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CAM III > GU part 1 > Flashcards

GU part 1 Flashcards

1
Q

Local sx of UTI

A

Dysuria
Frequency
Low-grade fever
Hematuria

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2
Q

Systemic sx of UTI

A

Fevers
Sepsis
Advanced tissue infection

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3
Q

What is the urinary tract comprised of?

A 
Kidneys
Ureters
Bladder
Prostate
Urethra
Testicles
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4
Q

Urethritis

A

Usually associated with sexual activity

Sx- pain, urethral burning during urination, urthethral d/c

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5
Q

Organisms of urethritis

A 
Chlamydia
Pseudomonas trachomatis
Ureaplasma urealyticum
Trichomonas vaginalis
Herpes virus
Neisseria gonorrhea
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6
Q

Predisposing factors for cystitis and pyelonephritis

A

DM
Pregnancy
GU anatomic abnormalities
Instrumentation

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7
Q

Pathogenesis of cystitis and pyelonephritis

A

Ascends antegrade from urethra
Occasional hematogenous dissemination
Community acquired UTIs generally from bowel flora

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8
Q

Predispositions to kidney infection

A

Vesicoureteral reflux, stones, urinary scar

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9
Q

Organisms of cystitis and pyelonephritis

A

E. coli
K. marcescens
Enterobacter
In women- vaginal flora

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10
Q

Clinical features of cystitis

A

Suprapubic pain
Burning on urination
Urinary frequency
Low back pain

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11
Q

Clinical features of pyelonephritis

A

Flank pain
Fever >101.5
Elderly or compromised pts may have no sx or fever, AMS, hypotension

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12
Q

Nl PSA for ages 40-49

A

0-2.5

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13
Q

Nl PSA for ages 50-59

A

0-3.5

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14
Q

Nl PSA for ages 60-69

A

0-4.5

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15
Q

Nl PSA for ages 70-79

A

0-6.5

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16
Q

When should PSA testing be done?

A

Starting at age 50 and yearly until age 80

Test 5 yrs earlier if FHx, AA, or high risk

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17
Q

Additional tests for BPH

A 
Post void residual (PVR)
Uroflow imagery (VFR)
Urodynamics
Cystoscopy
Rarely indicated- renal u/s (RUS), transrectal ultrasonagraphy (TRUS)
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18
Q

Lab dx for cystitis and pyelonephritis

A

Midstream urine sample shows WBCs +/- RBCs
WBC casts indicates pyelonephritis
Bacteria seen on spun urine confirms UTI
Catheterized urine, esp in females, to confirm infection
Culture confirms UTI, 100,000 colonies/mL confirms UTI

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19
Q

Specimen collection for cystitis and pyelonephritis

A

Midstream collection plated immediately for microbiology
Consider catheterized specimen in women, particularly obese or elderly
Urine left at room temp for hours can multiply and give spuriously high results
Do not collect urine from catheter bag
Refrigerated specimens not immediately plated

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20
Q

Tx and outcome of cystitis and pyelonephritis- female uncomplicated cystitis

A

TMP-SMX DS 1 PO BID x 3 days
Cipro 250 mg PO BID x 3 days
Nitrofurantoin 100 mg PO BID x 3 days

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21
Q

Tx and outcome of cystitis and pyelonephritis- complicated urinary tracts in women

A

Get a urine culture
Cipro 500 mg PO BID x 10 days
TMP-SMX DS 1 PO BID x 10 days
Macrobid 100 mg PO BID x 10 days

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22
Q

Tx and outcome of cystitis and pyelonephritis- recurrent UTI in men

A

Requires anatomic study of urinary tract

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23
Q

Components of chronic interstitial cystitis

A 
Pelvic pain, urgency, and dyspareunia
Neg urine culture
9:1 female to male ratio
Age 20s to 50s
Associated with autoimmune conditions
Dx of exclusion. Must r/o bladder CA
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24
Q

What autoimmune conditions is chronic interstitial cystitis associated with?

A

Endometriosis
Irritable bowel
Fibromyalgia
Migraines

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25
Q

Urethral syndrome

A

UTI and pyuria with no growth on culture

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26
Q

Causes of urethral syndrome

A

May be d/t low counts of bacteria, Chlamydia or Ureaplasma (do not grow on routine culture media)
Consider urethral culture for herpes simplex infection or Neisseria gonorrhea

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27
Q

Tx of urethral syndrome

A

Doxy 100 mg PO BID x 10 days

Azithromycin 1 g PO x 1 day

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28
Q

Tx of pyelonephritis

A

Cipro 500 mg PO BID x 14 days
Levo 500 mg PO qd x 14 days OR
Levo 750 mg PO qd x 5 days

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29
Q

F/u of pyelonephritis

A

Hosp admission if toxic, poor PO intake, poor social situation, questionable f/u and compliance, complicating features such as DM, renal stones, urinary obstruction, sickle cell

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30
Q

Abx resistant pyelonephritis

A

Usu in hosp acquired infections or debilitative pts
Hosp admission required for 3rd and 4th gen abx
Admit for Imipenem, Fortaz, Gentamicin, Tobramycin or infectious dz consult
Follow culture results carefully
Repeat culture after tx to confirm negative

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31
Q

Upper tract imaging and pyelonephritis

A

Suspect if no clinical improvement in 2-3 days of abx
Suspect if febrile for >7 days
Suspected IC or debilitated
Renal u/s- detects obstruction, abscess, small stones
CT scan- detects abscess, smaller stones, perinephric stranding, anatomic abnormalities

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32
Q

Complicated UTI

A

Infection recurs within 3 wks of stopping tx
Consider 6-12 wk course of prophylactic evening antibiotic
Urologic eval for all men with recurrent UTIs and women with difficult recurrent UTIs

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33
Q

Preventative measures for recurrent UTI in women

A 
Generally associated with intercourse
Encourage voiding after intercourse
Antibiotic around coitus
-TMP-SMX DS
-Cipro 250 mg
-NItrofurantoin 100 mg
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34
Q

Asymptomatic bacteriuria in cystitis and pyelonephritis

A

Generally in older or middle-aged women, rarely men
Urine culture >100,000 bacteria but no UTI sx
Generally untreated unless pregnant female or IC pt (pyelonephritis risk high)

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35
Q

Prostatitis

A

Infection of prostate gland in males
MC urologic dx in men <50 yo
Direct invasion through urethra

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36
Q

Sx of prostatitis

A

Low back pain
Perineal pain
Fever
Dyspareunia

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37
Q

Acute prostatitis

A 
95% bacterial
Pos culture
Toxic appearance
Septic 
Pyuria
Sx <24-72 hrs
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38
Q

Chronic prostatitis

A 
Prostate pain
Low-grade or no fever
5% pos urine culture
Sx for weeks or mos before presentation and tx
More common than acute
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39
Q

Workup for prostatitis

A

DRE- tender prostate or enlarged boggy prostate
UA generally neg
Urine culture gen neg bc it doesn’t pick up pus

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40
Q

Tx for chronic prostatitis

A 
4-12 wks of abx
Cipro 500 mg PO BID x 6 wks
TMP-SMX DS 1 PO BID x 6 wks
Levo 500 mg PO qd x 6 wks
Nitrofurantoin 100 mg PO BID x 6 wks
Doxy 100 mg PO BID x 6 wks
Sitz baths
Frequent ejaculation
Prostatic massage
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41
Q

What is the most common category of prostatitis?

A

Chronic pelvic pain syndrome (CPPS) categories IIIA and IIIB are the MC types

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42
Q

Urologic eval for prostatitis

A 
Refer to urologist if recurrent
Prostatic u/s (TRUS)
Express prostatic secretions (EPS)
Cystoscopy
Renal u/s
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43
Q

Acute bacterial prostatitis sx

A 
Fever
Chills
Dysuria
Perineal and low back pain
Possible sepsis
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44
Q

Exam of acute bacterial prostatitis

A

Distended bladder

Warm, boggy, tender and enlarged prostate

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45
Q

Lab analysis for acute bacterial prostatitis

A

Elevated serum WBC

Pyuria

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46
Q

Tx for acute bacterial prostatitis

A

Urinary drainage- suprapubic tube recommended
IV abx- Cipro, Genta, Ancef
Hosp admission 2-4 days and then outpt abx for 30 days
Prostate u/s r/o abscess or CT scan of pelvis

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47
Q

Sx of chronic bacterial prostatitis

A

LUTS- lower urinary tract sx
Pelvic pain
Sexual dysfunction
Blockage when urinating

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48
Q

PE of chronic bacterial prostatitis

A

Abd tenderness
Groin tenderness
Prostate tenderness

49
Q

Lab testing for chronic bacterial prostatitis

A

VB-1: 1st voided urine
VB-2: Midstream urine sent for culture
DRE performed, prostate massage
Expressed prostatic secretions (EPS) culture
VB-3: Collected for culture
Chronic bacterial prostatitis means EPS or VB-3 bacteria is 10x greater than a VB-1 or a VB-2

50
Q

Chronic pelvic pain syndrome

A

MC largest percentage of pts with prostatitis

Nonbacterial

51
Q

Sx of chronic Npelvic pain syndrome

A 
Perineal pain
Low back pain
Suprapubic pain
Groin pain
Scrotal pain
Voiding dysfunction
-Dysuria
-Weak stream
-Frequency
-Urgency
-Nocturia
Sexual dysfunction
-Painful ejaculation
-Low libido
All pts have pelvic pain
52
Q

Characteristics of noninflammatory CPPS

A 
Multiple positions
Frequent visits
Chronic pain
Psychological problems
Depression
Anxiety
53
Q

Lab dx for CPPS

A

Urinalysis nl

EPS nl or increased WBc

54
Q

Tx for CPPS

A 
NSAIDs
Prostatic massage or physical therapy
Frequent ejaculation
Warm sitz baths
Empiric 2-6 wk course of abx
Alpha blockers for LUTs
TCAs for chronic pelvic pain
55
Q

BPH

A

Nonmalignant enlargement of prostate glands
90% of all men will develop it during lifetime
Associated with ED and EjD

56
Q

Irritative LUTS in BPH

A

Frequency (>8 in 24 hrs)
Nocturia
Urgency
Urge incontinence

57
Q

Obstructive LUTS in BPH

A

Hesitancy
Slow stream
Intermittency
Incomplete emptying

58
Q

Pathophysicology of BPH

A

Prostate growth under influence of testosterone converted to dihydrotestosterone
5-alpha reductase converts testosterone to dihydrotestosterone (DHT)
Most BPH in transition zone of prostate

59
Q

BPH- smooth muscle vs glandular

A

Glandular component enlarges- obstructive
Smooth muscle tightening- obstructive
Usually a combo of glandular and smooth muscle component

60
Q

Dx of BPH

A

Detailed medical hx focusing on urinary sx
American Urologic Association Symptom Index
General PE including DRE
UA
PSA

61
Q

AUA symptom index

A 
Validated questionnaire of 7 questions
Includes QOL question
Classified
-Mild (0-7)
-Moderate (8-19)
-Severe (20-35)
62
Q

DDX of BPH

A 
Prostate CA
Prostatitis
DM
Neurologic dz
CVA
Urethral strictures
Med SEs
-Antidepressants
-Anesthetics
Slow stream is probably nerve condition
Feeling blockage with slow stream probably indicates urethral stricture
63
Q

What do alpha blockers do for BPH?

A

Make urination easier by relaxing smooth muscle tissue in the prostate and outlet of the bladder

64
Q

What do 5-alpha reductase inhibitors do for BPH?

A

Shrinks the prostate by suppressing hormones that stimulate prostate growth

65
Q

What are the names of the alpha-blockers for BPH

A 
Doxazosin
Terazosin
Tamsulosin
Aluzosin
Silodosin
66
Q

SEs of alpha adrenergic antagonists

A 
Dizziness
-Fall risk huge problem in elderly
-Take at night to sleep through SEs
Retrograde ejaculation
Hypotension
67
Q

5 alpha reductase inhibitors- MOA

A

Block intracellular conversion of testosterone to dihydrotestosterone
Most effective in large prostate gland (>30-60 g)
Decreases the risk of urinary retention
Decreases risk of surgical intervention
Takes 6-12 mos to achieve maximum response

68
Q

Names of 5 alpha reductase inhibitors

A 
Finasteride 5 mg
-25% risk reduction prostate CA
-Increased risk of high grade cancers
Dutasteride 0.5 mg 
-23% reduction in all prostate CAs
69
Q

SEs of 5 alpha reductase inhibitors

A

ED, might be permanent after stopping meds

70
Q

Phytotherapy for BPH

A

Saw Palmetto berry- phytosterols
African plum
Flax seed oil
Pumpkin seed

71
Q

Surgical management of BPH

A

Transurethral resection of the prostate (TURP)
-Gold standard
Transurethral microwave thermotherapy (TUMT)
Green light photovaporization of the prostate (PVP)
Transurethral laser incision of prostate (TULIP)
Simple open prostatectomy
Transurethral needle ablation (TUNA)
Alcohol ablation of prostate
Transurethral incision of the prostate (TUIP)

72
Q

Transurethral resection of the prostate (TURP)

A

A urologist passes a thin tube through the urethra into the center of the gland then scrapes away prostate tissue with an instrument inserted through the tube
Wears catheter for 3-4 days afterwards, 1 night in hosp
Lasts between 8 and 20 yrs

73
Q

Surgical risks of TURP

A 
Impotence
Retrograde ejaculation
Incontinence
Infection
Excessive blood loss
74
Q

Cooled thermo therapy for BPH

A

A minimally invasive and durable tx that is an alternative to surgery or a lifetime of drugs
Applies microwave energy to the prostate to continuously heat the diseased tissue
Applies continuous cooling to the urethra to minimize pt discomfort and risk to the urethra

75
Q

Advantages of cooled thermo therapy for BPH

A

No significant bleeding
Minimal convalescent period
NO associated urinary incontinence
No disturbance of PSA as a diagnostic test after 6 wks

76
Q

Interstitial laser coagulation for BPH

A

Transurethral procedure
Heat from laser coagulates excess tissue
Excess tissue absorbed by body
Gradual decrease of sx

77
Q

Photovaporization of prostate

A

Transurethral procedure
Heat from laser melts prostate tissue
Excess tissue vaporizes as gas
Fast improvement…immediate

78
Q

Transurethral needle ablation (TUNA)

A

Delivers low-level radio frequency energy into the middle of the prostate and relieves obstruction without causing damage to the urethra
Can be performed with local anesthesia in urologist’s office
Takes <1 hr
Catheterization, if required, is 0-2 days on average
Intended for men >50

79
Q

TUNA procedure results

A 
Most pts:
-Return to nl activities within 48 hrs
-Have few SEs
-Have low risk of sexual SEs
Long-term five yr clinical data shows the durability of the procedure
80
Q

Stress incontinence

A

Leaks with coughing, standing, sneezing, or laughing
MC in females after childbirth or hysterectomy
MC in males after prostate surgery

81
Q

What is first line for stress incontinence?

A

Kegel exercises but hard to adhere to

82
Q

Medical therapy for stress incontinence

A

Imipramine 25 mg PO BID

Pseudoephedrine 60 mg PO BID

83
Q

Surgical therapy for stress incontinence

A 
Female sling (bladder tack)
Male artificial urinary bladder
84
Q

Urge incontinence

A

Compelling urge to void quickly
Cannot get to bathroom in time
Day or nighttime frequency
Worse with foods or drinks that irritate bladder

85
Q

Tx for urge incontinence

A

Dietary mod

-Antimuscarinic anticholinergic meds

86
Q

Surgical tx for urge incontinence

A

Botox bladder
Interstim
Bladder augmentation

87
Q

Overflow incontinence

A

Weak bladder detrusor muscle

Obstructive outlet such as prostate or urethral stricture

88
Q

Tx for overflow incontinence

A

Bethanethol 25 mg PO QID
Interstim
Intermittent catheterization 5-6 times a day

89
Q

Functional incontinence

A

Does not know when voiding
Does not care if voiding
Common in nursing home or elderly

90
Q

Tx for functional incontinence

A

Times voiding
-Caretaker
-Apps
Diapers

91
Q

Types of urinary calculi

A

Calcium oxalate
Calcium phosphate
Mixed calcium oxalate and calcium phosphate
Struvite (infection)- magnesium ammonium phosphate hexahydrate
Cystine
Indinavir (5% of HIV pts receiving indinavir)

92
Q

Urolithiasis sx

A 
Renal colic
N/V
Hematuria
Dysuria
Acute onset
CVA tenderness
93
Q

Urolithiasis dx

A 
Hx
PE
UA
BMP, Ca
KUB or CT stone study
94
Q

Three premises of tx strategy for urinary calculi

A

Stone dz is a lifelong problem
-Risk of recurrences decreases >65 yo from decreased kidney concentrating ability
Surgical removal of impassable stones
Medical management of each stone type

95
Q

Factors affect urinary stone tx

A 
Duration of sx
Size of calculus
Type of calculus
Renal fxn
Age and medical condition
Infection
Occupation
Economic status
96
Q

Complications of urinary calculi

A 
Renal colic
-As stone passes down ureter
-Intense pain requiring narcotics
--IV morphine
--IV Toradol
Obstruction
-Transient of minimal consequence acutely
-Can be serious if long-standing
--Renal damage
-Silent obstruction 
Infection
-Combined obstruction and infection lead to urosepsis and permanent renal damage
-Instumentation may infect sterile calculi or urine
-Struvite calculi formation
Bleeding
-Not anemia
-Hematuria evaluations
97
Q

Etiology of urinary stones

A

Urinary supersaturation
Insufficient crystallization inhibitors
Contributors of crystallization

98
Q

Supersaturation and urinary stones

A

All stones form in supersaturated urine
Urine is occasionally undersaturated
Urine s normally saturated or supersaturated with calcium oxalate
Range of supersaturation is 1-20 times saturation concentration

99
Q

Inhibitors of urinary stones

A 
Citrate
Pyrophosphate (orthophosphates)
Urinary ribonucleic acid
Urinary glycosaminoglycans
Limited ability to influence inhibitors
100
Q

Contributors to urinary stones

A 
Anatomy
Diet
Genetics
Activity
Environment
Dz
Infection
Medication
101
Q

What contributes to renal calculi?

A

Renal calyceal diverticulum

Ureteropelvic junction obstruction

102
Q

What contributes to bladder calculi?

A

BPH
Neurogenic bladder
Urethral stricutre

103
Q

How does calcium contribute to calcium oxalate stones?

A

Calcium intestinal absorption increased by

  • Vit D
  • Protein
  • -56 g/day (6 oz lean meat plus other sources)
  • Soft drinks
  • Carbs
  • Milk products
  • -Lactose highly lithogenic
  • -Ca
104
Q

How does oxalate contribute to calcium oxalate stones?

A

Absorption is increased by:

  • Vegetables
  • -Spinach and greens
  • -Asparagus
  • -Soybeans
  • Berries
  • -Cranberries
  • -Strawberries
  • Fruits
  • -Citrus juice
  • Tea and coffee
  • Chocolate
105
Q

What promotes uric acid stones?

A 
High purine diet
High purines are in:
-Meat 
-Vegetables
-Caviar
-Beer
-Wine
106
Q

What increases struvite stones?

A 
Phosphorous
High phosphorous in:
-Milk
-Milk products
-Soft drinks
-Colas
107
Q

What genetic conditions contribute to urinary stone formation?

A 
congenital hyperoxaluria
-D/t amino acid enzyme defect
-Nephrocalcinosis
-Renal failure
Cystinuria
-Impaired transport of amino acids across intestines
Gout
-Altered protein metabolism
-20% will develop uric acid stones
108
Q

What types of activities contribute to urinary stone formation?

A 
Dehydration
-Vigorous physical activity
-Periods of food deprivation
Immobilization worsens hypercaliuria
-Stones precipitate in dependent areas of kidneys
-Sedentary occupations increase risk
-Spinal cord injury increases stone risk
109
Q

How does the environment contribute to urinary stone formatioin?

A 
Hot climates promote stones
Sunshine increases intestinal calcium absorption
Hard water promotes stones
-High in minerals and calcium
-Binds oxalate in intestines
-Well water 2x risk of city water
110
Q

Which diseases contribute to urinary stone formation?

A 
Primary hyperparathyroidism
-Parathyroid adenoma
-Serum calcium >10.2
-Treat with parathyroidectomy
Renal tubular acidosis
-Inability of distal nephron to maintain H+ ion gradient
-High urinary pH >5.3
-Serum pH <7.25
Medullary sponge kidney
-Dilation of ducts of Bellini
-Focal or diffuse stone formation
111
Q

How does infection contribute to urinary stone formation?

A 
Types
-Struvite
-Carbonate apatite
Form when:
-pH >7.0
-Urease-producing infection
112
Q

Meds that contribute to urinary stone formation

A 
Acetazolamide- calcium phosphate stones
Tiramterene- triamterene stones
Chemo- uric acid stones
Magnesium laxatives and antacids- struvite stones
AIDS tx- indinavir stones
113
Q

How to manage the first urinary stone

A

White adult with calcium oxalate stones

  • SMAC-7
  • Serum Ca
  • UA
  • Urine culture
  • 50% chance of a second stone if no changes
114
Q

Who gets a recurrent urinary stone workup?

A

Black adults
Children
Struvite, uric acid, and cystine stone formers

115
Q

Management of recurrent urinary stones 1 yr after stone

A 
Annual checkup
24 hr urine collection for vol
UA
KUB
Placebo effect >50% reduction
116
Q

Management of recurrent urinary stones 7 yrs stone-free

A

Annual checkup
UA
Do this until 20 yrs stone-free

117
Q

Recurrent urinary stone management

A 
Increase fluid intake
Daily 3,000 cc urine output
-Push pt for 1 mo
-Then more automatic
Even water consumption throughout the day
-Postprandial
-Sleep periods
118
Q

How to remove impassable urinary stones

A

ESWL- electrohydraulic shock wave lithotripsy
PUL- percutaneous ultrasonic lithotripsy
EHL- ureteroscopic electrohydraulic lithotripsy
Ureteroscopic ultrasonic lithotripsy
Ureteroscopic laser lithotripsy
Stone basket- ureteroscopic or cystoscopic (recurrent calcium oxalate)

119
Q

Dietary modification for urinary stones

A 
24 hr urine collection
-Ca, oxalate, magnesium, phosphorous, sodium, citrate, uric acid, potassium
Hydration
Low oxalate diet (40 mg/day)
Calcium moderation (800-1000 mg/day)
Low sodium diet (4-6 g/day)
-Sodium increases calcium urine excretion
Low phosphorous diet (1000 mg/day)
Low animal proteins
-Protein increases urine uric acid, oxalate, and  calcium
Increase high fiber
-Binds calcium and oxalate in gut
Low fat
Add citrate

CAM III (12 decks)

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