GU and reproductive disorders Flashcards
BPH clinical presentation
- Increased urinary frequency and urgency
- Nocturia
- Difficulty initiating urinary stream
- Weak stream, starting and stopping during micturition
BPH diagnostic testing
- UA and/or culture
- Postvoid residual volume test
- Transrectal US
- Rule out renal failure (prolonged urinary outflow obstruction can lead to hydronephrosis)
BPH treatment
- Avoid making symptoms worse
- Anticholinergics → TCAs, first gen antihistamines
- Opioid use and inactivity cause urinary retention
- Irritants → caffeine, alcohol
- Alpha blockers
- Tamsulosin (flomax) → lessens outflow obstruction
- 5-alpha reductase inhibitors → finasteride (proscar), dutasteride (avodart) → reduce size of prostate
- PDE-5 (tadalafil (cialis))
- Normally used for ED
- Should not be combined with alpha blockers or nitrates
- TURP
What are common causes of acute epididymitis in men <35, men >35, and MSM?
Age <35 → chlamydia, gonorrhea (sexual contact)
Age >35 → secondary to prostatitis
MSM → sexually transmitted enteric organisms
Acute epididymitis clinical presentation
- Acute onset irritative voiding
- Fever
- Acutely painful, enlarged epididymis
- Radiates up spermatic cord to ipsilateral lower abdomen
- Prehn sign: reduction in pain when scrotum is elevated above symphysis pubis
- Urethritis
- Scrotal swelling
- Mucoid penile discharge
Acute epididymitis diagnostic testing
- UA with culture
- CBC → WBC with left shift
- Urethral swab culture or NAAT for STI testing
- Consider blood culture if systemic symptoms
- Doppler US to rule out testicular torsion
Acute epididymitis treatment for men younger than 35 years
Ceftriaxone IM single dose + doxycycline x10 days
- Covers for risk of STI
Acute epididymitis treatment for MSM
Ofloxacin PO or levofloxacin IV/PO x10-14 days
Possible causes of acute prostatitis in older men, men younger than 35, and men older than 35
- Older men → e. coli, pseudomonas
- Men <35 years → gonorrhea, chlamydia
- Men >35 years → enterobacteriaeceae (coliform)
Acute bacterial prostatitis clinical presentation
- Fever
- Chills
- Malaise
- Arthralgia
- Irritative voiding symptoms
- Suprapubic pain
- Perineal pain
- Obstructive urinary tract symptoms → frequency, urgency, nocturne, difficulty initiating stream, sensation of incomplete voiding, weak stream
- Tender, boggy (sponge-like) prostate
Acute bacterial prostatitis diagnostic testing
- Midstream urine culture
- Urine based NAAT to detect STIs
- Prostatic massage for chronic prostatitis ONLY
Acute bacterial prostatitis treatment
- Men <35 years
- Men >35 years or MSM
- Men <35 years → cover STIs (single dose ceftriaxone and doxycycline x10-14 days)
- Offer testing for HIV, hep B, syphilis
- Immunization against hep A, hep B, HPV
- Men >35 years or MSM → oral fluoroquinolone (ciprofloxacin or levofloxacin)
Common causes of vulvovaginitis
- Bacterial vaginosis
- Vaginal candidiasis
- Trichomoniasis
What is bacterial vaginosis (BV)?
Disruption of normal vaginal flora allowing for overgrowth of anaerobes
- Risk factors: recurrent antimicrobial use, douching, tub bathing, OTC intravaginal hygiene products, IUD, frequent sexual intercourse, presence of other STIs
BV clinical presentation
- Amine or fishy odor (particularly after sex)
- Increased vaginal discharge
- Thin, gray, homogenous
BV diagnostic testing
Based on history, PE, microscopic examination
- Clue cells on saline smear
- Few WBCs
- Vaginal pH <4.5
- (+) whiff test
BV treatment
- Metronidazole x7 days or
- Metronidazole vaginal gel once daily or
- Clindamycin cream
What is candida vulvovaginitis?
Yeast infection involving candida albicans
- Risk factors: recent antibiotic use, DM
Candida vulvovaginitis clinical presentation
- Itching
- Burning
- Thick white to yellow, curd-like discharge
- Vulvovaginal excoriation and erythema
- Dysparenunia
Candida vulvovaginitis diagnostic testing
- Hyphae and pseudopyphae on microscopic examination
- pH <5
Candida vulvovaginitis treatment
- Fluconazole (diflucan) single dose
- Various 3, 7, 14 day therapies with azalea anti fungal vaginal creams, suppositories, tablets
What is trichomoniasis?
One of the most common STIs
- Caused by motile protozoan trichomonas vaginalis
Trichomoniasis clinical presentation
Men are typically without symptoms
- Dysuria
- Itching
- Vulvovaginal irritation
- Dysparenunia
- Yellow-green vaginal discharge
- Cervical petechial hemorrhages (“strawberry spots”)
Trichomoniasis diagnostic testing
Microbial examination with saline wet mount
- Flagellated, motile organisms
- Large number of polymorphonuclear leukocytes (PMNs)
Trichomoniasis treatment
Metronidazole 2 g PO single dose
Chlamydia clinical presentation in women
- Cervicitis
- Mucupurulent discharge
- Friable cervix
- Cervical motion and adnexal tenderness may indicated PID
Chlamydia clinical presentation in men
Most are asymptomatic
- Irritative voiding symptoms
- Mucopurulent penile discharge
- Chlamydial conjunctivitis → unilateral mucopurulent discharge, redness
Chlamydia diagnostic testing
- NAAT testing of endocervical, urethral, rectal, or oropharyngeal samples
- Voided urine sample
Is test of cure necessary following antibiotic treatment for chlamydia?
Only for patients with persistent symptoms or pregnant
- If pregnant, test of cure should be done 3 weeks after completion of treatment and again after 3-4 months
Chlamydia treatment (including expedited partner therapy)
- Azithromycin 1g PO single dose or
- Doxycycline PO x7 days
EPT → prescription without healthcare visit for partner should be considered
Gonorrhea clinical presentation in men and women
- Typically asymptomatic but if symptomatic will present with dysuria, milky blood tinged penile discharge
- Women
- Dysuria with milky to purulent, occasionally blood tinged, vaginal discharge
- Intermenstrual bleeding
- Dyspareunia
- Mild lower abdominal pain (if PID)
Gonorrhea diagnostic testing
First catch urine sample or vaginal swab
Gonorrhea treatment
- Is test of cure necessary?
Uncomplicated infection: combination therapy → single dose ceftriaxone IM + single dose azithromycin
- Test of cure 1 week following completion of therapy
What causes genital herpes?
Herpes simplex virus
- Genital herpes → HSV-2
- Cold sores (herpes labialis) → HSV-1
Genital herpes diagnostic testing
- Viral culture - collection of a sample from a sore
- PCR
- Serology
- If virology test is positive and serology negative → new infection
- If both are positive → recurrent infection
Genital herpes treatment
Antivirals to reduce frequency of recurrences or episodically to shorten the duration of lesions → acyclovir, famciclovir, valacyclovir
Cold sores → topical penciclovir
PID diagnostic criteria
New onset lower abdominal pain or pelvic pain with at least one of the following:
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
One or more of the following additional criteria:
- Oral temp greater than 101 F
- Abnormal cervical or vaginal mucupurulent discharge
- Presence of abundant numbers of WBCs on saline microscopy
- Elevated CRP or ESR
- Lab documentation of cervical infection with gonorrhea or chlamydia
PID clinical presentation
- Lower abdominal pain (bilateral)
- Deep dyspareunia
- Abnormal vaginal bleeding
- Abnormal vaginal or cervical discharge
- Fever, GI upset
PID diagnostic testing (imaging and labs)
- Elevated ESR or CRP
- Leukocytosis with neutrophilia
- Transvaginal US
- Tubal thickening with or without free pelvic fluid
- Tubo-ovarian abscess
- Cultures for STIs
PID treatment (outpatient)
Ceftriaxone IM one time dose followed by PO doxycycline x2 weeks with or without metronidazole
HPV mode of transmission
Direct contact with a person who has HPV (whether or not symptoms are present)
- HPV 16 and 18 risk for high malignancy
HPV infection clinical presentation
- Genital warts → condyloma acuminata
- Skin colored lesions
- Raised or flat with smooth/rough feel
- Cauliflower-like appearance
- Pain, itching, burning, bleeding
HPV infection diagnostic testing
- Biopsy for atypical presentation of lesions or patients with recurrent or resistant infection
- Cervical cancer screening (pap smears and HPV testing)
HPV infection treatment
- Spontaneous regression of genital warts without intervention
- Can use podofilox, imiquimod, cryotherapy
- Vaccination
- From ages 9-45 years (recommended up to age 26 years, starting at 11 to 12 years before sex)
- Two doses if younger than 15; three doses if given after 25 years
What organism causes syphilis?
Spirochete treponema pallidum
- Lesion forms 2-4 weeks after sexual contact
- Contagion greatest during secondary stage
What are the four stages of syphilis infection?
- Primary
- Secondary
- Latent
- Tertiary
Primary stage of syphilis infection
- Occurs days 3-90 after initial exposure (lasts for 3 weeks)
- Chancre
- Firm, round, painless genital and/or anal ulcers
- Localized lymphadenopathy
Secondary stage of syphilis infection
- Occurs 4-10 weeks after initial exposure
- Non pruritic skin rash (palms, soles, mucous membranes)
- Fever
- Lymphadenopathy
- Sore throat
- Patchy hair loss
- Headaches
- Weight loss
- Muscle aches
- Fatigue
Latent stage of syphilis infection
Stage when secondary syphilis resolves though patient remains seroreactive
- Occasional recurrence of skin lesions
Early latent considered if:
- Documented seroconversion or sustained fourfold increase in non treponema test titers
- Have symptoms of primary or secondary syphilis
- Sex partner documented to have primary, secondary, or early latent
Considered to have late latent if above criteria is not met
Tertiary stage of syphilis infection
Occurs 3-15 years after initial exposure
- Affects cardiovascular and CNS
- Include gummatous syphilis, cardiovascular syphilis, neurosyphilis
Syphilis diagnostic testing
- Screening tests with rapid plasma reagin (RPR) test, rapid immunochromatographic test, VDRL test
- Check for antibodies against syphilis
- If positive, second test should be performed to confirm diagnosis
- EIA, FTA-ABS test, TPPA test
Syphilis treatment (for all four stages)
Benzathine penicillin G
HIV screening guidelines (CDC)
Performed at least once for all patients aged 13-64 years, for those who seek evaluation or treatment for STIs
HIV diagnostic testing algorithm
Tests that are available: serology antibody tests (HIV1 and HIV2), virology tests (HIV antigens or RNA)
Ag/Ab combination test
- If positive, follow up with antibody immunoassay (HIV1/HIV2 antibody differentiation test)
- Repeat annually for high risk patients who have negative results
True/false: It can take 3-12 weeks for an HIV positive person to make enough antibodies to be detected by antibody tests
True - a negative result during this window requires repeat testing 3 months following possible HIV exposure
HIV treatment
- High risk → PrEP
- MSM with HIV positive partner or multiple partners, parter with multiple partners, partner with unknown HIV status and have anal sex without condom or recently had an STI, injection drug use
- PEP for people who have been potentially exposed
- Started within 72 hours and continued for 28 days
Who is most at risk of testicular torsion?
Adolescent males
- Increasing testicular weight during puberty increases torsion risk
- Left testicle most often affected
- Urologic emergency
Testicular torsion clinical presentation
- Sudden onset severe unilateral scrotal pain
- Swelling of ipsilateral testicle
- Absent cremastueric reflex
Testicular torsion diagnostic testing
Typically not warranted but if confirmation is needed will order doppler US (shows reduction in blood flow)
- Use TWIST scoring system to determine risk of torsion and need for US
- Testis swelling (2)
- Hard testis (2)
- Absent cremastueric reflex (1)
- N/V (1)
- High riding testis (1)
- Score of 5-6 indicates surgery referral
Testicular torsion treatment
Prompt referral to urological surgeon (bilateral orchiopexy)
- High testicular survival rate if accomplished within 6 hours
What is a varicocele?
Abnormally dilated spermatic vein within scrotum
- “Bag of worms” in left scrotum
- Disappears in supine position
- Sensation of scrotal heaviness or ache
Is diagnostic testing warranted for varicoceles?
Only when the diagnosis is in question
- Doppler US
Varicocele treatment
Treatment not necessary unless here is pain or testicular atrophy
- Surgery
- Scrotal support
- Normal fertility
ED risk factors
- DM
- Kidney disease
- Chronic alcohol abuse and smoking
- Vascular disease
- Neuropathy
- Urological surgery
- Medications
- Mood disorder
ED treatment
- PDE-5 inhibitors
- Sildenafil, vardenafil, avanafil, tadalafil
- Clinical effect lowered if taken with high fat meal
Prostate cancer screening recommendations
- American Cancer Society
- Discussion about screening at age 50 years with average risk and expected to live 10+ years
- If higher risk (AA, first degree relative diagnosed with prostate cancer at less than 65 years), start at 45 years
- If even higher risk (multiple first degree relatives affected at early age), start at 40 years
