteric Reflex?
No. Unaltered!
Epididymitis caused by which gram negative diplococci?
Gonorrhea
Epididymitis with no organisms but increased WBC caused by?
Chlamydia or non-gonococcal urethritis
Tx Epididymitis d/t gonorrhea and chlamydia?
Doxy + Ceft for 10-21 days
Tx Epididymitis not d/t sexually transmitted?
Bactrim, Cipro
Tx of Orchitis?
DEC and Anthel 10-14 days
What is Urethritis?
Inflammation of the urethra
Urethritis commonly a manifestiation of what?
STD
Urethritis two classifications?
Gonococcal or Non-gonococcal
Urethritis most commonly from which 2 bacteria?
N. gonorrhoeae
C. trachomatis
PE in Urethritis?
Brown/green discharge
Pruritus and burning at the urethral meatus
What sort of UA in Urethritis?
First catch urine WITHOUT cleaning
Tx for gonorrhea Urethritis?
250mg Ceftriaxone IM + 1 gram Azithromycin PO. Doxycycline BID for 7 days can be given with ceftriaxone.
Tx of chlamydia Urethritis?
Azithromycin 1 gram PO x 1
Doxycycline 100 mg PO BID x 7 days
Erythromycin 500 mg PO QID x 7 days
Which med causes a LOT of urinary incontinence
Anticholinergics
Nocturia definition
> 2 pee when sleeping
Which sacral nerves are perianal innervations?
S2-S4
What sort of test should women with urinary incontinence have?
Stress test with full bladder and standing. Relax and cough.
In men with a large Post Void Residual volume what test?
Renal U/S
Lifestyle change in Urinary Incontinence?
2L UO daily, avoid caffeine
Urinary Incontinence med?
Oxybutoinin
What is most common infectious illness over 65?
UTI
Breakdown of skin barrier in elderly causes what?
Compromised immune function
Fever present in elderly with UTI?
Absent in 30-50%
Baseline body temp in elderly is high or low?
Low, below 37C
Diagnostic testing in elderly with suspected UTI reserved for…?
Fever, dysuria, gross hematuria, worsening incontinence, suspected bacteremia
Rule for abx use in elderly?
Start low, go slow
Abx for elderly UTI work best when levels of the drug _____ the MIC?
Far exced the MIC
Drug levels should be monitored for what?
Avoid toxicity or subtherapeutic dosing
Duration of abx in elderly female UTI?
3-6 days
Elderly male UTIs complicated or uncomplicated? Abx duration?
Complicated.
Abx longer duration
First line Tx of GERD?
PPIs
Most common complaint with Diverticulitis?
LLQ Abdominal pain (sigmoid colon)
Diverticulitis dx?
CT scan!
Tx for mild diverticulitis?
IV abx for gram - and anaerobic until inflammation stabilized and pain resolving, 3-5 days. Then PO abx for total of 10-14 days on abx.
Chronic Constipation for at least how many weeks?
12 weeks
Constipating definition
Less than 3 poops/week
Constipation a symptom or disease?
Symptom
Alarm symptoms of constipation gets what test?
Abdominal CT
Which are the poop softeners?
Psyllium, cellulose, calcium poly, wheat dextrose, PEG, lactulose, MG salts
Which are the poop move fasters?
Stimulants: Bisacodyl, Senna
Secretory: Lubiprostone, Linaclotide
Diarrhea definition?
Decrease of fecal consistency more than 4 weeks
C. Diff and antidiarrheal agents?
AVOID! Can cause ileus and megacolon!
Tx for mild small bowel overgrowth?
Bismuth
Tx for severe small bowel overgrowth?
Cipro, Neomycin, rifaxim 14-21 days
Fecal Incontinence definition?
At least 1 month of continuous or uncontrolled passing of fecal material
Fecal Incontinence and DRE?
Check internal and external anal sphincter tone
Fecal Incontinence tx?
Disimpaction, schedule toilet poops, modify risk factors
Dentate line marks what for hemorrhoids?
Internal vs external
Internal hemorrhoids arise from which plexus?
Superior
External hemorrhoids arise from which plexus?
Inferior plexus
Hemorrhoid bleeding when? Painful?
When poop. Not painful.
When to scope butt for hemorrhoids?
50 y/o, or at 40 if 1st degree relative with colon cancer
Grade I hemorrhoid vs Grade 4
1=Do not prolapse below denate line
4=irreducable and bulge like a mofo
Most common tx for internal hemorrhoids?
Rubber band ligation
Tx NEVER to use on internal hemorrhoids?
Rubber band ligation
