GU part 1 Flashcards
Local sx of UTI
Dysuria
Frequency
Low-grade fever
Hematuria
Systemic sx of UTI
Fevers
Sepsis
Advanced tissue infection
What is the urinary tract comprised of?
Kidneys Ureters Bladder Prostate Urethra Testicles
Urethritis
Usually associated with sexual activity
Sx- pain, urethral burning during urination, urthethral d/c
Organisms of urethritis
Chlamydia Pseudomonas trachomatis Ureaplasma urealyticum Trichomonas vaginalis Herpes virus Neisseria gonorrhea
Predisposing factors for cystitis and pyelonephritis
DM
Pregnancy
GU anatomic abnormalities
Instrumentation
Pathogenesis of cystitis and pyelonephritis
Ascends antegrade from urethra
Occasional hematogenous dissemination
Community acquired UTIs generally from bowel flora
Predispositions to kidney infection
Vesicoureteral reflux, stones, urinary scar
Organisms of cystitis and pyelonephritis
E. coli
K. marcescens
Enterobacter
In women- vaginal flora
Clinical features of cystitis
Suprapubic pain
Burning on urination
Urinary frequency
Low back pain
Clinical features of pyelonephritis
Flank pain
Fever >101.5
Elderly or compromised pts may have no sx or fever, AMS, hypotension
Nl PSA for ages 40-49
0-2.5
Nl PSA for ages 50-59
0-3.5
Nl PSA for ages 60-69
0-4.5
Nl PSA for ages 70-79
0-6.5
When should PSA testing be done?
Starting at age 50 and yearly until age 80
Test 5 yrs earlier if FHx, AA, or high risk
Additional tests for BPH
Post void residual (PVR) Uroflow imagery (VFR) Urodynamics Cystoscopy Rarely indicated- renal u/s (RUS), transrectal ultrasonagraphy (TRUS)
Lab dx for cystitis and pyelonephritis
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
Specimen collection for cystitis and pyelonephritis
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
Tx and outcome of cystitis and pyelonephritis- female uncomplicated cystitis
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
Tx and outcome of cystitis and pyelonephritis- complicated urinary tracts in women
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
Tx and outcome of cystitis and pyelonephritis- recurrent UTI in men
Requires anatomic study of urinary tract
Components of chronic interstitial cystitis
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
What autoimmune conditions is chronic interstitial cystitis associated with?
Endometriosis
Irritable bowel
Fibromyalgia
Migraines
Urethral syndrome
UTI and pyuria with no growth on culture
Causes of urethral syndrome
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
Tx of urethral syndrome
Doxy 100 mg PO BID x 10 days
Azithromycin 1 g PO x 1 day
Tx of pyelonephritis
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
F/u of pyelonephritis
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
Abx resistant pyelonephritis
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
Upper tract imaging and pyelonephritis
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
Complicated UTI
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
Preventative measures for recurrent UTI in women
Generally associated with intercourse Encourage voiding after intercourse Antibiotic around coitus -TMP-SMX DS -Cipro 250 mg -NItrofurantoin 100 mg
Asymptomatic bacteriuria in cystitis and pyelonephritis
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)
Prostatitis
Infection of prostate gland in males
MC urologic dx in men <50 yo
Direct invasion through urethra
Sx of prostatitis
Low back pain
Perineal pain
Fever
Dyspareunia
Acute prostatitis
95% bacterial Pos culture Toxic appearance Septic Pyuria Sx <24-72 hrs
Chronic prostatitis
Prostate pain Low-grade or no fever 5% pos urine culture Sx for weeks or mos before presentation and tx More common than acute
Workup for prostatitis
DRE- tender prostate or enlarged boggy prostate
UA generally neg
Urine culture gen neg bc it doesn’t pick up pus
Tx for chronic prostatitis
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
What is the most common category of prostatitis?
Chronic pelvic pain syndrome (CPPS) categories IIIA and IIIB are the MC types
Urologic eval for prostatitis
Refer to urologist if recurrent Prostatic u/s (TRUS) Express prostatic secretions (EPS) Cystoscopy Renal u/s
Acute bacterial prostatitis sx
Fever Chills Dysuria Perineal and low back pain Possible sepsis
Exam of acute bacterial prostatitis
Distended bladder
Warm, boggy, tender and enlarged prostate
Lab analysis for acute bacterial prostatitis
Elevated serum WBC
Pyuria
Tx for acute bacterial prostatitis
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
Sx of chronic bacterial prostatitis
LUTS- lower urinary tract sx
Pelvic pain
Sexual dysfunction
Blockage when urinating
PE of chronic bacterial prostatitis
Abd tenderness
Groin tenderness
Prostate tenderness
Lab testing for chronic bacterial prostatitis
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
Chronic pelvic pain syndrome
MC largest percentage of pts with prostatitis
Nonbacterial
Sx of chronic Npelvic pain syndrome
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
Characteristics of noninflammatory CPPS
Multiple positions Frequent visits Chronic pain Psychological problems Depression Anxiety
Lab dx for CPPS
Urinalysis nl
EPS nl or increased WBc
Tx for CPPS
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
BPH
Nonmalignant enlargement of prostate glands
90% of all men will develop it during lifetime
Associated with ED and EjD
Irritative LUTS in BPH
Frequency (>8 in 24 hrs)
Nocturia
Urgency
Urge incontinence
Obstructive LUTS in BPH
Hesitancy
Slow stream
Intermittency
Incomplete emptying
Pathophysicology of BPH
Prostate growth under influence of testosterone converted to dihydrotestosterone
5-alpha reductase converts testosterone to dihydrotestosterone (DHT)
Most BPH in transition zone of prostate
BPH- smooth muscle vs glandular
Glandular component enlarges- obstructive
Smooth muscle tightening- obstructive
Usually a combo of glandular and smooth muscle component
Dx of BPH
Detailed medical hx focusing on urinary sx
American Urologic Association Symptom Index
General PE including DRE
UA
PSA
AUA symptom index
Validated questionnaire of 7 questions Includes QOL question Classified -Mild (0-7) -Moderate (8-19) -Severe (20-35)
DDX of BPH
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
What do alpha blockers do for BPH?
Make urination easier by relaxing smooth muscle tissue in the prostate and outlet of the bladder
What do 5-alpha reductase inhibitors do for BPH?
Shrinks the prostate by suppressing hormones that stimulate prostate growth
What are the names of the alpha-blockers for BPH
Doxazosin Terazosin Tamsulosin Aluzosin Silodosin
SEs of alpha adrenergic antagonists
Dizziness -Fall risk huge problem in elderly -Take at night to sleep through SEs Retrograde ejaculation Hypotension
5 alpha reductase inhibitors- MOA
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
Names of 5 alpha reductase inhibitors
Finasteride 5 mg -25% risk reduction prostate CA -Increased risk of high grade cancers Dutasteride 0.5 mg -23% reduction in all prostate CAs
SEs of 5 alpha reductase inhibitors
ED, might be permanent after stopping meds
Phytotherapy for BPH
Saw Palmetto berry- phytosterols
African plum
Flax seed oil
Pumpkin seed
Surgical management of BPH
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)
Transurethral resection of the prostate (TURP)
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
Surgical risks of TURP
Impotence Retrograde ejaculation Incontinence Infection Excessive blood loss
Cooled thermo therapy for BPH
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
Advantages of cooled thermo therapy for BPH
No significant bleeding
Minimal convalescent period
NO associated urinary incontinence
No disturbance of PSA as a diagnostic test after 6 wks
Interstitial laser coagulation for BPH
Transurethral procedure
Heat from laser coagulates excess tissue
Excess tissue absorbed by body
Gradual decrease of sx
Photovaporization of prostate
Transurethral procedure
Heat from laser melts prostate tissue
Excess tissue vaporizes as gas
Fast improvement…immediate
Transurethral needle ablation (TUNA)
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
TUNA procedure results
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
Stress incontinence
Leaks with coughing, standing, sneezing, or laughing
MC in females after childbirth or hysterectomy
MC in males after prostate surgery
What is first line for stress incontinence?
Kegel exercises but hard to adhere to
Medical therapy for stress incontinence
Imipramine 25 mg PO BID
Pseudoephedrine 60 mg PO BID
Surgical therapy for stress incontinence
Female sling (bladder tack) Male artificial urinary bladder
Urge incontinence
Compelling urge to void quickly
Cannot get to bathroom in time
Day or nighttime frequency
Worse with foods or drinks that irritate bladder
Tx for urge incontinence
Dietary mod
-Antimuscarinic anticholinergic meds
Surgical tx for urge incontinence
Botox bladder
Interstim
Bladder augmentation
Overflow incontinence
Weak bladder detrusor muscle
Obstructive outlet such as prostate or urethral stricture
Tx for overflow incontinence
Bethanethol 25 mg PO QID
Interstim
Intermittent catheterization 5-6 times a day
Functional incontinence
Does not know when voiding
Does not care if voiding
Common in nursing home or elderly
Tx for functional incontinence
Times voiding
-Caretaker
-Apps
Diapers
Types of urinary calculi
Calcium oxalate
Calcium phosphate
Mixed calcium oxalate and calcium phosphate
Struvite (infection)- magnesium ammonium phosphate hexahydrate
Cystine
Indinavir (5% of HIV pts receiving indinavir)
Urolithiasis sx
Renal colic N/V Hematuria Dysuria Acute onset CVA tenderness
Urolithiasis dx
Hx PE UA BMP, Ca KUB or CT stone study
Three premises of tx strategy for urinary calculi
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
Factors affect urinary stone tx
Duration of sx Size of calculus Type of calculus Renal fxn Age and medical condition Infection Occupation Economic status
Complications of urinary calculi
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
Etiology of urinary stones
Urinary supersaturation
Insufficient crystallization inhibitors
Contributors of crystallization
Supersaturation and urinary stones
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
Inhibitors of urinary stones
Citrate Pyrophosphate (orthophosphates) Urinary ribonucleic acid Urinary glycosaminoglycans Limited ability to influence inhibitors
Contributors to urinary stones
Anatomy Diet Genetics Activity Environment Dz Infection Medication
What contributes to renal calculi?
Renal calyceal diverticulum
Ureteropelvic junction obstruction
What contributes to bladder calculi?
BPH
Neurogenic bladder
Urethral stricutre
How does calcium contribute to calcium oxalate stones?
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
How does oxalate contribute to calcium oxalate stones?
Absorption is increased by:
- Vegetables
- -Spinach and greens
- -Asparagus
- -Soybeans
- Berries
- -Cranberries
- -Strawberries
- Fruits
- -Citrus juice
- Tea and coffee
- Chocolate
What promotes uric acid stones?
High purine diet High purines are in: -Meat -Vegetables -Caviar -Beer -Wine
What increases struvite stones?
Phosphorous High phosphorous in: -Milk -Milk products -Soft drinks -Colas
What genetic conditions contribute to urinary stone formation?
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
What types of activities contribute to urinary stone formation?
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
How does the environment contribute to urinary stone formatioin?
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
Which diseases contribute to urinary stone formation?
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
How does infection contribute to urinary stone formation?
Types -Struvite -Carbonate apatite Form when: -pH >7.0 -Urease-producing infection
Meds that contribute to urinary stone formation
Acetazolamide- calcium phosphate stones Tiramterene- triamterene stones Chemo- uric acid stones Magnesium laxatives and antacids- struvite stones AIDS tx- indinavir stones
How to manage the first urinary stone
White adult with calcium oxalate stones
- SMAC-7
- Serum Ca
- UA
- Urine culture
- 50% chance of a second stone if no changes
Who gets a recurrent urinary stone workup?
Black adults
Children
Struvite, uric acid, and cystine stone formers
Management of recurrent urinary stones 1 yr after stone
Annual checkup 24 hr urine collection for vol UA KUB Placebo effect >50% reduction
Management of recurrent urinary stones 7 yrs stone-free
Annual checkup
UA
Do this until 20 yrs stone-free
Recurrent urinary stone management
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
How to remove impassable urinary stones
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)
Dietary modification for urinary stones
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
