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326 Cards in this Set

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Which type of pain?

obstruction of ureter
urinary retention

prostatitis
pyelonephritis
viscus


capsule
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
two types of pain from obstruction:

_________ causes constant dull ache

_________ causes spasm causing colicky pain
distention

colic
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
acute; resulting from obstruction
ureteral pain
______ urinary retention: severe suprapubic discomfort

______ urinary retention: usually painless even with significant distention
acute

chronic
suprapubic pain w/o irritative voiding symptoms is rarely __________
vesicular (bladder)
pain of _______ however, referred to urethra, asso. w/ passing urine
cystitis
___________ Pain:

located in the perineum
is from inflammation
radiates to the LS spine, inguinal canals, lower extremities
can have painful urination
Prostate
penile pain in flacid penis, usually _______ or ___________
STDs

paraphimosis
penile pain in erect penis, __________ disease or __________
Peyronie's disease

priapism
Causes acute pain in the _______ radiating to the ispilateral __________:

trauma
torsion of the testis
epididymo-orchitis
scrotum

groin
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
usually on the left, dialated veins, feels like a bag of worms
varicocele
irritative voiding symptoms
urgency
dysuria
frequency
nocturia
Causes of increased _____________:

diabetes mellitis
diabetes insipidus
excess fluid ingestion
diuretics (caffeine and alcohol)
urinary output
causes of decreased _____________:

bladder oulet obstruction
neurogenic bladder disorders
extrinsic bladder compression
psychological factors (anxiety)
bladder capacity
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
hesitancy
uncontrolled release of last few drops of urine
post void dribbling
interruption in the urinary stream
intermittancy
causes of ____________:

prostatic hyperplasia
urethral stricture
neurogenic bladder
prostatic or urethral carcinoma
foreign body
obstructive voiding symptoms
involuntary loss of urine

total
stress
urge
overflow
incontinence
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
blood in urine

can be gross or microscopic

gross is _________ until proven otherwise
hematuria


malignancy
blood at the beginning of the stream that clears during the stream implies anterior _____________ source
initial hematuria

penile urethral
blood at the end of stream implies _____________ or _____________ source
terminal hematuria

bladder neck or prostatic urethral
blood throughout the stream implies _________ or ____________ source
total hematuria

bladder or upper tract source
renal colic with hematuria could mean a _______, but clots from a bleeding _________ can act the same way
stone

tumor
irritative sx in a young woman could suggest infection in the form of _____________, but in older women or men it could mean ___________
hemorrhagic cystitis

neoplasm
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
most common cause of pneumaturia is __________, then _______ cancer and ________ disease
diverticulitis

colon cancer

chron's disease
blood in ejaculate from prostatitis or semial vesiculitis

initial means from _________
terminal is usually from ____________
hematospermia

prostate

seminal vesicles
work up of hematospermia (3)
UA
DRE
prostatic massage w/ microscopic exam of secretions
__________ or ___________ with prostate biopsy in those with hematuria or abnormal DRE
cystoscopy

TRUS
most common symptoms of STDs

mucopuralent drainage from urethra in males and females with cervicitis or vagnitis in females
urethral drainage
bloody urethral discharge in an elderly patient suggests _______________
urethral carcinoma
usually ________ and/or ________ in STDs
dysuria

itching
may be from UTI or from alkaline urinary pH
cloudy urine
lymph in urine

causes:
fistula from lymph system to bladder
TB
retroperitoneal tumors

a rare symptom
chyluria
when asso. with other sx of UTI it helps localize the site of infection
fever
high fever in women usually means acute ___________

fever is usually not asso. with _________
pyelonephritis

cystitis
fever in men with urinary sx usually means:
___________
___________
___________
pyelonephritis
acute prostatitis
epididymitis
fever may present in cancer of:
_______
_______
_______
kidney
bladder
testes
older men with fever, frequency and urgency - do a _____ but not a ___________ because they can get septicemia
DRE

proastatic massage
usually the ______ kidney isn't palpable, if it is, do a work-up
left
may be renal artery stenosis, AV malformation, aortic bruits, or transmitted heart sounds
systolic bruits
for patients with flank pain, test with pin prick for ______________

may indicate nerve root irritation and radiculitis rather than ____________
hyperesthesia

renal pain
the bladder is normally not palpable unless filled with ____ mL of urine

__________ is the better method of evaluation
150

percussion
___________ means full bladder

___________ if air filled bowel is anterior to bladder
dullness

tympanic
bimanual exam is better technique for evalutating suspected ___________ of the bladder

best method for assessing mobility and potential resectability
neoplasm
always retract the foreskin in uncircumcised males to evaluate ___________ and ___________
urethral meatus

glans penis
what to look for at the urethral meatus (4)
inflammation
discharge
penile tumor
skin lesions
unable to retract foreskin

usually resolves at puberty, otherwise gentle stretching or circumcision if severe
phimosis
once retracted, the foreskin is trapped behind the glans penis

early, may be able to reduce foreskin with lubrication, otherwise circumcision is neccessary
paraphimosis
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
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
thick yellow penile discharge is ____________ urethritis

thin white penile discharge is ____________ urethritis
gonococcal

nongonococcal(chlamydia)
___________ 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
painless enlargemetn of one testicle needs _________

epididymal and spermatic cord masses are usually _________

______________ distinguishes solid from cystic mass
work-up

benign

transillumination
____________ masses are:

painless
firm
solid
within the testis
don't transilluminate
testicular
masses in the ____________ or ______ are:

mobile with movement of the structure
sometimes tender
usually transilluminate
epididymis or cord
located outside the testis usually in the cord (4)
varicocele
hydrocele
spermatocele
epididymitis
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
_______ sign: elevating the scrotum above the pubic symphysis provides relief
Phren's sign
early on may only be epididymal pain
later entire testicle may be painful (epididymo-orchitis)
may appear as a large tender mass
Acute Epididymitis
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
Imaging:
____ only helpful if exam is difficult because of large hydrocele
US
Differential

_______: painless, normal UA, normal epididymis on exam


_________________: usually in prepubertal males, acute onset of sx, normal urine
Tumors

Testicular tortion
Treatment:

Bed rest with scrotal elevation

Antibiotics determined by pathogen

GC – ____________

Chlamydia – ____________

Non sexually transmitted – usually _____________________
pen/ceftriaxone (rocephin)

Docycycline

trimethoprim/sulphamethoxazole
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
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
Left spermatic vein empties into left ____________

Right spermatic vein empties into the ____________
renal vein

inferior vena cava
Acute onset of right varicocele
Raises the question of ______________________ blocking the right spermatic vein
retroperitoneal malignancy
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
Torsion after _ hours – may be able to save testicle

After _ hours, impossible to save testicle
6

8
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
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
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
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
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
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
____________ 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
______________ 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
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
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
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
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
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)
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
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
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
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
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
Uric acid, oxylate, cystine, usually in acid urine
Phosphate, mostly in alkaline urine
Types of urinary crystals
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
Blood in the urine (2-5 RBC’s per hpf)
Hematuria
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
________ 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
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
Hematuria Associated Symptoms

Renal colic: suggests _______________

Irritative voiding symptoms: suggests inflammatory/infectious conditions such as ___________
obstructive uropathy (renal stones)

cystitis/prostatitis
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
Diabetes Mellitus
Sickle cell trait or disease (papillary necrosis)
Stone disease
Malignancy
assoicated medical problems causing hematuria
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
Generally harmless
Usually gross hematuria after exercise
More in males than females
“March” hematuria
Exercise hematuria
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
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
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
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
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
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
Causes of hematuria by age

Glomerulonephritis
Urinary tract infection
Congenital urinary tract problems
Age 0-20
Causes of hematuria by age

Urinary tract infections (females > males)
Calculi
Bladder cancer
Age 20-40
Causes of hematuria by age

Urinary tract infections (females > males)
Bladder cancer
Urinary calculi
Age 40 – 60
Causes of hematuria by sex

Benign prostatic hypertrophy
Bladder cancer
Urinary tract infection
Age > 60 (men)
Causes of hematuria by sex

Urinary tract infection
Bladder cancer
Age > 60 (women)
Hematuria with fever, rash, lymphadenopathy, abdominal or pelvic mass is a ________________
Systemic disease
Hematuria with hypertension or volume overload is from ______________
Medical renal disease
Hematuria with an enlarged prostate, flank mass, or urethral disease needs ______________
Urologic Evaluation
UA and C&S:

_________ and cast formation suggests renal origin

__________ suggests infection, especially with irritative voiding symptoms
Proteinuria

Bacteruria
Urine cytology:
Especially helpful in ________________

Three specimens needed for maximum sensitivity
bladder neoplasms
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
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
Lower urinary tract:
Bladder neoplasms
Urethral neoplasm
Benign prostatic hypertrophy
Radiation or chemical cystitis
Active bleeding

its preferred to allow better localization
Cystoscopy
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
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
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
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
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
Acute infection of the prostate -

Recurring infection of the prostate -
Acute bacterial prostatitis

Chronic bacterial prostatitis
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
No subjective symptoms
WBC’s are found in prostatic secretions or prostate tissue during evaluation of other disorders
Asymptomatic inflammatory prostatitis
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
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
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
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
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
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
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
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
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
non malignant enlargement of the prostate gland
The most common benign tumor in men
Age related
Risk factors-
Possibly genetic/possibly race
BPH
Two necessary factors for development of BPH are ____ and _____
DHT and aging
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
prostate has essentially 4 zones -
________
________
________ fibromuscular stroma
________

The transition zone surrounds the urethra, and is the origin of BPH
Peripheral

Central

Anterior

Transition
___________ obstruction:
Intrustion of hyperplastic tissue into the lumen or bladder neck
Causes high bladder outlet resistance
Poor correlation with prostatic size on DRE
Mechanical
_________ 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
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
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
the most important tool used in evaluating these patients?
AUA questionaire
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
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
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
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
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
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
Patients with mild symptoms (those with AUA score <7) may be treated with ______________
watchful waiting
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
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
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
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
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
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
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
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
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)
TUIP:
cutting instrument is inserted through the ________
no ________ tissue is removed
Incision is made where the prostate meets the _________
urethra

prostate

bladder
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
Suprapubic is performed _____________

Is the operation of choice if there is concomitant _________ pathology

Blunt dissection with finger to free the adenoma
transvesically

bladder
____________ prostatectomy:
Retropubic incision
Incision into surgical capsule of the prostate
Adenoma is enucleated as in open prostatectomy
Urethral catheter put in place
Retropubic
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
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
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
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
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
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
Pathology:
98% are _________, with 90% of those being transitional cell carcinomas
Most are ___________ growths
Higher grades lesions are sessile and ulcerated
epithelial

papillary
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
___________ 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
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
Intravesical Chemotherapy Agents:
Thiotepa mitomycin, doxorubicin, BCG

Side effects:
_____________ sx, _____________, systemic sx are rare
Irritative voiding

hemorrhagic cystitis
_________________ 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
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
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
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
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
_________ 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
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
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
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
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
Renal Cell Carcinoma - TX:

____________ is the primary treatment for localized RCC

____________ if single kidney, bilateral lesions, or significant renal disease
Radical Nephrectomy

Partial nephrectomy
T/F

THERE IS NO EFFECTIVE CHEMPOTHERAPY AVAILABLE FOR METASTATIC RENAL CELL CARCINOMA
TRUE
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
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
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
2 major categories:

1. ___________
Embrynal cell carcinoma (20%)
Teratomas (5%)
Choriocarcinomas (<1%)
Mixed cell types (40%)

2. ___________ (35%)
Nonseminomas

Seminomas
Staging: Nonseminoma tumors
Stage __ - confined to testis
Stage __ – regional lymph node involvement in the retro peritoneum
Stage __ – distant mets
A

B

C
Staging: Seminoma (MD Anderson system used)
Stage __ - confined to testis
Stage __ - retroperitoneal lymph node spread
Stage __ – supradiaphragmatic nodal or visceral involvement
I

II

III
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
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
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
Imaging:
Scrotal __________ can determine if mass is intratesticular or extratesticular
After diagnosis made, clinical staging done by chest, abdominal, and pelvic ____
ultrasound

CT
Epididymitis
Hydrocele
Spermatocele
Varicocele
DDX Scrotal Masses
Bulky retroperitoneal disease or metastatic nonseminomas treated with __________ combination after orchiectomy
cisplatin
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
___________ is not a screening tool for urinary tract problems in asx adults
dipstick UA