GU Flashcards
Myrbetric (mirabegron), used to treat overactive bladder, is classified as a:
Beta 3 agonist
According to the US Preventive Task Force, screening for prostate cancer:
Should include a discussion of benefits and burdens between patient and provider
Asymptomatic bacteruria:
. Does not require antibiotic treatment
What is the difference between UTI and ASB (asymptomatic Bacteriuria)?
- UTI
15.5% ID hospitalization/6.2% ID deaths
Prevalence > w/age; 30-40% institutionalized
Defined as:
Cystitis, pyelonephritis, prostatitis
Pyuria, symptomatic, culture confirming pathology - ASB
Prevalence > w/age; minimal-no mortality
Defined as:
105 CFU/ml or greater of 1 bacterial species in consecutive non-cath specimens (women=2; men=1)
What are some challenges when diagnosing UTI in older adults?
Symptoms highly variable Non-specific vs typical Difficulty assessing person with limited communication or poor baseline function Problems with collection Mid-stream clean catch or straight cath Remove IUC; new IUC to obtain specimen Results often misinterpreted/mishandled Pyuria poorly specific; absolute need for C&S and clinical eval
What are some contributing factors/risk factors to developing UTI?
Past UTI history
Male: BPH; PAF
Female: urethral stenosis; vaginal colonization; menopausal changes
Genetic pre-disposition; PVR; DM; iron deficiency anemia; pelvic prolapse; fluids; antibiotic use; coitus; catheterization
Healthy urinary tract is not sterile; may find bacteria in healthy adults
What does a physical assessment of r/o UTI include?
History
Physical Examination
U/A: *** definitive diagnosis
Urine Culture
What should you ask about in a history that you think may be a UTI?
“Classic” symptoms
Dysuria, flank or suprapubic pain, hematuria, frequency, urgency, foul-smelling or cloudy urine
“Non-specific”: ? Fever; UI, anorexia, nocturia, enuresis
Role of delirium
What should you include include in a physical assessment for UTI?
PE: often vague Vital signs CVA tenderness Abdominal Rectal Perineal/genital exam Other, prn
What might you find on a UA/UC with UTI?
Leukocyte esterase+ Indicates neutrophils assoc with pyuria Nitrate converts to nitrite+ UTI dx in elderly and men: pyuria (> 5-10 wbc/hpf) hematuria on u/a \+ dipstick > 105 on culture young women: dip; lower colony counts
what pathogens cause UTI in older adults?
E. coli
75-82% + culture in community dwelling women
Proteus mirabilis, pseudomonas, klebsiella pneumoniae
Catheter related: > 1 organism; proteus (mirabilis, stuarti, aeruginosia); candida, enterococcus
What does antibiotic treatment include for UTI/ASB in older adults?
ASB requires NO treatment/burden > benefit
Choice of agent: complicated vs. uncomplicated UTI
T/S; Nitrofurantoin
Fluoroquinolones (second line)
Length of treatment
3 days vs. 7-14 days
Continuous prophylaxis: relapse vs. reinfection
Differentiate between relapse and reoccurrence for UTI
Relapse: caused by bacterial persistence. Pathogen not completely eradicated by the course of ABX therapy
Reinfection: recurrence of infection due to new bacterial strain.
Most recurrent UTIs in women are due to reinfection.
Name some preventative measures for UTI/ASB
Can’t prevent ASB
Avoid catheterization
Antibiotic prophylaxis for recurrent UTI
Pre/post-coital strategies
Estrogen
fluids; cranberry juice/tablets; double voids; ? personal hygiene
Vaccines: being developed for prevention of E.coli UTI
What are Lower Urinary Tract Symptoms? (LUTS)
Storage or irritative symptoms Frequency Urgency/Urge UI/OAB Nocturia Voiding or obstructive symptoms Poor and/or intermittent stream/straining, Hesitancy/prolonged micturition/incomplete bladder emptying Dribbling
Define urinary incontinence and discuss prevalence and impact in older adult population.
Involuntary loss of urine Affects 17 million adults in the US 200 million world-wide 8-34% of non-institutionalized elderly 50-60% of LTC residents At least 11% of elderly in acute care Usually not life-threatening, but significant consequences
What are some anatomical and age-related contributing factors to urinary incontinence?
BPH/Menopause Age changes: increased PVR delay in onset of desire to void decreased bladder capacity change in voiding patterns DM; hysterectomy; stroke, obesity; functional impairments
What does DIAPERS stand for?
Types of Acute/transient UI Delirium Infection Atrophic vaginitis Pharmaceuticals Emotions, endocrine Retention Stool impaction
What does TOILETED stand for?
Types of transient/acute UI Thin, dry vaginal and urethral epithelium Obstruction Infection Limited mobility Emotional Therapeutic medications Endocrine disorders Delirium
What are types of chronic (established) UI?
Stress Urge/OAB Mixed Overflow Functional Iatrogenic
What are components of a Basic UI Evaluation
history physical exam urinalysis bladder stress test PVR (pts with risk factors for retention) \+/- bladder diary
UI history questions
Goal: clear picture of the UI and how it affects their life
Can you tell me about the problems with your bladder?
How often do you lose urine when you don’t want to?
What activities or situations are linked with leakage?
UI diagnostic tests
U/A: look for hematuria, UTI, etc. cytology PVR: >100 cc post-void Labs: ??? electrolytes BUN, creat thyroid function glucose
UI physical exam components
Abdominal: identify bladder fullness, tenderness, masses
Genital: irritation, lesions, d/c, atrophic vaginitis, pelvic prolapse, vaginal muscle strength
Rectal: tone, nerve innervation, muscle strength, constipation, BPH
Skin
when should you refer someone with UI?
Need for additional testing Abnormal U/A or culture/recurrent UTI Palpable abdominal or pelvic mass PVR > 100cc Abnormal prostate exam Vaginal bleeding; obstruction; new underlying disorder; surgical candidates
behavioral therapies for UI
PME With or without biofeedback Bladder retraining Habit training; prompted voiding Other nursing measures Dietary changes Nocturia: nursing measures/new meds
Management for OAB/Urge UI
Medications
Anticholinergics (Block binding at M3 receptors)
Actions
Relax the detrusor muscle
Reduce frequency, urgency and nocturia
Enable better filling and delay in voiding
Beta-3 Adrenergic Receptor Agonist
Targets B-3 adrenergic receptor pathway to relax detrusor smooth muscle
Botox injection (FDA approved 2014)
What are adrenergic agonists, side effects, and what do they treat?
treats OAB/Urge UI Mirabegron (Myrbetriq) 25 and 50 mg PO QD First in the class SE Increased BP Nasopharyngitis UTI Headache NO Constipation or dry mouth!
Meds for stress incontinence
Alpha-adrenergic agonist (increase outlet resistance; e.g. pseudoephedrine) No FDA approved meds
Surgical options for UI treatment
Stress UI
New work re: autologous stem cell transplantation
BPH; pelvic prolapse
OAB/urgency: Interstim (implanted stimulators)
Self care strategies for managing UI
Products; frequent toileting; medication “rearrangement”; special clothes; avoiding public transportation; decreased or avoidance of carrying heavy objects; avoiding intercourse; locating or staying near BR
Catheterization
Should be the last resort
Primary recommendations for practitioners seeing patients with UI
Ask about UI and evaluate prn Include prevention in routine visits Inquire about self-care strategies; assist in developing a reasonable plan Consider simple therapies first Refer prn
Describe the A&P of the prostate
accessory male sex organ surrounds prostatic urethra function: reproduction/antibacterial pre-prostatic zone transition zone (BPH); peripheral zone (CA)
Prostatic changes with age
Increase: size; BPH; prostate CA; calculi; prostatitis
Weight: increases with age.
Embryogenesis dependent on testosterone/conversion of T-DHT via 5 α-reductase
Decrease: prostatic antibacterial factor (PAF)
What are the NIH classifications for prostatitis?
NIH Classification Category I: Acute Bacterial Category II: Chronic Bacterial Category III: Chronic/Chronic Pelvic Pain Syndrome Category IIIA: Inflammatory Category IIIB: Non-inflammatory Category IV: Asymptomatic Inflammatory Discovered during another evaluation *Category I and II, about 5-10% of those with prostatitis Most are CP/CPPS, non-bacterial
Describe category 1 proctatitis
Acute Bacterial ProstatitisSigns and symptoms:
acute chills, fever, low back/perineal pain
irritative/obstructive symptoms
generalized malaise; flu-like symptoms
enlarged, tender prostate
prostatic secretions always abnormal
EPS: not recommended for ABP; rarely done by PCP
Pathogens causing ABP and treatment
Pathogens: gram negative anaerobes: most common is E.coli
Gram positive anaerobes: enterococcus; staph aureus
Complications: prostatic abscess
Treatment:
Broad spectrum ABX, usually 2-4 weeks minimum
Local measures
Consider need for hospitalizationStart with broad spectrum ABX. Most sources suggest 2-4 week treatment regime to prevent relapse.
Some pts may need hospital admission, IV fluids, etc.
Sitz baths, bedrest are some of the local measures.
Describe category II prostatitis
Chronic Bacterial ProstatitisIncidence is about 5% of those with chronic prostatitis
Possible routes of infection: ascending urethral infection; reflux; invasion of rectal bacterial
Relapsing, recurrent UTI is common
CBP clinical features and treatment
Clinical features: primary pathogen is e. coli
Usually no fever; irritative symptoms; leukocytes in prostatic sample; often non-specific
Prostate usually normal on exam, but may be boggy or tender
Treatment: prolonged ABX; TURP; local measuresABX for 4-6 weeks.
Fluoroquinolones may be superior to other ABX.
When to refer for prostatitis
Those who require IV antibiotics: high fever, severe perineal pain
Marked outflow obstruction
Prostatic mass requiring I & D
Refractory chronic infection
Urology consult or hospitalization
Risk factors/determining factors for developing BPH
AGE is the main determinant of BPH
Other factors likely play a role, but relationship is complex
? Income, educational status, marital status, access to care, dietary factors, race
Clinical manifestations of BPH
Asymptomatic
variable
many are asymptomatic, but show evidence on prostate biopsy
size DOES NOT determine symptomsSymptomatic/LUTS
obstructive
irritative
Approx.. 10% present with:
retention
renal failure
DDx for BPH
Irritative symptoms: UTI, prostatitis bladder CA bladder calculi radiation cystitis IC uninhibited bladder contractionObstructive symptoms: stricture atonic bladder prostate CA
***Both irritative and obstructive: spinal cord injury; PD; MS; prostatitis
How to evaluate suspected BPH
History: AUA Symptom Index**
Physical exam: DRE
Lab tests: to r/o other causes
U/A; serum creat; PVR;
? PSA; urine cytology
treatments for BPH
Watchful waiting: by history, PE, patient preference; symptom score < 7
Medications:
5ARI: finasteride (Proscar); dutasteride (Avodart)
Need lifetime treatment
SE: sexual dysfunction; gynecomastia
Alpha-blockers (non-selective): e.g., Hytrin; Caurdura
Selective alpha-blocker: Flomax (tamsulosin); Uroxatral (alfluzosin)
Saw palmetto: +/- effectiveness
PDE-5 inhibitors/BPH & ED
When to refer for BPH
Urinary retention Deteriorating renal function Hematuria PSA > 4; palpable mass Increasing symptom score Failure of pharmacologic therapy Possible surgical candidate (TURP)
Lifestyle changes/prevention of BPH options
Limited studies suggest a positive impact re: prevention of BPH
Factors that increase risk of CV disease may be associated with increased risk of BPH:
Obesity, limited physical activity, dyslipidemia, DM, HTN, heart unhealthy diet
Epidemiology of prostate cancer
Excluding skin cancer, prostate CA is the 2nd most commonly diagnosed CA in men of all ages
Incidence: AA men more than 2X Caucasian men
2018 estimates:
About 164,690 new cases of prostate cancer
About 29,430 deaths from prostate cancer
About 1 man in 9 will be diagnosed with prostate cancer during his lifetime
Risk factors for prostate cancer
Age > 80 Family hx/race/genetics Less clear: Chemical exposure Agent Orange STI/prostatitis ? Vasectomy Diet ? Red meat/high dairy ? Obesity/smokingInherited mutations of the BRCA1 or BRCA2 genes raise the risk of breast and ovarian cancers in some families. Mutations in these genes (especially in BRCA2) may also increase prostate cancer risk in some men. Men with Lynch syndrome (also known as hereditary non-polyposis colorectal cancer, or HNPCC), a condition caused by inherited gene changes, have an increased risk for a number of cancers, including prostate cancer. In the future, consider BRCA testing for those with significant family history
Prostate cancer for pathology
Primarily an adenocarcinoma
Multiple histologic patterns
Gleason sum score: grades tumor on basis of glandular patterns observed.
metastasis vs natural history theory of prostate cancer
Metastasis: spreads by local extension, vascular invasion, lymphatic invasion: e.g., regional pelvic lymph nodes, bone, lung, liver, adrenal glands
Natural history: controversial
clinical vs. histologic CA
Diagnosis/screening of prostate cancer
Signs and Symptoms: may be asymptomatic; ??obstructive or irritative symptoms; ? signs of metastatic disease
PSA: specific for prostate tissue, but not for prostate CA
? False + PSA: due to ABP; BPH; rectal exam
? False – PSA: Proscar; Avodart; saw palmetto*
screening for prostate cancer: the controversies
Controversial, still! Still important to do DRE for symptomatic USPTF (2018) Ages 55 to 69 (no risk factors): Discuss benefits/harms Small potential benefit of reducing chance of death 13 deaths over 13 years/1000 3 cases/1000 metastatic disease Don’t screen men who don’t want screening (C evidence) Don’t use PSA to screen men > age 70 (D evidence)
When to refer for prostate cancer
Indicated in all men with palpable nodule or suspicion of cancer.
Differential diagnosis: BPH; calculi; chronic prostatitis
Prostate biopsy via transrectal ultrasound
treatment options for prostate cancer
Active surveillance Watchful waiting Radiation therapy/radioactive seeds Hormone therapy CVD; DM; osteoporosis risks Chemotherapy Surgery Complementary therapies Support pre and post treatment
A&P of erection/ED
Flaccid state: penile smooth muscle is contracted. Arterial resistance high. Blood outflow unopposed.
2. Onset of erection: smooth muscle relaxes. Sinusoids distended with blood. Subtunical vessels compressed against tunica abluginea.
History needed to Dx ED
PMH, PSH risk factors urologic symptoms? Medication hx psychosocial hx sexual hx Review slide re: etiologies to focus the history
Physical exam for ED
Physical Exam
vascular
neuro
GU
Labs for ED dx
Labs: CBC; BUN; Cr; U/A; glucose; chol; testosterone; prolactin; PSA?, hematocrit
??TFTs; LH; FSH
What questionnaire can assess for ED/assist in grading severity of ED?
International Index of Erectile Function (IEF-5) Scoring IEF-5 Scoring (Sum of all responses) 22-25: No ED 17-21: Mild ED 12-16: Mild-Moderate ED 8-11: Moderate ED 5-7: Severe ED
treatment options for ED including referrals
Counseling/behavioral sex therapy; e.g. Masters and Johnson techniques; PLISSIT model
Medications:
First line: PDE-5 Inhibitors (e.g., sildenafil; vardenafil; tadalafil)
Second line: testosterone; vasodilators; papaverine; prostaglandin E1
Vacuum constriction devices
Vascular surgery
Penile prostheses
contraindications for sildenafil
PDE5 inhibitors are associated with a variety of cardiovascular effects. Sildenafil has two important cardiovascular actions in patients with heart disease: It is a vasodilator that can lower the blood pressure, and it can interact with nitrates. The most data are available for sildenafil.
●PDE5 inhibitors are contraindicated in patients taking nitrates of any form, regularly or intermittently, as the combination can lead to severe hypotension.
●Nitrate treatment should be delayed if a man who has taken a PDE5 inhibitor develops chest pain. The delay should be 24 hours if he has taken sildenafil or vardenafil and 48 hours if tadalafil; the delay should be longer for each if he has renal or hepatic dysfunction.
●Myocardial infarction and sudden death have been described with and after intercourse, both in men who have and have not taken a PDE5 inhibitor. Thus, the relation to the drug is uncertain.
●Higher doses of PDE5 inhibitors are used for patients with pulmonary hypertension as monotherapy or in combination with other agents, such as guanylate cyclase stimulants (eg, riociguat). However, the US Food and Drug Administration (FDA) has issued a warning against this combination because of an excess risk of hypotension
What are vacuum-assisted sexual devices, what are the risks/benefits, and when are they indicated?
Several mechanical devices have been developed that utilize vacuum pressure to encourage increases in arterial inflow and occlusive rings to limit venous egress from the penile corpora cavernosa (figure 3 and table 2B). A certain amount of mechanical dexterity is required to use these devices effectively, but once men become comfortable with using the vacuum and restraining rings many men can create an erection sufficient for vaginal penetration and sexual intercourse. The men may have difficulty ejaculating externally, however, because the occlusive rings that prevent venous drainage also compress the penile urethra sufficiently to prevent seminal fluid from reaching and traversing the urethral meatus. A number of devices are available for purchase over the counter. Although the initial dropout rate may be as high as 50 percent, long-term satisfaction of patients and partners has been reported by several groups [109]. This is especially true in patients who do not respond to penile injections.
The vacuum erection device may be used with oral PDE5 inhibitors to augment an insufficiently rigid erection post-ingestion of the PDE5 inhibitor [110]. Vacuum erection devices should only be applied for a maximum for 30 minutes. These devices can also be used in patients taking blood thinners, albeit with caution. Clinical experience has suggested that these devices are most often used by couples in stable relationships.
Vacuum devices successfully create erections in as many as 60 to 70 percent of patients [111]. Satisfaction with vacuum-assisted erections has varied between 25 and 49 percent. As an example, one prospective study evaluated 18 men by questionnaire at six months: 16 (89 percent) were able to attain satisfactory erections, and the overall satisfaction rate was 83 percent [112]. Sixteen of the 18 men found the device easy to use.
