RENAL-Male GU Flashcards
Pain Male GU
severe
Urinary tract obstruction
Inflammation -parenchyma of a GU organ
Pyelonephritis
Prostatitis
Epididymitis
Discomfort
Cystitis
Urethritis
GI- n/v/d, illeus
Tumor-painless
BUT…pain if obstruction or extends
Renal Pain
Ipsilateral CVA- lateral to the sacrospinalis muscle and beneath 12th rib
D/t-Acute distention of the renal capsule
DDX- irritation of the costal nerves, most commonly T10–T12
Not colicky/intermittent
Bladder Pain
overdistension
inlfammed
Prostatic Pain
Inflammation distention capsule Poorly localized Lower abdominal Inguinal Perineal Lumbosacral Rectal pain Irritative urinary sx Acute urinary retention
Penile Pain
Erecion d/t
Peyronie’s disease
priapism
Flaccid
inflammation bladder
urethra
Paraphimosis - cicumcised
Testicular Pain
Acute
Epididymitis
Torsion testicle
Chronic scrotal pain
Hydrocele, Varicocele
Dull, heavy, not radiate
Referred pain to kidneys or retroperitoneum
Lower Urinary Tract Symptoms
Irritative Symptoms: Urinary frequency Nocturia Dysuria Incontinence Stress Urge
Obstructive Symptoms: Decreased force hesitancy Intermittency/colic Post void dribbling Straining
Infections
Urethral Discharge
Fever and Chills:
Pyelonephritis
Prostatitis
Epididymitis (acute)
PMH risk
Systemic diseases: Diabetes Mellitus Multiple Sclerosis TB Schistosomiasis
Family history
Prostate cancer
Stones (cystine)
Renal tumors (some types)
Surgical History
Cigarette smoking
bladder cancer
Erectile dysfunction
Chronic alcoholism
Impaired urinary fx
Sexual dysfunction
Testicular atrophy
Physical Examination
General Observations Cachexia -Malignancy, TB Jaundice or pallor Gynecomastia Endocrinologic dz Alcoholism Hormonal therapy
Kidney mass
Bladder- percuss MC
Bimanual-anestheia ideal
Penius-
hypospadius-ventral side (below glans spot)
epispadius-dorsal (above glans
Physical Examination- inferior
Scrotum and Contents
Painful:
Torsion
Epididymitis
Painless
Spermatocele
Hydrocele
Varicocele
Transillumination
Cystic (ligts up) vs solid
***Painless solid testicular mass is tumor until proven otherwise
Rectal and Prostate
Digital rectal examination (DRE):
Every male after age 50 years (controversial)
Men who present for urologic evaluation
BPH epidem
40-50% men aged 51-60 years
>80% men >80 years
Considerable disability
Low rate of mortality
Size/volume- prostate inc. w/ age and tone, Urinary flow dec.
Post void residual inc. d/t pressure on the urethra from prostate
Develops in the periurethral or transitional zone
Diagnosis of BPH
Frequency nocturia hesitancy urgency weak stream (LUTS) Sx progress gradually
Rule out UTI/Prostatitis, urethral stricture, bladder or prostate cancer, bladder calculi, neurogenic bladder
Normal- smooth rubbery, firm, symmetrical
Evaluation for BPH
GU
DRE: Size, consistency, nodules (bladder), induration (infxn), symmetry
Neurologic exam- sphincter tone
UA-UTI/prostatitis- hematuria
Serum creatinine, blood glucose-Bladder outlet obstruction, renal/pre-renal dz, DM
Serum Prostate Specific Antigen (PSA)* >4.0 ng/mL prostate cancer
Total serum PSA, %free PSA ration:
% free PSA
LOW= prostate cancer,
HIGH= BPH
(Urology):Maximal urinary flow rate
<15 mL/sec indicates obstruction
Post void residual urine volume
>12 mL abnormal in men
Treatment of BPH MILD-SEVERE
MILD 0-7 AUA
Monitor
Treat symptoms
Prevention - behavior modification- no fluids past 7pm, avoid diuretics meds/food
Herbal-Saw palmetto (EU) plant extract, controversial
No- FDA, No standards
Severe >20
Transurethral resection of the prostate (TURP)
Standard
TX OF BPH MOD
Moderate BPH-combo no EVB, long therapy
DOC 1st- **α-1-adrenergic antagonists (terazosin, doxazosin)
helps outlet obstruction d/t tension of prostatic smooth muscle
NO change in volume
SE-orthostatic hypotension, start low 1-6wks titrate to TD
5-α-reductase inhibitors-(finasteride, dutasteride)
NO ED
Inhibit conversion of testosterone to dihydrotestosterone
Reduce size of the prostate
Side effects: decreased libido, erectile dysfxn
Decrease in serum PSA levels-
Phosphodiesterase (PDE-5) inhibitors
BPH with ED
Tadalafil (Cialis) approved by FDA for this purpose
also dec BP- Inc hypotensive effects of α-blockers
Erectile Dysfunction:
Inability to acquire or sustain erection
Impotence = symptoms >75% of the time
Normal Requires vascular, neurologic, hormonal, and psychological systems
Sexual competency - libido, erection, ejaculation and orgasm
ROS-Rapidity of onset local trauma Nocturnal or early morning erection interpersonal conflict PMH
Risk Factors Cigarette smoking Diabetes mellitus Hypertension Underlying cardiovascular disease Hypogonadism Substance abuse Obesity Depression
Erectile Dysfunction:Physical Examination
CV, Neuro, GU exam PV- pulses, bruits Breast: gynecomastia L Abdomen: ascites GU: penile lesions, testicular atrophy, asymmetry or masses Endocrine- Acanthosis nigricans-DM, central obesity Visual field defects if pituitary tumor
Erectile Dysfunction:Treatment
Lifestyle modifications to reduce risk factors
Restore the capacity to acquire and sustain penile erection
Reactivation of libido
Medication
Penile self-injections
Vacuum erection devices
Penile prostheses
Medications
1st Phophodiesterase-5 inhibitors
Increase intracavernosal cyclic GMP levels to restore erectile function (vasoactive)
**caution in any patient with CV disease
**Contraindicated in patients taking nitrates and α-adrenergic antagonists (hypotension)
Psychogenic- SSRI’s
Hypogonadism
Decrease in sperm and/or testosterone production
Primary: dz of testes
Secondary: dz. of pituitary or hypothalamus
S/S-dec. energy and libido, loss of body hair and muscle mass, infertility, gynecomastia, hot flashes, dec. bone density
obesity
aging;
Diagnosis: serum total testosterone
If low, repeat and order LH
Infertility eval: order semen analysis; if sperm count low, order FSH
Primary: testosterone and/or sperm count low, LH and/or FSH high
Secondary: testosterone and/or sperm count low, LH and/or FSH normal or low
Refer
Hypogonadism Treatment i
androgen replacement therapy
Check PSA in men >50 yrs, Hct
Contraindications: prostate ca, severe OSA, Hct >50%, severe LUTS, uncontrolled CHF
ADE: inc PSA, worse BPH, erythrocytosis, worse OSA
FU: at 2-3 mos, then q 6-12 mo: Serum testosterone, serum LH if primary hypogonadism, Hct, PSA
Varicocele
Collection of dilated and tortuous veins in the pampiniform plexus surrounding the spermatic cord
d/t increased venous pressure and incompetent valves
10-25% adolescents
L side
S/S- dull ache or fullness in scrotum on standing
“bag of worms” that increases with Valsalva or standing
Grade 1: small; palpable only with Valsalva
Grade 2: moderate; not visible on inspection, but palpable upon standing
Grade 3: large; visible on gross inspection
Varicocele: Management
observation
Abnormal: if right sided, acute onset, or persist when supine
-Order Doppler US
- IVC obstruction (IVC thrombus, right renal vein thrombosis, abdominal mass)
Surgery: Cosmetic Pain Infertility Testicular Atrophy
Surgical ligation or testicular vein embolization smaller than unaffected side Bil Grade 3 Scrotal pain is present
Hydrocele
Fluid accumulation in the potential space of the tunica vaginalis d/t:
Peds: processus vaginalis not close
Adult: epididymitis, orchitis, testicular torsion, torsion of the appendix testis, tumor, or trauma
S/S
Soft, cystic, anterior scrotal mass
Communicating-increase during day disappear at night
Non communicating-do not change with straining
transilluminates to indicate fluid
Doppler US
TX-Treat underlying cause
Non-communicating- < 2 y is supportive care
Communicating risk for incarcerated inguinal hernia
Surgical repair child-> 2 y or if scrotum tense to improve blood flow to testicles
Pt. Male dysuria, scotal , perineal pain. Fever, N, frequncy, hesitancy. DRE tender, boggy.
Prostatitis
Comman all ages. E.coli, Proteus, GC/Chlam, enters via urethra, bladder or epididymis. Trauma, dehydration, abstinence, catheter, structure
S/S- pelvic/scrotal, bladder, hematospermm, chills, malaise, myalgia. (FLUish), but pelvic pain, odor cloudy urine
DX- DRE-caution bacteremia
UA, culture, CBC, ESR, CRP
TX- 4-6wk, ABX, NSAIDs 2wk
Pt w/ Prostatis has + Nitrites and Staph which ABX?
Cephalxin
What is 1st line for Prostatisis?
floroquinolones- LEVO, MOX
Gram Neg and Pos
Empircally while waiting
What ABX if M culture shows enteroccocus?
Ampicillin
Pt now suffered from epidymitis… What other complications could occure?
Bacteremia
Prostatic abscess-drain
Chronic- Urology
Not common
Refer!
Pt M c/o scotral pain. NO trauma, dc, urinary sx, no fever, no n/v. NO mass. PE- LEFT tender scotom. Lab- +UA. what is this?
Epididymitis
Subacute common d/t sex, exercise, bike, instrumentation.
Acute Rare infection, but serious-UTI PRostatiis.
DX- KEY PE tender induration. ,35y Chlamydia*, >35, MSM, E.coli, GC
Pt young athlete, has acute diffuse pain
w/ high ridin testis (bell clapper, swelling INC. Negative Cremaster REfex? What is this TX?
Testicular Torsion
Surgery- Open the book
Pt has subacute upper pole pain. Postive cremeaster reflex. Blue dot sign.
Appendix of testis necrotics
Pt M c/o scotral pain. NO trauma, dc, urinary sx, no fever, no n/v. NO mass. PE- LEFT tender scotom. Lab- +Nitries UA. what TX?
Empirically while waiting
Nitirest- Ofloxacin or Levfloxacin
Ceftriaxone+#1Doxycycline (GC/C) x10d
RICE- NSAIDs
F/U
Febrile- IV ABX
If PT has a NEG UA after 100mi bike ride…what is TX and cause?
2nd to reflux via ejaculatory ducts and vas.
Neg UA
TX-conservaive RICE ABX Doxy (while waiting)
M PT w/ thick d/c, dysuria, in developed US recent unprotected sex?
MC GU
or NGU
co-infectin w/ Chlalm 15-25%
WHat is preffered test for GU of Urehriris and Cervicitis?
PCR- neutrophils sensitive 95% GC
Swab urethra hurts
M PT w/ thick d/c, dysuria, in developed US recent unprotected sex, skin rash, swollen joint?
Dissmenitaed Gonorrhea
What is 1st line of GU TX
NEVER Tetrcyclin, Cirp, or PCN- HIGH RESisistance
1-IM ceftriaxon
TX partner-AVOID sex 7d.]
Any uretritis treat for both GC and Chlamy
What is the most common cause of urethritis and cervicitis?
NGU
Chlamydia Trachomatis
OIB
Reinfection common
s/s-ASX, gradual 50% sx 4d post incub 7-21D. MUCUS d/c
DX- PCR, genital culture
TX- AZI 1gm PO single
Ceftrixone
What does Metronidazole TX? What are the ADRS
Trichomoniasis
TX- give emeitcs d/t N/V ADR
parasite flagella
Like w/ other STI
Preg, menses, sex
Also in M 70% of time
