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326 Cards in this Set
- Front
- Back
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Which type of pain?
obstruction of ureter urinary retention prostatitis pyelonephritis |
viscus
capsule |
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usually in CVA
radiates to umbilicus or testicle/labia constant in infection (pyelonephritis) comes and goes in obstruction (caliculi) nausea and vomiting pts move around to find a comfortable position |
renal pain
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two types of pain from obstruction:
_________ causes constant dull ache _________ causes spasm causing colicky pain |
distention
colic |
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site of obstruction:
pain to the scrotum and labia lower quadrants, confused with appendicitis on R and diverticulitis on L inflammation at the ureteral orifice so asso. w/ symptoms of bladder irritability |
upper
middle lower |
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acute; resulting from obstruction
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ureteral pain
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______ urinary retention: severe suprapubic discomfort
______ urinary retention: usually painless even with significant distention |
acute
chronic |
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suprapubic pain w/o irritative voiding symptoms is rarely __________
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vesicular (bladder)
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pain of _______ however, referred to urethra, asso. w/ passing urine
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cystitis
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___________ Pain:
located in the perineum is from inflammation radiates to the LS spine, inguinal canals, lower extremities can have painful urination |
Prostate
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penile pain in flacid penis, usually _______ or ___________
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STDs
paraphimosis |
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penile pain in erect penis, __________ disease or __________
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Peyronie's disease
priapism |
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Causes acute pain in the _______ radiating to the ispilateral __________:
trauma torsion of the testis epididymo-orchitis |
scrotum
groin |
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Chronic pain:
_____________ pain may last for months after treatment __________ or __________ causes heavy feeling in the scrotum kidney problems, retroperitoneal or inguinal problems can refer pain to the _________ |
epididymitis
varicocele or hydrocele testes |
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usually on the left, dialated veins, feels like a bag of worms
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varicocele
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irritative voiding symptoms
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urgency
dysuria frequency nocturia |
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Causes of increased _____________:
diabetes mellitis diabetes insipidus excess fluid ingestion diuretics (caffeine and alcohol) |
urinary output
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causes of decreased _____________:
bladder oulet obstruction neurogenic bladder disorders extrinsic bladder compression psychological factors (anxiety) |
bladder capacity
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a delay in the initiation of micturition caused by increased time required to bladder to raise pressure to exceed that in urethra due to obstruction
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hesitancy
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uncontrolled release of last few drops of urine
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post void dribbling
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interruption in the urinary stream
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intermittancy
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causes of ____________:
prostatic hyperplasia urethral stricture neurogenic bladder prostatic or urethral carcinoma foreign body |
obstructive voiding symptoms
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involuntary loss of urine
total stress urge overflow |
incontinence
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loss of urine at all times in all positions
loss of urine w/ increased abdominal pressure preceded by a strong urge to void occurs with chronic urinary retention |
total
stress urge overflow |
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blood in urine
can be gross or microscopic gross is _________ until proven otherwise |
hematuria
malignancy |
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blood at the beginning of the stream that clears during the stream implies anterior _____________ source
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initial hematuria
penile urethral |
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blood at the end of stream implies _____________ or _____________ source
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terminal hematuria
bladder neck or prostatic urethral |
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blood throughout the stream implies _________ or ____________ source
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total hematuria
bladder or upper tract source |
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renal colic with hematuria could mean a _______, but clots from a bleeding _________ can act the same way
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stone
tumor |
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irritative sx in a young woman could suggest infection in the form of _____________, but in older women or men it could mean ___________
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hemorrhagic cystitis
neoplasm |
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gas (air) in the urine
usually secondary to a _________ between GI tract and bladder patient reports bubbles or particulate matter in the urine |
pneumaturia
fistula |
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most common cause of pneumaturia is __________, then _______ cancer and ________ disease
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diverticulitis
colon cancer chron's disease |
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blood in ejaculate from prostatitis or semial vesiculitis
initial means from _________ terminal is usually from ____________ |
hematospermia
prostate seminal vesicles |
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work up of hematospermia (3)
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UA
DRE prostatic massage w/ microscopic exam of secretions |
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__________ or ___________ with prostate biopsy in those with hematuria or abnormal DRE
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cystoscopy
TRUS |
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most common symptoms of STDs
mucopuralent drainage from urethra in males and females with cervicitis or vagnitis in females |
urethral drainage
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bloody urethral discharge in an elderly patient suggests _______________
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urethral carcinoma
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usually ________ and/or ________ in STDs
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dysuria
itching |
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may be from UTI or from alkaline urinary pH
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cloudy urine
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lymph in urine
causes: fistula from lymph system to bladder TB retroperitoneal tumors a rare symptom |
chyluria
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when asso. with other sx of UTI it helps localize the site of infection
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fever
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high fever in women usually means acute ___________
fever is usually not asso. with _________ |
pyelonephritis
cystitis |
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fever in men with urinary sx usually means:
___________ ___________ ___________ |
pyelonephritis
acute prostatitis epididymitis |
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fever may present in cancer of:
_______ _______ _______ |
kidney
bladder testes |
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older men with fever, frequency and urgency - do a _____ but not a ___________ because they can get septicemia
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DRE
proastatic massage |
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usually the ______ kidney isn't palpable, if it is, do a work-up
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left
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may be renal artery stenosis, AV malformation, aortic bruits, or transmitted heart sounds
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systolic bruits
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for patients with flank pain, test with pin prick for ______________
may indicate nerve root irritation and radiculitis rather than ____________ |
hyperesthesia
renal pain |
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the bladder is normally not palpable unless filled with ____ mL of urine
__________ is the better method of evaluation |
150
percussion |
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___________ means full bladder
___________ if air filled bowel is anterior to bladder |
dullness
tympanic |
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bimanual exam is better technique for evalutating suspected ___________ of the bladder
best method for assessing mobility and potential resectability |
neoplasm
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always retract the foreskin in uncircumcised males to evaluate ___________ and ___________
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urethral meatus
glans penis |
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what to look for at the urethral meatus (4)
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inflammation
discharge penile tumor skin lesions |
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unable to retract foreskin
usually resolves at puberty, otherwise gentle stretching or circumcision if severe |
phimosis
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once retracted, the foreskin is trapped behind the glans penis
early, may be able to reduce foreskin with lubrication, otherwise circumcision is neccessary |
paraphimosis
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when the urethral meatus is located on the ventral surface of the penis, scrotum, or perineum
urethral meatus is located on the dorsum of the penis |
hypospadias
epispadias |
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urethral tumors can be found with palpation of the __________ surface of the penis
plaques in the dorsal penile shaft that are palpable are seen in ___________ disease |
ventral
Peyronie's disease |
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thick yellow penile discharge is ____________ urethritis
thin white penile discharge is ____________ urethritis |
gonococcal
nongonococcal(chlamydia) |
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___________ masses account for a common cause of urological referrals
testis are usually _________ cm masses in the testes are usually ___________ |
scrotal
4.5 X 2.5 malignant |
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painless enlargemetn of one testicle needs _________
epididymal and spermatic cord masses are usually _________ ______________ distinguishes solid from cystic mass |
work-up
benign transillumination |
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____________ masses are:
painless firm solid within the testis don't transilluminate |
testicular
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masses in the ____________ or ______ are:
mobile with movement of the structure sometimes tender usually transilluminate |
epididymis or cord
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located outside the testis usually in the cord (4)
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varicocele
hydrocele spermatocele epididymitis |
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Cause:
infection from E. coli, chlamydia or gonorrhea urinary reflux Symptoms: painful enlargement of epididymis fever sometimes irritative voiding symptoms entire scrotum may be painful may have scrotal swelling and inflammation pain can refer to flank, mostly scrotal pain relieved with recumbant position |
Acute Epididymitis
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_______ sign: elevating the scrotum above the pubic symphysis provides relief
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Phren's sign
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early on may only be epididymal pain
later entire testicle may be painful (epididymo-orchitis) may appear as a large tender mass |
Acute Epididymitis
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Labs for Acute Epididymitis:
CBC shows leukocytosis and left shift If sexually transmitted, gram stain of discharge will show GNID (gram negative intracellular diplococci) which is _________________, or may show WBC’s without organisms c/w non gonococcal urethritis which is usually ___________________ If non sexually transmitted, ___ shows pyuria, bacteruria, and possibly hematuria Urine _____ demonstrates the organism |
Nisseria gonorrhoeae
Chlamydia trachomatis UA C&S |
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Imaging:
____ only helpful if exam is difficult because of large hydrocele |
US
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Differential
_______: painless, normal UA, normal epididymis on exam _________________: usually in prepubertal males, acute onset of sx, normal urine |
Tumors
Testicular tortion |
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Treatment:
Bed rest with scrotal elevation Antibiotics determined by pathogen GC – ____________ Chlamydia – ____________ Non sexually transmitted – usually _____________________ |
pen/ceftriaxone (rocephin)
Docycycline trimethoprim/sulphamethoxazole |
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Fluid collection between two layers of tunica vaginalis
Dx by transillumination Communicating and non communicating Must evaluate the testes |
Hydrocele
10% of all tumors have associated hydrocele |
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Engorgement of spermatic veins above the testes
Feels like “bag of worms” Usually not painful May be related to infertility in males Most always on left |
Varicocele
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Left spermatic vein empties into left ____________
Right spermatic vein empties into the ____________ |
renal vein
inferior vena cava |
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Acute onset of right varicocele
Raises the question of ______________________ blocking the right spermatic vein |
retroperitoneal malignancy
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The spermatic cord that supplies the blood supply to the testicle is twisted cutting off blood supply to testicle
Usually in 10-20 year age group Acute severe pain and swelling of testis |
Testicular torsion
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Torsion after _ hours – may be able to save testicle
After _ hours, impossible to save testicle |
6
8 |
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PE findings
Acute onset of pain and swelling “high lie” in relation to other testicle May be nausea and dizziness when blood supply compromised Acute onset, lack of voiding sx, and young age helps differentiate it from epididymitis |
Testicular torsion
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Imaging: scrotal _________ to ascertain inturruption in blood supply
Treatment is surgery to untwist the testicle and fix with _________________ Removal of testicle if _____________ |
doppler
suture to scrotal wall gangrenous |
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If patient notices ability of either or both testicles to freely rotate within the scrotum
Testicles that are lower and/or slightly rotated |
Risks for Testicular torsion
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Urinalysis - In male, can use 3 separate specimens
1st 5-10 ml represents ________________ 2nd (midstream) urine represents contents of _______ and ________________ Then, prostate is massaged, and prostatic secretions examined under microscope If no secretions, then next 2-3 ml of urine would represent ___________ pathology |
urethral specimen
bladder and upper urinary tracts prostate |
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normal urinary pH is _____
May be helpful in some conditions: alkaline urine in pt. with ______ suggests urea splitting organism such as proteus, klebsiella, staphylococcus Acidic urine in patient with urolithiasis suggests ____________ or ___________ Failure to acidify urine in _________________ suggests distal renal tubule acidosis |
5-8
UTI uric acid or cystine stone metabolic acidosis |
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Dipstick can detect protein
in concentrations exceeding ___ mg/dl Measures __________ Is not sensitive for the light chains of immunoglobulins (_________) False ________ in urines with large amounts of leukocytes or epithelial cells |
10
albumen Bence Jones positive |
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____________ is from catabolism of conjugated biliruben in the gut by bacteria
Most is cleared by the _______ Only 1- 4 mg excreted in the _______ per day Hemolytic process or hepatocellular dz will _________ urinary levels Biliary obstruction and some antibiotics that alter gut flora will __________ urinary urobilinogen |
Urobilinogen
liver urine increase eliminate |
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______________ bilirubin is not filtered by the glomerulus
Normally no bilirubin seen on dipstick Conditions with higher levels of conjugated bilirubin will result in _______ urinary levels Ascorbic acid (Vit C) phenazopyridine (pyridium) can cause false ___________ |
Unconjugated
higher positives |
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Glucose usually doesn’t register on dipstick due to small amount excreted
Any glucose in urine requires evaluation for _________ Test is specific for glucose so doesn’t cross react with other sugars Vit C (ascorbic acid) and elevated ketones can result in false _________ |
diabetes
negatives |
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not usually in urine
Exercise, fasting, diabetes and pregnancy can cause increased amounts False positives: Dehydration Presence of levadopa metabolites Presence of sulphydryl containing compounds |
Ketones
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Normally not in urine
Indication of bacteruria 1st morning void is best specimin False negatives: dilute or acidic urine, non reducing bacteria, urobilinogen False positives: contamination by bacteria now present in urine, but not in urinary tract |
Nitrites
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Enzyme produced by white cells
Suggestive but not diagnostic of bacteruria False positive from contamination False negative from urobilinogen, high specific gravity, glycosuria, and some medications (rifampin, vit c, pyridium) |
Leukocyte Esterase
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Blood
Dipstick measures: Intact ___________ Free ___________ myoglobin False positives Women – menstrual blood Concentrated urine – normally we excrete 1000 RBC’s per mililiter of urine Vigorous exercise Foods with high oxidant levels False negatives – high ___________ |
erythrocytes
hemoglobin ascorbic acid (Vit C) |
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Leukocytes
Presence of 5 or more/hpf = _________ Counts vary with hydration, collection methods, and degree of injury to urinary tract Usually means _________ Can also mean: Calculous Stricture Neoplasm TB Glomerulonephropathy Interstitial cystitis |
pyuria
infection |
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Microscopic Urinalysis:
Presence of squamous epilthelial cells usually means ___________ Transitional epi cells can be seen in small numbers, but in large amounts be very concerned for ________(clumping) Warrants _________ examination of urine |
contamination
neoplasm cytology |
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Microscopic Urinalysis:
Bacteria and Yeasts Requires culture when identified especially if uncontaminated specimen Number of organisms/hpf usually correlates with the culture results _________, most common yeast Characteristic budding and clumping Amount per ml doesn’t always signify the _________ of the infection |
Candida
severity |
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urinary proteins which precipitate out in the renal tubules forming the cylindrical impression of the tubules
best detected in fresh specimen on low power |
Casts
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RBC casts mean _____________ or ____________
Leukocyte casts mean ____________ Epithelial casts – small numbers are normal, large numbers indicate internal _____________ _________ casts – are from degeneration of other cellular casts, and usually mean intrinsic renal disease as well |
glomerulonephritis or vasculitis
pyelonephritis renal disease Granular |
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Uric acid, oxylate, cystine, usually in acid urine
Phosphate, mostly in alkaline urine |
Types of urinary crystals
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Uric acid, phosphate, and oxalate can be seen in normal patients as well as stone-formers
Cystine crystals: Characteristic hexagonal benzene ring Seen only in __________, therefore are pathologic |
cystienuria
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Blood in the urine (2-5 RBC’s per hpf)
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Hematuria
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Painful hematuria can be caused by a number of disorders, including _________ and ________ in the urinary tract
Painless hematuria can also be due to many causes, including _________ |
infections and stones
cancer |
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________ hematuria refers to blood that is so plentiful in the urine that the blood is visible, with just the naked eye
_______________- when blood is visible only under a microscope: there is so little blood that it cannot be seen without magnification |
Gross
Microhematuria |
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Initial hematuria: blood at the beginning of the urinary stream, that clears during the stream implies ________ source
Terminal hematuria: blood at the end of the urinary stream implies ____________ or _________ Total hematuria: blood throughout the urinary stream which implies a ________ or ____________ |
penile (urethral)
bladder neck or prostate bladder or upper tract source |
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Hematuria Associated Symptoms
Renal colic: suggests _______________ Irritative voiding symptoms: suggests inflammatory/infectious conditions such as ___________ |
obstructive uropathy (renal stones)
cystitis/prostatitis |
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Anticoagulants (warrants investigation including cytology)
Analgesic abuse causing papillary necrosis -Aspirin, phenacetin, indomethacin, mefenamic acid, naproxin, ibuprofen Cyclophosphamide (cancer cell immunosuppression) and chemical cystitis Antibiotics and Interstitial nephritis (inflammation of the space between the tubules and the tubules themselves) -Penicillin, ampicillin, methcillin, sulphonamides, Also NSAIDS, furosemide, thiazide diuretics |
drugs causing hematuria
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Diabetes Mellitus
Sickle cell trait or disease (papillary necrosis) Stone disease Malignancy |
assoicated medical problems causing hematuria
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Mostly in young adults
Microscopic hematuria on routine exam Gross hematuria associated with: Febrile illness, exercise, immunization Diagnosed when other possibilities excluded Renal bx is normal Excellent prognosis 50% have complete resolution within 5 yrs Very few develop declining renal function |
Benign recurrent hematuria
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Generally harmless
Usually gross hematuria after exercise More in males than females “March” hematuria |
Exercise hematuria
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50,000 new cases per year
Much more common in men Most important risk factor is cigarette smoking The most common presentation is gross or microscopic hematuria |
Bladder Cancer
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More common in men
Peaks in ages 20-45 Higher in developed countries because of higher intake of animal protein with low-fiber diet Presenting sx usually hematuria (gross or microscopic) with sudden onset colicky flank pain |
Nephrolithiasis
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Most frequent renal neoplasm
Accounts for 2% of all cancer deaths Male to female ratio 2:1 Peaks between ages 50 and 70 |
Renal Cell carcinoma
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Classic clinical manifestation of renal cell carcinoma:
Triad of __________, ____________, and ______________ Seen in only 10% of patients But, any one of these features present in over ½ of all the patients as initial manifestation of the tumor |
hematuria, flank pain, and palpable flank mass
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Renal medulla highly susceptible to vaso occlusion
Causes urinary concentration defects One of the most common complications of __________ is painless hematuria due to papillary necrosis Causes acute episodes of painless hematuria May continue for weeks, resolving spontaneously |
Sickle cell
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Gross hematuria in women with irritative voiding symptoms
Gross hematuria can be a sign of bladder cancer (especially in older patients) Must re-check urine when symptoms resolve to make certain blood has cleared Failure to resolve with antibiotic treatment means patient needs further evaluation of the bladder and kidneys |
Hemorrhagic Cystitis
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Causes of hematuria by age
Glomerulonephritis Urinary tract infection Congenital urinary tract problems |
Age 0-20
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Causes of hematuria by age
Urinary tract infections (females > males) Calculi Bladder cancer |
Age 20-40
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Causes of hematuria by age
Urinary tract infections (females > males) Bladder cancer Urinary calculi |
Age 40 – 60
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Causes of hematuria by sex
Benign prostatic hypertrophy Bladder cancer Urinary tract infection |
Age > 60 (men)
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Causes of hematuria by sex
Urinary tract infection Bladder cancer |
Age > 60 (women)
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Hematuria with fever, rash, lymphadenopathy, abdominal or pelvic mass is a ________________
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Systemic disease
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Hematuria with hypertension or volume overload is from ______________
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Medical renal disease
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Hematuria with an enlarged prostate, flank mass, or urethral disease needs ______________
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Urologic Evaluation
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UA and C&S:
_________ and cast formation suggests renal origin __________ suggests infection, especially with irritative voiding symptoms |
Proteinuria
Bacteruria |
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Urine cytology:
Especially helpful in ________________ Three specimens needed for maximum sensitivity |
bladder neoplasms
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Upper tract imaging:
Abdominal and pelvic ___with and without contrast Identify: ________ of the kidney or ureter _________ conditions- Urolithiasis Obstructive uropathy Papillary necrosis Medullary sponge kidney Polycystic kidney disease |
CT
Neoplasms Benign |
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CT and MRI have replaced _____ for upper urinary tract imaging for hematuria
________ in hematuria May help in kidney evaluation Questionable in identifying ureteral disease Results depend on high degree of operator dependence so may be questionable |
IVP
Ultrasound |
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Lower urinary tract:
Bladder neoplasms Urethral neoplasm Benign prostatic hypertrophy Radiation or chemical cystitis Active bleeding its preferred to allow better localization |
Cystoscopy
|
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Hematuria:
______________ source identified in 10% of the cases Stone disease is 40% Medical renal disease 20% 10% renal cell carcinoma Transitional cell carcinoma of the ureter or renal pelvis 5% |
Upper urinary tract
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Gross hematuria in the lower tract in absence of infection is most commonly ___________________ of the bladder
Microhematuria in the male is most commonly from ______ In negative evaluations for hematuria, repeat evaluations are warranted: __________ in 3-6 months __________ or imaging in 1 year |
transitional cell carcinoma
BPH Cytology Cystoscopy |
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|
Secretes a thin milky fluid to the semen during emmision
Adds bulk to the semen Is slightly alkaline, as opposed to the seminal fluid and vaginal secretions which are acidic Sperm motility is optimal at more alkaline pH |
Prostate Gland
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Infection or inflammation of the prostate gland. Can be acute, chronic, infectious or non infectious problem
Most common urologic diagnosis in men over age 50 Third most common overall diagnosis in men over age 50 |
Prostatitis
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Recent bladder or urethral infection
Recent catheterization Job that exposes patient to prolonged sitting and prolonged vibrations Truck drivers Heavy equipment operators Those who cycle on a regular basis |
Risk factors for Prostatitis
|
|
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Acute infection of the prostate -
Recurring infection of the prostate - |
Acute bacterial prostatitis
Chronic bacterial prostatitis |
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Chronic nonbacterial prostatitis/Chronic Pelvic Pain Syndrome (CPPS) subgroups are:
______________ – presence of WBC’s in semen, EPS (expressed prostatic secretions), or postmassage voided bladder urine (VB-3) ________________– WBC’s are not found in semen, EPS, or VB-3 |
Inflammatory CPPS
Non inflammatory CPPS |
|
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No subjective symptoms
WBC’s are found in prostatic secretions or prostate tissue during evaluation of other disorders |
Asymptomatic inflammatory prostatitis
|
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Relatively rare but serious systemic illness
Causative organism usually gram negative rods (E coli, pseudomonas) Route of infection: Reflux of infected urine into prostatic ducts Ascent of organisms up the urethra |
Acute Bacterial Prostatitis
|
|
|
Signs and symptoms:
Fever Chills Dysuria (irritative voiding symptoms) Sacral (low back) pain Perineal pain Obstructive symptoms and urinary retention as prostate swells |
Acute Bacterial Prostatitis
|
|
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PE of Acute Bacterial Prostatitis:
High fevers Warm and exquisitely tender prostate on DRE Prostate is ________(soft tissue that has hardened) Perform rectal exam with caution, avoid inducing _________/__________ -Some urologists recommend no rectal exam if the clinical diagnosis is apparent- |
indurated
bacteremia/septicemia |
|
|
Acute Bacterial Prostatitis Lab:
CBC – ____________ Urinalysis- ________(WBC’s) ________(bacteria, + nitrites, + culture) ________ Urine C&S should identify the offending organism |
leukocytosis
Pyuria Bacteruria Hematuria |
|
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Acute Bacterial Prostatitis Differential Diagnosis:
___________/____________– difference in the location of pain _________________– sometimes confused, but history and urinalysis helps distinguish the two ______________ from BPH or malignancy distinguished by initial and follow up DRE -Also by sx pointing to infection as etiology |
Pyelonephritis/Epididymitis
Acute diverticulitis Urinary retention |
|
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Acute Bacterial Prostatitis Treatment:
Hospitalization for acutely ill patients Parenteral antibiotics (usually __________ and ___________) to start, with appropriate antibiotics after culture and sensitivities available After afebrile for 24-48 hours, oral antibiotics can be started (oral ____________) for 4-6 weeks of therapy |
ampicillin and gentamycin
quinalones |
|
|
Acute Bacterial Prostatitis Treatment:
Urinary retention may occur, use ______________ to relieve Follow up urine cultures and EPS examination post treatment to ensure eradication of organism Rare cases of ___________ can occur |
percutaneous suprapubic tube
prostatic abcesses |
|
|
May evolve from acute bacterial prostatitis
Many men have it without history of acute bacterial prostatitis Usually gram negative rods (e-coli) Routes of infection same as acute bacterial prostatitis |
Chronic Bacterial Prostatitis
|
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Signs and symptoms
Perineal, suprapubic, groin, low back, and scrotal pain Perineal and suprapubic pain often dull and poorly localized Voiding difficulty- Dysuria, weak stream, frequency, urgency, nocturia |
Chronic Bacterial Prostatitis
|
|
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Chronic Bacterial Prostatitis
Signs and symptoms: __________ dysfunction decreased libido painful ejaculation Physical findings: __________ tenderness Testicular or epididymal tenderness Prostate tenderness on _____ Prostate usually normal size on palpation May be enlarged if concomitant _____ |
sexual
Abdominal DRE BPH |
|
|
when there are 10 times more WBC’s on EPS or on VB3 than on VB1 or VB2
May also compare pre and post massage urines for WBC’s or pathogens Presumptive diagnosis made on basis of UA and clinical findings |
evaulutation of Chronic Bacterial Prostatitis
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Chronic Bacterial Prostatitis
Treatment: __________ combined with ____________, has the best cure rates Other effective agents ________(Cipro, Avelox, Tequin) Treatment for _____ weeks Supression therapy for relapsing infections _______ and sitz baths for sx treatment |
Trimethoprim
sulphamethoxazole Quinalones 6-12 NSAIDS |
|
|
Same sx as chronic bacterial prostatitis
No causative organism identified Thought to be caused by chlamydiae, mycoplasmas, ureaplasmas, and viruses, but never proven |
Inflammatory CPPS
|
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Symptoms
Identical to chronic bacterial prostatitis Pelvic pain exacerbated by stress, certain dietary factors, or vigorous exercise Quality of life of patient is severely impacted |
Inflammatory CPPS
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Physical Exam:
DRE non specific Prostate may be tender or indurated Usually normal Urinalysis: _________, with normal C&S EPS: May have increased ____ But, it is ________ |
Normal
WBC’s sterile |
|
|
Treatment:
General measures such as NSAIDS and Sitz baths Some recommend ____________ for patients who ejaculate infrequently Antibiotics – controversial 2 week course (directed against ureaplasma, mycoplasma, or chlamydia) – usually ____________ Terminated if no response Continue for six weeks if there is a response |
prostatic massage
erythromycin |
|
|
Important in CPPS:
In older men with irritative voiding symptoms and negative cultures, ____________ must be excluded |
bladder cancer
|
|
|
Younger men, ages 20-50
Sx of prostatitis Voiding sx, pelvic pain Stress is frequently part of the problem Lab: Negative urine cultures, normal EPS Physical: Normal prostate on DRE |
Noninflammatory CPPS/Prostadynia
|
|
|
Prostadynia/Non Inflammatory CPPS Treatment:
Supportive measures (sitz baths, reduce stress, biofeedback) ___________ antagonists are the primary pharmacologic agents used to treat this condition - Terazocin (Hytrin) and doxazocin (Cardura) NSAIDS and ____ for chronic pain - Anticholinergic effects can help with frequency and urgency |
alpha adrenergic
TCA’s |
|
|
3rd most common urinary tract disorder
240,000-720,000 cases/year in America Men>women 3:1 Initial episode mostly in 3rd and 4th decade of life In 6th and 7th decade, men and women equally affected |
Urinary Stone Disease
|
|
|
Calcium oxalate
Calcium phosphate Struvite Uric acid Cystine |
5 major types of urinary stones
|
|
|
Most common stones are composed of ________, so most are radiopaque (85%)
________ stones are radiolucent, but frequently composed of uric acid and calcium oxyllate, so radiopaque |
calcium
Uric acid |
|
|
Geographics:
High _________ and elevated ______ contribute to stone formation Incidence of symptomatic stones greatest during hot summer months |
humidity
temps |
|
|
Contributing factors
Diet: Increased ________ intake Increased ________ High ________(beer, choclate, brewed tea, almonds, peanuts, pecans, walnuts, certain fruits) High _______ (organ meats, alcohol, anchovies, sweet breads, game meats, gravy) Sedentary occupations and lifestyles |
sodium
protein oxalate purine |
|
|
Urinary Stone Disease Contributing factors
Genetics: Distal renal tubular ________- May be hereditary Stones in 75% of these patients __________ is autosomal recessive disorder Homozygous individuals have increased excretion of cystine Numerous recurring episodes of cystine stones |
acidosis
Cystinuria |
|
|
Colic
Occurs suddenly, may awaken patients from sleep Localized to flank Severe, with associated N and V Episodic, radiates to abdomen, testical, labia Patients constantly moving Increased urinary urgency and frequency if stone lodges in UVJ (ureterovesicular junction) Stone size does not correlate with symptom severity |
pain asso with urinary stones
|
|
|
Lab: UA
microscopic or gross ________ in 90% of patients But, absence does not exclude stone R/O infection, because infection with __________ needs prompt treatment pH gives clue to possible type of stone Persistent below _____ suggestive of uric acid or cystiene stone (radiolucent on plain film) Persistent above _____ suggestive of struvite (radiopaque on plain films) |
hematuria
obstruction 5.5 7.2 |
|
|
Plain film and _________ will diagnose most stones
_________ is prime method of evaluating flank pain All stones visible on non contrast CT whether radiopaque or radiolucent on plain film UVJ stones (suspected) can be evaluated by ___ with the aid of a full bladder Always recover stones for stone analysis |
renal ultrasound
Spiral CT US |
|
|
Recurrent stone-formers or patients with stone disease need extensive evaluation:
_______ urine on random diet for volume and pH, as well as calcium, uric acid, phosphate, sodium, oxyllate, and citrate excretion. _____ and calcium load tests |
24 hour
PTH |
|
|
To prevent recurrence, must have stone free status, ie eliminate stone fragments that will serve as _______ for future stones
_________ stone patients will have recurrence within months if not treated 50% of stones surgically removed will recur in 5 years if no follow up medical treatment |
nidus
Uric acid |
|
|
Fluid intake most important
Double previous fluid intake Taking in fluids only during the day may not Patients encouraged to sleep “stone side down” supersaturate overnight, and precipitate stone formation |
Treatment and Prevention of Urinary Stones
|
|
|
_____________ stones can be caused by absorptive, resorptive, and renal disorders
Hypercalciuric calcium nephrolithiasis: >200mg calcium/24 hours >4mg/kg/24 hours |
Hypercalciuric
|
|
|
Caused by increased absorption of calcium in the small bowel - _______________
|
Absorptive hypercalciuria (3 types)
|
|
|
____________________ from hyperparathyroidism
Hypercalcemia, hypophosphotemia, and hypercalciuria Elevated PTH Treat with surgical resection of parathyroid adenoma - Cures urinary stones |
Resorptive hypercalciuria
|
|
|
Renal tubules unable to reabsorb filtered calcium
Hypercalciuria results Causes secondary hyperparathyroidism _____________ are effective as long term therapy |
Renal Hypercalciuria
Thiazides |
|
|
_____________ stones
Causes: dietary excess of uric acid or metabolic defects Both can be treated with- Dietary restrictions Allopurinol |
Hyperuricosuric
|
|
|
____________ stones
Usually due to primary intestinal disorders History of chronic diarrhea associated with IBDz or steatorrhea Pathology- Increased fat combines with calcium. Calcium unavailable bind oxylate Oxylate freely absorbed Increased oxylate increases stone formation |
Hyperoxaluric
|
|
|
Hyperoxaluric stones Treatment:
Control diarrhea or steatorrhea Give oral _________ supplements with meals Increase ________ intake |
calcium
fluid |
|
|
Normal urine pH is _____
Uric acid stone formers typically have pH of less than _____ Increasing the pH above _____ increases solubility and dissolves large calculi |
5.85
5.5 6.5 |
|
|
______________ is the most frequently used med to increase pH of urine -
Taken as crystals given with fluid (10 meq) QID Patients given Nitrazine pH paper to measure urinary pH |
Potassium citrate
|
|
|
Contributing factors to uric acid stones:
Hyperuricemia, myeloproliferative disorders, abrupt weight loss, uricosuric medications Treat hyperuricemia with ____________ (Xyloprim) 300 mg/day |
allopurinol
|
|
|
_________ stones
Magnesium ammonium phosphate stones Mostly in women with recurrent UTI’s that don’t respond to appropriate antibiotics Frequently a “staghorn” calculus, forming a cast of the renal collecting system |
Struvite
|
|
|
Struvite stones:
Radiodense, need _____, ________, or __________ Urinary pH usually above 7.2 Caused by infections from urease-producing organisms Proteus, Pseudomonas, Providencia Less commonly by Klebsiella, Stahylococcus, and Mycoplasma NOT CONSISTANT WITH ________ INFECTION |
IVP, helical CT, or ultrasound
E-COLI |
|
|
Struvite Stones:
Stones are soft, and do well with ___________________ Recur rapidly, should take all precautions to make patient stone free Need post op irrigation to remove all stone fragments (nephrostomy tube) Acetohydroxamic acid is good urease inhibitor, but has significant ____ toxicity |
percutaneous lithotomy
GI |
|
|
_________ stones
Etiology: Cystinuria – inherited genetic disorder Abnormal excretion of cystine, (least soluble of all naturally occuring amino acids) Heralded by cystine crystals in the urine forming calculi |
Cystine
|
|
|
Cystine stone Treatment and Prevention:
Increased fluid intake (3-4 L/day) Maintain urinary pH above 7.5 (give _________) Penicillamine and tiopronin (if above fails) Treatment when medical efforts fail, do _____________________ |
K+ citrate
ultrasounic lithotripsy |
|
|
Three sites where stones get stuck -
___________ junction Crossing of ureter over _______vessel ___________ junction |
Ureteropelvic
iliac Ureterovesicular |
|
|
Stone less than __ mm on plain film usually passes
Can observe for __ weeks with appropriate pain meds If no passage, intervention is required |
6
6 |
|
|
Distal ureteral stones best managed with Ureteroscopic _____________ or extracorporeal _________________
|
stone extraction
shock wave lithotripsy |
|
|
Indications for _______________ earlier than 6 wks:
Pain unresponsive to medication Fever Persistant nausea and vomiting requiring IV hydration Patient has to return to work Anticipated travel |
surgical intervention
|
|
|
Proximal and mid ureteral stones (above the inferior margin of the SI joint)-
SWL or ____________(rare) |
ureteroscopy
|
|
|
Renal stones without pain, UTI’s, or obstruction
need not be treated but followed with serial radiographs and ___________ If growing, or symptomatic, intervention should be undertaken - Those less than 2 cm best treated with _____ __________________ for recurring and larger diameter stones |
ultrasound
SWL Percutaneous nephrolithotomy |
|
|
Urinary Tract Infections:
One of the most common things you will see In acute infections, usually one pathogen, in chronic infections, two or more Usually coliform bacteria Most common is _______ |
E coli
|
|
|
Non nosocomial infections usually respond to many antibiotics and respond quickly to them
Nosocomial causes are more resistant bacteria, and usually require ____________ AB’s |
parenteral
|
|
|
occurs when urinary tract not sterilized during therapy.
Causes: Bacterial resistance Non compliance Mixed infections where some of the pathogens are resistant Renal insufficiency Rapid emergence of resistant organism that was initially sensitive |
Unresolved bacteriuria
|
|
|
urinary tract initially sterilized during therapy, but persistant source of infection remains:
Infected stones Chronic pyelonephritis Fistulas Obstructive uropathy Foreign bodies Urethral diverticula |
Persistent bacteriuria
|
|
|
UTIs:
________ is most common route mostly in women due to shortened urethra and bacteria in vagina Sexual intercourse is precipitating factor Use of diaphragms and spermacides alters vaginal flora _____________ occurs with ascending infection up the ureter |
urethra
Pyelonephritis |
|
|
Routes of infection:
Hematogenous spread - unusual, exception being __________ and cortical renal abcess Lymphogenous spread – unusual and rare Direct extension – from other organs, especially from intraperitoneal abcesses in ____ or ____ |
tuberculosis
IBD or PID |
|
|
Susceptibility Bacterial virulence:
Fimbriated strains of E coli are associated with ____________ in the normal urinary tract Non fimbriated strains are associated with pyelo only when ________________ is present |
pyelonephritis
vesicoureteral reflux |
|
|
Host susceptibility factors Urinary tract factors:
Problems with emptying the bladder Problem with glycosaminoglycan layer in bladder which normally interferes with __________ adherence Lack of antimicrobial properties of urine such as high osmolality and extremes in ___ Vesiculoureteral reflux, deminished renal blood flow, and intrinsic renal disease may increase ___________ involvement |
bacterial
pH upper tract |
|
|
Female-specific Host susceptibility factors:
Short ________ More urinary tract mucosal binding sites for pathogens in women with recurrent UTI’s Lack of fucosyltransferase secretions (nonsecretors) |
urethra
|
|
|
Male specific Host susceptibility factors:
______________ males have higher incidence of UTI’s ________________ causes lower zinc levels in prostatic secretions |
Uncircumcised
Bacterial prostatitis |
|
|
UTI prevention:
Prophylactic antibiotics with more than ___ episodes of cystitis per year Need thorough urologic evaluation prior to starting therapy to R/O _____________ Single dose at bedtime or at intercourse is the recommended regimen Most commonly used are _________, nitrofurantoin, cephalexin |
3
anatomic abnormality TMP/SMX |
|
|
Bladder infection
Due usually to E coli Typically ascending from the urethra Symptoms and signs: Irritative voiding symptoms Suprapubic discomfort Gross hematuria may occur Sx often appear after intercourse Physical exam usually reveals suprapubic tenderness but may be normal No systemic toxicity |
Acute Cystitis
|
|
|
Lab:
Pyuria Bacteriuria Varying degrees of hematuria Above may not correlate with the severity of sx Urine culture + for bacteria, but counts > 105 not necessary for diagnosis Imaging: No need unless pyelo, recurring infections, or anatomic abnormalities suspected |
Acute Cystitis
|
|
|
Differential Diagnosis:
Women- Vulvovaginitis and _____ Men- __________ and ___________ Cystitis in men is rare and usually means pathologic process such as stone, prostatitis or urinary retention which needs further workup |
PID
Urethritis and prostatitis |
|
|
Pelvic irradiation
Chemotherapy (cyclophosphamide) Bladder cancer Interstitial cystitis Voiding dysfunction disorders Psychosomatic disorders |
Acute Cystitis Differential Diagnosis (non infectious causes)
|
|
|
Acute Cystitis Treatment:
Uncomplicated cystitis usually treated with short term antibiotics for ____ days TMP/SMX was the d.o.c., but a number of resistant organisms have emerged New d.o.c.’s for uncomplicated cystitis are _____________ and _____________ Sitz baths and phenazopyridine (pyridium) may provide relief In men, underlying problem should be investigated since cystitis is rare |
1-3
fluoroquinolones and nitrofurantoin |
|
|
Infectious inflammatory disease involving the kidney parenchyma and renal pelvis
Usually gram negative bacteria - E coli, Proteus, Klebsiella, Enterobacter,and Pseudomonas Rare gram positive - Enterococcus faecalis and Staphylococcus aureus Usually ascends from the lower urinary tract Except staph which is hematogenous route |
Acute Pyelonephritis
|
|
|
Symptoms:
Fever Flank pain Shaking chills Irritative voiding symptoms Nausea, vomiting, diarrhea are common Signs: Fever and tachycardia Pronounced CVAT |
Acute Pyelonephritis
|
|
|
Acute Pyelonephritis Imaging:
In complicated pyelonephritis, _______________ may be helpful if there is hydronephrosis from stone or other obstruction Hydronephrosis – an accumulation of fluid in the pelvis of the kidney due to ____________ |
renal ultrasound
obstruction |
|
|
Differential Diagnosis:
Any ____________ disease (Appendicitis, cholecystitis, pancreatitis, diverticulitis) Normal urinalysis usually seen with these Also, abnormal liver functions or _________ levels may help in the differentiation Lower lobe pneumonia may present same way, distinguishable by _________ Males - Epididymitis, prostatitis, cystitis Physical exam and location of pain helps make dx |
intra-abdominal
amylase chest x-ray |
|
|
Acute Pyelonephritis Labs:
CBC - __________ with left shift UA - Pyuria Bacteriuria Hematuria (varying) Casts Urine C&S - Heavy growth of offending agent Blood culture may also be positive (_________) |
Leukocytosis
Urosepsis |
|
|
Acute Pyelonephritis complications:
Sepsis and shock ________________ from gas-producing organisms in diabetics can be life threatening Healthy adults usually recover, but those with renal problems may be left with scarring or chronic pyelo. __________ could result from inadequate therapy |
Emphysematous pyelonephritis
Renal abcess |
|
|
Acute Pyelonephritis Treatment:
Severe infection or complicating factors requries _____________ Urine and blood __________ to identify pathogens and sensitivity IV ____________ and aminoglycoside started intitially until culture results are available |
hospitalization
cultures ampicillen |
|
|
For outpatient therapy, _____________ or _____________ may be started pending culture and sensitivity results
Fever may persist for up to ___ hours Failure to respond warrants imaging, usually ___________ to rule out complicating factor that requires intervention |
fluoroquinolones or nitrofurantoin
72 ultrasound |
|
|
___________ for urinary retention
___________ drainage (tube) for ureteral obstruction Inpatients, IV antibiotics for 24 hours after fever resolves, then oral antibiotics for __ day course of therapy Follow up urine cultures for several weeks post therapy completion |
Catheter
nephrostomy 7 |
|
|
Pain with full bladder, relieved by emptying, with associated urgency and frequency
Urine cultures and cytology are negative, and there is no other obvious cause such as radiation cystitis, chemical cystitis (cyclophosphamide), vaginitis, urethral diverticulum, or genital herpes a diagnosis of exclusion |
Interstitial Cystitis
|
|
|
Interstitial Cystitis:
Majority affected are _______ Mean age at onset is 40 History of _________ problems in childhood Higher prevalence in Jewish women Spontaneous remissions with average remission of 8 months without treatment Associated diseases: Severe allergies ___ and ___ |
women
bladder IBS and IBD |
|
|
Interstitial Cystitis Lab:
Always get ___ and ___ to r/o infectious process. They will be normal Always get urine ________ to r/o malignant process Urodynamic testing checks bladder sensation and compliance and excludes ________ muscle instability |
UA and C&S
cytology detrusor |
|
|
Cystoscopy:
Bladder distended with fluid Observation for _____________ (may or may not be present) _____ done to r/o cancer, eosinophyllic cystitis, or tuberculosis cystitis |
submucosal hemorrhages
Biopsy |
|
|
Interstitial Cystitis Treatment:
No cure symptomatic relief: Hydrodistention ___________ frequently used as 1st line medical therapy Calcium channel blockers (especially ___________) |
Amitriptyline
Nifedipine |
|
|
Interstitial Cystitis Treatment:
Pentosan polysulphate sodium (Elmiron) helps restore ______________ and helpful in some patients in clinical trial Bladder ___________: DMSO Heparin Bacillus Calmette-Guerin (BCG) |
bladder epithelial integrity
instillations |
|
|
Other modalities:
Transcutaneous electronic nerve stimulation (TENS) ____________ Surgery is the last resort - Cystourethrectomy with _____________ |
Acupuncture
urethral diversion |
|
|
Occurs when urine leaks involuntarily
Continence is dependent on: Compliant reservoir Sphincteric efficiency |
Urinary Incontinence
|
|
|
Loss of urine at all times and in all positions
Results as loss of sphincter efficiency - Surgery, nerve damage, cancer Also when abnormal connection exists between urinary tract and skin, bypassing the sphincter - Vesicovaginal or ureterovaginal fistula |
Total incontinence
|
|
|
Treatment of total incontinence – ________
Congenital etiology: Ectopic ureteral orifices, urethral diverticula, bladder extrophy Acquired etiology: Vesicovaginal fistulas Sphincter injuries following prostatectomy |
surgery
|
|
|
Loss of urine with activities associated with increased abdominal pressure - Coughing, sneezing, lifting, exercising
Laxity of pelvic floor musculature resulting in urethral sphincter insufficiency - Multiparous women or as a result of pelvic surgery |
Stress incontinence
|
|
|
Stress incontinence treatment:
Topical __________ cream if hypoestrogenism of the of the urethra or vagina is discovered _________ to lengthen urethra and place bladder in correct position Transvaginal or suprapubic sling __________ injectables to increase outlet resistance |
estrogen
surgery Periurethral |
|
|
Uncontrolled loss of urine preceded by strong unexpted urge to void
Not related to position or activity Due to detrusor hyperactivity or sphincter dysfunction Inflammatory conditions or neurogenic disorders of the bladder are associated with urge incontinence |
Urge incontinence
|
|
|
Urge incontinence treatment:
______________ medications such as oxybutinin (Ditropan) or tolterodine (Detrol) TCA’s – usually ____________ (Tofranil) at bedtime _________ nerve stimulation if urge incontinence is refractory |
Anticholinergic
imipramine Sacral |
|
|
Chronic urinary retention is the cause
Maximally distended bladder receiving more urine causes intravesicular pressure to exceed outlet resistance Small amounts of urine dribble out |
Overflow incontinence
|
|
|
Overflow incontinence treatment:
_________ acutely If ____ is cause - Medication or surgery Urethral ____________- internal urethrotomy or open urethroplasty __________ causes (external sphincter spasticity) - Intermittent catheterization with or w/o meds |
Catheter
BPH strictures Neurogenic |
|
|
Urinary Incontinence PE:
Exclude _______ in case of total incontinence ___________ abnormalities in cases of urge incontinence ____________ in cases of overflow incontinence |
fistula
Neurologic Distended bladder |
|
|
Urinary Incontinence PE:
Normal anal tone suggests intact external sphincter Lax sphincter suggests _______________ disease ______________ reflex further gives information regarding lower motor neuron problems |
lower motor neuron
Bulbocavernosis |
|
|
Urinary Incontinence Labs:
UA and C&S to r/o __________ _________functions (may be abnormal in overflow incontinence) __________ for fistulas and bladder neck problems in stress incontinence Post void residual volume measurements by catheterization and ultrasonography in __________ incontinence |
infection
Renal Cystograms overflow |
|
|
Urinary Incontinence Special tests:
__________ evaluation to assess bladder and sphincteric function Indicated- patients with moderate to severe In those suspected of having neurologic disease Urge incontinence where infecion and neoplasm excluded ___________ measures bladder capacity, accomodation, sensation, voluntary control, contractility, and response to pharmacologic intervention _________function - necessary in the w/u of incontinence |
Urodynamic
Cystometry Sphincteric |
|
|
the consistent inability to maintain an erect penis with sufficient rigidity to allow sexual intercourse
Age related Present in 25% of all men over age 65 Most cases have ________ rather than psychogenic cause |
Erectile Dysfunction
organic |
|
|
Loss of _________ due to androgen deficiency (decreased testosterone or gonadotropin) due to hypothalamic, testicular, or pituatary disease
Loss of ________ due to arterial, venous, neurogenic, or psychogenic causes Concurrent medical problems May damage one or more of the mechanisms of erection Medications: ______________ especially Centrally acting sympatholytics (clonidine) Beta blockers (decrease libido) Alpha blockers and dieuretics rarely cause erectile problems |
libido
erections Antihypertensives |
|
|
History may give a clue
Does the patient have early morning erections or erections during sleep? If so, probably not ________ cause Has the loss of erections been gradual over a period of time? More suggestive of organic cause Is there loss of emission? Several underlying organic disorders (especially _________ deficiency causing lack of prostatic and seminal vessel secretions) |
organic
androgen |
|
|
Causes of _____________:
Mechanical disruption of the bladder neck (TURP) Sympathetic denervation Meds (alpha blockers) Diabetes mellitus Radical pelvic or retroperitoneal surgery |
Retrograde ejaculation
|
|
|
Loss of orgasm with normal libido and erection is usually ____________
Premature ejaculation is usually _________ related that has no organic cause ____________ 25 mg prior to intercourse usually delays ejaculation 25% of all sexual dysfunction may be __________ related |
psychogenic
anxiety Clomipramine drug (meds) |
|
|
Physical Exam:
Assess __________ characteristics Neurologic and peripheral vascular exam Motor and sensory exam Lower extremity vascular pulses Genitalia exam for penile scarring and plaque formation (__________ dz) Abnormalities in size and/or consistency of ______ _________ exam |
secondary sex
Peyronie’s testes Prostate |
|
|
Lab:
______,______,______,______ Serum testosterone and prolactin Abnormal testosterone or prolactin needs serum ____ & ____ and _____________ consultation |
CBC, UA, lipids, Glucose
FSH & LH endocrinologic |
|
|
Special Testing:
Injection of vasoactive substances into the penis, will induce erections if intact _________ system ________________ testing devices during night will record frequency and rigidity of erections Patients with psychogenic impotence will have normal erections with this testing |
vascular
Nocturnal penile tumescence |
|
|
if penile injections do not produce erection:
Diameter and flow of cavernous arteries by _____________ If poor arterial flow without hx of PVD, get pelvic ____________ before arterial reconstruction |
duplex ultrasound
arteriography |
|
|
If normal arterial flow, may have venous leak, and should have:
_____________ - measuring flow required to get erection _____________ - contrast study to identify venous leak |
Cavernosometry
Cavernosography |
|
|
Treatment of ED:
Hormonal replacement __________ injections or topical patches 200 mg IM Q 3 weeks Topical patches 2.5-6mg/d Offered to men with documented ___________ deficiency Have undergone ___________ evaluation Have had PSA screening and DRE to r/o ___________ cancer |
Testosterone
androgen endocrinologic prostate |
|
|
Treatment of ED:
Vasoactive therapy Direct injection of _____________ into penile base Complications include _________, _________, fibrosis, and infection Rare prolonged _________ requires epinephrine and phenylephrine injection and aspiration of blood to achieve detumescence _______________ delivering vasoactive prostoglandins are available also |
prostoglandins
dizziness, pain erection Urethral suppository |
|
|
Treatment of ED:
Sildenafil (_______) In a class of drugs known as PDE (____________) ___ mgof sildenafil is taken 1 hour prior to sexual activity with peak action at 2 hours |
Viagra
phosphodiesterase 50 mg |
|
|
Treatment of ED: Viagra
No effect on libido, and no problem with priapism nitrites (TNG) may reduce cardiac preload and cause _________ aortoiliac atheroschlerotic disease will ________ the efficacy of the med Newer phosphodiesterase 5 inhibitors with longer half life are: Vardenifil (________) Tadalifil (______) Both have longer half lives |
hypotension
decrease Livitra Cialis |
|
|
Treatment of ED:
Penile Prosthesis Implanted directly into the ________ bodies May be rigid, malleable, hinged, or inflatable Variety of sizes and diameters Inflatable are more cosmetic, but more prone to _________ failure |
corporal
mechanical |
|
|
Treatment of ED: Surgery
Disorders of the _______ system Arterial reconstruction: Endarterectomy and ballon dilation for _______ arterial occlusion Arterial bipass procedures using epigastric arterial or deep dorsal vein venous segments for _______ occlusion |
arterial
proximal distal |
|
|
Treatment of ED: Surgery
_________ disorders Ligation of certain veins (deep dorsal and emissary veins) of the _____________ Experience with this type of surgery still limited and patients frequently fail to achieve rigid erections after surgery |
Venous
corpora cavernosa |
|
|
6 months of unprotected intercourse with no fertilization -
Less than 20 million sperm/ml in the ejaculate - Absence of sperm - Takes 74 days, so it is important to review history for the past 3 months - |
Infertility
Oligospermia Azoospermia Spermatogenesis |
|
|
Infertility History
Prior testicular insults: Torsion ____________ (one or both testes undescended) Trauma Infection: Mumps _________ Epididymitis Environmental factors: Excessive _____ , radiation, chemo |
Cryptorchidism
Orchitis heat |
|
|
Infertility History
Medications: ___________, cimetidine, spironolactone may affect spermatogenesis ________ lowers FSH Sulfasalazine and nitrofurantoin affect ________ Drugs such as __________ affect spermatogenesis |
Anabolic steroids
Phenytoin motility marijuana |
|
|
Infertility - Medical and surgical history
Loss of libido and headaches or visual disturbance can mean _________ tumor Thyroid or liver disease can cause abnormal _____________ Diabetic neuropathy associated with _____________ ejaculation Pelvic or retroperitoneal surgery causing absent ______________ due to sympathetic nerve injury ________ repair causing damage to vas deferens or testicular blood supply |
pituitary
spermatogenesis retrograde seminal emission Hernia |
|
|
Infertility - Physical Exam
__________ Underdeveloped _________________ Gynecomastia Diminished male pattern _______ distribution Eunichoid skeletal proportions: Arm span __ inches > height upper/lower body ratio < 1 |
Hypogonadism
secondary sex characteristics hair 2 |
|
|
Infertility - Physical Exam
__________contents: Testicular size (4.5 x 2.5 cm) Varicoceles Palpation of: Vas deferens Epididymis _________ |
Scrotal
prostate |
|
|
Infertility Lab
Semen analysis 72 hours after __________ Analysis w/in __ hour after collection Semen values Sperm concentrations should be above ___ million/ml Volume should be between ___ and ___ mls Motility – should be more than 50-60% motile Should have more than 60% normal morphology |
abstinence
1 20 1.5 and 5 mls |
|
|
Low ________ due to retrograde ejaculation or androgen deficiency
Abnormal _________ due to antisperm antibodies or infection Abnormal _________ from varicocele, infection, or exposure history |
volumes
motility morphology |
|
|
Infertility - Endocrinologic Lab
Elevated FSH and LH with low testosterone could mean primary testicular failure, which is usually reversible (________________________) Low FSH and LH with low testosterone is associated with secondary testicular failure and may be hypothalamic or hypopituatary In origin (_________________________) In these cases must do serum prolactin to exclude __________ |
hypergonadotrophic hypogonadism
hypogonadotrophic hypogonadism prolactinoma |
|
|
Infertility Imaging
Scrotal ultrasound: Subclinical ___________ Vasography: Suspected _____________ |
varicocele
ductal obstruction |
|
|
Infertility Special testing
Azoospermic patients should have post masturbation ________ samples to exclude retrograde ejacultion Azoospermic patients with ejaculate volumes less than 1 ml should have ejaculate __________ levels Its absence implies ejaculatory duct blockage |
urine
fructose |
|
|
Infertility Treatment - Education
Timing of intercourse in relation to ________ Avoidance of ___________ which may be spermicidal Removal of toxic agents or _________ which would interfere with fertility Treatment of active ______ |
ovulation
lubricants medications UTI |
|
|
Infertility Treatment
Hypo hypogonadism is treated with ______________ if primary pituitary disease has been r/o 2000 units IM 3x/week If no increase in sperm counts after 12 mo FSH therapy ________- 75 IU FSH and 75 IU LH in premixed vial ½ to 1 vial 3x/week |
chorionic gonadotropin
Pergonal |
|
|
Infertility Treatment: Retrograde Ejaculation
Alpha adrenergic agonists (______________ 60 mg TID) ___________ (Tofranil) 25 mg TID Collection of post masturbation urine for intrauterine insemination |
pseudoephedrine
Imipramine |
|
|
Infertility Surgical treatment
__________ – scrotal, inguinal, or laproscopic approach ________ obstruction – transurethral resection and unroofing of ducts in prostatic urethra _____________ obstruction – microsurgical approach (vasovasostomy and vasoepididymostomy) |
Varicoceles
Ductal Vas deferens |
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non malignant enlargement of the prostate gland
The most common benign tumor in men Age related Risk factors- Possibly genetic/possibly race |
BPH
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Two necessary factors for development of BPH are ____ and _____
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DHT and aging
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BPH is hyperplasia due to increase in cell numbers
Can be ________ cells (collagen and smooth muscle, supportive framework) - responds better to _______ blocker therapy Can be __________ cells - responds better to ____________ inhibitors |
stromal
alpha epithelial 5 alpha reductase |
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prostate has essentially 4 zones -
________ ________ ________ fibromuscular stroma ________ The transition zone surrounds the urethra, and is the origin of BPH |
Peripheral
Central Anterior Transition |
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___________ obstruction:
Intrustion of hyperplastic tissue into the lumen or bladder neck Causes high bladder outlet resistance Poor correlation with prostatic size on DRE |
Mechanical
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_________ component:
Stroma is composed of smooth muscle and collagen Adrenergic nerve supply Level of autonomic stimulation controls the tone of the prostatic urethra ________ blockers will decrease this tone and decrease outlet resistance |
Dynamic
Alpha |
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Response of the bladder to obstruction:
_________ muscle hypertrophy and hyperplasia Collagen deposition Results in decreased bladder compliance and detrusor instability _______________ symptoms results from these secondary responses |
Detrusor
Irritative voiding |
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BPH Symptoms:
___________- Hesitancy Decreased force and caliber of stream Sensation of incomplete emptying Double voiding Straining to urinate Postvoid dribbling ___________- Urgency, frequency, nocturia |
Obstructive
Irritative |
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the most important tool used in evaluating these patients?
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AUA questionaire
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Seven questions on severity of complaints with complaints ranging 0-5
Score can be from 0-35 with increaseing severity of sx. AUA symptom index: _____ mild _____ moderate _____ severe |
0-7
8-19 20-35 |
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BPH Signs:
PE, DRE, neurologic exam Prostate size should be noted but may not correlate with the degree of severity of sx or obstruction Usually BPH is _______ firm enlargement of the prostate _________ should make you think of cancer and warrant evaluation (PSA, transrectal ultrasound, and biopsy) Examine lower abdomen to assess for distended _________ |
smooth
Induration bladder |
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BPH Lab:
____ to exclude infection or hematuria Serum ___________ to assess renal function if found renal insufficiency warrants _______________ ____ is optional |
UA
creatinine upper tract imaging PSA |
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Upper tract imaging recommended:
If concommitant _________________ Or complications from ____ Hematuria UTI Renal insufficiency Bladder stone disease _________ - Only to assist in determining the surgical approach if pt chooses surgical therapy |
urinary tract disease
BPH Cystoscopy |
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BPH DDx:
History of urethritis or prior urethral instrumentation or trauma would suggest possible urethral ________ or _________ contracture __________ with pain suggests bladder stones Abnormal DRE and elevated PSA means possible ____________ _____ identified by UA and culture But can also be due to BPH |
stricture
bladder neck Hematuria prostate cancer UTI |
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BPH DDx:
Bladder cancer may present with irritative voiding complaints but urinalysis usually shows __________ ___________ bladder mimics BPH but history of stroke, DM, back injury, or neurologic disease is obtained abnormal ______________ reflex Abnormal anal sphincter tone |
hematuria
Neurogenic bulbocavernosus |
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Patients with mild symptoms (those with AUA score <7) may be treated with ______________
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watchful waiting
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Bladder and prostate have alpha 1 adrenoreceptors
Long-acting alpha 1 blockers Once a day dosing with titration _________(Hytrin) 1 mg/d x 3d then 2mg/day x 11 days, then 5mg daily __________(Cardura) 1mg/d x7days, then 2mg/d x 7d then 4 mg daily SE: _________________, dizziness, tiredness, retrograde ejaculation, rhinitis, headache |
Terazocin
Doxazocin Orthostatic hypotension |
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Newer alpha 1 blockers:
__________ (Flomax) __________ (Uroxatrol) subtypes of alpha 1 blockers which are alpha ___ receptor blockers localized to prostate and bladder neck fewer side effects don’t need ___________ |
tamulosin
alfuzocin 1a dose titration |
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alpha reductase inhibitors:
Block the conversion of free T to ___ by blocking 5 alpha reductase reduce the size of the gland and reduce sx by affecting the _____________ component of the prostate ___ months therapy is required for maximum size reduction (20%) |
DHT
epithelial 6 |
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5 alpha reductase inhibitors:
___________(Proscar) May decrease the incidence in ____________ and need for operative treatment in men with moderate to severe symptoms __________(Avadart) Latest 5 alpha reductase inhibitor on market |
Finasteride
urinary retention Duasteride |
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Use of plants or plant extracts for medical purposes
Used in BPH initially in Europe, now in US Examples: Saw palmetto berry Echinacea root Pollen extracts Mechanisms of actions are unknown, and safety and efficacy have not been tested |
Phytotherapy
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Conventional Surgical therapy - ________
Absolute indications for surgery: Refractory ___________ Large bladder _________ Recurrent ____ Recurrent gross ___________ Bladder stones Renal insufficiency |
TURP (Transurethral resection of the prostate)
urinary retention diverticula UTI hematuria |
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Risk factors associated with TURP:
___________ ejaculation Impotence Urinary __________ Complications of TURP: ________ Urethral stricture or bladder neck contracture Perforation of the prostate capsule with extravasation ____________ syndrome: a hypovolemic, hyponatremic state resulting from the absorption of isotonic irrigationg solution |
Retrograde
incontinence Bleeding Transurethral resection |
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Clinical manifestations of transurethral resection syndrome:
_______, vomiting, confusion, ____________, bradycardia, and visual disturbances Risk increases if TURP lasts over ____ minutes Treatment: _________ Hypertonic _________ administration in severe cases |
Nausea
hypertention 90 Diuresis saline |
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In men with moderate to severe symptoms and small prostates
Often have elevated bladder necks and benefit from “incision” of the prostate More rapid and less morbid than TURP Lower incidence of retrograde ejaculation |
TUIP (Transurethral incision of the prostate)
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TUIP:
cutting instrument is inserted through the ________ no ________ tissue is removed Incision is made where the prostate meets the _________ |
urethra
prostate bladder |
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Performed when the prostate gland is over 100 grams
Other indications: bladder diverticula, bladder stones, and whether dorsal lithotomy position is or is not possible Suprapubic or retropubic approach |
Open prostatectomy
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Suprapubic is performed _____________
Is the operation of choice if there is concomitant _________ pathology Blunt dissection with finger to free the adenoma |
transvesically
bladder |
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____________ prostatectomy:
Retropubic incision Incision into surgical capsule of the prostate Adenoma is enucleated as in open prostatectomy Urethral catheter put in place |
Retropubic
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Laser therapy
Transurethral needle ablation of the prostate Transurethral electrovaporization of the prostate Hyperthermia (microwave) High intensity focused ultrasound Intraurethral stents Transurethral balloon dilation |
Minimally invasive therapies
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2nd most common urologic cancer
Men > women 3:1 Average age at diagnosis is 65 Cigarette smoking (60%) and industrial dyes and solvents (15%) are risk factors |
Bladder Cancer
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Bladder Cancer Signs and Symptoms:
_________ Irritative voiding symptoms Frequently ___________ ___________ on bimanual if large infiltrating cancers Hepatomegaly or supraclavicular lymphadenopathy if metastasis Lower extremity lymphedema |
Hematuria
asymptomatic Masses |
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Lab:
Hematuria Occasionally _________ ________ occasionally if ureteral obstruction _________ if chronic blood loss or bone marrow mets Exfoliated urothelium cells (normal and abnormal) on voided urine _________ useful for initial diagnosis and for recurrence |
pyuria
Azotemia Anemia Cytology |
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Imaging:
IV urography, ____, ____ or ___ if filling defects in the bladder But the presence of bladder cancer is determined by _________ and __________ Imaging in urologic cancers mostly in upper urinary tract evaluation and in staging of more advanced lesions |
US, CT or MRI
cystoscopy and biopsy |
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Diagnosis and staging of bladder cancer made by cystoscopy then _________________
__________ exam before and after the procedure for size, position and fixation of mass if present Resection using ___________ is carried to muscular area of bladder wall for staging purposes |
transurethral resection
Bimanual electrocautery |
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Pathology:
98% are _________, with 90% of those being transitional cell carcinomas Most are ___________ growths Higher grades lesions are sessile and ulcerated |
epithelial
papillary |
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Progression is 19-37% in grade ___ cancers
Caricinoma in situ may occur focally or diffusely, but is associated with ___________ bladder cancer and identifies a patient at increased risk for progression and recurrence |
I
papillary |
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___________ of the bladder:
2% of all bladder cancer in the US ___________ Cancer of the bladder: 7% of all bladder cancer in the US Associated with - Schistosomiasis Vesicle calculi Chronic catheter use Staging - _____________ |
Adenocarcinoma
Squamous cell TNM classification |
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Delivered by urethral catheter
To iradicate disease or reduce likelihood of recurrence in those who have had transurethral resection (most effective scenario) Weekly for 6-12 weeks with possible maintenance Increasing contact time to 2 hours increases efficacy |
Intravesical Chemotherapy
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Intravesical Chemotherapy Agents:
Thiotepa mitomycin, doxorubicin, BCG Side effects: _____________ sx, _____________, systemic sx are rare |
Irritative voiding
hemorrhagic cystitis |
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_________________ is initial form of surgery for all bladder cancers but muscle infiltrating cancers need more aggressive treatment
________ cystectomy: solitary lesions ________ cystectomy: Men – removal of bladder, prostate, seminal vesicles and surrounding fat and peritoneal attachments and lymph nodes Women – uterus, cx, urethra, anterior vaginal vault, ovaries, lymph nodes |
Transurethral resection
Partial Radical |
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Treatment Radiotherapy:
External beam over a ____ week period is used, but 10-15% of patients develop bladder, bowel, or rectal complications Local recurrence __________ after radiotherapy Increasing use with _________ to improve local and distant relapse rates |
6-8
common chemo |
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Combination chemotherapy (_________-based) Should be considered:
Before _______ in those with bulky lesions or regional disease With _________ in those with T2 or limited T3 without hydronephrosis Postoperatively in those with _________ with high risk of recurrence |
cisplatin
surgery radiation cystectomy |
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Cancers of the Ureter and Renal Pelvis:
Rare _________ is risk factor as is long history of __________ abuse Mostly ___________ cell Ca Gross or microscopic hematuria, sometimes with flank pain Urine cytology + |
Smoking
analgesic transitional |
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Cancers of the Ureter and Renal Pelvis:
____ or ____ shows intraluminal filling defect, unilateral non vis of collecting system, and __________ (most common sign) DDX: _______, blood clot, papillary necrosis, or inflammatory or infectious lesions Treatment based on size, depth and number of tumors present |
IVP or CT
hydronephrosis stone |
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_________ Carcinoma:
2.6% of all adult cancers 2005 – 36,160 cases with 12,660 deaths Peak incidence 6th decade of life with 2:1 ratio males to females ___________ is only identifiable risk factor |
Renal Cell
Cigarette smoking |
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Renal Cell Carcinoma -
Clinical presentation: 60% present with gross or microscopic ___________ ________ pain or abdominal mass in 30% of cases _______ found in only 10-15% of cases Symptoms of ______ (bone pain, cough) in 20-30% of patients Because of increased US and CT scanning, more renal tumors are found in asymptomatic patients incidentally |
hematuria
Flank triad mets |
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Renal Cell Carcinoma - Lab:
_________ in 60% of patients _____________ syndromes can occur - Signs and symptoms due to substance eminating from tumor or reaction to tumor Ex: inappropriate ADH, hormones, _____________ due to increased erythropoetin found in 5% of pts _______ much more common ___________ in 10% of patients |
Hematuria
Paraneoplastic Erythrocytosis Anemia Hypercalcemia |
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Renal Cell Carcinoma - Imaging:
Often 1st detected by IVP or CT ___ determines if it is solid or cystic ___ is the most valuable test for RCC ____ for lung mets _______ in patients with large tumors or with elevated alk phos MRI and duplex Doppler ultrasonography to establish presence of tumor _______ in renal vein or IVC in selected patients |
US
CT scan CXR Bone scans thrombus |
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Renal Cell Carcinoma - DDX:
Solid tumors of the kidney are RCC until proven otherwise __________: fat density on CT ___________ CA of renal pelvis: more centrally located on CT, involve the collecting system, and has + urine cytology _______ tumors: superior to the kidney _________: can’t differentiate pre-operatively Renal _______ Angiomyolipomas and oncocytomas are the other two main primary tumors of the kidney besides RCC |
Angiomyolipomas
Transitional cell Adrenal Oncocytomas abcess |
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Renal Cell Carcinoma - TX:
____________ is the primary treatment for localized RCC ____________ if single kidney, bilateral lesions, or significant renal disease |
Radical Nephrectomy
Partial nephrectomy |
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T/F
THERE IS NO EFFECTIVE CHEMPOTHERAPY AVAILABLE FOR METASTATIC RENAL CELL CARCINOMA |
TRUE
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2-3 cases per 100,000 yearly (rare)
Survival has improved due to development of effective chemotherapeutic combination regimens 95% are germ cell tumors Seminoma Nonseminoma Remaining 5% are non germ cell neoplasms Leydig cell Sertoli cell Gonadoblastoma |
Testicular Carcinoma
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Testicular Carcinoma is more common on _______, as is cryptorchism
_________ is the most common bilateral primary testicular tumor __________ is the most common bilateral testicular tumor (secondary tumor) |
right
Seminoma Lymphoma |
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Congenital factors related to development of testicular cancer:
5% associated with ___________ Risk higher in ____________ testis (1:20) and lowest in _________ testis (1:80) |
cryptorchism
intra-abdominal inguinal |
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2 major categories:
1. ___________ Embrynal cell carcinoma (20%) Teratomas (5%) Choriocarcinomas (<1%) Mixed cell types (40%) 2. ___________ (35%) |
Nonseminomas
Seminomas |
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Staging: Nonseminoma tumors
Stage __ - confined to testis Stage __ – regional lymph node involvement in the retro peritoneum Stage __ – distant mets |
A
B C |
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Staging: Seminoma (MD Anderson system used)
Stage __ - confined to testis Stage __ - retroperitoneal lymph node spread Stage __ – supradiaphragmatic nodal or visceral involvement |
I
II III |
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Testicular Cancer Clinical findings:
Most common symptom is ____________ of the testis Sensation of _________ Patient 1st to notice these sx, but typically delay seeking medical attention (3-6 months) 10% may have acute testicular pain from intratesticular ___________ 10% asymptomatic 10% have sx secondary to ___________ disease - Back pain, cough, low extremity edema |
painless enlargement
heaviness bleeding metastatic |
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Physical Exam:
_______ or enlargement of the testis Secondary ___________ present in 5-10% of cases _______________ adenopathy in advanced disease ________________ mass in advanced disease ___________ in 5% of germ cell tumors |
Mass
hydroceles Supraclavicular Retroperitoneal Gynecomastia |
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Lab:
____ – occasionally elevated in seminomas, but levels lower than in nonseminomas ____ – occasionally mildly elevated in seminomas, more often and higher levels in nonseminomas ____ – elevated in either type of tumor _______ in advanced disease Increased LFT’s in mets |
HCG
AFP LDH Anemia |
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Imaging:
Scrotal __________ can determine if mass is intratesticular or extratesticular After diagnosis made, clinical staging done by chest, abdominal, and pelvic ____ |
ultrasound
CT |
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Epididymitis
Hydrocele Spermatocele Varicocele |
DDX Scrotal Masses
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Bulky retroperitoneal disease or metastatic nonseminomas treated with __________ combination after orchiectomy
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cisplatin
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May be seen as
Late manifestation of widespread dz Initial presentation of occult dz Primary extranodal disease Treated with orchiectomy, prognosis depends on stage |
Secondary testicular tumors
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___________ is not a screening tool for urinary tract problems in asx adults
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dipstick UA
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