z-Urology Flashcards
(349 cards)
1
Q
promotes the conversion of embryonic glands to testes in utero
A
testis-determining factor
2
Q
cells secrete testosterone beginning at the 8th week, masculinizes embryonic structures, and then hibernate until puberty
A
Leydig
3
Q
Testes develop in abdominal cavity and descend through what to get to pouch of peritoneum (tunica vaginalis)?
A
inguinal canal
4
Q
Causes wrinkles on scrotum
A
dartos muscle
5
Q
Responsible for elevating the scrotum
A
cremaster muscle
6
Q
site of sperm production. lead into efferent ducts
A
seminiferous tubules
7
Q
What do efferent ducts emerge to form and is also the final site of sperm maturation?
A
epididymis
8
Q
serves as a storage reservoir for sperm
A
ampulla of the vas deferens
9
Q
Secretion of what hormone inhibits anterior pituitary release of FSH
A
inhibin
10
Q
What hormone inhibits LH and GnRH production?
A
testosterone
11
Q
Contain receptor proteins for FSH in Sertoli cells
A
seminiferous tubules
12
Q
LH stimulates secretion of testosterone. Contain receptor proteins for LH
A
leydig cells
13
Q
When are the leydig cells fully mature?
A
10yrs
14
Q
Embryonically the determining factor in the development of male or female genital organs and characteristics
A
testosterone
15
Q
If the Leydig cells aren’t mature till after the age of 10, how does this differentiation occur?
A
HCG from mother stimulates testosterone secretion in the fetal testes
16
Q
If a male child is born with undescended testicles, what can be used to cause testes to descend in usual manner?
A
testosterone or LH
17
Q
Both ovarian and testicular tissue is present in the body
A
intersex
18
Q
Most common cause of female pseudohemaphroditism
A
congenital adrenal hyperplasia
19
Q
mature for two months until they become spermatozoa
A
spermatids
20
Q
Actually envelope spermatids for processing before release into lumen (protect and nurse sperm)
A
Sertoli cells
21
Q
divide in two stages, one of which is by the process of meiosis to form four spermatids, each containing 23 unpaired chromosomes
A
spermatocytes
22
Q
Four main functions of sertoli cells
A
form blood-testes barrier, secrete inhibin and androgen-binding protein, phagocytize residual bodies
23
Q
Where do sperm become fully motile and go through final maturation?
A
epididymis
24
Q
Regulates conversion of spermatogonia into spermatocytes
A
FSH
25
secrete mucoid material containing fructose, citric acid, prostaglandins, and fibrinogen
seminal vesicle
26
fluid from vas deferens, seminal vesicles, prostate gland, as well as the bulbourethral glands and glands throughout the urethra
semen
27
Average sperm count for ejaculate
400 million
28
Each ductus deferens is cut and tied. Interferes with sperm transport
vasectomy
29
Where are the most important sensory nerve signals located of male reproductive system?
glans penis
30
caused by parasympathetic impulses from sacral portion of spinal cord to penis. dilates arteries of the penis leading to high pressure flow into erectile tissue
erection
31
Emission and ejaculation are dependent on what nervous system?
sympathetic
32
relax the muscles around the urethra in men with symptoms from an enlarged prostate. Urine then flows more freely
alpha blockers
33
These medications reduce the level of a certain form of testosterone (DHT). The prostate shrinks when less DHT is present, improving urine flow
5-alpha-reductase inhibitors
34
Smooth muscle in the urinary bladder innervated by parasympathetic fibers responsible for involuntary contraction
detrusor muscle
35
skeletal muscle WHICH IS under voluntary control. This can be used to consciously prevent urination even when involuntary controls are attempting to empty the bladder
external sphincter
36
smooth muscle INVOLUNTARILY CONTROLLED with natural tone, and therefore prevents emptying of the bladder until the pressure in the main part of the bladder rises above a critical threshold
internal sphincter
37
Drug class that is used to treat overactive bladder due to muscles contracting at the wrong time
anticholinergics
38
Symptoms of deficiency of this hormone include decreased libido, energy, muscle mass, body hair
testosterone
39
Single most important diagnostic test for male hypogonadism
testosterone
40
Normal range for testosterone
300-800 ng/dL
41
When should testosterone levels be tested?
8AM
42
Testosterone low and LH and FSH high
primary hypogonadism
43
Testosterone low and LH and FSH low
secondary hypogonadism
44
Indirect measurement of prostate glandular size in men without cancer
PSA
45
Medications that reduce PSA
5-alpha reductase inhibitors, NSAIDs, Statins, thiazides
46
what is important to follow when using PSA values to assess for prostate cancer?
the trend-how much has the PSA increased over the last year
47
A higher value indicates greater likelihood of cancer.It is not considered to be as specific as PSA Velocity or Free/Total PSA (not useful)
PSA density
48
What happens to the percentage of free PSA and total PSA in men with prostate cancer?
free PSA decreases and total PSA increases
49
When should you talk to patients about prostate cancer if they're at an average risk?
age 50 if they're expected to live another 10 yrs
50
When should you talk to patients about prostate cancer if they have more than one 1st degree releative who had prostate cancer?
age 40
51
Remains the mainstay in investigating male fertility potential
semen analysis
52
What are patient instructions for semen analysis?
abstain from coitus 2-3 days and analyze within 1 hr
53
How is the diagnosis of chronic prostatitis made?
analyzing specimens obtained following prostatic massage (four-glass test)
54
What should not be used to diagnosis a UTI?
urinary bags or bed pans
55
How is a reliable sample obtained to diagnosis UTI in infants?
catheterization or suprapubic aspiration
56
What is the traditional gold standard for a positive urine culture of bacteriuria?
>100,000 cfu/mL of urine
57
Diagnostic test for bladder cancer
cystoscopy
58
Studies used to assess how well the bladder and urethra are functioning: Sphincter control and Bladder filling/emptying
urodynamic assessment
59
Screening tool for patients with suspected bladder outlet obstruction. Reserved for patients with severe symptoms where invasive therapy is considered—done by urologist
uroflowmetry
60
Graphic display of vesical pressure. Used to asses detrusor activity, sensation, capacity and compliance
cystometrogram
61
Used to asses total stone burden, composition, and location of stones.
KUB
62
Why might a KUB miss 15% of stones?
Pure uric acid, indinavir-induced, and cystine calculi are relatively radiolucent on plain radiography
63
Type of swab preferred to check for chlamydia in men
urine or urethral swab
64
test for males with suspected urethritis due to gonorrhea
Microscopy with Gram stain of a urethral swab
65
most common benign tumor in men
BPH
66
What happens pathophysiologically as the prostate gland enlarges?
Increased resistance to urine flow leads to bladder muscle hypertrophy. Predisposes to infection
67
What are the irritative symptoms of BPH?
frequency, nocturia, urgency
68
Obstructive symptoms include: hesitancy, weak stream, incomplete emptying, straining, dribble
BPH
69
What labs should you order for BPH?
UA, Cr, PSA
70
When is imaging such as IVU, IVP, CT or renal ultrasound ordered to evaluate BPH?
recommended only in the presence of concomitant urinary tract disease, or complications from benign prostatic hyperplasia
71
Medication primarily used for symptomatic relief of BPH
alpha blockers
72
Medication class used to reduce prostate size
5-alpha-reductase inhibitors
73
Most common alternative supplement for BPH
saw palmetto
74
What are the treatment recommendations for a man who has AUA score <7?
watchful waiting (limit fluids after dinner, avoid decongestants, void frequently)
75
Indications include refractory acute retention, hydronephrosis, repeated UTIs, recurrent or refractory gross hematuria, or elevated Cr level that responds to catheter drainage
prostatectomy
76
Most common surgical procedure for BPH
transurethral prostatectomy
77
Common complication of transurethral prostatectomy
Retrograde ejaculation resulting in infertility
78
Better surgical option for younger men with smaller prostates; reduces risk for retrograde ejaculation and subsequent infertility
Transurethral Incision of the Prostate (TUIP)
79
Most common cancer detected in american men and second leading cause of cancer related death. 'Merica!
prostate
80
Clinical findings suggestive of prostate cancer
induration at time of DRE and elevated PSA
81
Most common site of prostate cancer metastases
axial skeleton
82
standard method for detection of prostate cancer. Taken from the apex, midportion and base of prostate
transrectal-guided biopsy
83
Most frequently used to stage prostate cancer
transrectal ultrasound
84
When should you order a bone scan for prostate cancer?
those with advanced local lesions, symptoms of mets, high grade prostate cancer and PSA’s >20
85
Stage of cancer where tumor is microscopic and confined to prostate but is undetectable by a digital rectal exam (DRE) or by ultrasound
stage T1
86
Stage of cancer where Tumor is confined to prostate and can be detected by DRE or ultrasound
stage T2
87
Stage of cancer when it has spread to tissue adjacent to the prostate or to the seminal vesicles
stage T3 or T4
88
Stage of cancer when it has spread to pelvic lymph nodes, lymph nodes, organs, or bones distant from the prostate
N+ or M+
89
What stage tumors are candidates for curative therapy with either radiation therapy or radical prostatectomy. Usually external beam radiation therapy
T1 or T2
90
Benefits of external beam radiation therapy
lower risk of erectile dysfunction and incontinence
91
involves placing radioactive, rice-sized pellets directly into the prostate gland; the radiation is emitted from within the gland for a specified period of time and then dissipates
brachytherapy
92
Abx treatment for acute bacterial prostatitis caused by STD
A shot of ceftriaxone followed by a 7-day course of doxycycline
93
Common symptoms of acute prostatitis that are often not present with chronic prostatitis
perineal pain and exquisite tenderness of the prostate
94
In men older than 35, what bacteria typically cause prostatitis?
e. coli
95
Why are men over age 50 who have an enlarged prostate at increased risk for acute bacterial prostatitis?
due to their risk of urinary tract infection
96
What should you avoid during physical exam if you suspect acute bacterial prostatitis due to risk of sepsis?
prostate massage or DRE
97
Most common pathogens of chronic bacterial prostatitis
gram-negative rods
98
Exam findings associated with chronic prostatitis
asymmetrical enlarged prostate that is boggy and tender
99
Most common form of prostatitis. Presentation is identical to that of Chronic, without any UTI present. Recurrent symptomatic exacerbations, termed male chronic pelvic pain syndrome
nonbacterial prostatitis
100
Treatment for chronic prostatitis
Bactrim for 2-3 months or cipro for 4 weeks
101
Can help with symptoms of bacterial and nonbacterial prostatitis in addition to anti-inflammatories and sitz baths
alpha blockers
102
What is back pain unrelieved or worsened by lying down often associated with?
a tumor
103
Physical exam findings consistent with urinary tract infections
flank pain/CVA tenderness or abdominal tenderness in suprapubic area
104
Highly specific UA result for a UTI
presence of nitrites
105
Why should you consider imaging when working up patient with polycystic kidneys?
prone to abscess formation
106
What urinary tract complication are patients with tuberculosis prone to developing?
ureteral strictures
107
Inpatient abx classes for UTI
3rd gen cephalosporin or fluoroquinolones
108
Risk factors for urethritis
high risk sexual behavior and multiple partners
109
What testing should be done if patient has genital ulcers?
cultures for HSV and syphilis
110
How do you diagnose genital herpes besides physical exam?
viral culture by swab for one minute
111
Antiviral prescriptions for intitial outbreaks
Acyclovir (Zovirax) 400mg tid, Famciclovir (Famvir) 250mg po tid, or Valacyclovir (Valtrex) 1gm po bid all for 7-10 days
112
How do prescriptions for antivirals change for recurrent outbreaks?
only need to take for 5 days and doses decreased by half
113
How many herpes outbreaks are needed for consideration of suppression therapy?
6 in one yr
114
Topical treatments for HPV
Imiquimod (Aldara) or Conylox
115
Type of syphilis where pt develops one or more sores resembling large bug bites usually 10-90 days post exposure
primary
116
Presentation of secondary syphilis 1-3 months post-exposure
Rosy copper penny rash on hands and feet
117
Treatment for early primary, secondary, or latent <1yr syphilis
Benzathine Penicillin G 2.4 million U, IM single dose
118
Treatment for syphilis if PCN allergy
doxy or tetracycline for 14 days
119
Tropical disease that rarely occurs in US. Presentation is painless genital nodule
Granuloma Inguinale (Donovanosis)
120
Chlamydial dz that invades lymphatics. Presents with unilateral inguinal lymphadenopathy or painless red erosion on the genitals or rectum
Lymphogranuloma Venereum
121
Treatment for Lymphogranuloma Venereum
Doxycycline 100 mg bid for 21 days
122
Caused by gram-negative, anaerobic bacillus Haemophilus ducreyi. Begins as a small inflammatory papule that erodes to form an extremely painful deep ulceration plus inguinal adenopathy
chancroid
123
Recommended abx for chancroid
Azithromycin 1 g PO or Ceftriaxone 250 mg intramuscularly (IM)
124
Recommended abx for uncomplicated gonococcal infections
Ceftriaxone 250mg IM single dose or Cefixime 400 mg single oral dose
125
What is the treatment regimen if you suspect chlamydia or are unable to rule it out?
Azithromycin 1 g po single dose or doxy 100 mg bid 7 days
126
What is the recommended age group to screen for prostate cancer if you and your patient decide to screen?
50-70 yrs
127
Genetic risk factors prostate cancer
1st degree relative or African American
128
Predisposing factors for testiucular cancer
cryptorchidism or Klinefelter's
129
Environmental exposure that increases risk of testicular cancer
intrapartum estrogens or insecticides
130
Prognosis for testicular cancer and reason why self-testicular exams are important
excellent if discovered early
131
Predisposing conditions for colorectal cancer
ulcerative colitis and familial adenomatous polyposis
132
Important to include in STD education for herpes and syphilis
condom will NOT prevent many lesional STDs because the lesion will not be covered by the condom
133
Two big cancers caused by smoking
lung and bladder
134
Who should receive the pneumovax?
anyone over 65
135
How often should a patient have a Td booster?
every 10 yrs
136
Who should receive Zostavax?
anyone over 60
137
Most common abnormal location of the urethral orifice
hypospadias (ventral)
138
Abnormal location of the urethral orifice that can occur in males or females. Often extends to the bladder.
epispadias (dorsal)
139
Occurs when the glans penis becomes inflamed. Sx include pain/redness of glans and thick, purulent foul smelling exudate
balanitis
140
Important to rule out in suspected balanitis because it's an urological emergency
paraphimosis
141
Foreskin is tightened and cannot be retracted behind the glans. Uncircumcised patients. Urological referral
Phimosis
142
The foreskin has been left retracted behind the glans, resulting in painful engorgement and edema of glans (possible complication of balanitis!)
paraphimosis
143
Complications of paraphimosis
glandular ischemia w/arterial occulsion and necrosis of glans
144
Treatment for paraphimosis
ice, anesthesia/sedation, draw skin over glans. circumcision definitively
145
Fibrous plaque resulting in painful curvature of erect penis/sexual dysfunction. No pain when nonerect. May follow trauma
peyronie's disease
146
Initial treatment for peyronie's disease
watchful waiting
147
condition of prolonged painful erection…“greater than 4 hours”—NOT associated w/sexual excitement or desire. if ischemic is a urological emergency
priapism
148
Condition with genetic predisposition. Present as UTI or fever in infants. Diagnosed with US or VCUG. May need surgery to re-implant ureters
ureteral reflux
149
Urethral irritation due to chemicals, infection, or manipulation. pathogen is frequently e.coli. classic symptoms are dysuria and frequency
urethritis
150
What is the work-up for urethritis?
UA, urethral smear if discharge otherwise NAAT, STI testing
151
Common cause of balanitis
yeast- do KOH
152
Population related risks for prostate enlargement
BPH more common in American/Australian and less common in Asian cultures
153
Tests and exams for diagnosis of BPH
AUA symptom index, DRE, neuro exam, UA, PSA
154
Relax smooth muscle of the prostate and bladder neck without interfering with bladder contractility.Decrease bladder resistance to urinary outflowWork quickly and increase urinary flow
α-blockers , Alpha-1 adrenergic antagonists
155
Major side effect of α-blockers , Alpha-1 adrenergic antagonists
orthostatic hypotension
156
Name the α-blockers , Alpha-1 adrenergic antagonists
tamsulosin (flomax), doxazosin (cardura), Terazosin (Hytrin)
157
α-blockers , Alpha-1 adrenergic antagonist that causes less orthostatic HTN/fluid retention but may cause floppy iris syndrome
tamsulosin (flomax)
158
α-blockers , Alpha-1 adrenergic antagonist that may have secondary benefit to patients with cardiac dz
doxazosin (cardura)
159
α-blockers , Alpha-1 adrenergic antagonist often used for HTN and should be taken at bedtime to avoid hypotension
terazosin (hytrin)
160
Blocks 5-alpha reductase, the enzyme that activates testosterone in the prostate.Impairs prostate growth by inhibiting the conversion of testosterone to dihydrotestosterone
5-α-Reductase inhibitors
161
What zone of the prostate doe 5-α-Reductase inhibitorscause changes in the epithelial cells?
transition zone
162
Name the 5-α-Reductase inhibitors
Finasteride (Proscar) and Dutasteride (Avodart)
163
Antagonizes acetylcholine receptors. Used to help urgency symptoms by stabilizing the detrusor muscle
antimuscarinics
164
Herb derived from dark berries of a palm tree. Inhibits testosterone conversion to DHT. Stops DHT at receptor sites
saw palmetto
165
Vitamin that may prevent or decrease prostate enlargement
zinc
166
Name the PDE-5 inhibitors
Sildenafil (Viagra), Vardenafil (Levitra), Tadalafil (Cialis)
167
Work by blocking the action of type 5 phosphodiesterase maintaining vasodilation and increased blood flow to the penis
PDE-5 inhibitors
168
What should be avoided in patient who is taking a PDE-5 inhibitors due to sharp decrease in BP?
nitrates
169
Use for patients with ED who have contraindications to 5 PDE inhibitors. Available as intracavernosal injection or intraurethral suppository
Alprostadil (PGE1)
170
Should be avoided in patients with leukemia, myeloma, or sickle cell anemia or sickle cell trait
alprostadil
171
Treatment for premature ejaculation
SSRIs (fluoxetine or paroxetine) or TCA (clomipramine)
172
Undescended testes or absent testes (agenesis). Occurs when one or both of the testicles fail to move down into the scrotal sac
Cryptorchidism
173
What is the incidence of cryptorchidism directly related to?
birth weight and gestational age
174
When does spontaneous descent of an undescended testicle usually occur?
during 1st three months, rarely after 6 months
175
Long-term consequences of cryptorchidism
infertility, malignancy, inguinal hernias, testicular torsion
176
How do you differentiate between undescended and retractable testes?
retractable are palpable at birth, palpation in warm room can bring them down, and assume scrotal position at puberty
177
Excess fluid collects between the layers of the tunica vaginalis usually peritoneal fluid due to a weakness in the patent processus vaginalis
hydrocele
178
What are primary congenital hydroceles associated with?
indirect inguinal hernia
179
How long do you wait before doing surgical treatment of a hydrocele?
2 yrs
180
How should you evaluate a suspected hyrocele?
transillumination first. ultrasound if transillumination fails
181
What should a hydrocele in a young man be considered until proven otherwise?
cancer
182
Symptoms associated with a hydrocele
heaviness in the scrotum and pain in the lower back
183
Accumulation of blood in the tunica vaginalis. Can compromise testicle. Causes scrotal skin to become dark red or purple
hematocele
184
Painless, sperm-containing cyst that forms at the end of the epididymis. Located above and posterior to the testes. Attached to the epididymis
spermatocele
185
What is the treatment for a spermatocele if it has become painful?
excision
186
Cause of varicocele that results from damage to the elastic fibers and hypertrophy of vein walls
varicosities of the pampiniform plexus
187
Age group usually affected by varicoceles
15-35 yrs
188
Why are varicoceles more common in the left testicle besides presence of more incompetent valves?
left internal spermatic vein inserts renal vein at right angle and force of gravity from upright position causes venous dilatation.
189
Typically disappears in the supine position and feels like a bag of worms on palpations
varicocele
190
What is the surgical treatment for a varicocele in males showing testicular atrophy?
liagation of the gonadal vein
191
Twisting of the testes on the long axis of the tunica vaginalis rotates about the spermatic cord. usually presents before 18yrs. Urological emergency
testicular torsion
192
Patient presents with N/V, tachycardia, large/firm/tender testes with pain radiating to inguinal area. cremasteric reflex is absent. what should you order?
Color Doppler ultrasonography and emergent urology referral since this is the presentation for testicular torsion
193
Because most torsions twist inward and toward the midline, which way should you twist for manual detorsion?
outward and laterally
194
What STIs are associated with epididymitis?
gonorrhea and chlamydia
195
What bacteria are involved with non-sexually transmitted epididymitis that is associated with UTIs and prostatitis?
e. coli, pseudo, gram (+) cocci
196
Patient presents with unilateral pain/swelling of testes. Erythema and edema of scrotal skin, fever, and dysuria. What tests should you order?
CBC, UA w/culture, urethral culture (or NAAT), gram stain. This is presentation for epididymitis
197
Treatment for epididymitis besides antibiotics
bedrest, scrotal elevation, avoid sexual activity until sx resolve
198
Infection of the testes. Caused by primary infection of the GU tract or infection spread to the testes through the bloodstream or lymphatics
orchitis
199
Systemic source of orchitis that doesn't occur in prepubertal boys, but affects 20-35% of adolescent boys/young men
parotitis (mumps)
200
Patient presents with fever, painfully enlarged testes with small hemorrhages into the tunica abluginia, but no urinary symptoms. What is the best management?
none, course for orchitis is 7-10 days and unpredictable
201
What are the potential residual effects of orchitis?
hyalinization of the seminiferous tubules and testicular atrophy
202
What is the difference between scrotal and testes tumors?
benign scrotal tumors are common (carcinoma is rare) whereas nearly all tumors of the testes are malignant
203
Patient who is a road pavement worker presents with a scrotal ulceration that he says used to be a "wart." What are his treatment options?
excision of tumor w/inguinal and femoral node dissection (this is scrotal cancer)
204
Most common cancer in 15-35 yr age group that is highly curable if discovered and preventable by monthly self-testicular exams
testicular cancer
205
Strongest predisposing factor to testicular cancer
cryptorchidism
206
Most common type of testicular tumor. Confined to the testicle at the time of presentation. Grow slowly and do not spread rapidly. Arises from seminiferous epithelium
seminomas
207
Nonseminoma that most commonly affects boys up to 3 yrs of age
yolk cell carcinoma
208
Nonseminoma that occurs in 20-30 yr age group
embryonal carcinoma
209
Patient presents with solid, painless testicular mass that doesn't transilluminate. What is your next step?
order testicular ultrasound
210
What is the only way to confirm the diagnosis of testicular cancer?
inguinal orchiectomy
211
Metastases sites for testicular cancer
retroperitoneal lymph nodes, liver, lung, brain
212
Blood tests used in the process of staging testicular cancer and help monitor response to therapy (often first sign of relapse)
alpha-fetoprotein (AFP), hCG, lactic dehydrogenase (LDH)
213
Describe the stages of testicular cancer
1-cancer is limited to testis. 2- cancer has metastasized to lymph nodes. 3- cancer has spread to other organs
214
When does relapse of testicular cancer usually occur?
within two years
215
What are the major differences between the alpha-1 blockers and 5 alpha reducatase inhibitors
Alpha 1s are best at reducing symptoms. 5-alpha are best at reducing size and don’t cause orthostatic hypotension
216
Where are alpha-1 receptors located?
base of bladder and prostate
217
Which alpha-1 blockers cause more BP lowering effects than the others?
Terazosin (Hytrin) and Doxazosin (Cardura)
218
What are the initial prescription instructions for alpha-1s?
start at a small dose at bedtime and titrate up slowly over several weeks
219
How long might it take to notice reduction symptoms from 5 alpha reductase inhibitors?
up to a yr
220
What should you use when interpreting PSA results in patients on 5 alpha reductase inhibitors?
use a factor of 2 in first 24 months of therapy and then 2.5 there after
221
Name the phosphodiasterase inhibitors
Tadalafil (Cialis), Vardenafil (Levitra), Sildenafil (Viagra), Avanafil (Stendra)
222
What can happen if phosphodiasterase inhibitors are combined with nitrates or alpha-1 blockers?
severe hypotension
223
Which phosphodiasterase inhibitor can cause transient blue vision and may increase risk for nonarteritic ischemic optic neuropathy?
sildenafil (Viagra)
224
In general how long before intercourse should phosphodiasterase inhibitors be taken?
60 min
225
Which phosphodiasterase inhibitor has a 36 hr duration compared to 8-12 hrs for the others?
Tadalafil (Cialis)
226
How long should you hold nitrates even if the patient is having an MI and they've used a PDE-5 recently?
24 hours after use of a PDE-5 or for 48 hours if used taldafil (Cialis)
227
Can work in 3 different ways: binding to the androgen receptor, Act in tissues that express the enzyme 5-alpha reductase, and act as estrogen after converting to estradiol
testosterone
228
What is testosterone not used to treat?
impaired spermatogenesis
229
What do you need to screen for before prescribing testosterone?
prostate cancer in men over 50, erythrocytosis, and sleep apnea
230
good first choice of therapy for testosterone replacement. Well tolerated. Achieves normal testosterone levels in most. educate regarding transfer onto others
transdermal gel
231
How long after starting testosterone therapy do you need to check serum levels?
2-3 months
232
How long after starting testosterone therapy do you need to check PSA and DRE?
3-6 months then yearly
233
Name the urinary tract analgesic used for symptomatic relief of urinary burning, itching, frequency and urgency associated with UTI or post urologic procedures
Phenazopyridine (Pyridium)
234
Side effects of Phenazopyridine (Pyridium)
skin/sclera yellow and urine bright orange
235
Max amount of time you can use Phenazopyridine (Pyridium)
more than 2 days
236
Most commonly used muscarinic antagonists that increase bladder capacity and block release of Ach resulting in decreased urgency
Oxybutynin (Ditropan) (Ditropan XL) or Tolterodine (Detrol) (Detrol LA)
237
CI for muscarinic antagonists
dementia, gastric retention, angle closure glaucoma
238
How long does it take for muscarinic antagonists to take effect?
4-6 weeks
239
Patient presents with urinary frequency, burning sensations w/urination, hematuria, strong smelling urine, and feeling of discomfort in lower abdomen. What does this patient most likely have?
cystitis
240
Bladder pain of variable severity lasting over a protracted period of time
interstitial cystitis
241
Cells that play a central role in interstitial cystitis that damage urotheial lining
mast cells (histamine)
242
Only medical treatment available for interstitial cystitis
Pentosan polysulfate sodium
243
Requires work up especially in the older or smoking patient where it may suggest bladder cancer or renal disease
hematuria
244
Why does bladder cancer present in patients with h/o includes repeated UTIs, kidney stones, chronic urinary retention requiring catheter.
Chronic inflammation of the bladder increases the risk of bladder cancer
245
Other factors besides smoking and recurrent infections that increase risk of bladder cancer
exposure to arsenic, irradiation, aromatic hydrocarbons
246
Helps lower risk of bladder cancer
increased fluid intake
247
Most common type of bladder cancer
transitional cell carcinoma
248
Most common presenting symptom or sign for bladder cancer
hematuria
249
What type of hematuria does bladder cancer typically present with?
microscopic
250
Most important method for the initial work-up of bladder cancer
cystoscopy with biopsy
251
Treatment of superficial lesions of bladder cancer (T0, T1S, T1, low grade T2)
endocscopic resection and fulguration w/cystoscopy. Repeat every three months
252
used prophylactically to prevent new lesions and delay or prevent development of both metastasis and muscle invading tumors, and therapeutically to eradicate an existing lesion
Intravesical Therapy with BCG
253
can be used for patients whose tumors are not amenable to transurethral resection of bladder tumor
partial cystectomy
254
Treatment for muscle invasive tumors (T2, T3, and T4)
Radical cystectomy with urinary diversion
255
Percentage of patients with high grade invasive disease who are cured?
50%
256
no longer shown to be of benefit and is no longer used routinely is reserved for frail, elderly pts or those unfit for other approaches to pallliate local symptoms
pre-op radiation
257
are generally insensitive to chemotherapy and should NOT be considered for neoadjuvant bladder-sparing approach
non-urothelial (transitional) histology bladder cancer
258
5 yr survival rate for metastatic bladder disease
15%
259
Performed every year in patient who had been diagnosed with bladder cancer
CXR and CT of abdomen and pelvis
260
Occurs in more than half of men in 60s and can cause urinary incontinence
BPH
261
Type of incontinence characterized by "I have to go to the bathroom all the time. Sometimes the urge to urinate comes on so suddenly that I cannot make it to the toilet in time”
urge incontinence
262
Type of incontinence characterized by “Whenever I cough, sneeze, or even stand up I leak urine”
stress incontinence
263
Type of incontinence characterized by “I seem to leak all the time…sometimes I lose urine when I’m rushing to the restroom and other times when I cough or sneeze”
mixed incontinence
264
Type of incontinence characterized by “I feel like my bladder never empties even though I am going to the restroom all the time. Sometimes to urine even leaks out at unexpected times.” Associated with BPH
overflow incontinence
265
Caused by bladder over activity. Leakage occurs because of a sudden and unstoppable urge to void. Patient experiences nocturia, rushing to the bathroom, inability to hold urine, and loss of urine during sleep
urge incontinence
266
Caused by bladder over activity. Leakage occurs because of a sudden and unstoppable urge to void
urge incontinence
267
Contributing factor in women for urge incontinence
pelvic organ prolaspe
268
Most common in women but may occur in men who have undergone radical prostatecomy or other urogenital surgery. Urine loss occurs with activities that increase intra-abdominal pressure
stress incontinence
269
Bladder becomes stretched w/large volumes of urine due to obstructive processes or loss of contractility
overflow incontinence
270
Patient complains of passing small amt of urine frequently, difficulty starting stream/weak stream, straining while urinating, and sensation bladder isn't empty
overflow incontinence
271
Complication of overflow incontinence
hydronephrosis
272
Treatment for stress incontinence
kegels, sling surgery, artificial urinary sphincter
273
Treatment of overflow incontinence due to bladder outflow obstruction
catheter, meds to shrink prostate or removal of obstruction
274
Treatment of overflow incontinence due to loss of contractility
catheter placement
275
Procedure uses a mesh material to compress the urethra and provide bladder outlet resistance…can prevent leakage of urine when abdominal pressures rise during coughing, sneezing, laughing or lifting
male sling
276
works by using a small, water filled cuff to compress the urethra and hold urine in the bladder until the patient is ready to urinate
artificial urinary sphincter
277
If the bladder must by removed or if it is totally denervated. Surgeon creates a reservoir by removing a piece of the small bowel and directing the ureters to the reservoir. Urine is drained through a stoma into a catheter and bag
urinary diversion
278
Hematuria in these situations is usually characterized by circular erythrocytes and absence of proteinuria and casts.
surgical/urological nonglomerular causes
279
A patient in the ER received a urine culture/cytology, renal US and flexible cystoscopy. What was his most likely presenting symptom?
hematuria
280
Most common urologic emergency and a cause of the acute abdomen. Characterized by sudden onset of severe flank pain with N/V due to passage of renal stone
ureteric or renal colic
281
Imaging that can identify other non-stone causes of flank pain, is quick, and doesn't require contrast
helical CT
282
What is the management of ureteric stones smaller than 5mm?
opiates and hydration
283
What are the definitive treatment options for a ureteric stone that is either associated w/fever, unresponsive to analgesics, impairing renal fxn, or has caused obstruction > 4wks?
ESWL or percutaneous nephrolithotomy
284
Painful inability to void, with relief of pain following drainage of the bladder by catheterization due to either increased urethral resistance, low bladder pressure, or interruption of the innervations of the bladder
acute urinary retention
285
Initial management options for acute urinary retention
urethral catheterization or suprapubic catheter
286
Patient presents with distended bladder that isn't painful, urinary dribbling, overflow incontinence, and a palpable lower suprapubic mass
chronic urinary retention
287
What is chronic urinary retention associated with?
reduced renal function or upper tract dilatation
288
What happens if the bladder of a patient with chronic urinary retention is drained to quickly?
sudden decompression causing hematuria
289
Most common cause of an acute scrotum
epididymitis
290
How soon does irreversible ischemic injury to the testicular parenchyma begin with intravaginal testicular torsion?
4 hrs
291
How can you differentiate between testicular torsion and epididymitis?
absent cremasteric reflex in testicular torsion
292
During surgical exploration of testicular torsion what should be done to preserve both affected and unaffected testes?
affected testis places in dartos pouch (suture fixation) and unaffected testis fixed to prevent subsequent torsion
293
Patient presents with dysuria, fever, epidiymal tenderness or massively swollen hemiscrotum with abscence of landmarks. cremasteric reflex present
epididymo-orchitis
294
Should be avoided with epididymo-orchitis
urethral instrumentation
295
Type of priapism due to hematological disease, malignant infiltration of the corpora cavernosa with malignant disease, or drugs. Painful and most common type.
ischemic (veno-occlusive, low flow)
296
Type of priapism to perineal trauma, which creates an arteriovenous fistula. Painless
non-ischemic (arterial, high flow)
297
What is it important to warn all patients with priapism of?
possibility of impotence
298
Done to evaluate renal injuries if patient is transferred immediately to the operating theatre without having had a CT scan and a retroperitoneal hematoma is found
IVU
299
Imaging study of choice for renal injury. Accurate, rapid, and images other intra-abdominal structures
Contrast-enhanced CT
300
How is a traumatic kidney injury managed that doesn't have persistent bleeeding, an expanding hematoma, or pulsitile perirenal hematoma?
conservative (IV fluids and abx) follow-up ultrasound/CT
301
the peritoneum overlying the bladder, has been breached along with the wall of the bladder, allowing urine to escape into the peritoneal cavity.
intraperitoneal perforation
302
the peritoneum is intactand urine escapes into the space around the bladder, but not intothe peritoneal cavity
extraperitoneal perforation
303
Classic triad of symptoms and signs that are suggestive of a bladder rupture
suprapubic pain and tenderness, difficulty or inability in passing urine, and hematuria
304
Why are bladder perforations repaired openly?
unlikely to heal spontaneously, large defects, leakage causes peritonitis, and associated other organ injury
305
The majority a result of a straddle injury in boys or men. Can also be due to direct injuries to the penis, penile fracture, injuries by GSW, inflation of balloon catheter
anterior urethral injuries
306
Patient presents with blood at end of penis, difficulty passing urine, frank hematuria, and penile swelling. What should you use to establish the diagnosis?
retrograde urethrography
307
Management of a contusion anterior urethral injury
small-gauge urethral catheter for one week
308
Management of partial rupture of anterior urethra
suprapubic urinary diversion for one week. No catheterization
309
Management of complete rupture of anterior urethra
patient is unstable: a suprapubic catheter.patient is stable: the urethra may either be immediately repaired or a suprapubic catheter
310
Management of a penetrating anterior urethral injury
surgical debridement and repair
311
What do the great majority of posterior urethral injuries occur in association with?
pelvic fractures
312
Symptoms and signs include blood at the meatus, gross hematuria, and perineal or scrotal bruising.High-riding prostate
posterior urethral injury
313
Describe the different classifications of posterior urethral injuries
type 1 (rare)- stretch injury w/intact urethra. 2-partial tear. 3- complete tear
314
In women, what is the most common urethral injury associated with pelvic fracture?
partial rupture at the anterior position
315
Treatment of type 1 and type 2 urethral tears
stenting with a urethral catheter.
316
What is a patient at risk for who has a type 3 urethral tear?
urethral stricture, urinary incontinence, and erectile dysfunction (ED)
317
most common general surgical procedure
inguinal hernia repair
318
Difference in the epidemiology of inguinal and femoral hernias
inguinals are more common men and femoral are more common in women
319
Contributes to the formation or worsening of a hernia
any condition that increases the pressure of the abdominal cavity
320
Patient presents with a new lump in groin/abdomen that aches but isn't tender to touch. Lump increases in size when standing. May be pushed back into the abdomen
reducible hernia
321
Patient presents with painful enlargement of hernia that can't be returned to abdominal cavity. nausea and vomiting
irreducible hernia
322
Irreducible hernia where the entrapped intestine has its blood supply cut off. Patients may appear ill with or without fever
strangulated hernia
323
refers to trapping of the hernia ( at the internal or external ring or the femoral canal), so that it cannot be reduced
incarceration
324
What is the difference in origin between direct and indirect inguinal hernias?
indirect hernias originate lateral to the inferior epigastric artery whereas direct hernias arise medially
325
arise due to defective obliteration of the fetal processus vaginalis, which follows the path through the inferior anterior abdominal wall
indirect inguinal hernias
326
Which side do indirect inguinal hernias develop on more frequently?
the right
327
Inguinal hernias develop at the internal ring. In males this is the site where the spermatic cord exits the abdomen. What exits in females?
the round ligament
328
What do direct inguinal hernias occur through?
Hesselbach's triangle
329
What forms Hesselbach's triangle?
inguinal ligament, epigastric vessels, rectus abdominus muscle
330
Develop in the empty space at the medial aspect of the femoral canal.
femoral hernias
331
Where are the femoral nerve, artery, and vein located in relation to the empty space in the femoral canal where hernias develop?
lateral
332
Risk factors that contribute to formation of femoral hernias
pectineus muscle atrophy, prior inguinal hernia, weakness of pelvic floor muscles from previous childbirth
333
Cause of pain related to femoral hernias
stretching of ilioinguinal nerve
334
What position is it usually easier to demonstrate a hernia?
standing
335
Definitive treatment for all hernias
surgical repair
336
When is the risk of incarceration the greatest?
soon after hernia manifests
337
How does the likelihood of incarceration relate to the size of a hernia?
likelihood of incarceration also decreases as the hernia increases in size since it is less likely that intestinal or visceral contents will become caught within a large sac
338
Due to uninhibited bladder contractions and detrusor overactivity
urge incontinence
339
Occurs when increases in intraabdominal pressure overcome sphincter closure mechanisms in the absence of bladder contraction
stress incontinence
340
Common causes of stress incontinence
coughing, laughing, sneezing
341
Most common type of incontinence in women
mixed incontinence
342
Continuous leakage or dribbling of urine due to impaired detrusor contractility or bladder outlet obstruction
incomplete emptying (overflow incontinence)
343
Have patient void until they feel they have emptied their bladder completely. Then do bladder ultrasound
post-void residual
344
Abnormal values for post-void residual
greater than 100-150cc of urine
345
Why do you want to get serum calcium and glucose levels when evaluating incontinence?
water follows Ca+ and glucose-->diuresis if levels are high
346
Treatment for incontinence due to organ prolapse or stress incontinence
pessiaries
347
Used for urge & mixed if behavioral alone is not successful. Increase bladder capacity. CI narrow angle glaucoma
Anticholinergics- Tolterodine (Detrol LA), Solifenacin (Vesicare)
348
Used for urge & mixed if behavioral alone is not successful. direct antispasmodic effect on detrusor. less side effects than anticholinergics
Oxybutynin (Ditropan)
349
Vaginal surgeries to correct incontinence
midurethral sling or bladder neck sling
