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AGPCNP > GU > Flashcards

GU Flashcards

1
Q

Myrbetric (mirabegron), used to treat overactive bladder, is classified as a:

A

Beta 3 agonist

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2
Q

According to the US Preventive Task Force, screening for prostate cancer:

A

Should include a discussion of benefits and burdens between patient and provider

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3
Q

Asymptomatic bacteruria:

A

. Does not require antibiotic treatment

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4
Q

What is the difference between UTI and ASB (asymptomatic Bacteriuria)?

A
  1. 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
  2. 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)
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5
Q

What are some challenges when diagnosing UTI in older adults?

A 
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
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6
Q

What are some contributing factors/risk factors to developing UTI?

A

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

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7
Q

What does a physical assessment of r/o UTI include?

A

History
Physical Examination
U/A: *** definitive diagnosis
Urine Culture

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8
Q

What should you ask about in a history that you think may be a UTI?

A

“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

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9
Q

What should you include include in a physical assessment for UTI?

A 
PE: often vague
Vital signs
CVA tenderness
Abdominal
Rectal
Perineal/genital exam
Other, prn
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10
Q

What might you find on a UA/UC with UTI?

A 
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
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11
Q

what pathogens cause UTI in older adults?

A

E. coli
75-82% + culture in community dwelling women
Proteus mirabilis, pseudomonas, klebsiella pneumoniae
Catheter related: > 1 organism; proteus (mirabilis, stuarti, aeruginosia); candida, enterococcus

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12
Q

What does antibiotic treatment include for UTI/ASB in older adults?

A

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

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13
Q

Differentiate between relapse and reoccurrence for UTI

A

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.

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14
Q

Name some preventative measures for UTI/ASB

A

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

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15
Q

What are Lower Urinary Tract Symptoms? (LUTS)

A 
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
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16
Q

Define urinary incontinence and discuss prevalence and impact in older adult population.

A 
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
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17
Q

What are some anatomical and age-related contributing factors to urinary incontinence?

A 
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
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18
Q

What does DIAPERS stand for?

A 
Types of Acute/transient UI
Delirium
Infection
Atrophic vaginitis
Pharmaceuticals
Emotions, endocrine
Retention
Stool impaction
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19
Q

What does TOILETED stand for?

A 
Types of transient/acute UI
Thin, dry vaginal and urethral epithelium
Obstruction
Infection
Limited mobility
Emotional
Therapeutic medications
Endocrine disorders
Delirium
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20
Q

What are types of chronic (established) UI?

A 
Stress
Urge/OAB
Mixed
Overflow
Functional 
Iatrogenic
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21
Q

What are components of a Basic UI Evaluation

A 
history
physical exam
urinalysis
bladder stress test
PVR (pts with risk factors for retention)
\+/- bladder diary
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22
Q

UI history questions

A

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?

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23
Q

UI diagnostic tests

A 
U/A: look for hematuria, UTI, etc.
cytology 
PVR: >100 cc post-void
Labs: ???
electrolytes
BUN, creat
thyroid function
glucose
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24
Q

UI physical exam components

A

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

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25
Q

when should you refer someone with UI?

A 
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
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26
Q

behavioral therapies for UI

A 
PME
With or without biofeedback 
Bladder retraining
Habit training; prompted voiding
Other nursing measures
Dietary changes
Nocturia: nursing measures/new meds
27
Q

Management for OAB/Urge UI

A

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)

28
Q

What are adrenergic agonists, side effects, and what do they treat?

A 
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!
29
Q

Meds for stress incontinence

A

Alpha-adrenergic agonist (increase outlet resistance; e.g. pseudoephedrine) No FDA approved meds

30
Q

Surgical options for UI treatment

A

Stress UI
New work re: autologous stem cell transplantation
BPH; pelvic prolapse
OAB/urgency: Interstim (implanted stimulators)

31
Q

Self care strategies for managing UI

A

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

32
Q

Primary recommendations for practitioners seeing patients with UI

A 
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
33
Q

Describe the A&P of the prostate

A 
accessory male sex organ
surrounds prostatic urethra
function: reproduction/antibacterial
pre-prostatic zone
transition zone (BPH); peripheral zone (CA)
34
Q

Prostatic changes with age

A

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)

35
Q

What are the NIH classifications for prostatitis?

A 
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
36
Q

Describe category 1 proctatitis

A

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

37
Q

Pathogens causing ABP and treatment

A

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.

38
Q

Describe category II prostatitis

A

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

39
Q

CBP clinical features and treatment

A

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.

40
Q

When to refer for prostatitis

A

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

41
Q

Risk factors/determining factors for developing BPH

A

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

42
Q

Clinical manifestations of BPH

A

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

43
Q

DDx for BPH

A 
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

44
Q

How to evaluate suspected BPH

A

History: AUA Symptom Index**

Physical exam: DRE

Lab tests: to r/o other causes
U/A; serum creat; PVR;
? PSA; urine cytology

45
Q

treatments for BPH

A

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

46
Q

When to refer for BPH

A 
Urinary retention
Deteriorating renal function
Hematuria
PSA > 4; palpable mass 
Increasing symptom score
Failure of pharmacologic therapy
Possible surgical candidate (TURP)
47
Q

Lifestyle changes/prevention of BPH options

A

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

48
Q

Epidemiology of prostate cancer

A

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

49
Q

Risk factors for prostate cancer

A 
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
50
Q

Prostate cancer for pathology

A

Primarily an adenocarcinoma
Multiple histologic patterns
Gleason sum score: grades tumor on basis of glandular patterns observed.

51
Q

metastasis vs natural history theory of prostate cancer

A

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

52
Q

Diagnosis/screening of prostate cancer

A

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*

53
Q

screening for prostate cancer: the controversies

A 
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)
54
Q

When to refer for prostate cancer

A

Indicated in all men with palpable nodule or suspicion of cancer.
Differential diagnosis: BPH; calculi; chronic prostatitis
Prostate biopsy via transrectal ultrasound

55
Q

treatment options for prostate cancer

A 
Active surveillance
Watchful waiting 
Radiation therapy/radioactive seeds
Hormone therapy
CVD; DM; osteoporosis risks
Chemotherapy
Surgery
Complementary therapies
Support pre and post treatment
56
Q

A&P of erection/ED

A

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.

57
Q

History needed to Dx ED

A 
PMH, PSH
risk factors
urologic symptoms?
Medication hx
psychosocial hx
sexual hx
Review slide re: etiologies to focus the history
58
Q

Physical exam for ED

A

Physical Exam
vascular
neuro
GU

59
Q

Labs for ED dx

A

Labs: CBC; BUN; Cr; U/A; glucose; chol; testosterone; prolactin; PSA?, hematocrit
??TFTs; LH; FSH

60
Q

What questionnaire can assess for ED/assist in grading severity of ED?

A 
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
61
Q

treatment options for ED including referrals

A

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

62
Q

contraindications for sildenafil

A

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

63
Q

What are vacuum-assisted sexual devices, what are the risks/benefits, and when are they indicated?

A

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.

AGPCNP (30 decks)

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