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148 Cards in this Set
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What are causes of scrotal truama/Testicular injury? 15.8.1
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straddle injuries and falls are not the most common cause. Sporting injuries and kicks are.
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Presentation of Scrotal truama/testicular injury? 15.8.1
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pain, swelling, brusing, urinary retention, nausea, vomiting
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ST/T injury DDx/Tx? 15.8.1
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Hematomas/Contusions- Rest, ice, nSAIDS (conservative measures)
Fractures -surgery Torsion s/p blunt truama - surgery before 6 hrs Epi/pro/hydro - present for wks after, pain, swelling, fever |
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Testicular torsion s/sx? 15.8.1
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- Sudden onset unilateral
- scrotal/inguinal swelling - Nausea/vomit; abd pain - Hx of truama/strenous extertion PE: no relief w/ elevation, edema, erythema, hide riding testicle, horizaontal lie, absent cremasteric reflex |
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Testicular torsion risk factors? 15.8.1
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- Age - <25
- Bell Clapper Deformity - Cold weather - unDescended testicle - Exercise/trauma - Intermittent testicular pain |
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Test/Tx Testicular Torsion? 15.8.1
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- Ultrasound, UA, CBC
- Urgent Urology, Manual de torsion, surgical eval is mando. |
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Scrotal Truama/Urethral Injury? 15.8.1
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s/sx- pain, urinary retention, Hematuria
PE- Blood at meatus, high riding prostate, Ecchymosis of scrotum/perineum Tx- Refer uro |
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Urinary Retention s/sx and causes? 15.8.1
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Presentation:
Distress due to bladder distention Overflow incontinence Causes: Obstruction Infection Medications Neurogenic étiologies |
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Urinary Retention ddx Obstruction? 15.8.1
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Obstruction
BPH - common in older men PE: enlarged prostate Prostate cancer PE: nodular prostate Urethral strictures caused by prior instrumentation, infection, or trauma Bladder stones – common cause Tumors h/o hematuria and passage of clots |
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Urinary Retention ddx Infection/Drug? 15.8.1
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Infectious
Prostatitis Herpes Abscess Tuberculous cystitis Drug-induced, i.e., NSAIDs. Anticholinergics increase smooth muscle tone / para-sympathetic tone increases) Sudafed. Alpha-agonists increase sympathetic tone Cymbalta, some antipsychotics and antidepressants |
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Urinary Retention Tx/Dispo? 15.8.1
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Tx & Dispo:
Urinary catheter with leg bag (stop medications) Urology referral |
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Hematuria essentials of Dx? 15.8.2
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Blood in the urine
Gross: visible to the naked eye Microscopic: visible only under a scope >= 3rbc / hpf on two or more samples |
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Hematuria S/sx? 15.8.2
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Timing
initial, terminal, total flow Associated sx’s Colicky, irritative, systemic Physical exam Const- Fever, rash, LAD, abd or pelvic masses Renal dz– HTN, vol overload Urol exam- enlarged prostate, flank mass, urethral dz |
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Hematuria Labs? 15.8.2
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UA
Protein and cast -> renal cause Bacturia -> infectious cause UCx Pos -> infectious cause |
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Hematuria Image? 15.8.2
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CT abd and pelvis
Evaluates entire upper tract With and/or without contrast ID most neoplasms and benign conditions US is not as useful (kidney only) Cystoscopy allows localization of bleeding in bladder or urethra |
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Hematuria tx/follow up 15.8.2
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Treatment
Depends on the cause of the bleeding Consider meds NSAIDs -> Papillary necrosis Neg evaluation Repeat “weeks later” to re-evaluate |
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Cystitis/UTI Def/Cause? 15.8.2
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Def:
Infection of the bladder Cause: Usually coliform bacteria Route Usually an ascending infection from the urethra Rare in men Requires work-up to determine cause |
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Cystitis/UTI S/sx/Hx/PE? 15.8.2
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Symptoms and Signs
Irritative voiding sx’s & suprapubic discomfort Dysuria Frequency Hesitancy or urgency Hx: women often note recent sexual intercourse PE Suprapubic tenderness May be normal, i.e., afebrile |
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Cystitis/UTI Labs? 15.8.2
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Lab
UA Pyuria Bacteriuria Hematuria UCx Pos if colony count > 105 / ml Not required |
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Cystitis/UTI DDx Male? 15.8.2
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Urethritis
Prostatitis Pyelonephritis Bladder cancer Psychosomatic disorders Interstitial Cystitis |
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Cystisis/UTI DDx Female? 15.8.2
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Vuvlovaginitis
PID Pyelonephritis Bladder cancer Psychosomatic disorders Interstitial cystitis |
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Cystitis/UTI Tx Females? 15.8.2
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Females
Septra DS 1 po bid f3d Levofloxacin 250 mg daily f3d 2. Ciprofloxacin 250 mg bid f3d 3. Nitrofurantoin 100 mg bid f7d |
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Cystitis/UTI Tx males? 15.8.2
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Ciprofloxacin 250 mg bid f7-14d
Septra DS 1 po bid f7-14d |
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Pyelonephritis Def/Cause/Route? 15.8.2
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Def:
Infectious, inflammatory process of the kidney Cause: Usually gram neg. bacteria Route: Usually ascends from LUT May spread hematogenously |
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Pyelonephritis SSx/Hx/Pe? 15.8.2
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Classic findings:
Fever Flank pain Irritative voiding symptoms Pos UCx Hx: Fever Rigors Maybe nausea, vomiting, diarrhea PE Fever Tachycardia CVA tenderness |
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Pyelonephritis Labs? 15.8.2
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Lab
CBC shows leukocytosis (incr. WBCs) Left shift UA has pyuria, bacturia, and maybe hematuria White cell casts UCx pos BCx may be pos |
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Pyelonephritis DDx? 15.8.2
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Acute abdomen
Appendicitis, Cholecystitis, Pancreatitis, Diverticulitis Lower Lobe Pneumonia PID Epididymitis / Prostatitis Cystitis |
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Pyelonephritis Tx? 15.8.2
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Severe infections -> hospitalize
IV antibiotics (FQ + aminoglycocydes) Mild to Mod Cipro 500 mg po bid for 1-2 weeks Symptomatic treatment Fluids Analgesics |
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Acute Prostatitis def/cause/route? 15.8.2
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Def
Painful inflammation within the prostate Most frequent urologic diagnosis in men < 50 yo. Cause Usually gram neg. rods, i.e., E coli and Pseudomonas Route Ascent up the urethra, and reflux of infected urine into prostate. May also spread through lymph and blood. |
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Acute Prostatitis S/Sx, Hx,PE? 15.8.2
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Classic findings
Fever Irritative voiding symptoms Pain, esp. upon rectal exam Hx Abd, back, and or pelvic pain is common Obstructive symptoms may occur, as the prostate swells PE High fever Warm, exquisitely tender prostate (Be gentle. Vigorous exam may cause septicemia.) |
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Acute Prostatitis Lab? 15.8.2
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CBC shows incr. WBCs and a left shift
UA: pyuria, bacteriuria, maybe hematuria UCx: grows responsible bacteria |
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Acute Prostatitis DDx? 15.8.2
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UTI / Pyelonephritis
BPH Malignancy (prostate, bladder, colorectal) |
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Acute Prostatitis Tx? 15.8.2
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With s/s of sepsis
Hospitalize for iv abx and relief of obstruction Without sepsis Age < 35 Ceftriaxone 250 mg IM x 1 Doxycycline 100 mg bid f10d Age > 35 FQ (Ciprofloxacin 500 mg po bid f10d) or Septra DS 1 po bid f14d NSAID |
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Non- Bacterial Prostatisis S/Sx? 15.8.2
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Classic Findings
Symptoms of prostatitis No causative organism cultured Most common form of prostatitis Suspected causes: Chlamydiae Mycoplasma Ureaplasmas Viruses |
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Non- Bacterial Prostatisis Lab? 15.8.2
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Prostate secretions show incr. WBCs
No growth on culture |
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Non- Bacterial Prostatisis DDX? 15.8.2
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Chronic bacterial prostatitis
Bladder cancer Diagnosis of exclusion! |
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Non-bacterial Prostatitis Tx/Dispo? 15.8.2
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Tx
Trial of Abx Erythromycin 250 mg 4 x /d f14d Continue if there is a good response NSAIDs Sitz baths Px / Dispo Annoying sxs, but no serious sequelae Refer |
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Epididymitis Def/ Caues? 15.8.2
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Def
Pain and swelling of the epididymis Usually unilateral and occurs over days Causes & Routes STD Occurs in men < 35 C. trachomatis or N. gonorrhea Non STD forms Occur in men older than 35 Associated with UTIs and prostatitis Gram neg. rods |
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Epididymitis hx/PE? 15.8.2
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Hx
often follows: Physical exertion Trauma Sexual activity May also have symptoms of Urethritis- pain at tip of penis Cystitis- irritative voiding symptoms Pain occurs in scrotum and may radiate to flank PE Early Can distinguish epididymus from testes Later May feel like one swollen and tender mass Prehn sign Elevating the scrotum decreases pain due to epididymitis (Pos Prehn’s sign) Prostate May be tender |
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Epididymitis Lab? 15.8.2
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WBCs may be elevated
Gram stain of urethral secretions Swab for GC & chlamydia Pos LE on first morning void or WBC >10/hpf |
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Epididymitis DDX? 15.8.2
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Testicular torsion
Scrotal trauma Hydrocele Testicular trauma Inguinal hernia Testicular tumors |
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Epididymitis Tx? 15.8.2
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Antibiotics (except in viral epididymitis)
STD (men < 35) Ceftriaxone 250 mg IM, and Doxycycline 100 mg bid f10d Non-STD (men > 35) Ciprofloxacin 500 mg daily f10d or Levofloxacin 500 mg po bid f10d Failure to improve within 3 days -> reevaluate Dx and Tx. Supportive measures Bed rest Scrotal elevation Analgesics: Acetaminophen / NSAIDs Systemic illness: IVF IV antibiotics |
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Epididymitis Px/Dispo? 15.8.2
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Px / Dispo
Prompt tx usually resolves problems Delayed tx may cause: Epididymo-orchitis Decreased fertility Abscess Considerations for MEDEVAC? |
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Nephrolithiasis Def/Types? 15.8.2
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Def
Crystalline stones within the urinary system Causes flank pain, nausea, and vomiting Frequent reason for MEDEVAC from subs Types of stones Calcium oxalate – 85% Calcium phosphate Struvite Uric acid Cystine |
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Nephrolithiasis Causes? 15.8.2
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Causes of stones
Geography, i.e. hot & humid areas Diet & fluids Genetics / Obesity Medications Epidemiology Men > women by 3:1 (but narrowing) Whites > Hispanics > Asians > Blacks Rare before age 20 |
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Nephrolithiasis Hx/PE? 15.8.2
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Hx
Colic: severe pain, localized to the flank Radiates to the ipsilateral (same) groin Unable to find a position of comfort Stone size does not correlate with symptoms Nausea and vomiting are common PMH or FH of stones? PE Fever, tachycardia, hypotension -> sepsis CVAT |
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Nephrolithiasis lab? 15.8.2
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UA; hematuria in 85-90% of cases
CBC, renal function HCG |
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Nephrolithiasis DDx? 15.8.2
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Appendicitis
Bowel obstruction Pancreatitis PUD Gastroenteritis Pyelonephritis AAA Ectopic pregnancy Ovarian cyst |
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Nephrolithiasis tx? 15.8.2
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Approach to symptomatic relief
Hydration Analgesia Anti-emetics Medical Expulsion Therapy COMSUBFORINST 6000.2C Appendix F Maintain oral fluids for >1-2 L UOP daily IV if vomiting NS or LR @ 150 cc/hr, UOP >2L/d |
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Nephrolithiasis Tx? 15.8.2
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Tx - cont.
If signs of UTI (what are these signs?) Uncomplicated: Ciprofloxacin 500 mg bid f7d or Septra DS 1 tab po bid f7d Complicated (T > 101, WBC > 11k, hemo unstab) Unasyn 3 gm IV q6h or If PCN allergic, use Ceftriaxone 2 gm IV q24h or Cipro 500 mg PO bid Strain urine for stone analysis |
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BPH Def/cause/findings? 15.8.2
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Def
An increase in benign prostate tissue causing obstruction (static), as well as increased smooth muscle tone (dynamic) Cause Age related benign tumor growth Key Findings Obstructive and irritative voiding symptoms Enlarged prostate on DRE No other identified cause |
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BPH hx? 15.8.2
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Obstructive sxs
Hesitency Decreased caliber and force of urine stream Incomplete emptying Double voiding Straining Dribbling Irritative sxs Urgency Frequency Nocturia |
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BPH PE? 15.8.2
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PE
Physical exam DRE note size and consistency smooth, firm enlargement -> BPH Induration or nodules -> cancer Focused neuro exam |
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BPH DDx? 15.8.2
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DDX
Obstruction from strictures, stones, or tumor UTI Bladder cancer Neurogenic bladder |
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BPH Tx? 15.8.2
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Probable referral
Mild sxs: watchful waiting Mod or severe sxs: Watchful waiting Alpha blockers - relax smooth muscle in bladder neck Side effects: orthostatic hypotension, dizziness, tiredness, retrograde ejaculation, rhinitis, headache 5-alpha reductase inhibitors - reduce size of the gland Surgical procedures (TURP, TUIP, RPP, etc) |
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Syphilis def/findings? 15.8.3
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Def
Infection with the spirochete Treponema pallidum. “the Great Imitator” Route Infection during sex, thru skin or mucosal lesions Rarely by non sexual contact, blood transfusions, or congenitally Classic Findings Painless ulcer (chancre) Painless lymphadenopathy |
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Syphilis stages? 15.8.3
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Stages
Primary / Infectious - macule, ulcerates ->chancre usually 14-21 days after exposure Secondary - bacteremia and dissemination, skin rashes Latent - asymptomatic about 40% progress Tertiary - end organ damage years after exposure not contagious |
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Syphilis hx/pe? 15.8.3
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Hx
“At-risk populations” Multiple partners, other STDs, HIV, MSM, sex workers, drug users PE Genital ulcer; painless Resolves spontaneously Lymphadenopathy Non-tender Rash: appears on palms and soles |
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Syphilis labs? 15.8.3
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Lab
VDRL and RPR Good screening tests, but not very specific Become pos. 4-6 weeks after infection High rate of false pos. Remains pos. for 6 mos - 2 years after tx Treponemal Ab tests Good confirmatory tests (sensitive) |
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Syphilis DDX? 15.8.3
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Genital herpes
Chancroid, usually painful & uncommon in US Lymphogranuloma venerum, also uncommon HIV Scabies Eczema |
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Syphilis Tx? 15.8.3
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Early dx and tx prevents complications & spread
Primary - early latent Penicillin G 2.4 M units IM x 1 Abstinence until non-contagious Any positive test and late stage, ie, neurosyphilis Consult / get help Warning: Jarish-Herxheimer reaction Fever, HA, myalgia within 24 hr of abx |
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Chlamydia Def? 15.8.3
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Def
One of most common STDs in the world caused by Chlamydia trachomatis Family of intracellular parasites Women Endocervical canal infection may lead to PID and infertility Men Urethral infection may lead to epididymitis and prostatitis May also cause eye disease and pneumonia |
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Chlamydia hx? 15.8.3
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85% of men and women are asymptomatic
Risk factors Age < 25 Frequent or recent partner change No use of condoms H/o STDs Women May have odorless discharge Men May have dysuria and clear-white discharge May have scrotal pain |
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Chlamydia pe? 15.8.3
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Women
Cervical os may have cloudy or yellow discharge Cx may bleed easily Men Penile discharge Able to milk a discharge Tender, warm scrotum |
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Chlamydia DDx? 15.8.3
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DDX
Gonorrhea BV Candidiasis Trichomonas PID Screening Annual screening for all sexually active women 25 yo and younger Pregnant women |
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Chlamydia tx? 15.8.3
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Tx
Eradicate infection and treat contacts; prevent infertility Doxycycline 100 mg bid f7d Azithromycin 1 gm po as a single dose Primary Prevention Counseling on safe sex practices Screening for co-infections Secondary Prevention No TOC, but recheck in 3-4 mos for reinfecti |
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GC Def? 15.8.3
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Def
Infection with Neisseria gonorrhoeae a gram neg. diplococci May cause LUTS, conjunctivitis, or disseminated dz Route Almost exclusively sexually transmitted May be congenital |
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GC Findings? 15.8.3
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Classic Findings
Purulent and profuse urethral discharge & dysuria Men Epididymitus, prostatitis, urethritis, proctitis Women Asymptomatic or cervicitis, vaginitis, salpingitis, proctitis Disseminated dz Fever, rash, tenosynovitis, arthritis |
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GC Hx? 15.8.3
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Incubation
2-8 days Hx Greatest incidence in 15-29 yo’s Important elements of the sexual history include 5 Ps: Partners (gender, number in prior 2 mos/1yr) Prevention of pregnancy - trying to conceive or contraceptives Protection from STDs/HIV - what does the patient do to protect themselves? Practices of sexual activities (oral/vaginal/anal and insertive/receptive), condom use Past STDs/HIV |
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GC PE/LAB? 15.8.3
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PE
Males Penis, scrotum, and prostate Females External, pelvic, and bimanual Both Eyes, oropharynx, anus Fever, skin lesions, joints Lab UA, first morning void Gram stain Culture NAAT then, HIV and RPR testing |
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GC Ddx? 15.8.3
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DDX
Nongonococcal urethritis Chlamydia Trichomoniasis Other causes of urethritis, cervicitis/vaginitis/PID, epididymitis or prostatitis UTIs |
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GC Tx? 15.8.3
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Tx
High rate of FQ abx resistance (esp Asia, HI, CA) Partners need treatment Uncomplicated urethritis, cervicitis, PID, epididymitis, proctitis, or pharyngitis: Ceftriaxone 250 mg IM plus Treatment for chlamydia Complicated infections -> hospitalization! |
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GC Prevent? 15.8.3
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Px / Prevention
Tx intended to prevent infertility, ectopic pregnancy, and pelvic pain. In men, it is to prevent ascending infection of prostate, epididymus, and testes. TOC not required if 1st line tx provided Primary prevention Delay sexual activity Min number of partners Condoms Secondary prevention Reportable to local PHA Partner treatment |
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HSV Cause/Def? 15.8.3
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Def
Viral infection that causes oral, genital, and ocular ulcers Cause Human Herpesviruses Subclinical infection is more common than clinical illness HSV and VZV remains latent in sensory ganglia for the remainder of patient’s lifetime |
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HSV Hx/PE? 15.8.3
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Hx
Risk factors HIV infection High risk sexual behavior Immunosuppressive medications Weak: female, black, older, lack of condom use Dysuria (women) Tingling sensations PE Ulcers: mouth or genitals LAD Fever |
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HSV Lab/DDX? 15.8.3
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Lab
HSV culture PCR Technique for sampling? DDX Syphillis Chancroid LGV Scabies Fixed Drug Eruption Squamous Cell Carcinoma |
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HSV Tx? 15.8.3
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Episodic: shorten duration of outbreak
Oral antivirals – 1st choice, safe & effective Acyclovir, Famcyclovir, Valacyclovir Begin within 48-72 of onset of symptoms Continue until lesions resolve Symptomatic tx Topical Lidocaine (warn about allergic rx) Analgesics Sitz baths Topical antivirals – not for genital ulcers, may help oral Suppressive: reduce number of outbreaks or prevent transmission to partner |
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ARF Def/causes? 15.8.4
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Def
aka Acute Kidney Injury Sudden decline in Glomerular Filtration from baseline; may last ~ 6weeks Causes Poor kidney perfusion (Prerenal) Obstruction of kidney (Postrenal) Toxins to the kidney (Intrinsic) Kidney disease (Intrinsic) |
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ARF Prerenal? 15.8.4
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Hx
Blood loss Vomiting or diarrhea Inadequate maintenance fluids h/o sepsis or pancreatitis Symptoms: thirst, dizziness PE Tachycardic, hypo- or hypertensive Anuric or oligouric |
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ARF Postrenal? 15.8.4
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Hx
Usually older men Dysuria, frequency, urgency Flank pain PE CVAT Hematuria Abdominal distention |
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ARF lab? 15.8.4
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Labs
BUN, Cr UA and UCx (cath) CBC |
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ARF intrinsic? 15.8.4
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Hx – Intrinsic disease = ATN = damage to renal tissue
Review all medications NSAIDs (interstitial nephritis) Rad exams with contrast Muscle tenderness / heavy exertions PE Same as above |
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ARF Tx? 15.8.4
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Tx
Treat underlying cause Prerenal Improve perfusion Consider vasopressors Intrinsic Remove offending drugs Improve volume status Postrenal Remove the obstruction (foley, if possible) Mortality rates from 25-90% Prevention/recognition is key |
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CRF Def/Cause/Hx? 15.8.4
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Def
Decreased kidney function for > 3 mos Proteinuria and hematuria Cause Diabetes – 40% Hypertension Hx is usually vague Fatigue Nausea Edema |
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Hyponatremia def? 15.8.5
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low blood levels of Na
Def Na < 135 mEq/L Major extracellular solute “Water follows salt” |
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Hyponatremia Patients? 15.8.5
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Patients
Have increased morbidity and mortality Headache Muscle cramps Lethargy Psychosis >> Cerebral edema – brainstem herniation << |
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Hyponatremia casues? 15.8.5
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Iatrogenic/drug – giving hypotonic solution to patients
Renal failure CHF Hepatic Endocrine or Metabolic Psychogenic polydipsia CNS Neoplastic Respiratory |
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Hyponatremia Tx? 15.8.5
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Give proper fluids
Get help |
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Hypernatremia Def/dx? 15.8.5
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Def
Na > 145 mEq/L Due to water defecit or sodium gain Hx Usually occurs in the young and the old patients |
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Hypernatremia Effects? 15.8.5
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Effects
Hyperthermia Delirium Seizures Coma Cerebrovascular damage Death |
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Hypernatremia Causes/tx? 15.8.5
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Causes
Endocrine – DI, Cushings, Aldo Renal – DI, postobstructive diuresis GI – severe diarrhea, vomiting, laxatives or bowel cleansing Meds – diuretics Environment – heat, exercise, fever, burns Dietary – lack water, breastfeeding, salt ingestion, high-protein diet Tx - Get help / prevent the problem |
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Hyperkalemia Def/Symptoms? 15.8.5
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Def
K > 5.0 mEq/L Major intracellular solute Symptoms Muscle weakness ECG changes Arrhythmias --> life-threatening |
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Hyperkalemia Caues/tx? 15.8.
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Causes
Renal – ARF, CRF, RTA, Metabolic acidosis Endocrine – Hyperglycemia, CAH, Addisons, Drug-induced Cell or tissue breakdown – Rhabdo, tumor lysis Pseudohyperkalemia Tx Index of suspicion / prevention / supervision |
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Hypokalemia Def/Symptoms? 15.8.
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Def
K < 3.5 mEq/L Symptoms Muscle weakness ECG changes Arrhythmias -> may be lethal |
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Hypokalemia Causes? 15.8.
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Causes
Renal – RTA, renal dz from various syndromes GI – vomiting, bulimia, anorexia, severe diarrhea, “bowel cleansing” and laxatives Endocrine – Aldosteronism, Cushings, DKA, HONK, Exercising in a hot climate! Drugs – diuretics Critical illnesses, alcoholism, Psychogenic polydipsia Dialysis |
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Volume Depletion def/cause? 15.8.5
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Def
Reduction in ECF that occurs when salt and fluid losses exceed intake for a long period Causes Hemorrhage Vomiting Diarrhea Diuresis 3rd spacing |
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Volume Depletion s/sx? 15.8.5
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Signs & Symptoms
Tachycardia Hypotension Thirst Postural dizziness Fatigue Confusion Muscle cramps Chest or abdominal pain |
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Volume Depletion Hx? 15.8.5
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Risk factors
Diuretic use CKD Children and elderly AMS Prolonged exertion in a hot environment Postural dizziness Shock |
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Volume Depletion PE/LAbs? 15.8.5
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PE
Orthostatic hypotension Postural tachycardia OP, skin Labs CBC Chem 7 BUN/Cr |
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Volume Depletion Tx? 15.8.5
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Hemorrhage
IVF - isotonic PRBCs GI non-hemorrhagic losses ORT IVF – isotonic Antiemetics or antidiarrheals Skin loss (burns, profound sweating) & poor intake ORT or IVF |
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Volume Depletion Prevention? 15.8.5
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n/a, due to diverse causes
Consider access to food and water Consider causes of GI bleeds (NSAIDs) Monitor your patients Teach your crews to prevent volume depletion |
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Sexual Assault labs? 15.8.6
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GC/chlamydia swab of vagina, mouth, anus
Pap Wet prep for trich hCG HIV – repeat again in 2-4 months ? Hepatitis panel Consider blood and urine samples, if drugs or alcohol involved. |
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Sexual Assault tx? 15.8.6
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Tx
Consider analgesics, sedatives, and tetanus Ceftriaxone 250 mg IM Metronidzole 2 gms once Azithromycin 1 gm or Doxy 100 mg bid f7d Emergency contraception Vaccinate against HBV Consider HIV prophylaxis (PEP) Referral for counseling (MHC, Chaps) |
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prostate cancer Def/prob/hx? 15.8.7?
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Def
Malignant tumor of the gland Problem 3rd leading cause of cancer mortality in the US Uncommon in men < 50 Hx Risk factors Age > 50 Black men FH High levels of dietary fat Nocturia Frequency Hesitancy Dysuria |
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prostate cancer pe/labs? 15.8.7
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PE
UA, UCx DRE Palpable nodes Labs PSA Testosterone LFTs CBC Renal function Biopsy Imaging US, bone scan, CT, etc. |
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Prostate cancer tx/complications? 15.8.7
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Tx
Expectant Management Brachytherapy Ext Beam Radiation Therapy Radical prostatectomy Primary Prevention None, but may use 5-alpha reductase inh. Low fat diet Complications – ED, dysuria, GI issues |
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Bladder Cancer Def/prob/hx? 15.8.7
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Def
Urothelial cancers, most do not invade muscle Problem Smoking is greatest risk factor 4x more common in men than in women Hx Risk factors Tobacco exposure Age > 50 Exposure to chemical carcinogens Radiation or chemo Schistosomiasis / chronic inflammation Hematuria (gross) Dysuria |
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Bladder cancer Pe/lab/image? 15.8.7
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PE
Hematuria (micro or gross) Lab UA Urologist will order cytology Imaging Cystoscopy and advanced imaging |
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Bladder cancer DDX? 15.8.7
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DDX
BPH Hemorrhagic cystitis Prostatitis Cystitis RCC Nephrolithiasis Diverticulitis |
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Bladder cancer Tx? 15.8.7
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Tx
Surgery Chemo Primary Prevention Avoidance of tobacco Avoid exposure to carcinogens Secondary Prevention Vitamins Increased consumption of fruits and vegetables |
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Renal Cell Cancer Def/Prob? 15.8.7
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Def
Cancer arising from the parenchyma or cortex of the kidney Problem Risk in US is 1/10,000 |
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Renal Cell Cancer HX? 15.8.7
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Hx
Risk factors Smoking! Male Age 55-84 Blacks Obesity Htn FH Flank pain Abdominal mass |
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Renal Cell Cancer pe/lab? 15.8.7
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PE
Incidental finding Abdominal mass Lab UA shows hematuria Imaging Lots of advanced imaging required |
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Renal cell cancer tx/prevent? 15.8.7
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Tx
Surgery Primary Prevention Modify risk factors of: Obesity Hypertension Smoking |
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Vaginitis Def/cause route? 15.8B.4
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Def
Inflammation of the vagina caused by infection Cause Overgrowth of bacteria Overgrowth of yeast Trichomonas vaginalis, a protozoan infection Route Suppression of normal flora STD |
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Vaginitis Hx? 15.8B.4
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Vaginal discharge
Thin, malodorous, and white Thick, white, and cottage cheese-like frothy green, yellow, or white Associated odor Dysuria |
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Vaginitis Risk Factors? 15.8B.4
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Risk Factors: things that change the vaginal environment
IUD / OCP use Douching Menopause Child bearing age Sexual activity Poor or excessive hygiene Abx use HIV infection Diabetes |
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Vaginitis PE/LAB? 15.8B.4
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PE
External exam Erythema Internal Bleeding Discharge Lab Wet Prep KOH Amine “whiff” test pH |
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Vaginitis DDX? 15.8B.4
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DDX
Candidiasis BV Trichomoniasis Cervicitis GC/chlamydia Atrophic vaginitis PID |
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Vaginitis Tx? 15.8B.4
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BV
Metronidazol 500 mg bid po or 0.75% gel 5 gm pv f5d Caution about alcohol use Candidiasis *.azole cream or suppositories Diflucan 150 mg po x 1 Trichomoniasis Metronidazol 2 gm po once or 500 mg po bid f7d |
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Vaginitis Prevent? 15.8B.4
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Primary Prevention
Avoid douching and irritants Condoms may help prevent spread Secondary Prevention BV: treatment of partner not indicated Candidiasis: not an STD Trich: treat partners & screen for STDs |
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PID Def/Cause? 15.8B.4
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Def
Acute ascending infection of female genital tract Includes endometritis, salpingitis, tubo-ovarian abscess, & pelvic peritonitis Cause Usually Neisseria or Chlamydia Polymicrobial, to include normal flora |
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PID S/sx? 15.8B.4
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Classic Sx’s
Fever Vomiting Back pain Dyspareunia Lower abdominal pain + Lower urinary tract symptoms (LUTS) Epidemiology Often seen in young, single, sexually active females h/o STDs May affect 1 million US women a year |
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PID Risk factors? 15.8B.4
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Risk factors
Prior STD Early age of sexual activity Multiple sex partners Prior h/o PID IUD use Weak risk factors Smoking Low SES Douching Intercourse during menses |
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PID Pe/Labs? 15.8B.4
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PE
Systemic Fever Abd pain Vag discharge Pelvic: Uterine tenderness Cervical motion tenderness (CMT) Adnexal tenderness Labs CBC Wet prep for PMNs ESR Gen Probe 100% specific for N. g. and C. t. Advanced imaging – may be needed |
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PID Tx? 15.8B.4
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Tx
Mild to Mod PID Ceftriaxone 250 mg IM Doxycycline 100 mg PO BID f14d May add metronidazole 500 mg PO BID f14d Cure rates of 88-100% with oral abx Severe PID Clindamycin 900 mg IV q8h and Gentamicin 2 mg/kg IV/IM loading dose, then 1.5 mg/kg IV q8h or Unasyn 3 gm IV + doxycycline 100 mg PO/IV q12h |
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PID DDx? 15.8B.4
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DDX
Uterine fibroids Endometriosis Vaginitis Ovarian cysts Ectopic pregnancy Tubo-ovarian abscess |
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What are combined Hormnal contraceptives? 15.8B.5
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Pills, Patch, Rings
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OCP's Side Effects? 15.8B.5
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Side effects
Spotting Nausea Both usually resolve over 2-3 cycles, or with new pill Non-contraceptive benefits Improvement in conditions made worse by menses Improvement in other conditions, i.e. acne Reduced risk of developing conditions like ovarian CA |
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Patches Side Effects? 15.8B.5
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Side effects
Spotting Local skin irritation Nausea Concerns: Higher levels of estrogen may increase risk of clots May be less effective if wt >198 lbs |
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Vaginal Rings Side effects? 15.8B.5
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Side effects
Spotting Vaginal discharge Nausea May be spontaneously expelled; may also remove for 3 hrs/day without loss of effect. |
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CHC. 15.8B.5
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Extended / Continuous Use
Benefits Improved effectiveness Decreased blood loss Less symptoms of PMS, PCOS, etc. Pills Monophasics may be taken daily to suppress menses, i.e. to have a period every 4 months Skip the placebo pill Withdrawal bleeding occurs? When? Rings May be used for 35 days; change same day of month |
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Progestin Only? 15.8B.5
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Progestin Only
Forms Pill Injections Implants IUD MOA Thicken cervical mucus May suppress ovulation and prevent implantation Work well for women who cannot take Estrogen |
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Mini Pill? 15.8B.5
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Mini-pill
Moderately effective at 92-99% Side effects Spotting (may persist) Hair or skin changes Headaches Depression Decreased libido |
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Depo 15.8B.5
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Depo-Provera
Effectiveness: 97-99% Injection q 12-14 weeks Pros lowers risk of endometrial & ovarian CA Often become amennorheic Cons Vaginal spotting (most common) Weight gain Hair or skin changes Headaches Depression Decreased libido Black Box Warning (BBW): use < 2 yr, bone density loss |
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Implanon 15.8B.5
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Rod implanted subcutaneously on arm
Effectiveness: 99% for 3 years Many women become amenorrheic in months Side effects Vaginal spotting (common; may persist for years) Weight gain Hair or skin changes Headaches Depression Decreased libido. |
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IUD's 15.8B.5
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MOA:
Prevent fertilization Types: Mirena - progestin IUD, good for 5 yrs. Copper T - good for 10 yrs Pros Highly effective Long acting Reversible Copper T may be used as Emergency Contraception Cons Risk of infection (placement, STDs) Expulsion May be higher risk of ectopic pregnancies |
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Bilateral Tubal Ligation and vasectomy? 15.8B.5
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BTL
MOA: disrupt the fallopian tubes Effectiveness: 99% Risks Bleeding Infection Post-procedure regret Vasectomy MOA: prevent sperm from being ejaculated Effectiveness: 99% Risks: bleeding, infection, swelling |
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Emergency Contraception 15.8B.5
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aka “The Morning After Pill”
Types Progestin only (Plan B, Preven) OCPs Copper T IUD |
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Emergency Contraception Plan B. 15.8B.5
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Plan B / Preven
Should be taken within 72 hours MOA: prevents or delays ovulation Reduces risk of pregnancy by 89% 1 tab q 12h Side effects: nausea, spotting, change in menses May need to use anti-emetic OTC for women >= 18 yo in the USA |
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Emergency Contraception OCP's 15.8B.5
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Must be taken w/in 72 hours
MOA: preventing or delaying ovulation Reduces risk of pregnancy by 75% Side effects Nausea (worse than Plan B) Vomiting Spotting Change in menses |
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Emergency Contraception Copper T IUD
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May be inserted up to 5 days after unprotected intercourse
Nearly 100% effective MOA: prevents fertilization & implantation Side effects Risk of infection Heavier, more painful periods |
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4 abnormal vaginal bleedings 15.8B.6
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Pregnancy, Malignancy, Mechanical(fibroids, polyps), Hormones
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Definitions of Vag Bleeding. 15.8B.6
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Menorrhagia: menstrual blood loss of >80 mL per cycle (also for > 1 week)
Dysfunctional Uterine Bleeding (DUB): non-pathologic bleeding often a/w anovulatory cycles Polymenorrhea: menstruation more frequent than every 3 weeks Metrorrhagia: abnormal uterine bleeding between menstrual periods |
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Vaginal Bleeding Hx? 15.8B.6
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Hx
Details of nature and extent of bleeding Intermenstrual or post-coital bleeding? Symptoms Help identify source of bleeding (vagina, anus, urethra) Pain, fatigue, wt loss -> CA STD or pregnant? Contraceptive use? For how long? Last Pap? When? Results? Any known uterine pathology? Medications? Bleeding disorders? Premenarchal Bleeding Secondary sex characteristics present? Evaluate for infection or foreign body Consider sexual abuse Post-menopausal bleeding Endometrial carcinoma must be ruled out |
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Vaginal bleeding PE? 15.8B.6
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Hair, skin, nails, obesity ->Hypothyroidism
Pallor of the conjunctiva & nail beds -> Anemia Obesity, hirsutism, acanthosis nigricans -> psos Acne, male pattern balding, clitoromegaly -> hormonal embalance Jaundice, Hepatomegaly, bruising -> Hepatitis Amenorrhea, galactorrhea, (male-impotence/infertility) -> prolatinoma |
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Vaginal Bleeding ddx
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Malignancy (cervical, uterine, ovarian, or vaginal cancer; leukemia, lymphoma)
Diseases: thyroid, renal, or hepatic issues Miscarriage or ectopic pregnancy Infections: PID, Cervicitis, Endometritis, Vaginitis Mechanical (Fibroids, Endometriosis, Polyps) Medications Hormones: menorrhagia, PCOS, DUB |
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Pregnancy 15.8B.10
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OPNAVINST 6000.1C
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