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NURP 532 > Week 12 GU/Urinary > Flashcards

Week 12 GU/Urinary Flashcards

1
Q

how does prostatitis occur? most common organism?

A
  • ascending infection from urethra from urine into prostate
  • E.coli
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2
Q

acute bacterial prostatitis sx’s

A
  • acute onset
    • frequency, urgency, burning
  • weak stream, hesitancy (from inflamed prostate)
  • Fever
  • Suprapubic, perineal, or rectal pain
  • Painful ejaculation, hematospermia
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3
Q

acute bacterial prostatitis PE

A
  • abdominal exam
    • bladder distention
    • urinary retention
  • gentle digital rectal exam.
    • prostate → tender, enlarged, or boggy
    • don’t massage the prostate = spread infection
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4
Q

acute prostatitis diagnostics

A
  • Urinalysis
  • Urine culture
  • CBC w/ diff
  • GC/CT testing if
    • < 35
    • high-risk sexual behavior
  • Transrectal ultrasound
    • Only if not improving or Diagnosis unclear
  • PSA testing should not be done
    • will be elevated even 2 months after tx
  • Diagnosis based on history and physical + urinalysis
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5
Q

acute prostatitis management

A
  • if STI → give ceftriaxone and doxycycline x 10 days
  • if > 35 yrs → fluoroquinolone or Bactrim x 10 - 14 days (up to 4 wks if severe)
  • if lower urinary tract sx’s → hydration, pain control, and alpha-1 blockers
  • if chronic (> 3 months) → refer urology
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6
Q

admission for acute bacterial prostatitis

A
  • if failed outpatient management
  • inability to take oral medications if n/v,
  • resistance to recent fluoroquinolone use
  • if they’re systemically ill or toxic appearing
  • urinary retention
  • chronic prostatitis = managed by urology
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7
Q

conditions that cause urethritis

A

gonorrhea

chlamydia

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8
Q

urethritis diagnostics

A
  • most common cause non gonococcal → chlamydia
  • NAAT chlamydia/gonorrhea
    • women → vaginal swabs (preferred)
      • or clean catch urine (easier)
    • men → first catch urine
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9
Q

nongonococcal urethritis is most common with? Treatment

A

Chlamydia

  • Treat empirically for both infections if you do not have lab evidence of just one infectious cause**
    • Azithromycin 1 g once
    • OR
    • Doxycycline 100mg bid x 7 days + ceftriaxone
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10
Q

urethritis sx’s

A
  • gonorrhea - many asymptomatic
    • female: thin, purulent ,odorous leukorrhea, dysuria, intermenstrual bleeding, lower and pain
    • male: burning on urination, penile discharge
  • chlamydia - many symptomatic, dysuria
    • female: mucopuruluent discharge from cervical os
    • male: penile discharge
  • Erythema
  • Urethral pruritis
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11
Q

most common cause of epididymitis in men over 35? under 35?

A
  • men under 35: STI - chlamydia/gonorrhea
    • if anal sex: consider enteric organism
  • men over 35: urinary tract pathogen
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12
Q

epididymitis on exam

A
  • gradual onset
  • Severe scrotal pain and swelling
  • Pain radiate to lower abdomen
  • Fever
  • Dysuria • Frequency • Hematuria
  • Epididymis is tender and swollen; erythema.
  • Positive Prehn sign (pain relief when affected testicle elevated)
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13
Q

Epididymitis diagnostics

A
  • Doppler ultrasound (differentiate torsion)
  • UA and CBC (reveals WBC and bacteriuria)
  • NAAT - dx chlamydia/gonorrhea
  • CRP is not needed, but it is elevated in epididymitis
  • normal cremaster reflex
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14
Q

Epididymitis treatment

A
  • 2–14 yrs
    • Based on urine culture
    • Urology referral
  • Sexually active, < 35 years old
    • Empiric CT/GC treatment
    • ceftriaxone IM & doxycycline
  • Insertive anal intercourse
    • Empiric treatment for CT/GC and enteric organisms
  • > 35 years old:
    • Treatment for enteric organism
    • levofloxacin or ciprofloxacin
  • Bed rest, scrotal elevation, hot or cold compresses, NSAIDS as needed
    • F/u in 1 week if no improvement but should be improved in 3 days
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15
Q

orchitis occurs when? management

A
  • testicular edema
  • painful testes, tenderness
  • systemic post viral infection
    • mumps infection
  • same bacteria or STI that caused epididmyitits (can occur same time)
  • viral - conservative
    • NSAIDS
    • elevation
  • doppler ultrasound
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16
Q

testicular torsion sx’s /exam

A
  • trauma or strenuous exercise can cause pain
  • severe pain with an acute onset, swollen
  • unilateral
  • nausea, vomiting, fever
  • urinary symptoms
  • High rise- raised testicle
  • NO cremasteric reflex
  • Newborn:
    • painless firm, blue scrotal mass, non tender
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17
Q

testicular torsion management

A
  • ASAP ER → urologic consultation and surgical!
    • no US needed if high suspicion
    • if questionable, get US
      • if TT = absent or decreased blood flow on US
  • intervention w/in 6-8 hrs to save testes
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18
Q
  • can be asymptomatic
  • scrotum feels like “bag of worms”
  • dull aching pain
  • worse with standing; valsava/straining make more apparent
A

varicocele

  • abnormal dilation of the spermatic veins
  • very common
  • malfunctioning of the valves → retrograde flow
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19
Q

painless swelling in scrotum

long periods, can recur

A

hydrocele

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20
Q

hydrocele examination

A

diagnostic: tranillumination

intact cremaster reflex

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21
Q

hydrocele management

A
  • < 1 years old → watch & wait for 1 year
    • if persists → refer
  • adults → get US to r/o torsion, then conservatively for 6-9 months, refer if no improvement
22
Q

testicular tumor sx’s

A
  • Pain or discomfort in a testicle or in scrotum
  • Dull ache in lower abdomen or groin
  • Sudden build up of swelling in scrotum
  • Back pain
  • solid firm mass/ focal nodule in testicles considered tumor until proven otherwise
23
Q

work up for testicular tumor

A
  • order PSA, UA, refer to urology
  • Ultrasound - confirms size/location
  • CT - extent & location of metastasis
  • staging (1: testes, 2: retroperitoneal nodes, 3: beyond nodes)
  • serum tumor markers
24
Q

management for testicular tumor

A
  • surgery, chemotherapy, radiation
  • monitor tumor markers hog, AFP, LDH first year, q 2 months second year, q 3-6 months up to 5 yrs
  • 90% cases cured
25
Q

benign prostatic hyperplasia

A
  • enlargement of the prostate gland
  • from stromal and epithelial cell hyperplasia
  • causes urinary retention (→ UTI, bladder stones, kidney dz)
  • 50% 50 - 60 yrs
  • 90% > 80 yrs
  • unknown etiology; testosterone, lack of exercise
26
Q

Male Lower Urinary Tract Sx’s (M-LUTS) of BPH 2 types:

A
  • Irritative sx’s:
    • Frequency
    • Urgency
    • Nocturia
    • Decreased bladder capacity/instability OR infection
  • Obstruction sx’s
    • Hesitancy
    • Weak or intermittent urinary stream
    • Post-void dribbling
    • Feeling of incomplete bladder emptying
    • Bladder outlet obstruction (BOO)
27
Q

BPH exam

A
  • DRE - size, consistency, shape, symmetry, abnormalities
    • if nodules or induration = prostate cancer → refer
  • With BPH, prostate is smooth, non tender, focal enlargement
    • rubbery
    • obliterated median sulcus
  • lower abdominal exam - bladder distention from retention
28
Q

BPH evaluation

A
  • AUA BPH symptom score → assess severity
  • Urinalysis (r/o Upper urinary Infection, hematuria)
  • PE, DRE
  • BPH is NOT a risk factor for prostate cancer
    • PSA testing is only indicated if the patient has a life expectancy > 10 years if findings suggest prostate cancer (abnormal DRE findings)
29
Q

BPH mangement

A
  • mild sx/no complications (score < 7): behavioral
    • limit fluids before bedtime
    • limit caffeine, alcohol
    • double voiding
    • watchful waiting
  • mod - severe; no improvement with conservative treatment
    • Alpha-1 blockers- Terazosin, doxazosin bedtime
  • 5-alpha reductase inhibitors
    • finasteride - shrink prostate hyperplasia but takes 6-12 months
  • Conservative treatment first then pharmacological therapy.
    • Urology referral
    • TURP for BOO
30
Q

male sexual dysfunction causes

A
  • medications, smoking, lifestyle
  • increases with age
  • neurological causes
    • MS or Parkinson’s
  • cardiovacsulcar
  • pharmacologic
  • surgical procedures
  • alcohol/drugs
  • Psychogenic
    • stress, performance, anxiety, relationship issues, depression
    • obtain a full medical history and sexual history & assess emotional status and relationship status.
  • yes spontaneous morning erection = psychological
  • if sudden onset of symptoms = psychogenic etiology.
  • If gradual onset and no morning erection = organic (vascular, near, hormone, anatomy, drug)
31
Q

male sexual dysfunction management

A
  • identify and treat the underlying cause!
  • Lifestyle changes and RF modifications
  • if symptomatic CVD or > 3 risk factors for CAD → refer stress testing
  • check: lipid, glucose, testosterone, thyroid, FSH, LH
  • depression
  • pharm: #1: phosphodiesterase 5 inhibitor (Viagra or Cialis) if not high CVD risk
32
Q

uncomplicated UTI’s sx’s & management

A

sx’s of bladder irritation (freq, urgency, dysuria, suprapubic pain, odorous urine, hematuria)

infection in healthy, non pregnant, premenopausal female with normal urinary tract

Empiric! Give before UA results come back

  • phenazopyridine - urinary analgesic
    • orange urine
    • use 1-2 days for discomfort until antibiotics take effect
    • first line: Nitrofurantoin
      • Bactrim if < 20% resistance in community
33
Q

complicated UTI sx’s & management

A
  • Empiric!
  • fever, chills, flank pain, CVA tenderness, N/V (pyelonphritis or urosepsis)
  • male: fluroquinolone
    • or Bactrim or nitrofurantoin
  • pregnant: amoxicillin, fosfomycine, cefuroxime, cephalexin
34
Q

recurrent UTI in women

A

2+ infections in 6 months or 3+ in 12 months

35
Q

reinfection UTI

A

new bacterial strain or regrowth of same organism after complete eradication with treatment

36
Q

relapse UTI

A

infection caused by bacterial persistence - infection by previously treated pathogen, not completely eradicated by course of antimicrobial therapy

37
Q

UTI diagnostics

A
  • urinalysis + dipstick
    • clean void
  • nitrite test NOT good ( bacteria doesn’t always change nitrate to nitrites)
  • urine culture for pregnant, febrile, ill, hx freq UTIs, hospitalized, young men or complicated UTI
38
Q

when would you treat asymptomatic bacteriuria?

A
  • in pregnant women! screen, check urine culture and treat
  • no tx needed in older women, men or person with diabetes
39
Q

undescended testes management

A
  • Most resolve w/in 6 months of age, if not, refer to ped urology
  • Warm room
    • Cross legged in warm room
  • Positioning
    • Can feel in squatted position
  • higher rate of testicular cancer even with repairmen
40
Q

prostate cancer screening recommendations

A
  • 70+ don’t screen
  • 50+ with 10+ years expected to live
  • 45+ high risk (African American, 1st degree (father/bro) dx with prostate cancer < 65)
  • 40+ even higher risk (more than 1 first degree relative w/ ca early age)
  • get PSA and DRE
  • if low risk, start with DRE and can offer PSA as optional
41
Q

Is PSA trustworthy?

A

NO! if DRE, you feel prostate is asymmetric, hard nodule in lobe and PSA is w/in normal range, STILL refer to urology

42
Q

In the setting of a normal DRE, how should PSA be used to guide management?

A
  • Can be elevated in non-cancerous settings
  • Watch for rate of rise/trend in a year (.75 in a year )
43
Q

overactive bladder (OAB) management

A
  • # 1: lifestyle (weight loss, restrict fluids, bowel regulation, no smoking, bladder training (habit training, no caffeine, alcohol, spicy/acidic foods)
  • bladder training (void q 30 mins, then increase)
  • goal: void q 3-4 hrs
  • pelvic floor PT
  • if doesn’t work, anticholinergics or antimuscarininc
  • refer if no improvements
44
Q

overactive bladder (OAB)

A
  • common > 40 or all ages
  • detrusor muscle overactivity → urge to urinate at lower bladder volumes; frequency.
  • absence of an infection
  • r/o neuro issues (Parkinson’s, lumbar disc dz), meds
  • check post void residual with US or straight Cath (should be < 50ml)
45
Q

chronic pelvic pain syndrome:

non bacterial prostatitis

A
  • Non-bacterial
  • sx’s > 3 months
  • no growth of org in urine culture.
  • potential factors may be genetic, autoimmune, or psychological
  • pain in perineum, testicles, pubic area, penis
  • pain with ejaculation.
  • Chronic prostatitis symptom index to assess sx’s
46
Q

chronic pelvic pain syndrome:

non bacterial prostatitis workup

A
  • urine culture, pre- and post-prostate massage
  • STI testing and PSA testing if indicated
  • consider PSA testing if a family history of prostate cancer or an abnormal exam or more obstructive symptoms
  • urine cultures are typically negative
    • if growth of the same organism, consider chronic bacterial prostatitis.
47
Q

chronic pelvic pain syndrome:

non bacterial prostatitis management

A
  • screen anxiety and depression
  • Alpha blockers
  • possibly antibiotics
    • controversial
  • acetaminophen or NSAIDs.
  • urology referral
  • PT and acupuncture
48
Q

Chronic pelvic pain syndrome: Interstitial Cystitis/Bladder Pain Syndrome sx’s

A
  • pain in pelvis, vulva, vagina, b/t vagina/anus or scrotum/anus
  • pain lower abdomen, Lower back
  • chronic pelvic pain
  • frequency (60x day) small amts
  • pain when full bladder and relief after emptying bladder
  • painful sex
  • pain similar to UTI but NO INFECTION
49
Q

Chronic pelvic pain syndrome: Interstitial Cystitis/Bladder Pain Syndrome

evaluation

A
  • Hx, PE
    • Pelvic pain and Urgency/Freq Pt Sx Scale (PUF) scale
  • F → Pelvic exam
  • M → DRE
  • urine culture and urinalysis
  • urine cytology
    • if > 40 or smokers
    • cystoscopy if considering other pathology or the diagnosis is unclear or a complex presentation,
  • Potassium sensitivity test is widely used in the workup of interstitial cystitis, although it’s not universally accepted.
50
Q

Chronic pelvic pain syndrome: Interstitial Cystitis/Bladder Pain Syndrome

diagnosis

A
  • sx lasting > 6 weeks
  • negative urine cultures
  • exclusion of other disorders that have overlapping symptoms.
  • If diagnosis unclear → refer to either urology or urogynecology
51
Q

interstitial cystitis treatment

A
  • voiding diary → avoid triggers
  • meditation or imagery, behavior modifications,
  • local heat or cold application
  • OTC Pyridium
  • pelvic floor muscle relaxation techniques.
  • FDA approved: Pentosan
    • Others: amitryptiline or cimetidine
  • Screen depression
  • Cystoscopy under anesthesia/hydrodistention

NURP 532 (13 decks)

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