Pelvic / UTI (4 questions) Flashcards
Symptoms of nephrolithiasis
• unilateral flank pain
• hematuria
- nausea
- pain 10/10
- testicular pain
- unilateral CVAT
DDx for nephrolithiasis
- appendicitis: usually no hematuria
- cholecystitis: flank pain w/o hematuria
- pyelonephritis: fever uncommon in stones
- MS pain
- Herpes zoster: usually rash and no hematuria
- ectopic pregnancy
Lab results for nephrolithiasis
- UA, C+S
- Flat plate or helical CT - may not be able to visualize depending on stone density
- Urine dip
- leukocytes,
- +++ hematuria in UA
Tx of nephrolithiasis
- goals: pain relief, pass stone, prevent obstruction
- increase H2O, decrease dark cola
- strain urine, save stone for analysis
- RTC if fever or increased pain, gross hematuria
- Meds:
- Ketorolac 60mg IM followed by 10mg PO q4 hrs PRN. Pain relief. do not use >5 days
- Tamsulosin (Flomax) 0.4mg PO QD x 4 weeks - alpha blocker - relaxes muscle for easier passage
- Long term: prevent recurrence
Does animal protein put a person at higher risk for kidney stones?
yes! high animal protein
Does ca++ intake predispose a person to kidney stones?
only supplements - not dietary
Why does obesity put a person at higher risk for stones?
lowers urinary pH (only in men?)
GI condition that increases risk for stones
Crohns - high urinary oxalate d/t increased absorption of dietary oxalate
Conditions associated w/risk for stones
diabetes, gout, excessive exercise/physical activity, obesity, crohn’s, Vit D deficiency, dehydration
Where is pain located in upper urethral vs lower urethral obstruction (stones)
upper: flank
lower: may radiate to ipsilateral testicle or labium
Symptoms of endometriosis
- classica: dysmenorrhea, dyspareunia, heavy period (menorrhagia), infertility (often why present first)
- chronic mild lower abd pain
- cyclic with menses
- getting worse over time
- nausea, headache, bloating, lower back pain with menses
- tenderness on pelvic exam (CMT, uterine and adnexal tenderness)
- possible rectal bleeding around menses
Differential Dx endometriosis
- PID
- Adenomyosis
- Ovarian cancer
- Pelvic adhesions
- Colon cancer
- GI bleed
- IBS
- Diverticular disease
Labs / results of endometriosis
• urine hCG, GC/CT - r/o other etiology
• + stool hemoccult
- CA-125 -often high in endometriosis. and ovarian ca
- ?HE4 - ovarian ca
- ultrasound - transvaginal
• diagnostic laparoscopy -need biopsy for definitive dx
- GI workup - FOBT x 3 when no menses
- maybe colonoscopy
no labs clinically useful for dx
Tx of endometriosis
• Short term: pain relief, non-invasive eval
- Naproxen 500mg BID with food, start 2 days prior to menses and continue until menses day 3
- if ineffective change to Ponstel
• Long term: pain relief, preserve fertility
- Lo-Ovral 1 po QD
- low-fat vegetarian diet (assoc w/dec dysmenorrhea)
- dairy intake 3-4 servings/day (assoc w/dec Sx)
- exercis
- yoga and sexual activity
F/U and Tx if endometriosis not getting better
- Always return 4-6w for review
- Doing well: continue
- Not doing well: discuss GnRH vs laparoscopy, ?get pregnant sooner instead of later
Sx of Interstitial cystitis (painful bladder syndrome)
- urinary urgency, frequency, & pain increasing over time
- pain absent immediately after voiding
- pain worst in morning
- hx multiple UTIs
- nocturia
- dyspareunia with deep penetration
- occasional lower abd pain
- mild tenderness on pelvic exam
DDx of Sx of Interstitial cystitis (painful bladder syndrome)
- Leiomyomata
- PID
- Atypical IBS
What labs would you order for suspected interstitial cystitis
- hCG: r/o
- GC/CT: r/o
- C+S: r/o
- urine cytology: r/o
- hemoccult
Tx of interstitial cystitis
Goal: pain relief, tx or mgmt of underlying conditions
- Amitriptyline 25-100mg PO analgesia + relief of depressive sx w/pain
- Gabapentin (Neurontin) 100g consider if amitryptiline not effective
- Pentosan polysulfate sodium (Elmiron) 100mg PO tid, not with food - can combine w/for bladder sx, but is weak blood thinner!
- local heat/cold
- bladder training, physical therapy
- CBT
Sx of acute cystitis
• urinary pain, frequency, urgency with acute onset
DDx acute cystitis
- vaginitis
- urethritis
- structural urethral abnormalities
- painful bladder syndrome
- PID
- nephrolithiasis
Lab results / UA for acute cystitis
• +++ leuks, + nitrites, ++ blood on UA
Possible C+S & GC/CT
Tx of acute cystitis
- Nitrofurantoin (Macrobid) 100mg PO BID x 5-7 days
- Phenazopyridine (Pyridium) 200 mg PO TID x 3 days -orange urine!
- TMP-SMX (Bactrim) 160/800mg BID x 3 days -not w/impaired kidney function!
- RTC if fever, no relief ~2 days, blood in urine
- wipe front to back, keep well hydrated, don’t “hold it”, urinate after sexual activity
Sx of pyelo
- urinary pain, frequency, urgency
- pink-tinged urine
- fever
- nausea
- side pain
- CVAT
DDx pyelo
PID, nephrolithiasis
Labs ordered for suspected pyelo
- UA: ++++ leukocytes, + nitrites, ++++ blood
- C+S
- GC/CT - r/o
- hCG - r/o
Tx pyelo
- Ciprofloxacin 500mg PO BID x 7 days
- Tylenol for fever
- clear liquids
- RTC if fever not going down in 24h, vomiting, or urine sx persist
- F/U phone call in 2 days
When is there a risk for a complicated UTI?
• risk fx for complicated UTI: diabetes, pregnancy, renal failure, indwelling catheter, immunosuppression, renal transplantation, abnormality of urinary tract
Ectopic pregnancy: Sx
- severe, increasing lower abd pain
- pressure in rectum
- nausea
- skipped menses
- breast tenderness
- suprapubic tenderness, adenexal tenderness on exam
Ectopic Pregnancy: DDx
- UTI
- PID
- Nephrolithiasis
- Endometriosis
- Leiomyomata
- Appendicitis
Lab results ectopic pregnancy
- hCG high - urine and serum
- TVUS
Tx of ectopic pregnancy
Short term: alleviate pain, prevent fallopian tube rupture, clarify Dx
Long term: preserve fertility
- refer to OB/GYN
- increased risk of tubal pregnancy in future
BPH Sx
- urinary frequency, urgency, hesitancy, weak stream. No pain. Getting worse
- boggy prostate upon exam
BPH DDx
- urethral stricture
- bladder neck contracture
- carcinoma of bladder or prostate
- bladder calculi
- UTI and prostatitis
- neurogenic bladder
BPH labs / results
- neg hemoccult
- UA, C+S, urine cytology - r/o UTI
- maybe PSA ( <4ng/mL = normal, >10 may be cancer, >40 advanced disease)
- PV residual US?
BPH Tx
- Alpha blocker (terazosin, doxazosin, tamsulosin, alfusosin) 1st line, relieve obstructive sx
- 5 alpha reductase inhibitor (finasteride, dutasteride) - sx relief takes 3-6mths, up to 12mths for full effect
- PDE-5 inhibitor (sildenafil, tadalafil, vardenafil) -for erectile dysfunction, relaxes smooth muscle in bladder neck and urethra, penis muscle
- NSAID (celecoxib 100mg QD) - increases peak urine flow
- behavior management
BPH - what are the two major problems?
- Storage: frequency, urgency, nocturia, incontinence
- Voiding: weak stream, post void dribbling, straining, hesitancy, incomplete emptying
Ovarian cancer: labs
CA-125 +HE4 (in combo w/CA125 improved detection of ovarian ca)
Pathogenesis of Bladder Pain Syndrome
little is known. Possibly abnormal bladder lining, e.g., after infection
