L4 Genitourinary Flashcards
What is the PTs role in GU disorders?
-recognize S/S of GU dysfunction
-understand how GU disorders impact rehab
-follow guidelines for interventions
-recognize common referral of pain areas of GU
Normal age related changes of GU system
-Decreased blood flow to kidneys
-Increased volume of urine and decreased bladder capacity
-shift toward nocturnal urine production
Hyponatremia
low level of sodium in the blood
Functions of kidneys
- excretion of cellular waste productions
- regulation of blood volume
- electrolyte regulation
- Acid-base regulation
- Arterial BP regulation
- EPO secretion
Common S/S of genitourinary pathology
Pain
Change in voiding habits
Pain (S/S of genitourinary pathology)
Varies according to origin
Pain generally described as wave-like, burning, or dull ache in abdomen, back, buttocks
Innervation of urinary system
T10-S4
Kidney Innervation
T10 to L1
Pain referral can be lumbar spine, upper abdomen
Will be the same side as the affected kidney
Ureter Innervation
T11-L2, S2-S4
Pain referral can be groin, upper/lower abdomen, scrotum, medial/proximal thigh, thoracolumbar region
Urinary Bladder Innervation
T11-L2, S2-S4
Pain referral can be in sacral apex, suprapubic region, thoracolumbar region
Change in voiding habits (s/s of pathology)
Urinary frequency
Urinary urgency
Nocturia
Polyuria
Oliguria
Dysuria
Hematuria
Decreased force of urinary flow
urinary incontinence
dyspareunia
Urinary frequency
of times a day
lower UTI
Urinary urgency
how much you need to pee
lower UTI
Nocturia
night urination
diabetes, heart failure
Polyuria
> 2.5 L per day
increased fluid intake, diabetes, chronic kidney disease
Oliguria
<400 ml a day
dehydration, renal failure
Anuria
<100 ml a day
dehydration, renal failure
Dysuria
painful
lower UTI
Hematuria
must report to MD ASAP
blood in urine
traumatic foley catheter, renal disease, cancer
Decreased force of urinary flow
prostate enlargement, urethral obstruction
Urinary Incontinence
inability to control voiding
SCI, dementia, CNS issues
Dyspareunia
pain during intercourse
more common in women
endometriosis, UTI, post menopause
Diagnostic tests for GU system pathology
Urinalysis
Creatinine Tests
Blood Urea Nitrogen
Urinalysis
Looks at color, odor, pH, specific gravity, absence of certain materials
Urine color
varies from almost colorless to dark yellow
depends on fluid, supplement, dietary intake
Urine odor
should not be strong (normal)
Specific Gravity
a measure of solutes in the urine
should be 1.002 to 1.028
pH of urine
4.6 to 8.0
Urine should have an absence of
glucose, ketones
proteins
Hb/RBcs
Bilirubin
WBCs, bacteria
Glucose/Ketones in urine indicates
diabetes or keto diet
Proteins in urine indicates
GFM damaged, kidney disease
Hb/RBCs in urine indicates
cancer, excessive exercise
Bilirubin in urine indicates
live or bile duct problems
WBCs/bacteria in urine indicates
infection
Plasma Creatinine
Increased levels are indicative of decreased renal function
Creatinine Clearance
24 hr urine test, approximates GFR
decreased Cr clearance is indicative of decreased renal function
Blood Urea nitrogen
increased BUN indicates: decreased renal function or fluid intake, increased muscle catabolism, increased protein intake, acute infection
To implicate decreased renal function, BUN levels need to be correlated with plasma Cr levels
Mental status and BUN
alterations in BUN and creatinine levels may lead to alteration in patients mental status
X-rays are used to diagnose
kidney stone
IVP
blood flow
Cystoscopy
inspection of inside of bladder
Uroflowmetry
force of flow test
Radioisotope studies
diagnosis of kidney function
mostly used for those that need to receive a kidney
Ultrasonagraphy
shape of kidney
UTI
infection within the urinary tract
Lower UTI
bladder and/or urethra
Upper UTI
kidneys and/or ureters
Epidemiology and Risk Factors for UTIs
-highest incidence in individuals in skilled nursing/extended care facilities
-most common is urinary catheterization
-Increased age, diabetes, sexually active females
Clinical presentation of UTI
altered mental status, shortness of breath, nausea/vomiting
Relationship to falls and UTI
more likely to fall with altered mental status
Increased age and UTIs
lower immune system, decreased personal hygiene, increased sedentary time
Diabetes and UTI
decreased immune response, increased bacteria, neuropathy
Pathogenesis of UTI
usually gram-negative bacteria ascending into the urinary tract from the urethra
Changes in voiding habits and UTI
frequency, urgency, dysuria, nocturia, dyspareunia
cloudy, bad-smelling urine, or hematuria
Pain and Lower UTI
generally sudden onset of symptoms
hallmark: dysuria
Upper UTI pain
typically gradual onset and systemic symptoms like fever, chills, malaise
general UTI pain
suprapubic, lower abdomen, groin, flank or back pain, shoulder pain possible
Shoulder strap pain
infectious agents and/or inflammatory mediators can diffuse locally and activate afferent endings in diaphragm
visceral pain can be referred to shoulder pain
due to the convergence of sensory neurons on the same group of dorsal horn neurons in spinal segment
Insidious onset of back pain complaints
make sure to ask about history of recent infection
ask about changes in voiding habits, systemic S/S
Dx and Tx of UTI
Dx: History and urinalysis
Tx: increased hydration, ABX
Cranberry juice is statistically insignificant for treatment, and does not prevent
Pyelonephritis
infectious, inflammatory disease presumed to be caused by bacterial invasion of renal parenchyma
Can be acute or chronic
Acute Pyelonephritis
most common cause is backwards flow of infected urine from bladder into upper urinary tract.
often called ascending UTIs
sometimes caused by blood borne pathogens
Chronic Pyelonephritis
kidneys become increasingly damaged due to repeated urinary infections
can lead to scarring and loss of kidney function
Acute CP of Pyelonephritis
fever, chills, flank pain
pain over costovertebral angle
urinary frequency, dysuria, suprapubic discomfort
physical findings can vary
Chronic CP Pyelonephritis
weakness, loss of appetite, HTN, anemia, protein and blood in urine
Pyelonephritis pain referral
flank
Pain referral areas of kidneys
ipsilateral for involved kidney
Kidney Stones
renal calculi or lithiasis
3rd most common GU disorder
Can be in the urinary tract or kidneys
Generally due to increased blood concentration and urinary excretion, infection
can cause urinary obstruction
Composition of kidney stones
Dietary intake can impact reoccurrence
Calcium/calcium oxalate= 75%
Struvite = 15%
Uric acid = 6%
Cystine = 2%
Kidney Stones RF
30s-50s
males
excessive calcium, oxalate, purines
dehydration
CP of kidney stones
HALLMARK COMPLAINT: abrupt pain associated with urinary tract obstructions, known as renal collic
pain starts with stone leaves kidney. Generally abrupt onset
Kidney stones pain referral
L side
Dx Kidney Stones
urinalysis, looking for hematruia, infection, crystals.
Can identify location of stones with IVP or CT
Tx of kidney stones
time, plus pain meds, hydration, ABX if needed
extracorpreal shock wave therapy (ESWL)
Prevention of kidney stones
needed for high rate of recurrence
hydration, dietary change (specifically spinach to decrease oxalate)
Glomerulonephritis
Group of disease that damages glomerular portion of the kidney
condition accounts for 50% of pts requiring dialysis
RF for chronic glomerulonephritis
diabetes
systemic lupus
HTN
Many types of glomerulonephritis result from
immunologic problems !!
drug toxin effects
vascular diseases
systemic disorders
Patho glomerulonephritis
Immune: immune complexes form in the circulation and get trapped in membrane, producing inflammatory reaction and histological changes
vascular: capillaries become permeable, leading to proteinuria, hematuria, edema
CP of Glomerulonephritis
HTN
proteinuria, pyuria, hematuria
edema (albumin pulls water towards it)
Dx and Tx of Glomerulonephritis
Dx: urinalysis, HTN
Tx: SAIDs, dietary changes, dialysis, renal transplant. Treatment of primary disease!
Tips for working with pts with glomerulonephritis
pts with DM, SLE, hepatitis, HTN, vasculitis have higher chance of chronic glomerulonephritis
be alert to NEW edema and HTN
ask about hematuria and oliguria, pts are often on diuretics
call primary physician to report new S/S
ADRs of Diuretics
muscle weakness or cramps, fatigue, nausea, headache, dizziness, orthostatic hypotension, hypokalemia
Chronic Kidney Disease
progressive loss of renal function with permanent loss of nephrons due to multiple causes that continues to worsen even after causes are removed
deterioration of kidney function is variable
> 30 mi americans are affected
RF of Chronic Kidney Disease
- leading causes of new cases are DM (44%) and HTN (27%). Higher incidence in african americans
- Overconsumption of NSAIDs
- Age >65
CP of Chronic Kidney Disease
5 stages, s/s depend on severity and rapidity of failure, each stage is defined by eGFR
fatigue, weight loss, metallic taste in mouth, nausea, pruritus
End stage renal disease
<15% of kidney function
Neuromusculoskeletal CP of Chronic Kidney Disease
mental dullness
renal osteodystrophy, bone demineralization
muscle, joint, bone pain
extraskeletal calcification
restless leg syndrome
Cardiovascular CP of Chronic Kidney
dyspnea, orthopnea
edema
HTN
pericardial chest pain (nerves get bugged by edema)
Renal osteodystrophy
- Kidney failure, decreased GFR, calcitriol
- Secondary hyperparathyroidism, altered calcium set point
- Gut absorption of Ca, decreased calcium absorption, increased phosphate retention
- Bone remodeling, bone resorption
Altered set point of blood calcium, it all causes increased mobilization of calcium into blood. hyper phosphate in blood
Dx of Chronic Kidney Disease
S/s
Bun and Cr values (from eGFR)
imaging
serum PTH
Prognosis of Chronic Kidney Disease
Mortality rate of those >65 yr on dialysis is 7x that of age matched norms not on dialysis
People >60 year who start dialysis have life expectancy of 5 yrs
Tx options for Chronic Kidney Disease
Conservative: HTN tx, dietary changes, anemia control, calcitriol meds. For everyone, every stage
End stage: renal replacement, dialysis, transplant
Functions of Vitamin D
Active form of vitamnin D = CALCITRIOL
Promotes mineralization of new bone
increases calcium and phosphate absorption from gut
stimulates calcium, phospahte reabsorption
overall result of Vit D: increased plasma concentrations of Ca and phosphate
Renal Replacement
dialysis
renal transplant
Kidneys comprise 2/3 of organ transplant waiting list
median waiting time is 3.6 years
Dialysis outcomes
71% unemployment
little improvement in survival after dialysis
no significant improvement in health related QOL
Exercise training in adults with CKD
improves BP control and lipid profiles
improve glucose metabolism
increase hematocrit and hemoglobin
resistance training helps with bone density
increase functional capcity
Research and CKD exercise
Benefits of exercise for CKD
26% decrease in use of antihypertensive meds after 3 months of cycling during dialysis
$885 savings annually
combined aerobic and resistance is the best for those with CKD
Why is exercise not encouraged for those doing hemodialysis
lack of awareness of benefits
fear that it will cause harm
ACSM Guidelines for CKD
20-60 min of continuous activity 3-5 days a week
can use 3-5 min bouts
Resistance: 65% to 75% of 1 RM. Make sure to estimate, don’t perform
No exercise with CKD if
BP >200/100 mmHP
Serum K> 5 mEq
WBC <5000 or 10000 w/fever
Hct <25% or Hb <8
Platelets <20,000
AV fistula and exercise
be alert to infection risk
hand-washing is essential
do not measure BP on UE
avoid placing weight or pressure on the fistula
Potassium normal value
3.7 to 5.1
RPE and Dialysis
use it to guide exercise intensity because HR is unreliable for this population
aim for 9-13, talk but not sing
Exercise during dialysis
perform during first half to avoid hypotensive episodes
pedaling and stepping devices are common
don’t exercise arm with permanent AV access
continuous peritoneal dialysis might require fluid to be drained before exercising
Exercise AFTER dialysis
generally wait 2 hours after dialysis, due to fatigue
Renal Cell carcinoma
occurs in epithelial cells lining the kidneys
not common cancer, but common KIDNEY cancer
has four stages
incidence is rising, peak is 60-70 year of age, men.
RF for RCC
smoking, obesity, increased red meat, decreased fruit/veggie consumption, chemical occupational exposure increase risk
CP of RCC
hematuria
flank pain
palpable abdominal mass
Staging vs Grading
Grading = histologic differentiation
Staging = degree of spread
RCC Tx and Prognosis
Tx: surgery has better results than radiation
Prognosis: needs to be caught early for surgery to be effective
Tip for PTs with RCC
if pt complains of new unexplained abdominal flank, back pain, sternal pain, cough or hematuria, contact PCP immediately
Normal aging and male reproductive system
- shrinkage of testes
- thickening of seminiferous tubules (decreased sperm production)
- Enlargement of prostate gland, can double in size
- Decreases in plasma testosterone level (loss of muscle, changes in bone density)
Sample questions to screen for GU disorders in men >50 yr of age
- Urinary frequency/nocturia
- Problems stopping/starting urination
- Weak urine flow
- Bladder never completely empty
Prostatitis
(young man condition)
inflammation of prostate gland, can be acute or chronic. PTs are more likely to encounter pts with chronic prostatitis
Epidemiology and RF Prostatitis
Prevalence higher in men <40 yrs old
Lower UTI
Urinary catheterization
multiple sex partners
strong vibrations
Pathogenesis of Prostatitis
4 categories of prostatitis
most common type is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
causes are urine reflux, pelvic floor dysfunction
Chronic Prostatitis CP and DX
CP: low back and perineal pain. Pain w/prolonged sitting, voiding problems, sexual dysfunction
Dx: urinalysis, digital rectal exam, differentiated from BPH and prostate CA by presence of PAIN
Chronic Prostatitis Referral Pain
low back and perineal pain
Prevention and Tx Options of Prostatitis
Prevention: decrease time in seated position. try different bike seats
Tx: anti inflammatories, ABX, relaxants. PT (biofeedback, stretching)
Benign Prostatic Hyperplasia
age related nonmalignant enlargement of prostate gland
Men >50 yr of age
Moderate intake of alcohol has a decreased risk
Pathogenesis of BPH
unknown, maybe hormonal changes
multiple nodules comprised of proliferating cells progressively narrow the urethra
BPH CP
decreased force of urinary flow
urinary frequency, nocturia
untreated progression, UTI, bladder wall changes, hydroureter
Dx of BPH
history
uroflowmetry
palpation
TX of BPH
Monitoring
Surgery = TURP, resection of prostate
Common meds: alpha reductase inhibitors (shrinks prostate), alpha adrenergic blockers (relaxes smooth muscle)
ADRs of alpha adrenergic blockers
tachycardia
dizziness
orthostatic hypotension
increased risk of falls
Testicular Cancer
young man diseases
abnormal, rapid, invasive growth of malignant cells in testicles
most common cancer in males 15-35
RF of Testicular Cancer
past medical history of undescended testicles, abnormal development, previous testicular cancer
family history
caucasian
CP of Testicular Cancer
- enlargement, lump, swelling of testicle
- pain or feeling of heaviness in scrotum
- Dull ache in back/lower abdomen (may be ONLY symptom >20% of cases)
- Dyspnea
- Gynecomastia, excessive breast tissue
Dx, Tx, Prevention of Testicular Cancer
Dx: urologic history and exam, painless mass in testicle in key sign
Tx: chemotherapy, radiation, ectomies
Prevention: testicular self exam every 6 months, early detection
Testicular cancer pain referral
In males with this referral pattern with no mechanical source:
1. ask about testicular self-exam
2. Assess supraclavicular lymphadenopathy
3. Perform iliopsoas test
4. Refer to MD
Menopause
transition when ovaries stop releasing eggs, menstrual activity decreases and eventually ceases
estrogen and progesterone decrease, 1 year without menstruation
occurs age 50
Changes with menopause
labia atrophy
changed libido
hot flashes, mood changes, sleep disturbances
decrease in pelvic muscle tone
Endometriosis
endometrial tissue becomes implanted outside uterus; most commonly implants form on fallopian tubes, ovaries, or tissue lining pelvis
RF of Endometriosis
women of childbearing age w/out children
early menarche, short menstrual cycles, long menstrual period
family hx
Pathogenesis of Endometriosis
causes is unknown, roles suggested for hormones and immune system
Common theory: mentrual blood containing endometrial cells is retrogradely flushed back through tubes into pelvic caivty
endometrial cells form implants throughout the body
CP of Endometriosis
DYSMENORRHEA, DYSPAREUNIA, INFERTILITY
excessive bleeding, pain, symptoms vary on growth
Dx of Endometriosis
the classic triad
laparoscopy/laparotomy
Tx of Endometriosis
No cure. Goal is pain relief and preservation of fertility
NSAIDs, surgery, hyterectomy
Endometriosis Referral of Pain
if pain is present regardless of sexual position, pain source is less likely to be a joint dysfunction
Endometrial Cancer
cancer of uterine lining
most common cancer of female organs
incidence peaks in 60-70 yrs old
RF of Endometrial cancer
increasing age
obesity
increased level of estrogen
inactivity
CP of endometrial cancer
abnormal bleeding
abdominal/LE edema
Dx and Tx of Endometrial Cancer
surgery
hysterectomy
salpingo-oophorectomy
hormonal therapy
radiation
usually diagnosed early
Cervical Cancer
cancer that forms in cervix
pap smears help to control the amount of cases
HPV is the primary cause
Dx and Tx of Cervical Cancer
dx: pap smear
tx: based on stage of disease. Pre would be excision, laser. Later would be surgery, chemo, radiation
Pathogenesis and CP of Cervical Cnacner
HPV turns of cells tumor suppressing genes, allowing abnormal changes in cervical epithelium to perpetuate
CP: early stages are asymptomatic, advanced are abnormal bleeding, bowel bladder problems
Ovarian Cancer
usually diagnosed late
malignant neoplasm located on the ovaries
fairly uncommon but leading cause of death in female cancers. Usually dx when it has metastizied
RF of OVarian Cancer
more cycles, more risk
age >40 year
never breast fed
family history of breast, ovarian, colon
Pathogenesis of Ovarian Cnacer
unknown cause
correlated with number of times a woman ovulates
spreads locally to pelvis, abdominal cavity, bladder
can spread to lymph nodes
CP of Ovarian Cancer
often vague and nonspecific
sense of pelvic heaviness
vague lower abdominal bloating
unexplained back pain that worsens over time
gait disturbance due to brain metastases
Dx and Tx of Ovarian Cancer
Dx: screening test, pelvic exam that can show edema in perionetal cavity
Tx: surgery, chemo. Low survival rate due to being diagnosed late
PT and Ovarian Cancer
due to risk of recurrence, PT should note gait changes
Ectopic Pregnancy
implantation of pregnancy in any location other than the uterus, often in fallopian tube
RF for ectopic
things that disrupt fallopian tube structure
STDs, prior tubal surgery, IUD, history, pelvic inflammatory disease
Pathogenesis of Ectopic
dealyed ovum transport
fertilization and implantation occurs in tube
pregnancy outgrown blood supply
possibility of ruptured fallopian tube
CP of Ectopic
variable, delayed or slight vaginal bleeding
sudden, sharp, stabbing pain
Ectopic pain referral
emergency call to physician is warranted
Dx and Tx of Ectopic
Dx: pelvic ultrasound, elecated hCG, laparoscopy
Tx: medication, removal of egg
