Urology Flashcards
________ and __________ hold the uterus and upper vagina in their proper place over the levator plate.
Cardinal and uterosacral ligaments
Signs/sx’s of pelvic organ prolapse
urgency, freq, urge incontinence, recurrent UTIs
obstructive voiding sx’s due to urethral kinking
need unusual positions to void
Sx’s of rectocele
constipation and difficult defecation with distal stool trapping
patient reports manually assisting evacuation with finger in vagina
Most common type of pelvic organ prolapse
cystocele (anterior compartment prolapse) where bladder protrudes into vagina
How to workup cystocele with recurrent UTIs?
PVR eval (post-void residual)
If patient has positive PVR, what should be checked next?
check upper urinary tract/ kidneys for hydronephrosis
Enterocele or middle compartment prolapse
intestines prolapse into vagina
post hysterectomy
When should uterine prolapse be referred to urology?
dyspareunia
extension past introitus
difficulty defecating or urinating
Non-surgical therapy for prolapse
treat associative factors: chronic cough, obesity, constipation
Pessary - device placed into vagina to support uterus or bladder and rectum
Can imperforate hymen obstruct urine flow? What does it obstruct?
No urine flow blockage, but does prevent vaginal secretions
hydrometrocolpos
expanded fluid filled vaginal cavity, usually from imperforate hymen
PE of labial fusion
labia minora fused together in newborn
Labial fusions can spontaneously resolve, but when should it be treated? With what?
urine pooling in vagina with voiding, freq UTIs, parent request
tx: topical estrogen cream, consider surgical or manual separation
Orgasmic disorder in women
APA guidelines necessitates that an acceptable and preferred form of sexual stimulation has occurred and orgasm has not resulted
** absence of climax from coitus should not be diagnosed as sexual dysfunction unless it represents a distressing change from a woman’s prior state of affairs
vaginismus
Recurrent or persistent involuntary spasm of musculature of outer third of vagina that interferes with sexual intercourse
Medications that may cause female arousal/orgasm disorders
SSRI
Oral contraceptives
Pharm therapy for female sexual dysfunction
topical estrogen - estriol (E3) has highest affinity for vagina
PDE-5I like Viagra
Muscles of pelvic floor
levator ani muscles: puborectalis, pubococcygeus, iliococcygeus
coccygeus
If patient has high PVR, what should be checked next?
check upper urinary tract/ kidneys for hydronephrosis
CT urogram or U/S
When can transient incontinence occur?
after childbirth
during an acute UTI
When to refer to urology for incontinence?
Total incontinence Incontinence associated with pain Hematuria Recurrent infection Pelvic irradiation Radical pelvic surgery Suspected fistula Significant post void residual (>200cc)
Involuntary urine leakage on effort or exertion (sneezing, coughing) =
stress urinary incontinence
Majority of stress incontinence occurs in what women?
after middle-age
repeated vaginal deliveries and obstructed labor
Pathophysiology of incontinence
weakness/disruption of pelvic floor muscle and ligaments
hypermobility of sphincteric unit - loses closing efficiency
Medicine that can cause urinary incontinence
anti-cholinergics, opiates
How to treat mild and moderate stress urinary incontinence?
weight loss
caffeine reduction
pelvic floor muscle training
alpha adrenergic agonist (eg. Sudafed)
If initial management fails, refer for surgery
Possible causes of Overactive Bladder
Neuro injuries Radiation Inflammation Caffeine Diabetes BOO leading to bladder damage (detrusor m.)
Symptoms of urge incontinence
sudden urge with uncontrolled loss of urine
“I pee before making it to the bathroom”
Non-pharmaceutic treatment of urge incontinence
Lifestyle - fluids, caffeine, alcohol
Bladder training with scheduled voiding
PT for pelvic muscle training and relaxation techniques
Medical treatment of OAB and urge incontinence
Anticholinergics 1st line
- Oxybutynin (Ditropan)
- Tolterodine (Detrol LA)
More selective muscarinic (M3) receptor antagonists
Presence of stress incontinence and urge incontinence =
mixed urinary incontinene (MUI)
Treatment of mixed urinary incontinence
Treat most bothersome aspect, or if equal treat with anticholingeric first
Primary care provider’s role in treating Overflow incontinence?
refer, get cath
84 yo male with 3 diapers daily for incontinence. He is unaware of when he leaks. HIs creatinine is 1.8 and takes no meds. Three diagnostic labs or studies to eval?
UA, U/S kidney, PVR
Involuntary loss of urine associated with bladder over-distension =
overflow incontinence
2 pathophysiologic causes of overflow incontinence and how they may occur?
atonic bladder - meds, nerve injury, chronic overdistention
outflow obstruction - BPH, bladder neck contracture or stricture, cystocele, pelvic organ prolapse, previous incontinence surgery
How to dx overflow incontinence?
PVR of >200mL
Lower UTI in females age 16-35 vs 36-65 vs > 65
16-35: Sexual intercourse, diaphragm use
36-65: Gynecologic surgery, bladder prolapse
>65: Incontinence, Chronic use of urinary catheters
Host defenses of UTI
Unobstructed urinary flow
Urine components: osmolality, urea, organic acid, and pH, Tamm-Horsfall glycoprotein inhibit bacterial adherence
Normal flora of periurethral area (Lactobillus)
Urothelial cells express receptors - upon attachment of bacteria, inflamm mediators produced
Risk factors for UTI
Recurrent UTIs
Alterations in periurethral environment damage flora (menopause, abx use)
Soiling of perineum from fecal incontinence
Neuromuscular diseases
Bladder cath
Work-up of acute cystitis
UA, urine culture, if uncomplicated imaging not necessary
UA results of acute cystitis
nitrate and leuk positive
WBC and/or RBC in urine
Which abx to treat UTI has least resistance to E. coli?
nitrofurantoin
Reasons for recurrent cystitis in females
incomplete tx of previous UTI, kidney stones, obstructive uropahty, genetic predisposition, post-menopausal, fistula
Acute cystitis treatment
3-5 days of abx: Nitrofurantoin, TMP-SMX (Bactrim), or Fluoroquinolone (Cipro)
Work-up of recurrent cystitis
typical UA and culture PLUS upper tract imagine
U/S, IV pyelogram, cystoscopy, CT scan
What are signs of vesicovaginal fistula?
leaking urine/incontinence
hematuria
painless
What are signs of vesicovaginal fistula?
leaking urine
hematuria
??????
Management of recurrent cystitis
Longer antibiotic course required: 7-14 days of fluroquinolone
Surgical removal of reinfection source (such as urinary calculi or fistula)
Prophylactic abx: take low dose continuously, patient initiated therapy at sign of sx’s, take single dose post-coital
Alternatives to antibiotic therapy for prevention of recurrent cystitis
Intravaginal estriol in postmenopausal women
Lactobacillus vaginal suppositories
Cranberry juice
Post coital hygiene
Overflow incontinence treatment in men
alpha-adrenergic blocker to reduce prostate size in men
Common cause of UTI in pregnancy
hydronephrosis with resultant urinary stasis due to compression of urinary tract by uterus
Overflow incontinence treatment
alpha-adrenergic blocker to reduce prostate size in men
