Week 6 Menopause, ED, Incontinence, and UTI's Flashcards
1
Q
Signs and Symptoms of UTI
A
dysuria, frequency, urgency, suprapubic tenderness, low back pain (pyelonephritis), incontinence, change in urine character (color change, hematuria, change in odor), and mental status changes
2
Q
Risk Factors for UTI
A
women > men increases with age post-menopausal indwelling catheters, urethral or condom catheters urinary or fecal incontinence cognitive impairment neurological impairment Diabetes, unprotected and anal sexual intercourse poor perineal hygiene functional disability renal stones alkaline urine prior ATB therapy genetic predisposition BPH, prostatitis, urinary retention, institutionalization
3
Q
Most common bacteria that causes UTI
A
E. coli
4
Q
Second most common bacteria that causes UTI
A
staph saprophyticus
5
Q
Other organisms that cause UTI
A
klebsiella, proteus, and enterococcus, serratia, pseudomonas and staph aureus
6
Q
Diagnostic Criteria for UTI
A
UA + LE and/ or nitrates, pyuria (>10 neutrophils per hpf)
UTI symptoms
Urine culture + for bacteria
7
Q
Asymptomatic bacteriuria (ABS)
A
urinary culture with more than 105 colony forming units with no corresponding urinary tract symptoms is prevalent in the older adult (esp. in nursing homes) and is NOT diagnostic
Treatment is not recommended
8
Q
Medications for UTI uncomplicated in women
A
- nitrofurantoin (Macrobid) 100 mg BID x 3-7 days
- SMZ-TMP (Bactrim DS) 160 mg TMP/800 mg SMX BID x 3 days
- fosfomycin 3 grams x 1 dose
9
Q
Why is 3 day ATB treatment recommended for uncomplicated UTI in women?
A
to prevent development of candida vaginitis and nonadherence
10
Q
Uncomplicated UTI in men ATB Treatment
A
§ Fluoroquinolone or SMZ-TMP DS x 7 days
Older men may need longer therapy (10-14 days)
11
Q
Uncomplicated vs complicated UTI treatment
A
○ Uncomplicated UTI - 3-7 days of ATB tx
Complicated UTI - 10-14 days of ATB tx
12
Q
What medication is used for relieve dysuria
A
Phenazopyridine 200 mg q 8 hrs x 2 days
13
Q
Complications of untreated UTI
A
pyelonephritis sepsis shock death urethritis in men can lead to urethral strictures, periurethral abscess, urethral diverticula and fissures if left untreated
14
Q
Incontinence Risk Factors
A
- Female»_space; male
- vaginal deliveries, multiparity, hysterectomy
- enlarged prostate, BPH, proctectomy
- living in LTC or nursing home
- increases with age
- cognitive impairment
- physically frail with functional limitations
- pelvic muscle weakness
- estrogen depletion (post-menopause)
- increased intra-abdominal pressure (pelvic organ prolapse, pregnancy, tumors, obesity)
- diabetes and CHF
- neurological diseases (stroke, MS, Parkinson’s, spinal cord injury)
- fecal impaction
- poor fluid intake or excessive fluid intake
- smoking
- depression
- cancer
15
Q
Medications that can cause incontinence
A
- cholinergics
- anticholinergics
- diuretics
- antispasmodics
- opiates
- hypnotics
- calcium channel blockers
- ACE inhibitors
- alcohol and caffeine
16
Q
Stress incontinence
A
urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs or other physical stressors increasing abdominal pressure
17
Q
Urge incontinence
A
urine leakage associated by or immediately preceded by the feeling of an urgent need to void
also known as detrusor instability
18
Q
Mixed incontinence
A
a combination or stress and urge incontinence, marked by involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing
19
Q
Overflow incontinence
A
urine leakage when the bladder is over distended and may result in incomplete bladder emptying
- symptoms can present as constant dribbling, frequency, hesitation when initiating urination and nocturia
- often associated with bladder outlet obstruction, such as BPH in men and pelvic organ prolapse in women
20
Q
Functional incontinence
A
the inability to hold urine due to reasons other than neurological and lower urinary tract dysfunction including delirium, psychiatric disorders, UTI and impaired mobility
21
Q
Overactive Bladder (OAB)
A
urine storage symptoms such as urgency, frequency, and nocturia and may or may not be accompanied by urge incontinence
associated with involuntary contractions of the detrusor muscle
22
Q
What medications help with urge/stress incontinence and overactive bladder?
A
Anticholinergics/antispasmodics
- tolterodine (Detrol LA)
- oxybutynin (Ditropan XL, Urotrol)
- solifenacin (VESIcare)
- darifenacin (Enablex)
- trospium chloride (Sanctura XR)
- transdermal oxybutynin (Gelnique)
- fesoterodine (Toviaz)
23
Q
What medications help treat BPH and urinary incontinence in men??
A
alpha-1 adrenergic blockers
- tamsulosin (Flomax)
- terazosin (Hytrin)
- doxazosin (Cardura)
24
Q
What medications treat OAB and urge incontinence ?
A
TCA’s
imipramine (Tofranil)
amitriptyline (Elavil)
25
What medication is used to treat OAB that does not respond to anticholinergics?
Botulinum toxin (Botox) injection
26
Treatments recommended for stress incontinence?
alpha-blockers
| (men), SNRI's, surgery
27
Treatments recommended for urge incontinence?
anticholinergics
kegels
bladder training
28
Treatments recommended for overflow incontinence
treat underlying cause of bladder outlet obstruction and urinary catheterization
29
Treatment of functional urinary incontinence
scheduled toileting
30
Treatment of mixed incontinence
anticholinergics
31
Causes of hematuria from urethra
urethritis (gonococcal or nongonococcal)
stricture
calculus
trauma
32
Causes of hematuria from prostate/male GU tract
infection (prostatitis, epididymitis)
BPH
tumor
33
Causes of hematuria from kidney
```
infection
nephrolithiasis
renal cell cancer
trauma
glomerular disease
allergic interstitial nephritis (Drug-induced)
```
34
Causes of hematuria from ureters
nephrolithiasis
tumor
endometriosis
35
Causes of hematuria from bladder
```
infection
calculus
tumor
endometriosis
drugs (hemorrhagic cystitis)
```
36
Causes of pseudohematuria
```
menstrual contamination
phenothiazines
red food dye
beet consumption
quinine
rifampin
hemoglobinuria
```
37
Causes of hematuria systemically
pyelonephritis
| coagulopathies (thrombocytopenia, hemoglobinopathy, sickle cell dx)
38
Causes of proteinuria
- usually renal pathology, glomerular origin
- can be functional d/t acute illness, emotional stress or excessive exercise
- pyelonephritis
- glomerulonephritis, nephrotic syndrome
39
What causes Bence Jones proteinuria
-multiple myeloma, lymphosarcoma, Hodgkin's disease, leukemia
40
What can cause a false positive of proteinuria?
pH > 8.0
41
What causes colorless urine?
diabetes insipidus
diuretics
fluid overload
42
What causes dark urine?
hematuria
malignancy
stones
acidic urine
43
What causes cloudy urine?
UTI
hematuria
bilirubin
mucus
44
What causes pink/red urine?
```
hematuria
hemoglobin
myoglobin
beets
food coloring
```
45
What causes orange/yellow urine?
phenazopyridine (Pyridium)
rifampin (Rifampicin)
bile pigments
46
What causes brown/black urine?
```
myoglobin
bile pigments
melanin
cascara (laxative)
iron preparations
```
47
What causes green urine?
bile pigments
methylene blue
indigo carmine (food dye)
48
What causes foamy urine?
proteinuria
| bile salts
49
What causes increased specific gravity?
```
dehydration
CHF
adrenal insufficiency
diabetes mellitus
nephrosis
antidiuretic hormone
```
50
What causes decreased specific gravity?
diabetes insipidus
pyelonephritis
glomerulonephritis
excess fluid intake
51
What causes acidic urine?
```
diet
medications
acidosis
ketoacidosis
COPD
```
52
What causes alkaline urine?
```
diet
sodium bicarbonate
vomiting
metabolic alkalosis
UTI
```
53
What can cause + bilirubin on UA
jaundice
| hepatitis
54
What can cause + blood on UA
```
kidney stones
tumors
kidney disease
trauma
infection
injury from instrumentation
coagulation problems
menses
```
55
What can cause + glucose on UA
```
diabetes mellitus
pancreatitis
Cushing's disease
shock
burns
corticosteroids
renal disease
hyperthyroidism
cancer
```
56
What can cause + ketones on UA
```
starvation
diet
ketoacidosis
vomiting
diarrhea
pregnancy
```
57
What can cause + nitrates on UA
infection
58
What can cause + protein on UA
```
kidney disease
pregnancy
CHF
DM
cancer
benign cause
```
59
What can cause + leukocyte esterase (LEs) on UA
infection
60
What can cause + reducing substance on UA ?
- signifies the presence of glucose, fructose or galactose, lactose, pentose
- may also signify certain medications (salicylates, levodopa, ascorbic acid, nalidixic acid, tetracyclines)
- liver disease, hyperthyroidism
61
Older adults and STI's
may not wear condoms due to the possibility of pregnancy is eliminated and they do not think about protecting themselves from STIs
62
Age related changes in women regarding sex
- Decreased vaginal wall elasticity = potential for discomfort during sexual intercourse
- Decreased levels of circulating hormones = increased frequency of sexual dysfunction
63
Age related changes in men regarding sex
- Decreased levels of circulating hormones = increased frequency of sexual dysfunction
- Degeneration of seminiferous tubules = decreased seminal fluid volume, decreased force of ejaculation
64
Signs and symptoms of Genitourinary Syndrome of Menopause (GSM)?
vaginal dryness, burning and irritation (blood-tinged discharge)
sexual symptoms: dryness, discomfort, pain with intercourse
urinary symptoms: urgency, dysuria, recurring UTIs, incontinence (stress)
65
What do you use to diagnosis GSM?
- pelvic exam
- (Pap) Cervical cytology - to rule out abnormal cell changes
- Vaginal culture - to rule out infection
- pH measurement - elevated due to low estrogen
- Urinalysis - to rule out infection
66
What diagnostic results indicate atrophic vaginitis (GSM)?
- pale, dry, nonrugated vaginal mucosa
- Pap smear results should be normal
- vaginal pH by litmus paper will be > or equal to 5
- UA: could show signs of UTI or be negative
- if UTI is detected ask about symptoms once UTI is cleared
67
When to treat GSM?
For symptomatic women with moderate to severe symptoms or those who do not respond to lubricants/moisturizers, vaginal or low-dose systemic estrogen is the therapeutic standard
68
Common treatments of vulvovaginal atrophy (atrophic vaginitis):
- intravaginal estrogen (tablet, ring or cream)
* Contraindications: undiagnosed vaginal/uterine bleeding and is controversial in women with estrogen-dependent breast or endometrial cancer
- SERM = ospemifene (Osphena) off-label: raloxifene, lasofoxifene, bazedoxifene
* Improves vaginal dryness and dyspareunia - Off-label: conjugated estrogens, intravaginal DHEA, testosterone
- Regular sexual activity (partner, device, masturbation) may improve health of the vaginal tissue and reduce distressing symptoms
69
Common treatments of vaginal dryness?
- Water-soluble or silicone-based vaginal lubricants prior to sex
- Moisturizers
70
Common treatments for urinary symptoms of GSM
low dose vaginal estrogen
| Kegel exercises
71
Physiology of perimenopause and menopause
- Permanent decline of sex hormone levels
- Induced surgically via bilateral oophorectomy
- Induced medically due to chemo or pelvic irradiation
72
Perimenopause (early and late menopausal transition) physiology
- Can begin up to 10 years prior to FMP
- Ovulation becomes less frequent and the number of ovarian follicles is decreased as they become less likely to mature
- Small increase in FSH
- Shorter cycle length and/or increased menstrual bleeding
- Menses than can occur without ovulation and becomes lighter and occur less often until they completely stop
- Waxing and waning of ovarian function, as reflected in both ovulatory and anovulatory menstrual cycles of unpredictable duration and intensity, extended periods of estrogen deficiency, and heightened FSH and LH secretion with occasional follicular development and estradiol production
- Increased levels of LH lead to continued androgen production by ovarian thecal cells, named androstenedione = Increased facial hair
73
Menopause
permanent cessation of menses and ovarian function
| FMP = final menstrual period
74
Postmenopausal period
12 months after FMP it starts
75
What factors contribute to irregularities and cessation of menses?
estrogen deficiency
FSH and LH levels increased
ovulation stops occurring
76
Signs and symptoms of menopause
• Hot flashes
• Sleep disturbances
• Insomnia
○ Depression
○ Irritability, anxiety and fatigue
• Vaginal dryness - itching, bleeding, sexual dysfunction
• Vaginal atrophy
○ Incontinence
• Joint pain
• Diminished libido
• Cognitive changes
• Weight gain, harder to lose visceral fat
• Escalation of bone loss = decrease in height -> low bone mass
• Dry skin, wrinkling and atrophy of skin
• Facial hair
77
Menopause symptom management
- use fans, lower room temp, dress in layers, avoid triggers (stress, caffeine, alcohol)
- lose weight and regular exercise may help
- Diet high in complex carbs and fiber, low in fat (esp. animal fat) and high in antioxidants (fresh fruits and vegetables)
- SSRI or SNRI (paroxetine 12.5-25 mg, venlafaxine 37.5-75 mg)
- menopausal hormone therapy
- SERM = Duavee = bazedoxifene 20 mg + conjugated estrogen 0.45 mg
- phytoestrogens
- black cohosh
78
Menopausal Hormone Therapy for:
- prevention of osteoporosis
- relieves hot flashes
- treats vulvovaginal atrophy
- relieves GU symptoms
79
Menopausal hormone therapy contraindications
- hormone-dependent cancers
- undiagnosed vaginal bleeding
- liver disease
- active thrombosis
- history of stroke
- migraines (some patients)
80
Diagnostic testing for ED
- Lab tests to rule out causes of ED
○ FBS and HgbA1c- r/o DM
○ Lipid profile - r/o hyperlipidemia
○ TSH
○ Testosterone level: If < 300 ng/mL get a serum prolactin level
○ PSA screen
- Nocturnal penile tumescence and rigidity (NPTR) test
○ Usually have erections during REM sleep
○ Absence of erection = physiological cause
- Color doppler sonography of penis
81
Hormonal therapy for ED
- parenteral agents: testosterone cypionate (Depo-Testosterone); testosterone enanthate (Delatestyrl)
- oral: fluoxymesterone (Halotestin), methyltestosteone (Android, Methitest)
- transdermal testosterone patch
- testosterone implantable pellets
- testosterone buccal system (Striant 30 mg)
82
Vasoactive agents for ED
oral: sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis) and avanafil (Stendra)
injectables: alprostadil (Caverject, Edex)
transurethral suppositiories: alprostdil (Muse)
83
Half-life of sildenafil (Viagra)
4-5 hrs
| active for 3-5 hrs after consumed
84
Half life of tadalafil (Cialis)
17.5 hrs
| active up to 36 hrs after consumed
85
Half life of vardenafil (Levitra)
4-5 hrs
| active up to 6 hrs after consumed
86
Half life of avanafil (Stendra)
3-5 hrs
| active up to 6 hrs after consumed
87
Medications to avoid with ED medications
- nitrates
- alpha blockers
- careful with other meds that lower BP
88
Comorbid Diagnoses with ED
- stress, interpersonal conflict
- long-term alcohol use, tobacco use, recreational drug use (cocaine, marijuana, opiates)
- orthostatic hypotension
- goiter - thyroid disease
- AAA or vascular obstruction, circulatory issues
- peripheral neuropathy (DM)
- decreased mobility (neurological or musculoskeletal) -> spinal cord injury
- testicular atrophy or penile plaques
- enlarged prostate - BPH drugs
- testosterone deficiency
89
Medications that can cause ED
* Antiandrogens
* Anticholinergics
* Anticonvulsants
* Antidepressants
* Antipsychotics
* Centrally acting depressants (sedatives/hypnotics)
* H2 blockers
* Levodopa
* Lithium
* Stimulants (amphetamines)
* Beta blockers
* Spironolactone
* Methadone
* Cytotoxic agents
* Antihypertensives
* Urologic drugs (alpha blockers)
* Anti-inflammatories (baclofen, naproxen)
90
1st line treatment for uncomplicated UTI in elderly
Trimethoprim / Sulfamethoxazole
| Bactrim
