Genitourinary Conditions Flashcards
1
Q
What are the two types of hematuria?
A
Gross hematuria - visible to the naked eye.
Microscopic hematuria - detectable by examination of sediment, microscopy or urinalysis.
2
Q
Define the sources and percentages of patients with microscopic hematuria.
A
Upper urinary tract source - 10%
Stone disease - 40%
Medical kidney disease - 20%
Renal cell carcinoma - 10%
Urothelial cell carcinoma of the ureter or renal pelvis - 5%
3
Q
Microscopic hematuria in males is most commonly due to what condition?
A
Benign prostatic hyperplasia.
4
Q
This type of gross hematuria is defined as the presence of blood at the beginning of the urinary stream that clears during the stream.
A
Initial hematuria, implies anterior (penile) urethral source.
5
Q
This type of gross hematuria is defined as the presence of blood at the end of the urinary stream.
A
Terminal hematuria, implies bladder neck or prostatic urethral source.
6
Q
This type of gross hematuria is defined as the presence of blood throughout the urinary stream.
A
Total hematuria, implies bladder or upper tract source.
7
Q
What does hematuria associated with renal colic imply?
A
Ureteral stone.
8
Q
In the absence of other symptoms, gross hematuria can be indicative of what?
A
A tumor.
9
Q
Proteinuria and casts in a urinalysis suggest what origin?
A
Renal.
10
Q
What type of diagnostic imaging is indicated for patients with gross hematuria or those over 35 years old with asymptomatic hematuria?
A
Cystoscopy.
Evaluates for:
-Bladder or urethral neoplasm
-Benign prostatic enlargement
-Radiation or chemical cystitis
11
Q
What type of bacteria is responsible for the majority of UTIs (cystitis)?
A
Coliform bacteria, E. coli being the most common. Ascending infection from the urethra is the most common route.
12
Q
Uncomplicated cystitis in men is rare - what does it imply?
A
Pathologic process such as infected stones, prostatitis, or chronic urinary retention. Requires further evaluation.
13
Q
Signs and symptoms of cystitis.
A
Irritative voiding symptoms:
-Frequency
-Urgency
-Dysuria (painful urination)
Suprapubic discomfort
-Tender to palpation
Women may experience hematuria following sexual intercourse
Usually afebrile
14
Q
Treatment of cystitis in women.
A
Antibiotics:
Ciprofloxacin
-250mg q12h PO for 3 days
Urinary Analgesics:
Phenazopyridine
-100-200mg q8h PRN PO max of 3 days
Sitz baths for symptomatic relief
15
Q
When are women considered candidates for prophylactic treatment of cystitis? What are the 3 most commonly used oral prophylactic agents?
A
Women who have more than 3 episodes of cystitis per year.
Trimeothoprim-sulfamethoxazole (Bactrim)
Nitrofurantoin (Macrobid)
Cephalexin
Single dosing at bedtime or prior to intercourse is the recommended schedule for all 3.
16
Q
What is the first line treatment of pyelonephritis?
A
Ciprofloxacin
-750mg q12h PO 7-14 days
17
Q
This is an infectious inflammatory disease involving the kidney parenchyma and renal pelvis.
A
Pyelonephritis
Gram-negative bacteria are the most common causative agents; gram-positive are less commonly seen.
18
Q
Pyelonephritis infections usually ascend from the lower urinary tract, with the exception of what agent?
A
S. aureus infections which spread by a hematogenous route.
19
Q
Signs and symptoms of pyelonephritis.
A
Fever
Flank pain
Irritative voiding symptoms
Shaking chills
Associated nausea and vomiting
Diarrhea
Tachycardia
Pronounced costovertebral angle tenderness
20
Q
What is a typical CBC finding in a patient with pyelonephritis?
A
Leukocytosis and a left shift.
21
Q
What is a major complication of pyelonephritis?
A
Sepsis and shock.
22
Q
Acute prostatitis is usually caused by what strains of bacteria?
A
Gram-negative E. coli and Pseudomonas.
23
Q
What are the signs and symptoms of prostatitis?
A
Warm and exquisitely tender prostate - hallmark symptom.
Perineal, sacral or suprapubic pain.
Irritative voiding symptoms.
Obstructive symptoms which can lead to urinary retention.
24
Q
Outpatient treatment of acute prostatitis.
A
Antibiotics:
Ciprofloxacin, Levofloxacin or Bactrim
Analgesics/pain:
Acetaminophen or NSAIDs
Stool softeners
25
For a patient with acute prostatitis treated with IV antibiotics, how long are oral antibiotics prescribed to finish the full antibiotic treatment?
4-6 weeks.
26
For a patient with acute prostatitis who develops urinary retention, what type of treatment is required?
Percutaneous suprapubic tube
*Urethral catheterization is contraindicated.
27
A patient presents with irritative voiding symptoms, low back and perineal pain, and suprapubic discomfort.
He has a history of UTIs. His physical exam is unremarkable. What is his diagnosis?
Chronic bacterial prostatitis.
28
A patient's prostate with chronic bacterial prostatitis may present in what way?
Normal, boggy or indurate.
29
What is the treatment of chronic bacterial prostatitis?
Bactrim
-Associated with the best cure rates.
Or: Cipro, Levofloxacin.
NSAIDs and sits baths for symptoms.
30
What are the two forms of infectious epididymitis?
Sexually transmitted
-Typically men under 40
-Associated with urethritis
-Result from Chlamydia or Gonorrhea
Non-sexually transmitted
-Typically older men
-Associated with UTIs and prostatitis
-Caused by gram-negative rods
31
A patient presents with unilateral testicular swelling that is tender and painful to palpation. He has a fever and associated symptoms of urethritis and cystitis. What is his diagnosis, and what are three common causes of this condition?
Epididymitis
Acute physical strain, trauma, sexual activity.
32
The special test of elevating the scrotum above the pubic symphysis to test for epididymitis is known by what name? What is a positive finding?
Prehn sign.
Positive finding is if it relieves pain.
33
How do you treat sexually and non-sexually transmitted epididymitis?
Sexually:
Ceftriaxone AND Doxycycline.
Non-sexually:
Bactrim, Cipro or Levofloxacin
34
How do you symptomatically treat epididymitis?
Bed rest
Scrotal support
Ice packs
NSAIDs
35
Which sex is more commonly affected by urolithiasis, and what is the ratio?
Men are more commonly affected - 2.5:1
*Initial presentation occurs between the 3rd and 5th decade of life.
36
How many types of urinary stones are there, and what is the major type?
5 major types.
Calcium accounts for 85% of them.
37
What are major risk factors to developing urinary stones?
High humidity and heat.
Sedentary lifestyle, carotid calcification, cardiovascular disease.
High protein and salt intake, low water intake.
38
What are the signs and symptoms of urinary stones?
Episodic/colicky pain that radiates anteriorly to the abdomen.
-Pain can refer to the ipsilateral groin as the stone travels down.
Pain occurs suddenly, localized to a flank.
Nausea and vomiting are common.
Patient will be constantly moving to find a comfortable position.
39
A patient with urinary stones will often have what results in a urinalysis?
Microscopic or gross hematuria (90% of the time).
40
What diagnostic imaging will diagnose up to 80% of urinary stones?
KUB with renal ultrasound.
41
Urinary stones smaller than __-__mm in diameter can usually pass spontaneously.
5-6mm.
42
Medical expulsive therapy can increase the rate of spontaneous stone passage and is most useful for distal stones. What is an example of the medications used?
Alpha blockers
-Tamsulosin
NSAIDs
-Motrin
Oral corticosteroids
-Prednisone
43
What is the most important factor for reducing the reoccurrence of urinary stones?
Increased fluid intake - ensure a voided volume of 2.5 L/day.
44
Patients increasing fluid intake to avoid urinary stones should drink water at what intervals?
During meals, 2 hours after each meal, prior going to sleep and enough to wake the patient to void, and additionally during the night
45
Sodium and protein intake should be reduced to what amounts to avoid reoccurrence of urinary stones?
Sodium less than 150 mEq/day.
Protein spread throughout the day and no more than 1g/kg/day.
46
What paired arteries supply the penis with blood to form an erection?
Paired cavernosal arteries.
47
What key neurotransmitter initiates and sustains an erection?
Nitric oxide.
48
Organic erectile dysfunction can be an early sign of what type of disease?
Cardiovascular disease.
49
A loss of libido can be due to what type of deficiency?
Androgen deficiency.
50
What is the most common cause of erectile dysfunction?
A decrease in arterial flow resultant from progressive vascular disease.
51
What kinds of medications can cause erectile dysfunction?
Antihypertensives
Antidepressants
Opioid agents
52
This is a fibrotic disorder of the tunica albuginea resulting in penile pain, curvature and deformity.
Peyronie disease.
53
Androgen deficiency can cause what type of disorder that is associated with erectile dysfunction?
Anejaculation due to decreasing prostate and seminal vesicle secretions.
54
What lifestyle modifications should be considered in a patient with erectile dysfunction?
Smoking cessation
Reduce alcohol intake
Diet and exercise
Treat underlying conditions (diabetes, dyslipidemia, hypertension)
55
Phosophodiesterase-5 inhibitors are often prescribed to patients with what condition? What are examples of them?
Erectile dysfunction
Sidenafil
Vardenadil
Tadalafil
Avanafil
56
This is a major complication of erectile dysfunction that requires a MEDEVAC.
Priapism - erection lasting longer than 4 hours.
Results in ischemic injury of the corpora cavernous from venous congestion and cessation of arterial flow.
57
This is the most common benign tumor in men and its incidence is age related.
Benign prostatic hyperplasia - increased number of cells in the prostate.
55 years old: 25% of men report obstructive voiding symptoms.
75 years old: 50% of men report decrease in the force and caliber of urinary stream.
58
Symptoms of benign prostatic hyperplasia.
Obstructive symptoms:
-Hesitancy
-Decreased force and caliber of stream
-Feeling of incomplete bladder emptying
-Double voiding
-Straining to urinate
-Postvoid dribbling
Irritative voiding symptoms
59
The American Urological Association symptoms index is a tool used to evaluate patients with what condition?
BPH. It should be calculated for all patients before starting therapy. 7 questions on a scale of 0-5.
60
BPH patients with a 0-7 AUA score should be given what type of treatment?
Watchful waiting.
61
What types of medications can be given to men with BPH?
Alpha blockers - acts against bladder outlet obstruction
-Terazosin, Tamsuloin
5-Alpha-Reductase inhibitors - reduces size of prostate
-Finasteride
Phosphodiersterase-5 inhibitors - used in patients with ED
-Tadalafil
62
What AUA score warrants a referral to urology?
Score greater than 7.
63
This is the most common non-cutaneous cancer in American men and the second leading cause of cancer related death in men.
Prostate cancer.
64
What are the risk factors of prostate cancer, and likelihood of a 50 year old man developing prostate cancer?
Risk factors:
African Americans
Family history of prostate cancer
High fat intake
50 year old man has a:
Lifetime risk of 40% for latent cancer
16% for clinically apparent cancer
2.9% risk of death
65
Lymph node metastases can cause what symptom in patients with prostate cancer, and what is the most common site of the metastases?
It can cause lower extremity lymphedema and the metastases most commonly occurs in the axial skeleton.
66
How are most prostate cancers detected?
Elevations in serum PSA.
67
Prostate specific antigen (PSA) will be elevated above what value in men with prostate cancer?
4.0ng/mL
8-30% of men with intermediate degrees of elevation (4.0-10ng/mL) will be found to have prostate cancer
50-70% of men with elevations over 10ng/mL will be found to have prostate cancer.
68
What ages are PSA tests conducted for men with and without risk factors?
Baseline conducted at 50.
40 to 45 with patients that have risk factors
-African Americans
-Family history of prostate cancer
-Known or likely to have BRCA1 or BRCA2 mutations
69
A blunt testicular injury may appear in what way? What will it result in?
Sac fills with blood and appears as a large tender scrotal mass. May result in a contusion or rupture.
70
What is the imaging of choice for scrotal injuries?
Scrotal and testicular ultrasound
-Colored doppler studies can help determine the extent of testicular involvement and evaluate for rupture.
71
Scrotal lacerations or avulsions involving _____ can be closed by the IDC.
Involving the skin.
72
This condition is defined as necrotizing fasciitis of the subcutaneous tissues of the perineum often involving the scrotum.
Fournier's Gangrene
73
Fournier's Gangrene typically starts as what two conditions that lead to widespread necrosis?
Benign infection or simple abscess
74
What physical exam finding will make you highly suspicious of Fournier's Gangrene?
Scrotal, rectal or genital pain out of proportion to the physical exam.
75
This condition presents with tense edema of the scrotum, blisters, crepitus of the skin, fever, pain out of proportion to exam, tachycardia, and hypotension.
Fournier's Gangrene
76
What is the imaging of choice for Fournier's Gangrene?
CT and MRI
-May show air along the fascial planes or deeper tissue involvement.
77
What is the treatment for Fournier's Gangrene?
Aggressive surgical exploration and debridement.
Broad spectrum antibiotics - Ertapenem IV 1g q24h
Fluid resuscitation
MEDEVAC
78
This condition is defined as dilation of the pampiniform plexus of spermatic veins and is generally left sided.
Usually asymptomatic, the mass is separate from the testis and feels like a "bag of worms."
Varicocele
79
Right and left sided varicocele should raise suspicion for what?
Right: inferior vena cava and intraabdominal pathology.
Left: left renal vein obstruction or renal tumor.
80
This condition is defined as a collection of peritoneal fluid between the parietal and visceral layers around the testes and spermatic cord.
It is a gradually enlarging painless cystic mass that transilluminates, and may indicate a tumor.
Hydrocele.
81
This condition is a fluid filled cyst at the head of the epididymis that may contain nonviable sperm. It is palpated as distinct from the testis and typically transilluminates as cystic in nature.
Spermatocele.
82
What study is necessary for the diagnosis of testicular cancer?
Orchiectomy.
83
What are the symptoms of testicular cancer?
Painless enlargement of the testis and a sense of heaviness.
-Patient will recognize the abnormality but delay in seeking medical care for 3-6 months.
84
10% of testicular cancer patients manifest symptoms related to metastatic diseases. What are these symptoms and conditions?
Back pain - retroperitoneal metastases
Cough - pulmonary metastases
Lower extremity edema - vena cava obstruction
85
What is an important serum marker in the diagnosing and monitoring of testicular cancer?
Urine HCG
86
How are 75% of testicular cancer diagnoses made?
Inguinal orchiectomy
87
What are the complications of testicular cancer?
5 year disease free survival in patients with stage I-III are between 90-100%.
Patients with disseminated disease have a 5 year disease free survival rate of 55-80%.
88
How do testicular torsions produce ischemia, and where do they commonly occur?
They produce ischemia from reduced arterial inflow and venous outflow obstruction. They typically occur on the left side because of the longer spermatic cord and typically rotate medially.
89
How quickly must a testicular torsion be diagnosed and treated?
6 hours.
90
What are the symptoms of testicular torsion?
Acute scrotal pain
Profound tenderness and swelling
Nausea and vomiting
Negative cremasteric reflex
Bell clapper deformity
-High rising, transversely orientated testis
91
How do you treat a testicular torsion?
Manual detorsion ("opening a book")
-Rotate the testicle outward one to two full 360 degree turns
Prompt relief of pain, power position of testis and return of arterial flow suggests detorsion.
If that doesn't occur, try rotating in the opposite direction (1/3rd of torsions have a lateral rotation)
92
What are the chances of testicular salvage based on time in a patient with a testicular torsion?
80-100% salvageable at 6-8 hours.
0% at 12 hours.
93
What do 25% of patients with penile trauma require?
RBC transfusion due to blood loss.
94
Blunt trauma to the corpus cavernosa will have what symptoms?
Immediate pain
Deforming hematoma (eggplant deformity)
Cracking sound
Immediate detumescence
Urethral injury
95
How do you treat a zipper scrotal injury?
Local anesthetic and mineral oil lubrication, removal of tissue ASAP.
If this fails, wire cutting or bone cutting pliers to cut the zipper.
96
Penetrating injuries to the penis often involve what important structure?
The urethra.
97
How do you treat a penile contusion?
Conservatively with acetaminophen or NSAIDs, cold packs, rest, and elevation.
98
A high riding prostate should make you suspicious of what type of injury?
Urethral injury.
Will also present with blood at urethral meatus and perineal hematoma.
99
What is the most common cause of balanoposthitis, and how do you treat it?
Candidal infection.
Treat with good hygiene and topical anti fungal
-Clotrimazole, Miconazole, Terbinafine BID
Urologist can also perform a dorsal slit circumcision or complete circumcision.
100
How do you treat paraphimosis?
Compress the glans for 5-10 minutes (can also tightly wrap it with 2 inch elastic bandage for 5 minutes)
Consider icing the area.
Move prepuce distally while glans is pushed proximally.
-If unsuccessful, dorsal slit circumcision or elective circumcision may be necessary.
101
This condition is defined as an increase in serum creatinine.
It results in an inability to maintain acid-base, fluid, and electrolyte balance, and inability to excrete nitrogenous waste.
Acute Kidney Injury
102
What are the 3 types of acute kidney injuries?
Prerenal
-Kidney hypoperfusion leading to decreased GFR
Intrinsic
Postrenal
-Obstructive uropathy
103
What is the most common etiology of AKI that occurs in 40-80% of cases? How does it occur?
Prerenal.
Decrease in intravascular volume, change in vascular resistance, low cardiac output.
104
What is the least common cause of AKI that occurs in 5-10% of patients? Why is it important to detect it?
Postrenal.
Important to detect because it is reversible.
105
What are the causes of post renal (obstructive) AKI?
Urethral, bladder, or ureter/renal pelvis obstruction.
BPH.
Cancer
106
What are the four common sites of intrinsic AKI?
Tubules
Interstitium
Vasculature
Glomeruli
107
Hyponatremia is defined as serum sodium concentration of less than ___?
135 mEq/L
-Most common electrolyte abnormality and typically reflects excess water retention relative to sodium (not sodium deficiency).
108
Treatment of hyponatremia.
Restriction of free water and hypotonic fluid intake is the first step.
Free water intake should be less than 1-1.5 L/day.
109
What is a serious complication of hyponatremia?
Iatrogenic cerebral osmotic demyelination from overly rapid sodium correction.
110
Hypernatremia is defined as serum sodium levels above ____.
145 mEq/L.
These patients are typically hypovolemic due to free water losses.
111
What are the primary defenses against hypernatremia?
Intact thirst mechanism and access to water.
112
What is the treatment of hypernatremia?
Replace water and electrolytes.
Administer fluids over 48 hours aiming for a serum sodium correction of approximately 1 mEq/L/h.
113
Hypokalemia is defined as serum potassium levels below ___. What can severe levels produce?
3.5 mEq/L.
Arrhythmias and rhabdomyolysis.
114
What are the causes of hypokalemia?
Insufficient dietary potassium intake.
Intracellular shifting of potassium to the extracellular space.
-Cellular uptake of potassium is increased by insulin and beta-adrenergic (beta agonist) stimulation.
The most common cause is GI loss from infectious diarrhea.
115
How do you treat mild to moderate hypokalemia?
Oral potassium supplementation - 40-100 mEq/day for days to weeks.
116
Hyperkalemia is defined as serum potassium levels greater than ___.
5.0 mEq/L.
117
Hyperkalemia can develop in patients taking what medications?
ACEi
ARBs
Potassium-sparing diuretics
118
What are the symptoms of hyperkalemia?
It impairs neuromuscular transmissions causing:
Muscle weakness
Flaccid paralysis
Ileus
119
Fist clenching during venipuncture may produce what inaccurate result?
It may raise potassium concentration by 1-2 mEq/L by causing acidosis and potassium shift from cells.
120
Emergent treatment of hyperkalemia is indicated in what situations?
Cardiac toxicity, muscle paralysis, or severe hyperkalemia greater than 6.5mEq/L,
121
What agents can shift potassium intracellularly within minutes of administration for a patient with hyperkalemia?
Insulin, bicarbonate and beta-agonists.
122
What treatment may be required to remove potassium in patients with acute or chronic kidney injuries?
Hemodialysis.
