Genitourinary and Gynecological issues and disorders Flashcards
Involuntary urination occurs at an age when voluntary control should be present
Enuresis
Involuntary urination: Children who have never established control
Primary Enuresis
Involuntary urination: Dry for more than six to 12 months and begin wetting
Secondary
Involuntary urination: Incontinence during sleep
Nocturnal enuresis
Involuntary urination: Occurs during waking hours
Diurnal enuresis
Incidence:
The incidence of enuresis is difficult to assess; however, the estimated rat are:
Up to ___% in 3-year-olds
40%
Incidence:
The incidence of enuresis is difficult to assess; however, the estimated rat are:
Up to ___% in 5-year-olds
10%
Incidence:
The incidence of enuresis is difficult to assess; however, the estimated rat are:
Up to ___% in 10-year-olds
3%
Incidence:
The incidence of enuresis is difficult to assess; however, the estimated rat are:
Approximately ____% of cases are functional
95%
Signs and symptoms of enuresis:
HIstory of _____ wetting
bed
Laboratory/ diagnostics:
- ______
- Urine culture
- Urinalysis
Management:
_______ enuresis
a. Enuresis alarm, positive reinforcement such as
utilizing a star chart
b. Bladder control training (geared toward training the
bladder to hold more urine)
Functional enuresis
Managment:
Functional enuresis
c. Medications:
i. _______ 25 mg daily one hour before bedtime
time one week
ii. Desmopressin (DDAVP): available orally
iii. Oxybutynin (Ditropan): if less than six years for
detrusor muscle hyperactivity associated with
neurological disorders (spina bifida); 5 mg may be
given twice a day to a maximum of 5 mg three
times daily
c. i. Imipramine
Management for enuresis: Treat urinary tract _____ (__) if indicated
Urinary tract infection (UTI)
Bacterial infection and inflammation of the urinary tract are more common in males (uncircumcised) in the first year of life. Increases are seen in females at a 10: 1 ratio throughout the lifespan.
Urinary tract infection
Both the male and female UTI in childhood are typically caused by the following organism
a. ___ ___ 80 to 90%
b. _____ _____
a. E. Coli
b. Staphylococcus aureus
Predisposing factors include urinary _____, congenital or acquired obstructive lesions, non-obstructive causes ( e.g. neurologic bladder, poor hygiene, constipation, and sexual intercourse)
stasis
High-grade ______ reflux (VUR) may result in renal scarring, eventual hypertension, and renal failure related to urinary tract infection
vesicoureteral
Signs and symptoms of UTI in Infant include:
a. May have ____ signs or symptoms
b. Weight loss, FTT
c. dehydration
d. irritability
no
Signs and symptoms of UTI in children and adolescents include:
a. dysuria
b. _______
c. urgency
d. nocturia
e. suprapubic/ lower abdominal discomfort
f. hematuria
g. fever
b. frequency
Laboratory/ diagnostics for UTI:
a. A straight catheter (cath) or bladder tap for
culture/sensitivity is indicated in those who cannot void
voluntarily [ clean catch may be used for mild symptoms
or follow up]
b. UA: Leukocytse, ______, nitrites
c. ______ in the complete blood count (CBC)
b. erythrocytes
c. Leukocytosis
Management of UTI:
- Oral antibiotics for 10 to 14 days
a. [trimethoprim/sulfamethoxazole
b. Cephalosporins
c. Amoxicillin
d. Sulfisoxazole
e. ___________
- e. Nitrofurantoin
UTI:
Follow up in ___ days; change antibiotics if no improvement is seen.
Follow up in one to two weeks, then every one to three months for one year
two
Note: Children < ____ months of age with UTI should be hospitalized for parental antibiotics
2 months
Management for UTI:
a. Febrile infants
b. children 2 to 24 months
______ is indicated if ultrasound abnormal
Antimicrobial prophylaxis is not indicated
VCUG
A relatively common congenital abnormality in which the urethral opening is on the ventral surface (underside) of the penis
Hypospadias
a. The etiology is unclear; currently hypothesized to be a
deformity rather than a malformation
b. Occurs in 8.2: 1,000 live births or 1: 300 male infants;
often familial
c. Likelihood of other genitourinary (GU) anomalies such as
undescended testicles, inguinal hernia. or hydrocele is
noted
Hypospadias
Signs and symptoms of hypospadias
- Dorsally hooded foreskin (classic finding)
- urinary stream that aims downward
- _______ (ventral bowing of the penis)
- Chordee
Laboratory/ Diagnostics: hypospadias
- ___ lab test
- Diagnosis is made by clinical findings
No
Management: hypospadias
- Referral to a urologist at birth
- circumcision must ____ ___done (Foreskin is used in repair)
- Surgery is best done around 6 to 12 months of age
- not be
Absence of one or both of the testes from the scrotal sac due to failure to decent from the abdomen in utero
1. Occurs in 3% of newborn males and 20 to 30% of the
premature male newborn (descent normally occurs
during the last trimester)
Cryptorchidism (Undescended Testes)
Signs and symptoms of cryptorchidism
- Inability to palate ______
- Often no symptoms
- testicle
Laboratory/ diagnostics: cryptorchidism
- None typically
- If bilateral, karyotyping for _______ abnormalities may be ordered
- chromosomal
Management: cryptorchidism
- If undescended at ___ years refer to urology
- Testicular self- examination (TSE) for increased testicular cancer probability
- 1 year
Twisting and strangulation of the spermatic cord characterized by acute pain; constitutes a surgical emergency to prevent necrotic testicle and infertility
Testicular torsion
Cause/Incidence of Testicular Torsion:
1) Occurs most often in ____ to __ age group
2) Does not represent an infectious process
3) Interruption of the vascular flow produces acute pain
10 to 20 age group
Signs and symptoms of Testicular torsion:
1) Acute onset creates profound pin
2) Lack of irritative voiding symptoms
3) No systems symptoms and no fever
4) The affected testis may have a “ high lie”
5) Pain is not relieved by elevating scrotum
6) Absent __________ reflex
6) cremasteric
Stroking inner thigh results in retraction of the testicle on the same side
Creamateric reflex
Laboratory/ diagnostics: Testicular torsion
1) ______ in primary care
1) None
Management of Testicular torsion:
1) Refer for emency _______ intervention
surgical
Pain and cramping associated with menstruation?
Dysmenorrhea
________ dysmenorrhea
a) Absence of any pelvic pathology; is most commonly seen in adolescents
b) The etiology of _______ dysmenorrhea is believed to be hormonal and endocrine-related
c) Most causes of _____ dysmenorrhea begin 6 to 12 months after menarche, who symptoms gradually increasing until patients are in their mid-20s.
Primary
________ dysmenorrhea results from an underlying cause wich as pregnancy, pelvic inflammatory disease (PID), and endometriosis
Secondary
Signs and symptoms of dysmenorrhea include:
1) Painful menses
2) Lower abdominal pain associated with menstruation, usually worse in the first few days of bleeding
3) Associated pain
4) May be nausea, vomiting, fatigue, headache, and diarrhea
3) back
Laboratory/ diagnostics for dysmenorrhea include:
a) ______ dysmenorrhea: No testing necessary; diagnosis is made clinically
b) Testing for ____ dysmenorrhea: according to the suspected underlying cause
a) Primary
b) Secondary
Management of dysmenorrhea include:
1) Education about menstruation proper diet
2) Support measure:
a) Heat application
b) Psychological support
c) Over the counter (OTC) analgesics, preferably
________: 400 mg every four to six hours, beginning
at the onset of the menstrual cycle and continuing for
2 to 72 hours
3) Stronger non-steroidal anti-inflammatory drugs (NSAIDs) for moderate to severe dysmenorrhea
4) Oral contraceptives
5) Referral as needed
2) c) ibuprofen
A parasitic sexually transmitted disease, intracellular obligate which closely resembles a gram-negative bacteria; produces serious reproductive tract complications in with sex
Chlamydia
Causes/ Inceidnece of this STD. It occurs from Chlamydia trachomatous
Chlamydia
Most common bacterial STD in the United States.
Chlamydia
Over four million infections annually from this STD?
Chlamydia
Remains the most common cause of cervicitis and urethritis in adolescents
Chlamydia
Signs and symptoms of Chlamydia include:
1) Female often _______
a) Dysuria
b) intermenstrual spotting
c) postcoital bleeding
d) dyspareunia
e) vaginal discharge
f) lower abdominal and pelvic pain
g) rectal tenesmus
1) asymptomatic
Signs and symptoms of Chlamydia include:
2) Male often asymptomatic
a) Dysuria
b) thick, cloudy, penile discharge
c) testicular pain
d) rectal __________
2) d) tenesmus
Laboratory/ diagnostics of Chlamydia include:
a) Culture is most definitive but takes three to nine days
b) ______ _____ (__) for screening: Results in 30 to 120 minutes; low cost
b) Enzyme immunoassay (EIA)
Management of Chlamydia include:
1) _______ (_____) one gram orally in single dose or:
2) _______ (______) 100 mg orally twice a day for seven days
3) _____, ______, or _______ if pregnant
1) Azithromycin (Zithromax)
2) Doxycycline (Vibramycin)
3) Azithromycin, erythromycin, or amoxicillin
A bacterial STD caused by Neisseria gonorrhoeae (gram-negative diplococci); the organism may be cultured from the genitourinary tract, oropharynx, conjunctiva and or anorectal
Gonorrhea
Cause/ Incidence of Gonorrhea include:
1) Causes urethritis in men and cervicitis in women
2) Leading cause of ______ among females
2) infertility
Signs and symptoms of Gonorrhea include:
1) Females are often asymptomatic (____%)
a) Dysuria
b) Urinary frequency
c) Mucopurulent vaginal discharge
d) Labial pain/ swelling
e) Lower abdominal pain
f) fever
g) ____________
h) nausea/ vomiting
1) 80%
g) dysmenorrhea
Signs and symptoms of Gonorrhea include:
2) Male is often asymptomatic
a) Dysuria
b) Frequency
c) _____/__________ penile discharege
d) Testicular pain
c) White/ yellow-green
Laboratory/ diagnostics for Gonorrhea:
1) Gram stain of discharge shows gram-_____ ______ and white blood cells (WBCs)
2) Clerical culture for N.gonorrhoeae using Thayer-Marting or Transgrow media
1) negative diplococci
Management of Gonorrhea infection include:
1) _____________ intramuscular single dose
2) _______ ( ___) 1 gram orally x 1 dose to cover for chlamydia
3) ________ 100 mg orally x2 daily for seven days
4) Co- treat for chlamydia
5) All contact should be treated
6) Report to the health department
1) Ceftriaxone (Rocephin)
2) Azithromycin ( Zithromax)
3) Doxycycline
A sexually transmitted disease involving multiple organ systems and caused by Treponema pallidum a spirochete; the causative organism may be transmitted across the placenta
Syphilis
_______: Typical lesion or nearly positive syphilis screen
a) dark-field micsopy show treponemes in 95% of chances
Primary
________: clinical presentaiton with strongly reactive syphilis screen
Secondary
Latent _______: serologic evidence of untreated syphilis
Tertiary
_________
a. Chancre presents at the site of inoculation two-six weeks after exposure
b. Chancre indurated and painless
c. Regional lymphadenopathy
Primary
_______ syphilis
a) Seropositive, but asymptomatic
b) About 1/3 of untreated cases develop ____syphilis
Latent
b) tertiary
_________
a) Occurs six to eight weeks later
b) Flu-like symptoms
c) Generalized lymphadenopathy
d) Generalized maculopapular rash, especially on the palms and soles
Secondary
_________
a) Leukoplakia
b) Cardiac insufficiency: aortic, aneurysms, aortic regurgitation
c) Infiltrative tumors of skin, bones, liver
d) Central nervous system (CNS) involvement: meningitis, hemiparesis, hemiplegia, others
Tertiary
Serologic test: syphilis
1) Screening with non-________ antibody test: Veneral disease research laboratory (VDRL) and/ or rapid plasma reagin (RPR)
2) Confirmed with treponemal tests
a) Fluorescent treponemal Antibody Absorption (FTA-
ABS): Following the non- treponemal screen.
b) Microhemagglutination Assay for Antibody to
Reeponema Pallidim (MHA-TP)
1) treponemal
Management of Syphilis is:
a) ____________________
a) Benzathine Penicillin G
Management of Syphilis with PCN allergy is?
a) ___________
b) ___________
a) Doxycycline
b) Erythromycin
Syphilis _______ all cases to the health department
report
A vaginal infection in which several species of bacteria interact to alter the vaginal flora
Bacterial Vaginosis
Cause/ Incidence: bacterial Vaginosis
1) Increased pH and decreased __________
2) Most prevalent vaginal infection in women of reproductive age
3) ______ considered an STD/STI; seen more often in sexually active women
1) lactobacilli
3) Not
Signs and symptoms of bacterial vaginosis
a) increased ____ discharge
b) may have pruritus
c) Malodours “_____” discharge most evident after sexual intercourse
d) Cervicx/uterus/ adnexa within normal limits
a) milky
c) fishy
Laboratory/ Diagnostics for bacterial vaginosis
1) Wet mount
a) ____ cells: Epithelial cells covered with bacteria appear stippled (small dots or specks) with poorly defined borders
b) decreased/ absent lactobacilli
c) Few or absent WBC
2) Positive amine “whiff” test (fishy odor when potassium hydroxide (KOH) added to slide)
1) a) Clue cells
Laboratory/ Diagnostics for bacterial vaginosis
2) Positive amine “____” test (fishy odor when potassium hydroxide (KOH) added to slide)
2) “whiff”
Treatment for bacterial vaginosis:
1) ________ PO
2) ________ PO
3) Intravaginal ______ or _______
1) Metronidazole
2) Clindamycin
3) metronidazole or clindamycin
A recurrent, viral sexually transmitted disease that is associated with painful lesions
Herpes
Herpes-type ____: Found on the lips, face, and mucosa
Type 1
Herpes-type ____: Found on the genitalia
Type 2
Transmission by _____ contact with active lesions or by circus containing fluid (e.g. saliva or cervical secretions)
direct
Signs or symptoms for ______
1) Initial Fever, malaise, dysuria, painful/ pruritic ulcer for 12 days
2) Recurrent: Less painful/ pruritic ulcers for 5 days
Herpes
Laboratory/ diagnostics for herpes include?
- _____ or Tzanck stain
- ____ _____ is most diefinitivae
- Papanicolaou
2. Viral culture
Managment of herpes include?
1. _____ _____ treatment
2. Symtomatic treatment with drying and antipruiritic agents
3. Treatment options
a. ______ topical, oral, IV
b. ________ especially useful for asymptomatic viral
shedding of HSV-2
- No curative treatement
- a. Acyclovir ( Zovirax)
b. Valacyclovir
A disorder characterized by immunodeficiency as the result of infections by the human immune deficiency virus
Acquired Immune deficiency syndrome (AIDS)
Mode of transmission typically with AIDS is how?
Maternal infant perinatal transmission
______ is primary postanatl vertical route
Breastfeeding
Signs and symptoms of ______ include
a) Low birth weight and the falling ratio of head circumference to height/weight
b) Recurrent infections
c) diminished activity
d) developmental delay
e) hepatosplenomegaly, generalized lymphadenopathy
Acquired Immune deficiency syndrome (AIDS)
Screening in infants
1) ____ birth weight and a falling ration of head circumference to height /weight
2) recurrent infections
3) diminished activity
4) developmental delay
5) hepatosplenomegaly, generalized lymphadenopathy
1) Low
Laboratory/ diagnostics Screening in infants for HIV includes?
HIV polymerase chain reaction (PCR)
In older children, the ____-____ _____ ____ (___) screening is used (sensitivity >99.9%)
enzyme-linked immunosorbent assay (ELISA)
Confirmatory test for laboratory AIDS?
The western blot test is confirmatory
Progress towards AIDS
a) absolute CD4 lymphocyte count: Normal > ____ cells/uL
b) CD4 lymphocyte percentage of WBC
1) Risk of progression to AIDs high when < ___%
c) Viral load ideally, should be < 5000 copies, or “ zero” or “undetectable”
a) >800 cells/uL
b) 1) < 20%
Management of opportunistic infections with AIDS
a) ____ for pneumocystis pneumonia (Pneumocystis jiroveci) preventions
b) Monitor for ____
a) Bactrim
b) CMV
Management of AIDS with antiretroviral treatment
a) combination treatment : With ______ _____ (___)
b) Start no later than when the patient has a CD4 of 350uL
c) Drug resistance may develop readily; teach to take the medication exactly as prescribed: at the same time every day
d) Referral to an HIV infectious disease specialist
a) antiretroviral therapy (ART)
Management of Menopause?
a) Hormonal therapy
ii) Estrogen: Conjugated estrogen (_____), estradiol
(Estrace, Estraderm, Climara), Estrone sulfate
Premarin
Management of Menopause:
b) ______: cyclic or continuous (not necessary if hysterectomy)
Progestin
Management of Menopause:
c) ______, calcium supplementation (recommended in the present and absence of estrogen), and diet if HT is contraindicated or refused
c) Exercise
Management of Menopause:
d) Benefits/ risk must be made based on the three major possible concerns in family history:
i) _____ cancer
ii) Myocardial infarction/ CAD
iii) Uterine cancer
i) Breast cancer
Change of bone structure due to graduation in quantity, rather than composition, resulting in an abnormally low bone mass leading to increased risk of fractures
Osteoporosis
____ sexes experience a bone loss with again (type 2 osteoporosis)
Both
Osteoporosis in menopause results from the loss of stronger (type ___ osteoporosis)
1
___ of bone loss is due to hypoestrogenic states rather than to the aging process itself
3/4
In younger women, screen for the female athlete triad:
a) Eating disorders and/ or excessive exercise lead to:
b) ________ which least to :
c) Decreased amounts of estrogen, resulting in bone loss
b) Amenorrhea
Risk factors of Osteoporosis:
a) Female, white, or ______
b) Elderly
c) Early menopause
d) Estrogen deficiency
e) The small frame or underweight
f) Family history
g) High consumption of caffeine, phosphate, protein, sodium
h) smoking
i) Low intake of dietary calcium
j) Sedentary lifestyle
k) Alcoholism
a) Asian
Medication like _____ _____, corticosteroids, anticonvulsants are risk factors that lead to osteoporosis
thyroid hormone
Certain disease (e.g. thyroid and parathyroid conditions, ____ _____, liver dysfunction, intestinal malabsorption, COPD) lead to osteoporosis
kidney disease
Testing for osteoporosis:
a) __________________________
i) Measures amount of bone tissue in the hip, spine,
wrist, and ankle
ii) results are reported as T and Z scores
a) T score is the number of standard deviations (SD)
around the mean bone density for race and enter
b) The Z score compares the patient with population
adjusted for gender, age, and race
Dual-energy x-ray absorptiometry (DEXA)
Testing for osteoporosis:
a) Dual-energy x-ray absorptiometry (DEXA)
i) Measures amount of bone tissue in the hip, spine,
wrist, and ankle
ii) results are reported as _____ scores
a) ___score is the number of standard deviations (SD)
around the mean bone density for race and enter
b) The Z score compares the patient with population
adjusted for gender, age, and race
ii) T and Z
a) T
Testing for osteoporosis:
a) Dual-energy x-ray absorptiometry (DEXA)
i) Measures amount of bone tissue in the hip, spine,
wrist, and ankle
ii) results are reported as ____ scores
a) T score is the number of standard deviations (SD)
around the mean bone density for race and enter
b) The ___ score compares the patient with
population adjusted for gender, age, and race
ii) T and Z
b) Z
Testing for Osteoporosis with T score :
a) T score: _____ SD normal
> -1.0
Testing for Osteoporosis with T score :
b) Between _________ is osteopenia (now called “low bone mass”)
-1.0 to -2.5
Testing for Osteoporosis with T score :
c) below _____is osteoporosis
-2.5
Bone density testing recommendations
a) All women ___ years of age
b) all postmenopausal women < 65 years of age with one or more additional risk factors:
i) Family history
ii) Smoking
iii) Excessive exercise
iv) excessive alcohol use
v) Corticosteroid use
vi) Hyperthyroidism
vii) slender body size
c) Postmenopausal women with fractures
d) Patients considering treatment for osteoporosis for decision making
e) Women on hormone therapy for extended periods of time
> 65
Prevention:
1) Estrogen replacement therapy (as above)
2) Avoiding known risk factors
3) Weight exercise to strengthen bone
a. ______ ___ of moderate exercise 3 to 5 times a
week
b) Walking, jogging, dancing, climbing stairs, aerobics,
strength training
4. Increase calcium intake or supplementation (see chart
below; exact numbers may slightly vary)
30 minutes
Calcium Recommendation/ Day:
Male 14 to 18 years is ______ mg
1300 mg
Calcium Recommendation/ Day:
Female 14 to 18 years is ____ mg
1300 mg
Calcium Recommendation/ day:
Male 19 to 50 years is ____ mg
1000 mg
Calcium Recommendation/ day:
Female 19 to 50 years is ____ mg
1000 mg
Calcium Recommendation/ day:
Male 51 to 70 years is ____ mg
1000 mg
Calcium Recommendation/ day:
Female 51 to 70 years is ____ mg
1200 mg
Calcium Recommendation/ day:
Male 71+ years is ____ mg
1200 mg
Calcium Recommendation/ day:
Female 71+ years is ____ mg
1200 mg
Dietary source of calcium:
a. Dairy products, sardines, salmon with bones
b. Green leafy vegetables, tofu, calcium-fortified foods
c. Take Vitamin D (______ IU/day)
c. 800 to 1000 IU/day
Supplements
a. Most common: Calcium carbonate = greatest amount of
elemental calcium (40%)
b. Should not be taken with ____ ___ foods
c. Avoid aluminum-containing antacids (Ca++ binds with aluminum)
b. high fiber
Drug Therapies Osteoporosis:
a. Estrogens
b. ___________: Potential but rare reports of bisphosphonate-associated osteonecrosis of the jaw (BON) associated with this class of medication, especially in women with an underlying diagnosis of cancer. The FDA has not seen a clear connection between bisphosphonates use and the risk of atypical subtrochanteric femur fractures.
Bisphosphonates
Oral _________ are:
a) Risedronate (Actonel)
b) Alendronate (Fosamax)
c) Ibandronate (Boniva)
bisphosphonates
Elevated calcium levels often due to ______________
hyperparathyroidism
IV bisphosphonates:
a)
b)
a) Ibandronate (Boniva)
b) Zoledronic acid (Reclast)
Multisystem, an inflammatory autoimmune disorder that affects primarily women of childbearing age
Systemic Lupus Erythematosus (SLE)
Signs and Symptoms: Systemic Lupus Erythematosus (SLE):
- Fever
- Anorexia
- Malaise
- Weight loss
- ____ ____ (affects < 50% patients)
- Fingertip lesions
- Periungual erythema
- Splinter hemorrhages
- Alopecia
- Raynaud’s phenomenon in 20% of patients
- Joint symptoms often an early manifestation
- Photosensitivity
- Vasculitis
- _____
- Ocular manifestations
- Pericardial manifestations
- Pulmonary manifestations
- Abdominal pains, ileus, peritonitis
- Butterfly rash
14. Nephritis
Laboratory/Diagnostics: Systemic Lupus Erythematosus (SLE):
1. ANA + in equal to ____% patients
2. Antiphospholipid antibodies
3. Anemia, leukopenia, and thrombocytopenia are often
present
95%
Management: Systemic Lupus Erythematosus (SLE):
1. For mild symptoms: bed rest, midafternoon naps,
avoidance of fatigue
2. ____ ______
3. Topical glucocorticoid for isolated skin lesions
4. NSAIDs, hydroxychloroquine, glucocorticoids, and other therapies
- Sun protection
Drugs implicated in Lupus Like Syndrome:
- _______
- Atenolol (Tenormin)
- Bupropion (Wellbutrin)
- Captopril (Capoten)
- Carbamazepine (Tegretol)
- Chlorpromazine (Thorazine)
- Diltiazem (Cardizem)
- Gemfibrozil (Lopid)
- Glyburide (Diabeta)
- ________
- Griseofulvin
- Hydralazine (Apresoline)
- Hydroxychloroquine (Plaquenil)
- Isoniazid (tNn)
- Interferons
- _______
- Lovastatin (Mevacor)
- Methyldopa (Aldomet)
- Minocycline (Dynacin)
- Nitrofurantoin (Macrobid)
- Oral contraceptives
- Phenytoin (Dilantin)
- Procainamide (Pronestyl)
- Propylthiouracil (PTU)
- Quinidine
- _______
- Simvastatin (Zocor)
- Tetracycline
- Ticlopidine (Ticlid)
- Valproate
- Amiodarone (Cordarone)
- Gold salt
- Lithium
- Rifampin
Inflammation and infection involving the kidneys, ureters, bladder, and/or urethra Causes
Urinary Tract Infections (UTIs)
______ UTIs: Pyelonephfitis, Renal Abscess, etc.
Upper
_______ is the most common causative organism in women.
E. coli
_____ UTIs: Cystitis, Urethritis/Dysuria Frequency Syndrome
Lower
Signs/Symptoms of Lower UTIs:
- Dysuria is the key symptom Frequency
- Nocturia
- Urgency
- Hematuria - occurs in _____% of patients
40 to 60
Organisms of the ____ species are most common in men.
Proteus
Laboratory/Diagnostics
- Urinalysis - usually shows pyuria (> ____ white blood cells/ml)
- The presence of _____ by dipstick is very specific but not a sensitive test for bacteriuria.
- Esterase detection by dipstick is very sensitive but not specific.
- 10
2. nitrate
Management of Lower UTIs:
2. Commonly used agents: [_____-______] (Bactrim),
ciprofloxacin (Cipro) and amoxicillin/clavulanate (Augmentin)
3. Other considerations: Amoxicillin (Amoxil), levofloxacin (Levaquin), nitrofurantoin (Macrobid; Macrodantin), trimethoprim (Primsol), fosfomycin (Monurol)
Trimethoprim-sulfamethoxazole
Management of Lower UTIs:
1. ___-day therapy maximizes benefits and minimizes drawbacks of treatment (i.e., fewer side effects, more effective than single-dose, and less costly than a 7-day course)
3
Management of Lower UTIs:
4. During pregnancy: ______ (__), nitrofurantoin (Macrobid), cephalexin (Keflex) for 7 to 10 days of therapy
Amoxicillin (Amoxil)
Acute Pyelonephritis:
Laboratory/Diagnostics
1. ___ ____ cell casts seen on urinalysis
2. ESR elevated with pyelonephritis
- White blood
Symptoms/Physical Findings of Upper UTIs
1. Flank, low back, or abdominal pain may be present
2. Fever and chills often present and usually indicate
upper UTI**
3. Nausea/Vomiting
4. Mental status changes in the elderly
Acute Pyelonephritis
Management of Upper UTls
1. ___-day course vs. 6-week course
- Commonly used agents: [Trimethoprim-sulfamethoxazole] (Bactrim), ciprofloxacin (Cipro), other Quinolone, amoxicillin/clavulanate (Augmentin), Aminoglycosides (Gentamicin, Tobramycin, etc.)
- Patients with suspected pyelonephritis who have nausea and vomiting and those with more severe illness should be hospitalized.
- 14- day
Urinary Incontinence
- Urinary incontinence is common
b. Affects ___% of postmenopausal women - Associated with chronic risks such as falls and fractures
- Costly diagnosis: roughly $26 billion/annually (more than all cancer care for women)
40%
Urinary Incontinence
- Urinary incontinence is common
a. Affects ___% of reproductive-age women - Associated with chronic risks such as falls and fractures
25%
Urinary Incontinence
- Costly diagnosis: roughly $___ billion/annually (more than all cancer care for women)
26
______ (urethral incompetence)
a. Causes
1) Muscles impairing urethral support (most common)
2) Intrinsic sphincter deficiencies due to pelvic surgery
Stress
\_\_\_\_ (detrusor overactivity)
a. Causes
1) Detrusor hyperactivity by CNS abnormalities such as
strokes
2) Infections of the GU tract
3) Urinary stones
4) Neoplasms
5) Fecal impactionUrge
Symptom: Stress Incontinence
a) Precipitant
b) Timing
c) Amount
d) Frequency
e) Nocturia
a) activity
b) Immediate
c) Small/ moderate
d) rare
e) rare
b. Findings
1) Urine leakage from activities with increased pressure
on the bladder (lifting, coughing, exercise, sneezing,
laughing, climbing stairs, etc.)
Stress (urethral incompetence)
Management incontinence:
1. _____ of recent urinary activities (e.g., fluids, voids, and incontinence events)
Diary
b. Findings
Urgency, involuntary urinary loss, nocturia, frequency
Often referred to as an “overactive bladder”
Urge (detrusor overactivity)
Symptom: Urge Incontinence
a) Precipitant
b) Timing
c) Amount
d) Frequency
e) Nocturia
a) Urge
b) Delayed
c) Large
d) Common
e) Common
- ______ incontinence
a. Timed voids to prevent full bladder
b. Pessary
c. Surgery
Stress
- Patient teaching
a. Weight loss: Improved urge incontinence (great motivator for weight loss)
b. Fluid management: Drink for ____ only; lozenges for dry mouth
c. Avoid caffeine
d. Pelvic floor exercises: Squeeze, hold for 2 seconds, relax for 2 seconds (increase each by one second every week until 10 seconds is achieved)
b. thirst
- ______ incontinence
a. Urge suppression/distraction
b. Quick pelvic contractions
c. Medication
Urge
e. Bladder control strategies
1) ____ control: Freeze and squeeze
1) Urge
e. Bladder control strategies
2) ____ control: Squeeze before you sneeze (lift)
2) Stress
Pharmacotherapy: Muscarinic receptor antagonists Immediate release 1) \_\_\_\_\_\_\_ (Ditropan) 2) Tolterodine (Detrol) 3) Trospium (Sanctura)
1) Oxybutynin
Pharmacotherapy: Muscarinic receptor antagonists Extended-Release 1) Darifenacin (Enablex) 2) \_\_\_\_\_\_\_\_\_\_ (Toviaz) 3) Ditropan XL 4) Solifenacin (Vesicare) 5) Detrol LA 6) Oxybutynin transdermal (Oxytrol) 7) Oxybutynin gel (Gelnique)
Fesoterodine
Tanner Staging in boys
1)
2) Enlargement of scrotum and testes; scrotum roughens
and reddens
3) Penis elongates
4) Penis enlarges in breadth and development of glans;
rugae appear
5) Adult shape and appearance1) Preadolescent testes, scrotum, penis
Tanner Staging in boys
1) Preadolescent testes, scrotum, penis
2)
3) Penis elongates
4) Penis enlarges in breadth and development of glans;
rugae appear
5) Adult shape and appearanceEnlargement of scrotum and testes; scrotum roughens
and reddens
Tanner Staging in boys
1) Preadolescent testes, scrotum, penis
2) Enlargement of scrotum and testes; scrotum roughens
and reddens
3)
4) Penis enlarges in breadth and development of glans;
rugae appear
5) Adult shape and appearancePenis elongates
Tanner Staging in boys
1) Preadolescent testes, scrotum, penis
2) Enlargement of scrotum and testes; scrotum roughens
and reddens
3) Penis elongates
4)
5) Adult shape and appearancePenis enlarges in breadth and development of glans;
rugae appear
Tanner Staging in boys
1) Preadolescent testes, scrotum, penis
2) Enlargement of scrotum and testes; scrotum roughens
and reddens
3) Penis elongates
4) Penis enlarges in breadth and development of glans;
rugae appear
5)Adult shape and appearance
A collection of dilated veins around the spermatic cord
Varicocele
Signs/ Symptoms of Varicocele
a) Often asymptomatic
b) Scrotum pain
c) Scrotum looks like a “____ ___ ___”
d) Decreased fertility
bag of worms
Management of Varicocele
a) ______ for scrotal discomfort
b) Surgical ligation, venous embolization
a) NSAIDs
Acute inflammation of infection fo the scrotum, secondary to an inflamed epididymis
Epididymitis
1) Commonly occurring in men < 35 years of age with _____ as the causative agent
2) When occurring in men > 35 years: Likely the result of a bacterial ascension from the bladder or bacteria introduced during cauterization and/ or surgery
chlamydia
Symptoms/ History: Epididymitis
a) Pain
b) dysuria
c) ____/______
d) Low back/ perineal pain
e) Fever/ Chills
f) Malaise
g) Scrotal edema
c) urgency/ frequency
Physical Examination: Epididymitis
a) Enlarged, tender epididymis
b) A urethral discharge may be evident
c) Positive _____ sign
d) Normal cremasteric reflex, R/O
e) Testicular torsion
c) Prehn’s
Diagnostic tests for epididymitis:
a) STD testing
b) Culture of _____
c) Scrotal ultrasound R/O Testicular torsion
urine
Management of Epididymitis:
b) Adults under 35 years:
i) ___________ 250 mg IM x1 dose PLUS
doxycycline (Vibramycin) 100 mg twice a day or
ii) __________ 1 Gram orally once
i) Ceftriaxone (Rocephin)
ii) Azithromycin
Management of Epididymitis:
c) Adults over 35 years:
i) __________ 1 tablet twice a day x 10 days OR
ii) ___________ 250 mg twice a day x 10 days
d) Support/ elevate scrotum
e) Analgesics, NSAIDs, ice (early), heat (late), bed rest
i) TMP/SMZ- DS
ii) Ciprofloxacin (Cipro)
Inflammatory infection of the prostate
Acute Bacterial Prostatitis
Acute Bacterial Prostatitis
1. Usually caused by gram-negative bacteria (especially ___ ____
- E. coli)
Acute Bacterial Prostatitis
2. Nonbacterial prostatitis (mostly in young men) likely cause: ______, Mycoplasma, Gardnerella
Chlamydia
Symptoms/ history of actual bacterial prostatitis:
a) __________
b) lower back pain
c) Dysuria
d) Urgency frequency
e) Nocturia
a) Fever/ chills
Physical examination of acute bacterial prostatitis:
1) Edematous prostate may be warm tender/ _____ to palpation, pain
boggy
Diagnostic tests for actual bacterial prostatitis:
1) ____ ____ - positive for the causative agent
1) Urine culture
Management of actual bacterial prostatitis:
1) consult/ refer if septicemia or urinary retention evident
2) Antibiotic choices: ___________ (___), levofloxacin (Levaquin), norfloxacin (Noroxin), ofloxacin (Floxin), other
3) Sitz bath three times a day to 30 minutes eat treatment
4) No sexual intercourse until acute phase resolves
2) Trimethoprim-sulfamethoxazole (Bactrim)
Progressive, benign hyperplasia of prostate
Benign Prostatic Hypertrophy (BPH)
General comments: Benign Prostatic Hypertrophy (BPH)
1) By the age ____, approximately 50% of men while exhibit signs of BPH
1) 50
General comments: Benign Prostatic Hypertrophy (BPH)
2) By age ____, 80% of men will acquire this disorder
3) Etiology is unknown
2) 80
General comments: Benign Prostatic Hypertrophy (BPH)
4) The most common cause of bladder ______ in men over the age of 50 years
4) obstruction
Symptoms/ History of BPH:
1) Urgency frequency
2) _______
3) Dribbling
4) Retention
2) Nocturia
Physical Examination: BPH
a) Bladder distention may be present
b) The prostate is non-tender with either asymmetrical or symmetrical enlargement
c) Smooth _____ consistency with possible nodules
c) rubbery
Laboratory/ diagnostics:
a) U/A: Rule out UTI, no hematuria
b) Uroflowmetry
c) Abdominal ______: Rules out upper tract pathology
d) Serum creatinine/ BUN normal
e) Prostate-specific antigen (PSA): > 4 ng/ ml indicates disease
f) DRE
c) ultrasound
Management of BPH
a) Observer condition and consult/ refer to a urologist as needed
b) Alpha-blockers: _____ (____), prazosin (Minipress), tamsulosin (Flomax), etc. to relax the muscle of the bladder and prostate
b) Terazosin (Hytrin)
Management of BPH
c) 5- alpha-reductase inhibitors: ____ (__) and dutasteride (Avodart) to shrink large prostates
d) Saw Palmetto: Effective for some patients
Finasteride (Proscar)
Malignant neoplasm of prostate gland
Prostate cancer
General Comments: Prostate Cancer
a) Prostate cancer is the ____most common cancer among men in the United States
second
General Comments: Prostate Cancer
b) The third leading cause of cancer deaths in men older than ____ years of age
c) The cause is unknown, through high-fat diets may contribute to the disease
55 years
Symptoms/ History:
- Patients are usually asymptomatic
- May appear to be BPH in early stages (e.g. with frequency, nocturia, dribbling)
- In advanced stages: ____ pain from metastasis uremia secondary to obstruction may occur
Bone
Symptoms/ History:
- Patients are usually asymptomatic
- May appear to be BPH in early stages (e.g. with frequency, nocturia, dribbling)
- In advanced stages: ____ pain from metastasis uremia secondary to obstruction may occur
Bone
Physical Examination:
1) ______________
2) Bladder distention
3) Prostate palpates harder than normal with obscure boundaries, and nodules may be present
Adenopathy
Prostate-specific antigen (PSA) values > ___ ng/ml = abnormal; age- specific ranges are based on having had a PSA < ___ ng/ml
4
Prostate-specific antigen (PSA):
Age Value
40 to 49 = < _____
2.5
Prostate-specific antigen (PSA):
Age Value
50 to 59 = < ____
3.5
Prostate-specific antigen (PSA):
Age Value
60 to 69 = < ____
4.5
Prostate-specific antigen (PSA):
Age Value
70 to 79 = < ____
6.5
Thus, the higher the PSA, value, the more likely the diagnosis of cancer
** Approximately ___% of patients with prostate cancer
present with normal PSA values
40%
Laboratory/ diagnostics:
- Needle _____ of the prostate
- Ultrasound to identify solid nodules
biopsy
Management: Prostate Cancer
- Consult/ refer
- Other treatment options: _____, radiation, and hormone therapy
surgery
Inability to sustain an erection capable of intercourse
Erectile Dysfunction
A major cause of Erectile dysfunction:
1. Stress
a) Psychological issues
b) Anxiety (performance)
2. Atherosclerosis
3. Diabetes
4. Recreational drugs
a) alcohol
b) \_\_\_\_\_\_\_\_\_\_\_
c) barbiturates
d) cocaine
e) Marijuana
f) Methadone
g) Nicotine
h)- b. Amphetamines
A major cause of Erectile dysfunction:
- Medications
a) Diuretics
b) Antihypertensives
c) _____________
d) Antidepressants
e) Anti- anxiety agents
f) Anti-epileptics
g) Antihistamines
h) NSAIDs
i) Muscle relaxants
j) Parkinson’s disease medications
c) H2 blockers
Management of Erectile dysfunction:
- Explore underlying causes
- Check _______ level
- Phosphodiesterase inhibitors: Caution with concurrent use of nitrates
a) Sildenafil (Viagra)
b) Vardenafil (Levitra)
c) Tadalafil (Cialis)
d) Avanafil
- testosterone
Phosphodiesterase Inhibitors
Sildenafil (Viagra) Works in?
30 minutes
Phosphodiesterase Inhibitors
Sildenafil (Viagra) lasts?
4 hours
Phosphodiesterase Inhibitors
Sildenafil (Viagra) usual dose?
50 mg/d
Phosphodiesterase Inhibitors
Sildenafil (Viagra) max dose?
100 mg/d
Phosphodiesterase Inhibitors
Sildenafil (Viagra) take?
Without food
Phosphodiesterase Inhibitors
Sildenafil (Viagra) available in what dosages?
20, 25, 50, 100 mg
Phosphodiesterase Inhibitors
Vardenafil (Levitra) works?
60 minutes
Phosphodiesterase Inhibitors
Vardenafil (Levitra) lasts?
4 hours
Phosphodiesterase Inhibitors
Vardenafil (Levitra) usual dose?
10 mg/d
Phosphodiesterase Inhibitors
Vardenafil (Levitra) max dose?
20 mg/d
Phosphodiesterase Inhibitors
Vardenafil (Levitra) take?
without food
Phosphodiesterase Inhibitors
Vardenafil (Levitra) available dosage?
2.5, 5, 10, 20 mg
Phosphodiesterase Inhibitors
Tadalafil (Cialis) works?
15 minutes
Phosphodiesterase Inhibitors
Tadalafil (Cialis) Lasts?
up to 36 hours
Phosphodiesterase Inhibitors
Tadalafil (Cialis) usual dose?
10 mg/d
Phosphodiesterase Inhibitors
Tadalafil (Cialis) max dose?
20 mg/d
Phosphodiesterase Inhibitors
Tadalafil (Cialis) take?
with or without food
Phosphodiesterase Inhibitors
Tadalafil (Cialis) available?
5, 10, 20 mg
Phosphodiesterase Inhibitors
Avanafil (Stendra) works?
15 minutes
Phosphodiesterase Inhibitors
Avanafil (Stendra) Lasts?
Up to 36 hours
Phosphodiesterase Inhibitors
Avanafil (Stendra) usual dosage?
100 mg
Phosphodiesterase Inhibitors
Avanafil (Stendra) max dose?
200 mg
Phosphodiesterase Inhibitors
Avanafil (Stendra) take?
with or without food
Phosphodiesterase Inhibitors
Avanafil (Stendra) available?
50, 100, 200 mg
Gerontology Considerations
Renal:
1. Physiologic changes
a. Diminished renal blood flow (up to \_\_\_% per decade
after the age of 30 to 40)10
Gerontology Considerations
Renal:
b. Kidneys decrease in size, both the number and size
of nephrons diminish, and the number of glomeruli
decreases ______%.
30-40%
Gerontology Considerations
Renal:
c. GFR diminishes approximately 10% per decade after
the age of ___.
30
Gerontology Considerations
Renal:
d. Reduced hormonal response to ______ and an
impaired ability to conserve sodium (increases the
the risk for dehydration)
vasopressin
Gerontology Considerations
Renal:
e. Bladder tone, elasticity, and capacity are ______
reduced
Gerontology Considerations
Renal:
f. Increased residual urine and frequency, and more
_______ urine production
nocturnal
Gerontology Considerations
Renal:
g. Prostate ______ in men
enlargement
Gerontology Considerations
Renal:
2. Possible findings/results
a. Decreased drug clearance
b. Increased risk of:
i) Adverse drug reactions
ii) \_\_\_\_\_\_\_Nephrotoxicity
Gerontology Considerations
Renal:
iii) Fluid _______ (especially in heart failure
patients)
overload
Gerontology Considerations
Renal:
iv) ________ and dehydration (especially in
patients taking thiazide diuretics)
Hyponatremia
Gerontology Considerations
Renal:
v) ___________ (especially in patients with fever)
Hypernatremia
Gerontology Considerations
Renal:
vi) __________ (especially in patients taking
potassium-sparing diuretics)
vii) Metabolic acidosis
viii) Urinary urgency
ix) Incontinence (never a normal finding)
x) UTIs
xi) Polyuria at night
xii) Falls
Hyperkalemia
*Determine renal function (GFR) by calculating the creatinine clearance in the elderly.
Cockcrofi-Gault Equation:
Cockcrofi-Gault Equation:
a. Males:
Creatinine clearance (ml/min) =
72 x (serum creatinine in mg/dL)
Cockcrofi-Gault Equation:
b. Females: Multiply the calculated value by ____%
85% (0.85)
Normal creatinine clearance values in adults:
Males < 40 years = _________ mL/min or 1.8 to 2.3
mL/sec
107 to 139
Normal creatinine clearance values in adults:
Females < 40 years = ______ mL/min or 1.5 to 1.8
mL/sec
87 to 107
*Creatinine clearance values usually decrease as one ages (e.g., decrease by ___ mL/min for every 10 years after the age of 20).
6.5
Urinary Tract Infections
- Epidemiology: The most common clinical illness for adults over 65 years of age
a. Men: _____/100
b. Women: 14/100
10.9
Causes: Urinary Tract Infections
a. Gram-negative bacilli
1) _____ ______
2) Pseudomonas aeruginosa
1) Escherichia coli
b. Gram-positive organisms: Urinary Tract Infections
1) _________
2) Coagulase-negative staphylococci
3) Streptococcus agalactiae
4) S. aureus
Enterococci
c. ____ (especially in those patients with indwelling catheters) Signs/Symptoms
a. Classic signs may be absent, may present with:
1) Weakness
2) Frequency
3) Urgency
4) Dysuria
Fungi
b. Atypical findings (More common in elderly in the absence of UTI)
1) Incontinence
2) _____ _____
3) Lethargy
4) Decreased appetite
5) Dehydration
6) Confusion
Fecal impaction
4) Laboratory/Diagnostics
a. Urinalysis
i) WBCs may not be present in large numbers.
ii) Leucocyte esterase and ____ may be negative.
ii) nitrites
4) Laboratory/Diagnostics
b. Culture and Sensitivity
i) High incidence of ________ bacteriuria
ii) Multiple organisms often present
i) asymptomatic
