Week 8 GU Flashcards
PSA screening
-when to begin?
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
PSA screening
-when to stop?
• If age 60 with PSA <1 ng/mL: consider discontinuing
• All other men: discontinue at age 70
If life expectancy <10 years: discontinue screening
What Gleason score indicates well differentiated tumour?
What score indicates poor prognosis?
well differentiated: 7 and under
poor prognosis:
• Gleason grade 8 and higher
• Extracapsular involvement beyond seminal vesicles
PSA >30 ng/mL
PSA
4 possible causes of non-cancerous PSA elevation?
Causes of non-cancerous elevated PSA: • BPH • Prostatitis **do not test PSA during acute inflammation* • acute urinary retention catheterization /instrumentation
Risk factors for prostate cancer
- increasing age
- african descent
- family hx prostate cancer (paternal, first degree)
- high risk hereditary gene mutation (BRCA2)
- obesity
- high testosterone levels in lifetime
men presenting with LUTS (lower urinary tract symptoms) should have what two exams?
DRE
PSA
harms associated with prostate biopsy?
harms associated with prostate cancer treatment?
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
what is the role of topical estrogen in treatment of recurrent UTIs in older women?
• Topical estrogen may reduce recurrent UTIs in healthy older women
Normalizes pH, restores normal flora
first line treatment for uncomplicated cystitis?
pyelonephritis?
nitrofurantoin 100 mg BID x 5 days
*avoid if CrCl <40
if Pyelo:
cipro 500 mg BID x 7 days
common organisms responsible for UTIs in healthy men?
E coli, Proteus mirabilis, enterococci
what is guiding principle for treatment of UTI in those who have indwelling catheter?
○ Treat ONLY if typical symptoms/fever present without another obvious cause
○ UTI in patients with chronic catheter is diagnosis of exclusion
endometrial thickness of ______ is indication of need for endometrial biopsy
> 4 mm
4 mm and less has 99% negative predictive value for endometrial malignancy
what are the 4 main types of urinary incontinence in older people?
urge
stress
mixed urge and stress
nonspecific
definition of urge incontinence vs stress incontinence
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
definition of overactive bladder
symptom syndrome (not specific pathologic condition)
urgency, frequency, nocturia
+/- urge incontinence
when should older adults be screened for urinary incontinence?
annual screen for all older adults!
*50% do not talk to care providers or are not asked about it
risk factors for urinary incontinence?
- age
- functional dependence
- female
- obesity
- diabetes
- stroke
- depression
- prostate surgery
- fecal incontinence
- hysterectomy
- dementia / cognitive impairment
urination
voiding occurs with (sympathetic/parasympathetic) stimulation of _____ receptors in the ____ muscle
parasympathetic stimulation
muscarinic receptors in detrusor
urination
storage of urine occurs with (sympathetic/parasympathetic) stimulation of ____ receptors in the ______
STORAGE
sympathetic stimulation
alpha-adrenergic receptors in smooth muscle sphincter –> causes contraction
beta-adrenergic receptors in detrusor –> causes relaxation
what part of the brain is the centre for suppressing urinary urgency and preventing voiding?
prefrontal cortex
micturation centre in pons
workup for urinary incontinence?
urinalysis (look for hematuria) - glycosuria in DM
PVR: consider if complex neuro disease, longstanding poorly controlled DM, marked pelvic organ prolapse, on anticholinergic meds
Meds associated with urinary incontinence
-how do NSAIDs , gabapentin and CCB cause incontinence?
other classes of meds that cause UI?
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)
Differential causes of nocturnal polyuria:
- excess fluid intake (caffeine, alcohol)
- pedal edema associated with meds
- CHF
- sleep apnea***** consider in all patients with unexplained nocturnal polyuria
what is the definition of nocturnal polyuria?
> 1/3 of total 24 hour urine production occurring during hours of sleep
what behavioural therapies are used in urinary incontinence?
- bladder training
* frequent voiding starting q2h to keep bladder volume low
* urgency suppression - 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
what is the effect of oral estrogen (+/- progestin) in stress urinary incontinence?
WORSENS stress UI
vaginal topical estrogen can help with atrophic vaginitis
examples of antimuscarinics used in treating urinary incontinence?
- oxybutynin
- tolterodine
- solifenacin
- fesoterodine
considerations when prescribing antimuscarinics (eg oxybutynin) for urinary incontinence?
contraindications?
metabolism?
side effects?
- 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
example of beta-3 agonist for urinary incontinence?
mirabegron (Myrbetriq)
consideration when prescribing beta-3 agonist (mirabegron) for urinary incontinence?
- 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
consideration for use of desmopressin in treating urinary incontinence?
not used for frail older adults
*risk of hyponatremia
erectile dysfunction
specific questions to ask re: erections?
- onset and duration of ED
- sleep associated erections
- erections with masturbation
erectile dysfunction risk factors
most common cause?
second most common cause?
1: vascular (CVD risk factors, smoking, HTN, hyperlipidemia, etc)
erectile dysfunction
medications implicated?
- anticholinergics (antidepressants, antipyschotics, antihistamine)
- BP meds (especially clonidine and thiazide. Lower rates of ED with ACE-I and ARB
- OTC meds: cimetidine, ranitidine
psychogenic erectile dysfunction
- effect on sleep-associated erections?
- effect on masturbation erections?
Psychogenic: retention of sleep-associated erections or erections with masturbation intact
drug-induced erectile dysfunction
- effect on sleep-associated erections?
- effect on masturbation erections?
lack of both
erectile dysfunction
phosphodiesterase inhibitor eg sildenafil
- contraindications?
- side effects?
contraindicated if using nitrates or alpha-blockers (fatal hypotension)
side effects; headache, flushing, rhinitis, dyspepsia, transient colour blindness
3 age-related changes to the prostate?
glandular enlargement
increased smooth muscle tone
decreased compliance
what type of receptors are the predominant type present in smooth muscle of the prostate, helps to maintain urethral tone and intraurethral pressure?
alpha-1 adrenergic receptors
what is the role of 5-alpha-reductase in the prostate and pathophysiology of BPH?
converts testosterone to dihydrotestosterone –> stimulates development and growth of prostate gland –> BPH
what nerve is responsible for conscious control of voiding?
Pudendal nerve: innervates voluntary sphincter in bladder neck –> conscious control of voiding
what are some transient causes of LUTS?
Drugs diet restricted mobility constipation infection inflammation psychological
what are some disease states that cause LUTS?
DM CVA Parkinson MS spinal cord injury
what are the three groups of LUTS symptoms?
- Storage (irritative): increased frequency, nocturia, incontinence
- Voiding (obstructive): slow stream, intermittent stream, hesitancy
- Postmicturition: incomplete emptying, dribbling
physical exam for LUTS?
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
What to teach patients for self management of LUTS?
3 components
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
DDx of prostatitis
acute cystitis BPH urinary tract stones bladder cancer prostatic abscess enterovesical fistula
signs and symptoms of acute prostatitis?
UTI-like symptoms: dysuria, urinary frequency, lower ack pain
swollen tender prostate
prostate massage contraindicated
systemic symptoms: malaise, fever, myalgia
acute prostatitis vs chronic prostatitis
- timeline of symptoms?
- common organisms
acute: severe UTI symptoms, systemic
- enterobacter, enterococcus, P. aeruginosa
chronic: 3 months, usually recurrent UTI (same strain)
- enterobacter, enterococcus, P. aeruginosa
what is first line treatment for genitourinary symptoms of menopause?
vaginal gels/moisturizers
topical estrogen for severe/persistent symptoms
topical estrogen therapy for atrophic vaginitis
counselling on how to use?
-vaginal ring
-topical estrogen
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
which antidepressant is helpful for women with sexual dysfunction?
bupropion
not FDA approved but is centrally acting serotonergic agent
phosphodiesterace-5 inhibitors - effect on female sexual dysfunction?
-effective for women with antidepressant-related sexual dysfunction
*
DIAPPERS - causes for urinary incontinence
Delirium Infection (urinary) Atrophic urethritis and vaginitis Pharmaceuticals Psychological disorders, especially depression Excessive urine output Restricted mobility Stool impaction
Canadian urology association: when to repeat PSA if age 50-70 and…
PSA <1?
PSA 1-3?
PSA >3?
PSA <1: every 4 years
PSA 1-3: every 2 years
PSA >3: more frequent refer to urology
what are the side effects from brachytherapy (radiation) for prostate cancer?
younger men: risk of radiation-induced secondary cancer
later risk: chronic cystitis, proctitis
what are early symptoms of prostate cancer?
- Difficulty urinating (trouble starting, stopping), dysuria, increased frequency, nocturia
- Dribbling, slow stream
- Painful ejaculation
- Blood in urine or ejaculate
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?
Gleason score <7
PSA <10.0.
tumor stage
symptoms of LUTS?
mnemonic SHUFIS
stream (poor) hesitancy urgency frequency intermittent flow straining
DDx of LUTS
BPH
Prostatitis
UTI
BC guidelines:
age range for asymptomatic PSA screening?
55-69 with >10 years life expectancy
PSA adjustment if patients are taking 5-alpha reductase inhibitors (eg finasteride)?
PSA will drop by 50% so need to adjust by x2
risk factors for breast cancer
age mammographic density nulliparity or late age at first birth early menarche late menopause use of hormonal replacement therapy
what DECREASES risk for breast cancer?
early age at first delivery
activity
chest-feeding
what is the most common type of breast cancer?
ductal carcinoma
- treatable and curable
- found by mammogram
what type of cancer presents as skin disease like eczema (dermatitis, redness, scaly)
Paget’s
*very rare
erectile dysfunction
what ROS to assess?
CV (femoral bruits, pedal pulses, orthostatic hypotension) neuro endocrine (hypogonadism, hyperpolactinemia)
erectile dysfunction
phosphodiesterase inhibitor eg sildenafil
-patient teaching
- take 1 hour before sex
- will have little effect before sexual stimulation
- do not take nitrate or alpha blockers at same time
genitourinary syndrome of menopause
symptoms?
• GSM includes: ○ genital dryness ○ Burning ○ irritation associated with diminished lubrication ○ pain on penetration
DDx dyspareunia
- GSM
- vaginal infection
- cystitis
- bartholin cyst
- uterine prolapse
- endometriosis
- dermatosis (lichen sclerosus, lichen planus)
- excessive penile thrusting
- vaginismus
mechanism of action for 5-alpha-reductase inhibitors (eg finasteride, dutasteride)?
blocks conversion of testosterone –> dihydrotestosterone (DHT) –> reduces level of DHT –> prostate gland size reduction
what is the mechanism of action for alpha-blockers?
relaxes smooth muscles in prostate and bladder neck –> decreases resistance to urinary flow
treatment for acute bacterial prostatitis?
cipro 500-750 mg po BID x 2-4 weeks
treatment for chronic bacterial prostatitis?
-tx: cipro 500-750 mg po BID x 4-6 weeks
early menopause (age 40-45) is associated with increased risk for….?
CVD
OA
dementia
late menopause (age 54) is associated with increased risk for ….?
breast and endometrial cancer
what are some contraindications to menopausal hormone therapy?
- unexplained vaginal bleeding
- known or suspect breast ca
- acute liver
- acute VTE
- acute CVD
- recent CVA
- pregnancy
what are 4 non-hormonal rx options for management of menopause symptoms?
- gabapentin (VMS, sleep)
- SSRI eg paroxetine (VMS, sleep, mood)
- clonidine (VMS)
- CBT (VMS)
common side effects with estrogen menopausal hormone therapy?
breast tenderness, nausea, headache and bloating
common side effects with clonidine for hot flushes?
dizziness, dry mouth, drowsiness and constipation
common side effects with 5-alpha reductase inhibitors?
*may take 6 months to work
Sexual - decreased libido, erectile dysfunction, ejaculation dysfunction
Gynecomastia, breast tenderness
May persist after stopping rx
common side effects of alpha blockers for BPH eg terazosin?
Dizziness
Fatigue/weakness
Ejaculatory dysfunction
Orthostatic hypotension
prostate adenocarcinoma most commonly presents in anterior/posterior part of prostate?
posterior
what is the Gleason score?
looks at 2 more common architectural patterns seen in on biopsy
1 = well differentiated
5 = abnormal
added up together for total Gleason score
what lab test can indicate bony metastases?
elevated Alk phos
asymptomatic bacteriuria: when would it be reasonable to treat?
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
