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Clin Med > GU: treatments > Flashcards

GU: treatments Flashcards

1
Q

Urethritis

A

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)

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2
Q

Cystitis

  • uncomp + adjunct
  • comp
  • pregnant
A

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

  1. amoxicllin, augmentin****, cephalexin, Cefpodoxime, Nitrofurantoin and Fosfomycin
    * **DO NOT GIVE: bactrim, Aminoglycosides, Fluoros, Doxycycline
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3
Q

Overflow incontienence

A

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

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4
Q

Stress incontinence

A
  1. Pelvic floor muscle (kegel) exercises: initial TOC
  2. Life style mods + kegel: protective garments & pads, wt loss, smkoing cessation, drinking sm amt of h20
  3. Pessary: if 1-2 didnt work
  4. Surgery: midurethral sling–>higher success rates than conservative tx—more rapid and definitive tx
  5. Alpha-agonists: Midodrine & Pseudoephedrine—- mildly effacacious tho
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5
Q

Urge Incontinence

A
  1. 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
  2. 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
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6
Q

Enuresis

  • first line
  • most effective for long term therapy
A

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

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7
Q

Bladder CA

  • localized
  • invasive
  • recurrent
A

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

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8
Q

Gynecomastia

A
  • 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
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9
Q

Urethral Stricture

A
  • ENDOSCOPIC: dilation or surgical reconstruction

- prophylactic ABX recc prior to surgery

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10
Q

urethral injury

A
  • non-operative: catheter placement and monitor for healing–MILD
  • surgical: indicated in severe injuries–may involve temporary suprapubic catheter placement prior to surgery–SERIOUS
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11
Q

Hypospadias

A
  • 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
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12
Q

epispadias

A

surgical correction

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13
Q

paraphiosis

A
  • 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
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14
Q

phimosis

A
  • proper hygiene (wash that sucker out), stretching exercises
  • 4-8 weeks topical corticos can increase retractility
  • circumcisions for definitiive management
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15
Q

Priapism

  • ischemic
  • non ischemic
A

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

  1. 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)
  2. Terbutaline PO or SC–>constricts cavernosal artery, reducing arterial inflow—not as effective
  3. shunt surgery: refractory to medical tx and aspiration

TX FOR NONISCHEMIC (high flow)

  1. observation: most resolve within hours to days
  2. refractory: nonpermatent arterial embolization or surgical ligation
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16
Q

penile CA

A

early->limited excision

late–>penile amputation + lymph node dissection

17
Q

Cryptorchidism

A
  • 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
18
Q

Hydrocele

A

-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

19
Q

varicocele

A

TX

  • observation
  • surgery: in some cases for pain, infertility, or impaired testicular growth
20
Q

Epididymitis

A
  • 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
21
Q

Spermatocele/ Epididymal cyst

A

-no tx unless it is bothersome—>surgical excision for chronic pain (rare)

22
Q

Orchitis

A

-symptomatic: NSAIDs, bed rest, scrotal support, cool packs

23
Q

Testicular Torsion

A
  • 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
24
Q

testicular CA

A

TX
-5 yr survival rate for all is 95%

  1. Seminoma stage 1 (limited to testes)–>radical orchiectomy and possible radiation
  2. Seminoma, stage 2–>debulking chemo followed by orchiectomy and radiation
  3. nonseminoma, stage 1–>NO RADIATION bc its resistant— we just do radical orchiectomy
25
Q

these drugs can worsen s/s of BPH

A

sympathomimetics–pseudoephedrine

Anticholinergics

26
Q

BPH

A

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)

  1. 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

27
Q

Acute Prostatitis

A
  1. Acute <35 yo= Ceftriaxone + Doxcycline OR ceftiaxone + azithromycin
  2. 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
28
Q

Chronic prostatitis

A
  1. fluoroquinolones or trimethoprim-sulfamethoxazole x 6-12 weeks****
  2. if refractory, TURP
  3. Alpha 1 blockers can help with chronic pain
29
Q

Prostate CA

A

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

  1. external beam radiation
  2. hormonal tx=androgen deprivation (GnRH agonists and/or Flutamide) so the prostate doesn’t grow and/or orchiectomy
  3. Chemotherapy if hormonal tx is ineffective

Clin Med (52 decks)

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