Week 8: GU, Sexual Health & Renal Flashcards
1
Q
What is stress incontinence
A
Involuntary loss of urine with increased intra- abdominal pressure
2
Q
What is urge incontinence
A
= the urge to void immediately preceding or accompanying involuntary urine leakage
Patients are aware of the intense need to avoid but are unable to hold back urine
3
Q
What is the difference between urge incontinence and over active bladder (OAB)?
A
“Overactive bladder” is a term that describes a syndrome of urinary urgency with or without incontinence, which is often accompanied by nocturia and urinary frequency
The terms “urgency incontinence” and “overactive bladder with incontinence” are often used interchangeably.
4
Q
T/F with urge incontinence, the person typically piddles a little
A
False
typically the entire contents of the bladder are lost rather than a few drops.
**although up to date says it can be either
5
Q
Risk factors for urge incontinence (includes many associated medical conditions)
A
Urgency urinary incontinence is more common in older women and may be associated with comorbid conditions that occur with age.
May be idiopathic or secondary to other conditions…
Medical: CHF, DM, diuretics
Neurogenic: MS, PD, CVD, dementia, SCI
Bladder outlet obstruction: Previous bladder neck surgery, pelvic organ prolapse
Gyne: UTI, pregnancy, pelvic mass, urethral diverticulum, child birth
Psychosomatic: habits, anxiety, high fluid consumption
Obesity
Smoking
Stroke
Prior radiation to pelvis
Prostate: BPH, CA
6
Q
What is thought to cause urge incontinence? Basic patho
A
Thought to result from detrusor overactivity, leading to uninhibited contraction during bladder filling
Bladder hypersensitivity
7
Q
What the heck is the detrusor muscle?
A
The wall of the bladder is comprised of smooth muscle fibers oriented in multiple different directions. These smooth muscle fibers are collectively known as the detrusor muscle
8
Q
S&S of urge incontinence
A
-You have a sudden, intense urge to urinate followed by an involuntary loss of urine.
Frequency
Nocturia
9
Q
Diagnostics we may order for someone with urge incontinence?
A
-UA (UC if indicated)
-PVR
-Bladder stress test
10
Q
What are considered bladder irritants & should be avoided with urge incontinence?
A
caffeine
smoking
alcohol
acidic, spicy foods
carbonated beverages
11
Q
What are the 1st line treatments for urge incontinence?
A
Non pharm (1st line, try for 6+ weeks)
- PELVIC FLOOR PHYSIO!
-Reduce bladder irritants (caffeine, smoking, alcohol, carbonated)
-Fluid restriction
Bladder training: Regular voiding schedule
- Voiding diary
-Distraction techniques when urge comes on: deep breathing, crosswords…
-Encourage double voiding/ complete emptying.
-OTC products (pads, incontinence underwear, urine wicking devices)
12
Q
How should you instruct a patient to carry out a regular voiding schedule for stress incontinence?
A
Start timed voiding q1 hour, then increased by 15-30min/ wk or until 2d without incontinence
goal 3-4 hour without leaks
*want to avoid last minute rush to bathroom./
13
Q
If 6 or so weeks of nonpharmacologic strategies doesn’t fix urge incontinence, we can start to consider drugs. What are our typical pharm treatments?
A
Anticholinergics (oxybutynin, tolterodine, fesoteriodine, …) - These act at detrusor smooth muscle to reduce over activity.
B3 adrenergic agonist (mirabegron) (increases bladder capacity)
Vaginal estrogen in estrogen deficient females
14
Q
If pharm management of urge incontinence is inadequate. What kind of procedures can be helpful?
A
**once has failed 2 adequate trials of meds (4-12 weeks each):
Sacral neuromodulation (SNM)
Detrusor botox injection
Laser therapy
Intravesicular instillations
15
Q
Red flags warranting referral for incontinence
A
recurrent incontinence, incontinence assoc with pain, UT abnormalities, hematuria, recurrent infection, fistulas, prostate/ pelvic irradiation, previous radical pelvic sx, pelvic mass, lack of tx response
16
Q
What is the most common cause of incontinence in Canada?
A
stress (~50%)
17
Q
How common is urge urinary incontinence/OAB in Canada?
A
~16% of those with incontinence
18
Q
Which kind of urinary incontinence is typically the most responsive to pharm tx?
A
Urge/OAB
19
Q
What is the basic patho of stress incontinence?
A
-Thought to be related to lack of mechanical support of urethra/ insufficient resistance to outflow of urine with increased abdo pressure
-Sphincter incompetence
20
Q
Risk factors for stress incontinence?
A
-20-30% of F (F>M)
increased age
obesity
pregnancy/ vaginal delivery
post menopause
smoking/ chronic cough
neurological
genetics
high impact exercise
-Can also occur in M post prostate Ca tx (or rarely surgical tx BPH)
21
Q
S&S of stress incontinence
A
Leakage of urine with state increased intra abdominal pressure (cough, sneeze, laugh, sex)
The urine leakage may be an occasional drop or dribble if the condition is mild. In severe cases, you may leak a stream of urine
*I don’t think it usually involves irritative signs like dysuria or frequency, but some sources say it may…
22
Q
What investigations might you order for stress incontinence?
A
UA (if hematuria and irritative voiding symptoms: cytology; if pyuria/ bacteria: UC)
-PVR
23
Q
What is a normal PVR?
A
normal is <1/3 total volume, abnormal is >1/3 and indicates poor bladder contractility or bladder outlet obstruction
24
Q
Nonpharm treatment of stress incontinence
A
-urinary diary
-weight loss, smoking cessation
-Pelvic floor PT (kegels) (x8-12 weeks, then r/a)
-Devices for biofeedback or electrical stimulation (vaginal electromyography probe for biofeedback, vaginal cones, non implantable electrical stimulation)
-Pessaries to decrease leakage (or for pelvic organ prolapse)
25
pharm treatment of stress incontinence
***No meds have official indication - generally not recommended
-Can consider vaginal estrogen if GU sx of menopause (not oral!)
-Duloxetine, midodrine
26
Possible surgical/procedure treatments for stress incontinence
-Treat pelvic organ prolapse, if existing
-Vaginal laser, urethral bulking
-urethral slings
27
____% of those in Canada with urinary incontinence have mixed urinary incontinence
32%
28
What is mixed UI
How is it treated generally?
Characteristics or both OAB and SUI
**TREAT AS PER THE MOST DOMINANT CATEGORY
29
What is overflow incontinence? What is it caused by?
means that you have the urge to urinate but can release only a small amount. Since your bladder doesn't empty as it should, it gets too full. It then leaks urine later, even though you feel no urge to urinate
caused by detrusor underactivity (weak bladder muscle) or bladder outlet obstruction.
30
How does overflow incontinence typically present?
**typically presents with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying.
May be position dependent
- Associated symptoms can include weak or intermittent urinary stream, hesitancy, frequency, and nocturia.
When the bladder is very full, stress urinary leakage can occur, or low-amplitude bladder contractions can be triggered, resulting in symptoms similar to stress and/or urgency urinary incontinence.
31
Causes of overflow incontinence
- Conditions that affect nerves such as DM or MS. These make it hard to tell when bladder is full or make it harder for bladder to contract
- Blockage of urinary tract: stone, tumor, enlarged prostate, narrowing of the urethra
- detrusor weakness
- Some meds
32
Treatment of overflow incontinence
Treat constipation
Stop or decrease meds (especially if anticholinergic)
Double voiding
A-blocker (Tamsulosin) trial in men
Intermittent catheterization
33
How does GSM (genitourinary syndrome of menopause) contribute to incontinence?
In postmenopausal women, low estrogen levels result in atrophy of the superficial and intermediate layers of the urethral mucosal epithelium. Atrophy results in urethritis, diminished urethral mucosal seal, loss of compliance, and possible irritation, all of which can contribute to incontinence
34
Name some meds can contribute to urinary incontinence (up to date has a great table)
Antihistamines: Decreased contractility via anticholinergic effect
Decongestants (such as Pseudoephedrine): Increased urethral sphincter tone
Benzos: Impaired micturition via muscle relaxant effect
Opioids: Decreased sensation of fullness and increased urethral sphincter tone
Anticholinergics: Decreased contractility via anticholinergic effect
- Antimuscarinics *used to treat OAB
- splasmolytics (glyco, hyoscyamine, scopolamine)
- antiparkinsons meds
And many many others:
cardiac meds
antidepressants
antipsychotics
estrogens
alcohol
caffeine....
35
What is the DIAPERS acronym for incontinence in the elderly?
Describes transient causes of reversible urinary incontinence
DIAPERS
Delirium
Infammation/Infection
Atrophic vaginitis/urethritis
Pharmaceuticals/Psychological
Excess U/O
Restricted mobility/Retention
Stool impaction
36
Describe the pathogenesis of ABP(acute bacterial prostatitis)
-microorganism enter prostate gland via urethra (migrate from urethra or bladder)
-can also occur from direct innoculation after transurethral prostate biopsy or other procedures (i.e., catheterization, cystoscopy)
37
Who do we see stress incontinence in most often?
Common in middle aged
and older women, and
men following prostate
cancer treatment, or rarely
surgical treatment of BPH
38
Risk factors for ABP
-can occur in setting of cystitis, urethritis, or other urogenital tract infections
-conditions that predispose to urogenital tract infections (i.e., urethral stricture)
-urogenital instrumentation (including chronic indwelling bladder catheterization, intermittent cath, prostate biopsy)
-HIV
-Anecdotally- trauma (bike riding), dehydration, sexual abstinence
39
What is perimenopause? How long does it start before menopause?
years leading up to menopause characterized by irregular menses, +/- vasomotor (VMS) and other symptoms; may begin up to 10 yrs before LMP
40
Describe the clinical presentation (symptoms) of ABP
-LUTs (frequency, urgency, urge incontinence)
-voiding symptoms may be caused by inflamed prostate (dribbling, hesitancy, acute urinary retention)
-dysuria
-Pelvic pain
-Pain at tip of penis
-Systemic symptoms- fever, chills, malaise, myalgia
41
What time period if considered menopausal transition?
perimenopause and the first 12 months post LMP
42
Describe PE findings of ABP
-On DRE, prostate if firm, edematous, exquisitely tender
-Pyuria, bacteriuria
-Elevated WBC, CRP
-May have positive blood cultures
-Note that inflammation of prostate can also lead to elevated PSA (defer serum PSA for prostate cancer screening by 1 mo following resolution of ABP)
43
Do you still need contraception during the perimenopausal period?
Yes, until 55 or 12 months with no period. Consider progestin only contraceptive or low dose CHC
- Rxfiles recommneds that women 50 and older use a non-hormonal contraceptive. Continue until 12 months with no period.
- Women 55 years and older stop contraception as conception is very rare
(I feel like these guidelines goes out the window when we start treating vasomotor symptoms with estrogen/progesterone because we won't know when menses has truly stopped naturally)
44
Potential complications of ABP?
-bacteremia
-epididymitis
-chronic bacterial prostatitis
-prostatic abscess (need TR-US to ID- s&s would be similar to those of ABP but persist despite appropriate abx therapy, and fluctuance of prostate on DRE)
-metastatic infection (spinal or sacroiliac)
-endocarditis (if valvular heart disease or valvular prosthesis)
45
Average age of menopause?
Average age of menopause is 51 years
Occurs in 90% of females between 45-56
46
How do you diagnosed ABP?
-Symptoms of ABP
-DRE findings of edematous, tender prostate establishes diagnosis in context of hx
-ensure you collect UA, urine C&S
-blood cultures only if sepsis (and in this case, they should be in the ED)
47
S&S of menopause
Risk of what diseases increases at this time?
- urogenital tract: atrophy, vaginal dryness/itching, urinary frequency/urgency/incontinence, bleeding
* vascular: vasomotor instability (hot flashes, night sweats), increased risk of heart disease
* bones: bone loss, joint/muscle/back pain, fractures, loss of height
* brain: depression, irritability, mood swings, memory loss
48
Ddx for ABP?
-UTI/ cystitis (no constitutional symptoms, no overt prostate inflammation/ no prostate tenderness on DRE)
-epididymitis (again, no tenderness of prostate on DRE)
-BPH/ OAB (may present with LUTS, but do not have fever, pyuria, other S/S infection)
49
What % of AFAB individuals in menopause experience GSM?
GSM symptoms in 45-77%
50
When would a patient with ABP require hospitalization?
-s&s sepsis
-unable to tolerate oral abx
-acute urinary retention (up to date states that passage of urinary catheter through inflammed urethra is CI in those with ABP; cath would need to be done suprapubic!)
51
Vasomotor symptoms occur in ______% of individuals during menopause?
How long do these symptoms persist?
VMS in 80%
persist for 7-11 years
From sigma pocket guide: Although 50% of women experience VMS for 7 years or less, 15% may experience VMS for 15 years or longer.
52
Tx of ABP?
-abx
-empiric therapy to cover gram negative organisms
-fluroquinolones (i.e., ciprofloxacin or levofloxacin) first line or TMP-SMX (UTD, B&D)
-men <35 who are sexually active and men 35+ engaging in high risk sexual behavior should be tx with regimes covering GC & CT
53
What lifestyle/nonpharm treatments are available for menopausal symptoms?
CBT, mindfulness, hypnosis, weight loss, cooling techniques, avoiding triggers, physical activity
54
George, age 50, has been taking ciprofloxacin 750mg BID for 3 days for suspected ABP. His symptoms of fever, dysuria, urgency, and pelvic pain are not improving. What do you do?
Suspect abscess
Bugs and Drugs: - if lack of clinical improvement with culture-guided antibiotic therapy, consider CT to identify structural abnormalities or prostatic abscess +/- urology referral. NB: transrectal US is NOT recommended.
Up To Date: TR-US (TN also states do US if suspect abscess) or CT
55
T/F you can use low-dose vaginal estrogen for GSM, even if contraindications to estrogen use exist
True! Just can't use systemic estrogen
**black box warnings for breast CA/CHD
generally do not apply
56
What is chronic bacterial prostatitis (CBP)?
chronic or recurrent urogenital syndrome with evidence of bacterial infection of prostate (UTD_
Bugs and drugs- sx 3+ mo, subacute presentation
57
T/F if you start a patient on vaginal estrogen and they have a uterus, you need to also prescribe progesterone for endometrial protection
False - Low-dose vaginal estrogen does
not require a progestogen for endometrial protection
58
Pathogenesis of CBP?
-same as ABP
-entry of microorganisms into prostate gland, usually via urethra
-can be a complication of acute prostatitis following inadequate/ too short tx
59
You prescribe a patient systemic estrogen. They also have a uterus. What else do you need to prescribe? Examples of this?
Progesterone
examples: MIRENA IUD, PROMETRIUM, PROVERA
60
Risk factors for CBP?
-ABP
-hx manipulation of urinary tract
-DM
-smoking
-higher prostate volumes
-prostate stones
61
T/F combined hormonal contraceptives (CHCs) are a good treatment option for VMS in menopause
False
Avoid CHCs for
treatment of VMS in post-menopausal, as the estrogen
dose is ~3-6x higher vs MHT
62
What organism is the most common causative agent in CBP?
gram negative rods (e.coli most common)
63
Linda is having VMS. She asks you to check her hormone levels so you can decide if you need estrogen therapy. What's your next step?
Don't do it...
Measuring
serum estradiol, estrone, or SHBG is not recommended as
they do not correlate with menopausal symptoms
64
Presentation of CBP?
-can be subtle
-recurrent UTI (frequency, dysuria, urgency, perianal discomfort, low grade fever) with repeated isolation of same organism in urine
-may be asymptomatic with recurrent bacteriuria
-may have pain in perineum, lower abdo, testicles, penis, with ejactulation), bladder outlet
-may have blood in semen
65
Key 6 questions you should ask your patient in perimenopause (basically what symptoms are you asking about)
1. Any changes in your periods?
2. Are you having hot flashes?
3. Any vaginal dryness, pain or
sexual concerns?
4. Any bladder issues or
inconfinence?
5. How is your sleep?
6. How is your mood?
66
Findings on DRE of person with CBP?
-may have prostatic hypertrophy, tenderness, edema, nodularity
-frequently NORMAL prostate exam (UTD)
67
Your patient recently went through menopause and complains of low mood. What are some pharm treatment options?
MHT may benefit peri- and
early post-menopausal with low mood irrespecfive of VMS
Otherwise can treat anxiety/depression as you normally would
68
Lab findings in CBP?
-usually unremarkable
-normal leuks, inflamma markers
-elevated PSA only in 25% of pts
69
Your perimenopausal patient complaints of poor sleep. How to approach treatment?
Treat underlying cause (e.g. VMS, OAB, OSA).
Sleep hygiene
CBT-I
aerobic exercise; medications (e.g. venlafaxine 75mg/day; gabapentin
300mg QHS)
may try menopause herbal product (e.g. black cohosh
20mg/day; valerian root 530mg BID).
70
Dx of CBP?
The diagnostic standard for bacterial prostatitis is the finding of bacteria at higher levels in prostatic fluid compared with urethral and bladder specimens. However, maneuvers to express prostatic fluid can be cumbersome and are rarely performed in clinical practice. Instead, chronic bacterial prostatitis is often presumptively diagnosed and empirically treated with antimicrobials when men present with chronic (eg, longer than three months) or recurrent urogenital symptoms, particularly if bacteriuria is also present.
UTD suggests referral to urology to obtain prostate fluid samples for dx before starting on long term abx.
71
Mildred, 55, says her memory and concentration is poor since menopause. Treatment recommendations? Is hormone treatment useful for this?
↑ aerobic exercise and vegetable intake
MHT not proven helpful
72
ddx for CBP?
- chronic prostatitis (no clear evidence bacterial infection)/ chronic pelvic pain syndrome
-non inflammatory disorders of prostate/ bladder/ urinary tract
73
Hormonal treatments in menopause best treat which symptoms?
VMS: hot flashes, night sweats
74
Tx for CBP?
Prolonged abx therapy- at least 6 weeks! (UTD)
Infection frequently recurs
Fluroquinolone drug of choice.
Needs to have good penetration into prostatic tissue (fluroquinolones, sulfonamides, tetracyclines, macrolides)
75
Your patient is on systemic estrogen for VMS. She is also having vaginal dryness. T/F: it's not safe for you to add topical estrogen to treat this symptom
False! Can add it for GSM symptoms
76
You treat George, 60 years old, for CBP with a 6 week course of ciprofloxacin. 1 month later, his symptoms recur. What do you do?
Up To Date- recurrences of CBP common and warrant 2nd course of abx. Assess for causes of tx failure (abx resistance, incomplete adherance, impaired drug absorption).
For recurrent CBP episode, tx with fluoroquinolone (i.e., repeat cipro course) regardless of initial abx choice unless suspected resistances.
Would personally refer to urology before starting 2nd course of abx, esp. if did not previously collect prostatic fluid for culture.
77
T/F it's normal for a person who has started MHT to experience vaginal bleeding within the first 6 months
True
Rxfiles: Vaginal bleeding (e.g. breakthrough bleeding, prolonged menses on cyclical regimen, etc.): May
occur within first 6mo of MHT. Assess adherence; may ↓ estrogen dose; ↑ progestogen
dose; switch to DUAVIVE; switch progestogen regimen (confinuous → cyclical). Invesfigate
AUB if new onset after 6mo on tx or if abnormal uterine bleeding persists > 6mo.
78
Compare and contrast clinical features of ABP and CBP
Both: LUTs, pelvic pain, leukocytosis in prostatic fluid, positive bacterial cultures
ABP: Systemic signs (fever, chills, malaise), v tender prostate on DRE
CBP: NO systemic signs, may have asymptomatic DRE
79
T/F once a person starts MHT, they will likely be on it lifelong.
False
Anficipate 3-5yrs of MHT for many;
however, some may require shorter or
longer durations.
80
Tim, 50 years old, presents to clinic with dysuria, urgency, frequency, fever, chills, and lower abdominal pain. How would you diagnose ABP and what differentials would you consider?
-ABP- LUTs, acutely ill (fever, chills, malaise), pelvic pain, dysuria, irritative symptoms. PE- firm prostate, edematous, very tender. Positive UA and UC. Labs- elevated WBC, CRP.
-UTI/ cystitis- would likely not have systemic sx. No DRE prostate abnormalities.
-Pyelonephritis- (given LUTs, fever)- would have flank pain
-BPH, OAB- would not have systemic sx, insidious onset; negative UA
-epididymitis- presence of LUTs, systemic sx, but would have testicular/ scrotal pain, palpable swelling of epididymis, no tenderness of prostate on DRE
81
At what age must MHT be stopped?
Trick question!
There is no set age at
which MHT must be discontinued. Reevaluate need for MHT annually and with
any changes in health status.
82
What abx are first line for both ABP and CBP?
Fluroquinolones (ciprofloxacin)
83
What are the absolute contraindications to MHT
- Unexplained vaginal bleeding
- Acute liver disease
- Clotting disorder
- Hx of CHD (CAD, stroke, TIA, unprovoked VTE, PAD) or at high-risk
of CHD*
- Personal hx of estrogen-dependent CA (breast, endometrial, ovarian) or at
high-risk of breast CA**
- Moderate risk of CHD*/breast CA**
AND age ≥60yrs AND ≥10yrs since LMP
84
What is the difference in tx a patient with abx for ABP and CBP?
Length of therapy
ABP requires 10-14 days of cipro
CBP requires 4-6 wks
85
what is the optimal situation in which MHT is considered?
Age <60yrs or <10yrs
since LMP and low risk (no
cautions or contraindications)
86
Counselling for pt you initiate on a fluoroquinolone?
Usually well tolerated; common AE are mild GI upset, headache, dizziness, transient change in mood or sleep.
AE: tendinopathy (stop if experience pain/ swelling, and seek care), c. diff (stop and seek care if copious diarrhea, abdo pain, new fever), neuropathy (stop drug and seek care/ switch to diff abx class), QT interval prolongation (assess QT prolonging drugs, consider baseline ECG)
Avoid use in those with pre-existing tendinopathy, neuropathy, prolonged QT, aortic aneurysm, ehler danlos, marfan syndrome, uncontrolled HTN. Avoid in pregnancy and lactation. Avoid in myasthenia gravis (neuromuscular blocking activity can precipitate crisis)
MOA- bactericidal, inhibit bacterial DNA synthesis. Broad spectrum, potent activity against enteric gram negative bacilli.
Take with food (avoid taking with antacid or with dairy products alone)
87
Your patient is 65 years old and went through menopause 11 year ago. Are they a good candidate for MHT?
Probably not! Would need to look at the situation and risk factors but typically only want to prescribe MHT to
Age <60yrs or <10yrs
since LMP
**Consider non-hormonal treatments for this patient if they are still having symptoms.
88
Describe age related changes in sexual health for women.
Decreasing estrogen levels due to menopausal changes.
-vaginal dryness and thinning -> dyspareunia
-decreased libido, may take longer to become sexually aroused
-Self esteem issues around body changes.
89
Name some situations in which prescribing MHT is cautioned (not totally contraindicated but needs close risk/benefit analysis)
- Moderate risk of CHD* and/or CV risk factors (smoking, HTN, DM,
dyslipidemia, obesity) in age <60yrs or <10yrs since LMP
- Migraine with aura
- Hx of gallstones
- Moderate risk of breast CA**in age <60yrs or <10yrs since LMP
- Age ≥60yrs and ≥10yrs since LMP
90
Describe age related changes in sexual health for men
Testosterone levels begin to decrease.
-It may take longer for him to become sexually aroused.
-It may take longer for his penis to become erect.
-Erections may not be as firm or last as long.
-It may also take longer to ejaculate.
91
T/F transdermal estrogen is considered to have lower risk for VTE & gallstones when compared to oral
Yes! Can be good option for some of these individuals who fit the "caution" criteria.
Observafional data
suggest transdermal may ↓ risk of VTE & gallstones
92
What medical conditions can reduce sex drive/ reduce ability to become aroused or achieve orgasm?
* Neurovascular conditions are the most common cause of ED (erectile disfunction)
* Arthritis, chronic pain
* Incontinence
* Heart disease, vascular disease, HTN
* Neurologic disease – radiation therapy, spinal cord injury, autonomic dysfunction, surgical procedures
* Diabetes, other endocrine issues (hypo/hyperthyroidism, hyperprolactinemia)
* Obesity
* Dementia
* Stroke
* Depression
93
T/F MHT must be tapered carefully when discontinuing
False
MHT can be stopped abruptly or tapered
(VMS re-emergence rates similar irrespecfive
of disconfinuafion method). If tapering: ↓
dose preferred over alternate day dosing
due to MHT pharmacokinefics.
94
Describe some psychosocial factors that may contribute to ED.
-depression, stress, relationship issues
-ED that develops suddenly is typically due to performance anxiety
-fear of STI
-widower syndrome- older man involved in a new relationship feels guilt and develops impotence as a defense against his unfaithfulness to his dead spouse- a man will be able to achieve erection and ejaculation with masturbation if this is the cause of ED
95
T/F vaginal estrogen can be continued indefinitely
True!
Vaginal estrogen should be continued at
the lowest effective dose for as long as
benefit is noted (may be continued
indefinitely).
Discontinuation leads to the
vaginal mucosa returning to a hypoestrogenic state.
96
What medications can contribute to sexual dysfunction?
anticholinergics
antihypertensives
antidepressants
cimetidine
97
Amenorrhea for what time period is diagnostic of menopause?
12 months
98
99
T/F patient going through menopause will complain of high libido
False - more likely to have issues with decreased libido, dyspareunia, anorgasmia...
(see rx files for treatment options...)
100
101
Beyond MHT, what medications can help with VMS
SSRI/SNRIs,
gabapentinoids, or clonidine
Oxybutynin
102
103
What nonpharm/lifestyle modifications are used to treat VMS?
CBT
Mindfulness
Hypnosis
Weight loss (obesity is assoc with increased VMS)
Cooling techniques: breathable, layered clothing, fans, cold packs under pillow
Avoid triggers: alcohol, caffeine, spicy/hot foods, stressful situations
104
105
Around ____% women will have their hot flashes improve by ≥50% with MHT
80%
Pafients with the most
severe symptoms tend to receive the largest benefit.
106
In addition to improvement in VMS, patients that start MHT may also find benefit with what other symptoms of menopause?
improved mood or sleep
Hormone therapy also treats vaginal dryness and painful sex associated with
menopause
According to sigma resource: HT may improve sleep and fatigue, mood, ability
to concentrate, and overall quality of life
107
menopause means risk for decreased bone density & future osteoporotic fractures.
Does MHT affect this?
Yes! Is bone protective.
108
A patient is started on MHT. What common side effects should you warn them about?
breast tenderness, nausea, mild headaches, bloating, and irregular bleeding or spotting (especially if using cyclical dosing)
These settle within a few weeks
109
What criteria is needed to classify a UTI as RECURRENT?
Two uncomplicated UTIs within 6 months OR
Three or more positive cultures in the past 12 months. (MUMS)
110
In a UTI, what is considered a reinfection?
-Occurs after two week of completing antibiotic therapy.
-Caused by a different organism
-Follows ascension of microorganisms from the periurethral area into the bladder. (MUMs)
111
In a UTI, what is considered a relapse?
-Occurs within 2 weeks of completing antibiotic treatment.
-Caused by the original microorganism.
-bacteriuria often persists during therapy or reoccurs after 1-2 weeks of finishing abx tx.
(MUMS)
112
Name S&S of complicated UTI
Costovertebral angle tenderness
Flank pain
Perineal pain (in men)
Symptoms of systemic illness:
Fever
Hemodynamic instability
Chills or rigors
Nausea or vomiting
113
You received a fax from a nurse requesting antibiotic treatment for Linda, a resident at a LTC who has a positive urine C&S.
What other symptoms would support the need for antibiotic therapy?
a) Recent falls, confusion and cloudy urine.
b) Vaginal discharge, cloudy urine, malaise.
c) Fever, gross hematuria, and acute dysuria.
C is the right answer!
Note: the presence of vaginal discharge reduces the probability of UTI by 25%3
(https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/urinary-tract-infections#uti_classification)
Back to the case: It turns out Linda has no symptoms that warrant antibiotics. She likely has asymptomatic bacteriuria, which means that even though her urine is colonized, she doesn't have an active infection.
114
Name common pathogens that cause complicated UTIs.
E. coli (50%)
P. mirabilis (20%)
Enterococci
Klebsiella Proteus
P. aeruginosa
Other Gram -ve bacilli
(MUMS)
115
Name common first line antibiotics for complicated UTIs.
TMP/SMX
Trimethoprim
Macrobid
Norfloxacin
Ciprofloxacin
Levofloxacin
Second line: Amox/Clavu
(Mums)
116
When administering Macrobid, what should you be mindful of?
Calculate CrCl, generally contraindicated if <30-60
117
When would you order antibiotics for Linda, who resides in a long term care home?
If she has DYSURIA ALONE OR
FEVER AND new or worsening urgency, frequency, suprapubic pain, gross hematuria, CVA tenderness, acute urinary incontinence. (MUMS)
118
What is postmenopausal bleeding?
Spontaneous uterine bleeding that occurs more than one year after the date of the last menstrual period.
Bleeding can occur from the cervix, vagina, vulva, fallopian tubes, the bladder, or bowel, so a thorough physical assessment is recommended.
119
When prescribing HRT, what should be taken into consideration?
To reduce the risk of endometrial cancer, prescribe estrogen with progestin.
It is not necessary to routinely evaluate the endometrium of women with uterine spotting or light uterine bleeding in the first six months of continuous estrogen and progestin HRT.
Women receiving estrogen and CYCLICAL progestins can be expected to have indefinite progestin withdrawal bleeding and require no further investigation, provided that the dose and duration of cyclic progestins are adequate.
For women using cyclic progestins, bleeding outside the time of progestin withdrawal is considered abnormal and requires appropriate investigation.
120
What history should you obtain when evaluating postmenopausal bleeding?
-Evaluate the bleeding pattern, including quantity and timing
-Assess for the potential of pregnancy.
-Assess for risk of UTI
-Assess for non-gynecologic sources of bleeding: bladder/kidney, urethral caruncle, and bowel as a source
*Review risk factors:
-Age > 40 years
-Nulliparity
-PCOS (polycystic ovarian syndrome) with irregular cycles
-Diabetes
-HNPCC (hereditary non-polyposis colorectal cancer) -Current Tamoxifen use
-Unopposed estrogen exposure
121
In what instances would you book them for an urgent gynecology consult/RACE/send to ER in a patient with postmenopausal bleeding?
Alarm Features/Red flags
* Patient looks unwell
* Hypotension or Tachycardia
* Hemorrhage or heavy bleeding defined as soaking through a pad or tampon every hour
* Large uterine or cervical mass which is obstructing voiding
* Concerning cervical mass (irregular, possibly associated with inflammatory discharge (pus).
Cervical cancer must be ruled out with an urgent tissue sample.
122
What investigations could you consider for postmenopausal bleeding?
-Pap
-CBC
-Ferritin
-STI testing if indicated
-Pregnancy test if indicated
-TSH if thyroid dx is suspected
-Coagulation tests-in women with heavy bleeding since menarche or who have a family history/personal history of abnormal bleeding
- Transvaginal Pelvic Ultrasound to rule out uterine structural causes for abnormal bleeding (polyp)
123
If a patient with postmenopausal bleeding is found to have endometrial thickness of >5mm, what would be the next step?
If endometrial thickness >5mm with vaginal bleeding, refer to Gynecology or skilled community GP for endometrial sampling. Counsel patient to stop any hormone therapies if taking estrogen.
124
If a patient with postmenopausal bleeding is found to have proliferative endometrium or hyperplasia without atypia.
Begin progesterone treatment (Mirena® IUD or progesterone 200mg PO QHS).
Bleeding should stop within three to six months.
If bleeding persists, refer to Gynecology.
Repeat endometrial sampling is indicated in three to six months to ensure resolution of endometrial hyperplasia even if bleeding has ceased.
If sampling suggests hyperplasia with atypia or endometrial carcinoma, make an urgent referral to GyneONCOLOGY
If there is no endometrial explanation for postmenopausal bleeding, appropriate steps to evaluate patients for cervical cancer
125
126
MHT increases the risk of what?
breast cancer, coronary heart disease, stroke, DVT, and PE
But these risks are small and very rare in healthy individuals under 60
**Some other sources state that it's safe for the heart and there's no increased risk of stroke or dementia for the recommended populations
Sigma pocket guide says that MHT started at time of menopause is likely cardioprotective. Initiation of MHT > 10 years after menopause or after age
60 is associated with increased risk.
127
How long before a person will see benefits from MHT for VMS?
May take up to 4-8 weeks to see benefit, depending on dosage
128
T/F systemic hormonal treatment can be helpful for alleviating GSM
True - may see benefit for vaginal dryness, urinary frequency and recurrent UTIs...
but may also need topical estrogen
129
In what individuals will transdermal estrogen be a safer option than oral?
Transdermal estrogen therapy may be preferable for
women who are smokers or have migraine headaches,
hypertriglyceridemia, malabsorption syndromes, heterozygous carriers of Leiden Factor V mutation, a history of
thrombosis (on anti-coagulation), metabolic syndrome,
and hypertension
130
S&S of genitourinary syndrome of menopause (GSM)
(previously called vulvovaginal atrophy/atrophic vaginitis)
= a collection of symptoms and signs caused by hypoestrogenic changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder that occur in menopausal patients
- dryness, burning, and irritation
- sexual symptoms of lack of lubrication, discomfort or pain, and impaired function
- urinary symptoms of urgency, dysuria, and recurrent urinary tract infections
131
Treatment of GSM
Initial treatment: nonhormonal vaginal moisturizers and lubricants
For most patients with GSM who are not adequately treated with vaginal moisturizers and lubricants, we suggest low-dose vaginal estrogen
132
What is the normal size of a healthy adult prostate?
Walnut shaped with an average size of 20g
133
How many lobes does the prostate gland have? What are we able to palpate with a DRE?
4 lobes.
During DRE can palpate the posterior lobe and and the medial part of both lateral lobes
134
What changes occur in the prostate gland with normal aging?
Glandular enlargement, increased smooth muscle tone and decreased compliance secondary to altered collagen deposition
135
What does BPH stand for?
Benign prostatic hyperplasia
136
Pathophysiology of BPH?
There are both static and dynamic factors that contribute to BPH - what are these factors?
Androgen hormone and aging cause prostate changes which contribute to LUTS.
Static - enlargement of prostate impinging on the urethra
Dynamic - tension of the prostate smooth muscle.
137
T/F: Most men will end up with BPH in their older age
True
60% in > 60 year olds
80% in > 80 years olds
138
T/F: Most men with BPH require treatment
False. Only about 25% require treatment. Treatment indicated for more severe/bothersome cases
139
LUTS (lower urinary tract symptoms) are divided into three categories: storage/irritative, obstructive, post-micturition.
- Storage/irritative: urgency, frequency, incontinence, nocturia
- Obstructive: hesitancy, weak stream, intermittence, straining
- Post-micturition: dribbling, incomplete void, retention
140
There is a standardized questionnaire that should be used to quantify the severity of LUTS - what is it?
IPSS - International Prostate Symptom Score
141
What are some late symptoms of untreated BPH
- Acute urinary retention
- Recurrent UTIs
- Hydronephrosis
- Loss of renal concentrating ability
- Systemic acidosis and renal failure
142
An IPSS score < 7 is considered mild and lifestyle modifications and watchful waiting is usually all that is required for treatment. What are some lifestyle modifications?
- Limiting fluid intake before bedtime (2-4hrs) or prior to travel
- Limiting intake of mild diuretics (eg, caffeine, alcohol)
- Limiting intake of bladder irritants (eg, highly seasoned or irritative foods)
- Limiting intake of irritating meds (eg TCA, diuretics, decongestants, antihistamine). Take diuretics earlier in the day.
- Avoid / Tx Constipation
- Timed voiding & double voiding (bladder training) – urinate q90-120min during daytime; 2nd attempt to void w/in 1-2mins of initial void
- Pelvic floor muscle training (min 3mos trial) – can be done independently or via physiotherapy for pelvic floor dysfunction, OAB, urinary incontinence
- Increasing activity, including regular strenuous exercise
- Tx of metabolic syndrome / weight loss
- Urethral milking for post micturition dribble
143
If IPSS 7 + and patients experience bothersome symptoms despite lifestyle modification then medication is the next step. What is the first line drug class and how do they help?
Alpha-blockers.
Terazosin, doxazosin, tamsulosin, etc.
Works on dynamic component - relaxation of smooth muscle in the prostate and bladder neck decreases resistance to urine flow
144
Another drug class used for BPH is 5-alpha reductase inhibitors. Give an example of one of these drugs. How does it work?
Finasteride, dutasteride
Works on static component, reduced levels of dihydrotestosterone result in prostate gland size reduction
Most helpful for men with large prostates. Results may take 6 months of therapy.
These drugs can be combined with alpha blockers
145
What are some other drugs that may have utility in treating BPH?
Anticholinergics - can be used in combination with alpha-blockers to help relieve irritative symptoms.
Phosphodiesterease-5 inhibitors - Only tadalafil has been approved. Used as monotherapy.
146
When is surgery potentially indicated for BPH?
If there are complications of prostate obstruction: recurrent UTIs, hematuria, bladder stones, renal insufficiency
147
T/F: STI rates are as high in older adults as they are in younger adults
False.
Older adults have much lower rates than younger adults, but it does certainly still happen!
148
What are some reasons that STI rates in older adults are increasing?
- Improved longevity
- Lack of awareness of sexuality by healthcare professionals resulting in lack of communication
- Better health and higher rates of divorce
- Omission from STI prevention programs
- ED medications
- Ease of foreign travel to countries with easy access to sex industries
149
What physiologic changes in older adults can increase susceptibility to STIs?
- Decreased estrogen, decreased vaginal secretions and vaginal dryness/thinning may facilitate transmission due to micro abrasions with sex
- Decreased immunity
-STIs can mimic menopausal symptoms (pelvic pain, deep dyspareunia, postcoital bleeding) and delay recognition and treatment
150
What is an appropriate STI screening approach for older adults?
Routine asymptomatic screening is not recommended. Screen based on risk factors such as new or multiple sexual partners.
151
Define Erectile Dysfunction
Consistent (>3-month duration) or recurrent inability to obtain or maintain an adequate erection for satisfactory sexual performance
152
T/F: Erectile dysfunction is a normal part of aging
False.
Erectile dysfunction is not considered a part of healthy aging, but rather is caused by disease or iatrogenic.
153
T/F: Prevalence of ED is 40% of men in their 40's
True - 40% of men in their 40's experience varying degrees of severity of ED. Prevalence increases by 10% for each decade of age
154
List risk factors for ED
- CVD – obesity, DM, dyslipidemia, metabolic syndrome, lack of exercise, smoking
- Age
- OSA
- Liver disease
- Vitamin D deficiency
155
1/3 of ED is from psychogenic cause, while 2/3 are from organic causes. How do you differentiate the two?
Psychogenic causes
- Usually sudden onset
- Normal nocturnal/am erections
- Situational, stress, anxiety, performance anxiety
Organic causes
- Usually gradual onset
- Partial erectile function
156
What are some examples of organic causes of ED?
Vascular (70%)
- 5-7 years after MI or stroke
- Atherosclerosis, venous incompetence, PVD
Medication (10%)
- Antihypertensives – BB, CCB, thiazide diuretics, spironolactone
- Digoxin
- Opiates, antidepressants (SSRI, TCA, lithium, MAOI)
- Ranitidine, cimetidine
- Hormones (estrogens, anti-androgens, corticosteroids, 5-alpha reductase inhibitor (ex. finasteride))
- Methotrexate, interferon alpha, anti-convulsants
- Cannabis, cocaine, cigarettes, alcohol
Psychologic disorder (10%)
- MDD, GAD, stress, relationship issues, widower syndrome
Neurologic (5%)
- Spinal cord injury, polyneuropathy (DM, chronic ETOH), MS, Parkinson’s, dementia
Hormonal (3%)
- Hypogonadism, hyperprolactinemia, thyroid, Cushing’s, Addison’s
Other (2%)
- Peyronie’s, trauma, pelvic fracture, surgery
157
Outline important points to cover when taking a history for someone with ED
- Sexual history: orientation, relationships, emotional status, onset of issue
- Erections: obtaining, maintaining, quality of nocturnal erections, erections when masturbating
- Ejaculation, orgasms, pain, desire/libido
- Relationship difficulties, performance anxiety, stress, fatigue, depression
- Cardiac risk factors: HTN, DM, lipids, obesity
- Medications, substances, nicotine
- History of pelvic surgery, radiation or trauma
- Significance of issue to patient/partner.
158
What diagnostics would you consider for someone presenting with symptoms of ED?
Definitely A1C and lipids
Consider TSH, CBC, U/A, morning testosterone, prolactin, LH and PSA if indicated
159
What are some non-invasive interventions for ED
- Lifestyle changes – alcohol, smoking, physical activity
- Psychological – sexual counselling and education
- Change precipitating medications
- Treat underlying causes – DM, CVD, HTN, endocrinopathies
160
What is the class of drugs that is used in ED treatment? Examples?
Phosphodiesterase inhibitors
Sildenafil, tadalafil, vardenafil
161
What is an absolute contraindication for phosphodiesterase inhibitors?
Concurrent nitrate use - can cause extreme hypotension and death. SL nitro should not be used within 24 hours of PDE5i
162
T/F The decision to use PSA testing for the early detection of prostate cancer should be individualized?
True
163
Men who are diagnosed with prostate cancer, do they require immediate treatment or can they undergo a program of active surveillance first?
Undergo active surveillance first can be considered in order to avoid many harms associated with radical treatment.
164
If a man who receives a PSA testing, but is not experiencing symptoms or has any other clinical suspicion of prostate cancer, does MSP cover?
No, $35 fee
But If a patient-pay PSA level is abnormal, repeat PSA testing is an insured benefit.
165
For men without a diagnosis of prostate CA and PSA test results within the appropriate age-based reference range, is further testing in less than 2 years indicated?
No
166
If the pt is experiencing LUTS and his prostate feels on a DRE: enlarged, smooth or symmetric, what could that mean?
BPH
167
Your male pt is symptomatic with fever/chills, pelvic pain, and is experiencing LUTS. You decide to perform a DRE but he is extremely tender on palpation. What is your diagnosis?
Prostatitis
-if prostate is able to be palpated it would feel boggy and spongy
168
If you suspect prostate CA, how would the prostate feel?
Asymmetric, firm, hard areas, or discrete nodules
169
If the PSA test results are within the appropriate age-based reference range, but the prostate feels hard or irregular, what do you do?
Referral to urology
170
What medication reduces the growth of the prostate size?
5-alpha reductase inhibitor (5-ARI)
171
For men taking 5-alpha reductase inhibitors (i.e., finasteride & dutasteride), PSA will drop by approximately 50%. For accurate interpretation relative to lab-reported aged-based ranges, how much do you adjust the reported result by?
By a factor of 2
172
When should a PSA testing be avoided?
if the patient has signs or symptoms of acute prostatitis (e.g., dysuria, hematuria, pelvic/groin pain, fever/chills).
173
In attempt to lower PSA, can antibiotics help?
No, and this type of practice is detrimental
174
Risk factors of prostate cancer?
*Men of African descent;
*Family history of prostate cancer (paternal side; first-degree relatives (i.e., father, siblings, children);
*High-risk hereditary gene mutations associated with prostate cancer (e.g., BRCA2 genetic mutation in a first-degree relative
175
Men who are asymptomatic with risk factors for prostate cancer, how should you treat?
men at higher risk may consider PSA testing as early as 40 to 45 years of age and may consider re-testing every 2 years.
176
Does prostate cancer have a slow progression or a rapid onset?
Develops slowly. Many men with prostate cancer will not have clinical progression (i.e., symptoms or the need for additional therapies) of their cancer during their lifetime
177
Epidemiology of Prostate CA.
At 10 years follow-up, 64% of men on active surveillance continue to avoid treatment.
Autopsy studies suggest that prostate cancer is commonly found in men who have died of other causes (20% of men aged 50–59 and 33% in men 70–79%).
Prostate cancer accounts for 11% of all cancers diagnosed in men in BC. An expected 1 in 9 men will be diagnosed with prostate cancer in their lifetime. Of these men, 89% will be over the age of 60 when they are diagnosed and most men will survive their prostate cancer. It is estimated that 1 in 29 men who are diagnosed with prostate cancer would be expected to die of the disease.
178
Do patients with early stage prostate cancer experience clinical symptoms?
They do not. However, as the male ages, LUTS including voiding symptoms (e.g., poor stream, hesitancy, urgency, frequency, intermittent flow, and/or straining to pass urine), is more common and warrant investigation to rule out possible prostate cancer
179
T/F: DRE and PSA testing should not be performed for all patients initially presenting with LUTS, in the absence of more likely alternate diagnoses (e.g., acute prostatitis, urinary tract infection).
False - as per BC Guidelines, DRE and PSA SHOULD BE performed for all patients presenting with LUTS.
180
Your patient is 58, with a PSA level of 3.9µg/L and the DRE is normal, what is your next step?
0–49 years 0–2.5 µg/L
50–59 years 0–3.5 µg/L
60–69 years 0–4.5 µg/L
≥70 years 0–6.5 µg/L
consider other causes of elevated PSA
repeat PSA test
181
What other causes could elevate PSA?
BPH
Prostatitis (infection or inflammation)
Acute urinary retention
Bladder catheterization or instrumentation
182
What is the appropriate time frame to repeat PSA testing?
4-12weeks
183
Are PSA levels significantly altered after after cycling, intercourse, or digital rectal exam?
No
184
What is the acceptable age range for men, who can have a PSA testing?
Asymptomatic men aged 55-69 years, who have greater than 10 years life expectancy, may decide to pursue PSA testing.
185
If asymptomatic and have no risk factors, what age bracket is not indicated for PSA testing?
BC Guidelines states PSA testing is not indicated in asymptomatic patients <55 or >69 years of age who are without risk factors.
186
FYI: Controversy with PSA testing in BC, Canada, and US.
*BC Guidelines answer noted in previous MCQ
B.C. Ministry of Health does not support PSA testing of asymptomatic men for prostate cancer screening because the current level of evidence does not meet the B.C. Ministry of Health required standard for clinical effectiveness (2020).
The Canadian Task Force for Preventative Health recommends not screening men for prostate cancer with the PSA test (2014). https://canadiantaskforce.ca
The United States Preventative Services Task Force (USPSTF) recommends that for asymptomatic men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)–based screening for prostate cancer should be an individual one (2018). https://www.uspreventiveservicestaskforce.org/
The Genitourinary Cancer Tumour Group of BC Cancer recommends that asymptomatic men 50 years of age or older, with an estimated life expectancy of more than 10 years, and are well informed about the risks of over-diagnosis and over-treatment, consider PSA testing for the early diagnosis of prostate cancer (2012).
187
What is your next step if PSA is above age-based reference ranges?
consider DRE to guide a differential diagnosis.
188
DRE is also controversial, especially in a man who is asymptomatic, but why?
Has a poor sensitivity and specificity, high inter-observer variability, and may contribute to unnecessary biopsies
189
Can DRE lead to the identification of prostate cancer in asymptomatic men independent of PSA level?
Yes
190
Are an abnormal DRE and/or elevated PSA diagnostic of prostate cancer?
No
191
What is the gold standard of Prostate CA diagnosis?
Needle tissue biopsy
192
How is prostate CA graded?
Gleason Score - based on tissue samples from the prostate, looks at the differentiation of cancer cells and the pattern (arrangement) of the cancer cells in the prostate.
Strong predictor of disease progression and treatment outcomes
193
What does it mean if the Gleason score is higher?
Higher Gleason scores are associated with an increased risk of tumor recurrence, metastasis, and prostate cancer-specific mortality.
194
FYI-Description of grading system (Canadian Cancer Society):
There are 5 patterns of prostate cancer cells based on their differentiation. The lower the pattern number, the more cancer cells look, act and are arranged like normal cells. The pathologist will give a grade for each pattern of prostate cancer cells found in the biopsy. The grade of the cancer corresponds to the pattern number. Gleason patterns 1 and 2 look a lot like normal cells. Gleason pattern 5 looks very abnormal compared to normal cells. Gleason patterns 3 and 4 are somewhere in between. Most prostate cancers have a Gleason pattern of 3, 4 or 5.
195
FYI-Description of how grading system is calculated (Canadian Cancer Society):
If the pathologist sees only 2 patterns of cancer cells, they will add the grades for each pattern together to get the total Gleason score. For example, if the pathologist gives the cancer cells in the most common pattern a grade of 3 and the cancer cells in the second most common pattern a grade of 4, the total Gleason score is 7. This is often written on the pathology report as 3 + 4 = 7 out of 10.
If there is a third pattern in the biopsy samples, the grade of the most common pattern of cancer cells is added to the pattern with the highest grade. This may be the second most common pattern or the least most common pattern. For example, if the pathologist gives the cancer cells in the most common pattern a grade of 3, the cancer cells in the second most common pattern a grade of 4, and another pattern of cancer cells a grade of 5, the total Gleason score is 8.
To make the Gleason score easier to understand, doctors developed the Grade Group system. This gives a single score from 1 to 5 based on increasing Gleason scores. For example, Grade Group 1 corresponds to a Gleason score of 6 and Grade Group 5 corresponds to a Gleason score of 9 or 10.
Click the link below - an easy chart to read but I am sure we just need to know the Gleason score is the grading of prostate CA.
https://cancer.ca/en/cancer-information/cancer-types/prostate/grading
196
Who is eligible to receive Active surveillance?
Patients with low risk prostate cancer (PSA<=10, T stage <=2, Gleason score <=3+3=6/10) are eligible. Additionally, men with low risk cancers whose PSA is up to 15 will also be considered, as long as the PSA density is <0.2 ng/ml/cc.
Low risk Prostate CA:
- the cancer is small
- the cancer is only in the prostate
- the cancer isn't causing any symptoms
- the cancer is expected to grow slowly (it is Grade Group 1 or 2)
- the cancer is very low or low risk
- the prostate-specific antigen (PSA) level is less than 10 ng/mL
- you prefer not to have treatment right away so you can avoid treatment-related side effects and keep the quality of life that you're used to
197
What happens during Active surveillance?
You will have tests every 3 to 6 months to monitor the cancer. Tests may include:
-the PSA test
-a physical exam, including a digital rectal exam (DRE)
-a prostate biopsy
-a bone scan, chest x‑ray or CT scan depending on the signs and symptoms that develop
-an MRI of the prostate in some cases
198
Treatments are required when:
-the PSA level keeps going up over time
-samples from follow-up biopsies are given a higher Gleason score
-symptoms develop and tests show the cancer is starting to grow
199
What are the types of prostate CA?
Adenocarcinomas, starts in the gland cells.
200
T/F CKD cannot be diagnosed with one isolated abnormal measurement of eGFR or urine ACR
**NOTE: CKD was NOT included on the final exam outline but I just stuck what was in our ILO on here in case...
True!
201
eGFR <____ that persists ____+ months are diagnostic of CKD
eGFR <60 that persists 3+ months are diagnostic of CKD
A single isolated measurement < 60 mL/min does not satisfy diagnostic criteria for CKD, but could reflect reduced kidney function and requires confirmatory testing
202
You get an unexpected reduced eGFR result. What do you do?
If new unexpected finding of reduced eGFR, repeat the test to establish stability/ rapid deterioration
203
When should we consider a renal U/S?
Renal imaging should be undertaken to assess structural abnormalities and aid in diagnosis of CKD
Perform if obstructive urinary symptoms, unexplained microscopic or macroscopic hematuria, unclear etiology of CKD (esp. in young patients), suspicion of BPH, or family history of structural renal disease (i.e., cystic kidney disease)
204
What is the preferred method for checking for protein in urine?
ACR
*uACR quantifies albuminuria in a range which is not detected by dipstick urinalysis
205
Outline stage I CKD
Stage 1 = NO DISEASE!
Normal kidney function
eGFR >90
206
Outline stage II CKD
Mild-moderate decrease
GFR 60-89
Subtle S&S: HTN, Increasing creatinine and ureal levels
207
Outline stage IIIa CKD
Mild to moderate decrease
GFR 45-59
HTN
Mild Increasing creatinine and urea levels
208
Outline stage IIIb CKD
Moderate to severe decrease
GFR 30-44
HTN
Increasing creatinine and ureal levels
209
Outline stage IV CKD
Severely decreased/ severe kidney damage
GFR 15-29
Moderate S&S present:
HTN
Increasing creatinine and ureal levels
EPO deficiency anemia
Hyperphosphatemia
Increased triglycerides
Metabolic acidosis
Hyperkalemia
Salt or water retention
210
Stage V CKD
Kidney failure/ end stage kidney disease
GFR <15
Same S&S as stage IV but more severe
211
How does CKD affect bone health?
-Osteofibrosa: Bone inflammation with fibrous degeneration related to hyperparathyroidism
-Osteomalacia: bone resorption associated with vitamin D and calcium deficiency
Leading to....
-spontaneous fractures
-bone pain
-deformities of long bone
212
Effects of kidney failure on pulmonary system
-fluid overload associated with pulmonary edema
-metabolic acidosis leading to kussmaul resps
213
Why does CKD cause HTN?
-Extracellular volume expansion with hypersecretion of renin associated with HTN
- and kidneys not excreting fluids appropriately i assume!
214
Beyond increased HTN, how does CKD affect the cardiovascular system?
-Anemia increases cardiac workload
-Dyslipidemia promotes atherosclerosis
-Toxins precipitate into pericardium
Leading to...
-LVH, cardiomyopathy and ischemic heart disease
-dysrhythmias
-accelerated atherosclerosis
-pericarditis with fever
-chest pain
-pericardial friction rub
- edema
215
Neurologic effects of CKD
-Progressive accumulation of uremic toxins associated with end stage renal disease
-Stroke or intracerebral hemorrage assoc with chronic dialysis
Leading to....
encephalopathy
Fatigue
Reduced attention span
Difficulty with problem solving
-peripheral neuropathy
Pain, burning in legs/ feet
Loss of vibration sense and DTRs
-loss of motor coordination
-twitching, fasciculations
-stupor and coma with advanced uremia
216
Hematological effects of CKD
-Reduced EPO secretion and RBC production
-Uremic toxins shorted RBC survival and alter platelet function
Leading to
- anemia
- platelet disorders: easy bruising
217
What kind of anemia would you expect to see from CKD
normocytic/normochromic
218
GI effects of kidney failure
-Retention of metabolic acids and other metabolic waste products
-nausea, vomiting
-mouth ulcers
-stomatitis
-urine odor of breath (uremic fetor)
-hiccups
-peptic ulcers
-GI bleeding
-pancreatitis (end stage)
*Can use protein restricted diet to limit nausea/vomiting
219
Affects of CKD on integument?
-Retention of urochromes, contributing to sallow yellow color
-High plasma calcium levels and neuropathy associated with pruritus
Leading to:
- abnormal pigmentation
- pruritus
- uremic frost
220
T/F those with CKD are immunosuppressed
Yes. (not sure if we are just talking end stage here?)
Supression of cell mediated immunity, reduction in number and function of lymphocytes, diminished phagocytosis
-increased risk for infection that can cause death
-increased risk for carcinoma
221
Reproductive effects of CKD
-Dysfunction of ovaries and testes
-Presence of neuropathies
-sexual dysfunction
-menorrhagia
-infertility
-decreased libido
-decreased testosterone levels
222
Name some nephrotoxic drugs
NSAIDs
Diagnostic agents (radiographic contrast materials)
Aminoglycosides
Amphotericin B
Cyclosporine
Tacrolimus
223
Name some common medications which require dosing adjustments in CKD
NSAIDS
ACE/ARBS (protective in proteinuria CKD, DM, HF, but can decrease renal perfusion and cause hyperkalemia)
K+ sparing diuretics & other diuretics (furosemide, thiazide)
Metformin
SGLT2
OPioids
pregabalin/gabapentin
Digoxin
Acyclovir
Statins (risk of rhabdo)
Phenytoin
Hypoglycemics
Trimethoprim
Colchicine
PPI
224
Your patient needs contrast dye for a CT scan. Which meds should you hold?
ACEI, ARB, SGLT2, diuretics
I imagine maybe others as well but this is what is named within the BC guidelines for CKD)
225
What uACR result is considered abnormal?
uACR elevation (>3.0 mg/mmol) on serial testing is abnormal
226
Your patient doesn't have diabetes and has an ACR of 15. What do you do?
In patients without diabetes, no specific treatment is recommended for isolated uACR values between 3 and 30 mg/mmol. These individuals remain at risk of CKD progression and cardiovascular disease, therefore surveillance is warranted
227
In BC, what is the most common cancer for women?
Breast Cancer
- Breast cancer accounts for 28% of all cancer diagnoses for BC women and is the most common cancer in BC women.
- In 2021, an estimated 4060 BC women will be newly diagnosed with breast cancer.
- One in 8 women is expected to develop breast cancer during their lifetime, and one in 35 is expected to die of breast cancer.
- An estimated 96% of BC women who will be diagnosed with breast cancer will be over the age of 40 when they are diagnosed.
228
What can typically grow on breast cancer cells categorizing the type of breast cancer?
Estrogen receptors (ER)
Progesterone receptor (PR)
These receptors are overexpressed in the malignant breast tissue. Hormones will attach to these receptors.
229
What does prognostic factor mean?
provides information on clinical outcome at the time of diagnosis, independent of therapy. Such markers are usually indicators of growth, invasion, and metastatic potential.
230
What does predictive factor mean?
provides information on the likelihood of response to a given therapeutic modality.
231
In terms of evaluating breast cancer, the prognostic factor identified both receptors (ER & PR) on the tissue. This is stating that the tissue is positive for hormone receptor-positive tumors. What is the predictive factor?
likelihood of prognosis is positive. Both receptors together usually mean "less aggressive cancer" and may be responsive to Hormone Therapy.
ER and PR expression in breast cancer cells are generally linked to better outcomes for patients, particularly in the short term.
232
What does it mean if this is identified: ER positive and PR negative. In other words, there is an estrogen receptor available but no progesterone receptor present.
- **Endocrine therapy effectiveness**: Since ER-positive tumors are more sensitive to estrogen, they are more likely to respond well to endocrine therapy, which blocks estrogen's effects on cancer cell growth. Therefore, if ER expression is significantly higher compared to PR, the tumor may respond better to endocrine therapy.
Prognosis: ER-positive breast cancers tend to have better prognosis than ER-negative tumors. They often respond well to hormone therapy (e.g., tamoxifen, aromatase inhibitors), which blocks estrogen's effects on cancer cells.
233
What does ER-negative tumor mean?
*ER-negative tumors do not respond to hormone based therapies
-treatment options often focus on other strategies such as chemotherapy, targeted therapies (e.g., HER2-targeted therapy for HER2-positive tumors), and immunotherapy.
*ER-negative breast cancers tend to have a poorer prognosis compared to ER-positive tumors
234
What is adjuvant endocrine therapy?
additional treatment given after the primary treatment (such as surgery or chemotherapy) to lower the risk of cancer recurrence.
235
What does it mean if the PR is present or absent from the cancer cell?
PR-positive tumors have a less aggressive behavior and also have better outcomes when treated with endocrine therapy.
PR-negative breast cancers doesn't respond to hormone therapy, the tumors are often more aggressive and may have a higher likelihood of recurrence.
PR-negative may have a poorer prognosis.
236
Is this subtype of breast cancer aggressive or not: ER-positive, PR-negative?
Patients with ER-positive, PR-negative disease have a more aggressive subtype of hormone receptor-positive breast cancer.
237
What is a mammogram?
Xray of the breasts - takes 4 images
238
What is the neat part about a mammogram?
Mammograms can usually find lumps two or three years
before you or your health care provider can feel them.
Research has shown a 25 per cent reduction in deaths
from breast cancer among those who regularly screen.
However, Some cancers cannot be detected on a mammogram due to the location of the cancer or the density of your breast tissue. About 25 percent of cancers among those ages 40-49 are not detectable by a screening mammogram, compared to about 10 per cent of those older than 50
239
T/F: Breast cancer increases with age?
True
240
At what age can you start getting screened for Breast CA?
40yrs and older
241
If there is no family history, what is the recommended timeline for getting screened?
every 2 years
242
If you are aged 40 to 74 with a first-degree relative (mother, sister, daughter) with breast cancer, how often should you be screened?
It is recommended that you get a mammogram every year.
243
What is the high risk criteria for breast cancer?
Screening mammograms are recommended every year if you are between 30-74 and at least one of the following applies to you:
*You have a very strong family history of breast cancer
*You are a known BRCA1 or BRCA2 carrier or other pathogenic gene variant carrier2
*You are an untested family member of a BRCA1 or BRCA 2 carrier or other pathogenic gene variant carrier2
