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NR601 - Primary Care of the Mature and Aged > Week 5 - Genitourinary Disorders > Flashcards

Week 5 - Genitourinary Disorders Flashcards

1
Q

Urge incontinence

A

Leakage preceded by/associated with urgency.

  • Patho – unable to store urine due to uninhibited contractions of the detrusor muscle
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2
Q

Stress incontinence

A

Leakage with effort, exertion, sneezing, or coughing. Leakage may be provoked by minimal or no activity when there is severe sphincter damage.

  1. Leakage coincident with cough, laugh, sneeze, or physical activity suggests failure of sphincter mechanisms. Leakage that occurs seconds after the activity, especially if difficult to stop, suggests a cough-induced uninhibited detrusor contraction.
  2. Patho – inability to store urine due to inadequate sphinchter closure
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3
Q

Mixed urge/stress incontinence

A

Presence of both urgency and stress UI symptoms. Patients vary in the predominance, severity, and/or bother of urge versus stress leakage.

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4
Q

Nonspecific incontinence

A

Inability to void completely because of insufficient bladder contraction and/or bladder outlet obstruction

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5
Q

Overactive bladder

A

Symptom syndrome (not a specific pathologic condition) consisting of urgency, frequency, and nocturia, with or without urge incontinence.

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6
Q

Risk factors for urinary incontinence

A
  1. Female
  2. Obesity
  3. Diabetes
  4. Stroke
  5. Depression
  6. Fecal incontinence
  7. Hysterectomy
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7
Q

Medications associated with urinary incontinence

A
  1. Alcohol
  2. Alpha-adrenergic agonists/blockers
  3. ACE inhibitors
  4. Anticholinergenics
  5. Antiphsychotics
  6. CCB
  7. Cholinesterase inhibitors
  8. Estrogen
  9. Gabapentin
  10. Loop diuretics
  11. Narcotics
  12. NSAIDS
  13. Selective hypnotics
  14. Thiazolidinediones
  15. TCAs
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8
Q

What controls continence?

A

Continence is mediated by the central and autonomic nervous system

  1. Voiding occurs with parasympathetic stimulation
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9
Q

HPI for Incontinence

A
  1. Frequency and volume of leakage
  2. Type of UI symptoms
  3. Review PMH and medications that may impact UI
  4. Relationship beween illness (stroke) and UI
  5. Screen for depression and functional status
  6. Assess functional impairment
  7. Cognitive screening
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10
Q

Physical exam for urinary incontinence

A

Cognition, mobility, neuro, rectal, urnalysis, bladder diary, wet checks, PVR

Pelvic exam for women
1. Prolapse, masses, tenderness, urethral hypermobility, cystocele, rectocele

Genital exam for men
1. Digital rectal exam for prostate changes/nodules/masses/stool impaction

Urinalysis with reflex for UTI (if likely) – check for hematuria and glycosuria in diabetic patients

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11
Q

Types of urinary incontinence

A
  1. Urgency/OAB
  2. Stress
  3. Mixed
  4. Other/unclear
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12
Q

Management of incontinence

A
  1. Address comorbidities, lifestyle, medications
  2. Assess changes to QOL
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13
Q

Acute onset pelvic pain is a red flag for…

A

Neurologic or neoplastic disease, place urgent referral to urology or urogynecology

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14
Q

Nocturnal polyuria

A

> 1/3 of total 24-hour urine production occurring during the hours of sleep

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15
Q

Causes of nocturia

A
  1. Excessive fluid intake (caffeine or alcohol)
  2. Pedal edema
  3. CHF
  4. OSA
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16
Q

Using a bladder diary for evaluation of nocturia

A

Document time, amount of urine voided, amount of leakage

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17
Q

Treatments for UI in older person

A
  1. Address contributing comorbidity and medications
  2. Lifestyle interventions
  3. Behavioral treatment
  4. Pharmacological treatment
  5. Minimally invasive and surgical procedures
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18
Q

Lifestyle modifications for all types of urinary incontinence

A
  1. Weight loss
  2. Avoid excessive fluid intake, caffeine, alcohol, minimize night intake of fluids
  3. Quit smoking (stress UI)
  4. Afternoon loop diuretics
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19
Q

Behavioral modification for urinary incontinence

A

Urge, stress, mixed - usually more effective than medication.

  1. First line of treatment for older patients with UI
  2. Bladder retraining
    - Frequent voluntary voiding to keep volume low (start Q2 hours)
    - Urgency suppression using CNS and pelvic mechanisms
    - When urgency occurs, stand still, sit down, do pelvic muscle contractions, concentrate on making urgency decrease with deep breathing, visualize urge as a wave that peaks and falls
    - After 2 days with no leaks, increase time between voiding by 30-60 minutes (goal of Q4 hour voiding)
  3. Pelvic muscles exercise
    - Contract for 6-8 seconds, repeat 8-12 times (one set) complete 3 sets, 3-4 times per week for 15-20 weeks
    - Increase intensity and duration as able
    - Perform contractions white sitting, standing walking
    - Alternate fast/slow contractions
    - Biofeedback
  4. For patient with dementia the only available behavioral therapy is prompted voiding – every 2-3 hours, positive feedback with voiding, should improve within 3 days, if not check and change is advised
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20
Q

Pharmacological treatment for stress incontinence

A
  1. No FDA approved medications although duloxetine is effective but not approved for this indication
  2. Worsened with estrogen & progesteronep
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21
Q

Pharmacological treatment for urge incontinence and OAB

A
  1. Antimuscarinics (risk of cognitive impairment)
    - oxybutinin
    - tolterodine
    - fesoterodine
    - trospium
  2. Beta 3 Agonists (increases BP)
    - Mirbegrone (urge only)
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22
Q

Minimally invasive and surgical procedures for urinary incontinence

A
  1. Botox injection in detrusor muscle during cystoscopy
  2. Sacral nerve modulation – percutaneous implantation of an electrode at the S3 sacral root connected to external stimulator (permanent lead inserted if trial goes well)
  3. Surgery - gold standard for stress incontinence
    - Colposuspension
    - Slings
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23
Q

Treatment for stress incontinence

A
  1. Behavioral therapy - bladder training
  2. Duloxetine
  3. Urethral slings
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24
Q

Treatment for urge incontinence

A
  1. Behavioral therapy
  2. Anticholinergics
  3. Onaboulinum toxin A
  4. Neuromodulation
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25
Q

Treatment for Overactive bladder

A
  1. Anticholinergics
  2. Antimuscarinics or oral beta3 adrenoceptor agonist
    - Prescribe ER over IR (less dry mouth)
    - Manage constipation and dry mouth prior to trying another medcation
    - Transdermal oxybutinin
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26
Q

Criteria for diagnosing a UTI in older adults

A
  1. Localizing GU symptoms and + urine culture
  2. Acute confusion then treat for UTI
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27
Q

Asymptomatic bacteriuria

A

Presence of significant pyuria (>10 WBCs per low power field).

30% of asymptomatic older adults have significant and persistent pyuria
1. Found in nephrolithiasis, diverticulitis, IBD, intraabdominal abscess

Do not treat with no urinary symptoms.

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28
Q

Symptoms of UTI in older adults

A

Lower UTI
- Suprapubic pain, dysuria, frequency, urgency

Upper UTI
- Flank pain
- Fever

Treat with significant bacteriuria, pyuria and symptoms including confusion

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29
Q

Treatment for uncomplicated UTI

A

Patient is healthy, no DM or immunosuppression

  1. Nitrofurantoin
  2. Fosfomycin
  3. TMP/SMZ
  4. Pivmecillinam
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30
Q

Treatment for complicated UTI

A

Pyelonephritis

  1. Ciprofloxacin
  2. Levofloxacin
  3. TMP/SMZ
  4. Beta lactam
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31
Q

Diagnosing UTI in a patient with a chronic foley

A

Diagnosis of exclusion

32
Q

Recurrent UTIs with the same organism

A

Should prompt a search for anatomic defects that can be repaired

33
Q

What type of diagnosis is BPH?

A

A diagnosis of exclusion

34
Q

What part of the prostate is BPH usually found?

A

The transitional zone

35
Q

What questionnaire can assist in diagnosing BPH?

A
  1. International Prostate Symptom Score IPSS –

Score of 7 or less mild, 8-19 moderate, 20-25 severe (not diagnostic for BPH)

  1. Incomplete emptying
  2. Frequency
  3. Intermittency
  4. Urgency
  5. Weak stream
  6. Straining
  7. Nocturia
36
Q

Conditions that contribute to BPH

A
  1. Poorly controlled diabetes
  2. Neurogenic bladder
  3. UTI
  4. Previous urological conditions
37
Q

Diagnostic testing for BPH

A
  1. Assess for contributing factors (neuro/endocrine/etc)
  2. Digital rectal exam
  3. Urinalysis
  4. PVR
  5. Serum creatinine (assess kidney function)
  6. Pressure/flow studies
  7. PSA
38
Q

Lifestyle modifications for BPH

A
  1. Reduce nighttime fluids (2 hours before bed)
  2. Eliminate dietary diuretics (caffeine, alcohol)
  3. Behavioral interventions (bladder retraining)
  4. Avoid bladder irritants like artificial sweeteners and carbonation
  5. Bladder dietary to document frequency, volume and circumstances surrounding symptoms
39
Q

Pharmacological management of BPH

A
  1. Alpha blockers (terazosin, doxazosin, (first two require BP monitoring) tamsulosin, silodosin) - relax smooth muscle in prostate and bladder to decreasing resistance to urinary flow
  2. 5-alpha reductase inhibitors (finasteride, dutasteride) - reduce dihydrotestosterone levels to reduce size of prostate gland
  3. Combo of both
40
Q

Surgical treatment for BPH

A
  1. TURP,
  2. open prostatectomy,
  3. transurethral microwave thermotherapy
  4. laser ablation
41
Q

Current treatment options for prostate cancer

A
  1. Brachytherapy – radiation by internal implant
  2. EBRT – external beam radiation therapy
  3. Hormonal treatment
    - Mainly used for metastatic disease
  4. Cytotoxic chemo
    - Only used for treating symptomatic metastatic disease that has become resistant to hormonal agents
    - Treatment is not curative
  5. Surgical removal
  6. For over 70 years with well differentiated tumor
    - Active surveillance
42
Q

How often should you check a PSA level in prostate cancer patients?

A

Every 2 years

43
Q

Prostate cancer staging

A

A – no palpable lesion, biopsy only - observation

B1 – palpable nodule 1 lobe -prostatectomy, EBRT or brachytherapy

B2 – palpable nodules both lobes or one nodule >1.5cm - prostatectomy, EBRT or brachytherapy

C – locally advanced, invading the capsule - radiation/hormonal therapy

D1 – Extracapsular involves pelvic lymph nodes - LND and hormonal therapy

D1.5 – cmenical recurrence, rising PSA after prostatectomy- hormonal thearpy

D2 – extensive retroperitoneal lymph node involvement, distant metastisis -hormones

D2.5 – rising PSA after definitive treatment -cytotoxic therapy

44
Q

Risk factors for prostate cancer

A
  • Age
  • Black
45
Q

Risk factors for erectile dysfunction

A
  1. CV – HTN, CAD, HLD, PAD,
  2. DM
  3. Depression
  4. Obesity
  5. Alcohol
  6. Meds
  7. Neurological disease
  8. History of pelvic surgery/trauma
  9. Hypo/hyperthyroidism, steroid use
  10. hypogonadism
46
Q

Causes of erectile dysfunction

A
  1. Vascular disease (most common cause)
  2. Neurological disease (second most common cause)
  3. Medications
    - Antidepressants
    -. Antipsychotics
    - Antihistamines
    - Anti hypertensive (almost all)
    - OTC meds – cimetidine, ranitidine
  4. Psychogenic
    - Performance anxiety
    - Fear of STDs
    - Widower syndrome (rigid erection with masturbation)
  5. Hypogonadism, hypothyroidism, hyperprolactinemia
    - Serum testosterone <200ng/dL in a symptomatic man
  6. Endocrine (hypo/hyperthyroidism) – rare
47
Q

Evaluating a patient for ED

A
  1. Cause - decreased libido, inadequate erection, orgasmic failure
  2. Onet/duration (sudden - psychogenic, gradual - hypogonadism/neuro, vascular)
  3. Sleep associated erections?
  4. Medication review
  5. History - sexual, living, alcohol, stressors
  6. Risk factors
  7. PE
  8. Labs
48
Q

Vascular risk factors for ED

A
  1. Hypertension
  2. CAD
  3. PAD
  4. HLD
  5. Smoking
49
Q

Neuro risk factors for ED

A
  1. DM
  2. Pelvic injury
  3. Surgery
  4. Radiation
  5. Spinal injury or surgery
50
Q

Physical exam for ED

A
  1. Signs of vascular, neuro, endocrine disease
  2. Femoral bruit and diminished/absent pedal pulses suggest arterial
  3. Palpation of penile plaques suggest venous etiology
  4. Orthostatic hypotension/bulbocavernosus reflex suggest neuro etiology
  5. Small testes/gynecomastia suggest hypogonadism or hyperprolactinemia
51
Q

Lab testing for ED

A
  1. 2 morning serum testosterone levels
  2. CBC, CMP, TSH,
52
Q

Treatments for ED

A
  1. Phosphodiesterase inhibitors
  2. Vacuum
  3. Testosterone replacment
  4. Surgical prosthesis
53
Q

Pharmacological treatment for ED

A

Phosphodiesterase inhibitors
1. Sidenafil – improves rigidity and duration
* Transient color blindness

  1. Vardenafil – more potent, lower effective dose, fewer side effects
  2. Tadalafil – like vardenafil but with muscle pain, longer duration of action
  3. Avanafil – take 30 min prior (rapid onset)
    * Prolonged erection
54
Q

When is a vacuum appropriate for ED treatment?

A
  1. Effective for psychogenic, neurogenic, venogenic ED
  2. Requires a lot of manual dexterity
55
Q

When would you replace testosterone in patient with low T?

A

<200ng/dL

Given via:
1. IM injection
2. Transdermal patch
3. Gel

56
Q

ED assessment tools

A
  1. International Index of Erectile dysfunction – 15 questions addressing all domains of male sexual dysfunction
  2. Sexual health inventory for men – short version – 5 questions from international index question
57
Q

When to follow up with a patient being treated for ED?

A
  1. Every 6-8 weeks after initiation of treatment
  2. Failure for at least 4 sexual attemps prior to changing medication or treatment
  3. Refer for complicated cases
58
Q

Stages of menopause

A
  1. Premature menopause – starts early
  2. Perimenopause – changes in cycles prior to menopause
  3. Menopause
  4. Post menopause
59
Q

Pharmacological treatment for menopause symptoms

A
  1. Estrogen (increased risk for endometrial cancer)
  2. progesterone (increased risk for blood clots)
60
Q

Non-pharmacological management of menopause symptoms

A
  1. Hot flashes
    - avoid triggers like spicy foods, hot drinks, alcohol and caffeine
    - Maintain cool environment, layer clothing
    - Increase exercise
  2. Vaginal dryness
    - Vaginal estrogen
    - Vaginal moisturizer
    - Lubricants during sex
  3. Mood changes
    - SSRIs
  4. Osteoporosis
    - Calcium and vitamin D supplements
    - Bone density scans
61
Q

Causes of uterine bleeding

A
  1. Endometrial atrophy –-> treat with short course of systemic estrogen
  2. Endometrial polyps –-> surgical removal
  3. Uterine fibroids –-> surgical removal
  4. Endometrial hyperplasia – medical management to prevent progression to endometrial cancer –-> treat with systemic progesterones or IUD to thin uterine lining
  5. Cancers – endometrial, ovarian, cervical, vaginal –>TAH ro radiation
62
Q

Genital tract bleeding in non-HRT women or menopausal women on HRT is most commonly caused by…

A

Benign vaginal atrophy.

o Physical exam reveals thin, pale epithelium and narrowing of the introitus
o Woman may have post coital bleeding

63
Q

Genitourinary syndrome of menopause (GSM)

A

Includes vulvovaginal atrophy, atrophic vaginitis, urogenital atrophy due to estrogen deficiency
1. Education
2. Local estrogen
- Creams (Premarin, estrgyn, estriol, rings, ovules
- vaginal moisturizers

64
Q

Why is HRT prescribed?

A

For severe symptoms and prevention of bone loss

65
Q

How are HRT hormones delivered?

A

Systemically
1. Tablets, patches, injections

Locally
1. Creams, vaginal rings

66
Q

What are the risks associated with HRT therapy?

A

Risks of therapy
1. Blood clots
2. Stroke
3. Breast cancer

67
Q

Estrogen only HRT

A

Increased risk of breast cancer/blood clots

68
Q

Estrogen plus progesterone HRT

A

Used for women who have not had hysterectomy to prevent uterine cancer

69
Q

Selective estrogen receptor modulators (SERMs)

A

Block or activate estrogen receptors in certain areas of the body and used as alternative for women with a history of breast cancer or those with concerns about HRT

70
Q

Types of SERMs

A
  1. Tamoxifen – prevents breast cancer, increased risk uterine cancer
  2. Maloxifen/avista – prevent bone loss and fractures and prevent breast cancer, increased risk of hot flashes
  3. Bazedoxifene w/estrogen– combine with systemic estrogen, protects against bone lose, treats hot flashes, no bleeding
  4. Ospemifene – vaginal atrophy and dryness, oral tablet only
71
Q

Causes of ED in older men

A
  1. Vascular disease (gradual onset)- MOST COMMON
  2. Neurologic disease (gradual onset)
  3. Medication (sudden onset)
  4. Psychogenic (sudden onset)
  5. Hypogonadism (Gradual onset)
  6. Endocrine problem (hypothyroidism, hyperthyroidism) – RARE
72
Q

Medications associated with ED

A
  1. Anticholinergic
  2. Antidepressants
  3. Antipsychotics
  4. Antihistamines
  5. Antihypertensives
    - Clonidine and thiazide diuretics have higher incidence rates
    - ACES/ARBS lower rates
73
Q

Age associated sexual symptoms in women

A
  1. Symptoms
    - Vaginal dryness
    - Burning
    - Irritation due to decreased lubrication
    - Pain with sex
  2. Treatment
    - Vaginal gel/moisturizer
    - Topical estrogen for severe symptoms
74
Q

Tests for STIs

A
  1. Speculum assessment
  2. Bimanual pelvic exam
  3. Nucleic acid amplification test (NAAT)
  4. Potassium hydroxide (KOH) prep
75
Q

Treatment for chlamydia

A
  1. Doxycycline
  2. With gonorrhea – ceftriaxone 250mg IM dose once
76
Q
A

NR601 - Primary Care of the Mature and Aged (8 decks)

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