GU: treatments Flashcards
Urethritis
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)
Cystitis
- uncomp + adjunct
- comp
- pregnant
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
Overflow incontienence
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
- 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
- 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
- first line
- most effective for long term therapy
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 CA
- localized
- invasive
- recurrent
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
Gynecomastia
- supportive–>stop drugs
- Tamoxifen–>selective estrogen receptor modifier that is an estrogen antagonist in breast (used in breast CA)
- surgery if refractory to medical tx
Urethral Stricture
- ENDOSCOPIC: dilation or surgical reconstruction
- prophylactic ABX recc prior to surgery
urethral injury
- non-operative: catheter placement and monitor for healing–MILD
- surgical: indicated in severe injuries–may involve temporary suprapubic catheter placement prior to surgery–SERIOUS
Hypospadias
- should NOT be circumcised in neonatal periods–>foreskin may be used to repair defect!!
- surgical: arthroplasty–penile straightening–>only done in HEALTHY FULL TERM infants MC b/w 6mo-1 yr
epispadias
surgical correction
paraphiosis
- manual reduction–restore original position of foreskin–> BUT FIRST reduce edema with cool compresses or pressure dressing
- pharm tx: granulated sugar, injection of hyaluronidase
- definitive=incisions (dorsal slit) or circumcision
phimosis
- proper hygiene (wash that sucker out), stretching exercises
- 4-8 weeks topical corticos can increase retractility
- circumcisions for definitiive management
Priapism
- ischemic
- non ischemic
TX for ISCHEMIC (LOW-FLOW)
1. Intracavernosal Phenylephrine first line med
MOA: alpha-agonist cause contraction of the cavernous smooth muscle–>incrs venous outflow
CONTRA: cardiac or cerebrovascular hx
- Needle aspiration or corpus cavernosum and irrigation to remove blood ESP if over 4 hours with or without phenylephrine (with phenylephrine its called COMBO THERAPY** which is very effective)
- Terbutaline PO or SC–>constricts cavernosal artery, reducing arterial inflow—not as effective
- shunt surgery: refractory to medical tx and aspiration
TX FOR NONISCHEMIC (high flow)
- observation: most resolve within hours to days
- refractory: nonpermatent arterial embolization or surgical ligation
penile CA
early->limited excision
late–>penile amputation + lymph node dissection
Cryptorchidism
- orchiopexy–>bringing down the testes and attaching to scrotum as early at 4-6 MO–>ideally b4 1 year– HAS TO BE DONE BEFORE THEY ARE 2 YO
- Observation only done if under 6 MO–most descent by 3 MO
- hcg or gonadotropin release hormone–>HCG stimulates testosterone—rarely used
- orchiectomy if detected in puberty to reduce risk of testicular CA
Hydrocele
-usually no tx bc resolves on own
-surgical excision may be needed if persists after 1 year old– often occur at brith but resolve within 12 MO
OR
in adults with communicating types to reduce risk of hernia
varicocele
TX
- observation
- surgery: in some cases for pain, infertility, or impaired testicular growth
Epididymitis
- scrotal elevation, NSAIDS, cool compress
- if under 35 YO treat GC/CT—>Doxycyline 100 mg BID x10 days + Ceftriaxone 250 mg IM x1 dose OR and azithromycin 1G x1 dose alternative to doxycycline
- if over 35 yo– treat empirically with fluoroquinolones (cipro, ofloacin, levofloxacin) bc we suspect its E. coli——- trimethoprim-sulfamethoxazole is alternative
- bacterial in kids= cephalexin or amoxicillin
Spermatocele/ Epididymal cyst
-no tx unless it is bothersome—>surgical excision for chronic pain (rare)
Orchitis
-symptomatic: NSAIDs, bed rest, scrotal support, cool packs
Testicular Torsion
- urgent detorsion and orchiopexy within 6 hrs of pain onset
- irreversible damage likely if >12 hrs of ischemia
- manual detorsion should be done if surgical intervention not available
- orchiectomy if not salvageable
testicular CA
TX
-5 yr survival rate for all is 95%
- Seminoma stage 1 (limited to testes)–>radical orchiectomy and possible radiation
- Seminoma, stage 2–>debulking chemo followed by orchiectomy and radiation
- nonseminoma, stage 1–>NO RADIATION bc its resistant— we just do radical orchiectomy
these drugs can worsen s/s of BPH
sympathomimetics–pseudoephedrine
Anticholinergics
BPH
MEDICAL TX
monitor if just mild s/s*
1. Alpha 1 blockers (-OSIN) (usually first line): Doxazosin, Tamsulosin, Terazosin
MOA: smooth muscle relaxation of prostate and baldder neck leading to decr urethral resistance, obstruction relief and incr urinary outflow
-provides rapid s/s relief but NO effect in on clinical course of BPH
SE: dizziness and orthostatic hyPOtension (MC)
- 5-alpha reductase inhibitors: Finasteride and Dutasteride
MOA: androgen inhibitor–inhibs conversion of testosterone to dihydrotestosterone which supresses prostate growth which decrs size of prostate and decrs need for surgery
-doesnt provide immediate releif from s/s since it takes time for prostate to shrink
-SE: sexual dyfunction, decrs libido, breast tenderness and enlargement
SURGICAL TX
-if persistent, progressive or refractory to medical tx for 12-24 MO
-Transurethral resection of prostate (TURP)–removes excess prostate tissue
RISK of surgery–>sexual dysfunction and urinary incontinence
Acute Prostatitis
- Acute <35 yo= Ceftriaxone + Doxcycline OR ceftiaxone + azithromycin
- acute >35 yp=
OUTPATIENT: fluoroquinolones or trimethoprim-sulfamethoxazole x4-6 weeks***** (outpatient) (takes a long time bc little blood flow to prostate and so takes a while to heal)
*INPATIENT: IV fluoros with or without aminoglycoside OR Ampicillin with or w/o gentamicin
Chronic prostatitis
- fluoroquinolones or trimethoprim-sulfamethoxazole x 6-12 weeks****
- if refractory, TURP
- Alpha 1 blockers can help with chronic pain
Prostate CA
LOCAL DZ:
1. Observation/surveillance if low risk, clinically localized or life expectancy is <10 yrs
OR
2. definitive tx with external beam radiation, brachytherpay or radical prostatectomy
RISKS of prostatectomy= incontinence and ED!!!!
ADV DZ
- external beam radiation
- hormonal tx=androgen deprivation (GnRH agonists and/or Flutamide) so the prostate doesn’t grow and/or orchiectomy
- Chemotherapy if hormonal tx is ineffective
