GU/Renal Flashcards
Uterine Fibroids definition & MC location
benign tumors of the myometrium/connective tissue of the uterus
- Intramural is MC –> within the muscle layer
- subserosal
- submucosal (extending into the uterine cavity)
- pedunculated
Most common symptom of Uterine Fibroids + others
- Abnormal uterine bleeding = MC
- chronic pelvic pain
- bulk symptoms
- Anemia
- Urinary retention
- Constipation
- Infertility/ pregnancy complications
How common are uterine fibroids?
Very common! 70-80% of women have them by the tie they are 50 yo
Maybe familial component
MC in AA women
Uterine Fibroid Diagnostics
- CBC w/ diff
- BUN/Cr
- TSH
- Transvaginal U/S»_space;»> pelvic U/S
Uterine Fibroid Management
- Routine pelvic exams to monitor
- Combo OCP (estrogen + progestin)
- NSAIDs for pain
- Surgical options –> hysterectomy vs. myomectomy
Do fibroids cause fertility issues?
Yes, they can for younger patients
Is there ever any concern for malignancy w/ fibroids?
Typically not, but satellite growths are more concerning for malignancy
What is another treatment option to reduce bleeding w/ fibroids?
Tranexamic acid
Acute Bacterial Prostatitis definition
A bacterial infection that travels up the urethra & penetrates the prostate
50% of men will have one in their lifetime
MC bacteria in Prostatitis
E. coli, Klebsiella, other gram neg bacteria
STI – Gonorrhea or Chlamydia (suspect if penile discharge)
Symptoms of Prostatitis
- Dysuria (painful urination)
- Frequency & urgency
- Nocturia
- Poor stream & Hesitancy
- blood in urine
- Perineal pain w/ radiation to back, rectum, or penis
- Fever & Chills
Severity of symptoms increases if patient also has BPH
Prostatitis Physical Exam
- Examine external genitalia for erythema or swelling of scrotum
- DRE prostate is exquisitely tender & boggy
DO NOT MILK!! Can spread infection
Prostatitis Lab Diagnostics
-Urinalysis (leukocytosis, nitrites, +/- hematuria)
-Urine Culture
-GenProbe if STI concern
-CBC + blood culture if signs of sepsis present
+/- BMP for renal function
Acute Prostatitis management
STD risk – Ceftriaxone IM x1 + Doxycycline x10 days
Low STD risk – Cipro, Levo, or Bactrim (TMP/SMX)
follow up in 7 days for repeat urine culture & change of ABX if necessary
Chronic Prostatitis management
1st line = Cipro or Levo x4 weeks
2nd line = Bactrim (TMP/SMX) x 1-3 months
Fluoroquinolone education for Prostatitis patients
- avoid antacids w/in 6 hours
- tendonitis/tendon rupture
- CNS side effects
- C. diff associated diarrhea
Patient’s at higher risk of Prostatitis
- indwelling catheter
- recent urethral surgery or prostate biopsy
- recent GU tract infection like cystitis or epididymitis
- immunocompromised (HIV)
BPH definition
proliferation of cells in the transition zone surrounding proximal urethra
usually originates in periureteral and transition zones
80% of men have evidence of BPH by 80 yo
______ is the most commonly diagnosed non-skin cancer in men
Prostate cancer
Risk Factors for Prostate Cancer
- Age >50 yo
- Serum PSA >4
- Abnormal DRE
- FMHx of prostate cancer or BRCA1/2 mutation
- AA
- Obesity
- High fat, low fiber diet
Risk Factors for BPH
- increased caffeine intake
- lack of physical activity
BPH symptoms
- Urinary hesitancy
- Decreased caliber and force of stream
- Incomplete bladder emptying
- Double voiding
- Post-void dribble
- Nocturia
- DRE = enlarged, non-tender, symmetric
- Symptom Assessment via AUA*
- AUASS > 7 = mild symptoms
- AUASS >13 = moderate symptoms
- AUASS >19 = severe symptoms
Prostate Cancer symptoms
- can be asymptomatic until later in the disease
- First symptom may be bone pain…metastases
- Hematuria
- Hematospermia
- Weight loss
- Fatigue
DRE = indurated, hard nodules, asymmetric
PSA recommendation per American Cancer Society
- offer annually for average risk men > 50 yo, up until 76 yo (if > 10 year survival rate)
- DRE is controversial, but still recommended by ACS*
> 4 ng/mL can be concerning for prostate cancer…
10-20 = 50-75% chance
20 = 90% chance
Other PSA Testing for Prostate Cancer
- Free vs. Bound PSA = higher % bound to protein w/ cancer
- PSA Density = higher density w/ cancer
- PSA velocity = rate of increase over time, requires 3+ measurements over 18 mo…yearly >0.75 ng/mL increases likelihood of CA when PSA is still within normal limits
Imaging to assess for Prostate Cancer
- CT, MRI, or transrectal U/S
- Bone scan for mets
When should you refer someone to urology for BPH or suspected prostate cancer?
- PSA > 7
- Any rise in PSA while taking Fenasteride
- Abnormal DRE regardless of PSA
- Severe, intolerable symptoms of BPH
Management of Prostate Cancer
Depends on stage, life expectancy, pt preference
- Radical prostatectomy if life expectancy >10 yrs
- Radiation
- Hormone therapy
- chemotherapy
BPH management options
Lifestyle = avoid caffeine, alcohol, foods or meds that will make it worse – ex: cold & allergy meds, diuretics
Drugs for mild-to-moderate symptoms
- alpha blockers = Tamsulosin, Doxazosin
- 5-alpha reductase inhibitors = Finasteride
- Tadalafil = BPH + ED
If unresponsive to medical therapies = TURP
______ & _____ drugs will reduce PSA, causing a falsely low reading
Dutasteride & Finasteride
5-alpha-reductase inhibitors
block conversion of testosterone to DHT…reduce size of prostate
MCC of Pyelonephritis
Gram neg bacilli (95%)
- Ecoli
- Klebsiella
Triad of Pyelonephritis symptoms
-Fever
-Tachycardia
-Flank pain
+UTI symptoms (dysuria, frequency, urgency)
Lab work up for Pyelonephritis
- Urinalysis = pyuria + leuks + WBC casts + microheme
- Urine culture
- Urine HCG if childbearing age
Imaging for Pyelonephritis
Most do not require imaging
If no sign of improvement within 72 hours = CT
Complicated pt w/ hx of urologic problems = CT
CT looking for hydronephrosis, stone, anatomic abnormalities, abscess, etc.
Treatment for Pyelonephritis
Uncomplicated = Ceftriaxone IM + Fluro (Cipro or Levo)
if cannot tolerate fluoro…Bactrim or Augmentin 875
When should you admit a patient with Pyelonephritis?
- Bacteremia
- Inability to tolerate oral fluids
- Immunocompromised
- Pregnant**
IV Cipro/Levo, Zosyn, Carbapenem etc.
Complications of Pyelonephritis
- renal abscess formation
- Sepsis
- Papillary necrosis
- Acute renal failure
- Emphysematous pyelonephritis*- necrotizing infxn
- seen in diabetics
Distribution of Pyelonephritis in females & males
Females trimodal = 0-4; 15-35; >50 yo
males bimodal = 0-4; >35 yo
Women are 5x more likely to be hospitalized
What is the most important risk factor for a Complicated UTI?
Urinary tract obstruction
- Sexual intercourse…esp with new partner
- Use of spermicide
- DM
- Urinary incontinence
MC organisms for DM pt w/ Pyelonephritis
- Klebsiella
- Enterobacteriaceae
- Clostridia
- Candida
Sepsis Criteria
SIRS criteria + Source of Infection
SIRS = ≥ 2
- temp > 100.4 F
- HR >90
- RR > 20
- WBC >12,000
What analgesic can be specifically helpful for patients with dysuria symptoms? (pyelo)
Pyridium (aka AZO)
Simple cystitis vs. Pyelo
Pyelo will have HIGHER fever, CVA tenderness, more ill appearing
Polycystic Kidney Disease definition
Autosomal dominant disease (PKD1 or PKD2 gene mutation)
MC inherited kidney disease
Leads to continual fluid-filled yst formation and growth in kidneys + other organs (liver, spleen, pancreas)
Will eventually progress to ESRD
Common Symptoms of PCKD
Most are asymptomatic for first 3 decades of life
- Gross hematuria (cyst rupture)
- Flank mass/pain
- Nephrolithiasis (stones)
- Elevated BP (RAAS system)
- Polyuria
- Nocturia
- Increased thirst
Dx of PCKD
Renal U/S
Criteria by age
15 - 39 = at least 3 unilateral or bilateral cysts
40-59 = at least 2 cysts per kidney
60+ = at least 4 cysts per kidney
- CBC
- CMP –> BUN, Cr elevated
- Urinalysis
Management of PCKD
HTN control = ACE….goal BP 110/75
- Restrict sodium intake
- increase fluid intake >3 L per day
- Pain control – Acetaminophen
*May aspirate or surgically intervene for particularly large and painful cyst
Patient Education of PCKD
Their kids have a 50% chance of getting it
No cure – important to follow management closely to slow disease progression
If PCKD progresses what treatment options exist through nephrology?
- if in ESRD = dialysis
- kidney transplant
- nephrectomy
- aspiration of cysts
Extra-renal complications of PCKD
- intracranial hemorrhage leading to SAH
- Diverticulosis
- Aneurysms
- Cardiac abnormalities = MVP, AR
Ovarian Torsion definition
Twisting of ovary and tube
Rotation around infundibulopelvic & utero-ovarian ligament
-slows venous drainage –> congestion –> Infarction
Which side is ovarian torsion MC on? And what age range is MC?
- Right
- Women of reproductive age
Dx of Ovarian Torsion
Transvaginal U/S with Doppler Flow
- CBC
- BMP
- Urine HCG
- UA
- Lactic acid = looking for tissue necrosis
Management of Ovarian Torsion
Admit! Call OBGYN/Surgery
- NPO
- IV access x2
- IV Morphine 4mg
- IV Zofran
Surgery for immediate detorsion + cystectomy if mass is present
-if post-menopausal salpingo-oophorectomy is recommended (remove ovaries & tubes)
How to prevent recurrence of Ovarian Torsion
-High dose oral contraceptives w/ >50 mcg estrogen
-Oophoropexy = tacking ovary to abdominal wall
common in children w/ torsion
Pregnancy is associated with a ______ risk of ovarian torsion
Increased!
