Urology Flashcards
What are the 5 types of incontinence?
- stress
- urge
- overflow
- functional
- mixed
What is the most common type of incontinence in ppl >75yo?
urge
S/Sx of urge incontinence? (3)
- frequency
- urgency
- nocturia
Common etiologies of urge incontinence? (3)
- usually idiopathic
- overactive bladder
- detruser hyperactivity w/impaired bladder contractility (DHIC)
Nb. can also be d/t cystitis, tumor, stones, PD, dementia
Tx for urge incontinence (4)
- Timed voiding
- dietary manipulations to avoid irritants, weight loss
- kegels
- Meds: anticholinergics
What causes stress incontinence? (2)
- leakage d/t lack of pelvic supports
- intrinsic sphincter deficiency
Describe how lack of pelvic supports leads to stress incontinenc). What would usually cause this?
- usually hypermobility of the bladder neck (85%)
- 2/2 aging, hormonal changes, multiple vaginal births, pelvic surgery
What would cause intrinsic sphincter deficiency (stress incontinence)?
pelvic radiation, trauma, surgery
Tx for stress incontinence? (4)
- pelvic floor exercises
- Meds: alpha agonists, imipramine
- quit smoking
- surgery - bladder sling for support
What is the cause of overflow incontinence?
- detrusor underactivity
- bladder outlet obstruction
- Elevated PRV
What could cause detrusor under activity (overflow incontinence)? (5)
DM, MS, lumbar stenosis, spinal cord injury, meds (anticholinergics)
What would cause bladder outlet obstruction (overflow incontinence)? (3)
ureteral stricture, BPH, cystocele
What are the s/sx of overflow incontinence
small but continuous urine leak
Tx for overflow incontinence (2)
TURP, or intermittent catheterization
functional incontinence doesn’t involve _____
the lower urinary tract
functional incontinence results from _______
cognitive or functional impairments
Mixed incontinence (stress and urge) is most common in what population?
- older women (65% w/stress incontinence have urgency)
Tx of mixed incontinence
imipramine (anticholinergic and alpha agonist)
What are the 3 P’s you should assess for in the history of someone with incontinence? What should you also inquire about or suggest?
- Position of leakage (standing, sitting, supine)
- Protection (pads per day, wetness of pads)
- problem (quality of life)
- voiding diary
What are the different modalities you can use to diagnose incontinence? (4)
- UA
- PRV
- pad weight
- urodynamics
What other meds can be used to treat incontinence in addition to the aforementioned meds, lifestyle modifications, exercises, and bladder training?
- alpha adrenergic stimulators
- oral estrogen
- cymbalta (duloxetine) - increases urethral sphincter contraction
When do you screen for prostate cancer?
- high risk groups/AAs: 45 yrs
- Others: 50 yrs
- stop at 75 or <10 yr survival
RFs for prostate cancer (5)
- AA>white>Asians
- FMH
- Diet
- age
- environmental exposure
How do you determine someone’s gleason score?
- first # = majority of the tissue
- second # = 2nd most common
(4+3 is worse than 3+4)
What gleason score is the cut off for high grade?
> 6
PSA
- a serine protease from the prostate that breaks down products in semen
ULN for PSA
4
PSA is used mostly for _____
disease RECURRENCE more than screening
What things can elevate PSA? (8)
- ejaculation
- infection
- cancer
- instrumentation
- inflammation
- prostatitis
- BPH
- irritation
What does PSA free:bound ratio tell us
decreased free:increased bound means a greater cancer risk
what is PSA velocity? How do we measure it? What is this used for?
- the change in one’s PSA values over time
- 3 measurements over 2 years is best
- PSA 4 - threshold is 0.75 ml/yr increase
What is PSA density?
- density of PSA/total prostate fluid volume
What is the threshold for PSA density at which you’d biopsy?
> 0.15
What is the MOST COMMON cause of PSA elevation?
- aging!!! consider BPH in older men
Where in the prostate does PCa occur?
peripherally
Why is PCa often asx?
Since it usually occurs in the periphery of the prostate it doesn’t cause obstructive sx until later
If someone is newly dx’ed with PCa what should you look for?
BONE METS
When is watchful waiting indicated in PCa pts? (2) How does watchful waiting work?
- when they have <10 yr predicted survival
- low grade, low volume dz
- follow dz with 6 mos. PSA screening and biopsy if indicated
2 important outcomes after radical prostatectomy?
- nerve sparing for erections
- incontinence a major problem
AEs a/w Ext beam radiation tx for PCa? (2)
- 40% ED
- radiation proctitis(?)
AE a/w cryosurgery? How does the use of this compare with ext beam XRT in the setting of PCa?
- 50-60% incontinence rate
- used more after XRT failure
What hormonal drugs are used to treat PCa? (3)
- Leuprolide - GHRH agonist
- Flutamide - testosterone antagonist
- Ketoconazole - adrenal gland test blocker
SEs a/w hormonal tx for PCa? (6)
- decreased libido
- hot flaslhes
- impotence
- increased body fat
- loss of muscle
- loss of bone
When is hormonal tx used for PCa? Why?
- in setting of metastatic dz to control growth bc tumor will eventually become hormonally resistant
Prevalence of BPH
50% @ 50; 80% @ 80
How does BPH present?
LUTS (lower UT sx)
- obstruction
- irritation
- urethral stricture/bladder outlet obstruction
What are obstructive BPH sx? (5)
- weak stream
- hesitancy
- straining
- nocturia
- incomplete emptying
What are irritative BPH sx? (3)
- urgency
- frequency
- dysuria
What are the different types of bladder ca?
- TCC (90%)
- Squamous
- Adeno
How does BCa present?
- painless, gross hematuria
What is the diagnostic work up for BCa? (3)
- cytology (specific but not sensitive)
- cystoscopy
- TURBT
How does staging work for BCa?
Ta-T1: no muscle invasion
T2-T4: muscle invaded
Tx of BCa (localized and invasive respectively)
- localized: TURBT, then surveillance + intravescle immuno/chemotherapy
- invasive: radical cystectomy +/- chemo
What causes BPH?
- androgens effect on periurethral (transitional) zone which constricts the urethra
What are the steps for a diagnostic workup of BPH? (6)
- UA - r/o infection
- Cr - check renal fxn
- DRE - for masses
- PSA
- PVR
- Question survey for sx severity
Medical tx for BPH and their fxns? (3)
- finasteride (5-alpha reductase inhibitor) - shrinks prostate
- Terazosin/doxazosin/tamsulosin/alfuzosin - alpha adrenergic blockers (latter 2 are specific)
- Combination of the 2 - most effective
What are the SEs of alpha blockers for BPH? (4)
- orthostasis
- impotence
- decreased libido
- retrograde ejaculation
What are the SEs of 5-alpha R inhibitors for BPH? (3)
- impotence
- decreased libido
- decreased semen ejaculatory volume
What is a drawback to using medications for BPH vs. surgery?
- 30-40% d/c tx w/in 12 mos. d/t unwanted SEs
Indications for surgery in setting of BPH? (5)
- urinary retention
- recurrent UTI
- persistent hematuria
- bladder stones
- renal insufficiency
What’s the gold standard procedure for prostate removal d/t BPH? What does it accomplish?
- TURP
- removes just the transitional zone of the prostate
When would you do an open prostatectomy? (2)
- When the prostate is >100 g
- bladder stones
Which group most commonly has kidney stones?
white males who have previously had a stone (50% chance of recurrence at 10 yr post-stone)
How many kidney stones pass on their own? In what length of time?
80%
4 wks
80% of stones are < ____mm
4 mm
What are the indications for treatment of a kidney stone?
- > 5 mm
- persistent pain/bleeding
- chronic infection
- partial/complete obstruction
- causing parenchymal damage
- intractable N/V
- patient preference
Most kidney stones are _____ which form from ____ _____ _____
calcium oxalate
Randall’s plaque nidus
Causes of ca oxalate stones (4)
- idiopathic hypercalciuria
- primary hyperparathyroidism
- cancer
- sarcoidosis
Tx for pts w/ca oxalate/phosphate (4)
- thiazides
- hydration
- protein restriction
- Na restriction
Describe struvite stones
form in the calyces of the renal pelvis = stag horn calculi; 2/2 urease producing bugs that alkalinize the urine
What are the urease producing bacteria (4)
PROTEUS
klebsiella
enterobacter
pseudomonas
With what conditions do you tend to see uric acid stones? (3)
- gout
- xanthine oxidase deficiency
- high purine turnover states (chemo)
Describe the conditions (kidney/urine) that give rise to uric acid stones and how you diagnose them
- acidic urine; RTA Type I
- CT NOT x-ray - these are radiolucent
how do you treat uric acid stones
alkalinize the urine with CITRATE
What causes cysteine stones?
COLA transport deficiencies - cysteine, ornithine, lysine, arginine
What do the cysteine crystals/stones look like
- hexagonal crystals
- ground glass appearance on x-ray
those with cysteine stones have a positive ______ test
urinary cyanide nitroprusside test
cysteine stones do NOT respond to _____ tx
shockwave TEST QUESTION
T/F - Indinavir stones are radiopaque?
False - radiolucent
Decreased GFR in the setting of a kidney stone leads to elevated pressures, decreased blood flow and therefore _______
ischemia
kidney stone presentation may mimic ____ as the stone approaches the UVJ
cystitis
Hematuria occurs in ___% of pts w an active kidney stone
90
How do you dx a kidney stone? What is they’re pregnant?
CT abdomen/pelvis
- KUB if no CT (75-90%) of stones are radioopaque
- If pregnant: US
What is the medical management of kidney stones? (4)
- Analgesia: NSAIDs, narcotics
- DDAVP for renal colic
- metabolic stone eval for recurrent stones w/24 hr urine, serum electrolytes
- facilitate passage w/alpha blockers, CCBs
How do you work up recurrent stones? (3)
metabolic stone eval:
- 24 hr urine
- serum electrolytes
- stone composition
What are 2 modalities that can be used for stones that require removal (<3cm)?
ESWL, laser lithotripsy
What are the indications for stone removal vs. passage? (3)
- obstruction + infection
- renal deterioration
- refractory pain/nausea
What happens with the vasculature during an erection? (3)
- relaxation of the cavernous arteries
- filling of the venous sinusoidal spaces
- constriction of the subtunical venous plexus
What vascular conditions can give rise to ED? (5)
- HTN
- HLD
- DM
- smoking
- radiation
Which of the following drugs can cause ED?
- antipsychotics
- antidepressants
- antihistamines
- central anti-hypertensives
- BBs
- spironolactone
- small amts of alcohol
- large amts of alcohol
- antipsychotics: YES
- antidepressants: YES
- antihistamines: NO
- central anti-hypertensives: YES
- BBs: YES
- spironolactone: YES
- small amts of alcohol: NO - stimulatory!
- large amts of alcohol: YES
What type of ED is most common - organic or psychogenic?
Mixed
ED could be the presenting symptom of which conditions? (6)
- DM
- CAD
- HLD
- HTN
- SC compression
- pit tumor
What does the workup for ED involve?
- UA
- fasting glu
- CBC
- Cr
- lipids
- testosterone (prolactin, LH, free test for low T)
What are some medical modalities (medication or otherwise) used to treat ED? (7)
- PDE5 inhibitors
- psychotherapy
- Testosterone (if low T)
- intracavernosal injections
- intraurethral injections
- vacuum erection devices
- penile surgery
What are the 3 different intracavernosal injections used for ED and what are the risks a/w this tx modality?
- papverine, phentolamine, alprostadil
- risk of scars and priapism
How many degrees of rotation must the spermatic cord endure to become ischemic (testicular torsion)
720
What is the most common cause of testis loss in the US?
testicular torsion
Bell clapper deformity
extended tunica vaginalis resulting in horizontal lie of the testicle
- in 12% of males
How does testicular torsion usually present? (4)
- Negative Prehn’s sign (pain stays constant with elevation of the testes)
- loss of cremasteric reflex
- <30 yo
- intense acute onset pain
____ is used to dx testicular torsion; however it can distinguish between this and ______. In order to do this you must look at TESTICULAR PERFUSION
- US
- epididymitis
How do you treat testicular torsion?
- SURGICAL EMERGENCY (detorsion in 6 hrs = almost 100% salvage, 20% is 12 hrs)
- Detorsion w/orchidoplexy of affected and unaffected testicle
Appendiceal torsion
- what does it mimic?
- natural hx?
- what does duplex US show?
- whats a characteristic physical finding?
mimics testicular torsion except the testis is palpable with normal lie
- self limited, atrophies with time
- hypervascularity to region
- Blue dot sign - seen through the skin
(T/F) As a rule, penetrating trauma to the scrotum should be explored
T
What are the bugs responsible for epididymitis in the young and old?
young: GC
old: gram -s (UTI bugs) - like E. coli
What’s the presentation of epididymitis
- age
- which sign is +
- what’s tender
- describe the scrotum
- how is the urine affected
>30 yrs old \+ Prehn's sign epididymal tenderness scrotal thickening, erythema - pyuria
How do you dx epididymitis?
- UA
- culture
- duplex - increased blood to testes
How do you treat epididymitis?
Abx x 3 wks: textracyclines, fluoroquinolones
pain management
Acute orchitis
tx?
testicular inflammation/tenderness
- same as epididymitis (tetracyclines, flouros)
testicular abscess tx
I&D
Fournier’s gangrene
what populations do you usually see this in?
a fasciitis leading to gangrene of the perineum
- rapidly progressive, life threatening
- usually see this in DM, immunocompromised
What are 2 inflammatory processes involving the testes/scrotum?
- Henoch-Schonlein purpura vasculitis
- fat necrosis
Presentation of hydrocele (2)
- usually asx
- will transilluminate
How do you treat hydrocele?
- you don’t unless there’s a hernia or if it presents beyond 12-18 mos. of age
Hydrocele arises from fluid in what layer of the scrotum?
- tunica vaginalis
Bag of worms is the nickname for _____
varicocele
varicocele is dilatation of the _____ plexus and it’s seen in __% of men
- pampiniform
- 15%
varicocele usually affects which side more than the other and why?
- L
- drains into the L renal vein
varicocele (does/doesn’t) transilluminate
doesnt
how do you treat varicocele?
surgically only if sx
What are the 2 types of hernia?
- incarcerated
- strangulated
What are the most common bugs that cause UTI?
SEEKS PP
- Serratia
- E. coli (80%)
- Enterobacter
- Klebsiella
- S. Saprophyticus (5-15%)
- Proteus mirabilis
- Pseudomonas
What are 3 pathogenic factors of UTI bacteria
- PILI w/phase variation that allows them to avoid phagocytosis - implicated in pyelo
- K antigen
- hemolysin
What are the host defenses against UTIs? (7)
- normal flora of the periurthra
- urea in urine
- high osmolarity
- acidity
- genetic predisposition
- mucosa
- antibody in kidney
What physiologic factors affect colonization of normal flora in females? (3)
- changes in estrogen
- low vaginal pH
- cervical IgA
____ in the urine may facilitate infection
glucose
Bladder epithelium has _____ to recognize bacteria, recruit WBCs and induce exfoliation
TLRs
Uncomplicated UTI
UTI in a normal, healthy patient (acute cystitis/pyelo)
complicated UTI
infection in a pt w/conditions predisposing to infection (BPH, hyronephrosis, stones, neurogenic bladder, systemic illness like DM, pregnancy, anal intercourse, FB in tract)
recurrent UTI
occurs after a documented infection that has resolved
reinfection of UTI
a new event w/reintroduction of bacteria to GU
persistent UTI
recurrent UTI caused by same bacteria
- stones, chronic prostatitis, infected kidney, ectopic ureter, foreign body, cysts, abscess
UTIs are mostly from the periurethral area, but may be ______ in immunocompromised patients or neonates. In these cases the common bugs are ____(3)
- hematogenous
- staph, candida, TB
Generally speaking, what are 2 RFs for UTI development?
- reduced urine flow (OBSTRUCTION, VUR)
- altered defense (PREGNANCY, spinal cord injury)
How do you diagnose UTIs and why are the respective modalities effective? (3)
- Dipstick: LE highly sensitive and specific, nitrite specific but not very sensitive, pyuria is very sensitive (95%)
- Cx: >100K colonies diagnostic
- Imaging: for pets who don’t respond to treatment, looking for anatomic abnormality
How do you treat UTIs?
hydration, relief of obstruction, foreign body (FB) removal, abx
Put the following abx in order of highest urine concentration --> lowest concentration: cipro amoxicillin bactrim cabrenicillin cephalexin nitrofurantoin
cabrenicillin cephalexin amoxicillin bactrim cipro nitrofurantoin
When and how do you treat uncomplicated UTIs? What if the person has DM, is pregnant, greater than 65 yrs, or has hx of pyelo?
- ONLY when they’re symptomatic
- fluoroquinolones x 3 d (use if >10-20% R to bactrim); bactrim x 3 d
- DM/pregnant/>65yo/pyelo hx: 7-10 d of tx
When and how do you empirically treat complicated UTIs (abnormal tract, immunocompromised, MDR)
- treat even when they’re asx
- parenteral ampicillin, aminoglycosides (vanc if allergic) x 14 d, switch to PO at 48 hrs
blood cultures are positive in ____% of people with complicated UTIs
20-40%
Which UTI abx are safe to use in pregnancy and which aren’t?
- safe: nitrofurantoin
- not safe: fluoroquinolones - tendon malformation in infants
How long do you treat acute prostatitis w/abx? Chronic prostatitis?
- 4 wks
- 6-12 wks
In which cases would you want to repeat cultures for a UTI so you can test for the appropriate cure? (3)
- pregnancy
- pyelo
- relapsing UTI
who has a greater risk of UTI thoughout childhood, boys or girls? What is their respective prevalence? What about during the first year of life?
girls: 8%
boys: 2%
- in first year of life boys get them more (10x increase in uncircumcised)
children tend to present with UTIs w/ _____ symptoms
nonspecific - poor feeding, irritability, lethargic, vomiting, diarrhea, distension
_____ are the 2nd most common cause of nosocomial UTI in children and can spread systemically with the high potential to become _____ in the NICU
- Fungi
- invasive candidiasis
Fungi can give rise to ____ in the kidney. A renal and bladder US can diagnose these
fungus balls
Viral cystitis is usually caused by ____(4) and is usually self limited
- HSV
- flu
- adenovirus
- polyoma
____ and ____ kids are at greater risk for viral cystitis
- transplant
- immunocompromised
The most common serious sequelae from pyelonephritis in a child is _____
renal scarring
Pyelonephrosis in a child requires _____ for treatment.
urgent PCNT placement and abx
recurrent pyelo in a child may lead to ______ and _____
reflux nephropathy
ESRD
how do you diagnose a UTI in children?
- dipstick
- UCx
- BCx
(std is 10^5 colonies/ml)
Under what circumstances and when do you image a child with a UTI? What imaging modalities?
FEBRILE infant OR child 2 mos. - 2 yrs w/1st UTI
- RBUS: anytime
only for voiding cystourethrogram: as soon as the child is infection free
- renal and bladder US, voiding cystourethrogram
In children, ____ is the most commonly isolated bug with uncomplicated cystitis and can be treated with _______
- enterobacter
- nitrofurantoin and bactrim
40% of children with UTI have ______ which is a congenital cause of UTIs
- can be detected with ___
- natural hx: ____
- VUR
- voiding cystourethrogram (VCUG)
- generally self resolves
60% of children with congenital hydronephrosis have ______
- this is d/t ______
- natural hx: ____
- UPJ obstruction
- poor peristalsis or anatomic abnormality
- may resolve or requires pyeloplasty
When a child has a UTI in the first few months of life you think of _____
- you diagnose this by looking for the _____ sign on US
- ureteroceles
- drooping lily sign
Ectopic ureter is a congenital abnormality that may present as ___ or ___ in girls; or ____ or ____ in boys
- girls: UTI, incontinence
- boys: UTI, epididymo-orchitis
Neuropathic bladder in children is usually due to ____ or ____
spina bifida
trauma
posterior urethral valve is the most frequent cause of congenital ________
- US shows ____
- 1/3-1/2 also have ___ or ___
- bladder outlet obstruction
- thick bladder, b/l hydronephrosis
- VUR or renal dysplasia
Prune belly syndrome
deficiency of the abdominal wall, dilatation of the ureters, bladder, urethra, w/b/l cryptorchidism
In neonates w/a constant wet umbilicus you think of _____
urachal remnants
Stones occur in children who have _____
- Most of these stones are located where?
- how do you treat them?
metabolic d/os
- in the kidney
- 50% pass spontaneously w/in 2 wks
What are 3 acquired causes of UTIs in children?
- stones
- sexual abuse
- dysfunctional voiding syndrome
Dysfunctional voiding syndrome
lack of coordination between detrusor and external sphincter activity in children
In cases of hematuria, dipstick is ____% sensitive and ___% specific. You should also confirm with _____
- 95%
- 75%
- microscopic examination
microhematuria is defined as ___ RBCs/HPF on ___ (#) specimens
> 3
2/3
RFs for hematuria include:
- age?
- sex?
- smoking hx?
- exposures? which ones?
- previous ____, _____
- specific sx…
- > 40
- M
- yes
- chemicals - cyclophosph, benzenes, mitotane
- pelvic radiation, urologic dz
- irritative voiding
the likelihood of malignancy in someone with hematuria is __%. Which malignancy is most common?
10%
- TCC
What are the main causes of glomerular hematuria? (3)
- IgA nephropathy/Bergers*
- thin BM disease
- hereditary nephritis (alports)
What are the main non-glomerular causes of hematuria:
- upper tract (5)
- lower tract (5)
- upper: stones, pyelo, RCC, TCC, obstruction
- lower: UTI, BPH, exercise, TCC, instrumentation
What impact does excessive anticoagulation have on hematuria?
- does NOT lead to de novo hematuria but may worsen current hematuria
What is the w/u for non-high risk hematuria?
- UA
- culture if infection suspected, then treat, then repeat UA
What is the w/u for high risk hematuria (any of the RFs, or gross hematuria) (7)
- evaluation of upper and lower UT
- US,
- cytology
- contrast CT
- cystoscopy
- retrograde ureterogram
- bladder wash
What if the w/u for hematuria in a high risk patient turns up negative?
re-evaluate in 48-72 mos. 3% will develop malignancy
NO EBM RECS FOR SCREENING ASX PTS FOR HEMATURIA
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