Week 4 PBL

Question 1

list the questions asked in a focused Hx for urinary incontinence, symptoms of BPH and UTI

Answer 1

1. duration, frequency, urge and severity of UI
2. amount of fluid consumed daily
3. associated S/S (dysuria, hematuria, pain)
4. current meds that might affect UI
5. past medical Hx that may affect ability to get to washroom/realize urge to urinate (i.e dementia, arthritis)
6. bowel habits to rule out bowel obstruction that pushes on bladder
7. social/family Hx to elicit risk factors for infection and cancer

Question 2

describe the physical exam for urinary incontinence, symptoms of BPH and UTI

Answer 2

1. abdominal exam–assess bladder size, kidney size, CVA tenderness or flank pain, bowel sounds
2. genitalia examination–assess for abnormalities
3. rectal exam–anal tone (neuro responses), prostate size and nodules, rectum texture (check for nodules)
4. neuro exam–perianal sensation, knee and ankle reflexes

Question 3

what are terazosin and doxazosin?

Answer 3

alpha antagonists

Question 4

terasozin and doxazosin side effects

Answer 4

• decrease BP
• reflex tachycardia
• orthostatic hypotension (especially severe in elderly)
• ejaculatory problems (small risk in terazosin)
• major interaction with phosphodiesterase inhibitors (VIAGRA)

Question 5

what are tamulosin and alfuzosin?

Answer 5

alpha 1 selective antagonist

Question 6

SEs of tamulosin and alfuzosin

Answer 6

more retrograde ejaculation for tamulosin

less severe side effects compared to terazosin and doxazosin (except for ejaculatory problems)

Question 7

SEs of 5-alpha reductase inhibitors

Answer 7

• 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)

Question 8

side effects of anticholinergics, TCAs (which are designed to facilitate storage)

Answer 8

dry mouth
dry eyes
blurred vision
may produce or exacerbate glaucoma
increased HR
dry warm skin/flushing
difficulty emptying bladder
constipation
headaches
confusion

Question 9

side effects for alpha agonists (designed to facilitate storage)

Answer 9

fatigue
headache
drowsiness
dry mouth
dry nose
increases in BP
many more

Question 10

list the tests that would be appropriate to order (depending on specific clinical context) in the setting of lower urinary tract obstruction (LUTS)

Answer 10

urinalysis
urine culture
PSA
electrolytes, BUN, creatinine
U/S

Question 11

rationale for urinalysis in LUTS

Answer 11

blood, leukocytes, bacteria, protein, glucose testing

Question 12

rationale for urine culture in LUTS

Answer 12

exclude infection if irritative voiding

usually follows abnormal urinalysis findings

Question 13

rationale for PSA in LUTS

Answer 13

PSA can indicate enlarged prostate; not necessarily indicative of cancer

Question 14

rational for electrolytes, BUN, creatinine in LUTS

Answer 14

screen for chronic renal insufficiency in patients with postvoid residual urine volumes

Question 15

rationale for ultrasound in LUTS

Answer 15

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

Question 16

What LUTS symptoms would classify as “complicated” and indicate need for detailed management?

Answer 16

suspicious DRE
hematuria
abnormal PSA
pain
infections
palpable bladder
neuro disease

Question 17

when is a PSA recommended on presentation of LUTS?

Answer 17

when life expectancy is > 10 years and if the diagnosis of prostate cancer can modify the management

Question 18

what is the difference between complicated and uncomplicated UTI?

Answer 18

difference in anatomical

Question 19

what is an uncomplicated UTI?

Answer 19

infection of structurally and neurologically normal urinary tract

genetic and behavioural determinants

most common in young, sexually active females

Question 20

what is a complicated UTI

Answer 20

symptomatic infection of structurally or neurologically abnormal urinary tract (either upper or lower)

men, children and pregnant women

Question 21

etiology of UTI

Answer 21

“KEEPS”

Klebsiella pneumoniae
Enterobacter spp. (E. coli)
Enterococcus spp.
Proteus mirabilis (Pseudomomas in complicated UTI)
Staph. saprophyticus (5-15%, group B strep

Question 22

UTI symptoms in kids

Answer 22

nonspecific symptoms (failure to thrive, vomiting, fever)

Question 23

UTI symptoms in kids > 2 years

Answer 23

Localized symptoms

frequency, dysuria, abdominal/flank pain

Question 24

Lower UTI symptoms in adults

Answer 24

no fever
frequency
painful urination
possible suprapubic pain and possible hematuria

Question 25

Upper UTI symptoms in adults

Answer 25

FEVER with possible chills flank pain accompanying lower UTI symptoms for 1-2 days

Question 26

symptoms of UTI in elderly

Answer 26

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

Question 27

Urinalysis: indications of UTI

Answer 27

1. leukocyte esteras positive--alone is not helpful for determining UTI 2. nitrite positive: probably uTI 3. LE and nitrite positive: specificity of 96% for UTI

Question 28

Displide: indications of UTI

Answer 28

1. CLED grows only gram negative bacteria | 2. EMB grows both gram positive and negative bacteria

Question 29

Culture: indications of UTI

Answer 29

significant colony count = indicative of UTI

Question 30

treatment for uncomplicated UTI

Answer 30

trimethroprim-sulfamethoxazole (SEPTRA) for 3 days quinolones for 3 days nitrofurantoin for 5-7 days fosfomycin

Question 31

Treatment for complicated UTI

Answer 31

quinolones for 7 days

Question 32

treatment of pyelonephritis

Answer 32

aminoglycosides IV

Question 33

treatment for UTI in kids

Answer 33

may consider amixicillin-clavulinic acid

Question 34

Diagnostic process for prostate cancer

Answer 34

1. screening using DRE + PSA 2. if highly suspicious of prostate cancer, perform TRUS needle biopsy 3. gleason score, grade the carcinoma, if present 4. if suspect metastatic disease, do bone scan 5. treatment method will vary depending on cancer stage

Question 35

what is currently the gold standard treatment for prostate cancer?

Answer 35

surgery--removing the entire prostate and seminal vesicles (radical prostatectomy) radical retropubic prostatectomy (RRP) radical perineal prostatectomy (RPP) laparoscopic radical prostatectomy (LRP)

Question 36

how does radiation treat prostate cancer?

Answer 36

high powered xray aimed at tumor region, free radicals form, disruptiono f DNA, decrease cell reproduction and increase scell death

Question 37

what procedure is challenging surgery as new gold standard for prostate cancer therapy?

Answer 37

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

Question 38

complications of brachytherapy

Answer 38

malaise for up to 3 months

Question 39

what are GnRH analogues?

Answer 39

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

Question 40

name two GnRH analogues

Answer 40

Leuprolide, Goserelin

Question 41

What do GnRH antagonists do?

Answer 41

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

Question 42

what are antiandrogens?

Answer 42

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"

Question 43

list lifestyle modifications to manage symptoms related to enlarged prostate

Answer 43

1. decrease fluids, caffeine, alcohol 2. time diuretics--consuming during the day to prevent nocturia 3. avoid decongestants which have alpha 1 stimulation 4. exercise and weight loss 5. sleep apnea--body normally produces more ADH during sleep but sleep apnea interrupts this process 6. diet

Question 44

list minimally invasive surgical therapies to manage enlarged prostate

Answer 44

1. interstitial laser coagulation 2. transurethral microwave therapy 3. transurethral needle ablation

Question 45

interstitial laser coagulation

Answer 45

green light used to vaporize prostate

Question 46

transurethral microwave therapy

Answer 46

microwave to heat and destroy excess prostate tissue requires 2-14 days of catheterization which can lead to UTI

Question 47

transurethral needle ablation

Answer 47

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

Question 48

what is the gold standard surgical procedure to deal with enlarged prostate?

Answer 48

transurethral resection of the prostate (TURP)

Question 49

Describe the long term "side effects" or TURP

Answer 49

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

Question 50

risks of TURP syndrome

Answer 50

- 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