GU: infections +incontinence + CA Flashcards
Urethritis
- define
- etiologies–mc?
- cm
- dx–most specific? most sensitive?
- tx
superficial infection of urethra
ETIOLOGIES
- nongonococcal urethritis (NGU)
- ->Chlamydia trachomatis MCC in this category
* incubation=5-8 days
* main s/s is urethral discharge— BUT UP TO 40% are ASYMPTO
- ->OTHERS: Ureaplasma urealycticum, Trich, M. genitalium and viruses - Gonococcal urethritis:
- ->incubation is 3-4 days
- ->opaque yellow/greeen/white thick discharge with itching
- ->only 20% asympto
CM
- urethral discharge with itching
- dysuria
- abdm pain
- abnormal vagina bleeding
DX
- Nucleic acid amplification test MOST SENSITIVE and MOST SPECIFIC (do it with first catch/clean catch urine sample)
- urine culture using swab from urethral opening (if theres discharge) –>gram (-) diplococci=gonorrhoeae OR if no organisms=NGU
- UA/dipstick–> (+) leukocyte esterase or large amt of WBC (pyuria)
TX
20-30% have co-infection–empiric tx of both is recc if testing not available:
If testing available:
Chlamydia= azithromycin 1 g PO single dose OR doxycycline 100 mg PO BID x10 days
Gonorrhoeae: ceftriaxone 250 mg IM x1 dose + Azithromycin 1g x1 dose (additional coverage due to increase resistance as well as to cover for possible chlamydia)
Acute Cystitis -quick patho -rf -define complicated cystitis -etiologies-- list the pathogens--MC overall , MC in sexually active women, CM -dx -indications for urine culture -tx--uncom, comp and pregnant
- infection of lower urinary tract (urethra + bladder) aka UTI
- usually an ascending infection of the lower urinary tract from the urethra
RF
- women: “honeymoon cystitis”, spermicidal use,
- Pregnancy: progesterone + estrogen causes ureter dilation & inhibition of bladder peristalsis
- elderly postmenopausal
- DM
- indwelling cath
COMPLICATED
- underlying condition with risk of therapeutic failure
- ->symps > 7 days
- -> pregnancy
- ->dm
- -> immunosuppression
- ->catheter
- ->anatomic abnormality
- ->elderly
- –>ALL MALES
ETIOLOGIES
- E. coli MC (>80%)
- Staph saprophyticus 2nd MC in sexually active women
- other gram (-): Klebsiella, Proteus, Enterobacter, Pseudomonas
- Enterococci with indwelling caths
CM
Irritative s/s: *Dysuria/ burning *frequency *urgency
*hematuria
*suprapubic pain and tenderness
DX
- UA/dipstick–> pyuria (WBC >10,000), hematuria, Leukocyte esterase, nitrites, cloudy urine
- Urine Culture–>DEFINITIVE DX–>
* men or cath PT : >1,000 CFU/ML or uropathogens on a clean catch
* women: >100,000 CFU
* INDS for urine culture
- ->complicated UTI
- ->infants/kids
- ->elderly
- ->males
- ->urologic abnormalities
- ->refractory to tx
- ->catheterized PT
UNCOMPLICATED
1st line= Nitrofurantoin or Trimethoprin-sulfamethoxazole (bactrim) x 3-5 days
2nd line= Fluoroquinolones*** or cephlaosporins or cefpodoxime —>if sulfa allergy or increased resistance patterns or refractory to 1st line or really complicated cases
ADJUNTS
1. Phenazopyridine–>bladder analgelsic–>really bad dysuria–>not used for more than 48 hrs bc of SE (methomeglobinemia and hemolyic anemia)–> turns urine ORANGE
COMPLICATED 1st line= Fluoroquinolones PO or IV OR Aminoglycosides x7-10 days or 14 days (dep on severity)
PREGNANT
- amoxicllin, augmentin****, cephalexin, Cefpodoxime, Nitrofurantoin and Fosfomycin
* **DO NOT GIVE: bactrim, Aminoglycosides, Fluoros, Doxycycline
PT education for cystitis (4)
- incr fluid intake
- urinate after sex
- peeing in a bathtub of warm water can help with dysuria
- if s/s dont improve in 24 hrs or fever develops–>go to ER–>concernd that infection went to kidneys
list 3 types of incontinence
urge
stress
overflow
Overflow incontinence -define -patho -etiologies---MC -cm dx' -tx
*urinary retention + incomplete bladder emptying leads to involuntary urine leakage once the bladder is full (it overflows)
PATHO: bladder detrusor muscle under-activity (impaired contractility) OR bladder outlet obstruction
ETIOLOGIES
- MCC neurological disorders or autonomic dysfunction–> DM, MS, spinal injuries, spinal stenosis, periph neuropathy assoc with B12 def
- OTHERS: BPH*******, uterine fibroids, pelvic organ prolapse, prior pelvic floor surgieres–causes bladder outlet obstruction
CM
- loss of urine with no warning (as in urge) or triggers *as in stress(
- leakage or dribbling in setting of incomplete bladder emptying, weak or intermittent urinary stream, hesitancy, frequency and nocturia
- leakage can often occur during changes in position
DX
-post void residual >200 mL
TX
intermittent or indwelling cath=1st line
Cholinergics (Bethanechol)–>incrs detrusor activity
If due to BPH–>alpha-blockers for rapid s/s relief. can also use 5-alpha reductase inhibitors
Stress Incontinence
- aka
- mc in who
- define
- etiologies
- CM
- tx
AKA: laugh n Pee
- invol leakage of urine occurs from increased abdominal pressure»_space;>than urethral pressure
- incr in abd pressure–> exertion, coughing, sneezing, laughing
- MC in younger women 45-49 YO is highest incidence
ETIOLOGIES
- Laxity of pelvic floor muscles: childbirth, surgery, post-menop estrogen loss, (rare in men but can be due to postprostatectomy)
- Urethral Hypermobility: insuff support from pelvic floor musculature and vaginal connective tissue to the urethra and bladder neck
CM
- urine leakage during times of incr intra-abd pressure—laughing, sneezing, coughing, lifting heavy objects
- NO urge to urinate prior to leakage
TX
- Pelvic floor muscle (kegel) exercises: initial TOC
- Life style mods + kegel: protective garments & pads, wt loss, smkoing cessation, drinking sm amt of h20
- Pessary: if 1-2 didnt work
- Surgery: midurethral sling–>higher success rates than conservative tx—more rapid and definitive tx
- Alpha-agonists: Midodrine & Pseudoephedrine—- mildly effacacious tho
Urge Incontinence -mc in? -define -etiology -patho cm dx tx--lifestyle, pharm, surigcal
MC in older women
*invol leakage preceded by or accompanied by sudden urge to urinate— PT has a strong urge to void with an inability to make it to the bathroom in time
PATHO
*detrusor muscle overactivity—>normally stimulated by muscarinic acetylcholine receptors—overactivity leads to uninhibited (involuntary) detrusor muscle contractions during bladder filling
Etiologies:
- incr age
- idiopathic
- bladder infections– cystitis
CM
- incr urgency, frequency
- small volume voids
- nocturia
- pt has strong urge to void with inability to make it to bathroom in time
TX
- Bladder training: 75% improvement, timed frequent voiding, using a voiding diary to ID the shortest voiding intervals, decr fluid intake
* diet: avoid spicy foods, citrus fruit, chocolate, alcohol, caffeine
* kegels - Pharmacotreatment
* first line: antimuscarinincs–>Oxybutynin **** or Tolterodine—->they are anti-spasmotics that increase bladder capacity + anticholinergics
- alternatives
- ->Mirabegron: causes bladder relaxation & beta-3 agonist
- ->TCAs: Imipramine– anticholinergic affect and alpha-adrenergic agonist (bladder relaxation, incr bladder outlet resistance, antispasmodic, incr urethral sphincter tone)
–>SURGICAL: incrs bladder compliance: botox, bladder augmentation
Enuresis
- define
- how to evaluate
- define monosymptomatic enuresis
- primary vs secondary
- tx—first line
- most effective for long term therapy
- distinct episodes of urinary incontinence (bedwetting) while sleeping in children 5 years of age or older without any neurologic or urologic causes
- Monosymptomatic: enuresis in absence of lower UTI symps + without bladder dysfunction–>has a high rate of spontaneous resolution
EVALUATION: complete history, PE, voiding diary and UA
PRIMARY: absence of any period of nighttime dryness–MC type–may have family hx—
SECONDARY: enuresis after a dry period of at least 6 MO–usually due to stressful event (divorce, brith of sibling, etc)
TX
BEHAVIORAL–>first line
- motivational therapy (esp in kids 5-7)
- education & reassurance
- use of washable products and room deodorizers
- BLADDER training–>regular voiding schedule, deliberate voiding prior to sleep, waking the child up to urinate intermittently, avoid caffine-based drinks with high sugar content, fluid restriction
ENURESIS ALARM
- most effective long-term therapy
- usually used if kids fail to respond to behavioral therapy
- often attempted b4 medical therapy
- sensory placed on bed pad or undergarmnets and goes off when wet–>usualy continued until there is minim of 2 weeks of consecutive dry nights
DESMOPRESSIN (DDAVP)
-used in nocturnal polyuria with normal bladdder function capacity
-better for short-term use
MOA: synthetic antidiuretic hormone–>which reduces urination–>may cause HYPONATREMIA–>pt need to use liberal amounts of salt to reduce the incidence
IMIPRAMINE
–>TCA that may be used in refractory cases
MOA: stimulates ADH secretion—detrusor relaxation–decreases time spent in REM sleep
Bladder Carcinoma
- mc type
- RF
- CM —mc?
- Dx –gold standard
- tx–localized, invasive,
- recurrence
***MC GU cancer
MC type=Urothelial (transitional cell) carcinoma (90%)
Others: squamous cell carcinoma, adenocarcinoma, sarcoma and small cell
RF
- smoking MC (60%)
- occupational exposures: dye, leather and rubber (beautificans and auto workers)
- Age >40 YO
- white
- male > female
- Schistosomiasis
- MEDS: cyclophosphamide, Pioglitazone
- long term indwelling catheter use and infected bladder stones are assoc with sqaumous cell carcinoma
CM
- PAINLESS gross hematuria mc—intermittent and throughout micturation
- irritative s/s: dysuria (second mc symp), urgency, frequency
DX
- UA with microscopy and cultures to r/o benign causes (Ex: UTI and pylenonephritis)
- imaging of GU: CT urography (preferred) or intravenous pyelogram
- Cystocopy with biopsy GOLD STANDARD (diagnostic and curative)
TX
Localized or superficial: transurethral resection of tumor—>electrocautery—and follow up every 3 MO
Invasive disease (adv or muscular invasion): radial cystectomy, chemo, radiation tx
RECURRENCE
*Intravesicular BCG (Bacillus-Guerin) vaccine if electrocautery is unsuccessful–?immune rxn stimulated cross rxn with tumor antigens—do not use this vaccine if immunosuppressed or if gross hematuria present
