GU Flashcards
hesitancy, decreased caliber and force of stream, post void dribbling
Bladder outlet obstruction (BOO)
- sx of BPH
frequency, urgency, nocturia
lower urinary tract sx (LUTS):
- sx of BPH
One of most common disorders in older men
Increased # of stromal and epithelial cells within the prostate gland itself → enlargement
Associated with lower urinary tracts sx (LUTS)
Divided into 3 groups: filling and storage sx, voiding sx, post-micturition sx
These have a large impact on QOL → monitor closely
BPH
PE for PBH
DRE (nontender, rubbery and smooth, often can’t feel median sulcus), quantify sx using AUA Symptom index for BPH, lower ABD exam, neuro exam (focused to assess sacral nerve roots)
Diag for BPH
U/A, BMP, bladder ultrasound for post void residual, PSA?
How to manage BPH
Behavioral modifications
Alpha-blockers, 5ɑ-reductase inhibitors, phosphodiesterase 5 inhibitors
TURP (transurethral incision of the prostate), Prostatectomy
Shrink the gland, can take 6-12 mos for effect. Avodart can affect PSA results. Given for BPH
5ɑ-reductase inhibitor: dutasteride and finasteride
administer at bedtime to reduce dizziness and assist urine flow. Given for BPH
alpha -adrenergic antagonists: Terazosin and doxazosin
Asymptomatic in early stages then may develop -> urinary hesitancy, urgency, nocturia, frequency & hematuria.
> advanced = back pain and impotence, signs of metastasis
Prostate cancer
How to manage prostate cancer
watchful waiting - monitoring PSA and DRE- if no mets
Radiation, Brachytherapy, hormonal therapy (goal = suppress testosterone), surgery
Diagnosing Prostate CA?
PSA (above 4 ng/mL; although can be normal)
4-10ng/mL may suggest early prostate CA;
above 10 ng/mL suggest CA; PSA velocity (rate of rise) more than 0.75ng/mL; DRE, TRUS (transrectal US) with biopsy.
Younger men PSA > 2.6ng/mL consider biopsy
What to do after tx for prostate cancer?
recheck PSA at 6 and 12 mos and then annually; any subsequent increase in PSA warrants biopsy
Screening for prostate cancer?
shared decision-making. Greatest benefit age 55-69 q2 yrs.
bacterial infection
Chills, fever, blood in urine/ semen, urinary sx.
prostatitis
Dx and labs for prostatitis
dx: DRE
Labs: CBC, BMP, PSA, UA with gram stain and culture
Consider STI te
Tx of acute prostatitis
Acute bacterial:
Severely ill bacterial prostatitis: hospitalization for IV fluoroquinolones (levo or cipro).
Consider hospital if febrile.
Outpatient tx: trimethoprim-sulfamethoxazole (Bactrim) AND fluoroquinolones for 2-4 weeks.
Sitz baths, analgesics, antipyretics, and stool softeners. Consider bed rest.
Tx of chronic prostatitis
trimethoprim-sulfamethoxazole (Bactrim) DS 1 tab (PO BID x 6 weeks) or Cipro 500 mg PO BID x 6 weeks
May combine with alpha-blockers for sx relief and reduce recurrence. Avoid coffee, tea, and alcohol. Assess use of anticholinergics, sedatives, and antidepressants.
Nonbacterial: fluoroquinolones with alpha- blockers and NSAIDs
Education for prostatitis
use condoms to prevent reintroduction of bacteria into urethra; avoid anal intercourse with acute bacterial prostatitis.
Basic guidelines for managing PSAs? referral…
Urology referral
- PSA > 4 = (age adjusted) and no signs of prostatitis OR
- PSA increase > 0.75 ng/mL in 1 year (even in level under 4)
- nodule on DRE
Screening PSAs?
always do DRE with PSA. get family hx
Age adjusted PSA threshholds
age 40-49 = 2.5
age 50-59= 3.5
age 60-69= 4.5
age 70-79= 6.5
common in kids. Common causes: fever. Persistent may be a/w renal disease. 24hr urine protein recommended. If not able can get spot first morning urine.
proteinuria
How to manage asymptomatic hematuria in kids?
requires periodic evaluation every 1 to 2 years to reevaluate for coexisting conditions or proteinuria, and to revisit family history of hematuria or hearing deficits.
Dx hematuria in kids?
Urine dipstick analysis for pyuria, proteinuria, hematuria, and concentration
If greater than 1+ hematuria by dipstick- microscopic examination for RBCs is needed to differentiate RBCs from hemoglobinuria or myoglobinuria.
What to do if proteinuria found in kids?
common
repeat lab - early am
if neg or trace - recheck 1 year
if >2 + refer
what to do if Wilms tumor or nephrolithiasis is suspected
Renal ultrasound
suggestive of an upper tract disorder in kids
flank pain
suggests an obstruction, such as Wilms tumor, cystic disease, or posterior valves in kids
Abdominal or flank mass
Malformed ears
congenital renal disease
persistent proteinuria, hypoalbuminemia, HLD, and peripheral edema
Often immunologic in children (atopic disease), DM #1 cause in adults
nephrotic syndrome
periorbital edema; ill appearing, muscle wasting, HTN, GI sx
nephrotic syndrome
What to do if you suspect nephrotic syndrome?
REFER to hospital; can lead to renal failure
UTD on routine immunizations; salt and protein restriction. Prompt tx of infections. Risk of recurrence- chronic condition. Tx w/ corticosteroids
Labs for nephrotic syndrome
UA, CBC with diff, CMP, lipid panel
Gross proteinuria
hypoalbuminemia
hyperlipidemia
peripheral edema
nephrotic syndrome
Gross hematuria
recent infection: throat/ skin
Glomerulonephritis
unilateral; a/w congenital anomalies (cryptorchidism, ureteral duplication, and hypospadias). Familial or idiopathic. Mets present in 10-15% of cases on diagnosis
Often diagnosed b/t 3.5-4yrs old
Cure rate 90%
CM: asymptomatic unilateral mass. Abd pain/distention. HTN, n/v, FUO
Diag: CBC, CMP, UA, US; ABD and pelvis MRI or CT w/ contrast and chest CT for mets
Tx: Chemo, kidney resection. Radiation in advanced cases.
Wilms tumor/Nephroblastoma
most common in children 4-14yo
1-2wks after strep throat and 3-5 wks after strep skin infection
CM: hematuria* (macroscopic or microscopic) can persist for 1-2 weeks and show up as microscopic on UA for 2 yrs, edema, htn
Post streptococcal glomerulonephritis-
Dx and tx of Post streptococcal glomerulonephritis-
Dx: UA (RBC casts, hematuria, proteinuria)
- ASO (antistreptolysin antibody)- strep infection
- Anti-DNAce B (usu + following impetigo)
- Complement profile (low C3, Normal C4)
- US
- Renal biopsy if disease course is atypical
Tx: fluid and NA restriction, ABX, loop diuretics, supportive care. Hospitalize if severe oliguria and HTN.
Gross hematuria oliguria lethargy anorexia may have htn
glomerulonephritis
Renal cell carcinoma (RCC) most common
RF: smoking, abdominal imaging, obesity, long-term dialysis, and fam hx. M>W; higher incidence in black men
Mets often to lungs; mets often present at diagnosis
Prognosis poor
Surgery only cure
kidney cancer
obstruction or tumor of ureters can cause hydronephrosis
ureter cancer
RF: cigarette smoking
CM: intermittent hematuria throughout urination. May have urgency, frequency, and dysuria.
Diag: CT urogram, refer for cystoscopy
Tx: transurethral resection of tumor; radical cystectomy
bladder cancer
with increased ABD pressure (coughing, sneezing)
Anatomic vs intrinsic sphincter deficiency (bladder neck remains open, even mild increase in pressure causes leakage)
Stress incontinence
incontinence most often associated with BPH
overflow
urinary and frequency common - may not have overflow incontinence
OAB (over active bladder)
DIAPPERS for incontinence
Delirium, Infection, atrophic urethritis/vaginitis, Pharmaceuticals, psychological (severe depression; rare), excess UOP (CHF, hyperglycemia), Restricted mobility, Stool impaction
PE for incontinence
abd, GU, pelvic, rectal, neuro, extremity edema
Men: phimosis, balanitis, infection, rectal masses, prostate nodules, fecal impaction.
Women: urethral mobility (Q-tip test), cough (observe for incontinence) supine or standing, pelvic organ prolapse, bladder distention. Lack of estrogen is r/t incontinence
Dx for incontinence
UA w/ culture, BUN/creat, post-void residual, bladder stress test, BMP, glucose/ HgbA1C
Tx for incontinence … stress
timed voiding, double voiding, pelvic muscle exercises, pessary placement, bowel management. Tobacco cessation (bladder irritant and cough increases ABD pressure), bowel management
Refer: pelvic floor PT, pessary fitter
Meds:; alpha-adrenergic agonists (pseudoephedrine (Sudafed)), estrogen replacement.
Periurethral Estrogen cream (daily for 2 weeks, twice weekly after)- counsel on risk vs benefit and use for shortest time possible
Imipramine or other TCAs for younger pts if other txs ineffective. 10-25mg one-three times daily
Tx for incontinence … urge
same as stress; bladder training (resist urge and void on a schedule). Avoid spicy, acidic, and caffeinated foods. Chocolate, tomatoes, citrus fruits or juices, nuts, coffee, tea, dark soda, alcohol. Moderation of fluid intake to 48-64 oz/day
Meds: anticholinergic-antimuscarinics
Tolterodine tartrate (Detrol) and oxybutynin chloride (Ditropan)- can contribute to cognitive decline in elderly
Vaginal estrogen for postmenopausal women
TCAs
Tx for incontinence … mixed
Duloxetine/cymbalta
Tx for incontinence … overflow
timed and double voiding; clean intermittent catheterization, pessary, surgery
Meds men only!: for BPH- tamsulosin (Flomax) terazosin (Hytrin), finasteride (Proscar), dutasteride (Avodart)
RF: heavy cigarette use, obesity, OSA, HTN, DM, CV disease, psychological issues, stressors
Determine if organic or psychogenic cause
DDx: cardiovascular disease
*Common SE of SSRI, SNRIs, and TCAs
Male sexual disease
Tx for Male sexual disease
therapy, PDE5 inhibitors: sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis) (once daily), and avanafil (Stendra) → cannot be taken with nitrates; caution with alpha blockers
2nd line: intraurethral suppositories, intracavernous injections, vacuum pump devices
Alprostadil (prostaglandin E1): neurogenic, psychogenic, or angiogenic causes→ refer to urology for management
Workup for ED?
CBC w/ diff, TSH, fasting serum glucose or A1C, electrolytes, BUN & creatinine, PSA, Testosterone, prolactin levels, lipids, UA
What to screen for in all men with ED?
Cardiac- ASCVD risk
increases risk of CV disease and ESRD. Predictor of HTN. Can be exercise induced
protinuria
hallmark of renal disease
Proteinuria: More than 150 mg/day (10-20 mg/dL) hallmark
sign of early renal disease, esp with diabetes. 30-150 mg protein/day
Microalbuminuria
Macroalbuminuria
> 300 mg/day
Dx labs proteinuria ?
1. repeat UA, CBC with diff, BMP, HgA1c, lipids, urine c/s, SPEP/UPEP, albumin/ Cr ratio, protein/ Cr ratio, 24 hr urine protein
proteinuria (1+ or greater) on urine dipstick should be investigated. 24-hr urine protein and creatinine (urine protein >150 mg in 24hrs).
3.5g/day or more of protein; with hypoalbuminemia, hyperlipidemia, and edema → send to a nephrologist
Nephrotic syndrome
Bence Jones proteins in urine (SPEP/UPEP)
Multiple myeloma
Tx of proteinuria?
Manage underline disease, and eliminate trigger meds.
ACE or ARB; control DM, HTN, and hyperlipidemia. May need Na and protein-restricted diet
ACE inhibitors and ARBs reduce proteinuria by lowering the intraglomerular pressure, reducing hyperfiltration. These drugs tend to raise the serum potassium level and reduce the glomerular filtration rate (GFR). _ must monitor the serum K, Cr levels, and the GFR
Proteinuria in pregnancy
after 24wks thinking preeclampsia/ before 24wks think infectious cause (glomerulonephritis)
most common sign of bladder CA
hematuria
Definition of hematuria
3 or more RBCs per high-power field.
Gross vs microhematuria
visible vs not visible
decreased GFR, increased serum creatinine, and albumin in urine.
Regular UAs are recommended for pts with HTN and DM to assess urinary albumin/creatinine ratio to detect early kidney disease.
renal failure
↑ serum creatinine of 0.3 mg/dL over 48 hrs OR ↑ serum creatinine to 1.5x baseline in 7 days OR UOP < 0.5 mL/kg/h for 6 hours.
AKI
Decrease in kidney function over 3mos. Decrease in GFR and albumin in urine are first signs.
pts who receive dialysis or a kidney transplant are eligible for Medicare regardless of age
CKD
CM: typically asymptomatic until GFR <35. ARF: confusion, anorexia, n/v, edema, and weight gain.
PE: fundoscopic (AV nicking, diabetic retinopathy, papilledema), peripheral pulses, fluid overload (JVD, adventitious lung sounds, edema), pericarditis. Auscultate for renal artery bruits, palpate kidneys, abd for ascites and percussion for bladder distention. Skin: ecchymosis and rashes, uremic frost
CKD
DIag CKD?
serum creat with eGFR and urine sample for albuminuria. ACR(albumin creatinine ratio) >30 mg/g confirm with a first morning urine
Tx CKD?
avoid nephrotoxins (NSAIDs, contrast dye), manage fluid intake, low protein and low salt diet, ACE-I or ARB (only d/c inf creat increases 30%). Monitor serum potassium (thiazide diuretic may need to be added to manage hyperkalemia). If pt can’t take ACE-I or ARB, next is nondihy CCB Avoid potassium-containing salt substitutes
Ensure UTD on vaccines (flu, pneumococcal and hep B) qualify for pneumococcal earlier than 65. Assess for depression, insomnia, anxiety and sexual dysfunction.
GFR <30 (or >25% decrease)→ initiate advance-care planning and refer to nephrologist
Monitor for anemia once-twice yearly
Replace vit D when <30 ng/mL
How to manage diabetics with CKD
d/c metformin if GFR<30, consider switching when GFR <45
Medicare will cover annual medical nutritional therapy with a registered dietician for pts with DM or CKD at no cost to pt
Management of Stage 3 CKD
diet? Supplements?
3a= 45-59 GFR 3b= 30-44 GFR
limit phosphates in diet (excretion is decreased … hyperphosphatemia and hyperparathyroidism leads to calcium removal from bones)
Ca: 1000 mg/day for adults and 1200 mg/day for older adults.
Calcium acetate recommended for later stage CKD, helps remove phosphate
What to give to tx Hyperlipidemia in pts with CKD?
atorvastatin requires no renal dosing. Only use fluvastatin in pts with severe renal dysfunction
Chronic inflammation of the bladder
CM: Bladder pain, urinary frequency or urgency, or nocturia in the absence of another disease that could cause the sx. Suprapubic pain or pain in low back or buttocks
interstitial cystitis
