FINAL - GU & Sexual health Flashcards
What are risk factors for STI?
-new or multiple partners (>2 in past year)
-casual partners
-sexual contact with person with known STI
-sexually active youth <25 years,
-no condoms/ barriers
-no contraception or sole use of non- barrier methods of contraception,
-unregulated drugs/ substance use, IVDU,
-prev hx STI,
-use of meds for ED,
-hx IPV,
-social environments (i.e., parties, post- secondary institutions),
-unsafe sexual practices (blood exchange, sharing toys, unprotected),
-sex workers and clients,
-survival sex,
-street involvement, homelessness,
-anonymous sexual partnering,
-victims of sexual assault/ abuse
T/F When applied properly, condoms provide nearly 99% protection from all STIs
F Barrier methods reduce risk for STI, but do not provide complete protection against syphillis, HPV, HSV (lesions or asymptomatic shedding can occur in areas not covered by barrier)
Name some important considerations for pre/ post STI test counselling.
-Motivational interviewing (i.e., around condom use)
-Modes of transmission
-Risk of exposure and association to substance use, sex practices
-Risk reduction adapted to persons situation (condoms, PrEP, PEP)
-Travel history- STBBI varies by country)
-Vaccination (HPV, HAV, HBV)
-Information about treatment/ outcomes (different for curable vs. chronic STBBI
-Importance of treatment adherance/ follow up (i.e., TOC)
-Benefits of partner being tested, implications of partner not testing/ treating
-Psychsocial supports
-Mandatory reporting, limits to confidentiality
-Process of partner notification
What is the most commonly diagnosed and reported bacterial STI in BC?
Chlamydia
Does chlamydia affect more males or females?
F
What age group has the highest rates of CT?
20-24 year olds
How long is the incubation period of chlamydia?
10-30 days
Is this longer than the incubation period for gonorrhea?
Yes (CT 10-30 days, G 3-7 days)
Who should be screened for chlamydia?
-Screen asymptomatic sexually active people age <25, pregnant people 1st and 3rd trimester, neonates born to mom with CT/G, those at risk of ST/BBI
Where can chlamydia infection occur?
Infection can occur in penis, vagina/ cervix, urethra, anus, throat, eyes
What are chlamydia symptoms in females?
70% of F asymptomatic, but can include
* Urethritis, dysuria
* May see yellow discharge on endocervical swab from mucopurulent cervicitis
* Vaginal bleeding between periods/ after sex, dyspareunia, vaginal discharge
What are chlamydia symptoms in males?
50% asymptomatic, but may include
* White penile discharge
* Urethritis, dysuria
* Urethral symptoms (discharge, intermittent itching/ tingling, meatal erythema)
What sequelae of STI are important to assess for?
PID in F, epididymitis in M
And I would think pregnancy
How to dx an STI?
Dx with NAAT (first void urine sample or vaginal, cervical, urethral, pharyngeal, or rectal swabs)
What is the treatment for chlamydia? (Drug name only)
Doxycycline or Azithromycin
What are important counselling considerations when treating a patient for STI?
Need to tx/ treat all partners in past 60 days regardless of s/s (or last partner if none in past 60 days)
Refrain from unprotected intercourse for 7 days after initiation of treatment and avoid exposure to untreated
contact
Encourage repeat screen in 6 mo (reinfection rates high)
T/F Everyone needs a TOC after receiving treatment for chlamydia infection
F- TOC only needed if pregnant or lactating, uncertain compliance, not initially treated with right regimen
TOC is done 3-4 weeks after initiation of tx
How common is gonorrhea?
2nd most commonly diagnosed bacterial STI in BC, increasing rates
Is gonorrhea more common in M or F?
M, MSM
Who have the highest rates of gonorrhea (by age)?
M 25-29
F 20-24
T/F Gonorrhea rarely occurs with chlamydia
F- often co-occurs
Symptoms of gonorrhea in females?
-Most F asymptomatic
-May see:
* Urethritis, dysuria
* May see yellow discharge on endocervical swab from mucopurulent cervicitis
* Vaginal bleeding between periods/ after sex, dyspareunia, vaginal discharge
S/S gonorrhea in males?
-Most M develop symptoms
* Yellow (or green) penile discharge
* Urethritis, dysuria
* Urethral symptoms (discharge, intermittent itching/ tingling, meatal erythema)
What are the sequelae of untreated gonorrhea infection?
Can lead to rash, tenosynovitis, monoarticular arthritis, meningitis, PID, epididymitis
What is the pharmacological tx for gonorrhea? (drug names only)
Cefixime or ceftriaxone PLUS doxy or azithro (concomitant tx for chlamydia required)
Who needs a TOC following antibiotic treatment of gonorrhea infection?
- Pregnant (TOC by culture 3-7 days after initiation of tx)
- Gonococcal pharyngeal infection
- Treated with non-recommended regimen
- Treatment failure suspected
- Antimicrobial resistance to therapy documented
- Compliance uncertain
- Re-exposure to untreated partner
- NAAT for G TOC should be done 2-3 weeks after initiation of tx
Which of the following are reportable? (SATA)
a) chlamydia
b) gonorrhea
c) HSV
A and B
How common is HSV infection?
Affects most adults worldwide
What are the two types of HSV and how are they typically transmitted?
HSV 1 typically transmitted by direct contact with oral secretions or lesions
HSV 2 from direct contract with infected genital secretions
T/F HSV is a chronic infection
True- persists for life in the sensory ganglion
What are triggers for HSV reactivation?
immunodeficiency, stress, UV exposure, fever
Describe the general presentation of HSV lesions
Can be mild, subclinical, or asymptomatic
Painful lesions in mouth, genitalia, or any skin/ mucous membrane. Multiple vesicular lesions (very painful to touch) that open, weep, crust, dry over, and disappear without scar formation
How does primary HSV infection present?
- Sudden onset
- Multiple small (1-3mm) vesicular lesions on inflammatory, erythematous base
- Usually grouped in single anatomic site (vermilion boder), though auto inoculation can occur
- Last 10-14+ days
- Prodrome of paresthesia can occur with recurrent infection
- May have ulcerative enanthema
- Primary infection may have fever, malaise, HA, arthralgia, local pain, edema
How does primary HSV 2 typically present?
- Initial presentation can be severe with painful genital ulcers, dysuria, fever, tender local inguinal lymphadenopathy
How do recurrent HSV infections present and how is this different from primary infection?
-Usually do not have systemic sx (i.e., fever) unlike primary infection
-Prodrome is instead 24 hours (tingling sensation or mild pain)
-Recurrent outbreaks resolve faster )5-7 days vs. 2-3 weeks)
How does one diagnose an HSV infection?
Clinical, though can swab vesicles (unroof them) (cell culture and PCR are preferred tests)
Differentials to consider for HSV?
HZV (shingles), varicella (chicken pox), HFMD, bullous impetigo, scabies, fungal pathogen, chancroid,
Describe the treatment for HSV infection
Mostly self limited
Antivirals can help limit length/ frequency/ severity of HSV
Valacylovir
Lifestyle counselling for HSV?
Supportive counselling
* No reportable
* Provide guidance in how patients will inform present/ future sexual partners
* Advise abstain from intercourse during promdrome and when lesions present in any stage
-Consistent condom use to reduce transmission rates
-Wash hands after touching lesions- prevent autoinoculation
-NB that having genital HSV can increase the risk for acquiring and transmitting HIV
What is epididymitis?
Inflammation of the epididymis
T/F: epididymitis can stem from both infectious and non-infectious causes
True. Non infectious causes include trauma, autoimmune diseases, chemical (reflux of urine into ejaculatory ducts)
What are the most common causative organism of infectious epididymitis?
Age 35 and younger: N. gonorrhoeae and C. Trachomatis
Age > 35 and/or penetrative anal intercourse: E.coli and other gram negative bacteria
What are risk factors for epididymitis?
UTI
Unprotected sexual contact
Instrumentation/catheterization
Increased pressure in prostatic urethra (straining, voiding, heavy lifting) may cause reflux of urine
along vas deferens → sterile epididymitis
Immunocompromised
How does epididymitis present?
Acute onset scrotal pain and swelling +/- radiation along cord to flank
Scrotal erythema and tenderness
Fever
Storage symptoms (frequency, urgency)
Purulent discharge
May have a reactive hydrocele
Phren’s sign will be _____
The cremasteric reflex will be _____
Phren’s sign will be positive (lifting/elevation of the testicle relieves pain)
Cremasteric reflex will be intact
T/F: Epididymitis is the most common cause of in-office acute scrotal pain
True
What is an important differential/ red flag condition to rule out with scrotal pain?
What are other differentials to consider?
Testicular Torsion
Fournier’s gangrene, torsion of the appendix testes, post-vasectomy pain, inguinal hernia, mumps orchitis, testicular cancer, IgA vasculitis, referred pain
How is epididymitis diagnosed? Would you consider any diagnostics?
Diagnosis can be made presumptively based on history and physical
Complete a urinalysis, urine culture and NAAT for G/CT
T/F: Wait for cultures/NAAT to come back before starting treatment
False.
Treat empirically for the most likely pathogen while results pending
What is the empiric treatment for men > 35 years old
Ciprofloxacin 500mg BID or 1g OD x 10 days
OR
Levofloxacin 500mg OD x 10 days
What is the first line empiric treatment for men 35 years or younger or men with multiple sex partners?
Cefixime 400-800 mg PO x 1
OR
Ceftriaxone 250mg IM x 1
AND
Azithro 1g po x 1
OR
Doxy 100 mg BID x 10 days
Epididymitis may require up to 6 weeks of treatment if secondary to which condition?
Prostatitis
Re-evaluate treatment if patients do not start to see improvement within _____
3 days
What are some potential complications of epididymitis?
If severe can lead to testicular atrophy
30% of patients have persistent fertility problems
If inadequately treated can progress to chronic epididymitis or epididymo-orchitis.
There are 4 categories of prostatitis
Acute bacterial prostatitis
Chronic bacterial prostatitis
Chronic pelvic pain syndrome (symptoms without evidence of infection)
Asymptomatic prostatitis
T/F: acute bacterial prostatitis is the most common type of prostatitis
False. It is actually the least common type, but it is the easiest to treat.
The most common type is Chronic pelvic pain syndrome - not caused by bacteria, causes pain/discomfort that comes and goes
What is usually the causative organism of bacterial prostatitis?
E. Coli
Or other gram negative bacilli - S. aureus, E. Faecalis
How does acute bacterial prostatitis present?
LUTS
Pelvic pain
Systemic signs: fever, chills, malaise
Leukocytosis in prostatic fluid
Positive bacterial cultures
How does chronic bacterial prostatitis present differently from acute?
Has the same findings of LUTS, pelvic pain, leukocytosis in prostatic fluid and positive bacterial cultures, but no systemic symptoms
Frequent UTIs
What would your history and physical consist of for bacterial prostatitis ?
History: HPI, GU and sexual history
Physical: abdominal exam, external genitalia, perineum and prostate exams
How is bacterial prostatitis diagnosed?
Diagnosis can typically be established with history indicating typical symptoms of prostatitis and the finding of an edematous and tender prostate exam.
Urine culture should be done to determine bacterial etiology.
What is first line treatment for acute bacterial prostatitis?
TMP/SMX 2 tabs BID
Trimethoprim 200mg BID
Norfloxacin/levofolxacin/ciprofloxacin
for 10-14 days according to Mums… but then it says to continue for 2-4 weeks after resolution of symptoms. UTD suggests at least 4 weeks of abx
If severe may require hospitalization, catheterization (due to obstruction) and IV abx
What is first line treatment for chronic bacterial prostatitis ?
Norfloxacin 400 mg BID
Levofloxacin 500 mg daily
Cipro 500 mg BID
Only if abscess or positive urine culture present.
If no response inn 4-6 weeks, refer to urology.
Describe what is happening in testicular torsion
Twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction
How does testicular torsion present?
Sudden onset severe unilateral scrotal pain, swelling of scrotal sac, high position of the testicle, abnormal cremasteric reflex, negative Phren’s sign.
Pain may radiate to the lower abdomen/groin, may have N/V, scrotum may be indurated and erythematous, reactive hydrocele may occur
What the heck is a negative cremasteric reflex?
The cremasteric reflex is a superficial reflex, when the inner thigh is stroked – yes stroked – the cremaster muscle should contract and pull the ipsilateral testicle toward the inguinal cancel (basically the scrotum contracts).
This won’t be present in testicular torsion
What the heck is a negative Phren’s sign?
Positive Phren’s sign is a relief of testicular pain with elevation of the scrotum – present with epididymitis
Phren’s sign is negative in testicular torsion
Your patient booked a same day appointment in your primary care clinic this morning, he has acute onset testicular pain with a negative cremasteric reflex and negative Phren’s - What do you do?
Transfer to ED – this is a surgical emergency
True of False – surgical intervention recommended within 4 hours
False – 2 hours. Surgical delay can lead to ischemia and a non-viable testis
The TWIST score can be used to help rule out the diagnosis of testicular torsion, what clinical findings do you think it considers?
TWIST score for testicular torsion (Up To Date)
*Nausea or vomiting: 1 point
- Testicular swelling: 2 points
- Hard testis on palpation: 2 points
- High-riding testis: 1 point
- Absent cremasteric reflex: 1 point
Score <2 excludes torsion with sensitivity 100%, specificity 82 %, negative PPV 100%
When would an orchiectomy be part of the surgical intervention? How about an orchiopexy?
Orchiectomy is done when the testicle is non-viable and needs to be removed
Orchioplexy is done bilaterally when TT occurs to prevent recurrence by anchoring the testes
At which ages does TT most commonly occur?
Small peak in neonatal period, large peak in adolescence. Can occur at any age.
How might TT present in infants?
Hardened, fixed, nontender scrotal mass with a discolored scrotum
What are some differentials for TT?
Epididymitis
Orchitis
Hydrocele
Testicular tumor (hard, enlarged, painless testicle)
Acute appendicitis
Varicocele
Scrotal/testicular trauma
Diagnostics for testicular torsion?
US – definitive diagnosis not required to go to OR if causing too much of a delay
T/F Only 10% of cases of acute scrotal pain are due to TT.
False – 40%
Treatment of PID generally requires broad antimicrobial coverage. Why?
PID is an ascending polymicrobial infection caused by cervical microorganisms (including Chlamydia trachomatis and Neisseria gonorrhoeae, and potentially Mycoplasma genitalium), as well as the vaginal microflora, including anaerobic organisms, enteric gram-negative rods, streptococci, genital mycoplasmas, and Gardnerella vaginalis, which is associated with bacterial vaginosis.
GC and CT should be the main targets for tx, even if swabs are negative as upper tract infections cannot be ruled out (as per UTD).
Kristy, a 27 year old cis female presents to clinic. She has had 2 new sexual partners over the last 6 months. Her s/s are low abdominal pain, a change to her vaginal discharge, pain during sex and has noticed some spotting after intercourse. On physical exam, you discover cervical motion tenderness. What is your working diagnosis and differentials?
Working diagnosis:
PID
Differentials:
Ectopic pregnancy
Appendicitis
Ruptured ovarian cyst or tumour
Diverticulitis
Cystitis
Septic abortion
What are some red flags in a patient diagnosed with PID, that may indicate the need for hospitalization and IV tx?
Fever > 38.5, n/v
Pelvic abscess
Possible need for invasive diagnostics to evaluate alternate etiology (eg appendicitis or ovarian torsion)
Inability to take oral meds
Pregnancy
Lack of response to oral therapy
Concern for nonadherence to oral therapy
What is the 1st line tx recommendation for mild to moderate PID?
UTD suggests the following regimen:
500 mg - 1 g ceftriaxone IM - one dose
PLUS
Doxy AND flagyll p.o.
MUMS recommends:
Cefixime 800 mg single oral dose
OR
250-500 mg ceftriaxone IM one dose
PLUS
Doxy 100 mg BID x 14 days
+/- flagyll 500 mg BID x 14 days
Which organism is the culprit in trichomoniasis?
The flagellated protozoan Trichomonas vaginalis.
What are the top 3 vaginal complaints among reproductive-aged females?
Trich
BV
Candidiasis
as per UTD
Possible clinical presentations of acute trichomoniasis in people with female reporductive organs?
-purulent, malodorous thin vaginal discharge
-vaginal burning
-genital pruritus
-dysuria, urinary frequency
-low abdo pain
-dyspareunia
Be mindful that typical s/s may occur in only 11-17% of those infected, so have a low threshhold to test for trich when vaginal discomfort is present.
A person with a chronic trich infection can be asymptomatic for months before developing s/s.
True/false?
True.
Rates of asymptomatic infection have been reported at 66-85%!
So I think it is a good one to add to routine screening yeah?
Trichomoniasis can cause symptoms of urethritis in males. What might you see?
When present, symptoms consist of a clear or mucopurulent urethral discharge and/or dysuria and are the same as for urethritis from any cause. There may also be mild pruritus or a burning sensation in the penis after sexual activity. However, T. vaginalis infection is asymptomatic in over three-quarters of cases and often transient (spontaneous resolution within 10 days), although untreated infection can persist for months.
How do you test for trich?
NAAT for vaginal or urethral discharge
or
vaginal pH and microscopy
Tx for trich?
From UTD:
The 5-nitroimidazole drugs (metronidazole, tinidazole, and secnidazole) are the only class of drugs that provide curative therapy of trichomoniasis.
Most strains of T. vaginalis are highly susceptible to these agents.
Randomized trials using these drugs have generally reported cure rates of 90 to 95 percent.
Choice of agent is generally determined by availability, preference for single-day therapy, and cost.
Tx options for gonorrhea?
Which of these is preferred if you are treating pharyngeal gonorrhea or your client is MSM?
As per RXFiles:
-Ceftriaxone 250 mg IM one dose (dose increases with heavier bodies up to 1g for >150 kg) - recommended tx for pharyngeal tx or in MSM populations
OR
-Cefixime 800 mg p.o. one dose
OR
-Azithromycin 1g p.o. one dose
Recommended tx for chlamydia?
Azithromycin 1g p.o. one dose
OR
Doxy 100 mg BID x 7/7
Your pregnant client has tested positive for chlamydia. The recommended treatment choice is doxycycline 100 mg BID x 14 days.
True or false?
False.
Doxy is contraindicated in pregnancy.
Treatment options that are approved are azithromycin 1g p.o. one dose or amoxicillin 500mg TID x 7/7.
Possible s/s of chlamydia?
Painful urination
Vaginal discharge
Discharge from the penis
Painful sexual intercourse in women
Vaginal bleeding between periods and after sex
Testicular pain
Other sites that chlamydia infections may be present other than vagina/penis? These may be asymptomatic, but what s/s might you see?
Eyes - conjunctivitis
Throat - may have a sore throat
Rectum - Rectal pain, discharge or bleeding
Possible complications of untreated chlamydia?
Pelvic inflammatory disease (PID).
Epididymitis.
Prostate gland infection -rare.
Infections in newborns.
Ectopic pregnancy.
Infertility.
Reactive arthritis.
Gonorrhea is often asymptomatic.
If s/s are present, what might you see?
Male symptoms of gonorrhea infection include:
-Painful urination.
-Pus-like discharge from the tip of the penis.
-Pain or swelling in one testicle.
Female symptoms of gonorrhea infection include:
-Increased vaginal discharge.
-Painful urination.
-Vaginal bleeding between periods, such as after vaginal intercourse.
-Abdominal or pelvic pain.
NAAT tests have high specificity and sensitivity (>90%) to diagnose which possible causes of vaginitis?
BV
Candida
Trich
Cervicitis caused by GC and CT
Which form of vaginitis is the most common cause of abnormal vaginal discharge in people with vaginas, of child-bearing age?
BV accounts for 40-50% of vaginitis cases.
What is the 1st line pharmacological treatment recommended for BV?
Which abx can be considered if an alternative is needed?
Metronidazole (po or pv)
PO: 500mg BID x 7/7
PV: 0.75% gel 5 gram pv QD x 5/7
Clindamycin po or pv supps may be used if C/I to above.
What are some risk factors for developing vulvovaginal candidiasis?
Increased estrogen levels (OCP, pregnancy)
Abx
Glucocorticoids
Diabetes Mellitus
IUD use
What is the recommended fluconazole dosing for candidiasis tx?
Flucanozole 150 mg 1 tab is usually effective for mild cases.
A 2nd dose may be needed 72 hours after the 1st dose in moderate cases.
How does pregnancy change your tx options for yeast infection?
Oral meds are contraindicated and so topical clotrimazole or miconazole, or nystatin supps are recommended for initial tx.
Note: fluconazole is ok in breastfeeding
Gross hematuria vs. microscopic hematuria, as defined on UTD.
Gross hematuria is visible to the naked eye, microscopic hematuria is only detectable by microscopy or urinalysis.
What are some possible causes of hematuria?
The causes can vary with age.
The most common is infection or inflammation of the bladder.
Kidney stones
Kidney or bladder malignancy is more common in older age. UTD defines older age as 35 yrs and up! BC Guideline states 40 yrs +.
BPPH (incidence also increases with age)
Hematuria is common in young patients and is often benign with unidentified cause.
True or false?
True
Microscopic hematuria identified in a person with female reproductive organs during menses or shortly after acute trauma or vigorous exercise should be confirmed by repeating the urinalysis.
What are the recommended wait times, as per UTD?
(I’m not sure if this is useful information)
In menstruation, the urinalysis should be repeated later in the cycle once menstrual bleeding has ceased. If this is not possible, a tampon can be inserted, and urinalysis can be obtained after the perineum is cleansed.
In patients who had hematuria identified in the setting of vigorous exercise, the urinalysis should be repeated approximately four to six weeks later during a period of no exercise.
Patients with acute trauma and microscopic hematuria should have a confirmatory urinalysis after six weeks.
In the presence of hematuria, when is imaging indicated?
-Unilateral flank pain suggestive of obstructive nephrolethiasis (CT or U/S with abdo xray)
In the absence of infection:
-gross hematuria with visible blood clots in urine: CT urography (CTU). This patient should also be referred for urgent urology evaluation for cystoscopy
Gross hematuria with no visibly clots in urine:
-AKI? refer
-No AKI? CTU and urology referral for cystoscopy
-Pregnant patients should have kidney and bladder U/S rather than CT.
Microscopic hematuria: pregnant patients as above
-nonpregnant patients with malignancy risks or previous hx of urologic disorder: CTU and referral to urology for cystoscopy
If your patient is black and presents with hematuria, what is something to keep in mind?
Populations of African heritage have a greater incidence of sickle cell disease, which can cause papillary necrosis -> hematuria.
How does the BC guideline on microscopic hematuria differentiate b/n significant and insignificant hematuria?
Sig: 3 or more RBC/hpf on unrine microscopy
Insig: 0-2 RBC/hpf
If your patient has significant microscopic hematuria (3 or more RBC/hpf) what are the possible next steps, as per BC guideline?
Renal fx tests (ACR, creatinine/eGFR
BP
Imaging - 1st line is kidney/bladder U/S
Possible referral to urology
Re: microscopic hematuria - who to refer to urology for cystoscopy?
As per BC guideline
All patients > 40 yrs old
All patients with risk factors for urolethial cancer
Positive imaging findings
Re: microscopic hematuria - who to refer to nephrology?
As per BC guideline
Abnormal creatinine/eGFR
Protenuria (ACR >30)
Red cell casts
Dysmorphic RBCs
Greater than or equal to 5-10 WBCs/hpf without infection
Is it recommended to screen the general population for microscopic hematuria to detect bladder cancer?
No, there is not sufficient evidence to support the benefit of this.
No cause will be found for microscopic hematuria in many cases.
When no specific cause for persistent microscopic hematuria is found, the patient should be followed annually with:
Urine ACR
Urine microscopy
Creatinine/eGFR
Blood pressure
Urine cytology (only in patients with risk factors for urothelial cancer)
What are overactive bladder s/s?
Urinary frequency and urgency that immediately precedes or accompanies involuntary urine leakage.
What are some recommended initial treatment approaches to overactive bladder (OAB) as per UTD?
With an emphasis on improving quality of life aligned with patient goals and expectations:
Pelvic floor exercises to suppress urgency
Modifications of contributory meds/substances (big list of meds on UTD)
Promotion of healthy lifestyle and behaviours (Smoking cessation, healthy body weight
Bladder training
Treatment for vulvovaginal atrophy if present with topical estrogen therapy
Pharmacological treatments for OAB?
Which class should you trial first and why?
Beta-3 adrenergic agonist drugs and antimuscarinic agents are the main options for treatment of OAB symptoms.
Efficacy is similar for the two groups, we (UTD) and others suggest initial drug treatment with beta-3 adrenergic agonists because of the increased risk of side effects, including long-term risk of dementia, with anticholinergic drugs.
However, from a practical perspective, choice of initial agent is often influenced by third-party payor coverage, availability and cost. The beta-3 adrenergic agonists are a newer drug class and therefore, in the United States, tend to be more expensive with less coverage across insurance providers than anticholinergics.
They can also be used in combo with each other.
OAB rarely responds to pharmacological tx.
True/false?
False!
It is the most responsive urinary incontinence disorder.
How are some ways that incontinence can affect quality of life?
It is associated with depression and anxiety, work impairment, and social isolation.
Urinary incontinence during sexual intercourse (coital incontinence) can negatively impact sexual function in 10% of people experiencing incontinence.
True or false
False, the amount of people living with incontinence who also experience coital incontinence is as high as 1/3.
Risk factors for urinary incontinence in women?
Age:
-3% of women >35 yrs old
-7% of 55-64 yrs
-38-70% over 60 yrs
Obesity - nearly 3x risk vs. non-obese
Multiparity
Vaginal deliveries > C-sections
Family Hx
Comorbidities/meds
High impact exercise
Smoking
Diet - Caffeine and ETOH may be factors but limited evidence. Artificial sweeteners are linked to 10x risk of mixed incontinence
Urogenital microbiome - conflicting evidence
What are the 4 main types or urinary incontinence?
The main types of urinary incontinence are stress, urgency, and overflow incontinence. Many women have features of more than one type, which is termed mixed urinary incontinence.
What is stress urinary incontinence?
Individuals with stress urinary incontinence (SUI) have involuntary leakage of urine that occurs with increases in intra-abdominal pressure (eg, with exertion, sneezing, coughing, laughing) in the absence of a bladder contraction.
SUI is generally thought to be related to the lack of mechanical support of the urethra and/or poor coaptation of the urethral tissues resulting in insufficient resistance to outflow of urine during increased abdominal pressures.
It is the most common type in younger women, with the highest incidence in women ages 45 to 49 years.
What is urgency urinary incontinence?
The urge to void immediately precedes or accompanies involuntary leakage of urine.
The amount of leakage ranges from a few drops to completely soaked undergarments. The terms “urgency incontinence” and “overactive bladder with incontinence” are often used interchangeably.
It is more common in older women and may be associated with comorbid conditions that occur with age.
What is overflow urinary incontinence?
Overflow urinary incontinence typically presents with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying.
Associated symptoms can include weak or intermittent urinary stream, hesitancy, frequency, and nocturia. When the bladder is very full, stress urinary leakage can occur or low-amplitude bladder contractions can be triggered resulting in symptoms similar to stress and/or urgency urinary incontinence.
Overflow urinary incontinence is caused by detrusor underactivity or bladder outlet obstruction.
What is functional urinary incontinence?
Functional urinary incontinence occurs when a patient has intact urinary storage and emptying functions but is physically unable to toilet themselves in a timely fashion.
Ie; frail elders, persons with mobility issues.
What are some meds that can contribute to urinary incontinence?
(there are many listed on UTD)
Antihistamines
Decongestestants
Benzos
Opioids
Anticholinergics
Cardiac meds: ACEIs, Alpha-agonists, Alpha-1 blockers, antiarrythmics, diuretics
SNRIs and TCAs
1st gen. antipsychotics
Skeletal muscle relaxants
Oral estrogens
Beta 3 agonist - also this is one of the 1st line treatments for overactive bladder. Leads to decreased contractility.
A bladder stress test is recommended to confirm diagnosis of stress urinary incontinence in people with female GU systems.
What is a bladder stress test?
This test is performed with the patient in the standing position with a comfortably full bladder. Ideally, the bladder should have at least 150 to 300 mL for an adequate assessment. While the examiner visualizes the urethra by separating the labia, the patient is asked to Valsalva and/or cough vigorously. The clinician observes directly whether or not there is leakage from the urethra. This test may be difficult in women with severe obesity, mobility or cognitive impairments; these women may benefit from performing the test in the dorsal lithotomy position.
CAN YOU IMAGINE!! There seems to be a lot of encouraging us to watch people pee!!
What are some treatment options for women experiencing stress incontinence?
DEVICES: Pessaries - generally fitted by a gynecologist or urologic continence specialist.
MEDS: Duloxetine (SNRI) may be helpful but evaluate for potential adverse effects reported by 1 in 3.
Alpha-adrenergic agonists ( ie. phenylpropanolamine)
SURGERY: Mid-urethral sling procedures are the standard. Strong evidence for efficacy.
Urethral bulking injection procedures
Other alternative procedures of limited evidence
Usual pathogens that cause UTI?
E.coli, S. saprophyticus, other enterobacterales
GBS (S. agalactiae) also in pregnancy
In peri- or post-menopausal women with vaginal atrophy and either stress or urgency incontinence, what is the recommend 1st line tx?
Topical vaginal estrogen.
Is a test of cure required for uncomplicated UTI generally?
What about in pregnant people?
Not in general pop, if typical symptoms and adequate response to therapy
Pregnant: YES - Pre/ 1 week post treatment urine cultures recommended, followed by monthly urine cultures during remainder of pregnancy
Define UTI
symptoms suggestive of UTI + evidence of pyuria and bacteriuria on U/A or urine C&S
What is asymptomatic bacteremia?
if asymptomatic + 100,000 CFU/mL (organisms per mL)
Complicated vs uncomplicated UTI
Uncomplicated: lower UTI in a setting of functionally and structurally normal urinary tract
Complicated: structural and/or functional abnormality, male patients, immunocompromised, diabetic, iatrogenic complication, pregnancy, pyelonephritis, catheter-associated
Risk factors for UTI
Stasis and obstruction: residual urine due to impaired urine flow (e.g. PUVs, reflux, medication, BPH, urethral stricture, cystocele, neurogenic bladder)
foreign body: introduce pathogen or act as nidus of infection (e.g. catheter, instrumentation)
decreased resistance to organisms
DM, malignancy, immunosuppression, spermicide use, estrogen depletion, antimicrobial use
other factors: trauma, anatomic abnormalities, female, sexual activity, menopause, fecal incontinence
In what populations would you treat for asymptomatic bacteremia?
pregnancy, immunosuppressed, prior to urologic surgery
Steps for acute cystitis diagnosis according to MUMS….
STEP 1: AFTER completing your clinical assessment you conclude the patient likely has uncomplicated acute cystitis, determine the number of the following criteria that are present.
What are the 3 criteria?
1) Burning or pain on urination
2) Presence of leukocytes (more than trace amount)
3) Presence of nitrates (any positive, including trace amount)
For each of the aforementioned criteria, you give the patient 1 point. How would you proceed if the patient has either a score of 0 or 1?
Risk for positive urine culture = 26-38%
Perform urine culture before deciding the need for antibiotics. Treat with empiric tx if symptoms are severe (or if pt is uncomfortable and not willing to wait for culture results)
How will you proceed if the patient scores a 2 or 3?
Risk for positive urine culture = >70%
Start empirical antimicrobial therapy without waiting for urine cultures
Why do we reserve fluoroquinolones for severe situations only when treating acute cystitis?
**Due to the importance of fluoroquinolones for other indications and concern of developing resistance with overuse
What is pyelo? When do we suspect it?
Acute pyelonephritis is a bacterial infection of the kidney and renal pelvis and should be suspected in patients with flank pain and laboratory evidence of urinary tract infection
The highest incidence of pyelo occurs in what population?
otherwise healthy women 15 to 29 years of age
E. coli accounts for approximately ____% of uncomplicated pyelonephritis cases.
90%
S&S of pyelo
rapid onset (<24 h)
* LUTS including frequency, urgency, hematuria; NOT dysuria unless concurrent cystitis
* fever, chills, nausea, vomiting, myalgia, malaise
* CVA tenderness and/or exquisite flank pain
T/F A midstream urine spec is much less likely to be contaminated than with preparatory cleansing only.
False - Several studies demonstrate no reduction in contamination rates with preparatory cleansing or midstream catch
catheterization is not necessary for specimen collection.
Diagnostic imaging should be considered in what circumstances with pyelo?
Sepsis
Concern for urolithiasis (kidney stones)
New renal insufficiency with eGFR is less than or equal to 40
Known urologic abnormalities
Failure to respond to appropriate therapy within 48 to 72 hours
What is the preferred imaging to use in cases of pyelo?
When diagnostic imaging is indicated, contrast-enhanced computed tomography of the abdomen and pelvis is the preferred modality.
When contrast or radiation is contraindicated, such as during pregnancy, ultrasonography and magnetic resonance imaging may be used.
Can pyelo be treated in community?
Yes, if mild/uncomplicated/ non-obstructive
- outpatient oral ABx treatment ± single initial IV dose
If severe, send to ER.
1st line tx of pyelo if treating in community?
1st line:
- Septra
- Trimethoprim
- Norfloxacin
- Ciprofloxacin
- Levofloxacin
Second-line:
- Amoxiclav
How do we diagnose pyelo?
clinical diagnosis of flank pain, fever, and elevated WBC
Common underlying causes of pyelo?
stones, strictures, prostatic obstruction, vesicoureteric refux, neurogenic bladder, catheters,
DM, sickle-cell disease, PCKD, immunosuppression, post-renal transplant, instrumentation,
pregnancy
Is nephrolithiasis more common in men or women
M>F (2:1)
What is nephrolithiasis?
Kidney stones
Peak incidence of nephrolithiasis occurs in what age?
30-50 years
Do people who get kidney stones often experience them more than once in their lives?
YES
Recurrence: 10% at 1 year, 50% at 5 year, 60-80% lifetime
What lifestyle/dietary conditions are risk factors for kidney stones?
minimal fluid intake, excess vit C, oxalate, purines, calcium
What medications increase risk of kidney stones?
- loop diuretics like furosemide
- acetazolamide
- topiramate
- acyclovir
- triamterene
- sulfadiazine
What medical conditions increase risk of kidney stones?
- UTI (esp with ureal splitting organisms like proteus, pseudomonas, klebsiella, mycloplasma, s. aureus),
- myeloproliferative disorder
- IBD
- gout
- DM
- hypercalcemia
- obesity (BMI >30)
List the most to least common stone types:
Calcium (74-85%)
> uric acid (5-10%)
> struvite (5-10%)
> cystine (1%)
Patho of nephrolithiasis
Supersaturation of stone constituents (at appropriate temp and pH)
Stasis, low flor, low volume of urine (dehydration)
Crystal formation
Loss of inhibitory factors (citrate, magnesium)
-Obstruction to urine flow causes upstream distention and pain
S&S of nephrolithiasis. Where is the pain felt?
-Flank pain from renal distention
-Severe waves of pain (colicky/ cramping) radiating from flank to groin, testes, or tip of penis from distended collecting system or ureter (ureteral colic)
-Writhing, persistent discomfort, moving around frequently to try and find comfortable position
-Urgency
-n, v
-diaphoresis, tachycardia
-hematuria (90% microscopic)
-CVA tenderness on percussion
Diagnostics for nephrolithiasis
-UA (hematuria), UC
-CBC
-Imaging: US, CT KUB
When is surgical intervention required for stones?
-Stones < 5mm in ureter will pass spontaneously in 75% of patients= MEDICAL tx
-Stones >5 mm or presence of complications= procedural/ surgical
What does medical management of stones consist of?
- Analgesic + antiemetic
- NSAIDs (lower intra-ureteral pressure)
- alpha blockers (increase rate of spontaneous passage in distal ureteral stones)
- Abx for bacteremia
- IV fluids if vomiting (do NOT promote stone passage)
What are the indications for hospital treatment of a person with nephrolithiasis?
- intractable pain
- intractable vomiting
- fever (suggests infection)
- compromised renal function (single kidney, bilateral obstruction, acute renal failure)
What happens if you try to medically manage the stone but symptoms worsen or fail to improve?
Progress to interventional treatment
Uric acid stones –> dissolution therapy
Non-uric acid stones: ESWL, ureteroscopy, PCNL, stent/nephrostomy
T/F the progrestin-only pill is taken for 21 days, followed by 7 days of sugar pills
False - there is no pill free interval for progestin only. All 28 pills in pack contain medication.
A 13 year old patient wants to start on birth control but heard from a friend that it made her fat. Is this a known side effect?
As per Up to Date: the use of CHCs does not appear to result in significant weight change, either gain or loss.
I have heard anecdotally of people who feel they gained weight but I think the research generally shows this isn’t linked
____ is the most common early side effect after CHC initiation
Unscheduled bleeding
*affects 1/2 of women during the first cycle of use and quickly improves over subsequent months
Contraindications for CHC use?
Age ≥35 years and smoking ≥15 cigarettes per day
●Two or more risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)
●Hypertension (systolic ≥140 mmHg or diastolic ≥90 mmHg for the CDC and systolic ≥160 mmHg or diastolic ≥100 mmHg for the WHO)
●Venous thromboembolism – Women with a history of thromboembolism not receiving anticoagulation or women with an acute embolic event
●Known thrombogenic mutations
●Known ischemic heart disease
●History of stroke
●Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)
●Breast cancer
●Cirrhosis
●Migraine with aura
●Hepatocellular adenoma or malignant hepatoma
Side effects of CHCs (broken down by estrogen and progestin-based SE’s if you’re feeling keen…)
Estrogen-related:
Nausea
Breast changes (tenderness, enlargement)
Fluid retention/bloating/edema
Weight gain (rare)
Migraine, headaches
Thromboembolic events
Liver adenoma (rare)
Breakthrough bleeding (low estradiol levels)
Progestin-related:
Amenorrhea/breakthrough bleeding
Headaches
Breast tenderness
Increased appetite
Decreased libido
Mood changes
HTN
Acne/oily skin*
Hirsutism*
What are the advantages of CHCs?
Highly efective
Reversible
Cycle regulation
Decreased dysmenorrhea and heavy menstrual
bleeding (less anemia)
Decreased benign breast disease and ovarian
cyst development
Decreased risk of ovarian and endometrial
cancer
Increased cervical mucus which may lower
risk of STIs
Decreased PMS symptoms
Less acne
Osteoporosis protection (possibly)
Patient controlled
What assessment do you need to do before starting a person on hormonal contraceptives?
thorough history and BP measurement
(do NOT need a pelvic exam)
When starting a hormonal contraceptive, should you tell your patient to start it on a particular day of their cycle?
can start at any time during cycle but ideally within 5 d of LMP (because then protection will be faster)
…but just start the next day! Better chances they will actually follow through and not get preggers in the meantime..
Possible side effects specific to the Nuva Ring? What is a “pro” of this method?
- side efects: vaginal infections/irritation, vaginal discharge
- associated with less breakthrough bleeding than other methods
How is the contraceptive ring used (Nuva ring)? How effective is it? Is it progestin only?
- thin flexible plastic ring that is inserted into the vagina
- left there for 3 wk then removed for a week to allow for menstruation
- as effective as OCP in preventing pregnancy (98%)
How do estrogen and progestin work in contraception?
- progestin: prevents LH surge, suppresses ovulation, thickens cervical mucus, decreases tubal motility,
decidualizes endometrium
What kind of birth control is a good option for people who are breast feeding?
How early to start this?
Progestin only methods (estrogen may interfere with milk supply)
Ideally don’t start before 6 weeks postpartum
If your patient is having breakthrough bleeding on a CHC, you can change to a pill with higher _____ to combat this issue
Estrogen
Depot provera is given every _______ weeks?
12 weeks (can give between 11 weeks up to 14 weeks)
Your patient presents 16 weeks after their last depo shot. What do you do?
From Up to Date: In women more than two weeks late for their injection (>15 weeks from the last injection), we suggest a pregnancy test before administering DMPA and back-up contraception (or abstinence) for seven days
**Options for Sexual Health also uses the 15 weeks cutoff for assuming protection from pregnancy
You start your patient on depo provera. They are protected from pregnancy right away, right?
No (it depends). need to use a backup method of birth control such as condoms, or not have sex for 7 days.
BUT if you happen to get your shot within the first 5 days of your period you are protected right away.
How long does it take to regain fertility after using the depo shot?
Up to 1-2 years!
Average is 9 months
Some people get pregnant right away but not good option for those wanting to get preggers anytime soon.
Emergency contraception can be taken for up to ___ days after unprotected sex
5 days
Copper IUD can be inserted up to 7 days (and hormonal IUD has proven to have similar efficacy but isn’t official yet)
Progestin only pills must be taken at the same time every day. If you are ___ hours late, you will need backup contraception for ____ days.
3 hours
2 days (48 hours)
What is a unique potential adverse effect of the depo shot?
Decreased bone density (may be reversible)
*encourage vit D/calcium supplementation
If your patient hasn’t been using their contraceptive pill as prescribed or has missed the window for their depo provera shot, what do you need to rule out?
Pregnancy!
If they have had unprotected intercourse in the past 5 days, consider ECP!
How long are copper and hormonal IUDs good for?
Copper - 10 years
Hormonal (Mirena, Kyleena) for 5 years….however the Mirena website now says up to 8 years (and this is starting to be more widely accepted in practice)
At what age does routine PAP screening begin
25
Your patient has their first PAP test and the results come back normal. How long until they need screening again?
3 years
Your patient’s PAP comes back abnormal. What further procedures might be recommended for them based on abnormal results?
- possibly just need to return for another PAP in 6 moths
- Colposcopy
- LEEP (if confirmed has high grade abnormality requiring excsision)
*The PAP result will tell you which one of these the patient needs
What is the upper age limit for recommended routine PAPs?
Can stop at age 69
Approximately 70 per cent of all cervical cancer is caused by the human papillomavirus (HPV) types ___ and ___
16 & 18
T/F the HVP vaccine protects against all strains of HPV
No, just the highest risk strains and the ones that cause genital warts
There are over 100 strains of HPV.
T/F most people clear HPV infections on their own
True - but if it doesn’t clear, can lead to cancer. And you can get re-infected with the same strains…
Gardisil 9 protects against 9 strains of HPV. Cervical cancer is the only kind of cancer that is caused by HPV.
T or F?
False!
Protects against lots of different cancers relevant to both men and women:
- Cervical
- Vulvar and vaginal
- Anal
- Certain head and neck cancers, such as throat and back of mouth cancers
…and Genital warts
