Genitourinary: Part 7 Flashcards
Define EPIDIDMO-ORCHITIS
Acute epididymo-orchitis is a clinical syndrome of pain, swelling and inflammation of the epididymis that can extend into the testes
What spread causes epididymo-orchitis
extension of infection from the urethra or bladder
Under 35 causes of epididymo-orchitis
- Chlamydia trachomatis
2. Neisseria gonorrhoea
Over 35 causes of epididymo-orchitis
- UTI (KEEPS):
- Mumps
- Trauma
- Catheter
Risk factors for epididymo-orchitis
- Previous infection
- Indwelling catheter
- Structura;/functional abnormality of urinary tract
- Anal intercourse
Clinical presentation of epididymo-orchitis
- Subacute onset of unilateral scrotal pain and swelling
- Urethritis or urethral discharge in STD
- Sweats/fever
- Tenderness and palpable swelling of the epididymis and testicles
Differential diagnosis of epididymo-orchitis
- Testicular torsion - urological emergency (SURGICAL EXPLORATION)
NEEDS TO BE RULED OUT:
- Short pain duration (sudden)
- Associated nausea/abdo pain
- High-riding/bell-clapper testis
- Hydrocele, trauma, abscess formation
Diagnostics of epididymo-orchitis
- NAAT (Nucleic acid amplification test):
If intracellular gram-NEGATIVE DIPLOCOCCI are present - Gonorrhoea - Mid-stream urine dipstick for UTI symptoms
- Ultrasound to rule out abscesses
- STD screening
- Urethral smear and swab
How is Chlamydia treated
- ORAL DOXYCYCLINE 7 days
OR
STAT AZITHROMYCIN
How is Gonorrhoea treated
- IM CEFTRIAXONE + STAT ORAL AZITHROMYCIN
How is UTI treated
- ORAL CIPROFLOXACIN for 2-4 weeks
- NSAIDs
- ABSTAIN
- Partner notification and testing
What is the most common STD
Chlamydia
What causes Chlamydia Trachomatis
GRAM-NEGATIVE bacterium
What causes Neisseria gonorrhoea
gram-NEGATIVE diplococcus bacterium
In what parts of the body does chlamydia and gonorrhoea effect
- Urethra
- Endocervical canal
- Rectum
- Pharynx
- Conjunctiva
In neonates, what part of the body is effected by chlamydia and gonorrhoea
- Conjunctiva
2. Atypical pneumonia
Primary site of CT and GC in males
Urethra
Clinical presentation of CT and GT
Dysuria
Urethral discharge
Incubation for CT and GC
CT: 7-21 days
GC: 2-5 days
Percentage of people who are asymptomatic
- CT: 50%
2. GC - 10%
Transmission rate female to male in CT and GC
CT: 70%
GC: 60-80% (20% if single encounter)
Complication with CT
Epididymo-orchitis
Reactive arthritis
primary site of CT and GC in females
Cervix
Non-specific symptoms of CT and GC in females
- Dysuria
- Menstrual irregularity
- Discharge
Percentage of CT and GC who are asymptomatic
CT: Over 70%
GC: 50%
Incubation time for GC in women
10 days
Complications for GC and CT in females
- PELVIC INFLAMMATORY DISEASE
- NEONATAL TRANSMISSION
- FITZ HUGH CURTIS syndrome
What is pelvic inflammatory disease
Infection spreads up to the fallopian tube leading to inflammation and scarring
Complications of pelvic inflammatory disease
Tubular factor infertility
- Ectopic pregnancy
- Chronic pelvic pain
Symptoms in neonates with CT and GC
Conjunctivitis
Pneumonia
What is Fitz hugh syndrome
Peri-hepatitis but no decline in liver function
Cons of NAAT with first void urine
Lower sensitivity
How is gonorrhoea in females tested
- Near patient test
- Culture mid-stream urine
- Antibiotic sensitivity testing
- NAAT
What is the near patient test
- Microscopy of gram stained smears of genital secretions - GRAM-NEGATIVE DIPLOCOCCI
Sample from urethra in males + endocervix in females
How to treat chlamydia in pregnant women
- ERYTHROMYCIN for 14 days or AZITHROMYCIN STAT
Parasympathetic control of LUT
S3,4,5
Sympathetic control of LUT
T10, L1 and L2
What causes sphincter weakness incontinence
- Sphincter weakness
2. Small leak of urine when intra-abdominal pressure rises (laughing, coughing and standing up)
Causes of sphincter weakness (stress incontinence)
- Women secondary to birth trauma
- Men: Post-prostatectomy
- Neurogenic or congenital
Treatment of incontinence in females and males
- Pelvic floor excursuses
- DULOXETINE
- Surgery: Sling or artificial sphincter
- Males - artificial sphincter or male sling
What is DULOXETINE
Antidepressant
What is urge incontinence
Strong desire to void and unable to hold urine
What causes urge incontinence
Detrusor overactivity - rise in detrusor pressure on filling associated with urgency (most often in women)
Bladder hypersensitivity due to UTI, stones or tumour
How is urge incontinence treated
- Bladder exercises: gradually increasing the interval between voids
- Behavioural therapy: controlling caffeine, alcohol and frequency volume charts
- Drugs
- Bladder augmentation
What drugs are given for urge incontinence
- Anticholingeric agents
- Beta 3 agonist
- Botox of bladder
Name an anticholinergic agent
OXYBUTYNIN - decreases detrusor excitability
Name a beta 3 agonist
MIRABEGRON - activates beta 3 receptor on bladder, allowing detrusor relaxation
Why do we give botox to th bladder
Stops release of ACh from pre-synaptic terminal and paralyses the bladder
Surgical name for bladder augmentation
Detrusor myectomy
Cystoplasty
What is a cystoplasty
Adding bowel to bladder to increase SA
Gives increased bladder capacity and reduced detrusor overactivity
May have to self-catheterise due to muscle loss
Role of the periaqudecutal grey
- Co-ordination
2. Completion of voiding
What is the guarding reflex
A spinal reflex where proximal part of sphincter senses urine and sends impulses to spinal cord to tell onus’s nucleus to store urine
What is spastic spinal cord injury
Reflexes work but not controlled by brain
Clinical features of spastic spinal cord injury
- Supra-conical (high part of spinal cord) lesions
- Loss of co-ordination and completion of voiding
- Reflex bladder contractions
- Poorly sustained bladder contraction
- Kidney failure potentially
What is flaccid spinal cord injury
- Conus lesions (lower spinal cord) - decentralised bladder
What three things are lost in flaccid spinal cord injury
- Reflex bladder contration
- Guarding reflex
- Rece[tive relxation
Features of flaccid spinal cord injury
- Areflexic bladder
- Stress incontinence
- Risk of poor compliance
- Puts kidneys at risk
What is spastic paralysis
- Conus functioning but not controlled by brain
- Reflex bladder - involuntary urination
- Reflex bowel - involuntary defecation
What is flaccid paralysis
- Conus destroyed or non-functional
- Areflexic bladder - fills til overflows
- Areflexic bowel - fills til overflows
Three goals of flaccid and spastic injuries
- Prevent autonomic dysreflexia
- Maintain bladder safety
- Symptom control
- TAMSULOSIN or sphincterectomy
- Cystoplasty
- Permenant catheterisation
What causes autonomic dysreflexia
- Over-distention of bladder in lesions above T6
Overstimulation of sympathetic nervous system below the levelk of lesion in response to stimulus
Symptoms of autonomic dysreflexia
headache
Severe hypertension
Flushing
Why do we want to maintain bladder safety
Puts kidneys at risk
Risk factors for bladder injuries
- Raised bladder pressure
- Vesico-ureteric reflux
- Chronic infection (stones)
How do we control symptoms in flaccid and spastic issues
Suppress reflexes by converting bladder to flaccid type and empty regularly
ORAL TAMSULOSIN or sphincterectomy
How do we treat sepsis
- Give high flow oxygen via non-rebreathe bag
- Take blood cultures
- Give IV antibiotics
- Start IV fluid resuscitation
- Check lactate
- Monitor hourly urine output and consider catheterisation
- WITHIN 1 HOUR
Why is Saline given to patients
Replace fluids and increase BP if low - normal composition to ECF
What is onctained in each litre of normal saline
- Around 150mmol of Na
- Around 150 mol of Cl
- Around 300mmol of osmotically active ions
- NO K+
What type of drug is Sildenafil
Phosphodiesterase (TYPE V) inhibitors
When is Sildenafil given
- Erectile dysfunction
2. Primary pulmonary hypertension
Pharmacology of Sildenafil
- Selective for phosphodiesterase type 5 which is found in smooth muscle of corpus cavernous of penis and lung arteries
Causes vasodilatation by inhibiting PDE5 which breaks down Cyclic GMP - increased Cyclic GMP causes smooth muscle relaxation
Adverse effects of Slidenafil
- Flushing, headache, dizziness, HYPOTENSION, tachycardia and palpitations
- Increased risk of MI and stroke
AVOID where vasodilatation is dangerous
What drugs contraindicate slidenafil
- Drugs that increase NOX - severe vasodilatation and Cv collapse
How does OXYBUTYNIN work (anti-muscarnic)
- Inhibits acetylcholine, blocking muscarinic receptors and promoting bladder relaxation to increase capacity
SELECTIVE for M3
Adverse effects of Oxybutynin
- Dry mouth
- Tachycardia
- COnstipation
- Blurred vision
- Contraindicated in UTI
Why can’t oxybytynin be used in glaucoma
Causes rise in intraocular pressure and in patients with arrhythmias and those at risk of urinary retention
How does Bicalutamide work
- Anti androgen - decreases body’s response to androgens - prostate cancer
Contraindications for bicalutamide
GI disturbance and liver injury
