FPMRS Exam Pro Flashcards
Complications of CIC (3)
urethral false passage,
possibility of silent deterioration of upper urinary tract, and bladder perforation from forceful
incorrect catheterization.
Bladder cancer has not been associated with CIC.
how often should you change an indwelling catheter
At least every 3 months
ways to reduce indwelling cath obstruction
- acidify urine (if patient’s urine output is not low otherwise crystal will form)
- treat infections with Proteus mirabilis and P. stuartii as these may obstruct
- use a silicon catheter
operative cystoscopy: what size sheath do you need to pass a grasper, biopsy forceps, and bugbee?
greater than 17Fr
How long to keep stent after ureteral injury?
4-6 weeks
steps for stent placement
30° scope → open-end cath → contrast → guide wire → stent → pusher.
What are the indications for indwelling cath?
H. - hematuria
O. - obstruction
U. - urologic surgery
D. - does patient have pressure ulcer or wound
I. - Input and output
N. - neurogenic bladder (patient who has long term inability to empty bladder such as spinal cord injury, etc.)
I. - immobilization (due to physical constraints or multiple fractures etc.)
bladder cancer recurence rate
50%
urothelial cancer: monoclonal theory vs field theory
monoclonal theory states that multiple tumors descend from a single genetically transformed cell that populates the urothelium.
The field theory states that exposure to a carcinogen leads to “cancerization” of the entire urothelium
What are the four pillars of fecal continence?
Rectal sensation
Stool consistency
Rectal distensibility
Pelvic floor muscle function
Responsiveness of a questionnaire is…
its ability to detect clinical change.
Reliability of a questionnaire means?
Reliability is synonymous with reproducibility and repeatability. In other words, the level of agreement between measures either by the same individual, by different individuals, at same or different times is called reliability
What is the kings health questionnaire?
Urinary incontinence symptoms and quality of life
26 languages
10 domains
32 questions
100 pts, 5 pt change shows meaning difference
What is it the Bristol Female Lower Urinary Tract (BFLUTS?
Urinary incontinence Symptoms and quality of life, impact on sexual functioning
34 questions
Pelvic Floor Impact Questionnaire
How many questions?
What symptoms?
Long form is 31,
Short form 7
It assess the impact of pelvic floor dysfunction on all of the following areas:
household chores,
physical activities,
movie/concert going,
travel by car or bus > 30min,
participation in social activities away form home,
emotional health, and
feelings of frustration.
Manchester Health Questionnaire
Symptom assessed?
FI questionnaire adapted from kings health questionnaire
What size foley should be placed after cystotomy repair and why?
20fr to avoid obstructing blood clots
% estrogen and %testosterone drop after b/l oophorectomy
estrogen (» 80%) and testosterone (» 50%)
top 3 indications for benign hyst in the USA
1 fibroids, #2 endo, #3 pelvic organ prolapse
7-14% of all benign hyst in the USA are for prolapse
another name for the cardinal ligament?
the ligament of Mackenrodt,
What percentage of patients would decline hysterectomy if presented with equally efficacious alternative?
60%
FDA approved drug for hypoactive sexual desire disorder.
how is it given?
Vyleesi- peptide and acts by activating the melanocortin receptors.
subq injection into the thigh or abdomen
side effects of vyleesi
nausea, pain at injection site, headache, and darkening of skin around gums, face, and breasts
FDA approved drug for hypoactive sexual desire disorder
vyleesi contraindication
HTN
FDA approved drug for hypoactive sexual desire disorder
Why are renal transplant patients at greater risk of Urinary frequency, nocturia, and bladder pain?
one theory is that they are anuria before the transplant and decreased bladder compliance.
then they start making urine after the transplant and the bladder is pissed.
60% of renal transplant patients develop frequency, nocturia and bladder pain
psych med that increases night time urine production?
lithium
other meds: alcohol, caffeine, diuretic, theophylline
definition of nocturnal polyuria
> 1/3 total urine is produced at night
Your patient has nocturnal polyuria and you want to diureses her before bed. What med can you prescribe and what time should she take it?
furosemide at 4-6pm
medical conditions besides DM, peripheral vascular disease, CHF that cause noturnal polyuria
low albumin, hypercalcemia
urethral bulking:
Animal source material that does not require skin testing prior to injection
Porcine dermal collagen (Permacol) does not need skin testing
bovine collagen (Contigen) does
How is skin testing done for bovine collagen urethral bulking?
skin test into the volar aspect of the forearm to be done at least 30 days prior to the urethral injection because 3% of patients will have a reaction indicating a pre-existing sensitivity to bovine dermal collagen through dietary exposure
off market since 2011
Why was Polytetrafluoroethylene (Teflon) removed from market?
bulking agent, removed due to particle migration and granuloma formation in distant organs, Particles size of < 80 micrometers
Durasphere
-What is it?
-What was the second generation modification?
Nonabsorbable carbon-coated zirconium beads suspended in a water-based polysaccaride carrier gel
-decreased particle size due to difficulty injecting large particles through 18 gauge needle. 212 to 500 micrometer–> 90 to 212 micrometers
urethral bulking material that can be injected without cystoscopy
macroplastiq - silicone microimplants
Why was Ethylene vinyl alcohol (Tegress) taken off the market in 2007?
stone formation, urethral erosion,
its a liquid that turns semi-solid when it comes into contact with water within the periurethral tissue cells.
5 indications for SNM
FI, non-obstructive urinary retention, Urgency, frequency, UUI
UDS findings
VLPP and MUCP to dx intrinsic sphincter deficiency
VLPP<60 cm H2O and MUCP <20cm H2O
as in leakage with little vasalva force and weak urethral closure
mnemonic DIAPPERS
Transient causes of urinary incontinence
- Delirium
- Inection- Urinary tract infection or urethritis.
- Atrophic urethritis or vaginitis
- Psychologic
- Pharmaceuticals
- Endocrine / Metabolic (hyperglycemia, hypercalcemia)
- Restricted mobility
- Stool impaction
per AUA guidelines, basic eval for urinary incontinence
history
physical exam
PVR
UA to rule out infection
Steps for the pad test
how much to drink?
how many movements?
how many grams in one hour is postive
Test started without patient voiding first
Subject drinks 500cc (2 cups) of sodium free liquid
Must bend to pick up objects x5, cough x10, stand up x10, wash hands x30min, walks/stairs x30min
If pad saturated- weighed and another pad used
1g may be due to sweating/vag discharge
Change of >4g/ 24 hr is positive (1g/ 1 hour is a positive test)
No high correlation btw weight and UI severity
of leuks needed to dx pyuria by cytometry
By definition, “pyuria” is present when there are >10 leukocytes per MILLILITER on unspun urine by hemocytometer technique.
of leuks needed to dx pyuria by microscopic analysis
By definition pyuria is present when there are >3 leukocytes/HIGH POWER FIELD on unspun urine (by microscopy technique). Microscopy is not as sensitive as cytometry and thus just 3 leukocytes are enough to make the diagnosis of pyuria.
Which bacterial UTI results in false negative nitrite result on UA?
Staphylococcus saprophyticus, Pseudomonas species, or enterococci because they do not have he enzyme to convert nitrates into nitrites
enterobacter is the only bacteria that has the enzyme to convert nitrates into nitrites
Number of hours for bacteria to convert nitrate to nitrite at levels that are reliably detectable
4 hours for bacteria to convert nitrate to nitrite in the urine at levels that can be reliably detected, so the urine dip for nitrites is best done on the 1st void of the morning.
urine must be plated within ________ hours to to avoid exaggeration of CFU and a false positive.
If the urine specimen is not plated on the culture medium within 2 hours then the # of CFU/mL on the culture will be exaggerated and false positive results will be reported.
Number of positives on combined UA dipstick (WBC, RBC, nitrite) needed before treating a symptomatic patient
0, you can treat symptomatic patients even if UA is negative.
you send a urine culture for fungus. how amny hours of “no growth” do you wait before the test is considered negative?
48 hours for fungus
24 for bacteria
Minimum # of CFU/mL for Gram stain of unspun urine to be able to reliably detect bacteria
> 100k, gram stains are for complicated patients and you need an answer NOW
Diagnostic criterion for a positive culture of catheterized urine (how many CFU/ML?)
> 100 CFU/ML
What’s a normal spec gravity?
1.002 and 1.030
What is 45 CFR part 46?
a law for human participant protection and regulation set forth by the US Department of Health and Human Services. This law protects a person from risks in research studies.
list the 4 most common pessaries
ring with support
gelhorn
donut
cube
most common demographic for urethral prolapse (2)
prepubertal black females or postmenopausal white women, should resolve in a few weeks
if persistent–>surgery
Which chromosome has been linked to pelvic floor muscle coding and POP?
9
DLPP for low compliance
< 20 mL/cm H2O
DLPP for hydronephrosis
> 40 cm H2O
cut off for Low VLPP
Low VLPPs (<60 cm H2O)
define polyuria
> 40 mL/kg body weight during 24 hrs or > 2.8 litres of urine in 24 hrs for a woman weighing 70 kg.
causes of Non-relaxing urethral sphincter obstruction (NUSO)
a sacral or infrasacral lesion such as menigomyelocoele, and after radical pelvic surgery
define “pulsion” enterocele
A “pulsion” enterocele results from repetitive chronic increases in intra-abdominal pressure which herniates the culdesac peritoneum and bowel in between the rectovaginal septum and the posterior vaginal wall.
IUGA/ICS mesh complication classification
what are the groupings for time since surgery?
clinically dx: 48 hrs, 48 hr-2months, 2-12 months, over 12 months
IUGA/ICS mesh complication classification
what are the categories (affected organ systems)?
vaginal no epithelial separation/small or equal than 1cm
vaginal larger than 1 cm,
Urinary Tract,
rectum/bowel,
skin/msk/pt compromise
MSK is the highest grade
IUGA/ICS mesh complication classification
what are the pain categories?
FIX THIS CARD
vaginal no epithelial separation/small or equal than 1cm
vaginal larger than 1 cm,
Urinary Tract,
rectum/bowel,
skin/msk/pt compromise
IUGA/ICS mesh complication classification
Site categories
(vaginal suture line, away from suture line, trochar passage, other skin/msk, intra-abdominal)
sample size calculation
you are conducting a 1:1 RCT. What variables do you need for the calculation
n = [(S1 + S2) / (m1 - m2)] / W
W= constant depending on alpha
- mean in the control group
- effect size you are looking for
- Power
- alpha
- Standard deviation if its a continuous variable
Sample size calculation
you will need a larger sample size if the following are true?
( higher/lower) power level chosen,
(larger/smaller) alpha chosen,
(smaller/larger) the difference between the groups being compared (i.e. mean differences)
(larger/smaller) the standard deviation (more spread) within each group
higher power level chosen,
smaller alpha chosen,
smaller the difference between the groups being compared (i.e. mean differences)
larger the standard deviation (more spread) within each group
Calculation for variance
variance is standard deviation squared
calculation for effect size
variance aka standard dev squared…divided by the mean difference between groups
formula to increase sample size for dropouts
sample size divided by 1 minus dropouts
ex. 66/(1-0.1)
Continence is maintained by active and passive forces.
name active forces
- pressure in urethra increases before a cough
- Urethral attachment to pubourethral ligaments and to pelvic floor muscles actively changes the shape of the urethra during filling, coughing, and voiding
Continence is maintained by active and passive forces.
name passive forces
- Coaptation of the urethra because of connective tissue and vascular seal of lamina propria layer - vascular cushions provide ⅓ of resting urethral pressure
- Delancey’s “hammock hypothesis” - connective tissue supports of the posterior urethral wall keep the posterior urethra a stable hammock, pressure of a cough presses the anterior wall into the stable posterior wall thereby closing it an preventing SUI
The blood supply of the distal urethra is from the _______ artery .
The blood supply of the proximal urethra is from the ________ arteries .
vaginal artery
superior and inferior vesicle
Innervation to the urethral striated sphincter is from the __________ nerve
pudendal s2,3,4
bladder bx result
glandular-appearing tubules covered by cuboidal cells with normal appearing nuclei
dx?
nephrogenic ademona
-seen in patients with repeated trauma to the bladder (stones, rUTI, indwelling cath, etc)
what is the biggest risk factor for bladder cancer?
aryl amines, rubber, coal, β-naphthylamine, benzidine
and cigarettes
what makes a UTI complicated?
12
pregnant, elderly, diabetic, obstructed, stone, neurogenic bladder, renal insufficiency, immunosuppression, atypical sx, recurrent infxn, persistent infxn, functional/metabolic/anatomic condition that increases risk of tx failure
rUTI
how long should you do daily ppx?
6 months then stop and see if they recur.
can restart ppx if recurs
rUTI
What’s the dosage and frequency for the following daily ppx meds?
Nitrofurantoin TMP-SMZ (40/200) or (80/400) TMP Cephalexin Fosfomycin Ciprofloxacin
Nitrofurantoin 50 mg or 100 mg nightly
TMP-SMZ (40/200) or (80/400) nightly or three times per week
TMP 100 mg nightly
Cephalexin 125 mg or 250 mg nightly
Fosfomycin 3 grams every 10 days
Ciprofloxacin 250 mg twice per week - least common regimen
persistent UTI with the same bacteria
what’s your plan? meds and dosage?
CT scan or ultrasound for structural problem like stones
Cipro 400 mg IV then Cipro 500 mg bid for 7 days Cipro 500 mg bid for 7 days Levofloxacin 750 mg daily for 5 days
Whats a fever in Celsius?
38 degrees
What is a staghorn calculus?
stones that include the renal pelvis and extend into at least 2 calyces.
Staghorn calculi are most often composed of ___________
struvite (or magnesium ammonium phosphate)
80% of stones are composed of __________
calcium oxalate
most common location for renal stone obstruction
ureteropelvic junction
most common bacterial UTI associated with struvite stones (mag ammonium phosphate)?
beside proteus which is the most common
Pseudomonas
Providencia
Klebsiella
Staphylococcus
three reasons to have stone analyzed after a 24hr urine collection
multiple calculi,
recurrent calculi,
stone in young person (<40 yrs)
Macrobid
common side effects?
rare side effects?
Nitrofurantoin
common SE: flatulence, nausea, headache
rare toxicity: pulmonary hypersensitivity, chronic hepatitis, peripheral neuropathy, hemolytic anema
Bactrim
common side effects?
rare side effects?
TMP-SMZ
common SE: photosensitivity, hematologic complications (neuropenia, thrombocytopenia), urticaria, rash, nausea, vomitting, anorexia
rare toxicity: Steven-Johnson syndrome, toxic epidermal necrosis, fever
Ciprofloxacin
common side effects?
rare side effects?
Ciprofloxacin
common SE: insomnia, restlessness, headache, drowsiness, nausea, vomitting, diarrhea rare toxicity: Achilles tendon rupture, seizures, confusion
why is nitrofurantoin contraindicted in patients over 65yrs old?
- nitrofurantoin is not effective in patients with creatining clearance of less then 40 mL/min^2
- reduced renal function puts older patients at higher risk of drug accumulation
- older patients have a higher risk of having the side effects of nitrofurantoin
risk factors for fungal UTi (5)
prior antibiotic therapy,
presence of an chronic indwelling catheter,
diabetes mellitus,
renal transplant,
immunocompromised condition.
What are Tamm-Horsfall protein?
protein in the renal tubules of the outer medula that bindto bacteria and allow them to wash out in the urine
what are the three gram + bacteria associated with UTIs?
Staphlyococcus saprophyticus is the most common (Enterococcus faecalis
Streptococcus agalactiae, aka GBS) usually represent contamination if isolated from a voided urine sample.
why do elderly patients have more urine production at night?
ANP increase with age and this lead to increased urine production at night.
when should you use Spearman’s rank?
Spearman’s rank is a measure of correlation between two non-normally distributed variables and thus gives a correlation coefficient.
When to use each of the following tests?
one way ANOVA
two way ANOVA
Difference between means (medians) of ≥ 3 groups
normally distribution, comparing one or 2+ factors,
most common cause of gross hematuria in a 9 year old:
IgA nephropathy
your hematuria patient needs CT urogram, but is allergic to contrast.
Name alternative test option.
non-contrast CT with retrograde pyleogram
describe the three components of urethral resting pressure.
- submucosal vascular cushions
- smooth urethral sphincter muscles
- striated urogenital sphincter (extrinsic urethral sphincter mechanism - compressor urethrae, urethrovaginal sphincter, and sphincter urethrae)
Components of the urethral sphincter
Which layer is used from continence?
Which layer is used for micturition?
thin outer circular layer increases urethral resistance
thick inner longitudinal layer facilitates micturition when stimulated.
which two parts of the female urinary tract contain squamous epithelium?
trigone, distal urethral
all the rest is transitional epithelium
What is the line of Hart?
keratinized squamous epithelium external to the vestibule and the nonkeratinized squamous epithelium lying within the vestibule and vaginal canal.
What is the ileopectineal ligament?
coopers ligament
burch connects coopers and pubocervical fascia
what are the components of the pelvic diaphragm?
levator ani (IC, PR, PC) and coccegyeus muscles
What are the subdivisions of the pubococcygeus muscle?
puboperineal, pubovaginalis, puboanalis
What are the components of the levator plate?
where the levator muscles meet in the midline
What are the borders of the presacral space?
superior- aortic bifurcation
inferior- pelvic floor
anterior- rectosigmoid
posterior-sacrum
right lateral-urethers and internal illiac vessels
left lateral-left common iliac vein
Senior living facilities
If a patient has impaired ADLs and IADLs, which type of facility should they be discharged to?
SNF
Senior living facilities
If a patient has normal ADLs, but impaired IADLs, which type of facility should they be discharged to?
Assisted Living facility
Senior living facilities
If a patient has impaired ADLs and IADLs, which type of facility should they be discharged to?
SNF
Senior living facilities
If a patient has normal ADLs AND normal IADLs, which type of fac
Independent living facility
out to in TOT muscles
skin → subcutaneous fat → Gracillis → Adductor brevis → ±Adductor magnus → Obturator externus → Obturator membrane → Obturator internus → pubocervical “fascia” (periurethral fascia) –> index finger.
Senior living facilities
If a patient has impaired ADLs, but the spouse has normal ADLs and IADLs, where can they go together?
Continuing Care retirement community
MAKE CARDS FOR PELVIC SPACES
REVIEW WK ON MESH CONTROVERSY
rectal prolapse surgeries
out to in TOT muscles
skin → subcutaneous fat → Gracillis → Adductor brevis → ±Adductor magnus → Obturator externus → Obturator membrane → Obturator internus → pubocervical “fascia” (periurethral fascia) –> index finger.
layers of the urothelium
GAG
umbrella cell stratum-covered in a protein called uroplain that E. coli attach to
intermediate cell stratum
basal cell stratum
basil lamina
out to in TOT muscles
skin → subcutaneous fat → Gracillis → Adductor brevis → ±Adductor magnus → Obturator externus → Obturator membrane → Obturator internus → pubocervical “fascia” (periurethral fascia) –> index finger.
how does bactrim affect coumadin?
increases coumadin levels
reduces coumadin metabolism
decreases serum protein binding
changes CYP2C9/10 enzyme activity
risk of stone formation in diverticulum?
10%
Most common diverticula symptoms
Recurrent urinary tract infections
Stress urinary incontinence
Incomplete voiding
Dysuria
Urgency
Urgency incontinence
4 stages of wound healing
Stages of wound healing are:
- hemostasis or coagulation
- Inflammation
- proliferation and fibroplasia (oxygen and nutrient sensitive phase)
- remodelling and maturation
Vaginal injury occurs with __________ rads of cumulative radiation
> 8000 rads
