Male GU Flashcards
urethral discharge dysuria, abd pain/abnml vaginal bleeding
Uretheritis
NAAT or urinalysis/dipstick with positive leukocyte esterase or large amount of wbc
urethritis
Chlamydia treatment
Azithromycin
Gonorrhea treatment?
Cetriaxone
All males with cystitis
complicated cystitis
MC pathogen of cystitis
E. coli.
Dysuria, bruning, frequency & urgency, hematuria, suprapubic pain, and tenderness.
Cystitis
Urinalysis/dipstick with pyuria (<10 WBC/hpf), hematuria, leukocyte esterase, nitrites, cloudy urine.
cystitis
Definitive diagnosis for cystitis
Urine culture w/ 100,000 CFUs and exact pathogen
What diagnosis for cystitis do you do for complicated cases
urine culture
First line cystitis treatment
Nitrofurantoin
Complicated cystitis treatment
Fluoroquinolones
Terrible dysuria treatment
phenazopyridine- don’t use for more than 48 hrs and orange pee
Pregnant cystitis
Nitrofurantoin, fosfomycin, augmentin or amoxicillin.
involuntary urine leakage when the bladder is full
overflow incontinence `
when bladder detrusor muscle is underachieve or with bladder outlet obstruction (enlarged prostate)
overflow incontinence
MCC of overflow incontinence
neurologic disorder or autonomic system dysfunction like MS, spinal injuries, sclerosis/stenosis
loss of urine with no warning and leakage or dribbling in setting of incomplete bladder emptying, weak or intermittent urinary stream, hesitancy, frequency, and nocturia.
overflow incontinence
Diagnose overflow incontinence
Post void residual > 200 ml
First line overflow incontinence
intermittent or indwelling catheter
med to increase detrusor activity
Cholinergics (Bethanechol)
overflow incontinence treatment if enlarged prostate
alpha blockers
involuted leakage of urine with increased abdominal pressure that is greater than urethral pressure
stress incontinence aka laugh n pee
stress incontinence risk factors
young women who have had vaginal deliveries, surgery, estrogen loss, and prostatectomy.
urine leakage with no urge to urinate prior to leakage
stress incontinence
stress incontinence treatment
kegels, lifestyle modification- protective garments, weight losses smoking cessation, drinking less water
2nd line stress incontinence treatment
Pessaries, surgery (midurethral sling), alpha agonists
involuntary leakage preceded by or accompanied by sudden urge to urinate- strong urge to void with inability to make it to bathroom to urinate
urge incontinence
urge incontinence mc in
older women
cause of urge incontinence
detrusor muscle overactivity (involuntary contractions). Occur with increased age and bladder infections.
increased urgency and frequency, small volume voids, and nocturia.
urge incontinence
Treatment for urge incontinence
bladder training and Kegels
First line med treatment for urge incontinence
Antimuscarinics (oxybutynin)- antispasmics that increase bladder capacity and they are anticholinergic
cause bladder relaxation
Mirabegron
anticholinergic effect and alpha adrenergic agonist
TCAs
Surgery for urge incontinence
bottom to relax bladder muscle
bedwetting while sleeping in children 5 y/o or older
enuresis
enuresis primary
Absence of any period of time with nighttime dryness. May have a family history. Most common type
enuresis secondary
Enuresis after a dry period of at least 6 months. Usually due to a stressful event (parental divorce, birth of sibling, etc.)
First line enuresis
motivational therapy, education. Bladder training.
Most effective long term treatment for enuresis
enuresis alarm: sensor on bed pad and goes off when wet continued until min of 2 wks of consecutive dry nights
Desmopression in enuresis
nocturnal polyuria with normal bladder function capacity.
Refractory enuresis
TCAs
MC GU cancer
Bladder cancer
MC of bladder cancer
Urothelial (Transitional cell) carcinoma
MC risk factor for bladder cancer
smoking, male, over 40 y/o, occupational exposure to dyes, leather, rubber.
painless int hematuria (often gross), dysuria, urgency and frequency
Bladder cancer
Diagnosis for bladder cancer
urinalysis, CT urology, cystoscopy w/ biopsy –> gold standard
Treatment for bladder cancer
Localized or superficial = tumor resection with f/u every 3 months
Invasive = cystectomy, chemotherapy, radiation
Recurrent = injection of BCG vaccine b/c immune reaction will stimulate cross reaction with tumor antigens
increased estrogen or decreased androgens
gynecomastia
gynecomastia risk factors
high maternal estrogen, puberty, older males
palpable mass of tissue at least 0.5 cm in diameter and centrally located under nipple, symmetrical, tender to plapation
gynocomastia
management for gynocomastia
Supportive = stop offending medications
Tamoxifen = selective estrogen receptor modifier that is an estrogen antagonist in the breast
Surgery if refractory to medical therapy
narrowing of lumen due to infection, injury, or surgical manipulation produces a scar that reduces the caliber of urethra
urethral strictures
chronic obstructive voiding sxs (weak urinary cream & incomplete bladder emptying)
urethral strictures
urethral strictures diagnosis
Cystourethroscopy (or variation of)
urethral strictures treatment
Dilation or surgical reconstruction
MC urethral injury
men
MCC of urethral injury
blunt force trauma, pelvic fractures, MVA
gross hematuria, difficulty urinating, urinary retention, lower abd pain, blood at urethral meatus, swelling or ecchymosis of scrotum, penis or perineum or high riding prostate.
TRIAD: Blood at meatus, inability to void, distended bladder
urethral injuryq=
urethral injury diagnosis
Retrograde urethrogram
urethral injury treatment
surgery, catheter placement & healing for mild
hypospadias
ventral placement of urethral opening
MCC of hypospadias
failure of the urogenital folds to fuse during development
increased UTIs, erectile dysfunction, abnml foreskin with incomplete closure around glans, abnml penile curvature
hypospadias
hypospadias management
Do NOT circumcise while infant - foreskin may be used to repair later Surgical correction (arthroplasty) which may include penile straightening. Usually performed between 6 months and 1 year
epispadias
dorsal placement of urethral opening
epispadias MCC
failure of midline penile fusion
upward curvature of penis, absent dorsal foreskin, clitoris w/ two tips, small/laterally displaced labia majora.
epispadias
epispadias diagnosis
prenatal US
retracted foreskin that can’t be returned to normal position
Paraphimosis
Paraphimosis causes
forceful retraction of foreskin and can occur after blantitis or penil inflammation
severe pain and swelling for penis
Paraphimosis
Paraphimosis management
Manual reduction after reducing edema with cool compresses or pressure dressing
Definitive = incisions (dorsal slit) or circumcision
inability to retract foreskin over glans caused by scarring of foreskin after trauma
phimosis
phimosis management
Proper hygiene (wash that sucker out!), stretching exercises 4-8 weeks topical corticosteroids can increase retractility Circumcisions for definitive management
prolonged painful erection without sexual inflammation
priapism
priapism causes
ischemia (decreased venous outflow)
Etiologies of priapism
MC- idiopathic, 2nd is sickle cells
priapism diagnosis
Cavernosal blood gas:
ISCHEMIC (low-flow) = hypoglycemia, hypoxemia, hypercarbia & acidemia
NON-ISCHEMIC = normal
Doppler sono = will show blood flow
priapism management of ischemia
Phenylephrine (found in Sudafed & Preparation H) via intracavernosal injection (OUCH!). This will cause contraction of the cavernous smooth muscle, which will allow more venous outflow.
Needle aspiration of corpus cavernosum & irrigation to remove blood, especially if erection > 4 hours, with or without phenylephrine, and ice
Surgery if not responsive to above
age of diagnosis for penile ca
60
MC type of penile ca
squamous cell, HPV 16, 6, 18
risks of penile ca
smoking, lack of circumcision, HIV
leukoplakia on shaft of penis associated with HPV 16 some will progress to squamous cell carcinoma
Bowen’s Disease
mass or palpable lesion on penis, mc on clans, coronal sulcus, or prepuce
penile cancer
cryptorchidism
testicle not descended into scrotum by 4 months
MC cryptorchidism
right side
risk factors for cryptorchidism
prematurity, low birth weight, maternal obesity or DM
empty, small scrotum, inguinal fullness
cryptorchidism
Cryptorchidism diagnosis
Scrotal sono or MRI
Cryptorchidism treatment
Orchiopexy (bringing down the testes and attaching to scrotum) as early as 4-6 months, ideally before 1 year, must be done before 2 years
Cryptorchidism complication
testicular cancer
serous fluid collection within layers of tunica vaginalis of scrotum
hydrocele
MCC of what is hydrocele
painless scrotal swelling
MCC Of hydrocele
idiopathic,
fluid from abdomen enters scrotum via patent processes vaginalis that failed to close
communication hydrocele
fluids from mesothelial lining of tunica vaginalis
noncommunicating hydrocele
painless scrotal swelling often increases during the day
hydrocele
hydrocele PE
translucency (transilluminates), fluids located anterior and lateral to the testes, swelling worse w/ valsalva if it is the communicating type
Diagnosis of hydrocele
testicular sono
hydrocele management
Usually no treatment is needed because often resolves spontaneously
Surgical excision may be needed if persists after 1 year old (often occur at birth but resolve within 12 months) or in adults with communicating types to reduce the risk of a hernia.
cystic testicular mass of varicose veins
varicocele
asymptomatic varicoceles usually painless by may cause dull ache or heavy sensation
varicocele
On left, scrotal mass with bag of worms of spaghetti in bag superior to testicle, dilation worsens when pt is upright or with valsalva, less apparent when the pt is supine or with testicular elevation
varicocele
varicocele management
Surgery in some cases for pain, infertility or impaired testicular growth
r sided varicocele due to
abd malignancy
left side varicocele
renal cell carcinoma
gradual onset of localized testicular pain and swelling usually unilateral may be associated with fevers, chills, dysuria, urgency & frequency, no n/v.
epididymitis
MCC in male 14-35 of epididymitis
chlamydia or gonorheaa
MCC in males of epididymitis
e. coli
Positive Prehn sign and + cremasteric reflex
epididymitis
diagnosis of epididymitis
Scrotal sono = best initial test; will show enlarged epididymis, increased testicular blood flow (can also rule out torsion)
Urinalysis = check for infection
CT/GC testing
epididymitis
Scrotal elevation, NSAIDS, cool compresses
If under 35 y/o, treat with….ceftriaxone and azithromycin
If over 35 y/o, treat empirically with Fluoroquinolones
painless, cystic testicular mass
spermatocele (more than 2 cm) /epididymal cyst (less than 2 cm)
soft round mass at head of epididymis, seperate from testicles freely movable transilluminates
spermatocele/epididymal cyst
scrotal pain, swelling and tenderness
orchitis
scrotal erythema and tenderness
orchitis
orchitis treatment
Symptomatic - NSAIDS, bed rest, scrotal support/elevation, cool pack
orchitis MCC
mumps
abrupt onset of scrotal, inguinal, lower abd pain, n/v
testicular torsion
swollen, tender, retracted (high) testicle, may lie horizontally, negative preen sign, negative cremasteric reflex
testicular torsion
testicular torsion diagnosis
Clinical diagnosis -> immediate surgery!
Testicular doppler sono - most commonly used
Emergency surgical exploration (definitive) - preferred over sono if highly suspected!
testicular torsion management
Urgent detorsion & orchiopexy within 6 hours of pain onset.
Irreversible damage likely if > 12 hours.
Manual detorsion should be done if surgical intervention not available
Orchiectomy if not salvageable
MC age for testicular cancer
15-25 y/o (avg32)
Risk factor for testicular cancer
undescended testicle, white, Klinefelter syndrome, hypospadias
Seminomas
Simple (no alpha-fetaprotein)
Sensitive to radiation
Slower growing
Stepwise spread
Nonseminomas
Associated with increased serum alpha-fetoprotein & beta-hCG and resistant to radiation.
Yolk sac (MC in boys 10 y/o and younger)
Choriocarcinoma (worst prognosis)
Gonadoblastoma
testicular lymphom
painless testicular mass may have dull pain or testicular tenderness
testicular cancer
firm hard fixed mass that does no transilluminate
testicular cancer
testicular ca diagnosis
Sonogram - initial test of choice
Tumor markers (what are tumor markers?)
If nonseminoma, increased serum alpha-fetoprotein & beta-hCG a
Seminoma, Stage I
management
Radical orchiectomy & possible radiation
Seminoma, Stage 2
management
Debulking chemo followed by orchiectomy & radiation
Nonseminoma, Stage I management
radial orchiectomy
increased frequency, urgency, nocturia, hesitancy, weak or int stream, incomplete emptying & dribbling,
BPH
diagnosis of bph
Digital Rectal Exam (DRE): uniformly enlarged, firm, nontender, rubbery prostate
Prostate Specific Antigen (PSA): correlated with risk of symptom progression. (Normal < 4 ng/mL)
U/A to look for hematuria (or other cause of symptoms)
Urine cytology if at risk of bladder cancer (Smoker)
BPH management
sxs relief: 1st line- Alpha 1 blockers (Tamsulosin, Terazosin, Doxazosin)
2nd line- 5 alpha reductase inhibitors (finasteride & dutasteride)
Alpha-1 blockers: Tamsulosin, Terazosin, Doxazosin
MOA and SE
Smooth muscle relaxation of prostate & bladder neck leading to decreased urethral resistance, obstruction relief and increased urinary outflow.
SE = dizziness & orthostatic hypotension
5-alpha reductase inhibitors: Finasteride & Dutasteride
MOA and SE
inhibits conversion of testosterone to dihydrotestosterone which suppresses prostate growth which decreases size of prostate and decreases need for surgery
SE = sexual dysfunction, decreased libido, breast tenderness & enlargement
BPH Surgery
If persistent, progressive or refectory despite medical therapy for 12-24 months
Transurethral resection of prostate (TURP) removes excess prostate tissue
Risks = sexual dysfunction, urinary incontinence
Men < 35 MCC of acute prostatitis
Chlamydia and gonorrhea
men > 35 MCC of acute prostatitis
e.coli
children acute prostatitis
mumps
fever, chills, perineal pain, lower back or abd pain, increased frequency, urgency, nocturia, hesitancy weak or int stream =, incomplete emptying and dribbling
acute prostatitis
tender, got boggy prostate
acute prostatitis
Diagnosis of acute prostatitis
Urinalysis & culture = WBC increased, bacteria
Avoid prostatic massage (may cause bacteremia)
acute prostatitis management
Acute < 35 y/o = Treatment for CT & GC.
Acute > 35 y/o = Fluoroquinolones or Bactrim x 4-6 WEEKS (outpatient); IV fluoroquinolones with or without Aminoglycoside)
chronic prostatitis MCC
e coli
recurrent Otis or int dysfunction, malaise, arthralgia, increased frequency, urgency, nocturia, hesitancy, weak or intermittent stream, incomplete emptying & dribbling
chronic prostatitis
non tender boggy prostate
chronic prostatitis
diagnosis chronic prostatitis
Urinalysis & culture often normal, so prostatic massage often done (IF and only if you know it is chronic) to increase bacterial yield
management of chronic prostatitis
Fluoroquinolones or Bactrim x 6-12 WEEKS
If refractory, TURP
Alpha-1 blockers can help with chronic pain
2nd mc ca in men
prostate cancer
MC type prostate cancer
adenocarcinoma
prostate cancer
slow growing tumor of prostate
risk factors of prostate cancer
Age (>40) & genetics
Black men have higher incidence
Diet (high in animal fat)
Most pts are asymptomatic and are dx either abnormal DRE or via workup after abnormal PSA or after invasion of bladder, urethral obstruction or bone involvement
Back or bone pain with METS to bone, weight loss
prostate cancer
diagnosis of prostate cancer
DRE = hard, indurated, nodular, enlarged, ASYMMETICAL prostate PSA = above 4 ng/mL (but elevated PSA can be seen with other disorders)
If either of these are “positive,” then a biopsy is typically done:
Transrectal ultrasound-guided needle biopsy = most accurate test
If the PSA is over 10, a bone scan is usually also done, because the most common site of METS is the bone
Gleason grading system is used to determine aggressiveness or malignant potential (higher grade = more benefit from surgical removal of prostate)
management of local prostate cancer
Observation/surveillance if low risk, clinically localized or life expectancy < 10 years
VS
Definitive treatment with external beam radiation, brachytherapy or radical prostatectomy
Risks of prostatectomy = incontinence and erectile dysfunction
management of advanced prostate cancer
External beam radiation
Hormonal therapy = androgen deprivation (meds) and/or orchiectomy
Chemotherapy if hormonal therapy is ineffective
