Genitourinary (M & F) - 5% Flashcards
Benign Prostatic Hyperplasia
Normal aging process; 50% by 60yo; avoid anticholinergics, sympathomimetics, and opioids
Sxs
- Decr force of urinary stream, incomplete emptying
- hesitancy (stop and start), straining, Post void dribbling
- Freq, nocturia, urgency, recurrent UTIs
Dx
- DRE - uniformly large, firm, rubbery prostate
-
PSA elevated
- < 4 normal
- >4 think BPH, prostate CA and prostatitis
- UA r/o pathos
Tx
- Observation if mild
-
a-1 blockers - Tamsulosin/flomax - muscle relaxation and decr resistance in bladder neck
- can cause orthostatic hypotension
-
5-a reductase inhibitors (REDUCE the size) - Finasteride and Dutasteride
- inhibits conversion of testoterone to dihydrotestosterone (suppresses prostate growth) & reduces obstruction
- TURP - if refractory to meds
Bladder Carcinoma
MC - Transitional Cell carcinoma; M 3x > F
Sxs
- Painless hematuria in smoker
Dx
- Cystoscopy w/ bx** - gold
Tx
-
endoscopic resection w/ cystoscopy q 3 mos
- Recurrent or multiple lesions - intravesical chemo
Cryptorchidism
Undescended testicle - MC in premature
Unrepaire = incr risk for infertility and malignancy
Ultrasound; karyotype if both testes are not palpable
Tx - orchiopexy by age 1; or asap after 4 mos
Cystitis
Infection of bladder; MC d/t E.coli, ascends up urethra
sxs:
- dysuria, frequency, urgency, suprapubic tenderness
- following sexual intercourse
- unremarkable PE
dx:
- urine dipstick; nitrite, leukocyte esterase
- UA - pyuria, bacteriuria, +/- hematuria
- Urine culture - definitive >10^5 CFU clean catch
- if epithelial squamous cells = contamination
- imagine reserved for pyelo
Tx:
- Uncomplicated - Bactrim DS BID x3d or Nitrofurantoin 100mg x5-7d
- Increased fluids, prevention
- hot sitz bath/urinary analgesics - phenazopyridine/Azo - pee orange
- Lower UTI in pregnancy
- Macrobid/nitrofuratoin 100 mg PO BID x 7 days
- Cephalexin/Keflex 500mg PO BID x 7d
- Lower UTI in pregnancy
Cystocele / Bladder Prolapse
Prolapse of bladder into superior end of vagina
RFs: childbirth, heavy lifting, violent coughing, pelvic m sprain
Sxs
- Bulge of bladder into vaginal wall (bladder hernia)
- Pelvic pressure
- urinary symptoms + retention and incontinence
Dx
- Voiding & urodynamic studies
Tx
- Pessary
- Kegel exercises, pelvic floor training
- surgical repair w/ mesh augmentation
Epididymitis
Acq’d retrograde spread of organism through vas deferens
- Men < 35 - G & C
- Men > 35 = E coli
Sxs:
- Dysuria
- unilateral dull aching scrotal pain r-> ipsilateral flank
- Swollen epididymitis, tender
- fever/chills
- Positive (+) Prehn’s sign - relieve w/ elevation
- Positive (+) Cremasteric sign (normal) - ele of testicle after stroking on inner thigh
Dx:
- UA - pyuria - bacteriuria + culture
- scrotal US - increased testicular blood flow
Tx:
- Supportive care; bed rest, scrotal elevation, analgesics
- <35 yo
- Ceftriaxone 250mg IM x1 + Doxycycline/Azithromycin 100 mg PO BID x 10d
- treat partner as well
- >35 yo E coli
- Levofloxacin 500mg PO x 10 days
- Ofloxacin 300 mg PO BID x 10d
Epispadias
Urethral opens on topside of penile shaft
Penopubic - base of penis and abd wall - most severe
Penile - along shaft
Glanular - hear head of penis - least severe
Dx - PE, excretory urogram
Tx like hypospadias
Erectile Dysfunction
Psychological vs organic etis (HTN, aths, neuro DM, hormonal dysfx, drugs)
Psychological - able to have erection in sleep
- Libido - think about androgen deficiency
- SSRI - loss of orgasm (not libido)
Dx
- DRE, neuro exam, look for PAD
- labs - including serum testosterone, prolactin, thyroid
- vascular testing - duplux US, vasoactive substances, arteriography
- Psych testing
Tx - underlying cause
-
PDE-5 Inhibitors
-
Sildenafil (take on empty stomach), Tadalafil (longest half life), Vardenafil (take with food)
- C/i NTG, nitrate, alpha blocker for BPH
- can cause priapism - > 4hrs of erection
- intracavernosal injections
- vacuum restriction devices
-
Sildenafil (take on empty stomach), Tadalafil (longest half life), Vardenafil (take with food)
- penile implants
- Testosterone replacement
Genitourinary Trauma
Urethral Trauma
- blood at meatus
- high riding ballotable prostate on rectal; scrotal or perineal ecchymosis
Bladder Trauma
- blunt force bladder - lower abd trauma + pelvic fractures from MVA
- contusion, intraperitoneal or extraperitoneal rupture
Penile Fracture
- pain and snapping
- S shaped, tender, swelling and ecchymosis
Dx - Retrograde urethrogram - get before foley to r/o urethral injury
Tx
- Surgery = penile fracture or urethral injury + intraperitoneal or large bladder rupture
- extraperitoneal bladder rupture = foley drainage and obs
- Bladder contusion = foley/bladder drainage, f/u cystography
Hypospadias
Urethra opening at bottom of penile shaft
Sxs - position of urethral meatus
- Glanular - head of penis (less severe)
- Midshaft
- Penalscrotal - most severe
Dx
- PE
- excretory urogram
Tx - Sx repair before 1-2 yo
- do not circumcise - urethral reconstruction
Incontinence
Eti, Sxs, Tx
Urge Incontinence
- MC elderly and nursing home
- Overactive detrusor muscle = incr freq and involuntary loss of urine
- Sxs - sudden urge to urinate, loss of large volume w/ small PVR, nocturnal wetting
- Dx - Urodynamic study
- Tx - bladder training, or anticholinergics (oxybutin) or TCA (imipramine)
Overflow Incontinence
- common in DM or neurologic disorders
- inadequate bladder contractions (imparied detrusor contractility) or outlet obstruction => urinary retention and bladder overdistention
- Nocturnal wetting; large PVR >100ml
- Tx - int self cath, cholinergic (bethanechol) to incr bladder cntrx;
- a blockers = terazosin, doxazosin - decr sphincter resistance
Stress Incontinence
- women after childbirth
- weakness of pelvic diaphragm = loss of bladder support
- involuntary loss of urine (spurts) during incr in intraabd pressure (cough, laugh, sneeze, exercise); small PVR
- Tx - Kegel exercises, vaginal estrogens, use of pessary , surgery via mid urethral sling
Functional Incontinence
- normal voiding but difficulty reaching toilet d/t physical or mental disabilities
- Tx - scheduled voiding time
Mixed Incontinence
- Stress and urge
- tx - LSMs, and pelvic floor exercises
Incontinence
dx
Dx
- UA r/o UTI
- PVR - urinary retention
- overflow = high PVR
- stress + urge = low PVR
- Urodynamic studies - bladder contractions
- stress = normal bladder cntrx
- urge = decr bladder cntrx
Nephrolithiasis
dx, tx
Dx:
- UA - microscopic/gross hematuria, leukocytes/crystals
- non-contrast CT - gold std*
- Renal US - ID stones in kidney, prox ureter, UVJ
Tx:
- <5mm - likely to pass on own, lots of fluid - strain urine, adq analgesics
- 5-10mm - can’t pass spont., incr fluids & analgesics
- elective lithotripsy/ureteroscopy
- refer to uro w/ 9mm stone
- >10mm - incr complications
- tx as inpatient - maintain PO intake, vigorous h20
- Ureteral stent - percutaneous nephrostomy = gold std
- ample analgesia
Nephrolithiasis
eti, sxs
50% recurrence w/in 10 yrs of 1s stone
Renal Calculi - occur in urinary tract
Calcium stones MC > uric acid > struvite > cystine
Sxs:
- Asymptomatic until inflammation or complete/partial ureteral obstruction develops
- Colicky unilateral back/flank pain radiating to groin
- CVA tenderness
- N/V
- Dysuria, urinary freq, fever, chills, hematuria
Orchitis
Inflammation of testicles - bacteria or virus ascending through urinary tract
25% postpubertal M w/ MUMPS
MCC - Coxsackie Rubella, Echovirus, Parvovirus
Sxs:
- Unilateral swollen testicles
- tenderness w/ erythema and shininess of overlying skin
- fever/tachy
- usu a/w epididymitis, unless MUMPS
Dx:
- UA - pyuria, bacteriuria
- positive Prehn’s sign - relieve of pain with elevation of scrotum
- Positive (normal) Cremasteric Reflex - testicle draws upward w/ inner thigh stroke
Tx:
- if mumps - tx mumps + ice/analgesia
- if bacterial - tx like epididymitis
- < 35 yo
- Ceftriaxone 250 mg IM + doxy 100 mg BID x 10d < 35
- If > 35 (usu E coli)
- Cipro 500 mg BID 10-14 d
- < 35 yo
