GU 2 Flashcards
1
Q
what are features of chronic urine retention?
A
- more insidious and may be painless
- more difficult to define
- incomplete bladder emptying
- results in a increased risk of infection
- can be low pressure with detrusor failure
- can be high pressure with risk of interactive obstructive uropathy
2
Q
what is a complicated UTI? what are features of treatment and complications?
A
- infection in patients with abnormal urinary tract e.g. stones, obstruction or systemic disease involving the kidney e.g. diabetes mellitus, sickle-cell, or virulent organism e.g. Staphylococcus Aureus
- treatment failure is more likely
- complications are more likely e.g. renal papillary necrosis and renal abscess
- majority of UTI’s in men are considered complicated, associated with urological abnormalities such as bladder outlet obstruction
3
Q
what is the epidemiology of UTIs?
A
more common in women - affects 1/3rd in lifetime
4
Q
what are risk factors for UTIs?
A
- female
- sex
- pregnancy
- menopause
- decrease in host defence
- urinary tract obstruction resulting in urine stasis
- catheter
5
Q
what is the pathogenesis of UTIs?
A
- infection of urinary tract via the ascending transurethral route; sex and urethral catheter contribute
- women are most susceptible due to shorter urethra and proximity to anus facilitates the transfer of bowel organisms to bladder
- E.coli is the most common cause and arises from patients own flora
6
Q
what is pyelonephritis?
A
infection of the renal parenchyma and soft tissues of renal pelvis and upper ureter
7
Q
what are the main organisms causing pyelonephritis?
A
KEEPS • Klebsiella spp. • E.coli - majority • Enterococcus spp. • Proteus spp. • Staphylococcus spp - coagulase negative
8
Q
what is the epidemiology of pyelonephritis?
A
- predominantly affects females under 35 yrs
- associated with significant sepsis and systemic upset
- unusual in men
- mainly caused by uropathogenic E.coli, typically with P pilli on surface to all ureteral ascent
9
Q
what are risk factors for pyelonephritis?
A
- structural renal abnormalities
- calculi (stones)
- catheterisation
- pregnancy
- diabetes
- immunocompromised patient
10
Q
what is the pathophsyiology of pyelonephritis? how is it spread?
A
- infection is mostly due to bacteria (primarily E.coli) from own patients bowel flora
- most commonly spread via the ascending transurethral route but can be via the bloodstream or lymphatics
11
Q
what are the adhesive factors of E. coli?
A
- P pilli to allow ureteral ascent
- aerobactin - for Fe acquisition
- haemolysin- for pore formation
12
Q
what is the triad of common symptoms in pyelonephritis?
A
loin pain, fever and pyuria
13
Q
what is the clinical presentation of pyelonephritis?
A
- triad of: loin pain, fever and pyuria
- may have severe headache
- rigors
- significant bacteriuria
- malaise, nausea, vomiting
- oliguria (small amounts of urine) if it causes AKI
14
Q
what are differential diagnoses of pyelonephritis?
A
diverticulitis, abdominal aortic aneurysm, kidney stones, cystitis, prostatitis
15
Q
what is used to diagnose pyelonephritis?
A
- tender loin on examination
- urine dipstick
- midstream urine microscopy, culture and sensitivity; gold standard for diagnosis
- bloods
- urgent ultrasound
16
Q
what are features of pyelonephritis on urine dipstick?
A
- nitrites, released by bacteria breaking down nitrates
- leucocyte elastase
- foul-smelling urine
- protein
17
Q
what is seen on bloods in pyelonephritis?
A
- FBC shows elevated white cell count
* CRP and ESR may be raised in acute infection
18
Q
what is the treatment of pyelonephritis?
A
- rest
- cranberry juice and lots of water
- analgesia
- antibiotics
- surgery to drain abscesses or relieve calculi that are causing infection
19
Q
what antibiotics are used to treat pyelonephritis?
A
- oral ciprofloxacillin or oral co-amoxiclav
- if severe then IV gentamicin or IV co-amoxiclav
20
Q
what is the epidemiology of cystitis?
A
urinary infection of the bladder
- much more common in women
- can occur in children
- most common cause is E.coli
21
Q
what are risk factors for cystitis?
A
- urinary obstruction resulting in urinary stasis
- previous damage to bladder epithelium
- bladder stones
- poor bladder emptying
22
Q
what is the clinical presentation of cystitis?
A
- dysuria
- frequency
- urgency
- suprapubic pain
- haematuria
- offensive smelling/cloudy urine
- abdominal/loin tenderness
23
Q
what is used to diagnose cystitis? what is seen in a urine dipstick?
A
- gold standard is microscopy and sterile midstream urine sample
- dipstick urinalysis: positive leucocytes, blood and nitrites
24
Q
what are the first and second-line antibiotic treatments for cystitis?
A
1st: trimethoprim or cefalexin
2nd: ciprofloxacin or co-amoxiclav
25
what is prostatitis?
* infection and inflammation of the prostate gland
| * can be acute or chronic
26
what is the epidemiology of prostatitis?
- common in men of all ages
- most common UTI in men < 50
- usually presents > 35 yrs
- associated with LUTS
27
what are causes of acute and chronic prostatitis?
* bacterial e.g. Streptococcus faecalis, E.coli or Chlamydia
| * non-bacterial e.g. elevated prostatic pressure, pelvic floor myalgia
28
what are the risk factors for prostatitis?
- STI
- UTI
- indwelling catheter
- post-biopsy
- increasing age
29
what is the clinical presentation of acute prostatitis?
* systemically unwell
* fever, rigors, malaise
* pain on ejaculation
* significant voiding LUTS e.g. poor intermittent stream, hesitancy, incomplete emptying, post micturition dribbling, straining, dysuria
* pelvic pain
30
what is the clinical presentation of chronic prostatitis?
* acute symptoms for > 3 months
* recurrent UTIs
* pelvic pain
31
what are the differential diagnoses of prostatitis?
cystitis, BPH, calculi, bladder neoplasia, prostatic abscess
32
what is used to diagnose prostatitis?
- DRE
- urine dipstick is positive for leucocytes and nitrites
- mid-stream urine microscopy and sensitivity
- blood cultures
- sexually transmitted infection screen, for chlamydia in particular
- trans-urethral ultrasound scan
33
what is seen on DRE in prostatitis?
* prostate is tender or hot to touch
| * hard from calcification
34
what is the treatment of acute prostatitis? what drugs are given?
* IV gentamicin + IV coamoxiclav or IV tazocin or IV carbapenem
* 2-4 weeks on a quinolone e.g. ciprofloxacin (antibiotic) once well
* second line - trimethorpin
* TRUSS guided abscess drainage if necessary
35
what is the treatment of chronic prostatitis?
* 4-6 week course of quinolone e.g. ciprofloxacin (antibiotic)
* but they don’t tend to respond as well to antibiotics
* +/- alpha-blocker
* NSAIDs
36
what is urethritis?
* urethral inflammation due to infectious or non-infectious causes
* primarily a sexually acquired disease
37
what is the epidemiology of urethritis?
- most common condition diagnosed and treated in men at GUM clinics
- non-gonococcal urethritis is the more common than gonococcal urethritis
- chlamydia is the most common STI in young people aged 15-24 yrs
38
what is the most common STI in young people aged 15-24?
Chlamydia
39
what are the infective causes of urethritis?
- Neisseria gonorrhoea
- Chlamydia trachomatis (most common cause)
- Mycoplasma genitalium
- Ureaplasma urealyticum
- Trichomonas vaginalis
40
what are non-infective causes of urethritis?
- trauma
- urethral stricture
- irritation
- urinary calculi
41
what are the risk factors for urethritis?
- sexually active
- unprotected sex
- male to male sex
- being male
42
what is the clinical presentation of urethritis?
- may be asymptomatic (90-95% with gonorrhoea, 50% of patients with chlamydia)
- dysuria (painful urination) +/- discharge; blood or pus
- urethral pain
- penile discomfort
- skin lesions
- systemic symptoms
43
what are differential diagnoses of urethritis?
Candida balantis, epididymitis, cystitis, acute prostatitis, urethral malignancy
44
what is used to diagnose urethritis?
- nucleic acid amplification test
- microscopy of gram-stained smears of genital secretions
- blood cultures
- urine dipstick to exclude UTI
- urethral smear
45
how is nucleic acid amplification test used to diagnose urethritis?
* female: self collected vaginal swab, endocervical swab, first void urine
* male: first void volume
* high specificity and sensitivity
46
what is epididymo-orchitis? what is it mainly caused by?
- acute epididymo-orchitis is a clinical syndrome of pain, swelling and inflammation of the epididymis that can extend into the testis
- caused mainly by the extension of infection from the urethra or bladder
47
what is the epidemiology of epididymo-orchitis?
most common in male 15-30 yrs olds and those over 60
48
what are the infective causes of epididymo-orchitis for those under 35 years?
* Chlamydia trachomatis
| * Neisseria gonorrhoea
49
what are the infective causes of epididymo-orchitis for those over 35 years?
UTI - KEEPS:
- Klebsiella spp
- E.coli (most common)
- Enterococci
- Pseudomonas
- Staphylococcus - coagulase negative
50
what are the non-infective causes of epididymo-orchitis?
- mumps
- trauma
- in elderly its predominantly catheter related
51
what are risk factors for epididymo-orchitis?
- previous infection
- indwelling catheter
- structural/functional abnormality of urinary tract
- anal intercourse
52
what is the clinical presentation of epididymo-orchitis? what is seen on examination?
- subacute onset of unilateral scrotal pain and swelling
- in STD epididymo-orchitis there may be urethritis or urethral discharge
- mumps usually presents with headache, fever and unilateral or bilateral parotid swelling
- sweats/fever
- on examination there is tenderness and palpable swelling of the epididymis and testicles
53
what are differential diagnoses of epididymo-orchitis?
testicular torsion, hydrocele, trauma, abscess formation
54
how should testicular torsion be differentiated from epididymo-orchitis? what are features that are suggestive of tosion?
```
• must rule this out
• if in any doubt then do surgical scrotal exploration
• features suggestive of torsion:
- short duration of pain - sudden onset
- associated nausea/abdominal pain
- high-riding/bell-clapper testis
```
55
what is used to diagnose epididymo-orchitis?
- nucleic acid amplification test
- mid-stream urine dipstick for UTI symptoms
- ultrasound to rule out abscesses
- STD screening
- urethral smear and swab
56
what is the treatment of epididymo-orchitis?
- chlamydia: oral doxycycline 7 days or stat azithromycin
- gonorrhoea: IM ceftriazone and stat oral azithromycin
- UTI: oral ciprofloxacin or oral ofloxacin
- antibiotics should be used for 2-4 weeks
- analgesia - NSAIDs e.g. ibuprofen
- scrotal support - supportive underwear
- abstain from sexual intercourse
- partner notification and testing
57
what organism causes Chlamydia?
Chlamydia trachomatis
58
what organism causes Gonorrhoea?
Neisseria gonorrhoea
59
what is the epidemiology of Chlamydia vs Gonorrhoea?
* Chlamydia is more common in women and 15-25yr olds
* Gonorrhoea is more common in men and is less common than chlamydia
* asymptomatic carriage of chlamydia is much more common than gonorrhoea
60
where are sites of occurrence of Chlamydia and Gonorrhoea in the adult?
* urethra
* endocervical canal
* rectum
* pharynx
* conjunctiva
61
where are sites of occurrence of Chlamydia and Gonorrhoea in the neonate?
* conjunctiva
| * atypical pneumonia
62
what are features and intubation of CT and GC in males?
- primary site of infection is urethra
- dysuria and urethral discharge (mainly gonorrhoea)
- CT: 7-21 days
- GC: 2-5 days
63
what are features of asymptomatic CT and GC in males?
* CT - at least 50% - more likely to be asymptomatic thus more likely to get complications since undetected and thus untreated for longer
* GC - 10%; 90% men have symptoms
64
what is the transmission of CT and GC from female to male?
* CT - 70%
| * GC - 60-80% (20% if single encounter)
65
what are features and intubation of CT and GC in females?
- primary site of infection is cervix
- non-specific symptoms of dysuria, menstrual irregularity and discharge
- CT: ill-defined
- GC: up to 10 days
66
what are features of asymptomatic CT and GC in females?
* CT - over 70%
| * GC - 50%
67
what is the transmission of CT and GC from males to females?
* CT - 70%
| * GC - 50-90%
68
what are complications of CT and GC in females?
- pelvic inflammatory disease
- neonatal transmission
- Fitz Hugh Curtis syndrome; peri-hepatitis but no decline in liver function
69
what are features of pelvic inflammatory disease as a complication of CT and GC?
- infection spreads up to the fallopian tube leading to inflammation and scarring
- tubular factor infertility
- ectopic pregnancy
- chronic pelvic pain
70
how is Chlamydia diagnosed?
* often diagnosed in established relationships since there is a long asymptomatic carriage
* Nucleic Acid Amplification Tests: high specificity and sensitivity, but negative test doesn't mean non-infection
71
how is Gonorrhoea diagnosed?
* associated with recent partner change
* near patient testing
* culture on selective medium to confirm
* antibiotic sensitivity testing
* NAAT
72
how is near patient testing used to diagnose Gonorrhoea?
- microscopy of gram stained smears of genital secretions, looking for gram negative diplococci
- males; sample from urethra
- females; sample from endocervix
73
what is the treatment of Chlamydia? what drugs are used?
* partner management
* test for other STIs
* oral azithromycin stat (convenient - just 1 dose) or oral doxycycline for 7 days (less convenient, but more effective)
74
what is the treatment of Chlamydia in pregnant women?
erythromycin for 14 days or azithromycin stat
75
what is the treatment for Gonorrhoea? what drugs are given?
* partner notification
* test for other STIs
* continuous surveillance of antibiotic sensitivity
* single dose treatment is preferred
* IM ceftriaxone with azithromycin stat
76
what is the neural control of the lower urinary tract?
- parasympathetic (cholinergic); S3 ,S4 and S5:
• drives detrusor contraction
- sympathetic (noradrenergic); T10, L1, L2:
• urethral contraction (smooth muscle component but remember the main part of the sphincter is skeletal muscle)
• inhibits detrusor contraction
77
in which gender is urinary incontinence more common in?
females
78
what is stress incontinence?
- caused by sphincter weakness
| - small leak of urine when intra-abdominal pressure rises e.g. when coughing, laughing and standing up
79
what are the causes of stress incontinence?
* women; secondary to birth trauma
* men; post-prostatectomy
* neurogenic or congenital
80
what is the treatment of stress incontinence in females?
- pelvic floor exercises
- duloxetine
- surgery: sling, artificial sphincter
81
what is the treatment of stress incontinence in males?
artificial sphincter or male sling
82
what are the causes of urge incontinence?
* detrusor overactivity; rise in detrusor pressure on filling associated with urgency (most common in women)
* less commonly by bladder hypersensitivity from local pathology e.g. UTI, bladder stones or tumour
83
what is the treatment of urge incontinence?
* bladder exercises; gradually increasing the interval between voids
* behavioural therapy; controlling caffeine, alcohol and frequency volume charts
* drugs
* surgery
84
what drugs are used to treat urge incontinence?
- anticholinergic agents
- beta3 agoinst e.g. mirabegron
- botox of bladder
85
what is an example of a beta3 agonist?
mirabegron
86
what are surgical treatments of urge incontinence?
- detrusor myectomy
| - cystoplasty
87
how is cystoplasty used to treat urge incontinence?
- adding some bowel to bladder to increase surface area
- gives increased bladder capacity and reduced detrusor overactivity
- may have to self-catheterise due to muscle loss
88
what spinal reflexes control the bladder?
- reflex bladder control from sacral micturition centre
| - guarding reflex
89
what is the guarding reflex?
proximal part of sphincter senses urine and sends impulse to spinal cord to tell Onuf’s nucleus to store urine
90
what is the effect of a spastic spinal cord injury on the bladder?
* supra-conal (higher in spinal cord) lesion
* loss of co-ordination and completion of voiding
* reflexes work but are not controlled by the brain
91
what are features of spastic spinal cord injury?
- reflex bladder contractions
- detrusor sphincter dyssynergia; loss of completion of voiding
- poorly sustained bladder contraction
- potentially unsafe - puts kidneys at risk
92
what is the effect of a flaccid spinal cord injury on the bladder?
conus lesion (lower spinal cord injury) - decentralised bladder
93
what is lost in a flaccid spinal cord injury?
- reflex bladder contraction
- guarding reflex
- receptive relaxation
94
what are the features of a flaccid spinal cord injury?
- areflexic bladder
- stress incontinence
- risk of poor compliance
- potentially unsafe - puts kidneys at risk
95
what are features of spastic paralysis vs flaccid paralysis?
spastic paralysis:
- conus (lower end of spinal cord) functioning but not controlled by the brain
- reflex bladder - involuntary urination (i.e. when senses full)
- reflex bowel - involuntary defecation
flaccid paralysis:
- conus destroyed or non-functional
- areflexic bladder - fills until it overflows
- areflexic bowel - fills until it overflows
96
what are features of autonomic dysreflexia caused by neuropathic bladder problems?
* commonly causes by over-distension of bladder
* cccurs in lesions above T6
* overstimulation of sympathetic nervous system below the level of lesion in responses to a noxious stimulus
* headache, severe hypertension and flushing
97
what are features of maintaining bladder safety through treatment of neuropathic bladder problems? what could it lead to if not treated?
• an unsafe bladder is one that puts kidneys at risk
• risk factors:
- raised bladder pressure
- vesico-ureteric reflux
- chronic infection e.g. residual urine/stones
98
what are features of symptom control of neuropathic bladder problems?
* harness reflexes to empty bladder into incontinence device, but may not keep bladder safe!
* suppress reflexes converting bladder to flaccid type and then empty regularly
99
what is the treatment of neuropathic bladder problems?
* alpha adrenergic blockers e.g. oral tamsulosin or sphincterotomy
* cystoplasty
* permanent catheterisation
100
what is the sepsis 6?
* give high flow-oxygen via non-rebreathe bag
* take blood cultures and consider source control
* give IV antibiotics
* start IV fluid resuscitation
* check lactate
* monitor hourly urine output and consider catheterisation
* within 1 hour
101
what is the use of saline?
* used to replace fluids and try to increase blood pressure
| * normal saline is physiologically similar to the normal composition of extracellular fluid
102
what does each litre of normal saline contain?
- around 150mmol of Na+
- around 150mmol of Cl-
- around 300mmol of osmotically active ions
- virtually no K+
103
what are examples of alpha blockers?
tamsulosin, alfuzosin, doxazocin
104
what are indications for alpha blockers?
- first line treatment for benign prostatic hyperplasia where lifestyle changes are insufficient
- can be used alongside 5-alpha reductase inhibitors e.g. finasteride or surgery
- can be used to aid passage of kidney stones
105
what are the mechanisms of action of alpha blockers?
- highly selective for the alpha1 adrenoceptor found mainly in smooth muscle including blood vessels and the urinary tract (bladder neck and prostate)
- stimulation induces contraction, blockage induces relaxation so thus causes vasodilatation and a fall in blood pressure and a reduced resistance to bladder outflow
106
what are the adverse effects/contraindications of alpha blockers?
- can cause postural hypertension, dizziness and syncope
- should not be used in existing hypotension
- combining antihypertensives can provide profound effect so omitting doses of other medications when starting can help avoid first dose hypertension
107
what is an example of 5-alpha reductase inhibitors?
finasteride
108
what are indications for 5-alpha reductase inhibitors?
- used for treatment of benign prostatic hyperplasia as an add on to alpha blockers
- provides less relief and takes longer for effect
109
what are mechanisms of action of 5-alpha reductase inhibitors?
- 5-alpha reductase is the enzyme that converts testosterone to dihydrotestosterone (active form of testosterone), so blocking this conversion results in a dramatic decrease in serum dihydrotestosterone levels
- this reduces prostate volume so improves symptoms of the enlarged prostate and reduces the risk of cancer
110
what are adverse effects/contraindications of 5-alpha reductase inhibitors?
- since this treatment lowers PSA it may hide prostate cancer, there is a possible risk of sexual dysfunction
- contraindicated for used in women
111
what are examples of PDE type V inhibitors?
sildenafil
112
what are indications for PDE type V inhibitors?
- erectile dysfunction
| - primary pulmonary hypertension
113
what are mechanisms of action of PDE type V inhibitors?
- sildenafil is selective for phosphodiesterase type 5 (PDE5) which is predominantly found in the smooth muscle of the corpus cavernous of the penis and the arteries of the lung
- causes vasodilatation by inhibiting PDE5 which is responsible for the breakdown of cyclic GMP, thus increasing cyclic GMP concentrations which then causes arterial smooth muscle relaxation and vasodilation and penile engorgement
114
what are adverse effects/contraindications of PDE type V inhibitors?
- flushing, headache, dizziness, nasal congestion and more seriously, hypotension, tachycardia and palpitations
- increased risk of MI and stroke
- should be avoided where vasodilatation is dangerous i.e. in recent stroke, acute coronary syndrome or other CVD and should be used with caution in hepatic and renal failure
- contraindicated with other drugs that increase nitric oxide i.e. nitrates, since combined effect on cyclic GMP can cause severe vasodilation and cardiovascular collapse
115
what are examples of anti-muscarinics?
oxybutynin, tolterodine
116
what are indications for anti-muscarinics?
to reduce urinary frequency, urgency and urge incontinence in an overactive bladder
117
what are mechanisms of action of anti-muscarinics?
- competitively inhibits acetylcholine, blocking the muscarinic receptors and promoting bladder relaxation to increase capacity
- this reduces urgency and frequency of urination
- these muscarinics are selective for M3 receptor which is the main receptor in the bladder
118
what are adverse effects/contraindications of anti-muscarinics?
- dry mouth, tachycardia, constipation and blurred vision
- contraindicated in UTI, use with care in the elderly as can cause drowsiness
- use with care in angle closure glaucoma as can cause rise in intraocular pressure, and in patients with arrhythmias and those at risk of urinary retention
119
what are examples of androgen receptor blockers?
flutamide, bicalutamide, cyproterone acetate
120
what are indications for androgen receptor blockers?
used to treat prostate cancer
121
what are mechanisms of action of androgen receptor blockers?
- anti-androgens decrease the body’s response to androgens so are beneficial in prostate cancer, as the cells require androgen for growth
- drug competes with circulating androgens for receptors on prostate cells and promote apoptosis and inhibit growth
- can be used as monotherapy or with surgery or chemotherapy
122
what are adverse effects/contraindications for androgen receptor blockers?
- bicalutamide is better tolerated
| - GI disturbance and possible liver injury
