Week 4 PBL Flashcards
list the questions asked in a focused Hx for urinary incontinence, symptoms of BPH and UTI
- duration, frequency, urge and severity of UI
- amount of fluid consumed daily
- associated S/S (dysuria, hematuria, pain)
- current meds that might affect UI
- past medical Hx that may affect ability to get to washroom/realize urge to urinate (i.e dementia, arthritis)
- bowel habits to rule out bowel obstruction that pushes on bladder
- social/family Hx to elicit risk factors for infection and cancer
describe the physical exam for urinary incontinence, symptoms of BPH and UTI
- abdominal exam–assess bladder size, kidney size, CVA tenderness or flank pain, bowel sounds
- genitalia examination–assess for abnormalities
- rectal exam–anal tone (neuro responses), prostate size and nodules, rectum texture (check for nodules)
- neuro exam–perianal sensation, knee and ankle reflexes
what are terazosin and doxazosin?
alpha antagonists
terasozin and doxazosin side effects
- decrease BP
- reflex tachycardia
- orthostatic hypotension (especially severe in elderly)
- ejaculatory problems (small risk in terazosin)
- major interaction with phosphodiesterase inhibitors (VIAGRA)
what are tamulosin and alfuzosin?
alpha 1 selective antagonist
SEs of tamulosin and alfuzosin
more retrograde ejaculation for tamulosin
less severe side effects compared to terazosin and doxazosin (except for ejaculatory problems)
SEs of 5-alpha reductase inhibitors
- decreased sex drive
- increased ejaculatory dysfunction (such as a smaller amount of semen ejaculated)
- difficulty getting an erection
- breast tenderness or enlargement (even in men)
side effects of anticholinergics, TCAs (which are designed to facilitate storage)
dry mouth dry eyes blurred vision may produce or exacerbate glaucoma increased HR dry warm skin/flushing difficulty emptying bladder constipation headaches confusion
side effects for alpha agonists (designed to facilitate storage)
fatigue headache drowsiness dry mouth dry nose increases in BP many more
list the tests that would be appropriate to order (depending on specific clinical context) in the setting of lower urinary tract obstruction (LUTS)
urinalysis urine culture PSA electrolytes, BUN, creatinine U/S
rationale for urinalysis in LUTS
blood, leukocytes, bacteria, protein, glucose testing
rationale for urine culture in LUTS
exclude infection if irritative voiding
usually follows abnormal urinalysis findings
rationale for PSA in LUTS
PSA can indicate enlarged prostate; not necessarily indicative of cancer
rational for electrolytes, BUN, creatinine in LUTS
screen for chronic renal insufficiency in patients with postvoid residual urine volumes
rationale for ultrasound in LUTS
determine bladder, prostate size, degree or hydrinephrosis in patients with urinary retention or signs of renal insufficiancy
TRUS of prostate recommended to determine dimensions (if unsure) of prostate in certain cases
What LUTS symptoms would classify as “complicated” and indicate need for detailed management?
suspicious DRE hematuria abnormal PSA pain infections palpable bladder neuro disease
when is a PSA recommended on presentation of LUTS?
when life expectancy is > 10 years and if the diagnosis of prostate cancer can modify the management
what is the difference between complicated and uncomplicated UTI?
difference in anatomical
what is an uncomplicated UTI?
infection of structurally and neurologically normal urinary tract
genetic and behavioural determinants
most common in young, sexually active females
what is a complicated UTI
symptomatic infection of structurally or neurologically abnormal urinary tract (either upper or lower)
men, children and pregnant women
etiology of UTI
“KEEPS”
Klebsiella pneumoniae
Enterobacter spp. (E. coli)
Enterococcus spp.
Proteus mirabilis (Pseudomomas in complicated UTI)
Staph. saprophyticus (5-15%, group B strep
UTI symptoms in kids
nonspecific symptoms (failure to thrive, vomiting, fever)
UTI symptoms in kids > 2 years
Localized symptoms
frequency, dysuria, abdominal/flank pain
Lower UTI symptoms in adults
no fever
frequency
painful urination
possible suprapubic pain and possible hematuria
Upper UTI symptoms in adults
FEVER with possible chills
flank pain
accompanying lower UTI symptoms for 1-2 days
symptoms of UTI in elderly
often asymptomatic (as frequency, dysuria, hesitancy and incontinence is found in many/most elderly these arent indicative symptoms in this age group)
higher incidence of bactereia
Urinalysis: indications of UTI
- leukocyte esteras positive–alone is not helpful for determining UTI
- nitrite positive: probably uTI
- LE and nitrite positive: specificity of 96% for UTI
Displide: indications of UTI
- CLED grows only gram negative bacteria
2. EMB grows both gram positive and negative bacteria
Culture: indications of UTI
significant colony count = indicative of UTI
treatment for uncomplicated UTI
trimethroprim-sulfamethoxazole (SEPTRA) for 3 days
quinolones for 3 days
nitrofurantoin for 5-7 days
fosfomycin
Treatment for complicated UTI
quinolones for 7 days
treatment of pyelonephritis
aminoglycosides IV
treatment for UTI in kids
may consider amixicillin-clavulinic acid
Diagnostic process for prostate cancer
- screening using DRE + PSA
- if highly suspicious of prostate cancer, perform TRUS needle biopsy
- gleason score, grade the carcinoma, if present
- if suspect metastatic disease, do bone scan
- treatment method will vary depending on cancer stage
what is currently the gold standard treatment for prostate cancer?
surgery–removing the entire prostate and seminal vesicles (radical prostatectomy)
radical retropubic prostatectomy (RRP)
radical perineal prostatectomy (RPP)
laparoscopic radical prostatectomy (LRP)
how does radiation treat prostate cancer?
high powered xray aimed at tumor region, free radicals form, disruptiono f DNA, decrease cell reproduction and increase scell death
what procedure is challenging surgery as new gold standard for prostate cancer therapy?
brachytherapy
placement of radioactive source directly into or adjacent to the tumor
suitable for well localized tumor–fast, convenient and has a low risk for serious long term complications
best for low-intermediate risk patients
complications of brachytherapy
malaise for up to 3 months
what are GnRH analogues?
analogues to luteinizing hormone releasing hormone–LHRH tells the pituitary to produce more LH which would case the testes to make more testosterone
initially with these drugs testosterone would rise, but chronic use will cause LHRH receptors to downregulate–> reduces testosterone
name two GnRH analogues
Leuprolide, Goserelin
What do GnRH antagonists do?
directly inhibit the LHRH receptors that tell the pituitary to produce more LH–rapid reduction in testosterone
may cause release of histamine and thus an allergic reaction
what are antiandrogens?
molecules that competitively inhibit the binding of DHT (from testosterone) to the androgen receptor that modulates testosterone formation
less prominent side effects
generally used in conjuction with GnRH analogue to reduce the “hormone flare”
list lifestyle modifications to manage symptoms related to enlarged prostate
- decrease fluids, caffeine, alcohol
- time diuretics–consuming during the day to prevent nocturia
- avoid decongestants which have alpha 1 stimulation
- exercise and weight loss
- sleep apnea–body normally produces more ADH during sleep but sleep apnea interrupts this process
- diet
list minimally invasive surgical therapies to manage enlarged prostate
- interstitial laser coagulation
- transurethral microwave therapy
- transurethral needle ablation
interstitial laser coagulation
green light used to vaporize prostate
transurethral microwave therapy
microwave to heat and destroy excess prostate tissue
requires 2-14 days of catheterization which can lead to UTI
transurethral needle ablation
delivers low level radio frequency energy to relieve obstruction
can be performed with local aneasthetic in the office in less than 1 hour
low risk of sexual side effects
what is the gold standard surgical procedure to deal with enlarged prostate?
transurethral resection of the prostate (TURP)
Describe the long term “side effects” or TURP
recovery is 306 weeks with uncomfortable urination
sexual activity ok after 6 weeks and erections are not affected
70% experience retrograde ejaculation
10% of men will require second TURP within 10-15 years
risks of TURP syndrome
- excess absorption of fluids from irrigated scope during surgery–dilutes blood causing hyponatremia and hemolysis
- can cause leg cramps, heart failure, confusion, seizures, come and death
