Male/Female GU Disorders Flashcards
Normal physiologic changes (andropause)
- average age = 45
- prostate hypertrophy
- testicular mass decreaes
- testosterone decreases (gradually)
- sclerosis of epididmyis, seminal vesicles, and prostate
- changes in sexual response: decreased penile rigidity, lengthened excitement phase, lower ejaculatory volume, less well-defined sense of impending orgasm, shortening of ejaculatory event and orgasmic phase
Normal physiologic changes (menopause)
- 12 months without period = menopause
- average age = 45
- vaginal dryness
- dyspareunia (painful intercourse)
- thinning of vaginal epithelial lining
- decreased ovarian and uterine size
Adolescent Considerations
- puberty onset (10 for girls, 11.5 for boys)
- tanner staging describes onset and progression of puberty changes
Hematuria - key characteristics
- 5+ RBCs in 3/3 specimens obtained at least 1 week apart
- gross or microscopic (3+ RBCs)
- symptomatic or asymptomatic
- transient or persisent
- can be isolated or associated with proteinuria and other urinary abnormalities
Hematuria - symptomatology and hx
- gross vs. microscopic
- timing during urination
- irritative voiding symptoms?
- prior hx?
- meds (+ duration of use)
Hematuria - Diagnostics
- UA dipstick + UA with microscopy
- if female, ask when LMP was (are they pregnant) are they on period)
- other: coags, BUN/creatinine, urine cytology, CT, renal biopsy, cystoscopy (urology referral)
Hematuria - Management
- Medical: asymptomatic (isolated) generally = no tx, associated with abnormal diagnostics = treat based on primary dx/cause
- Surgical: may be necessary based on anatomic abnormalities (Ureter-Pelvic Junction (UPJ) obstruction, tumor, significant urolithiasis)
- Consultation: required with urinary tract abnormalities or certain systemic diseases (systemic disease = nephrology consult)
- Follow-up: persistent microscopic = 6-12 month intervals
Urinary Tract Infection - most common pathogen
E. coli
Urinary Tract Infection - risk factors
- Reduced urine flow: outflow obstruction (ex: BPH, foreign body), neurogenic bladder, inadequate fluid intake
- Colonization promotion: sexual activities, spermicide, antimicrobial agents
- Facilitation of ascent: catheterization, incontinence, residual urine (post-void)
Uncomplicated UTI vs. complicated UTI
Uncomplicated: infection in healthy patient with anatomically and functionally normal urinary tract
Complicated: infection associated with factors increasing colonization, anatomic or structural abnormality, immunocompromised, multidrug resistant,, males are usually considered complicated
Recurrent vs. Reinfection vs. Persistent UTIs
Recurrent: occurs after documented infection that has resolved
Reinfection: new event with reintroduction of organism(s) into urinary tract
Persistent: UTI caused by same organism from focus of infection
UTI - key characteristics
- rare in males < 50
- always considered complicated in men because of length of urethra (tx assumes that infection of upper tract has occurred )
- must more common in women
- acute = single pathogen
- chronic = 2+ pathogens
- acute cystitis = infection of bladder
- pyelonephritis = infection of bladder
UTI (acute cystitis) - key characteristics
- dysuria
- frequency and urgency
- suprapubic pain
- +/- hematuria
- foul smelling urine
- males may not present this way but with pyelonephritis symptoms
UTI (acute pyelonephritis) - key characteristics
- acute cystitis symptoms plus any of the following
- fever
- chills
- flank pain
- n/v
UTI - exam findings
- ask about previous UTIs, DM, HIV, on prednisone (immunosuppression), recent GU surgery)
- VS (febrile, tachycardia)
- flank pain/CVA
- suprapubic tenderness
- inguinal adenopathy
- men may have inguinal tenderness or meatal discharge
UTI - diagnostics
- UA: evidence of pyuria is most valuable diagnostic tool for UTI
- pyuria = > 10 WBCs, most reliable indicator
- absence of pyuria strongly suggests alternative dx
- CBC (if worried about pyelonephritis, may see left shift)
UTI - management (non-pharm)
- hydration
- condom utilization
- appropriate use of indwelling urinary catheters
UTI - management (pharm) for uncomplicated cystitis
- Nitrofurantoin 100 mg BID
- Bactrim PO BID
- duration of treatment: women = 3 days, men = 7-14 days
UTI - management (pharm) for acute pyelonephritis
- ciprofloxacin 500 mg BID or 1000 mg ER PO daily
- levofloxacin 500-750 mg PO daily
UTI - why admit to hospital?
- isn’t able to take oral meds
- dehydrated
- elderly
- unstable
- unable to keep food down
- symptoms aren’t improving
- pregnant
- immunocompromised
UTI - management (pharm) for hospitalized pts
- fluoroquinolones such as IV levoquin
UTI - referrals and consultations
- urology: males with structural abnormalities, recurrent UTIs
- ID: unusual or resistant microorganisms
- Pharmacokinetics: management of dosing antibiotics
- repeat UA is not done routinely in women but is in men
Varicocele - key characteristics
- BAG OF WORMS
- dilation of pampiniform venous plexus and internal spermatic vein
- cause of decreased testicular function
- vast majority of cases is left testicle
Varicocele - symptomatology
- dull, aching scrotal pain
- testicular atrophy
- infertility
- usually asymptomatic (usually seeks tx after failed conception)
Varicocele - exam findings
- BAG OF WORMS
- grading:
1. small (palpable only with valsalva maneuver)
2. moderate (non-invisible upon inspection but palpable upon standing)
3. large (visible on gross inspection
Varicocele - diagnostics
- physical exam
- doppler ultrasound: when exam findings are questionable, this is diagnostic
Varicocele - management
Medical:
- no effective treatment
- older men who have completed reproduction and only present with minor scrotal discomfort = NSAIDs and scrotal support
- younger, fertile men = surgery may be needed
Surgery:
- veriocele ligation
Hydrocele - key characteristics
- fluid collection with tunica vaginalis of scrotum or along spermatic cord
- little risk of clinical consequence
Hydrocele - symptomatology
- fullness of scrotum
- swelling of scrotum
- painless
Hydrocele - exam findings
- soft, non-tender collection with hemiscrotum
- may be able to palpate scrotal contents
- may be massive and tense
- TRANSILLUMINATES
Hydrocele - diagnostics
- physical exam
- transillumination
- ultrasound - if findings show tenderness or fever, or there is a shadow seen during transillumination
Hydrocele - management
Medical:
- observation (asymmptomatic males with an isolated, non-communicating hydrocele) until they become symptomatic
Surgical:
- inguinal or scrotal approach
Prostatitis - 4 syndromes
I - acute bacterial
II - chronic bacterial
III - chronic/chronic pelvic pain syndrome (CPPS)
IV - asymptomatic inflammatory
Acute Bacterial Prostatitis - key characteristics
- acute infection of prostate
- very common
- young/middle aged men
- entry into prostate via urethra
Acute Bacterial Prostatitis - most common organism
E. COLI
Acute Bacterial Prostatitis - symptomatology
- acutely ill
- c/o chills, fevers, malaise, irritative urinary symptoms, pain, cloudy urine, pain at tip of penis
Acute Bacterial Prostatitis - exam findings
- warm, firm, edematous, very tender prostate
Acute Bacterial Prostatitis - diagnostics
- *DRE - finding tender and edematous prostate + classic symptomatology usually establishes dx
- UA + culture/gram stain
- Imaging - reserved for pts in which findings aren’t showing anything, still having symptoms, no improvement despite medical tx
Acute Bacterial Prostatitis - management
ANTIMICROBIALS!
- TMP/SMX (Bactrim) PO BID
- Cipro 500 mg PO BID
- Levofloxacin 500 mg PO daily
- 6 weeks tx duration
Chronic Bacterial Prostatitis - key characteristics
- *hallmark = reoccurring, relapsing UTI involving same pathogen
- chronic/ recurrent urogenital symptoms with evidence of infection
- young/middle aged men
Chronic Bacterial Prostatitis - common pathogen
E. COLI
Chronic Bacterial Prostatitis - symptomatology
- subtle
- recurrent dysuria, frequency, urgency, perineal discomfort, low-grade temps
Chronic Bacterial Prostatitis - exam findings
- may see prostatic hypertrophy, tenderness, edema, nodularity
- prostate may be normal
Chronic Bacterial Prostatitis - diagnostics
- DRE
- UA + culture/grain stain
- semen culture
Chronic Bacterial Prostatitis - management
- prolonged antimicrobial therapy
- *Cipro 500 mg PO BID
- *Levofloxacin 500 mg PO BID
- *4 week duration for fluoroquinolones
- urology referral
Chronic/Chronic Pelvic Pain Syndrome (CPPS) - key characteristics
- unexplained pelvic pain
- constellation of symptoms: associated with irritative voiding and/or pain in groin, genitalia, or perineum in absence of pyuria and bacturia
- need to have:
1. long standing symptoms
2. no objective explanation for symptoms
3. no satisfactory tx or cure that is helping
Chronic/Chronic Pelvic Pain Syndrome (CPPS) - symptomatology
- irritative voiding symptoms
- consider administering NIH-CPSI
Chronic/Chronic Pelvic Pain Syndrome (CPPS) - exam findings
- prostate usually non-mildly tender
- thorough abdominal/pelvic exam
Chronic/Chronic Pelvic Pain Syndrome (CPPS) - diagnostics
- DRE
- UA + culture/stain
- PSA
- imaging?
Chronic/Chronic Pelvic Pain Syndrome (CPPS) - management
- *alpha-blockers + antimicrobials
- reassurance
- consultations: urology, PT, psych
Asymptomatic Inflammatory Prostatitis (non-bacterial) - key characteristics
- symptoms of prostatitis without positive cultures
- may be caused by some other organism such as chlamydia, gonorrhea, fungi, etc.
- may be non-infectious cause such as allergies, autoimmune
Asymptomatic Inflammatory Prostatitis (non-bacterial) - symptomatology
- irritative voiding symptoms
Asymptomatic Inflammatory Prostatitis (non-bacterial) - exam findings
- non-specific
- normal vs. tender prostate
- may see enlarged boggy prostate
- may have pelvic trigger points
Asymptomatic Inflammatory Prostatitis (non-bacterial) - diagnostics
- DRE
- UA + culture/stain
- expressed prostatic secretions
- voiding cystourethrography
Asymptomatic Inflammatory Prostatitis (non-bacterial) - management
Trial of antimicrobials
- TMP/SMX, cipro, levofloxacin
- if improvement, proceed with full 4 week tx
STI testing
Analgesics
Adjuctive therapies - biofeedback, sitz bath, acupuncture
Acute Epididmyitis - key characteristics
- inflammation of epididymis
- most common cause of acute scrotal pain in adults in outpatient setting
- most commonly infectious etiology
Acute Epididmyitis - symptomatology
- gradual onset of scrotal pain and swelling (over days)
- localized to one side
- dysuria, frequency, and/or urgency
- fever/chills
- no n/v
- may c/o urethral discharge preceding onset
Acute Epididmyitis - exam findings
- induration and swelling of involved epididymis
- exquisite tenderness
- PREHN SIGN - RELIEF OF PAIN WHEN ELEVATING AFFECTED SIDE
(if pain is worse (positive = torsion!) - may see scrotal wall erythema or reactive hydrocele in advanced cases
Acute Epididmyitis - diagnostics
Lab
- UA - should always be done in suspected cases (can be negative in those without urinary complaints)
- urine culture (if UA positive)
- consider urethral swab (if urethral discharge)
Ultrasound
- if concerned for torsion
Acute Epididmyitis - management
combination of ceftriaxone, doxycycline, levofloxacin, ofloxacin
Acute Epididmyitis - supportive therapy
- reduction of physical activity and scrotal support/elevation
- ice packs
- NSAIDs
- avoidance of urethral instrumentation
Testicular torsion - key characteristics
- torsion of spermatic cord and loss of blood supply to ipsilateral testicle
- *UROLOGIC EMERGNECY!
- predominately disease of adolescents and neonates
- etiology spontaneous, sports/physical activity induced
- *testicular viability significantly decreases after 6 hours!
Testicular torsion - symptomatology
- sudden onset severe unilateral scrotal pain
- inguinal or scrotal swelling
- pain may lessen as necrosis becomes more complete
- gradual onset is uncommon
- fever, n/v
Testicular torsion - exam findings
- very tender testicle
- may see swollen, high-riding testis
- loss of cremasteric reflex (or diminished)
- *positive Phren sign (elevation of scrotum is more painful)
- edema or enlargement of testicle
- scrotal erythema
Testicular torsion - diagnostics
- clinical exam (diagnostics are not needed)
Testicular torsion - TWIST scoring
- testicular workup for ischemia & suspected torsion
Testicular torsion - management
- *SURGERY - immediate surgical exploration and detorsion is needed to salvage testis
- analgesics and antiemetics
Erectile dysfunction - types
Organic
Iatrogenic
Psychogenic
Erectile dysfunction - Organic
- Vascular: most common cause (atherosclerosis, venous insufficiency, venous leak)
- Endocrine: hypogonadism, hyperprolactinemia
- Neurogenic: 2nd most common cause (DM, stroke, Parkinson’s)
- Primary penile disorder (priapism)
Erectile dysfunction - Iatrogenic
- Meds: antihypertensives, anticholinergics, antidepressants
- Surgery: radical prostatectomy, pelvic surgery
- Etoh, tobacco, illicit drugs
Erectile dysfunction - Psychogenic
- Pyschosocial - depression, performance anxiety
4 Major categories of sexual dysfunction in older men
- erectile dysfunction (ED)
- low desire (libido)
- performance anxiety and other psychological problems
- inability to climax
Erectile dysfunction - key characteritic
inability to achieve or maintain erection sufficient for satisfactory sexual performance
Erectile dysfunction - Exam
- emphasis on GU, vascular, and neurologic systems
- focused exam on BP, peripheral pulses, sensation, genitalia and prostate, testes, any penile abnormalities
Erectile dysfunction - diagnostics
- UA recommended to rule out infection
- labs to consider: hormone testing, Hgb A1c, chemistry panel, lipid panel
- injection of prostaglandin E1: direct injection into corpora cavernosa. if penile vasculature is normal, erection should develop within minutes
Erectile dysfunction - management
- identify underlying case
- identify and treat CV risk factors (smoking, obesity, HTN, lipid disorder)
- *medication: phosphodiesterase-5 inhibitors (Sildenafil, vardenafil). take on empty stomach about 1 hour before sex
- contraindications to phosphodiesterase-5 inhibitors: men taking nitrates
BPH - key characteristics
- proliferation of cellular elements of prostate
- common problem among older men
- prostate weight increases after age 50
- can lead to bladder outlet obstruction
BPH - symptomatology
- lower urinary tract symptoms: increased daytime frequency, nocturia, urgency, incontinence
- voiding symptoms: slow stream, splitting/spraying of stream, intermittent stream, hesitancy, drippling
- slow/insidious onset with progression over years
BPH - exam
DRE - examin prostate for size, consistency, nodules, induration, and symmetry
BPH - diagnostics
- DRE
- UA: should be obtained to detect blood or infection
- creatinine
- PSA
BPH - management
- *watchful waiting is recommended for mild symptoms
- behavioral modification: avoiding fluids before bedtime, reduction of etoh and caffeine, double voiding)
Prostate cancer - key characteristics
- most common non-cutaneous cancer in men in US
- likelihood increases with age
- ranges from microscopic well-differentiated to aggressive high-grade cancer with mets
Prostate cancer - risk factors
- tobacco use
- african american
- high fat diet
- family hx
Prostate cancer - symptomatology
- asymptomatic (majority)
- urinary complaints: frequency, urgency
- retention
- back pain
- hematuria
- advanced: weight loss, loss of appetite, bone pain, anemia, leg pain and/or edema
Prostate cancer - diagnostics
- DRE?: provider dependent, serial exams are best, nodule is suspicious and warrants evaluation
- PSA + DRE findings
- UA: should be done to check for hematuria or infection
- *needle biopsy for elevated PSA and/or abnormal DRE. Use Gleason score
Prostate cancer - most common type
- *adenocarcinomas
Prostate cancer - management
- initial evaluation of tx discussion involves 2 things:
1. patient’s life expectancy and health status
2. biologic characteristics of tumor and predicted aggressiveness - active surveillance, watch and wait
- radical prostatectomy if intermediate risk
Bladder cancer - key characterisics
- *highest rate of recurrence of any malignancy
- occupational exposures associated with increased risk
- incidence increases with age
Bladder cancer - most common type
- *transitional cell carcinoma
Bladder cancer - most common cause
- *tobacco
Bladder cancer - symptomatology
- *painless hematuria (gross or microscopic)
- irritative voiding symptoms
- often intermittent
Bladder cancer - diagnsotics
- UA + micro
- urinary cytology: texts dx, suggestive urinary cytology findings suggests urologist to perform cystoscopy
- cystoscopy: criterion standard for dx but invasive and expensive
- urinary tumor markers
- CT/MRI - rule in/out mets
Bladder cancer - staging
- *TNM system is used
Bladder cancer - management
- *non-muscle invasive: immunotherpay with BCG is most effective
- *muscle-invasive: TURBT for early stages, chemo (Cisplatin is standard), for mets = platinum based combos
Testicular Cancer - key characteristics
- most common solid malignancy in males aged 19-35
Testicular Cancer - most common type of tumor
- *germ cell tumors (GCT)
Testicular Cancer - symptomatology
- *nodule or painless swelling of one testicle
- commonly: dull ache or heavy sensation in lower abdomen, perianal, or scrotum
- advanced: signs of mets (neck mas, cough, anorexia, n/v, back pain, bone pain)
Testicular Cancer - exam findings
- bimanual exam of scrotal contents: ovoid mass, firm, mixed, hard always suspicious
- may find hydrocele
- abdominal exam for nodal disease
- lymph node exam
Testicular Cancer - diagnostics
- scrotal US
- *serum tumor markers: alpha fetoprotein (AFP), beta-HCG, LDH)
Testicular Cancer - staging
- *uses TNM staging
Testicular Cancer - management
- *diagnostic radical orchiectomy also serves as initial tx
- *baseline sperm count and sperm banking
- active surveillance post-tx
Post-Coital Emergnecy Contraception
- copper IUD
- oral antiprogestins
- oral levonorgesral (plan B)
- all victims of sexual assault should be offered emergency contraception
- should be taken 72-120 hours after
Dysmenorrhea - primary
- menstrual pain with menstrual cycle in ABSENCE OF PATHOLOGIC FINDINGS
- tx: NSAIDS (start 1 day prior and continued 1-2 days after)
Dysmenorrhea - secondary
- menstrual pain with organic causes (ex: fibroids, endometriosis)
- tx: depends on cause
Amenorrhea - primary
- absence of menses by age 16
- causes: congenital lack of uterus, chromosomal abnormalities, stress, vigorous exercise, dieting
Amenorrhea - secondary
- absence of menses for 3 months (for 6 months of women with irregular cycles)
- causes: #1= PREGNANCY
Amenorrhea - management
- depends on cause
- refer
Dysfunctional uterine bleeding
- includes menorrhgia (heavy bleeding), metorrhagia (light, irregular bleeding between periods), and menometrorrhagia (heavy, irregular bleeding)
- *big cause is endometriosis
- check for anemia and coags if heavy bleeding
- consider referral if patient is > 35 and/or exposure to unopposed estrogen
PID Salpingitis - what is it?
Acute or chronic inflammation of upper female genital tract (into fallopian tubes) caused by bacterial infection
PID Salpingitis - most common organism
- *N. gonorrhoeae and C. trachomatis
PID Salpingitis - presentation
- Early: lower abdominal pain, menstrual cramp-type pain, low grade fevers
- Later: more severe abdominal pain, higher fevers, purulent discharge
- *Chandelier sign: cervical and uterine motion tenderness, marked tenderness of cervix, uterus, and adenexa
PID Salpingitis - diagnostics
- minimum critiera: female, sexually active, uterine or adenexal tenderness with cervical motion tenderness, temperature > 101, cervical or vaginal discharge, WBCs on vaginal microscopy, ESR, elevated CRP, positive gonococcal or chlamydia infection
PID Salpingitis - treatment
- *ceftriaxone 250 mg IM once + doxycycline 100 mg BID for 14 days (with/without metronidazole)
Bacterial Vaginosis - most common pathogen
- *overgrowth of gardnerella vaginalis
Bacterial Vaginosis - when do we treat?
- only if bothersome in non-pregnant women and always in pregnant women
Bacterial Vaginosis - presentation
- pruritus, vaginal irritation, pain, unusual/ malodorous discharge
Bacterial Vaginosis - diagnostics
- can usually treat without vaginal exam
- Amsel criteria: requires 3 of the following -
1. discharge
2. *Clue cells present
3. vaginal fluid pH > 4.5
4. positive Whiff test (vaginal swab + KOH prep) - *gram stain = (gold standard lab method) - look for clue cells
Bacterial Vaginosis - treatment
- *metrondiazole 500 mg BID for 7 days
Vulvovaginal candidiasis - presentation
- thick, clumpy, white, cottage cheese discharge
- pruritus, erythema
Vulvovaginal candidiasis - risk factors
- pregnancy, on antibiotics, long-term steroids
Vulvovaginal candidiasis - diagnostics
- usually done just by clinical symptoms
- gram stin
- swab + KOH wet prep
Vulvovaginal candidiasis - treatment
- *fluconazole 150mg once
- also intravaginal agents
Trichomonas vaginalis - presentation
- frothy, gray or yellow/green discharge, malodorous
- *strawberry cervix (petechiae on cervix)
Trichomonas vaginalis - most common pathogen
- *trichomonas vaginalis
Trichomonas vaginalis - diagnostics
- *Nucleic Acid Amplification Test (NAAT) - swab, highly sensitive
Trichomonas vaginalis - treatment
- *metronidazole 2g PO once
- test for other STIs because if they have this they usually have something else going on
Chlamydia - presentation
- women: no symptoms in 70-80%, lower abdominal pain, discharge, dysuria
- men: no symptoms in up to 50%, cloudy thick penile discharge, unilateral testicular pain and swelling
- may have ulcerations, lesions, erythema on external genitalia
Chlamydia - pathogen
- *chlamydia trachomatis
Chlamydia - diagnostics
- *NAAT test
Chlamydia - treatment
- *azithromycin (Zithromax) 1g single dose
Gonorrhea - presentation
- asymptomatic or symptomatic
- females: up to 80% asymptomatic, dysuria, frequency, labial pain, pharyngitis, discharge, systemic signs (later)
- men: more symptomatic, whitish urethral discharge, dysuria, pharyngitis, *profuse purulent yellow/green discharge (later)
- can lead to PID, ectopic pregnancy, and infertility if not treated
Gonorrhea - pathogen
- *N. gonorrhoeae
Gonorrhea - diagnostics
- *NAAT
- *identified on gram stain with use of modified thayer-martin medium
Gonorrhea - treatment
- *Ceftriaxone (Rocephin) 250 mg IM once + azithromycin 1g PO once
Herpes Simplex Virus - presentation
- vesicular eruptions clustered on lightly erythematous base
- HSV type 1: most common, cold sores
- HSV type 2: gential
- can get sick with flu-like symptoms
Herpes Simplex Virus - diagnostics
- would see classic, painful vesicle eruptions
- HSV culture: test of choice now
Herpes Simplex Virus - treatment
- no cure but can treat symptoms
- *acyclovir (Zovirax) 7-10 days or until healing is complete
Syphilis - stages
NEED TO KNOW
- Primary: chancre - painless ulcer/sore, usually 3-4 weeks after exposure, may have regional lymphadenopathy
- Secondary: dissemination, systemic, flu-like symptoms, rash on palms and soles of feet, wart-like lesions throughout body, will progress to latent stage of not treated
- Latent: may be asymptomatic, can last 2-20 years, blood test remains positive for antigen
- Tertiary: takes on many forms (neuro, CV, soft-tissue syphilis, etc)
Syphilis - pathogen
- *Treponema pallidum
Syphilis - diagnostics
- dx requires 2 tests (a non-treponemal test and treponemal test)
- treponemal test looks for antibodies (VDRL and RPR)
- non-treponemal test looks for damage (dark-field microscopy and direct fluorescent antibody test)
Syphilis - treatment
- *Benzathine penicillin G 2.4 million dose injection once and then follow up (primary and secondary)
- titers monitored (don’t want increase)
- 3 months and 6 months if necessary
Human Papillomavirus - presentation
- usually transient and without any clinical manifestations
- some get genital warts
Human Papillomavirus - types
- HPV-6 and HPV-11: low risk, more common, non-oncogenic
- HPV-16 and HPV-18: high risk, oncogenic, accounts for up to 70% of cervical cancers
Human Papillomavirus - diagnostics
- biopsy: if dx uncertain, patient is immunocompromised, if lesions don’t respond to standard tx
- pap smear: usually how dx is found in women, sexually active women > 21
Human Papillomavirus - treatment
- no cure, just helps with symptoms
- ointments and cryotherapy for warts
- sometimes just leave them, they can come and go
Expedited Partner Therapy
- treating sex partners if patient is diagnosed with chlamydia or gonorrhea by providing meds to take to partner WITHOUT EXAMINATION OF PARTNER
