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547 > Week 8 GU > Flashcards

Week 8 GU Flashcards

1
Q

PSA screening

-when to begin?

A

Canadian Urology Association
• start at age 50 in most men
• start at age 45 if increased risk of prostate cancer (family history of first or second degree relative with prostate ca)

BC Guidelines:
-consider starting at age 55

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2
Q

PSA screening

-when to stop?

A

• If age 60 with PSA <1 ng/mL: consider discontinuing
• All other men: discontinue at age 70
If life expectancy <10 years: discontinue screening

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3
Q

What Gleason score indicates well differentiated tumour?

What score indicates poor prognosis?

A

well differentiated: 7 and under

poor prognosis:
• Gleason grade 8 and higher
• Extracapsular involvement beyond seminal vesicles
PSA >30 ng/mL

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4
Q

PSA

4 possible causes of non-cancerous PSA elevation?

A 
Causes of non-cancerous elevated PSA:
	• BPH
	• Prostatitis **do not test PSA during acute inflammation*
	• acute urinary retention
catheterization /instrumentation
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5
Q

Risk factors for prostate cancer

A
  • increasing age
  • african descent
  • family hx prostate cancer (paternal, first degree)
  • high risk hereditary gene mutation (BRCA2)
  • obesity
  • high testosterone levels in lifetime
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6
Q

men presenting with LUTS (lower urinary tract symptoms) should have what two exams?

A

DRE

PSA

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7
Q

harms associated with prostate biopsy?

harms associated with prostate cancer treatment?

A

20-25% of men diagnosed with prostate cancer have cancer that would not cause harm in their lifetime

biopsy: bleeding, pain, infection
treatment: erectile dysfunction, urinary incontinence

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8
Q

what is the role of topical estrogen in treatment of recurrent UTIs in older women?

A

• Topical estrogen may reduce recurrent UTIs in healthy older women
Normalizes pH, restores normal flora

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9
Q

first line treatment for uncomplicated cystitis?

pyelonephritis?

A

nitrofurantoin 100 mg BID x 5 days
*avoid if CrCl <40

if Pyelo:
cipro 500 mg BID x 7 days

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10
Q

common organisms responsible for UTIs in healthy men?

A

E coli, Proteus mirabilis, enterococci

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11
Q

what is guiding principle for treatment of UTI in those who have indwelling catheter?

A

○ Treat ONLY if typical symptoms/fever present without another obvious cause
○ UTI in patients with chronic catheter is diagnosis of exclusion

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12
Q

endometrial thickness of ______ is indication of need for endometrial biopsy

A

> 4 mm

4 mm and less has 99% negative predictive value for endometrial malignancy

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13
Q

what are the 4 main types of urinary incontinence in older people?

A

urge
stress
mixed urge and stress
nonspecific

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14
Q

definition of urge incontinence vs stress incontinence

A

urge:

  • preceded by/associated with urgency
  • precipitated by running water, hand washing, cold, need to rush to toilet

stress:

  • leakage with effort, exertion, sneezing or coughing
  • if severe sphincter damage: can be provoked by minimal or no activity
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15
Q

definition of overactive bladder

A

symptom syndrome (not specific pathologic condition)
urgency, frequency, nocturia
+/- urge incontinence

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16
Q

when should older adults be screened for urinary incontinence?

A

annual screen for all older adults!

*50% do not talk to care providers or are not asked about it

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17
Q

risk factors for urinary incontinence?

A
  • age
  • functional dependence
  • female
  • obesity
  • diabetes
  • stroke
  • depression
  • prostate surgery
  • fecal incontinence
  • hysterectomy
  • dementia / cognitive impairment
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18
Q

urination

voiding occurs with (sympathetic/parasympathetic) stimulation of _____ receptors in the ____ muscle

A

parasympathetic stimulation

muscarinic receptors in detrusor

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19
Q

urination

storage of urine occurs with (sympathetic/parasympathetic) stimulation of ____ receptors in the ______

A

STORAGE
sympathetic stimulation
alpha-adrenergic receptors in smooth muscle sphincter –> causes contraction
beta-adrenergic receptors in detrusor –> causes relaxation

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20
Q

what part of the brain is the centre for suppressing urinary urgency and preventing voiding?

A

prefrontal cortex

micturation centre in pons

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21
Q

workup for urinary incontinence?

A

urinalysis (look for hematuria) - glycosuria in DM

PVR: consider if complex neuro disease, longstanding poorly controlled DM, marked pelvic organ prolapse, on anticholinergic meds

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22
Q

Meds associated with urinary incontinence

-how do NSAIDs , gabapentin and CCB cause incontinence?

other classes of meds that cause UI?

A

pedal edema –> nocturnal polyuria

  • ETOH
  • alpha-adrenergic agonists and blockers
  • ACE-I (cough)
  • anticholinergics (retention, constipation, impaired emptying)
  • antipsychotics (anticholinergic)
  • Cholinesterase inhibitors
  • estrogen (worsens stress and mixed leakage in women)
  • loop diuretics
  • narcotics (retention, fecal impaction)
  • sedative hypnotics
  • TCA (anticholinergics)
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23
Q

Differential causes of nocturnal polyuria:

A
  • excess fluid intake (caffeine, alcohol)
  • pedal edema associated with meds
  • CHF
  • sleep apnea***** consider in all patients with unexplained nocturnal polyuria
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24
Q

what is the definition of nocturnal polyuria?

A

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

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25
Q

what behavioural therapies are used in urinary incontinence?

A
  1. bladder training
    * frequent voiding starting q2h to keep bladder volume low
    * urgency suppression
  2. pelvic muscle exercises
    * isolated pelvic contraction without contracting buttocks, abdomen or thighs, hold for 6-8 seconds
    * repeat 8-12 times for one set
    * 3 sets 4x/week
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26
Q

what is the effect of oral estrogen (+/- progestin) in stress urinary incontinence?

A

WORSENS stress UI

vaginal topical estrogen can help with atrophic vaginitis

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27
Q

examples of antimuscarinics used in treating urinary incontinence?

A
  • oxybutynin
  • tolterodine
  • solifenacin
  • fesoterodine
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28
Q

considerations when prescribing antimuscarinics (eg oxybutynin) for urinary incontinence?

contraindications?

metabolism?

side effects?

A
  • immediate and long term cognitive impairment
  • no antimuscarinic is “safer” for all patients or those with dementia
  • should not be used with cholinesterase inhibitors (risk increased impairment)
  • do not use in narrow-angle glaucoma
  • extreme caution if impaired gastric emptying or hx urinary retention

metabolized by CYP-450 watch drug interactions

side effects: think anticholinergic - dry mouth, constipation

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29
Q

example of beta-3 agonist for urinary incontinence?

A

mirabegron (Myrbetriq)

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30
Q

consideration when prescribing beta-3 agonist (mirabegron) for urinary incontinence?

A
  • preferred for patients with cognitive impairment (including if on cholinesterase inhibitor)
  • monitor BP: can increase BP
  • do not use in severe uncontrolled HTN
  • caution if on anticholinergic meds

metabolism: CYP2D6 inhibitor (watch metoprolol)
* can raise digoxin level

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31
Q

consideration for use of desmopressin in treating urinary incontinence?

A

not used for frail older adults

*risk of hyponatremia

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32
Q

erectile dysfunction

specific questions to ask re: erections?

A
  • onset and duration of ED
  • sleep associated erections
  • erections with masturbation
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33
Q

erectile dysfunction risk factors

most common cause?
second most common cause?

A

1: vascular (CVD risk factors, smoking, HTN, hyperlipidemia, etc)

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34
Q

erectile dysfunction

medications implicated?

A
  • anticholinergics (antidepressants, antipyschotics, antihistamine)
  • BP meds (especially clonidine and thiazide. Lower rates of ED with ACE-I and ARB
  • OTC meds: cimetidine, ranitidine
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35
Q

psychogenic erectile dysfunction

  • effect on sleep-associated erections?
  • effect on masturbation erections?
A

Psychogenic: retention of sleep-associated erections or erections with masturbation intact

36
Q

drug-induced erectile dysfunction

  • effect on sleep-associated erections?
  • effect on masturbation erections?
A

lack of both

37
Q

erectile dysfunction

phosphodiesterase inhibitor eg sildenafil

  • contraindications?
  • side effects?
A

contraindicated if using nitrates or alpha-blockers (fatal hypotension)

side effects; headache, flushing, rhinitis, dyspepsia, transient colour blindness

38
Q

3 age-related changes to the prostate?

A

glandular enlargement
increased smooth muscle tone
decreased compliance

39
Q

what type of receptors are the predominant type present in smooth muscle of the prostate, helps to maintain urethral tone and intraurethral pressure?

A

alpha-1 adrenergic receptors

40
Q

what is the role of 5-alpha-reductase in the prostate and pathophysiology of BPH?

A

converts testosterone to dihydrotestosterone –> stimulates development and growth of prostate gland –> BPH

41
Q

what nerve is responsible for conscious control of voiding?

A

Pudendal nerve: innervates voluntary sphincter in bladder neck –> conscious control of voiding

42
Q

what are some transient causes of LUTS?

A 
Drugs
diet
restricted mobility
constipation
infection
inflammation
psychological
43
Q

what are some disease states that cause LUTS?

A 
DM
CVA
Parkinson
MS
spinal cord injury
44
Q

what are the three groups of LUTS symptoms?

A
  1. Storage (irritative): increased frequency, nocturia, incontinence
  2. Voiding (obstructive): slow stream, intermittent stream, hesitancy
  3. Postmicturition: incomplete emptying, dribbling
45
Q

physical exam for LUTS?

A

DRE (hyperplasia only inovlves transitional zone so may be unremarkable)

Lower abdo/suprapubic exam: distended bladder

U/A: r/o UTI, hematuria, glycosuria (BPH will be unremarkable)

PVR if urinary retention suspected
Cr: to r/o renal disease/obstructive uropathy

46
Q

What to teach patients for self management of LUTS?

3 components

A

Education and reassurance: LUTS is common even in absence of cancer

Lifestyle modifications: fluid restrict at bedtime, avoid caffeine and ETOH, bladder irritants (artificial sweeteners, fizzy drinks), timing of diuretics

Behavioural interventions: bladder retraining

47
Q

DDx of prostatitis

A 
acute cystitis
BPH
urinary tract stones
bladder cancer
prostatic abscess
enterovesical fistula
48
Q

signs and symptoms of acute prostatitis?

A

UTI-like symptoms: dysuria, urinary frequency, lower ack pain
swollen tender prostate
prostate massage contraindicated

systemic symptoms: malaise, fever, myalgia

49
Q

acute prostatitis vs chronic prostatitis

  • timeline of symptoms?
  • common organisms
A

acute: severe UTI symptoms, systemic
- enterobacter, enterococcus, P. aeruginosa

chronic: 3 months, usually recurrent UTI (same strain)
- enterobacter, enterococcus, P. aeruginosa

50
Q

what is first line treatment for genitourinary symptoms of menopause?

A

vaginal gels/moisturizers

topical estrogen for severe/persistent symptoms

51
Q

topical estrogen therapy for atrophic vaginitis
counselling on how to use?
-vaginal ring
-topical estrogen

A

improvement in 2-4 weeks
reduce risk of recurrent UTI

vaginal ring replaced q90 days
-lower systemic absorption and and lower risk adverse events compared to cream

estrogen cream:
-dime-size amount to vaginal introitus daily x 2 weeks, then 2-3 x/week

52
Q

which antidepressant is helpful for women with sexual dysfunction?

A

bupropion

not FDA approved but is centrally acting serotonergic agent

53
Q

phosphodiesterace-5 inhibitors - effect on female sexual dysfunction?

A

-effective for women with antidepressant-related sexual dysfunction
*

54
Q

DIAPPERS - causes for urinary incontinence

A 
Delirium
Infection (urinary)
Atrophic urethritis and vaginitis
Pharmaceuticals
Psychological disorders, especially depression
Excessive urine output
Restricted mobility
Stool impaction
55
Q

Canadian urology association: when to repeat PSA if age 50-70 and…

PSA <1?
PSA 1-3?
PSA >3?

A

PSA <1: every 4 years

PSA 1-3: every 2 years

PSA >3: more frequent refer to urology

56
Q

what are the side effects from brachytherapy (radiation) for prostate cancer?

A

younger men: risk of radiation-induced secondary cancer

later risk: chronic cystitis, proctitis

57
Q

what are early symptoms of prostate cancer?

A
  • Difficulty urinating (trouble starting, stopping), dysuria, increased frequency, nocturia
    • Dribbling, slow stream
    • Painful ejaculation
    • Blood in urine or ejaculate
58
Q

American urological association recommendation:
do not treat low-risk clinically localized prostate cancer without discussing active surveillance as part of shared decision-marking

what defines low-risk clinically localized prostate cancer?

  • Gleason score?
  • PSA?
  • tumor stage?
A

Gleason score <7
PSA <10.0.
tumor stage

59
Q

symptoms of LUTS?

mnemonic SHUFIS

A 
stream (poor)
hesitancy
urgency
frequency
intermittent flow
straining
60
Q

DDx of LUTS

A

BPH
Prostatitis
UTI

61
Q

BC guidelines:

age range for asymptomatic PSA screening?

A

55-69 with >10 years life expectancy

62
Q

PSA adjustment if patients are taking 5-alpha reductase inhibitors (eg finasteride)?

A

PSA will drop by 50% so need to adjust by x2

63
Q

risk factors for breast cancer

A 
age
mammographic density
nulliparity or late age at first birth
early menarche
late menopause
use of hormonal replacement therapy
64
Q

what DECREASES risk for breast cancer?

A

early age at first delivery
activity
chest-feeding

65
Q

what is the most common type of breast cancer?

A

ductal carcinoma

  • treatable and curable
  • found by mammogram
66
Q

what type of cancer presents as skin disease like eczema (dermatitis, redness, scaly)

A

Paget’s

*very rare

67
Q

erectile dysfunction

what ROS to assess?

A 
CV (femoral bruits, pedal pulses, orthostatic hypotension)
neuro
endocrine (hypogonadism, hyperpolactinemia)
68
Q

erectile dysfunction

phosphodiesterase inhibitor eg sildenafil

-patient teaching

A
  • take 1 hour before sex
  • will have little effect before sexual stimulation
  • do not take nitrate or alpha blockers at same time
69
Q

genitourinary syndrome of menopause

symptoms?

A 
• GSM includes: 
○ genital dryness
○ Burning
○ irritation associated with diminished lubrication
○ pain on penetration
70
Q

DDx dyspareunia

A
  • GSM
  • vaginal infection
  • cystitis
  • bartholin cyst
  • uterine prolapse
  • endometriosis
  • dermatosis (lichen sclerosus, lichen planus)
  • excessive penile thrusting
  • vaginismus
71
Q

mechanism of action for 5-alpha-reductase inhibitors (eg finasteride, dutasteride)?

A

blocks conversion of testosterone –> dihydrotestosterone (DHT) –> reduces level of DHT –> prostate gland size reduction

72
Q

what is the mechanism of action for alpha-blockers?

A

relaxes smooth muscles in prostate and bladder neck –> decreases resistance to urinary flow

73
Q

treatment for acute bacterial prostatitis?

A

cipro 500-750 mg po BID x 2-4 weeks

74
Q

treatment for chronic bacterial prostatitis?

A

-tx: cipro 500-750 mg po BID x 4-6 weeks

75
Q

early menopause (age 40-45) is associated with increased risk for….?

A

CVD
OA
dementia

76
Q

late menopause (age 54) is associated with increased risk for ….?

A

breast and endometrial cancer

77
Q

what are some contraindications to menopausal hormone therapy?

A
  • unexplained vaginal bleeding
  • known or suspect breast ca
  • acute liver
  • acute VTE
  • acute CVD
  • recent CVA
  • pregnancy
78
Q

what are 4 non-hormonal rx options for management of menopause symptoms?

A
  • gabapentin (VMS, sleep)
  • SSRI eg paroxetine (VMS, sleep, mood)
  • clonidine (VMS)
  • CBT (VMS)
79
Q

common side effects with estrogen menopausal hormone therapy?

A

breast tenderness, nausea, headache and bloating

80
Q

common side effects with clonidine for hot flushes?

A

dizziness, dry mouth, drowsiness and constipation

81
Q

common side effects with 5-alpha reductase inhibitors?

A

*may take 6 months to work
Sexual - decreased libido, erectile dysfunction, ejaculation dysfunction

Gynecomastia, breast tenderness

May persist after stopping rx

82
Q

common side effects of alpha blockers for BPH eg terazosin?

A

Dizziness
Fatigue/weakness
Ejaculatory dysfunction
Orthostatic hypotension

83
Q

prostate adenocarcinoma most commonly presents in anterior/posterior part of prostate?

A

posterior

84
Q

what is the Gleason score?

A

looks at 2 more common architectural patterns seen in on biopsy
1 = well differentiated
5 = abnormal

added up together for total Gleason score

85
Q

what lab test can indicate bony metastases?

A

elevated Alk phos

86
Q

asymptomatic bacteriuria: when would it be reasonable to treat?

A

pyuria AND symptoms

  • pyuria alone is not a useful indicator of UTIs
  • can be present in nephrolithiasis, diverticulitis, IBD, intraabdominal abscess

• No benefit to treating asymptomatic bacteriuria UNLESS pt is having prostate resection

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