Genitourinary #1 Flashcards
Urge Incontinence
-Pathophysiology
-Management Order
-Patho: Detrusor muscle overactivity
-Mgmt:
1) Bladder training (voiding diary, decrease fluid intake)
2) Diet (avoid alcohol, caffeine, spicy, chocolate)
3) Kegel exercises
4) Antimuscarinics (Tolterodine, Oxybutynin)
5) Mirabegron
6) Botox injections, bladder augmentation
Overflow incontinence
-Pathophysiology
-Etiologies
-Symptoms
-Diagnostics (GOLD)
-Management
-Patho: Detrusor muscle under activity (impaired contractility)
-Etiologies: MC in neurological disorders (DM, MS, spinal injuries). Also bladder outlet obstruction (BPH, uterine fibroids, prolapse)
-Symptoms: loss of urine w/o warning, leakage, dribbling, hesitancy, frequency, loss with changes in position
-Diagnostics: Post void residual > 200mL
-Management: Intermittent indwelling catheterization (first line), Cholinergics (Bethanechol) increases detrusor muscle activity
Stress Incontinence
-Pathophysiology
-MC type of…
-Etiologies
-Symptoms
-Management
-Leakage of urine when abdominal pressure > urethral pressure during coughing, straining, sneezing, etc.
-MC type of incontinence in young women
-Etiologies: laxity of pelvic floor muscles (childbirth, surgery, postmenopausal) OR urethral hyper mobility (insufficiency support from pelvic floor muscles)
-Symptoms: urine leakage, no urgency prior to leakage
-Management: Kegel exercises (initial TOC), lifestyle modifications (weight loss, no smoking, pads, drink less). Pessaries. Midurethral sling (definitive)
Uterine Prolapse (uterine herniation into the vagina)
-Risk Factors
-Symptoms
-RF: Weakness of pelvic floor muscles (childbirth, obesity, multiple births, heavy lifting, loss of estrogen in postmenopausal state)
-Symptoms: vaginal fullness, heaviness sensation, low back pain, abdominal pain, urgency, frequency, stress incontinence
Uterine Prolapse
-Grades
-Management
-Grade 0: no descent
-Grade 1: uterus descent into upper 2/3 of vagina
-Grade 2: cervix approaches the introitus
-Grade 3: cervix outside the introitus
-Grade 4: entire uterus outside the introitus
-Management: pessaries, surgical (hysterectomy or sacrospinous ligament fixation)
Peyronie Disease
-What is it?
-Symptoms
-Management (depends on the curvature degree)
-Fibrotic changes of tunica albuginea leads to abnormal penile curvature
-Symptoms: penile pain, curvature, shortening, sexual dysfunction
-Management: urologist referral.
–Observation: if curvature 30’ or less
–Oral pentoxifylline or intralesional injection collagenase (Clostridium histolyticum) if 30 degrees or more, > 3 months, or sexual dysfunction.
Vesicoureteral Reflux
-What is it?
-MC type
-Symptoms (prenatal vs postnatal)
-Diagnostics
-Management
-Retrograde passing of urine from bladder into the upper urinary tract
-Primary (MC Type): inadequate closure or incompetent UVJ
-Symptoms: hydronephrosis on prenatal US, febrile UTI if postnatal
-Diagnostics: Renal and bladder US (initial), Voiding cystourethrogram (DOC)
-Mgmt:
–Grades I and II: observation and ABX to avoid recurrent UTI.
–Grades III and IV: surgical correction
Acute Cystitis
-Pathophysiology
-Risk Factors
-What makes it complicated?
-Etiologies
-Patho: Ascending infection of lower urinary tract from urethra
-RF: Sex in women, pregnancy, elderly, DM, immunocompromised, indwelling catheter
-Complicated: symptoms > 7 days, males, elderly, pregnant, DM, immunocompromised, catheter use
-Etiologies
–E. Coli (MC)
–Enterococci with indwelling catheters
Acute Cystitis
-Symptoms
-Diagnostics
-Symptoms: irritative symptoms (dysuria, urgency, frequency), hematuria, suprapubic pain, tenderness
-Diagnostics
–UA: pyuria (>10 WBC’s/hpf), hematuria, cloudy urine, nitrites
–Urine culture: definitive
—Do culture if complicated UTI
Acute Cystitis Treatment
-Uncomplicated (1st and 2nd line)
-Adjunct
-Complicated
-If Pregnant…
-Uncomplicated: Nitrofurantoin, Bactrim, or Fosfomycin (first line). Fluoroquinolones (-oxacin) if sulfa allergy.
-Adjunct: increase fluid intake, void after sex, Hot sitz baths
-Complicated: Fluoroquinolones PO or IV, Aminoglycosides (-micin or -mycin) x 7-10 days
-Pregnancy: Amoxicillin, Augmentin, Nitrofurantoin (NO BACTRIM, AMINO, FLUORO, or DOXY)
When should you treat asymptomatic bacteriuria?
-Pregnant, history of hip arthroplasty
Pyelonephritis
-MC etiology
-RF
-Symptoms (think BOTH)
-Diagnostics
-E. Coli MC etiology
-RF: DM, history of recurrent UTI’s, pregnancy
-Symptoms: upper tract symptoms (fever, chills, back/flank pain, nausea, vomiting). Lower tract symptoms (dysuria, urgency, frequency). CVA tenderness, fever, tachycardia.
-Diagnostics
–UA: Pyuria (>10 WBCs/hpf), Nitrites, hematuria, cloudy urine, bacteriuria, WBC casts
-CBC: leukocytosis with left shift
-Culture: Definitive diagnostic
What is HALLMARK for pyelonephritis on UA?
WBC Casts**
Pyelonephritis Treatment
-Outpatient
-Inpatient
-Pregnancy
-Outpatient: Fluoroquinolones (1st line)
-Inpatient: 3rd or 4th gen Cephalosporin, Fluoroquinolones, Aminoglycosides
-Pregnancy: IV Ceftriaxone
Urethritis
-MCC of Non-Gonoccocal Urethritis?
-Symptoms
-Diagnostics
–Most sensitive
–Gram stain (no organisms vs gram-negative diplococci)
-Chlamydia Trachomatis MCC of NGU
-Urethral discharge, pruritus, dysuria, abdominal pain or abnormal vaginal bleeding
-Gonorrohea: abrupt onset of symptoms, opaque/white/yellow/clear thick discharge
-Diagnostics
–NAAT (most sensitive). First void or first catch urine.
–Gram Stain: no organisms seen is suggestive of NGU.
–Gram-negative diplococci = Gonorrhea
Urethritis Treatment
-Gonorrhea: Ceftriaxone 250mg IM x 1 dose PLUS Azithromycin 1g x 1 dose
-Chlamydia: Azithromycin or Doxycycline
30% have co-infection with both, so treat both most times.
Prostatitis
-prostate gland inflammation secondary to ascending infection
-Etiologies of Acute
-Etiologies of Chronic (>3 months)
-Symptoms
–General
–Acute vs Chronic
-Acute
– > 35 years old: E. Coli
– < 35 years: Chlamydia and Gonorrhea
–Children: Viral (Mumps MCC)
-Chronic: E. Coli, Proteus
-Symptoms
–General: irritative voiding symptoms (Frequency, urgency, dysuria). Obstructive voiding symptoms (hesitancy, poor stream, straining, incomplete emptying)
–Acute: fever, chills, perineal pain, lower pain.
–Chronic: recurrent UTI’s, malaise, symptoms milder. NO FEVER
Prostatitis
-Exam Findings
-Diagnostics
-Management
-Boggy prostate
–Acute: exquisitely tender, boggy
–Chronic: usually contender, boggy
-Diagnostics: UA and culture (pyuria and bacteriuria in acute). Avoid prostatic massage in acute because it can lead to bacteremia. May massage in chronic to increase bacterial yield.
-Treatment
–Acute > 35: Fluoroquinolones or Bactrim x 4-6 weeks (outpatient)
—IV Fluoro if hospitalized
–Acute < 35: Ceftriaxone + Doxy/Azithro
–Chronic: Fluoroquinolones of Bactrim x 6-12 weeks
–Refractory: TURP
Epididymitis
-Etiologies
–Males 14-35
–Men > 35
-Symptoms
-Exam Findings
-Diagnostics
-Treatment
-Males 14-35: Chlamydia and Gonorrhea
-Men > 35: E. Coli
-Symptoms: Gradual onset of testicular pain and swelling. Groin, flank, abdominal pain. Fever, chills, irritative symptoms.
-Exam Findings: scrotal swelling, tenderness. Testis in vertical position. Positive Prehn Sign. Positive (normal) cremasteric reflex.
-Diagnostics: Scrotal US (best initial) = enlarged epididymis, increased testicular blood flow.
–UA: Pyuria and bacteriuria
–NAAT for STI’s
-Management: scrotal elevation NSAIDs, cool compresses
–< 35: Doxy + Ceftriaxone or Azith + Ceftriaxone
-> 35: Fluoroquinolones (Cipro, Oflox, Levo)
Orchitis
-MCC
-Symptoms
-Management
-Viral (Mumps MCC)
-Scrotal pain, swelling, tenderness, scrotal erythema, tenderness.
-Management: Symptomatic (NSAIDs, bed rest, scrotal support, cool packs)
Testicular Torsion
-Pathophysiology
-Symptoms
-Insufficient fixation of lower pole of testis to tunica vaginalis (bell-clapper deformity) leads to increased mobility of the testis.
-Abrupt onset of scrotal, inguinal, or lower abdominal pain.
-Swollen, tender high-riding testicle.
-Negative Prehn Sign
-Negative (absent) Cremasteric reflex
Testicular Torsion
-Diagnostics
-Management
-Diagnostics:
–Emergent surgical exploration (definitive) = preferred over US if likely diagnosis.
–Testicular Doppler US: decreased or absent testicular blood flow
–Radionuclide scan: most specific, but not often used.
-Mgmt: Urgent detorsion and orchiopexy ideally within 6 hours of pain onset (irreversible damage after 12 hours of ischemia).
