GU
Terms
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- describe hematuria
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1. red/brown urine discoloration secondary to RBCs
2. correlates c/ the presence of >5 RBCs/high-powered field on microanalysis - what is your ddx with painLESS hematuria?
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1. primary renal dz (tumor, glomerulonephritis)
2. tuberculosis (TB)
3. vesicular dz (bladder tumor)
4. prostatic dz - what is your ddx with painFUL hematuria?
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1. nephrolithiasis
2. renal infarction
3. UTI
4. ask if pt is a smoker!!! - what is myoglobinuria or hemoglobinuria?
- where hemoblobin dipstick is positive, but no RBCs are seen on microanalysis
- what do you check when you find RBCs in urinary sediment (hematuria)?
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1. UA--WBC (infx) or RBC casts (glomerulonephritis)
2. CBC--anemia (renal failure), polycythemia (renal cell CA)
3. urogram--will show nephrolithiasis and tumors - what is your ddx c/ hematuria?
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SHITTT:
S=stones
H=hematologic
I=infxn
T=tumor (malignancy)
T=trauma
T=TB - what is your first question with painful gross hematuria?
- are you a smoker????
- what is your work-up for gross, painless hemautria?
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1. CT--1st!!! s/ contrast for urolithiasis
CT--2nd c/ contrast (IV)
2. cystoscope--look into the bladder, try to scope when pt is bleeding
3. retrograde pylogram--to look for filling defects; look for narrowing
4. urine cytology--look for abnml cells; high grade lesions sometimes aren't visualized as well
5. US--of ureter parenchema of kidney (not great for dx)
6. IVP--shows parenchema of kidney (not used much anymore) - is plavix/coumadin a reason for hematuria??
- NO!!!!!!!!!
- when do you use cystoscopy for hematuria?
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only after UA and IVP; best for lower urinary tract
*use to look into the bladder, try to scope when pt is bleeding - define BPH
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benign prostatic hperplasia:
hyperplasia of the periurethral prostate causing bladder outlet obstruction - who gets BPH?
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1. common after age 45
2. autopsy shows that 90% of men older than 70 have BPH
3. BPH does NOT predispose to prostate CA - what are si/sx of BPH?
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1. urinary frequency
2. urgency
3. nocuria
4. decreased size and force of urinary stream leading to hesiancy and intermittency
5. sensation of incomplete emptying worsening to continuous overflow incontinence or urinary retention - what does the rectal exam show on a pt c/ BPH?
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1. enlarged prostate (classically a rubbery vs. firm, hard gland that may suggest prostate CA)
2. loss of median furrow - what labs should you check in BPH?
- 1. PSA--elevated in up to 50% of pts, not specific, so not useful marker for BPH
- how do you dx BPH?
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symptomatic scoring system:
1. prostate size >30 mL (determined by Utz or exam)
2. maximum urinary flow rate (<10mL/s)
3. postvoid residual urine volume (>50 mL) - what is tx for BPH?
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1. alpha-blocker (terazosin)
2. 5-alpha-recuctase inhibitor (Finasteride)
3. AVOID: anticholinergics, antihistaminerigics or narcotics!! - what do you do for refractory BPH?
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refractory dz requires surgery: 1. transurethral resection of prostate (TURP)
2. open prostatectomy recommended for larger glands (>75 g) - what are si/sx of prostatitis?
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1. fever
2. chills
3. low back pain
4. irriative voiding sx
5. exquistie tenderness common on rectal exam
6. positive urine culture - what are common offending agents in acute bacterial prostatitis?
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1. e. coli
2. pseudomonas
3. other gram-negative rods - what is contraindicated in acute bacterial prostatitis?
- expressing prostatic secretions!!!
- what differentiates chronic from acute bacterial prostatitis?
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chronic=UA is often normal; expressed prostatic secretions demonstrate increased numberes of leukocytes (>10 per high power field) and lipid-laden macrophages (unlike acute bacterial prostatitis)
*these sx are consistent with inflammation and is not diagnostic of bacterial prostatitis - what are the lab findings in acute bacterial prostatitis?
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1. CBC=shows leukocytosis and a left shift
2. UA=shows pyuria, bacteriuria and varying degress of hematuria
3. urine cultures will demonstrate the offending pathogen (often gram-negative rod) - what is tx for acture bacterial prostatitis?
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1. hospitalization may be required
2. IV abx (ampicillin and aminoglycosides)
3. after pt is afebrile for 24-48 hrs, begin PO abx (quinolones) for 4-6 wks of threapy - what is the best tx for chronic bacterial prostatitis?
- bactrim is a/c with best cure rates (TMP-SMX)
- describe the frequency of impotence in men
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1. affect 30 million men in US
2. strongly a/c age
3. 40% among 40-yr olds
4. 70% among 70-yr olds - what are the primary causes of erectile dysfunction?
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primary=never been able to sustain erections:
1. psychological (sexual guilt, fear of intimacy, depression, anxiety)
2. decreased testosterone secondary to hypothalamic-pituitary-gonadal disorder
3. hypothyroidism or hyperthyroidism, Chshing's syndorme, increased prolactin - what are the secondary causes of erectile dysfunction?
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secondary=acquired, >90% from an organic cause:
1. vascular dz=atherosclerosis of penile arteries &/or venous leaks causing inadequate impedance of venous outflow
2. drugs=diuretics, clonidine, CNS depressants, tricyclic antidepressants, high dose anticholinergics, antipsychotics
3. neurologic dz=stroke, temporal lobe seizures, mulitple sclerosis, spinal cord injury, autonomic dysfunction secondary to diabetes, post-TURP or open prostatic surgery - how do you dx impotence/erectile dysfunction?
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1. clincial--r/o organic causes
2. nocturnal penile tumescence testing differentiates psychogenic from organic--nocturnal tumescence is involuntary, positive in psychogenic, but not in organic dz - how do you tx impotence?
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1. sildenafil (viagra)--selective inhibitor of cyclic guanosine monoophosphate-specific phosphodiesterase type 5a
*it imporves relaxation of smooth muschles in corpora cavernosa - what are the side effects of sildenafil?
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viagra:
1. transient HA
2. flushing
3. dyspepsia
4. rhinitis
5. transient visual disturbances (blue hue)--rare
6. lowered blood pressure--use of nitrates is an absolute contraindication!!! - what is an absolute contraindication with the use of sildnafil?
- concurrent use of nitrates!!!!! can cause very low blood pressure--deaths have resulted from the combo!!
- what are non-drug tx of impotence/
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1. vacuum constriction devices use negative pressure to draw blood into penis w/band placed at base of penis to retain erection
2. intracavernosal prostaglandin injection has mean duration of approx 60 min (risks=penile bruising/bleeding & priapism)
3. surgery=penile prosthese implantation; venous or arterial surgery
4. testosterone therapy for hypogonadism
5. behavoral tx, counseling for depression and anxiety