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2015-03-01 12:48:44

Urology topics for PAs
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  1. Urethritis
    • urethreal infection
    • most common cause--e. coli
    • STIs-->chlamydia tachomatis, Nesseria gonorrhoeae Trichomonas vaginalis, HSV common in both sexes
  2. Urethritis
    Signs and Symptoms
    • Urethral discharge
    • pruitis
    • dysuria
    • Gonococcal--opaque yellow white or clear discharge
    • Nongonococcal--pruritus, hematuria and pain w/ intercourse
  3. Urethritis
    • Urinalysis
    • Urine C/S
  4. Urethritis
    • STDs pending resuls Tx empirically ceftriaxone 250mg IM plus azithromycin 1g PO or doxy x7days
    • Recurrent NGU give 1x dose of metronidazole + erythromycin x7 days
  5. Urethritis
    • Men: epididymitis, infertility, reactive arthritis, septic arthritis
    • Women: PID, infertility, ectopic pregnancy
    • Children/Infants: neonate pneumonia, neonatal conjunctivitis (erythromycin ointment at birth to prevent blindness)
  6. Epididymitis
    • Inflammation of epididymis
    • most common cause--Neisseria gonorrhea, chalamydia tracomatis in young men
    • older men--E. coli, klebsiella, pseudomonas, proteus
    • Viral most common in children--MUMPS
    • Refractory M. tuberculosis
  7. Epididymitis
    Sigs & Symptoms
    • gradual onset scrotal pain, erythema, swelling
    • MC unilateral groin pain/abdominal pain
    • dysuria, urgency, frequency, fever, chills
    • PE findings--epididymal tenderness/induration, + PHREN's sign (relief of pain w/ elevation of affected scrotum)
  8. Epididymitis
    • UA/C/S-->pyruira/bacteruria-->urethritis suggests cause
    • CBC: leukocytosis
    • Scrotal US--> enlarged epididymis R/O torsion, check for hydrocele
    • Test for HIV
  9. Epididymitis
    • Symptomatic relief-scrotal elevation, cool compress, NSAIDs
    • Acute-Azithromycin/ceftriaxone or doxy for STI
    • Flouroquinolones, cipro/TMP/SMX doxy
    • Keflex/amoxicillin for children
  10. Acute Prostatitis
    • prostate gland infection secondary to ascending infection
    • G- bacteria MC E coli
    • Chalmydia/Gonorrhea MC in men <35
    • Viral (mumps)
  11. Acute Prostatitis
    Signs & Symptoms
    • Generalized fever, chills, malaise, myalgia
    • exquisitely tender prostate, hot and boggy
    • suprapubic tenderness
    • perineal pain
  12. Acute Prostatitis
    • UA & C/S for bacteria
    • Avoid prostatic message can cause bacteremia
    • clinically hot, tender, and boggy prostate
  13. Acute Prostatitis
    • Fluoroquinolones, Bactrim, Amp w/ Gent x1month
    • STI? Tx with ceftriaxone/azithromycin
  14. Acute Prostatitis
    chronic prostatitis or bacteremia
  15. Chronic Prostatitis
    • MC E coli, enterococci, Trichomonas, HIV, inflammatory or strucutural abnormality
    • Progresses from acute
  16. Chronic Prostatitis
    Signs and Symptoms
    Nontender boggy prostate
  17. Chronic Prostatitis
    • UA C/S often negative
    • message recommended to increase bacteria yield on UA and culture
  18. Chronic Prostatitis
    • Fluroquinolones/Bactrim x6-12wks
    • Transurethral resection of prostate (TURP) for refractory
  19. Orchitis
    • Infection of testes
    • MC viral--Mumps
    • other viral causes--rubella, coxsackie, echovirus, parvovirus
    • Bacterial infections not common
  20. Orchitis
    Signs and Symptoms
    • initially unilateral then spreads to other testicle
    • scrotal pain and swelling
    • systemic symptoms, tenderness, enlargement, induration, edema, erythema
  21. Orchitis
    • clinical evaluation w/ Hx of Mumps
    • confirm w/ PCR or serological testing
    • US to R/O torsion
  22. Orchitis
    • Suppportive-analgesics/cool compress
    • ABX if bacterial
    • Urology follow up
  23. Testicular Cancer
    • MC solid tumor in males 15-35
    • higher incidence in pts w/ cryptorchidism
    • Mc in white males and on R side
    • MC subtype seminomas-spread stepwise
  24. Testicular Cancer
    Signs and Symptoms
    • scrotal solid nodular mass that is painless, dull aching heaviness
    • hydrocele present in 10% of cases
    • hematoma or hydrocele raise suspicion
  25. Testicular Cancer
    • US or mass
    • Serum studies--AFP, HCG, LDH
    • Staging done with biopsy, pelvic, abdominal, and chest CT
    • Seminoma (SGCT)-radiosensitive and LACKS tumor markers w/ HYPOECHOIC mass on US
    • Nonseminoma (NSGCT)-elevated AFP/HCG
  26. Testicular Cancer
    • Radical inguinal orchiectomy (castration)
    • Radiation therapy w/ surgery is done for seminoma
    • Orchiectomy w/ retroperitoneal lymph node dissection for nonseminoma
    • HIGH grade seminoma debulking with chemo prior to orchietomy
  27. Testicular Cancer
    • 5 yr survival is 90%
    • surveillance needed with nonseminoma more commonly--especially those with lymph node ressection
  28. Bladder Cancer
    • 90% transitional cell carcinoma (TCC)-->squamous-->adeno-->sarcoma
    • Mets to lymph nodes, lungs, liver and bone MC
  29. Bladder Cancer
    Risk Factors
    • Smoking in 50% of new cases
    • Occupational exposure--dye, leather tannerym rubber
    • White male >40yo
    • Chronic irritation from schistosomiasis, chronic UTI and catheters
  30. Bladder Cancer
    Signs & Symptoms
    • Microscopic/gross hematuria is bladder cancer until proven otherwise
    • Irritation with voiding
  31. Bladder Cancer
    • Cystoscopy with biopsy can be Dx and curative
    • Urine cytology may  detect malignant cells
    • Invasive tumor need CT of chest, abdomen, pelvis
  32. Bladder Cancer
    • Transurethral resection/electrocautery
    • Invasive-radical cystectomy, chemo, radiation
    • Recurrent/Metastatic--BCG immune therapy (contraindicated in immunosuppressed and or gross hematuria)
  33. Bladder Cancer
    • superficial --good
    • recurrent--poor
    • squamous and adenocarcinomas have worst prognosis
  34. Prostate Cancer
    • 95% adenocarcinoma
    • MC cancer in men >50 in US
    • Slow growing--die with rather than from
  35. Prostate Cancer
    risk factors
    • Fam Hx of 1st or 2nd degree relative
    • Obesity, high fat diet
    • African American
    • Age >65
  36. Prostate Cancer
    signs and symptoms
    usually asympotomatic until bladder, urethral, bone involvement
  37. Prostate Cancer
    • Screening with DRE >50 unless AA or fam Hx then >40
    • DRE findings--hard nodular asymmetric enlarged prostate
    • PSA >10 increased likelihood of mets
    • Biopsy if PSA >4
    • US guided transrectal needle biopsy
    • Bone scan to rule out mets
  38. Prostate Cancer
    • Gleason grade
    • <6 well differentiated
    • 7 moderately differentiated
    • 8-10 poorly differentiated
    • Gleason score, clinical stage, and PSA predict pathological stage and prognosis
  39. Prostate Cancer
    • local dz-radical prostatectomy with active survalence
    • advanced dz-radiation and hormone androgen deprivation (castration)
  40. Prostate Cancer
    • localized--good, no life expectancy lost
    • advanced--poor life expectancy 1-3 years
  41. Benign prostatic Hypertrophy
    • aging leads to hyperplasia in periurethral/transitional zone
    • narrowing of urethra leads to obstruction
  42. Benign Prostate Hypertrophy
    signs and symptoms
    • frequency, urgency, nocturia, hesitancy, weak stream, incomplete emptying, and incontinence
    • can lead to urinary retention
    • DRE--firm and uniformly enlarged and rubbery
  43. Benign Prostate Hyperplasia
    • DRE--enlarged, symmetrical, firm, rubbery prostate
    • PSA-moderately elevated, if >4 biopsy
  44. Benign Prostate Hyperplasia
    • Avoid anticholinergics, sympathomimetics, antihistamines, and opiods bc they increase urinary retention
    • 5-alpha reductase inhibitors-finasteride & dustasteride b/c they inhibit affects of androgens and thus reduce growth
    • Alpha 1 blockers provide rapid relief through relaxation of smooth muscle--relieve urinary retention
    • Surgery--TURP or laser prostatectomy
  45. PSA Testing
    screening guidelines
    • <40 no screening
    • 40-54 screen if fam Hx or AA
    • 55-69 screen every 2 years with DRE if life expectancy is > 10yrs
    • >70 no screen unless LE >10
  46. PSA testing
    benign problems that affect PSA
    • BPH
    • prostate infarction
    • prostatitis
    • prostatic massage
    • 5 alpha reductase inhibitors (decrease PSA by 50%)
    • Test PSA prior to DRE
  47. Varicocele
    • varicose veins from pampiniform plexus and internal spermatic vein
    • MC on left side bc of drainage in L renal vein as opposed to vena cava of R vein
    • MC cause of male infertility
  48. Varicocele
    signs and symptoms
    • bag of worms
    • pain and fullness when standing
    • possible testicular atrophy
    • bag of worms relieved and laying down and made worse when standing or valsalva maneuver
  49. Varicocele
    clinical evaluation
  50. Varicocele
    • surgery (atrophy)
    • sudden onset--renal cell carcinoma
    • R side in kids < 10 retroperitoneal malignancy
  51. Hydrocele
    cystic collection of fluid in testicles leading to swelling
  52. Hydrocele
    sings and symptoms
    • painless scrotal swelling that trans illuminates
    • non-communicating--does not change in size with position
    • communicating--increase in size when upright or with intra-abdominal pressure
    • Infants--usually from patent process vaginalis and closes within first year
  53. Hydrocele
    • clinical--balls light up with transillumination
    • U/S to R/O testicular cancer
  54. Hydrocele
    fluid aspiration
  55. Testicular torsion
    • spermatic cord twists and cuts off testicular blood supply
    • bell clapper malformation allowing testicle to be too free floating
  56. Testicular torsion
    signs and symptoms
    • MC in males 10-20, decresed risk with age
    • acute severe scrotal pain
    • nausea vomiting
    • PE--swollen retracted testicle, (-) Phren's sign (pain is not relieved with elevation of testicles)
    • (+) Blue Dot sign-->torsion of testicular appendix
  57. Testicular Torsion
    • emergent surgery--orchipexy within 6 hours of symptoms
    • Orchiectomy for necrotic balls
  58. Cryptorchidism
    • failure of one or both testicles to descend
    • typically descending occurs at 28 weeks of gestation
    • 70% descend spontaneously
    • MC on r side
    • Increases risk of infertility, testicular cancer, torsion, and inguinal hernia
  59. Cryptorchidism
    signs and symptoms
    • empty scrotum at birth
    • ascending scrotum with child's height
    • inguinal fullness (balls caught in canal)
  60. Cryptorchidism
  61. Cryptorchidism
    • surgical repair
    • orchiopexy (6mo-1yr)
    • observation < 6mo
    • HCG or GRH hormone therapy prior to orchiopexy
    • Orchiectomy if detected during puberty or later
  62. Phimosis
    • inability to retract foreskin
    • normal in children up to age 5
  63. Phimosis
    Balanitis, UTI, urinary tract obstruction, skin irritation
  64. Phimosis
    • unnecessary if no complications
    • Betamethason with gentle stretching
    • circumcision if conservative methods fail
  65. Paraphimosis
    • entrapment of foreskin in retracted position
    • band can constrict penis cutting off blood flow-->amputation
  66. Paraphimosis
    signs and symptoms
    enlarged painful glans penis with constricting band of foreskin behind the glans
  67. Paraphimosis
    clinical--glans penis constriction observed
  68. Paraphimosis
    • manual reduction-firm circumferential compression of the glans
    • pharmacologic- hyaluronidase injection, granulated sugar, incision w/ dorsal slit-->circumcision when edema resolves
  69. Erectile Dysfunction
    • consistent inability to generate and maintain erection
    • vascular, neurologic, psychological and hormonal are common eitologies
    • other causes-trauma, surger, HCTZ, CCB, B-blockers
    • Abrupt-psychological, gradual-systemic
  70. Erectile Dysfunction
    signs and symptoms
    sexual dissatisfaction, limp penis
  71. Erectile Dysfunction
    • Clinical
    • H&P scale 1-4 for hardness?
    • Testosterone levels
    • Nocturnal penile tumescence test (postage stamp test)
    • US of penile blood flow
    • Mental health assesment
  72. Erectile Dysfunction
    • Treat cause
    • oral phosphodiesterase inhibitors are 1st line -fil sildenafil, tadalafil increase nitric oxide levels icreasing cyclic GMP (contraindicated in patients with nitrates and CVD)
    • testosterone replacement for low T
    • intracavernosum injection therapy ->vasodilation
    • pumps, rings, prosthesis, revascularization