Urology: Edited by Alex J. Weinstein MD, FACS, Urologist.

Contents: Male Anatomy: Renal Stones: Infections: Urinary Retention: Priapism: Trauma: Malignancies: Penile: Pediatric: Scrotal Pain: Testicular Mass: Erectile Dysfunction: Sexual Disorders: Male Hypogonadism: Peyronie: Prostatitis: BPH: Nocturia: Incontinence: Catheters: Interstitial Cystitis: Male Infertility: Hematuria: Proteinuria: Preamble & Abbrev: 8-15-01. Male Anatomy:

Urinary Calculi (Stones / Urolithiasis): Links: S/s: Lab: Tx: PV: W/u Recurrent: Underlying Etiology: Hypercalciuria: Hyperuricuria: Hyperoxaluria: Hypocitruria: Struvite: Cystinuria: Calcium-Phosphate: References: 5-12% lifetime risk, M: F, 3:1, most between ages 20-50, 60% recurrence rate. PP: supersaturation of urine --> crystallizes, and then aggregates. May have dec amount of urinary stone inhibitors (primarily citrate). Risks: Low urine output states (dec fluid intake), diets high in salt/ oxalate/ protein, chronic diarrheal states, gout, FHx of stones, prolonged immobilization, recurrent urinary infections, Drugs (Indinavir, acetazolamide, triamterene). Chronically sleeping on the side at risk of calculi formation can be seen in pts with unilateral stone dz (J Urol 2001;165:1085), consider attatching a tennis ball to sleepware to break this habit. S/s: Renal colic: Aching flank pain that waxes and wanes. No position of comfort ( unlike Appy, diverticulosis, salpingitis/ peritoneal inflammation(makes patient want to lay still). Pain often radiates from flank to groin, testicle or labia and can be accompanied by nausea, vomiting and hematuria. Urgency and frequency can occur if stone is close to bladder, Pain resolves with passage of stone, may persist temporarily from ureteral edema. Ddx: appendicitis, PID, pyelonephritis, diverticulitis, dissecting AAA, cholecystitis, ovarian pathology

and ectopic pregnancy. Lab: U/A, BUN or Cr. + CBC, lytes, Ca, P. Hematuria in 85%. X-ray: KUB: Best study if PMHx of stones. 90% contain calcium and are radiopaque (yet only 30% seen in ER, up to 70% with IVP), if >2-3 mm should see on KUB. (r/o calcified mesenteric lymph node, phlebolith, fecalith, renal calcification, barium), misses 10% as uric acid and cysteine are radiolucent. Spiral (helical) CT without contrast now considered best overall study to establish diagnosis, takes less than 5 minutes, no risk of contrast reaction, detects all stone types, rules out other pathologic processes (r/o AAA if age >55yo). Takes 0.5mm cuts from top of bladder to top of kidneys (nl abd CT take 1cm cuts). IVP: Delayed images required if high-grade obstruction (delayed blush if obstructed) and/or ultrasounds can also be helpful. Three places stones get caught : ureteropelvic junction (UPJ), midureter (at iliac vessels), ureterovesicle junction. Tx: For acute pain IV Toradol or Morphine, hydration (no benefit to stone passage), strain urine, Abx if evidence of infection. If stone <4 mm 80-95% pass spontaneously (may take up to 40 days). If 5-7mm about 50% pass, >7mm only about 20 % pass Time: Takes an average of 8 days to pass if <2mm, 12 days if 2-4mm and 22 days if >4mm. (Time to stone passage. J Urol 1999;162:688-91). Send passed or removed stone for analysis. Calcium channel blockers, NSAIDs and steroids can facilitate stone passage but unproven. F/u: If fail to pass stone in 5-7 days, fever, unrelenting pain, vomiting. Consult Urology: stone >5 mm diameter, severe persistent pain, not passed spontaneously in 1-2 wks (depending on size), an upcoming away trip from home, persistent hydronephrosis, infection/sepsis, staghorn calculus, solitary or transplant kidney, occupation (pilot or bus driver), anuria or renal failure. Treatment Options for Urologist: 1. Emergent Decompression: With either a nephrostomy tube or ureteral stent. Septic patients with obstruction should have nephrostomy tube placed (can be done with local anesthesia), drainage can be monitored as opposed to internal stent that might not be draining properly. 2. Extracorporeal Shock Wave Lithotripsy (ESWL): Usually under mild IV sedation although some machines require general or regional anesthesia Shockwaves break up the stone into small fragments that pass out on own. Best choice for renal, proximal and mid ureteral stones <2 cm. 85% overall success rate. Occasionally a fragment can obstruct the ureter and require intervention. Repeat treatment required 10-20%. 3. Ureteroscopy: with stone basketing or endoscopic (laser) lithotripsy can be successful in up to 95% for distal stones. . Treatment of choice for distal stones. 4. Percutaneous Lithotripsy: Best for large/staghorn renal calculi, can be followed by ESWL for residual fragments. Complications of Urolithiasis: renal failure, ureteral stricture, infection/ sepsis, urine extravasation, perinephric abscess, xanthogranulomatous pyelonephritis. Prevention of Ca stones: Diet: Fluid therapy is safe, cheap and effective: Increase water (8-10

ten ounce glasses a day) this will dec&61472;recurrence by 55%. Try to maintain 2L urine output a day. Lemon juice/ lemonade increases citrate excretion, particularly in those with hypocitraturic stone former. (4 ounces a day in divided doses). Avoid excess: Protein (restrict to 1g/kg/d), Salt (restrict to 2-3g/d by avoiding processed foods), oxalates (if Ca-oxalate stones, particularly if have hyperoxaluria), dairy products (2 ounces of cheese or 2 glasses of milk a day ok), prevent recurrent infections. W/u of Recurrent/ Multiple stones: 24hr Urine (commercial kits are available); otherwise evaluate for volume (>2L), pH (Ca-phos stones form if pH > 7, may be due to distal RTA if low urinary citrate, vegetarian diet if high citrate. If pH >7.5 suspect infection. If pH <5.5 suspect uric acid, cysteine, chronic diarrhea or strenuous physical exercise), Ca (<300mg men, 250mg women, 4mg/kg child), Oxalate (15-40mg), Phosphorus, Na (100-125mEq), Mg (60-120mg/d), Citrate (300-900mg), Uric Acid (<800mg/d men, <750mg women), cystine. Stone analysis. Repeat 24hr Ur after modify diet (PO Ca load and deprivation), acid load test or add meds. Check serum for: Ca, P, uric acid, creatinine, alkaline phosphatase, intact PTH. Underlying Causes of Stones: Links: Hypercalciuria: Hyperuricuria: Hyperoxaluria: Hypocitruria: Struvite: Cystinuria: Calcium-Phosphate: Urine pH: Uric acid and cystine stones associated with acid urine. Renal tubular acidosis (type I), and infection related stones associated with alkaline urine. Treatment of uric acid and cystine stones includes alkalinization of urine, limit proteins Hypercalciuria: (50%) (>300mg/d in M, >250 in F), Causes 45% of Ca stones. Determining the specific etiology of hypercalciuria with special diets often not that helpful since it makes little difference in treatment. May be due to: 1. Absorptive hypercalciuria: Inc intestinal absorption causes inc serum Ca (high normal), which suppresses PTH, dec P. 2. Renal Hypercalciuria: defective resorption of Ca in kidney, have dec serum Ca and inc PTH, no change with fasting state. Due to Ca leaking from distal tubules. 3. Primary Hyperparathyroidism: Inc PTH --> inc bone resorption of Ca and inc 1,25(OH)2D to stimulate intestinal absorption. More common in women. R/o if high-normal serum Ca. The intact hormone assay is the best choice for proving subtle HPT. This need to be treated with Alendronate, Calcitonin of Mithramycin. 4. Unclassified Hypercalciuria: normal PTH and serum Ca with inc urinary Ca and no change with fasting. Other --> RTA, Addisons, sarcoid, hyperthyroid, V-D intoxication, milk-alkali syndrome. Only 5% have associated dz (RTA or hyperparathyroidism). Tx of Hypercalciuria: Thiazide diuretic: Start HCTZ @25-50mg qd, increase up to 50mg BID as dictated by 24hr urine. Adding K-citrate 20-30mEq BID will inc&61472;excretion of citrate (a stone inhibitor) as well as prevent dec&61472;K. Can also add a K-sparing diuretic. Limit dietary protein, oxalate and Na (<2g/d). Avoid severe restriction of dietary Ca as low intake actually increases the

risk of stones. 1/3 of females with Ca stone have medullary sponge kidney. Inc risk of osteoporosis in hypercalciuria: thiazides are beneficial. Ca-citrate is the preferred Ca supplement in postmenopausal females with stones. Can also use Bendroflumethiazide 2.5 mg BID, Trichlormethiazide 2-4mg qd, Na-cellulose phosphate 2.5-5g TID or Orthophosphate 500mg BID. (J Urol 1997;158) (Am J Clin Nutr 1994;60) Hyperuricuria: (15%)(>800mg/d M, >750mg F) uric acid (8%):. Can be seen in chronic diarrheal states that cause loss of water and bicarb., hypermetabolic states, myeloproliferative disorders, medications such as thiazides. Uric acid can serve as a nidus for Ca-oxalate stones (12% of pts). Tx: Increase fluid intake. Avoid Purine rich foods, restrict animal protein to 5-7oz of meat/ fish per day) + Allopurinol (Zyloprim) @100-300 mg/d to dec uric acid production(especially if hyperuricemia) . Inc Ur pH with bicarb or K- citrate 10-30 mEq TID to alkalinize so inc solubility of uric acid (goal is pH of 6.5-7 f, pt can measure with nitrazine paper, higher than 7 may cause CaP to precipitate). Can dissolve them at a rate of 1cm/mo. Purine Content of Foods: Very-very high: herring & roe, mussels, sardines, yeast. Very high: anchovies, crab, lobster, trout, salmon, turkey, veal, beef, bacon, pheasant, venison. High: bass, halibut, oysters, tuna, chicken, pork, ham, duck, asparagus, cauliflower, kidney/ lima beans, spinach, whole grains, mushrooms, peas. Low: non whole grains (breads, cereals), cheese, eggs, nuts, fruits, peanut butter, tea/ coffee, chocolate, butter, soft drinks. Hyperoxaluria: (15%) (>40mg/d of oxalate). 75% of all stones are composed of some CaOxalate, Mixed Ca-Oxalate-P in 34%. 15% is related to dietary consumption of oxalate or inc Vit-C. Also seen in Crohns, chronic pancreatitis, celiac sprue, Ca restriction, primary hyperoxaluria or other ileal dz because of inc absorption as Ca is bound to free fatty acids. Recurrance rate for untreated Ca-Oxalate stones --> 10% at 1 year, 35% in 5yr, 50% recur in 10yr. If inc urine output to >2L/d will cut in the recurrence rate. If serum Ca>10.3 --> check PTH. Tx: avoid excess oxalates (spinach/ leafy dark greens, nuts, rhubarb, instant coffee, tea, chocolate, berries, purple grapes, Tofu, wheat germ), Ca or Mg-oxide 200-400mg BID supplements + Pyridoxine 25-100 mg qd (as many deficient) with meals to bind oxalates in the gut. K-Mg-Citrate: for recurrent Ca-Oxalate stones, less GI SEs than K-citrate (10-30 mEq qd). Dose of 42mEq K + 21mEq Mg + 63mEq citrate qd (J Uro 1997:158). Other less efficacious: Cholestyramine 4g TID, Mg-citrate 10 mEq BID. Oxalate Content of Foods: High content: beets, black tea, chocolate, cocoa, dried figs, ground pepper, lamb, lime peel, nuts, parsley, poppy seeds, rhubarb, sorrel, spinach, swiss chard. Moderately high: beans, all types of berries, carrots, celery, coffee, concord grapes, okra, green onions, oranges, green peppers, sweet potatoes, tomatoes. Hypocitruria: (20%)(<450-600mg/d M, <650-800 in F) citrate is a stone inhibitor. Tx: K-citrate @ 0.5-1mEq/kg/d in divided doses (10-30 mEq qd), unless hyperkalemia is present. Avoid Na-citrate unless K-citrate not tolerated. The dosage should be adjusted to maintain a urine pH 6.5-7. Causes: Often idiopathic, may be RTA, met acidosis, high protein/ salt diet, dec K or Mg, UTI, carbonic anhydrase inhibitors, renal insufficiency, dehydration, thiazides, diarrhea.

Struvite: (8%): (Mg-P-NH3), From urea splitting organisms (Proteus, Pseudomonas, Providencia). Treatment includes removal of entire stone. Consider Amoxicillin suppressive therapy 250mg PO qd or Acetohydroxamic acid 250mg TID. Cystinuria: (3%): consists of two cystine molecules linked with a disulfide bond. Tx: Stones can form rapidly increase fluids to 4-5L/d (round the clock). Alkalinize to pH>7-7.5 with K-citrate 10-30mEq TID, Pyridoxine 50mg/d. Bind sulfhydryl groups to other molecules (chelation) by adding: D-Penicillamine 250mg QID, Captopril 50mg BIDor Mercapto-proprionylglycine 250mg TID to interfere with disulfide bond formation. Calcium Phosphate (CaP): (7%): often have Distal RTA, giving an alkaline urine. Tx: K-citrate to increase the inhibitor level to normal to correct the hypercalciuria. HypoMg-uria: <50mg/d and no diarrhea d/o. Triamterene: found in diuretics and Indinavir. **Ref:(Campbells Urology, 7th ed, 1998, WB Saunders) (Urologic Clin NA 1997;24:1, pp50-122) (N Engl J Med 1992;327:1141-52) (Prevention of recurrent nephrolithiasis. Am Fam Physician. 1999;60:2269-76) (Nephrolithiasis. Semin Nephrol. 1999;19:381-8) (Urolithiasis. Uro Clin North Am 2000;27:2) Urologic Infections: Links: UTI: Pyelonephritis: Urethritis: Balanitis: Epididymitis: Orchitis: Prostatitis: Fourniers: STDs: Urinary Tract Infections (UTI): Links: S/s: Labs: Bugs: Tx: PV: Recurrent: Prophylaxis: Referral Indications: Asymptomatic: Men: Pregnant: Ddx: Fungal: Elderly: Pediatric: References: The most common of all bacterial infections. 50-80% of all women get a UTI in their lifetime, 25% get recurrent episodes (Ave 2.6/yr), 90% are reinfection. M:F ratio (prevalence): 1.5:1 in neonates, 1:1 infants (1.5%), 1:10 in preschool age(4.5%F, 0.5%M), 1:30 in school age (1.2%F, 0.03%M), 1:50 in reproductive age (50%F, 0.1%M) and 1:1.5 in geriatric age (20%F, 10%M). R/o Subclinical Pyelo: check Cx if high risk: pregnant/ DM/ sx>1wk/ h/o pyelo in past 1yr/ relapse after 3d tx/ anatomic abn/ elderly. S/s: dysuria, frequency, urgency, gross hematuria, suprapubic pressure, may have N/V if young/older. If fever >102.5F consider pyelonephritis (see below). Hx: F/C, foul odor to urine. Past bladder/ pelvic surgery. Lab: Pyuria: >10 WBCs/ml, most sensitive indicator. +Cx = >10-3rd CFU with predominant sp. With sxs 10-2nd CFU. >3orgs=contam, Hematuria is common, but need to re-check UA after infection clears to r/o other causes. Common organisms: E. coli (83%), Staph saprophyticus (Coagulase-negative Staph, young females, spermicides), Proteus mirabilis, Klebsiella pneumonia, Enterococcus faecalis. If negative

Cxs with sxs and pyuria --> check Grams and AFB stains, urine cytology etc., consider urine for chlamydia to seek out unusual organisms, rule out cancer, stones, etc.. Tx: Acute uncomplicated Cystitis: No culture required in young, healthy, out-patient female. Aherent women can accurately self-daignose and self-treat recurrent UTIs (Ann Intern Med 2001;135:9). Rx X 3days of Cipro 100 BID, Levaquin 250mg PO qd, Floxin 200mg BID, Norfloxacin 400mg BID, Macrobid (Nitrofurantoin) 100 BID with food. Augmentin 500mg PO BID. Monourol (Fosfomycin) 3g mixed in water X1 with or w/o food (Orange flavor), safe in pregnancy. Bactrim DS BID x 3d or Cephalothin if low resistance area. 3 days in asymptomatic pregnant Treat X 7 days if --> age>65, pregnant UTI, use a diaphragm, sxs lasting >7d, 3rd or recurrent infection, males. Treat 10-14d if --> suspect upper tract involvement (pyelonephritis) or complicated UTI (anatomical, functional, pharmacologic factors such as BPH, indwelling catheter, resistant bacteria. Treat 4-6wks if --> polycystic kidney dz, DM, renal transplants or early relapse of same organism. If >2 UTIs/yr give self start therapy (see below). Unresolved Bacteriuria: (grow same species as initial UTI): either resistance or noncompliance, check C&S, give 3-7 days of Quinolone. Prevention of UTI: Empty bladder within 1hr of urge to urinate. (Completely! As little as 10ml residual volume can reinfect. Consider double voiding by emptying bladder twice within 5min.) Urinate soon after sexual intercourse. Avoid using spermacide or a diaphragm. -PO fluids and drink 8oz of cranberry juice TID. If postmenopausal use HRT or intravaginal estrogen. Anti UTI breakfast --> yogurt (lactobacilli) to dec pH and make biosurfactants), cranberry juice, blueberry muffin (hippuric acid bacteriostatic & acidify). Acid-ash diet or Vit-C to acidify the urine, could also alkalinize urine with tsp of baking soda in a glass of water. Urine pH <5.5 or >7.5 is inhospitable for bacterial growth. If having Excessive BMs: use OTC fragrance free towelettes to wipe and cleanse the rectal area BID. Recurrent Cystitis: Sx with Cx >100 CFU/ml. Most are reinfection. Initial Tx X 7-10d based on

Cx with a quinolone. Some women are more prone due to combo of genetic, hormonal, immunologic, and local defenses against colonized bacteria. Risk: inc sexual activity, use of spermicidal jelly or diaphragm, urinary/ fecal incontinence, DM, postmenopausal w/o HTR, incomplete bladder emptying, GU tract anomaly, age >65. Consider IVP to r/o stone or anatomic anomaly. Prophylaxis for Frequent (>4 UTIs/yr): (and unrelated to intercourse). Start @ qHS or QOD with 1 tab X 4-6mo then stop for observation or change medications. Can also use qHS dose perimenstrually if linked to menstruation. Can have pt self test, give them dipsticks with instructions or tx by sxs. Self medication: Aherent women can accurately self-daignose and self-treat recurrent UTIs (Ann Intern Med 2001;135:9). --> X 3d for symptomatic episodes --> pt to call or RTC if --> not improved in 48hr or if F/C/N/V, low back pain, hematuria. --> check U/A & Cx. Have pt keep a diary of their infections and response to tx and review it yearly. Write an Rx that is refillable for 1yr. Meds used: Septra/ Bactrim RS qd or after intercourse, Trimethoprin 100mg, Nitrofurantoin 50-100mg (avoid in G6PD def), Norfloxacin 200mg, Ofloxacin 100mg, Cipro 125mg ( of 250mg

tab), Keflex 250mg. Ceclor 250 mg. Postcoital Prophylaxis: (if <4 UTIs/yr) Take single dose immediately before or after intercourse. Avoid spermicide coated condoms. Max 2 doses/d. Can also try an antimicrobial cream placed at the urethral meatus just prior to intercourse. Adolescence: if not sexually active, consider vesicoureteral reflux. Indications for Urologic Referral: Usually do not need referral as very rare functional/ anatomic abnormality. Persistent hematuria, unusual organisms, childhood Hx of UTIs, poor response to antimicrobial therapy, pyelonephritis and suspect obstruction, >6 UTIs/yr or if infection is prolonged. Males with urinary infections should be referred for evaluation. Asymptomatic Bacteriuria: 20% of those age >65, 5% younger, 2 consecutive Cxs with >105 org/ml of same organisms and no sxs, no WBCs. If pregnant need tx (for 7 days with Keflex/ Amox or Nitrofur). If <5yo, also need to eradicate as frequent UTIs --> irreversible damage the kidneys. Also tx if about to undergo an invasive genitourinary procedure, implantation of a prosthesis or at high risk such as secondary neutropenia of transplantation. Men with UTI: 12% adult will have a UTI, considered complicated as usually have stricture, stone, prostatitis, BPH. Only need 10-3rd CFUs/ml to be significant. Get pre and post Tx Cxs, tx 7-10 days. Pregnancy/ Lactation: All pregnant women need screening for bacteriuria at 16the wk of gestation, if + have 40% risk of symptomatic infection. Tx: Check Cx pre & post tx. Give 5-7d of Nitrofurantoin (contra in 3rd trimester due to risk of hemolytic anemia, avoid if G6PD def). PCNs % Cephs can be used throughout pregnancy: Keflex, Augmentin 500mg BID, Ceftriaxone, Ceftazidime, Ampicillin or Amox. Consider monthly U/A, r/o renal stones. Consider postcoital prophylaxis with Keflex if have a strong Hx. If pyelonephritis use Gentamicin + Ampicillin then a PO Cephalosporin. Avoid sulfa drugs (Bactim, etc) during 3rd tri (neonatal hyperbilirubinemia, kernicterus). Avoid Trimethoprim during 1st tri as teratogenic potential of folic acid antagonist. Dysuria Ddx: Candida, Trichomoniasis (inc Sx during and following menstruation), HSV (primary infection only, 75% with vag d/c), atrophic vaginitis, Chlamydia, trauma, FB, irritant/ allergy (soaps, douches, lubricants, spermicidal jelly, perfumes, toilet paper), interstitial cystitis, pelvic muscle spasms. Vulvitis --> from powerful laundry detergents will cause burning only when the urine (ammonia) reaches the vulva. Fungal UTI: often seen in those on broad spectrum Abx with a Foley cath. See mycelial elements on the UA, may grow >100K yeast on Cx. Treat with Diflucan 200mg, then 100mg qd X 14d. Elderly UTI: Most common cause of sepsis. Asymptomatic bacteriuria (needs no tx, even if pyuria) is seen in 10% F & 2% M @60yo, 25% F & 15% M @80yo. Predisposing: estrogen def --> incr pH and Gcolonizing, try estrogen creams or 0.5ug qHS X 14d, then 2X/wk. Check post void residual. Long term cath --> colonies after 4-5 days, best to intermittent straight cath or use absorbent pads.

Only long term if: sacral ulcers, urinary retention & difficulty with intermittent cath, terminally ill or severely impaired & frequent change of clothes or lines uncomfortable. Cystocele: have residual urine, try pessary after apply vaginal estrogen the burning doesnt occur at start, but as passes over vulva, think yeast inf. Rads: recurrent or >48-72hr fever or persistent fever --> r/o perinephric abscess or obstruction. Abd x-ray and US will detect 90%. Tx: if ill, hypo/ hyperthermia, MS changes --> hydration, Ampicillin (enterocoel) & Aminoglycoside (G-) (adjust for GFR with estimate of CC (140-yo age) X (lean (ideal) BW in kg)/72XCr (X 0.85 if Female), Cefotetan (quinolone for amp if PCN allergy). If no IV access, consider IM Rocephin or IM Gent. Pyelonephritis: Infection involving the upper urininary tract, usually ascending from the bladder and thus most common in women. Can be due to hematogenous seeding of the kidneys. Predisposition: renal stones, bladder dysfunction, DM, ureteral reflux, generalized sepsis (usually S aureus). S/s: fever (often >102F = 38.9C), N/V, flank pain, systemic toxicity, associated cystitis sxs prior to onset. W/u: Check Ur Cx, CBC. If uncomplicated --> 14 day outpatient tx with Quinolone or Bactrim. Hospitalize --> If Temp>40C/ persistent N/V, Age>65, DM, pregnant, immunosuppressed. Tx: Hydration, analgesics, Abx. Acute Uncomplicated --> if G- give quinolone, if G+ give Amox. If need IV due to N/V use Rocephin or quinolone X 14 day coarse. If Enterococcus sp add PO/IV Amox. PO Cipro 500mg BID X 7d has a 96% cure rate. Complicated --> for 6wks, if not improved check CT scan to r/o abscess. If pregnant give Rocephin & Gent, not pregnant give Rocephin & Cipro or Bactrim. Consider voiding cystourethrogram to r/o vesicourethral reflux. **Ref: (Comparison of Oral Cipro (7 days) and Bactrim (14 days) for uncomplicated pyelonephritis in women. JAMA 2000;283:12) (Antimicr Agents 1994;4:101-11) (Issues in urinary tract infections in the elderly. World J Urol 1999;17:396-401) (Postcoital Prophylaxis, J Urol 1994;152:136-38) (Bacteriuria in pregnancy. Infect Dis Clin NA 1997;11:593) (Uncomplicated UTI. Infect Dis Clin NA 1997;11:551) (Urinary tract infections in adults. Am Fam Physician. 1999;59:1225-34) (Urinary tract infections in children. Epidemiology, evaluation, and management. Pediatr Clin North Am. 1997;44:1133-69) (Urinary tract infections. Med Clin North Am. 1997;81:719-30) (Management of pyelonephritis and upper urinary tract infections. Urol Clin North Am. 1999;26:753-63) Pediatric Urinary Tract Infection (UTI): Links: S/s: Dx: Tx: Vesicoureteral Reflux: References: 50% have congenital anomaly, if febrile w/u aggressively. Immature kidney more susceptible to parenchymal scarring (10-15%), <1yo M>F, S/s: fail to thrive (FTT), feeding difficulties, jaundice, irritability, lethargic, fever, emesis. Neonate --> hypothermia, hyperthermia, FTT, N/V/D, irritable, lethargy, jaundice, malodorous urine. Toddler

--> abd pain, N/V/D/C, abnormal voiding pattern, malodorous urine, fever, poor growth. On PE, check BP, neuro, genitalia, abd/ flank. Dx: high index of suspicion if febrile >39C (102.2F) as U/A may be normal, consider routine Cx in all (especially if male <6mo or female <2yo). Avoid adhesive perineal bags/ wringing diaper as fecal contamination (high F+)(growth of <10,000 CFU/ml evidence against UTI), + --> 5WBC/ HPF, LE/ Nitr not sensitive in child. Culture + = any colonies on suprapubic cath or >10-to 4th, (if 10-to 3rd then repeat) on intermittent (straight, in --> out) transurethral cath, or >10-to 5th midstream (clean void) if female (>10-to 4th if male). Radiological studies needed if: Pyelonephritis, 1st UTI in boy of any age, 1st UTI in girl <3yo, 2nd UTI in girl >3yo, 1st UTI in child with FHx of anatomic urinary abnormality. Ddx: vaginitis, urethritis, bubble baths, pinworms. Tx: Bactrim @4mg of Trimethoprim/kg BID. Or Amoxicillin 10-15mg/kg TID. Or Nitrofurantoin 2.5mg/kg TID. Keflex, Sulfisoxazole. IV --> Claforan, Rocephin, Gentamicin. <3mo: Need to admit for empirical IV AMP/Gent, ceftriaxone for 5-7d, as 33% have +blood Cxs. <5yo M/F, or >5yo M --> no systemic signs --> PO Abx, then check US & VCUG as 40% will have reflux as a cause. Systemic signs --> Parenteral Abx/ US/ Renal Cortical Scintigraphy, then VCUG. If >1yo hydrate and give broad spectrum Abx, observe 4-6hrs, 2wks tx, then check VCUG and sonogram and UTI prophylaxis with Septra or Macrodantin until eval complete. Repeat culture 3-7 days after Abx to r/o relapse. Prophylax if reflux and not surgical candidate or other structural abnormality and 3 documented UTIs in 1 yr. (single dose nitrofurantoin @1-2mg/kg/d or Septra @2mg/kg trimethoprim/d for 6 or more mo.) front-to-back wipe, avoid bubble bath, tight clothes, constipation. If >3yo and Recurrent: > 2 in 6mo R/o --> Vesicoureteral Reflux: abn backwash of urine via ureter, High risk of renal scarring in 1st few years of life. Get a cystogram (2 types): Voiding Cystourethrography (VSUG) --> wait until UTI controlled, some radiation. Best to ID severity (grade) and anatomic abnormality of the bladder seen in boys. or Nuclear (isotope) cystogram (Renal Cortical Scintigraphy) --> More sensitive, less radiation, best for F/u of patient with prior dx, screening siblings (1/3 will have reflux) and in girls, best for inflammation and scarring, replaces IV urography, uses T99 or DMSA. Intravenous Urography --> precise anatomic image, yet higher radiation and contrast reaction, little role in children. Renal Ultrasound (U/S) --> unreliable in child to find reflux, scarring or inflammatory changes. Tx: Abx prophylaxis until reflux resolved. 80% resolve in 2-3yrs in Grade 1-2. Grade 3 resolves in 50%, only 25% for Grade 4. If dx reflux, check upper tract study, treat constipation, voiding dysfunction. Check annual nuclear cystogram and upper tract study. May need surgery (unilateral ureteral reimplantation is successful in 95%, can try subtrigonal injection of collagen which works in 68%) if new renal scarring, breakthrough UTI, poor compliance, intolerance to tx, persistence at puberty. If renal scarring need annual BP and U/A. **Ref: (Am Fam Phys 1998;57:10) (J Ped 1997;11:180-81) (Primary vesicoureteral reflux. Pediatr Nephrol 1998;12:249) (Vesico-ureteric reflux: occurrence and long-term risks. Acta Paediatr Suppl. 1999;88:22-30) (Vesicoureteral reflux. Pediatr Clin North Am. 1997;44:1171-90)

Pediatric Voiding D/os: Links: Nocturnal Enuresis: References: Have an increased risk getting reflux and UTIs. Functional if no anatomic or neuro lesion, in general Tx: is timed voiding, tx constipation, prophylactic Abx, + anticholinergics such as Oxybutynin (Ditropan) or Propantheline (Pro-Banthine) or biofeedback Functional Small-Capacity Hypertonic Bladder: Sx: freq/ urg/ urge incont/ staccato voiding/ nocturia and or enuresis/ dysuria/ recurrent UTIs. Have small capacity with marked urgency at capacity, often with incomplete emptying. Voiding Cystourethrography (VCUG): small bladder, trabeculation, sphincter spasms, US: thickened bladder wall. Tx: bladder retraining to help child relax during voiding, completely empty bladder, Abx prophylaxis, anticholinergics/ antispasmodic (oxybutynin 5mg 2-3X/d if >5yo, propantheline of hyoscyamine) to reduce intravesicular pressure. Detrusor Hyperreflexia: Daytime frequency/ urgency/ urge incontinence/ posturing (squatting)/ +nocturia, nocturnal enuresis, UTIs. Due to contraction of detrusor m during filling. Imaging: essentially normal. Tx: voiding retraining program, anticholinergics, Abx. Infrequent Voider (Lazy Bladder Syndrome): Infrequent voiding (2-3X/d), urgency, posturing, and/or daytime overflow incontinence after prolonged period w/o voiding. F>M, may have frequent UTIs, chronic constipation, encopresis. VCUG --> very large bladder, often incomplete emptying. Tx: Voiding retraining with rigid voiding schedule q2-3hr, control constipation, cholinergic agent (bethanechol) to stimulate voiding, +Abx prophylaxis. Psychologic Non-neuropathic Bladder (Hinman syndrome, Occult neurogenic): Have bladder and bowel dysfunction. Urgency and or stress incont, infrequent voluntary voiding, straining to void, UTIs, chronic constipation, fecal soiling. Due to sphincter contracting during filling, detrusor contracting during voiding --> incoordination --> outflow obstruction, incomplete emptying. VCUG --> large capacity, trabeculations, vesicoureteric reflex. Tx: alleviate psych pressures aggravating, prevent infections, improved bladder/ bowel emptying with timed schedules, anticholinergics, alpha-adrenergics to relax outlet. Other Causes Voiding Dysfunction: detrusor instability, incomplete bladder emptying. Giggle incontinence --> release large amount of urine with laughter. Daytime urinary frequency syndrome, unstable bladder syndrome. Nocturnal Enuresis: =>1-2X/mo involuntary passage of urine and age >5yo. Females gain control by 5yo, M by 6yo, but 25% subsequently have one + relapses.

Incidence: 12-15% @ age 6. 5% @age 10. 3% @ age 12. 2% @age 15. <1% @age 18. Primary: if never have been dry, genetic link --> 77% when both parents wet the bed, 44% if one, 15% if neither. Secondary: continent then relapse. Most commonly caused by simple maturational delay (97%) =nonorganic, if nl H&P dont need testing. Organic in only 1-2%, most UTIs. Hx: Psychosocial stressors. FHx of wetting and DM. Fluid intake 2-3hr qHS?, frequency, longest period of dryness, toilet training Hx, measures attempted to deal with, volume, freq/urg, improving/ changing/ worsening? Lab: U/A and Cx in AM void. Tx: Behavior Modification: 1st line, 25% cure, 70% marked improvement. No punish, instruct that they did not cause the problem but do have a role in the tx. They must assume responsibility by bringing sheets to wash, offer praise for dry mornings, limit fluids after dinner (not restrict). Use charting to monitor progress, awards given for dry nights. Start with behavioral technique: Have them lie in bed with eyes closed, pretend its the middle of the night --> bladder full --> starting to hurt --> pretend its trying to awaken you, its saying get up before its too late --> run to the bathroom and empty your bladder. Remind yourself to do this during the night. Bladder Retention Training/ stretching: works 20%, 66% improve, taught to consciously hold urine for longer periods each day or drink a lot and try and hold an extra 10-15 min, while on toilet count to 10, then 20, then 30 sec. Self/ parent awakening: 90% success, 20% relapse. Timed alarms q2hr to get up and pee, age3-7yo. Behavioral conditioning: Enuresis moisture sensing signal alarms. Sensor in underpants, alarm Velcros to P.J.s. Works in 70% but takes wks, best if >7-8yo requires commitment, cost $40-60, first drops complete a circuit and set off alarm/ vibrates, child gets up urinates and changes clothes. Use until 3 week of dryness. Wet-Stop --> 800-364-4488, $65. Potty Pager --> $50, 800-497-6573. Nytone Enuretic Alarm --> $54, 800-973-4090. Meds (If age >7yo): Imipramine (Tofranil): anticholinergic to inc bladder capacity, inc sphincter tone, works 30-50%. Easy to use, 25mg PO qHS, if after 1 wk unsatisfactory response, can increase to 50mg (up to 75mg if >12yo), but relapses and SEs (drowsiness, OH, restlessness, insomnia, anticholinergic, nausea, H-A, photosensitivity). If wets bed early in night, give a 4pm and at qHS. Can try Hyoscyamine (Levsin): 0.125mg. Levsinex Timecaps 0.375mg. Oxybutynin (Ditropan): 5-10mg qHS. Desmopressin (DDAVP): Analog of arginine vasopressin (antidiuretic hormone) to dec urine production, nasal works in 50% of other failures. (increases water retention) Start with 2 sprays (one spray/ nostril 10mcg/ spray) qHS X2wks. May increase by 1 spray weekly to max 40ug qHS, spray (maintain for 2-3mo once dry then taper by 10ug q2wks) has 10-70% success, 90% relapse). Age >12yo can get up to 60ug. Give for 3-6mo, then slowly taper in increments of 10ug/mo. Can combine with anticholinergic. **Ref: (Nocturnal enuresis in children. Curr Opin Pediatr 1998;10:167-73) (Ped Rev 1997;18:183-90) (Voiding disorders. Am Fam Phys 1999; 59:5)

Urethritis: Gonococcal (GU) in 20%, Non-GU (NGU) in 80% (C. trach 40%/ Ureaplasma urealyticum 30%/ Trichomonas vaginalis 3%, HSV 2%, also from Trichomonas vaginalis, and Mycoplasma genitalium, unknown 20%.). Noninfectious from chemical irritation/ FB/ congenital/ tumor. Sx: discharge, dysuria, urethral itching. Often asymptomatic. Incubation: 2-6d for GU Vs 7-35d for NGU which tends to have a scantier d/c that is nonspontaneous and mucoid. Dx: Hx, urethral sample (swab inserted 2-4cm, rotated unidirectional), gram stain --> nl to see extracellular pleomorphic G+ & G-s, urine can also be sent for chlamydia testing. GU: G-, intercellular diplococci. NGU: GC is absent. Have any 1 of 3: urethral d/c or >15 PMNs/ HPF of 1st 15ml voided urine or >5 PMNs/ HPF of urethral exudate or swab specimen. Tx: empiric with 125-250 IM Ceftriaxone and 100mg PO Doxy BID X 7-10d. Alternative drugs include EM, Cipro or Levaquin. Azithromax 1g PO X1. Or Doxy 100mg BID X7d. If pregnant give Emyc base 500mg QID X7d or Amox 500mg TID X7d. If child <8yo give Emyc base @50mg/kg/d divided QID for 10-14d. Balanitis: Infection and inflammation of the glans penis. If involves the foreskin it is called posthitis. Usually bacterial or fungal (r/o DM), allergic reaction (latex, contraceptive jelly), fixed drug eruption (sulfa, TCN, barbital), plasma cell infiltrate (Zoons) Risk: foreskin, oral Abx (Candida), diabetes Ddx: leukoplakia, lichen planus, psoriasis, Reiters, lichen sclerosis. Tx: Warm compresses, sitz baths, local hygiene with mild soap and water. Topical antifungal or antifungal and steroid combination( i.e., Nizoral, Mycolog, Lotrisone) Consider oral antibiotics if severe inflammation. circumcision if recurrent balanitis or phimosis **Ref: (Update on the prevention and treatment of sexually transmitted diseases. Am Fam Physician. 2000;61:379-86) (Urethritis and cervicitis. Aust Fam Physician. 1999;28:333-8) (Nongonococcal urethritis--a new paradigm. Clin Infect Dis. 1999;28:S66-73)

Epididymitis: Most common cause of acute scrotal pain, may have h/o UTI or prostatitis. Related to sexual activity. In prepubertal boys need to check renal/bladder U/S and voiding cystourethrogram to r/o structural problems. If no Hx of sex, need to r/o torsion or mumps, 90% chlamydia. S/s: Gradual onset (3-24hr) painful swelling, fever (30%), purulent d/c, dysuria. PE: +cremasteric

reflex, relief of pain with elevation or recumbent position (+ Prehns sign, considered unreliable). Tender & swollen epididymis or posterior testes, normal cord palpated above testes. Lab: pyuria/ bacteriuria (50%). Tx: as urethritis. if <35yo --> Doxy 100mg BID X 7-10d (Chlamydia), ice, NSAIDs, bed rest, scrotal elevation. Septra DS BID X 14d if >35 (E. coli),or quinolone Azithromax 2g powder X1, mix in glass of juice. If recurrent h/o consider intermittent torsion. Acute Orchitis: An inflammatory process of the one or both testicles. Etiology: Viral --> most due to mumps, also seen with coxsackie B, HIV, CMV. Bacterial --> usually from epididymitis. E. coli, Klebsiella pneumonia, Rickettsia, Brucella, Staph, Strep, P aeruginosa. Other --> TB, toxo, fungi (histo, Candida, Blasto, Crypto), GC, Syphilis. S/s: Sudden pain, swelling, fever, N/V. May have proteinuria, hematuria. May have prostatitis, scrotal edema, hydrocele and inguinal adenopathy. Mumps (+parotitis) --> orchitis occurs in 25-30% of postpubertal cases, usually at day 3-4, 15% bilat. Can have a moderately enlarged testes or normal shape. Most with slight hydrocele, cord may be tender. Syphilis --> any age, usually 18-30yo. Testes enlarged 2-3X normal, may be nodular. Hydrocele in 60%. Not tender or painful as testicular sensation is lost. Tumor --> usually after age 20. Steady increase in size, initially smooth, then nodular. Hydrocele in early stages, later a hematocele. W/u: CBC, U/A with C&S, testicular U/S (r/o abscess), mumps titer. Tx: ice, bed rest, scrotal support, IV Abx if bacterial. Ddx: neoplasia, torsion, GC epididymoorchitis, vasculitis, autoimmune dz, hematoma. Prostatitis: Links: S/s: 4 Types: Classification: W/u: Tx: Chronic/ toxic: Ddx: Prostatodynia: Prostate Cancer: References: Consider in any man with urinary sxs or disturbance in sexual function. In 90% of cases, no cause is found. PP: ductal anatomy-reflux of urine/ascending urethral inf, hematogenous. S/s: freq, urgency, nocturia, pain with ejaculation, ill-defined perineal discomfort, LBP, hematuria, F/C. A boggy tender prostate may be detected, physical findings are often subtle. 4 Major Types: Acute Bacterial (1-5%): 80% E. coli, followed by Proteus, and Klebsiella. Acute illness in age 40-60yo, fever, chills, irritative void symptoms, tender, warm prostate. Avoid vigorous palpation to

prevent bacteremia. Predictable and prompt Abx response,., occasional need for suprapubic catheter. Chronic Bacterial (5-10%): Recurrent UTIs, age 50-80yo. Enlarged boggy gland, >10 prostatic fluid WBCs/HPF. Abx response is usual but slow. +4 cup test. Same symptoms as below. Chronic Non-Bacterial (inflammatory) (40-65%): 8X more frequent. Due to inflammation with no identifiable organism. Etiology: ?viral, genetic, hormonal, chemical, autoimmune, aging, possibly due to Ureaplasma or chlamydia. Sxs similar to prostatodynia. GU and voiding discomfort in age 30-50yo, variable prostate exam, always find WBCs on 4 cup test, negative Cx, no Hx of prostatitis/ UTI. Occasional response to Abx. No cystitis-like dysuria, may have deceased urine stream, frequency, nocturia, postvoid dripping, erectile dysfunction and pain (penile, testicular, perineal, lower abd, ejaculatory), which is the most prominent sx. Pain may be continuous or intermittent Tx is similar to prostatodynia. Chronic Pelvic Pain Syndrome (CPPS) (Prostatodynia) (20-40%): Same sxs as above. Pain and voiding problems in age 30-40yo, normal prostate exam. Negative Cx, no response to Abx. Normal number wbcs in expressed prostatic fluid. Prostatodynia: 1999 NIH Classification System: Category I = Acute bacterial prostatitis --> AN acute infection. Category II = Chronic bacterial prostatitis --> Recurrent infection. Category III = Chronic nonbacterial prostatitis/ CPPS --> Sxs but no demonstrable infection. 80% of patients. Category IIIa = Inflammatory CPPS --> WBCs in semen, EPS or VB3. Category IIIb = Noninflammatory CPPS --> No WBCs. Category IV = Asymptomatic inflammatory prostatitis --> No sxs but +WBCs (an incidental finding). W/u: U/A, G-stain, Cx, check urethral swab for GC, chlamydia, + CBC/ BUN/ Cr/ IVP/ urine cyto. Consider blood Cx. Sequential quantitative Cxs (4 Cup Test): Not often done as inconvenient, time consuming, $$. VB1= first 5-10ml. VB2=midstream 50-100ml. (+if bacteria >5/HPF) EPS = Expressed Prostatic (massage) Secretions = massage each lat lobe to midline from proximal to distal (pt is kneeling), then milk the perineum/ urethra, collecting on swab/ cup. Inc WBC (>10/HPF) will be found in bacterial and nonbacterial prostatitis. Only +Cx is with bacterial. VB3= first 5-10ml after prostatic massage.

+Test if: A. 3X inc PMN in VB3 vs VB1. B. EPS bacterial count 10X >VB1 or VB2. Or C. VB3 is 10X >VB1 or VB2. Tx: Abx X 4-6 weeks for acute and chronic bacterial infections only. 4 wks of a Quinolone best for empiric tx or TMP/SMX, Doxy X 4-6wk or 14d full strength + 14days reduced dosage if acute, some tx 12-16wk if chronic. Since Abx only eradicate the bacteria in 60%, expect recurrance, may need long-term suppressive therapy such as 3X/wk Cipro 100mg or Bactrim or Nitrofurantoin 100mg. If age <40yo --> Treat with Doxy 100 mg BID X 14d or macrolide for possible Chlamydia or Mycoplasma, can continue full 4 wks if improved at 2 weeks. All ages: Sitz bath in warm-hot tub, hydration, stress reduction, avoid spicy food and caffeine, encourage sexual activity. NSAIDs, Alpha blockers if obstructive symptoms, stool softener. Check f/u Urine Cx 14d after tx completed, if find a pathogen, re-tx X12 wks. Prostatic massage?: initially 2-3X/wk, the q3-4d to dec bogginess by squeezing out excess secretions and alleviating discomfort. May cause bacteremia in acute bacterial prostatitis patients. Repeatedly press the lobes of the prostate toward its cents, start at base = as far as can reach and sweep in a series of longitudinal strokes to distal apex. Eventually massage may help clear the bacteria and inflammatory refuse allowing the Abx to penetrate better as well as shrinking the prostate so that it is less tender. This may help with CPPS as well, but controversial. Ureaplasma urealyticum: also implicated in NGU. Tx with 1g of Azithromycin. If chronic or toxic: Check a trans abd U/S to r/o abscess. Abscess: fluctuant on DRE, often immunocompromised. Tx: transurethral drainage. If severe or AUR give IV Gentamicin 5mg/kg q8hr + amp 2g q6hr or Bactrim or Cipro X 5-7d first. Some have advocated adding Allopurinol 300-600mg/d to lower urate concentrations in the prostatic fluid. Quecetin (Prosta-Q, a bioflavenoid in green tea, onions, red wine) at 500mg PO BID X 30d may give some sx benefit. Granulomatous: hard fixed indurated by DRE, r/o CaP. Etiology: fungal, parasite, HSV, RA, sarcoid, TB, syphilis. Calculi: Can cause bacterial persistence despite prolonged therapy. Occurs in 75% of 50yo, misinterpreted as CaP, TRUS confirms dx. Urinary retention sxs: add alpha blocker such as Hytrin, consult urology. If AUR may need 7-14 d Foley or suprapubic cystostomy. Ddx: BPH, CA, prostatodynia (no inflammatory cells on expressed prostatic secretions (EPS)) urethral stricture, bladder Ca, cystitis, NGU, prostatodynia. Prostatodynia: Non-inflammatory prostatitis from inc tension of bladder neck/ prostatic urethra. Affects young and middle age men (22-56yo). Urologys functional pain syndrome. Often seen in type A personality. Cause is unknown, may be an atypical infection, urinary reflux into the prostate, misdiagnosed

voiding dysfunction, or may be related to depression or other somatization syndromes. S/s: May have urinary frequency/ dysuria/ urgency. Ejaculatory or complaints perineal/ back pain/ suprapubic/ penile tip pain, unilateral testicular/ scrotal pain, vague discomfort that may be continuous or spasmodic. Normal PE, check EPS (normal). Tx: Consider 10-14 day coarse of antibiotics (Bactrim, TCN or Cipro), will not likely respond however. Reassure pt that no infection or malignancy is present. Warm sitz baths. NSAIDs. Avoid: ETOH, Caffeine, spicy foods. Stress reduction if cant relax long enough to urinate (exercise, hobby, sex, yoga, biofeedback) to divert attention away from discomfort. Prostate massage, Diazepam and Kegal exercises in suspect tension myalgia of pelvic floor. May need an air cushion of pillow for extra perineal support when sitting. Sit on a hot water bottle of in a bathtub. If a cyclist, get a specially shaped seat. Saw Palmetto: may inhibit 5-alpha reductase, adrenergic receptors or act as an intraprostatic androgen receptor blocker. Alpha-blockers to relax the smooth muscle tone in the pelvis and perineum while improving urine flow. Diazepam 2mg TID PRN for tension myalgia of pelvic floor. Anticholinergic such as Oxybutrin 5mg qHS for voiding urgency. Fourniers Gangrene: H/o trauma, UTI, rectal dz, DM, immunocompromised.

Sx: explosive onset of edema, extreme pain, black necrotic skin, crepitant, rapidly progressive Aspiration yields purulent fluid with bacteria. Flex sig. Tx: aggressive surgical debridement, possible colostomy, suprapubic catheter broad spectrum Abx. **Ref: (The four categories of prostatitis. Clev Clin J Med 2001;68;5) (Consultant 1998;2:345-56) (Infect Dis Clin Pract 1995;4:325-333) (Prostatitis. Hosp Med. 1999;60:710-3) (Prostatitis: evolving management strategies. Urol Clin North Am. 1999;26:737-51) (The urogenital and rectal pain syndromes. Pain. 1997;73:269-94) (Prostatitis and urinary tract infection in men. Am J Med 1999;106:327-34) (NIH chronic prostatitis symptom index. J Urol 1999;162:396-75) (Saw palmetto for the treatment of men with lower urinary tract symptoms. J of Urol 2000;163:1408-120) Acute Urinary Retention (AUR): Links: Etiology: Tx: Chronic: Sx: unable to pass urine, usually associated with pain, Irritative symptoms (urgency, frequency, small volume voids also usually present prior to complete retention Etiology: BPH, prostatitis, stricture or bladder neck contracture, bladder stone acting as ball valve, constipation, medications, neurogenic conditions (SCI, MS). Meds --> anticholinergics, decongestants, TCAs, tranquilizers, sympathomimetics (that tighten the bladder neck), diuretics, CCBs, antihistamines, antiparkinsonian, hormonal (test, progest, estrogen), antipsychotics, hydralazine, benzos, Flexeril, Nifedipine, Indocin, Carbamezapine, dopamine, Vincristine, morphine. Tx: Foley cath or (use coude cath (angled tip to negotiate prostate) if BPH suspected), start oral Abx, leave Foley in place to leg bag. Consult Urology. Use a smaller sized catheter if stricture suspected. Apply perineal pressure during catheter insertion to direct the catheter into the prostatic

urethra. Get patient to relax-increased stress will cause tightening of urethral sphincter making catheter difficult to pass. Confirm location before ballon insertion by return of urine or catheter aspiration. Secure in anatomic postion (abdomen for male, thigh for female) If unable to pass Foley: fill a 10 ml syringe (catheter-tipped) with Xylocaine jelly and instill into urethral meatus. Next use a Coude catheter (has a curved tip designed to navigate through an enlarged prostate). If there is proximal resistance then patient likely has a stricture and will need small catheter (i.e. 12 FR) or special dilators. DO NOT FORCE A CATHETER INTO THE BLADDER, Call a urologist if initial 1-2 attempts unsuccessful as he/she has an excellent chance of passing a catheter via cystoscopy and placement of a catheter over a guidewire. Last resort is suprapubic catheterization. Temporary prostatic stent or catheters such as the ContiCath, which bridges the space from the bladder neck through the prostate and ends proximal to the external sphincter can be used as long as 30 days to permit voiding with less discomfort. Chronic Retention: may have bladder size >1.5L. Presents with overflow incontinence, lower abd mass, UTI, renal insufficiency. Most common cause is prostatic enlargement. May need a permanent prostatic stent such as UroLUme that can be place with local anesthesia. **Ref: (Acute urinary retention. BJU Int. 2000;85:186-201) Priapism: Links: High Flow: Low Flow: Tx: Injection: Persistent usually painful erection not associated with sexual stimulation or desire Etiology: Two most common causes are idiopathic or heme-onc (SS, Leukemia, local neoplasia), Other causes include Trauma (stones, thrombosis, hematoma), Neurogenic (High spinal cord lesion, MS, tabes dorsalis), Chemical/Toxic infection, mumps, tetanus, tularemia, periurethral abscess), Medications: Trazodone, Compazine, warfarin, MUSE, Viagra. Penile injection therapy for treatment of impotence causes priapism in 1-2% of patients. High flow: Usually idiopathic or trauma to the pudendal or cavernous arteries. Not an emergency as the cavernous spaces are filled with oxygenated blood. The end result is a chronic semi-erection. Low Flow: ischemic, from decreased venous outflow/ stasis. A painful rock-hard penis with tissue hypoxia and acidosis. Intracavernosal blood gas sample reveals acidosis (pH <7.25) and dec O2 tension (PO2<30), PCO2 >60. Aspirate 60ml blood and then inject 200ug phenylephrine (1000 ug/ml concentration, achieved by diluting 1mg in 9ml H2O). Can repeat the injection 3X at 20-30min intervals. If detumescence does not occur check Doppler. Tx: High flow priapism only needs treatment if it is bothersome to the patient. They may undergo an elective angiographic embolization or super-selective ligation of the injured artery. If low-flow priapism is not treated within 12h, it can lead to penile fibrosis and impotence. Options include injecting an alpha-adrenergic to induce contraction of the smooth muscle in the corpora cavernosa. Injection: Need a 27g needle for penile block, 10ml syringe, 1% Lido w/o epi, 19g butterfly needle for aspiration, two 30ml syringes for aspiration/inj. Medications: The preferred agent is Phenylephrine (Neo-Synephrine, as it is a pure alpha-agonist.) (10mg/cc = 1 amp) 1cc + NS 9cc in

10cc syringe; inject 0.2-0.4 cc via ins syr or 2. Mix 5 mg vial NEO into 500 cc NS; aspirate blood via 19 g needle then inject 20-25 cc or 3. Neo Synephrine 1cc in 20 cc NS; inject 5-100cc after aspiration; Aspirate 10-20 cc of blood prior to injection of one of the above medications. Monitor blood pressure during and after injection and observe for at least one hour. For persistent priapism call urologist for surgical intervention. Can try a SC injection to deltoid area or thigh: Terbutaline (Brethine, Bricanyl): 0.25-0.5 mg can repeat in 15-20 min. May give PO 5mg Terbutaline X1, 50% unable to urinate and need Foley. Pain control with ice pack may lead to detumescence in 2-3, + ice water enema, dilute epi injection, transfusion/O2 for SS. **Ref: (Priapism. Hematol Oncol Clin North Am. 1996;10:1363-72) (Campbells Urology, 7th ed, 1998, WB Saunders) (Idiopathic priapism. Pediatr Emerg Care. 1999;15:404-6) (Priapism: etiology and management. Acad Emerg Med. 1996;3:810-6) Urologic Trauma: Links: Renal: Bladder: Urethral: Penile: Foreskin: Renal: Injuries classified as blunt or penetrating. Children especially prone to injury as kidneys are relatively large and not well cushioned by fat or abdominal wall musculature. The quantity of blood in the urine does not always correlate with the degree of renal injury Step #1: Asses hemodynamics, if unstable to laparotomy. If stable, CT scan is procedure of choice, especially for penetrating injuries. An adult with no hypotension and microhematuria after blunt trauma can d/c with f/u U/A in 3wks. If gross hematuria and/or hypotension or child with any amount of hematuria must get a CT or IVP. Bladder: If injured will likely have gross hematuria. If ruptured will have abdominal distention and often shoulder pain. Can be diagnosed with cystogram or CT. An indwelling catheter alone can be used to treat if retroperitoneal rupture; surgical repair recommended for intraperitoneal rupture Urethral: suspect if blood at meatus, inability to void, significant blunt trauma to pelvis (90% of urethral injuries associated with pelvic fractures) PE: may see ecchymosis of the penis, scrotum or perineum. DRE may reveal a high riding prostate (sheared from pubic bone attachments, ascends with bladder cephalad as pelvis fills with blood). Do not try to pass catheter as it can transform a partial tear into a complete tear-obtain a retrograde urethrogram first, if normal then pass Foley into bladder and do a cystogram to rule out a bladder injury. Treatment of urethral injury usually requires placement of suprapubic catheter or urological realignment with endoscopy and placement of a catheter. Penile: Constricting items: rings can be removed by compressing the distal portion via wrapping the penis from the distal end with string or umbilical tape. Bottles removed with lubricating jell and traction. Hard objects can be cut with metal cutters. Penile Fractures: usually from vigorous intercourse with female on top with erect penis slipping out and being injured by pubic bone. Pt may experience a snapping sensation, sudden pain, then swelling and ecchymosis. Can be associated with urethral injury. Most urologists recommend immediate operative repair.

Foreskin Trauma: Cleanse, debride nonviable tissue and suture any significant lacerations. Forcible retraction leads to cracks and bleeding. Use compression to stop the bleeding, topical Abx ointment and sitz baths. Advise parents that young boys foreskin is self-cleaning and should not be forcibly pulled back until age 6-7. By age 7 the normal preputial adhesions will spontaneously lyse and the foreskin can be retracted during bathing. Zipper Injury: Skin entrapped in the mechanism of a zipper. Avoid temptation to just unzip, this will likely tear the skin and SC tissue. Use wire clippers or bone cutter. Numb area with lidocaine w/o epi (not required). Cut the bridge of the zipper (central bar of the slide) at area under the surface and it will split in . Abx with anti-Staph if delayed presentation or when the skin is ulcerated. **Ref: (Anterior urethral injury. World J Urol. 1999;17:96-100) (Lower urinary tract trauma. World J Urol. 1998;16:69-75) (Radiographic staging of renal injuries. World J Urol. 1999;17:66-70) (Urologic emergencies. Trauma injuries and conditions affecting the penis, scrotum, and testicles. Postgrad Med. 1996;100:187-200) Urologic Malignancies: Links: Penile: Prostate: Bladder: Renal Cell: Testicular: Renal Oncocytoma: <5% of renal tumors, benign, presents similar to RCC. Tx with radical nephrectomy. Angiolipoma: a benign hemartoma. Often seen in tuberous sclerosis. Most in women. Tx if >4cm. Wilms tumor (Nephroblastoma): The most common primary malignant renal tumor in children. An embryonal renal neoplasm that affects children <5yo. There is a familial autosomal dominant form in 1% of cases. Usually asymptomatic, may presents with an abd mass, abd pain, fever, hematuria and HTN. Tx with chemo, radiation. 91% survival if favorable histology, 20% if have diffuse anaplasia. Penile Cancer: rare, seen in <1% of neoplasms in males. More common with poor hygiene, uncircumcised, tropical climates and HPV-16. Usually occurs on the prepuce or glans as a small papillary or ulcerative or exophytic mass. Carcinoma of the penis seldom occurs in circumcised males. It is extremely rare in Israel, where neonatal circumcision is practiced. Only 10 cases of carcinoma of the penis were reported in a 20-year period. It has been postulated that early circumcision helps prevent carcinoma of the penis, but when practiced later in life, circumcision does not confer protection. An unretractable prepuce impairs adequate penile hygiene; as a consequence, smegma accumulates in the preputial sac. The maximum accumulation of smegma in the preputial sac occurs in phimosis; in our past experience, 92% of patients with penile carcinoma showed phimosis Tx with a partial penectomy. Bx any inguinal node that are clinically enlarged. Ddx: Penile Malignant Tumors: Squamous cell carcinoma, Transitional cell carcinoma, Adenocarcinoma, Melanoma, Metastatic (carcinoma or lymphoma), Soft tissue sarcoma, Kaposis sarcoma, Fibrosarcoma, Malignant schwannoma, Malignant fibrous histiocytoma, Epithelioid sarcoma, Clear cell sarcoma, Leiomyosarcoma. Premalignant Penile Lesions: Buschke-Lwenstein Erythroplasia of Queyrat (Bowens disease), Pagets disease, Leukoplakia, Balanitis xerotica obliterans.

Prostate Cancer (CaP): Links: S/s: Risks: PSA: Dx: Staging: TNM: Tx: References: One in 3 men >50yo has histological evidence of CaP. There is a 12-15% lifetime prevalence (%males diagnosed) for clinically apparent dz, but only will 3% die due to prostate cancer. CaP is the cause of death in 3% of whites and 4% of blacks. The median age at diagnosis is 71yo for whites, 68yo for blacks. S/s: No sxs until locally invasive or metastatic, urinary frequency & obstruction (local tumor mass), leg edema (pelvic lymph node mets), bone pain Local advanced dz sxs: obstruction, urg/freq/hematuria/ UTI/ hematospermia. PE: firm, indurated, asymmetrical, stony (like the bridge of the nose), can also have normal exam (diagnosed with elevated PSA and biopsies) Risk: inc with age (no peak age), Male age 40-50yo with a FHx of a primary relative --> 2X risk, >2 primaries --> 9X risk. Hereditary in 5-10% that develops in age <55yo. African-American ancestry age 40-50. Diet high in red meat/fat. Prostate Specific Antigen (PSA):.Links: Age Adjusted: Free-PSA %: Refer: Velocity: Density: PSA testing detects tumors earlier than digital rectal exam (DRE). PSA is a serine protease used as a marker for prostate cancer, increases with prostate size, volume of cancer, urinary infections, urological manipulation, etc. 20-30% of those with cancer will have a normal PSA (as it take 2g cancer to raise the PSA). If the PSA is >4 ng/ml then there is a ~25% risk of CaP, if 10-20 ng/ml then 50% risk of CaP, if >20 then 80% risk. Serial PSAs will pick up 70% of organ confined CaP. May have confounding variables such as 20% of those with BPH have inc PSA. Avoid: Ejaculating for 48hr before test PSA to reduce false +s (get a 1 ng/ml rise). No significant rise with rectal exam. A PSA 4.1-10 has a 25% probability of CaP, if >10, then 50%. (NEJM 2001;344:18). PSA is covalently bound and inactive in the blood to two protease inhibitors, alpha-1-antichymotrypsin (ACT) and alpha-2-macroglobulin (A2M). Age Adjusted PSA (ng/ml): Age: 40-49 --> Asian:0-2, African:0-2, Caucasian:0-2.5. Age: 50-59 --> Asian:0-3, African:0-4, Caucasian:0-3.5. Age: 60-69 --> Asian:0-4, African:0-4.5, Caucasian:0-4.5. Age: 70-79 --> Asian:0-5, African:0-5.5, Caucasian:0-6.5. (Urol Clin NA 1997:24:339, Mayo Clinic Proc 1997;4) Screening: Check annual DRE & PSA if: healthy age 50-75. If black or +FHx (start @ age 40). If PSA<2: re-check in 2yr (as 4% risk of rise >4.1). Stop early detection attempt : asymptomatic and age >75yo, life expectancy <10yr. Ddx inc PSA: BPH, prostatitis (elevated 3+ months), salivary gland / breast tissue mass.

PSA (total) 4-10ng/ml: Gray Zone as 25% risk of malignancy. Check a % Free PSA = unbound to total PSA ratio. Check if PSA 3.5-10. If %Free >25% --> 92% will not have CaP. If <10% there is 60% risk of cancer, Improves the specificity of the total PSA . If <25% --> get Bx. Free PSA is the active form, it is low in CaP due to low unbound PSA. Both the total PSA and the % free PSA levels increase with age. Since only of Bxs finds cancer, using this ratio if PSA is 4-10 improves the specificity of the total PSA by 20%, and costs ~$65 Vs Needle Bx at ~$1,000. (Percent free PSA. Urology 2001;57:594-98) Refer to Urology for U/S & Bx if: abnormal DRE, inc PSA according to age adjusted level (see above), normal PSA that has inc 0.8 ng/dL in 1 yr. PSA velocity: change in PSA over time, rise in more than 0.75 a year is worrisome, note that PSA levels fluctuate PSA Density (PSAD): the serum PSA divided by the prostate volume (estimated from the TRUS). A ratio greater than 0.15 indicates cancer. Limited clinical usefulness as there is daily variation in both the PSA and the prostatic volume. PSA Doubling Time (PSADT): an important predictor of clinical progressiong of residual/recurrent CaP in those who have undergone readical prostatectomy (Mayo Clin Proc 2001;76:576) Human Kallikrein 2 (hK2): A newly identified enzyme in blood from prostate that may help identify 91% of men in the intermediate PSA (actually hK3) range of 2.5-4 ng/ml an normal exam that may have cancer. Helps identify those who need Bx. Still under study. Diagnosis: transrectal (TRUS)-prostate needle biopsies. Relatively painless, with minimal morbidity (1-2% risk of infection, bleeding, retention), needs antibiotic prophylaxis in advance, systematic biopsies of prostate, accuracy about 80%, if negative biopsies need repeat PSA and exam in 6 months. Often use a ultrasound-guided Bx: Uses an 18g needle attached to a spring loaded gun to obtain bilateral Bxs from base, apex and middle (six Bxs in a sextant pattern) using lidocaine jelly as an anesthetic. Staging Studies: Bone Scan: recommended if PSA >20, sxs suggestive of mets or a high grade cancer (Gleason score >8). If PSA is <10, do not need bone scan or CT in initial cancer w/u, as no mets are likely. If there is an indication for a bone scan (as above), and if it is normal, consider a staging pelvic CT scan. (Counseling patients with newly diagnosed prostate cancer. Primary Care Cancer 2001;2:9-13) Prostascint Scan: = Iridium Capromab Pendetide Scan: Useful for inc PSA recurrence after radical prostatectomy, if cancer and PSA greater than 20 or high grade cancer A scintigraphic radiolabeled monoclonal Ab imaging test. Helps improve pt selection for local salvage treatment. Other studies: CT or MRI though 20-40% false positive and false negative rates. Gleason Score (2 to 10): estimate the tumor aggressiveness histologically by cell architecture pattern. <4 = low grade. 5-6 = intermediate grade of aggressiveness. >7 biologically aggressive. Bases on architectural criteria.

TNM Classification: T1 incidental, T1a <3 foci, T1b >3foci, T2 limited to the gland, T2a <1.5cm, T2b >1.5cm or more than 1 lobe. T3 invades apex, beyond capsule, involves bladder neck or seminal vesical, not fixed. T4 fixed or invades other adjacent structures. N 0 = no nodes, N1 single node < 2cm, N2 multiple nodes <5cm, N3 any node >5cm. M0 no mets, M1 mets. Tx: Links: Mets: Nutrition Therapy: Hormone Refractory: Brachytherapy: Other: The best treatment depends on the individual patient characteristics, stage of disease and preferences. Definitive treatment not necessary in all (slow growing tumor) Organ confined disease and Age<70: radical prostatectomy most common treatment in US. 80-90% cure rate, 2-3 % risk of severe incontinence, 5-10% risk of mild incontinence,40% risk of impotence if nerve sparing surgery used. Surgery may eliminate the cancer and is generally well tolerated, however, it is a major surgery with significant risks. If metastatic: Androgen deprivation --> castration (medical or surgical) Eventually most develop hormone refractory dz. Lupron (Leuprolide): or Zoladex (Goserelin): A GnRH agonist-antagonist. Suppresses testicular production of testosterone, May cause hot flashes and initial worsening of sxs, asthenia, edema, long term treatment causes osteoporosis. Monitor PSA, serum testosterone. Lupron (Leuprolide): 7.5mg IM qmo or 22.5mg q3mo or 30mg q4mo. A GnRH analogue. May cause hot flashes and initial worsening of sxs, GI upset, asthenia, edema. Monitor PSA, AP, serum testosterone. Viadur: 65mg Lueprolide implant. Osmotically driven to deliver 120ug/d over 1yr. Insert SC into inner aspect of upper arm. Decreases PSA by 90% in 75% at 6mo. Caution urinary tract obstruction may occur, usually in 1st few week. Casodex (Bicalutamide): 50mg PO qd. and Flutamide (Eulexin): oral antiandrogens sometimes used in combination with Lupron or Zoladex, monitor LFTs, can cause diarrhea. Flutamide: [125mg caps] take 250mg TID. Used as an adjunct with GnRH analogues in locally confined stage B2-D2 metastatic prostate cancer. Monitor LFTs and PSA, caution if on Warfarin. Bone Mets: Strontium-89 (Metastron): localizes to actively forming new bone, serves as a Ca analog, then decays by beta emission at osteoblastic areas. Gives 75-80% improvement in pain and quality of life in patients. Given IV. Nutritional therapy: selenium (150-200ug/d may lower the risk, trace mineral with antioxidant properties), lycopene (tomatoes derived antioxidant to dec tumor grade. 30mg qd (equals the consumption of ~2lb of tomatoes), reduce animal fats, red meats, increase soy intake Hormone Refractory Prostate Cancer (HRPC): Eventually most develop hormone refractory dz, even if attempt maximum androgen blockade with both an antiandrogen and androgen suppression. Has increased risk of progression to death. Median time (wks): liver mets (10wks), wt loss (12), anemia (22), functional status decline (24), pain increase (32), elevated AP (35), bone scan change (41), PSA increase (52wks).

Ketoconazole: 400mg TID with prednisone can give a 50% reduction in PSA in >60% by 4mo, with pain improvement. Cytotoxic Chemo: Mitoxantrone + Prednisone give a 40% response rate lasting 7mo. Estramustine (Estradiol chemically combined with nitrogen mustard) is often combine with Etoposide, Taxine, Taxotere or Paclitaxel. Herbal: PC-SPES: Six caps/d, costs $108 for 10 days (60 pills). A group of 8 herbs (7 are Chinese) that has been shown to lower the PSA. PC is for prostate cancer, SPES is Latin for hope. It contains S. baicalensis (chrysanthemum), Serena repens (Saw palmetto), Glycyrrhiza (licorice), Isatis indigotica (dyers woad), G. lucidum (reishi), P. ginseng, rabdosia and baikal skullcap. Studies have shown a 54% dec PSA activity, lasting a median of 16wks before progression. Not pharmaceutical grade. It costs $400/mo and leads to 10% risk of thromboembolic events due to phyto-estrogens. (Medical Letter 2001;43:1098) Some recommend adding 1mg Warfarin/d. Nausea and diarrhea also common. MGN-3 is another common herbal blend. Other treatment choices: external beam radiation, cryosurgery. Brachytherapy: implant radiation seeds using U/S guidance via a hollow needle through a template that has been mounted against the perineum. Gives a concentrated dose of radiation. Implantation alone is used only if PSA <10 and Gleason score <6 (small cancer confined to the prostate). It is an outpatient procedure using either local, spinal or general anesthesia. SE: dysuria and hematuria for 2-3 days, nocturia may be permanent, rectal irritation may last 1-2 months, no change in sexual function other than less ejaculatory fluid. Can use Palladium (Pd103, T- of 2mo) or Iodine (I125, T- of 6mo), once they are spent the titanium casings remain (not detected by airport metal detectors). Overall has similar benefit as external beam radiation. Other: External-Beam Radiation: given over a 5-7wk period for localized dz. 10% get cystitis, proctitis. Erectile dysfunction in 50%, urinary incontinence in 5%. Cryoablation: does not remove the prostate gland, may not eradicate the cancer unless it is localized. Complex procedure with a steep learning curve. Surveillance: best for men who have a life expectancy of <10yr as cancer will likely advance and significantly impact the pts quality of life. **Ref: (Prostate-specific antigen best practice policy. Urology 2001;57:217-24) (Nonmetastatic tx, West J Med 1999;171:97-101) (Diagnosis and treatment of prostate cancer. Am Fam Phys 1998;57:1531-47) (Free PSA. Mayo Clin 1997;72:337-334) (Management of prostate cancer. N Engl J Med 1994;331:15) (Management of carcinoma of the prostate. Hosp Med. 1999;60:700-3) (Prostate specific antigen and benign prostatic hyperplasia. Curr Opin Urol. 2000;10:3-8) (Early prostate cancer diagnosis and therapy. Adv Intern Med. 2000;45:41-64) (Complications of advanced prostate cancer. Urology. 1999;54:8-14) (Advance in prostate cancer therapy. US Medicine 2000;36:S4-24) (Prostate specific antigen testing. N Engl J Med 2001;344:18) Bladder Cancer: Links: S/s: Tx: .. 4th most common cancer in men, 8th in women, the 2nd most common GU cancer. M: F is 3:1, ave age is 65yo.

Risks: cigarette smoking (65% of all cases), occupational exposures (aniline dyes, aromatic amines, benzidine in the rubber, paint, leather and print industries), dietary nitrates/ nitrites, analgesic abuse (phenacetin) schistosomiasis (Middle East), cyclophosphamide (Cytoxan), pelvic irradiation, age >50yo. S/s: irritative voiding sxs (freq/ urg/ dys), hematuria (gross or micro). Dx: Cystoscopy is gold standard. IVP to make sure upper tracts ok. Urinary cytology & Chemical Screening tests: Urine cytology positive in most high-grade cancers and CIS, will miss most low-medium grade cancers. BTA: urinary bladder tumor antigen. stat test with dipstick color change positive in 2/3 of cancer. False + rate high (with recent GU irritation (stone, UTI or intravesicular BCG)). NMP22: Have >25X normal levels if cancer. Used mostly to monitor for recurrence. Survivin: a gene inhibitor of apoptosis, currently useful for monitoring recurrence, may be useful in dx of new bladder Ca (JAMA 2001;285:324-8). Tx: Transurethral resection (for treatment and staging). Patients with recurrent superficial tumors or CIS intravesical therapy advised (BCG, Mitomycin Thiotepa, Interferon, Valrubicin). 80% are superficial (Ta or T1), but 70% recurrence rate. Invasive, nonmetastatic, cancer best treated with radical cystectomy. **Ref: (J Urol 1998;159;6) (J Urol 1997;158;6) (Cambells Urology 1998;2328) (Postgrad Med 1999;106:6) (Postgrad Med 1996;100:2) (Bladder cancer. Curr Opin Oncol. 1999;11:207-12) Renal Cell Carcinoma (RCC): Links: Risks: Eval Renal Mass: S/s: Mets: Tx: 10th most common cancer in the USA, 3% of adult malignancies, median age at dx is 63yo. Most tumors are now found incidentally on imaging studies. 1-3% bilateral, Male : Female is 2:1. Makes up 85% of all primary malignant renal tumors, transitional cell CA of renal pelvis makes up ~15%, and Wilms tumor (Nephroblastoma) in children (5-6%). 80% of RCCs develop in the renal parenchyma (in the PCTs), most are adenocarcinomas. Has a rising incidence, possible due to the incidentaloma detection with the rise in high resolution scanning. It spreads by direct extension, may go into the renal vein to the inferior vena cava and to the R atrium. Birch Hirschfeld in 1984 introduced the term Hypernephroid tumor (hypernephroma), which is an incorrect term. Other names include the Internists tumor or the radiologists tumor. Risk Factors: male, age, FHx, cigarette smoker (2X risk or 1/3 of cases), industrial carcinogens (cadmium give RR of 2, asbestos with RR 1.4, petroleum products with RR 1.6), obesity (mostly females), high-protein diet, phenacetin abuse, analgesic abuse nephropathy, amphetamine abuse, HTN, von Hippel-Lindau dz (40% get RCC), non-Hodgkin lymphoma, Tuberous sclerosis, polycystic kidney dz, dialysis (~30-50% of pts on long term dialysis develop acquired cystic disease & up to 6% of these pts with acquired cystic disease develop renal cancer). Familial form (assoc with translocations between chromosome 3 & 8 or 3 & 11). Hemangioblastomas of the CNS (>2/3rd of pts with this phakomatosis develop RCC).

Evaluation of Renal Masses: Ultrasound --> can determine if mass is solid or cystic, if mass is round ,sharply demarcated with smooth walls, no echoes (anechoic) with a strong posterior wall echo It is almost certainly a benign simple cyst. CT Scan --> check If the criteria for simple sonographic cysts are not met or if IVP suggests a solid or complex mass. MRI --> If contrast contraindicated or U/S or CT failed. Or when IVC involvement is suspected as an MRI with IV gadolinium is superior to CT. S/s: renal triad --> palpable abd mass (35%), hematuria (55%), flank pain (40%). Only 9% have all three, and if present, it suggests metastatic dz. Hematuria seen only with tumor invasion of the collecting system. When severe, bleeding may cause clots & colicky discomfort. Abd mass is usually associated with lower pole tumors, usually firm, homogenous, nontender and moves with respiration. Also may have wt loss, fever (15%), fatigue, anemia, HTN, cough, SOB, bone fxs, hypercalcemia, liver abnormalities, erythrocytosis, scrotal varicocele in males (fail to empty when pt is recumbent as due to obstruction of the testicular vein where it enters the renal vein), night sweats, a onset of LE edema, paraneoplastic syndromes (Amyloidosis, Erythropoietin, PTHrP, Gonadotropins, ACTH), anemia (30%, normocytic or microcytic), erythrocytosis (3%), cachexia. Metastases --> Lung -50-60%, Bone -30-40%, Liver -30-40%, Brain -5%. Evaluation for distant Mets: CBC, Chem 18, CXR, Bone Scan, LFTs, head CT if neuro sxs. Liver enzymes can be elevated without having metastatic disease. Dx: CT, LFT, bone scan if suspect mets, renal artery angiography prior to surgery for the anatomy. Tx: partial or complete nephrectomy. Follow up with screening CXR, CT blood work depending on tumor grade. >80% cure rate if a low-stage. Once the disease has spread beyond the kidney there is no cure. Radical nephrectomy can be done, but nephron sparing surgery (NSS) has been shown to be as effective for unilateral RCC. Chemotherapy is ineffective. Modifiers of Biologic Response: Interferon/ Interleukin for treatment of advanced disease. Renal Cancer Ddx: Oncocytomas, Angiomyolipoma, Collecting Duct Tumors, Renal Sarcoma, Nephroblastoma or neuroblastoma (in children) Histological type: Clear cell - 75-85%, (loss of heterozygosity of chromosome 3p in ~90%). Chromophilic (papillary): 14%, ~low stage at presentation, better prognosis than clear cell type. Chromophobic: 4%(excellent prognosis). Oncocytic: rare. Collecting duct (Bellinis duct): extremely rare. Five Year Survival: Stage I: 65-85%. Stage II: 45-80%. Stage III: 15-35%. Stage IV: 0-10%. **Ref: (Renal cell carcinoma: management of advanced disease. J Urol 1999;161:381-86) (Managing kidney cancer. Patient Care 2000;4:91-102) (Clinical manifestations and evaluation of renal cell carcinoma. Uptodate; Volume 7; No 3; 1999) Testicular Cancer:

Links: Risks: S/s: Labs: Dx: Tx: References: Average age is 32yo occurs in 20-34 years old and small number >60yo. Accounts for 1-2% of male malignancies, but it is the most common solid tumor in young adult men age 20-34. 90% can be cured. 95% are Germ cell (germinal): Seminoma --> 40%, vs. Nonseminoma (embryonal, choriocarcinoma, teratoma), Spread via lymph, but nonseminomatous (choriocarcinoma) spreads via heme also. Other Types --> 7% lymphoma (peaks age >50yo. Risk: Caucasian, cryptorchidism (10% of cancers, as 3-10X the risk), testicular atrophy/ dysgenesis, FHx. S/s: Painless hard mass or dull ache/ sensation of scrotal heaviness. May have diffuse swelling/ pain/ hardness in the scrotum. Often get hematoma or hydrocele (20%) from minor trauma. Check for gynecomastia (Bilat, in 10% of presentations) and adenopathy of SC node, abd mass. (do not have inguinal adenopathy). LBP indicates retroperitoneal spread, which is usually the first area it metastasizes to. Lab: U/S (differentiates extra from intratesticular & solid from cystic). Once tumor is suspected get tumor markers: AFP. Beta-hCG as tumor markers elevated in 7O% of testicular cancers, helpful when elevated, negative markers dont exclude malignancy. LDH (inc in 50%, nonspecific but proportional to tumor volume). Dx: Scrotal U/S is nearly 100% accurate in dx. The earlier the better as doubling time usually 10-30d. Never do trans-scrotal Bx as it will seed tumor along the needle tract and alter lymphatic drainage. Inguinal exploration and orchiectomy if tumor confirmed Tx: Depends on stage and pathology. Chemo/ XRT. 5yr survival: 98% if stage 1 (confined to testes), 97% if stage 2 (retroperitoneal), 72% if stage 3 (mets above diaphragm or to visceral organs). Sperm cryopreservation should be offered to all as both XRT & Chemo are toxic to the gonads. **Ref: (Testicular Cancer, 2nd ed, 1998, PRR of Huntington) (J Clin Onc 1997;15:594-603) (N Engl J Med 1997;337:4) (Testicular Mass, Am Fam Phys 1998;57:4) Miscellaneous Penile Conditions: Links: Paraphimosis: Phimosis: Dermatological: Nerve Block: Hematospermia: Peyronie: Erectile Dysfunction: Catheters: Penile Ca: Paraphimosis: Foreskin (prepuce) is retracted over the glans and trapped proximal behind the corona sulcus and becomes incarcerated causing edema of the prepuce and glans due to the tight band of constricting tissue. A urologic emergency in uncircumcised males as can lead to arterial occlusion/ gangrene. May be iatrogenic after urethral catheterization or cystoscopy.

S/s: penile pain, with a glans that appears enlarged and congested with a collar of swollen foreskin around the coronal sulcus Tx: Manual reduction: 1st apply crushed ice and give topical / oral analgesic, +sedation. Wrap the edematous foreskin from the tip --> proximally in a cold gauze sponge with 5% Lidocaine gel or Emla cream and manually compress for 5-10 min to reduce the edema as much as possible with maximal pressure applied distally and gradually reduced toward the base or the penis. Can use compressive elastic dressing wrapped from glans to base. Lubricate corona with K-Y jelly.

Then grab the shaft just proximal to the paraphimotic ring between the index & middle fingers of both hands. While applying traction on the foreskin gently press the glans of the penis through the phimotic ring with both thumbs (may take 3-5 min), using the fingers for countertraction. If this fails try a penile block plus 2% Lido jelly and puncture the swollen foreskin 4-6X with a 19-20g needle, then squeeze out the edematous fluid as less traumatic than a dorsal slit. Or dorsal

slit surgery (excise the constricting band with #15 blade). F/u with Urology in 1-2 days. Circumcision advised to prevent recurrent problems. Some advocate spreading granulated sugar over the edematous glans and prepuce to create an osmotic gradient to draw fluid out. Meatal stenosis: usually secondary to circumcision trauma or infection, if severe stenosis then meatotomy needed. Phimosis: stenosing fibrosis and contracture of the preputial opening, leading to inability to retract the foreskin over the glans, caused by trauma, infection, poor hygiene/inflam. Tx: Local hygiene, circumcision. **Ref: (Paraphimosis: current treatment options. Am Fam Phys 2000;62:12) (Benign conditions of the external genitalia. Prim Care. 1989;16:981-95) (Abnormalities of the external genitalia. Pediatr Clin North Am. 1997;44:1267-97) Penile Dermatoses: Psoriasis: The most common inflammatory reaction that affects the male genitalia. Two forms, inverse and penile. Inverse psoriasis: see bright red, well-defined inguinal plaques. No scale, no central clearing. May involve the entire scrotum, inguinal folds and penis. May have similar lesions in the axilla or popliteal fossa. Unlike other types of psoriasis, it is often pruritic. Pt may have no h/o psoriasis. Penile psoriasis: often aggravated by trauma. Has typical scale, no itching. Tx: low-potency corticosteroid creams. Consider adding Nizoral as Candida may precipitate attacks. Dovonex cream also helps. Fixed Drug Eruptions: sudden onset of single or multiple well-defined circular plaques on the glans or shaft. May be bullous, necrotic and painful. 500 known medications cause fixed drug eruptions. Lichen planus & Lichen nitidus: violaceous, flat-topped papules, 2-10 mm. Seen with drugs and Hep C. Look for lesions in the oral cavity to dx lichen planus. Also see on wrists and ankles. Lichen sclerosis: atrophic, white plaques on the glans or prepuce. Often fissure and cause adhesions. Need Bx to exclude cancer. Smegma: Whitish particulate mass composed of desquamated epithelial cells and sebaceous gland secretions. Can remove with regular retraction of the prepuce and meticulous foreskin hygiene. Pearly Penile Papules: occurs around the coronal sulcus And occasionally near the frenulum Uniform-sized papules that arise at the time of maximum pubertal changes). Seen in 15% of teens. No tx necessary. Angiokeratoma Scroti (scrotal varicosities): red shiny papules. Angiomas along superficial blood vessels. Tx: light cauterization (like cherry angiomas) for cosmesis (if desired).

Penile Nerve Block: To anesthetize penis Contra: uncorrectable coagulopathy. Equipment: sterile prep, gloves, drapes, 10ml syringe, 22-27g needle. 1% lidocaine (do not use epinephrine). Step #1: pt supine, prep and drape penis/ anterolateral scrotum. Step #2: Advance needle 1cm cranially from penopubic jct. near lateral border of penis until penetrate through Bucks fascia. Aspirate and inject 5ml just beneath the fascia.

Step #3: repeat on opposite side. Step #4: at base of penis, circumferentially infiltrate skin with 5ml 1% lidocaine. Avoid puncturing superficial dorsal veins of the penis and its tributaries. Complications: hematoma --> apply direct pressure. **Ref: (Campbells Urology, 7th ed, 1998, WB Saunders) (Benign conditions of the external genitalia. Prim Care. 1989;16:981-95) (Abnormalities of the external genitalia. Pediatr Clin North Am. 1997;44:1267-97) PEDIATRIC UROLOGY: Links: Cryptorchidism: Hypospadias: Epispadias: Nocturnal Enuresis: Pediatric Voiding Disorder: UTI: Cryptorchidism (undescended testicle): Failure of normal descent into scrotum. Incidence primarily depends on the birth wt and age. Occurs in17-33% preemies (100% if <910g, 17% if 2-2.5kg), 3-5% full term (12% if <2.7kg, 0.7% if 3.6-5.2kg)--> 0.8% @1yo and 0.7 in adulthood. Most descend in 3mo, rare spontaneous descent after 1yo. Risks: firstborn child, FHx, hypospadias, low birth w, congential subluxation of the hip, toxemia of pregnancy. Associated abnormalities: very rare endocrine disorders, genetic syndromes, anatomic abnormalities. Complications: testicular malignancy (30X inc or 5% of pts), increased risk of malignancy in contralateral testicle and affected testis even if orchidopexy performed, orchidopexy does make self exams easier, infertility, and psychological stress.

PE: hard to locate in child as small and active cremasteric reflex, need relaxed pt sitting cross-legged, warm hands, use milking action if hard to locate. 5 Types: 1. Retractile testes: brought into scrotum w/o any tension, no tx needed as not truly undescended. 2. Ectopic: located between scrotum and external ring. Usually in superficial inguinal pouch. 3. Undescended: in abd or inguinal canal. 4. Absent Testes: 30% of impalpable testes are absent, likely due to intrauterine testicular torsion. 5. Latent or Acquired Undescended Testes: once descended, probable retractile, but stuck in the upper scrotum or inguinal canal. Lab: If bilateral --> Karyotyping, measure FSH/ LH/ Test before and after hCG to predict presence. Inc LH & FSH with low testosterone --> anorchidism. If hCG (2,000 IU/m2) X 3d --> < several fold rise in serum testosterone, then likely cryptorchidism, check U/S or CT/MRI. Tx: hCG IM qweek X3-4 (max 10,000IU) will promote descent in 20-50%, GnRH intranasally works 20-50% (hormonal therapy not popular in US, surgery for either orchidopexy or to determine if absent testicle. Surgery advised if still undescended by age one. Hypospadias: congenital penile anomaly where urethral meatus is located in too ventral a position including sometimes the scrotum or perineum. Incidence is 1:200 boys. Do not circumcise at birth, as foreskin may be necessary for doing the repair. Epispadias: urethra and meatus are on the dorsal aspect (top) of the penis. Found in 1:120,000. May coexist with bladder exstrophy. **Ref: (Cryptorchidism. Current concepts. Pediatr Clin North Am. 1997;44: 1211-27) (Pediatric testicular problems. Pediatr Clin North Am. 1998;45: 813-30) (Hypospadias and urethral development. J Urol. 2000;163:951-6) (Treatment of hypospadias: an update of current practice. Hosp Med. 1998;59:553-6) (The undescended testicle. Fam Prac Rec. 2001;23:3) Acute & Chronic Scrotal Pain: Links: W/u Acute pain: Testicular Torsion: Appendiceal Torsion: Blunt Trauma: Ddx Acute: Chronic Testalgia: References: Scrotum has 4 basic parts: scrotum, spermatic cord, epididymis and testes. Consider testicular torsion, epididymitis, hernia, testicular cancer. Blue Balls: due to congestion in testes from prolonged sexual arousal w/o relief. May get a blow out in the epididymis causing a sperm granuloma. Also seen post-vasectomy due to sperm build-up. Tx as typical epididymitis. . W/u: Step #1: careful H & P and U/A: If testes/ epididymis indistinguishable and normal U/A, r/o torsion with color flow Doppler ultrasound, if increased blood flow diagnosis most likely epididymitis, if no blood flow torsion.

Testicular Torsion: Links: Hx: S/s: Tx: Spermatic cord twists and occludes blood supply Ave age 17.5, 31% prepubertal, only 5% >30yo. Hx: Can occur in sleep, trauma, strenuous exercise, often have h/o minor similar pain that resolved spontaneously (47%). Some think that it may be due to cremasteric reflex stimulation such as stepping on a cold floor, having a vasectomy scalpel coming toward you, hearing the sound of a towel whip in the shower. S/s: Sudden onset severe unilateral unremitting global scrotal pain, N/V, edema, erythema, abd pain, fever (25%). Exams shows a globally/ diffuse tender, firm testes that may be retracted upward. May be in nl position if rotated 360 deg or 720 deg. An absent cremasteric reflex or elevation of scrotum providing no relief (Prehns sign) are unreliable (outdated) signs. Lab: 90% with nl U/A. 20% have pyuria, 1/5 fever. Dx: H&P, U/S may be normal if spontaneously detorses and may delay tx. Tx: Urology for exploration and orchiopexy. If uncertain get Doppler or radionucleotide scan, in 90% spermatogenesis saved if blood flow restored in 6hr, 20% if >24hr. Hormone function saved blood flow restored by 12h. Manual Derotation: externally rotate the affected testes from medial to lateral 180 deg works in 80% (as if opening a book from the vantage point of looking up the legs), if not effective turn the opposite direction for the 20% that rotate out. If successful the pt should have decreased comfort. Pt still needs definitive treatment with elective orchiopexy. May still re-torsion after orchiopexy. Can lose one testes and still have normal fertility and hormones. Appendiceal Torsion: Testicular appendix --> Mullerian duct remnant at superior pole of testes. Epididymal appendix --> Wolffian duct, on the head of the epididymis. Age 7-12yo. S/s: Sudden onset (less severe and more gradual onset than testes torsion), no emesis or systemic sxs, has tiny, tender mass/ nodule, focal pain localized to upper pole. +Blue Dot sign seen on skin (hemorrhage/ intact). Normal or inc blood flow on Doppler U/S. Lab: U/A normal. Tx: NSAIDs, scrotal support, resolves in 10-14d.

Blunt Scrotal Trauma: Must also consider underlying testicular torsion, tumor or epididymitis. W/u: U/A and a scrotal sonogram will detect testicular rupture (laceration of tunica albuginea (need immediate surgery) Vs epididymitis Vs Neoplasia Vs intratesticular hematoma/hematocele. Traumatic epididymitis may occur in 1-3 days.

Ddx Acute Scrotal Pain: Orchitis, strangulated inguinal hernia, tumor, AAA, hemorrhage, pancreatitis, Familial Mediterranean Fever, venomous bites, HSP, torsion of spermatocele, appy, tick bite, sigmoid diverticulitis, cystercicosis, referred pain from lumbar dz or renal stone, idiopathic scrotal edema --> rapid onset, +erythema, no TTP, tx with bed rest and elevation. Chronic Testicular Pain (Testalgia): Referred pain --> ureter, hip, hernia, L-spine. Traumatic --> cycling, heavy lifting, direct trauma. Entrapment neuropathy --> ilioinguinal, genitofemoral. Iatrogenic --> scar tissue from IH repair/ vasectomy, other surgery. Other --> idiopathic, infectious, diabetic neuropathy, tumors, varicocele, torsion, retroperitoneal fibrosis, epilepsy, PAN, self-palpation orchitis, arterial aneurysm. Tx: After r/o other and if still unknown cause, manage as any other chronic pain. Pain clinic for inguinal injection of BED, TCA, Tramadol. **Ref: (Diagnosis and treatment of the acute scrotum. Am Fam Physician. 1999;59:817-24) (Assessment of acute scrotal symptoms and findings. A clinician's dilemma. Urol Clin North Am. 1998;25:715-23) (Acute scrotal pain. Emerg Med Clin North Am. 1998;16:781-809) (Campbells Urology, 7th ed, 1998, WB Saunders) (Chronic orchialgia in the pain prone patient: the clinical perspective. J Urol. 1991;146:1571-4) (Management of chronic orchialgia of unknown etiology. Int J Urol. 1995;2:47-9) Testicular Masses: Links: Varicocele: Spermatocele: Hydrocele: Hernia: Cancer: References:

The normal testis has slight irregularities at the superior pole.

Hx: duration of mass, rate of enlargement, associated urinary sxs or pain, h/o trauma/ surgery/ TB. PE: transilluminate to differentiate solid from cystic masses. If transillumination is negative --> Scrotal U/S, if spermatocele/ epididymal cyst/ loculated hydrocele and asymptomatic just follow clinically. Other Causes of Masses: testicular cancer, trauma, cyst (epididymal), sperm granuloma (from vasectomy). Idiopathic Genital Edema: localized urticarial reaction that causes swelling of the penis. Benign. Genitals can become edematous also secondary to CHF, lymphatic obstruction, venous obstruction. Varicocele: Tortuosity and dilation of pampiniform venous plexus and internal spermatic vein that sit above the testes, seen in 15% of males, but 30% of infertile males. Most are on Left. R/o renal tumor if sudden occurrence or in older man, or if on R r/o inferior vena cava obstruction/ retroperitoneal adenopathy. 70% associated with dec sperm count or testicular atrophy. PE: Bag of worms or spaghetti. Dilation inc upright and dec as supine, valsalva accentuates. Compare the size of the testes (volume), a decrease in volume suggests testicular damage and risk of infertility. Ddx: hydrocele, spermatocele, epididymal cyst/ tumor. Tx: Naprosyn 375mg X 30d & scrotal support, monitor for growth. To Urology for surgical consideration if: bilateral, symptomatic (painful), infertility (test sperm count first), atrophy of testes (>3ml difference), in adolescent, R-sided. Spermatocele: Painless cystic mass that is separate from the testes. It is usually superior and posterior to testes and transilluminates easily. Aspiration usually reveals opalescent fluid and occasionally dead sperm, no tx unless bothersome, trial of NSAIDs. Hydrocele: 1% of adult males, peritoneal fluid between parietal and visceral layers of tunica vaginalis, occurs at any age. Sx: heaviness in scrotum, painless scrotal swelling that can slowly worsen throughout the day. PE: + transillumination, r/o hernia, irreducible mass, no bowel sounds on auscultation. Communicating: in infants can close spontaneously age 1-2yo w/o tx, assoc with patent processus vaginalis and indirect inguinal hernia. If persistent over age 1-2 surgical repair necessary Noncommunicating in adult due to imbalance of secretion and absorption, often from prior injury, infection, neoplasia, torsion or surgery that might have interrupted lymphatics (varicocele or hernia repair).

Tx: May need to aspirate to palpate testes or get U/S. No tx unless discomfort from bulky mass or a cosmetic concern, treatment options include aspiration (most re-occur), aspiration plus injection of sclerosant or hydrocelectomy. Groin Hernias: 10% lifetime risk. 96% of hernias are inguinal (bilateral in 15%), 4% femoral (more often in female, irreducible and often strangulate). (Am Fam Phys 1999, 59;1) Difficult to tell difference in 30% of pre-op exams. Best way to tell is to reduce the hernia, then occlude the internal ring with 2 fingers and ask the pt to cough, if the hernia is restrained it is indirect (pops out if direct). Classification: Defined by Hesselbachs triangle --> laterally as inferior epigastric artery, medial as lateral border of rectus muscle, and inferiorly as the inguinal ligament. Direct (16%): weakness in inguinal floor, Usually acquired, due to inc intra-abd pressure. Reduces easily, rarely strangulates. More common in those >40yo. Usually painless. Bulge in area of Hesselbach triangle, may push against the side of the finger on exam. Indirect (80%): often has a congenital component as testis descends through the processus vaginalis, thus either the potential space is not obliterated or the fascia is weakened where the spermatic cord exits at the internal abd ring. Most common is the indirect inguinal. Pain on straining. Feel bulge with fingertip in area of internal ring. Femoral (4%): F>M, rare in child. Occurs through the femoral ring, femoral canal and fossa ovalis. R>L. Pain may be severe, inguinal canal is empty on exam. Irreducible and often strangulates. S/s: often asymptomatic, can also present with painful lump or mass, pulling sensation or heaviness, especially with straining If negative exam and U/S and pt still having pain, consider CT of pelvis to r/o obturator hernia. Tx: all should be surgically repaired unless terminally ill (and no evidence of incarceration) or uncontrolled ascites. 90% can be repaired with only a local anesthetic. Recurrance rates ~5-8%. Try to reduce --> Use the flat of the hand to direct the hernia upward toward the contralateral shoulder. Four main repairs: Open Anterior Repair(Bassini, McVay, Shouldice techniques). Open Posterior (Iliopubic tract repair and Nyhus technique). Tension-Free Repair with Mesh (most common approach, use Lichtenstein and Rutkow techniques). Laparoscopic Procedures (transabdominal preperitoneal (TAPP) or total extraperitoneal (TEP) approach). **Ref: (Testicular lumps in general practice. Practitioner. 1998;242:627-30) (Pediatric hernias and hydroceles. Pediatr Clin North Am. 1998;45:773-89) (Testicular masses. Am Fam Physician. 1998;57:685-92) (Benign and malignant pediatric scrotal masses. Pediatr Clin North Am. 1997;44:1229-50) (Postgrad Med 1999;105:4) (Testicular lumps in general practice. Practitioner 1998;242:627-30) (Campbells Urology, 7th ed, 1998, WB Saunders) (Benign conditions of the external genitalia. Prim Care. 1989;16:981-95) (Abnormalities of the external genitalia. Pediatr Clin North Am. 1997;44:1267-97)

Erectile Dysfunction (Impotence): Links: Ddx: Hx: PE: Labs: Tx: Sexual Dysfunction: Female Dysfunction: Male Hypogonadism: Premature Ejaculation: Peyronie: References: Persistant inability to achieve/maintain an erection for normal penetration to the mutual satisfaction of both partners. Occurs in 52% of males 40-75yo, 75% by age 80 yo. Sexual intercourse is ~= walking up 2 flights of stairs. Bicyclist: avoid perineal nerve injury by level seat or slightly nose downward, use wider seat. Knees should bend slightly at bottom of the pedal stoke so legs help support wt. Stand up and pedal every 10min. Rise out of seat when going over bumps. Impotence Ddx: Inflammatory: prostatitis, seminal vesiculitis, urethritis. Mechanical: congenital, hypo/epispadia, Peyroniess, phimosis. Post-op: pelvic surgeries, AP resection, vascular surgery. Occlusive vascular: large or small vessel dz, smoking. (85% of cases). Trauma: pelvic fx or injury, straddle injury to perineum. Endurance related: MI, angina, COPD, CRF, nutrition, etc. Neurologic: neuropathy, spinal inj, spina bifida, Parkinsons, MS. Chemical: illegal, medications, meds. Endocrine: pituitary, thyroid, DM, gonadal failure, adrenal, Only 5% due to hypogonadism Psychogenic: Only ~10%, due to anxiety, fear of failure, depression, marital conflict, ignorance/ misinformation, OCD. Often sudden onset, situational, pt has rigid erections in noncoital situations, may have underlying psychosexual problems or a partner problem (partner wants multiple erections). Hx: Onset: sudden may indicate psychological or trauma, gradual --> organic. Quality: how turgid comparison to best erections, can they still have intercourse? Type: is problem attaining (neuro, psych, endo) or maintaining (vascular) erection. Stimulus: upon awakening & self-stimulation (if able, maybe psychogenic or performance anxiety --> refer for sexual counseling), Orgasmic/ ejaculatory function. Libido: the spirit is willing but the flesh is weak. PE: r/o Peyronies dz, check penile, perineal sensation, anal sphincter tone, bulbocavernosus reflex, LE pulses, secondary sexual characteristics, testicular size and consistency. Dx: H & P. Lab: Consider: 1. U/A (for glucosuria) 2. Chem 17. 3. recent PSA. +CBC, lipids. If dec Libido --> check morning serum testosterone level (free if more accurate than total) --> if low (<270), check

FSH, prolactin, LH (should be inc). Tx: Links: Viagra: Uprima: Vacuum: Injections: Urethral Suppository: Surgical: Unproven: Lifestyle changes: diet, exercise, stop ETOH/ TOB. If psychogenic refer to a sex therapist. Erectile function correlates with HbA1c in diabetics. Treatment options for Organic Impotency: 1. Oral Medications: Sildenafil (Viagra): 25, 50 & 100mg. Try 3 times with 50mg, then once with 100mg, to seek optimal dose. Rx: 50mg PO #6, with 5 refills. If Age>65 or hepatic/renal impairment start with 25mg. (100mg cut , is same price as 25mg). Take 1hr prior to anticipated intercourse (peaks in 1hr, but works in -4hr after taking), only works if sexually aroused and stimulated (does not cause erection on own, dont just watch TV). Phosphodiesterase inhibitor so no breakdown of molecular messengers from NO, cyclic GMP, specific w/in the corpora cavernosa. Overall 70% success rate. Max 1/d, avoid fatty meals & ETOH as decreased absorption. Works well even for psychogenic impotence in young men. Dont drive after 1st dose. Can be used in those with cardiovascular dz such as stable angina w/o nitrate use, successful coronary revascularization, mild valvular stenosis, NYHA class 1, uncomplicated AMI >6wks ago, and controlled HTN. Contra: Do not prescribe if patients on nitrates (nitroglycerine or amyl nitrate AKA popper), will inc&61472;potency 50X --> hypotension as increases venous dilation. Avoid if active CAD (if frequent angina, may need a treadmill test to 4-6 METS), active CHF and borderline low BP or dec volume status, concurrent use of meds inhibiting 34A (EM, digoxin, Diltiazem, Verapamil, Quinidine). Avoid in retinosa pigmentosum. SE: 16% HA, facial flushing, dyspepsia (8%), transient visual disturbances (blue flashing/ stars/ hue, impaired blue-green discrimination all due to PDE-6 in the eye). Uprima (Apomorphine): 1 tab sublingual. Works in 15-30min by stimulating dopaminergic receptors in the brain to improve local blood flow into the penis. SE: bradycardia, hypotension, fainting. Yohimbine (Yocon): 5.4mg PO TID or 1hr precoital X 6wks, avoid if HTN. 40% success in psychogenic impotence. 2. Vacuum Assist Devices: 5 steps: apply lubricant to shaft, cylinder over (trim hairs), pump air out --> 2 Minn to erect, transfer constriction band (can leave on 30min). Unnatural as venous rather than arterial blood (cooler), may bruise on 1st use, but 60-90% success rate. 3. Drug injection: to relax trabecular smooth m, Prostaglandin--> Alprostadil (Caverject) @ 10-20ug directly into corpus cavernosum.

First trial done in office --> Initial dose 2.5ug, increase by 2.5 if partial response, then in increments of 5-10ug (older --> higher doses). Alcohol wipe, pt standing. Use 27-30g, advance perpendicularly @dorsolateral, proximal 1/3 the entire then withdraw a little. Inject over 5-10 sec. Have pt apply pressure over injection site and with thumb & forefinger at base to prevent systemic distribution X 2-3min. Evaluate the quality of the erection q15min. Takes 5-20min to work, lasts 30-60min. Pt no leave until near complete detumescence occurs. If no response may give 2nd injection in 1hr. Alternate inj site, max 3X/wk with 24hr between doses. SE: pain, priapism, hematoma, fibrosis, Contra: myeloma, leukemia, deformity, implants, SS or carrier. If priapism occurs (>4hr erection) need to come in for immediate aspiration of corporal blood or injection of phenylephrine. Then need to decrease meds so no erection is longer than 1hr. 4. Urethral Suppository: Alprostadil (Muse): start @ 125-250ug suppository inserted 1 into urethra after urination, takes 5-10 min, adjust does to 500-1000ugs. 65% success. (Max 2/d); first dose should be given in office for teaching and to watch for hypotension. Contra: stricture, severe hypospadias. 5. Surgical Implants: expensive, invasive, irreversible. two types, inflatable vs semirigid rods. Satisfaction rate 90%, overall complication rate approximately 10%. Treatment failures: non-resceptive partner, no partner, lack of desire, interruption issues, loss of effectiveness. May need marital or sex therapy. Other Unproven therapies: Trazodone 50mg PO qHS. L-arginine: precursor to NO (natural Viagra), OTC, safe, @3-6g PO qd, takes 2 weeks to start working. Transdermal NTG: apply to end of penis 1hr prior to intercourse. Yohimbine (Yocon): 5.4mg PO TID or 1hr precoital X 6wks, avoid if HTN. 40% success. Ginkgo may help at 60-240mg BID. DHEA: 50mg/d, assists with low libido and improves erections. Takes several months to work. Follow PSA. Sexual Dysfunction: Links: Hx: Female Dysfunction: Male Hypogonadism: Premature Ejaculation: Hematospermia: Erectile Dysfunction: Common Sexual Problems in most couples: Problem: %Females, %Males: Dec Sexual Libido --> 40 %F, 30 %M. Failure to attain or maintain arousal --> 60 %F, 50 %M. Premature Orgasm --> 10 %F, 15 %M. Frequently Anorgasmic --> 35 %F, 2 %M. Dyspareunia --> 15 %F, 5 %M. Ddx of Loss of libido: Endocrine --> hypothalamic, pituitary, thyroid dz, Addisons, Cushings. Psychological --> depression, anxiety, idiopathic. General dz --> any chronic condition, cancer, infection. Antiandrogen --> spironolactone, cimetidine, flutamide, finasteride, cyproterone. Hyperprolactinemia --> phenothiazines, metoclopramide, Haldol, pimozide, methyldopa, reserpine, cimetidine.

Sexual History Taking: Opener: Id need to ask you some Qs about your lifestyle that will help me take better care of you. It might include info on your use of seat belts, tobacco, ETOH, exercise and sexual activity. Many people have Qs about sexuality or their own sex lives, do you have any Qs or concerns? How satisfied are you with your sexual functioning? Are you sexually active? What methods of birth control/ STD protection? How many different partners have you had? Do you have sex with men, women or both? Do you or any of your partners use IV drugs? Do you have any problems achieving orgasm/ maintaining erections/ pain during penetration? Has anyone ever done anything to you sexually that you didnt want them to do? Is there anything you think is important that we havent discussed. When find a Problem --> Where on the arousal continuum does the problem lie? Desirearousalorgasmsatisfaction. Does it occur all the time or only in certain situations? What is your explanation for the problem? Male Hypogonadism: Links: Low Testosterone: Etiology: Adult Androgen Def: S/s: W/u: Tx: Free Testosterone: In males the normal is 9-30 ng/dL, <8 ng/dL or <325 mg/dL is considered low. Total Testosterone: normal is 300-1200 ng/dL. The prevalence of low testosterone by age is 19% (60s), 28% (70s) and 49% (80s) (J Clin Endocrin 2001;86:742). Ddx of Male Sexual Disorders: feminizing tumor of the testes/ adrenal, testicular dz, estrogens, GnRH analogs. Cytotoxic agents that cause testicular damage including ETOH. If Decreased Serum Testosterone: After age 30yo, the levels of total and bioavailiable testosterone in men decreases 1-2%/yr due to dec production and inc binding globulin. There is a normal diurnal variation, reaches a max level of 25nmol/L (710 ng/dL) at ~8am in declines to a mean minimal level of 15 nmol/L (426 ng/dL) at ~10pm in young men. Circulating testosterone is metabolized to dihydrotestosterone (DHT) in the skin, liver, prostate by the enzyme 5-alpha-reductase. It is also metabolized to estradiol (E2) by aromatase in the brain, fat and testes. Normal DHT: total testosterone ratio is ~1:10 and the E2: total testosterone ratio is 1:200. Causes of Low Testosterone: decreased sex hormone-binding globulins (cirrhosis, chronic renal dz). Secondary hypogonadism (hypopituitarism), estrogen therapy, orchiectomy, consuming >2oz of alcohol/d correlates with lower free testosterone as well. Primary Testicular Failure --> Klinefelter (47, XXY), cryptorchidism, orchitis, trauma, AIDS, myotonic muscular dystrophy, retroperitoneal fibrosis. Hypogonadotropic Hypogonadism --> congenital GnRH def (Kallmann syndrome), Prader-Willi syndr, idiopathic hypopituitarism, pituitary tumors, suprasellar tumors, hemochromatosis, severe illness, massive obesity, inflammatory/ traumatic/ vascular lesion of the hypothalamus and pituitary.

If deficiency before/during puberty: Failure of secondary sexual characteristics, juvenile voice, eunuchoid body habitus, gynecomastia. Lack of scrotal rugations, absent libido, small penis (<5cm stretched length), small testes (<5ml volume or <3.5cm in length). Autosomal Recessive enzyme defects in testosterone production: 20,22-Desmolase:

ambiguous genitalia, no puberty, have elevated LH and FSH with low cortisol. 3B-ol dehydrogenase: associated with male hypospadias and poor pubertal development. May have normal to increased LH and FSH will dec&61472;cortisol. 17a-hydroxylase: ambiguous genitalia, poor pubertal development, low LH with increased FSH and mineralocorticoids. 17,20-Desmoslase: male genitalia but remain prepubertal. 17-Ketosteroid reductase: has female or ambiguous genitalia with partial puberty. If Androgen Deficiency as an Adult: Hypothalamic Pituitary D/o --> panhypopituitarism, isolated LH def, LH & FSH def (Kallmanns syndrome), biologically inactive LH. Gonadal Abnormality --> Klinefelters, bilateral anorchia, Leydig cell aplasia, adult Leydig cell failure (ADAM = Androgen Decline in the Aging Male = Andropause), defects in androgen biosynthesis or other chromosomal defects. Defects in Androgen Action --> complete insensitivity, incomplete insensitivity type 1, or type 2 (5-alpha-reductase def). Ddx of hypogonadism: obesity, severe systemic illness, malnutrition, AIDS, uremia, sickle cell dz and hepatic cirrhosis. S/s of hypodandrogens: dec libido, dec erectile function, dec body hair (pubic/ axillary), dec frequency of shaving/ beard growth, depression, dec energy levels, h/o bone fxs, chronic illness, visual field abnormalities, osteoporosis, dec muscle mass, inc visceral fat, small testes (<15 ml volume or <4cm in length), small prostate, gynecomastia, dec HCT, infertility, fatigue, depression, loss of motivation, irritability, vasomotor phenomena. W/u: serum (plasma) total testosterone (T). If low --> check plasma free T, serum hormone binding globulin (SHBG), FSH, LH, Prolactin. If High gonadotropins give T replacement. If normal/ low investigate pituitary gland. The calculated free testosterone index may be as well. Androgen Replacement Therapy: Check baseline PSA and lipid profile, HCT. Check testosterone peak & nadir levels at 1mo to adjust dose, then q6-12mo. Check PSA & DRE q6mo. Check HCT (causes polycythemia in 25%) at 3mo then annually. Will enhance mood, energy, libido and sexual function if serum testosterone is decreased. IM Forms: Testosterone Enanthate (Delatestryl) or Cypionate (Depo-T): 150-200mg IM q2-4wk X4 (if effective give 200-400mg q3-4 wks). Inexpensive. Often produces supraphysiological serum levels shortly after injection, then subnormal levels at the end, with fluctuations in sexual function/ energy/ mood.

Transdermal Forms: Androderm: 5mg patch to nonscrotal skin qHS to arm, back, upper buttocks, leave on 24hr. Achieves normal serum circadian T levels and normal ratios with E2 and DHT. May be left on during sex, shower. Local skin irritation common (9% discontinue). Testoderm: 4 & 6mg/d patch qd to scrotum, leave on 22-24hr/d. Mimics normal circadian rhythm, have transient scrotal itching/ discomfort. Area needs to be dry and shaved. Remove while showering, swimming or having sex. Testoderm TTS: two patches to deliver 5mg/d. Androgel: 1% gel, start at 5g (50mg testosterone) qd apply to shoulders, upper arms and/or abd. Risk of androgenization of sexual partner and household members. 15min of skin to skin contact with lead to doubling of partners testosterone levels. PO Testosterone: Should be avoided secondary to hepatic risks. **Ref: (Safe use of Sildenafil in patients with CAD. Clev Clin Med 2001;68:4) (New insights into erectile dysfunction: a practical approach. Am J Med. 1998;105:135-44) (Postgrad Med 1999;105:2) (Testosterone replacement, Postgrad Med 1998;103:5) (Am Fam Phys 1999;61:1) (Sexual concerns in women, J of FP 2000;49:3) (Androgen deficiency in aging men. Med Clin NA 1999;83(5):1279-89) (Impotence. Dis Mon 1999;45:1) (Sexuality and older people. Elder Care 1999;11:12-5) (Medical treatment of erectile dysfunction. Ann Med 1999;31:388-98) (Erectile dysfunction in the aging man. Med Clin North Am 1999;83:1267-78) (Female sexual dysfunction. Postgrad Med 2000;5:S35-39) (Dyspareunia and vaginismus. Clin Obstet Gyneco. 1984;27:750-9) (Female Pt 1999;8:suppl) (Female sexual problem. WJM 1999;171:358-60) (Female sexual dysfunction. Am Fam Phys 2000;62:1) (Dyspareunia. Post Grad Med 2000;108:2) (Transdermal testosterone treatment in women. N Engl J Med 2000;343) (Evaluating sexual dysfunction in women. Clin Obstet Gynecol 1997;40:616-29) (Hypoactive sexual desire. Psychiatr Clin North Am 1995;18:107-21) (Sexual dysfunction, Part II: Diagnosis, management, and prognosis. J Am Board Fam Pract. 1992;5:177-92) (Sexual dysfunction, Part I: Classification, etiology, and pathogenesis. J Am Board Fam Pract. 1992;5:51-61) (Andropause: a misnomer for a true clinical entity. J Urol. 2000;163:705-12) (Replacing testosterone in men. Drug Ther Bull. 1999;37:3-6) Premature Ejaculation: Defined as an intravaginal ejaculation latency of < 2min in more than 50% of intercourse. Has a 45% prevalence in the US, but few seek treatment. Tx: First line tx is behavioral therapy from a sex therapist who instructs techniques such as the pause-squeeze technique and teaching them to limit their focus on his erectile state. Such techniques are limited by the need for partner cooperation and have poor long term success. A topical anesthetic such as Nupercaine ointment applied to the coronal ridge and frenulum prior to intercourse can be effective as it reduces hypersensitivity. 45-53% show improvement with Serotonergic antidepressants such as Clomipramine (Anafranil) given at 25mg X7d, then 50mg X2mo (max 250/d). Sertraline (Zoloft) @50mg X1wk, then 100mg X2mo. Paroxetine (Paxil) is also effective. Sildenafil (Viagra) can also be helpful. Hematospermia: Bloody semen. Usually benign 99% of cases. Most due to inflamation, pervious surgery/ instrumentation, ductal obstruction, cysts or vascular abnormalities. Occasionally seen in TB,

prostatic cancer, prostatitis, bleeding d/o. S/s: acute, fresh blood staining of the ejaculate. Usually very concerning for the pt. May be confused with bleeding that originates from the sexual partner, in which case the ejaculate should be collected in a condom and brought in for guaiac testing. W/u: Complete physical looking for local and systemic dz. Examine prostate, get U/A, PSA. If persists consider a transrectal U/S. Tx: Reassurance, most cases resolve spontaneously. Consider a trial of antibiotics (quinolone or Doxycycline). **Ref: (Pharmacological treatment of premature ejaculation. Curr Opin Urol. 1999;9:553-61) (J Urol 1998:159). (Antidepressants in the treatment of premature ejaculation. J Sex Marital Ther 1996;22:85-96) (Pharmacologic treatment of rapid ejaculation. Psychiatr Clin North Am 1995;18:85-94) (Evaluation and treatment of premature ejaculation: a critical review. Int J Psychiatry Med. 1992;22:77-97) (Sexual Dysfunction. Postgrad Med 2000;5;S28-30) (Hematospermia. Am Fam Physician. 1985;32: 67-71) Peyronies Disease: Unknown etiology, though trauma or autoimmune mechanism most likely explanations. A fibrous plaque forms on the tunica albuginea of the corpora cavernosa leading to a hard nodular mass that inhibits expansion of the affected portion causing a subsequent curvature and occasionally painful erections (2/3 of patients). The pain often resolves spontaneously in 12-18mo, but the curvature usually persists or worsens. --> higher incidence in Dupuytrens contracture and Ledderhoses dz (fibrosis of palmar and plantar fascia) associated with Peyronies in about 10% of cases. The overall incidence is 0.4%, the average age at onset is 53yo, it is more common in those of Irish descent. Sx: penile curvature or hourglass deformity with erections, nodular area in penis, pain in penis seen in some cases at start of process (pain is self limiting). May have discomfort or inability to penetrate due to curvature. Tx: Oral therapies not shown to be very successful. Can try Vit-E 400 IU QID, Potassium Aminobenzoate(PABA) 12g/d divided into 6 doses of four 500mg tabs (24 tabs/d) X 6-12mo (expensive and can cause GI upset). Colchicine, an antioxidant and antigout agent that inhibits microtubule formation given 1.2 mg BID for 3-6 months may work if tolerated. Penile verapamil injections by urologists another option. If severe curvature and no response to medical therapy then surgery necessary (process must be stable for one year). Most remain stable, 25% progress to calcification. Spontaneous remission in 50%, approximately 10% will require surgery (if patient so desires) self-limiting pain subsides as plaque growth ceases and fibrous tissue matures. **Ref: (Peyronie's disease: current management. Am Fam Physician. 1999;60:549-52) (What's new in Peyronie's disease. Curr Opin Urol. 1999;9:569-71) (Sexual dysfunction. Postgrad Med 2000;5:S31-33) Benign Prostatic Hypertrophy (BPH):

Links: Sxs: AUA Sxs: PE: W/u: Tx: Nocturia: Prostate Cancer: References: Urinary Retention: Enlargement of the prostate. The most common benign tumor in men. Histologically present in 50% at 50, 90% at 90. ~50% of males with enlarged prostates will develop sxs. Etiology unknown, may be due to inc estrogen to androgen ratios as age. Sxs: Obstructive sxs: hesitancy, weak stream, straining, terminal dribble, prolonged void, Irritative sxs: frequency, urgency, nocturia, urge incont, small volumes due to detrusor instab and change in bladder dynamics. Frequency Ddx: bladder irritability/ UTI/ bladder stone/ neurologic dz/ neoplasm. The normal bladder capacity is ~300-500 ml, a sensation of fullness @ ~250-300ml in most individuals. Hesitancy Ddx: urethral stricture/ bladder neck contracture/ urethral valves/ neurogenic condition such as DM. Complications of BPH: urinary retention, urinary infections, renal damage/failure/, bladder stones, hematuria (gross and microscopic) American Urologic Association (AUA) Sx Index: Obstructive Voiding Sxs: Past Months

Sxs: Incomplete Bladder emptying: None (0 pt), 20% (1), <50% (2), 50% (3), >50% (4), Most of Time (5). Urinate >q2 hr (Frequency): None (0 pt), 20% (1), <50% (2), 50% (3), >50% (4), Most of Time (5). Stop/start stream (Intermittency): None (0 pt), 20% (1), <50% (2), 50% (3), >50% (4), Most of Time (5). Difficult to postpone (Urgency): None (0 pt), 20% (1), <50% (2), 50% (3), >50% (4), Most of Time (5). Straining to initiate urine: None (0 pt), 20% (1), <50% (2), 50% (3), >50% (4), Most of Time (5). Weak Stream: None (0 pt), 20% (1), <50% (2), 50% (3), >50% (4), Most of Time (5). Nocturia: None (0 pt), 20% (1), <50% (2), 50% (3), >50% (4), Most of Time (5). (0-7 points --> mild sxs. 8-19 --> mod. 20-35 --> severe sxs) PE: DRE usually reveals smooth firm elastic enlargement --> abd exam (percuss suprapubic area for dullness that might suggest a distended bladder). Size or prostate doesnt always correlate with obstructive sxs. Ddx: Malignancy --> prostate nodule or indurated areas. W/u: Hx, PE with DRE, U/A & Cx, Cr, PSA. Check cysto & IVP if UTI or hematuria, U/S if inc Cr, large PVR, check prostate U/S and biopsies if abn PSA or DRE, check post void residual if sx severe or tenderness or suprapubic mass. If AUA score >20 consider urodynamic testing, uroflowmetry or cystoscopy. Tx: Links: Alpha-blockers: Finasteride: Interventions: Indications for tx: severe sxs based on AUA score (>7), recurrent UTIs, bladder stones, hematuria (aftr r/o other causes). Mild sxs --> watchful waiting or OTC Herbs: Saw Palmetto or Pygeum Africanum or Serenoa (Permixon), a herbal with minimal SEs, can be tried for 6-8wks if pt wary of taking meds and have only mild sxs. Moderate-Severe sx: Alpha-Blockers: Relaxes the fibromuscular stroma of prostate. Effective in 2-3 weeks, expect ~50% dec sxs and inc flow. Can be used in combination with Finasteride. SE: 10% stop due to dizzy/HA, 4% get hypotensive, 2% nasal congestion that wears off. Need slow titration when starting and stopping the meds. Terazosin (Hytrin): start @1mg qHS, titrate to 2, 5 or 10mg/d Doxazosin (Cardura): start @1mg

qAM or PM, titrate over 1-2wks to 2, 4, 8mg. Prazosin (Minipress): 1-20mg/d at BID-TID dosing. Flomax (Tamsulosin): 0.4-.8mg qd anytime. Selective alpha-1 blocker lower incidence of postural hypotension/ dizziness, no need to titrate dose. SE: decreased ejaculation, facial flushing, can still cause cardiovascular side effects seen with other alpha blockers Finasteride (Proscar): 5-alpha-reductase inhibitor. Blocks testosterone --> dihydrotesterone, results in decrease in prostatic size. Only useful in larger (>40g = golf ball size prostates) ~28% dec size @6mo, need to check PSA at 0, 6mo and qyr as reduces PSA by 30-50%, (r/o CaP if a rise in PSA or fails to fall to age specific nl while on the drug). SE: minimal dec libido, dec volume of ejaculate (%5), impotence. Finasteride very effective at reducing hematuria associated with BPH. Finasteride can also be combined with alpha blockers in men who have moderate-severe symptoms and large prostate. Try stopping the alpha blocker after 9 months of combined therapy. Interventional Treatment: Minimal invasive: transurethral microwave thermotherapy (TUMT), prostatic stents, trans needle ablation (TUNA)The TUMT is an outpatient procedure that can be performed on patients who are anticoagulated, success rate slightly less than TURP, but can have more irritative and obstructive symptoms than a TURP for 4-6 weeks before improvement noted. It is performed with IV sedation. More invasive: trans resection of Prostate (TURP)= gold standard as dec sx 80%, trans incision (TUIP) laser prostatectomy, Open prostatectomy if larger >80g. Other: Trans electrovaporization of (TEUVP\TVP), laser, Open prostatectomy if larger >80g. Visual laser ablation of the prostate (VLAP), High intensity focused U/S (HIFU). Common SEs include retrograde ejaculation (40%), ED (5%). Nocturia: Awakening during the night to urinate. Contributes to fatigue due to sleep deprivation as well as injury due to falling. 72% of elderly individuals arise at least once a night with the urge to void. Up to 25% routinely arise >3 times. PP: need to differentiate excessive urine production from irritable bladder etiology vs. poor emptying. nocturnal polyuria due to increased urine output during the night due to disruption in the diurnal variation of vasopressin. Also due to diminished nocturnal bladder capacity, worsened by 3rd spacing of fluid to LE (CHF, venous stasis) and OSA (inc atrial natriuretic peptide). Tx: Depending on the etiology. Start with a voiding diary. Afternoon naps, compressive stockings, reduce Na intake and evening fluid restriction PRN. Treat pts with OSA with CPAP to decrease their nocturia. Try to mobilize any edema from the lower extremities during the daytime. Use compressive stocking, afternoon nap or leg elevation. Dose any diuretic 6hr before bedtime. Arginine Vasopressin (Desmopressin): start with 10 ug intranasally or 0.1mg PO and increase by increments of 10 ug or 0.1mg every 3rd night until desired effect or to max of 40 ug or 0.4mg. Helps with Parkinsons, autonomic dysfunction, MS, BPH and DI. **Ref: (Mayo Clin 1998;73:597-602) (Treatment of nocturia in the elderly. Drugs Aging 1999;15:429-37) (Nocturia. J Urol. 2000;163:5-12) (Clinical features and management of benign

prostatic hyperplasia. Hosp Med. 1999;60:705-9) (Benign prostatic hyperplasia. Am J Med Sci. 1997;314:239-44 (Benign prostatic hyperplasia: an overview. Urology. 1999;53:1-6) (Nocturia. J of Urol 2000;163) Overactive Bladder/ Urinary Incontinence (UI): Links: Ddx: Drug SE: Age Changes: Hx: S/s: Referral: Labs: Types & Tx: UI: SI: Overflow: Functional: Mixed: Pediatric Voiding Disorder: References: Definition: Uncontrolled voids or accidental loss of urine. 2/3 are females, many suffer in silence, embarrassed or think that incontinence is an inevitable consequence of aging. Prevalence: 20% females age 15-60yo have difficulty containing urine, especially during physical activity. 30% > age 60yo (community dwelling). 30% of hospitalized elderly >65yo. 50% of homebound/ nursing home age >65. 12% community dwelling males >60yo, 3% males age 15-64. In nursing homes it is estimate that that the cost in incontinent care is >$6,000/yr based on additional use of diapers, gloves, laundry, and the time utilized by certified aids (Clinical Geriatrics 2001;9:1). Requirements For Continence: Adequate mobility/ dexterity/ cognitive function. Motivation to be continent. Effective lower tract function for storage, sensation of fullness, no involuntary contractions or obstructions and coordination of lowering of outlet resistance with bladder contraction. Ddx to R/o Transient (Reversible) Conditions that Cause/ Contribute: delirium, hypoxemia, excessive fluid intake, impaired mobility, atrophic vaginitis, fecal impaction, UTI, glycosuria, medication side effect (sedatives, narcotics, alpha blockers in women or men with weak sphincters. Drug SE: ACEi --> cough. Ca blocker --> dec smooth m contraction leading to overflow incont, inc peripheral edema get PM urine loss. Alpha blocker --> relax smooth muscle of the sphincter, dec urethral pressure and inc bladder emptying. Alpha stimulants --> can inc urethral closure pressure and lead to urinary retention. Sedatives --> confusion & dec motility. Anticholinergics/ antihistamine --> impaired bladder contractility (urinary retention) & overflow incont. Diuretics--> produce frequent & large bladder volumes that may over-whelm ability to reach to bathroom in time. Narcotics -->depression of sensorium and ability to discern need to empty bladder. Can cause fecal impaction that presses on the bladder and decreases the bladder capacity. Other --> Parkinsonian meds (cause dribbling via dec sphincter strength), Disopyramide (anticholinergic) Age Associated Bladder Changes: dec bladder capacity, shorter time between awareness of need to go and symptomatic urgency. Incomplete emptying (inc residual volume). Dec Flow rate. Inc number of involuntary bladder contractions (detrusor instability). Dec strength of pelvic floor muscles. Atrophic changes in urethral lining and bladder trigone in postmenopausal female. Women who have had a hysterectomy have a 60% greater risk ( Lancet 2000;356:535). Hx: Tell me about the problems you are having with your bladder? Have you ever discussed the problem with a physician before? When/how often/ how much is lost. Any precipitators (exercise/ cough/ sneeze/ stand/ lifting/ laugh/ getting to the bathroom). The impact of incontinence on daily activities? Do you wear a pad? Meds, other dzs (COPD, neuropathy, DM) Voiding diary (2-7d). Chronic constipation (impairs pelvic floor function). Acute: sudden onset (usually reversible) Vs

chronic: gradual insidious onset (except paralyzing or traumatic). S/s: Exam Links: Stress Test: PVRV: Office Cystometry: Urethral Hypermobility: Check S1-2 perineal area for pinpoint/ pressure/ vibration, sphincter tone/ levator ani contraction strength/ reflex, bulbocavernosus/ clitoral reflex.

Stress Incontinence (SI) / Overactive Bladder = Urge Incontinence (UI) / Mixed (M). # Times urinate during day? --> =Frequency >8/d. --> Yes (SUI), Yes (UI), Yes (M). Wake up more than1X/ night? --> =Nocturia. --> Seldom (SI), Usually (UI), Usually (M). Hurry to reach bath? --> =Urgency. --> No (SI), Yes (UI), Yes (M). Ever not reach toilet in time? --> =Urge incontinence. --> No (SI), Often (UI), Often (M). Leak urine if laugh, cough, sneeze, jump or run? --> =Stress incontinence. --> Always (SI), Sometimes (UI), Always (M). Do you usually leak a drop or quite a bit more? --> =Amout of leakage. --> Usually small (SI), Large, but varies (UI), often large (M). Cough (Stress) Test: with full bladder have pt lie supine then standing (more likely to leak standing) --> and cough forcefully 3X or valsalva, see if urine leaks. Can use a gauze pad (or paper towel) placed over perineum X 20min. If this does not provoke, have them run in place or bend knees to pick up phone book. Some women will have detrusor activity as cause of + stress test. Instantaneous leakage suggests SI, delayed leakage or dribbling suggests UI. Have pt drink 16oz H2O prior to visit and not void for 2hr. Pelvic Exam for laxity: cystocele, rectocele, enterocele, or Atrophic vaginitis (genital organ estrogenation). Postvoid Residual Volume (PVRV): with U/S (bladder scan) or Foley, nl =50-70 ml. Possibly abnormal if >100 ml, definitely abnormal if >200ml or more than 20% voided sample =inadequate emptying. Will need augmented voiding techniques or intermittent catheterization. Normal Voiding Volume: If <200ml per void, then urge. If 300-500, then likely stress. If >600ml then overflow incontinence. Simple Office Cystometry: use non-ballooned catheter with 50ml syringe (remove plunger). Keep center of syringe ~15cm above the symphysis pubis. Insert sterile water until pt reports strong urge to void or until bladder contractions occur,

(see movt of water fluid level in the syringe). Bladder Filling (to Capacity): and sensation by filling it with sterile H2O at room temp to determine 1st sensation/ urge to void, subjective fullness/ max capacity. If severe urgency or involuntary loss at <300ml, suggests urge incontinence. >600ml suggests overflow. Normal bladder capacity is 600ml in the young and 300ml in the elderly. Next remove Foley and asses sphincter competence by straining and coughing. Provoked leakage suggests stress incont, unprovoked is likely urge incont assoc with detrusor instability. + Urethral Hypermobility --> lubricated CTA inserted into urethra should lie parallel to the pelvic floor both at rest and Valsalva if normal, Vs. +=upward deflection. NOT very helpful.

If unsure refer for more definitive studies: Urodynamic testing: If failure of conservative, severe urogenital prolapse, prior anti-incontinence surgery, radiation tx or neuro deficits in area . Can do cystometry, US of bladder /kidneys, electrophysiologic sphincter testing, cystourethroscope, uroflowmeter. Referral Criteria: risk for bladder Ca (irritative sx, smoker, chemical exposures). Recurrent UTI. H/o pelvic surgery or irradiation. Marked pelvic prolapse (cystocele), marked BPH or prostatic nodule. Post void residual >250ml, hematuria/ proteinuria w/o infection. Failure to respond to therapeutic trial. Neurologic condition. Other Labs: U/A, BUN/ Cr, BS, Ca if polyuria, urine cytology if hematuria or irritative sxs w/o UTI. Types & Tx of Incontinence: Links: Urge (UI): Bladder Relaxants: Stress (SI): Overflow: Functional: Mixed: Kegals: Biofeedback: Bladder Retraining: Fluid Management: Mechanical Support: Other: PV: 1. Urge Incontinence (UI) = Overactive Bladder: Leak variable (often large) amounts of urine because of inability to delay voiding after sensation of bladder fullness is perceived. Most common

type in age >75, seen in 35% Vs. 8% among 45-49yos. Due to bladder inflammation (infection), poor bladder capacity/ compliance, CVA, MS, PD, and psychogenic causes. Bladder/ detrusor muscle is hyper/ overactive may be from a neuro condition, infection, local GU condition such as stones, tumors, diverticula or outflow obstruction. Can be due to CNS d/o such as stroke dementia, parkinsonism or spinal cord injury/ lesion that leads lack of central inhibition. An independent risk factor for falls and fxs in the elderly. Sx: urgency & frequency. The sxs can overlap with stress incontinence (SI). Compared to SI, pt has no leak with activity, often has nocturia, and if leaks will leak large amounts, not reaching the toilet in time. Urgency is the desire to reach toilet immediately when the urge to urinate is perceived, even if bladder not full. Frequency is when they need to urinate >q2hr or more while awake, ask Can you postpone urination? Nocturia is when they awake from sleep due to urge to urinate, nl is ~2X in >65yo. Tx: Behavioral Bladder Training: Timed voidings, biofeedback. If urgency felt --> stop, relax entire body & contract pelvic ms for 5-10sec, relax, repeat 3X or until desire to urinate controlled. This will eventually give you 5-10 min to get to a bathroom w/o breaking a leg, will leak the first few times.) If rush to bathroom --> inc intraabdominal pressure and exposure to visual cues that trigger incontinence. Reduce bladder irritants such as caffeine, alcohol, acidic foods and beverages. . Estrogen: topical works best. Estrace 2 gms 3X/ wk or fingertip method (apply cream 2-3X/wk with tip of finger inserted and wiped around, improves sxs in 6-8wks) if atrophic vaginitis. Bladder Relaxants: Tolterodine (Detrol): [1, 2mg tab] start @ 2mg BID, with or w/o food, can be lowered to 1mg as tolerated. May need to go to 4mg BID. Start with 1mg if dec hepatic function or taking drug that inhibits CYP3A4. Detrol LA: 4 mg q day (more effective than regular strength. Uroselective antimuscarinic, less dry mouth and CNS side effects c/w Ditropan), will decrease urgency, frequency and incontinence episodes by 50%. Costs $80/mo. Anticholinergics: Oxybutynin (Ditropan): [5mg, 5mg/ml] --> 5 mg 2-4X/d. SE: dry mouth, blurred vision, dry skin, nausea, constip. Contra: narrow < glaucoma, GI obstruction. 80% stop from dry mouth, blurry vision). Generic is only $10/mo. Inhibits involuntary bladder contraction Ditropan XL: [5,10,15mg tabs] q day. Start @ 5-10mg PO qd. Over 20mg/d with no added benefit. 85% get improvement, 7% stop due to SE primarily dry mouth or confusion. TCAs: Imipramine (Tofranil): 10-25mg qHS-QID (dry mouth, dizzy, nausea, confusion, avoid MAOi or resent AMI), Doxepin @ 10-25mg 1-3X/d. Other: Urispas (Flavoxate): 100-200mg TID-QID, Cystospaz (Hyoscyamine). NuLev (disintegrating Hyoscyamine: 0.125mg tab PO q4hr. Age 2-12yo @1/2-1 tab q4hr (max 6/d), age >12yo @ 1-2 tabs q4hr (max 12/d). Indicated for irritable bowel, spastic colon, peptic ulcer, cystitis, neurogenic bladder, parkinsonims, biliar/renal colic, rhinitis and anti-cholinesterase poisoning. Dicyclomine (Bentyl): 10-20mg qd-QID. 2. Stress Urinary Incontinence (SUI or SI): Involuntary loss of urine (usually small amounts) associated with cough/ sneeze/ lift/ exercise/ position change. Urethra/ sphincter cant maintain pressure gradient usually due to urethral hypermobility or excess displacement as intra-abdominal

pressure rises. Weakness of tissue surrounding urethra (pelvic floor)/ bladder neck, levator muscles or sphincter. Risk: genetics, inc # babies, obese, chronic cough, strenuous exercise, radical prostatectomy (3-8% risk). Dx: 4 Criteria: urine loss during episodes of raised intra-abd pressure, +cough stress test, post void residual capacity < 50ml, functional bladder capacity >400ml. Tx: Conservative --> Preexercise voiding, caffeine avoidance, use of an extrinsic vaginal support during exercise or as needed (tampon, pessary, bladder neck support prosthesis (Introl). Use of barrier devices (Impress, FemAssist, CapSure) during exercise or as needed, pelvic m strengthening/ retraining (Kegals, vaginal cones, biofeedback, electrical stimulation). Alpha-agonists (Sudafed (Pseudoephedrine) or Sustained release Phenylpropanolamine (Entex LA) @13-30mg qd-TID, caution with HTN, arrhythmia and anxiety. Imipramine, Ephedrine 25-50mg QID. These medications are poorly tolerated and usually not very effective Estrogen supplements, Estrace or Premarin cream most popular 2-4 grams per vagina 2-3 times a week or use fingertip method. Urethral Bulking agents: Periurethral injections of collagen or Durasphere, 2-4 injections, improvement seen in about 50% of women, multiple injections usually needed but can be done in the office. Not very effective in males. Surgery: females can achieve 85-90% cure rate with Pubovaginal sling or a Burch procedure, both usually outpatient surgery. Males with moderate-severe stress incontinence are usually best treated with an artificial urinary sphincter. 3. Overflow (Retention) Incontinence: Urine leaks (usually small amounts) because of an enlarged, distended bladder. Typical Reasons: 1. Detrusor hypoactivity: poorly or acontractile bladder; often associated with a disc compression, neuropathy (DM), idiopathic. 2. Neurogenic: Reflex incontinence due to detrusor-sphincter dyssynergia due to spinal pathology, seen with MS, and other supraspinal cord lesions. 3. Sphincter/ anatomic obstruction: BPH, stricture, mass, cystocele. Tx: Decompression with catheter or intermittent catheterization for several weeks, then perform a voiding trial. Surgical removal of obstruction, bladder retraining If some voiding possible can try augmented voiding with alpha- blocker 4. Functional Incontinence: Sometimes called Psychological Incontinence as due to factors outside the urinary tract. Urinary accidents related to impairment of physical and/or cognitive function. (combo of things: immobility problems, DJD, dementia). Or psychological unwillingness (depression, hostility) or environmental barriers (inaccessible toilets or drug SE). Tx: Behavioral interventions (caregiver dependent) --> Prompted Voiding Protocol: Contact the person every 1-2hr initially, then q2hr from 7am-7pm. Ask them if they are wet or dry. Check them

for wetness, record in diary, give feedback on whether their response was correct. Ask if they would like to use the toilet, offer assistance, record results, give reinforcement by spending extra time talking. If they say no, repeat the question. Environmental manipulation, incontinence undergarments and pads. Mixed Incontinence: Have both detrusor instability/ hyperreflexia (urge) and stress incontinence. Best to check urodynamic studies for adequate tx decisions. In general benefit from same txs as stress incontinence. Kegal exercises: Pelvic muscle re-education. Great for stress incontinence. Start and stop urine flow midstream = contracting proper muscles. 35% cure, 85% improve. Pt needs to feel tired like having gone to the gym after each set (hold CTX ~6-10sec, relax ~10s X 30min or total of ctxs 30-80X/d). Also, do contractions 10-15X quickly at end of set. To verify technique, insert 1-2 fingers into vagina, ask pt to squeeze down on finger, these are the muscles they need to strengthen. Not the belly muscles, thigh or buttocks, the body should not move, do not hold breath. Contracting anal ms will reduce leaking 60%, may be easier to learn than pelvic floor m. exercising. Takes 2-3 weeks until see improvement, 6-8 weeks for full benefits. Biofeedback: Re-education of the pelvic floor muscles. An adjunctive therapy to pelvic floor rehab in mixed and urge UI. Uses weighted (20-100g) vaginal cones (retain cone15-30min/d, has string on end) The sensation of loosing the cone causes an internal sensory response to contract the pelvic floor muscles. 41-70% success rate after 12mo with stress or urge incontinence. Now covered by Medicare after documentation of failure of pelvic floor exercises. Bladder re-training: To expand the volume capacity and allow a 2-4hr wait between voiding episodes. Get a 50% reduction in incontinence episodes. Time and labor intensive, need to be cognitively able to keep a diary to monitor fluid intake and urine output. Delay voiding and additional 5-10 min qd until desired goal of q2-3hr, or urinate according to a set timetable with distraction techniques employed to increase intervals. Avoid dehydration (RDA: 30ml/kg/24hr or 1/2oz/ #/ d), deceased fluid intake (if excessive). 15% get complete resolution of sxs, 60% get improvement. Use in conjunction with fluid management and dietary restriction of irritating foods (caffeine, ETOH, spices, acidic beverages). Timed/ prompted voiding : habit training, use scheduled voiding to reduce UI episodes by 86%. No systemic effort is made to delay void, rather timed void to match patents natural voiding schedule. If demented: monitor dryness status on a regular basis, pt is prompted to void on a regular basis and continent behavior is reinforced. Fluid Management: Increase fluid intake to 8 glasses/d to reduce bladder irritation due to concentrated urine and low bladder volume. Then can restrict fluids after 7pm to reduce nocturia. If have fluid overload or pedal edema, need to rest during the afternoon to allow for fluid redistribution. Avoid bladder irritative fluids such as coffee, tea and alcohol. Anatomic Mechanical supportive devices: vaginal pessary (for pelvic prolapse), tampons, contraceptive diaphragm. Vaginal inserts: good for exercise induced, need good manual dexterity and no prolapse

Urethral occlusion devices (Introl) --> bladder neck support pessary, to reduce hypermobility and improve in 84%. Ring shaped intravaginal device with two fingerlike prongs that sit on either side of the urethra. FDA approved. Impress --> a single use soft foam patch with adhesive on one side that can seal urethral meatus. Is removed for voiding and then replaced with new. (both by UroMed Corp, Needham, MA). FemAssist --> silicone cup occludes the urethral meatus by creating a suction over the urethra. Can be reused for ~1wk. Can be difficult to use. Reliance Urinary Control Insert --> disposable intraurethral occlusive device similar to a catheter w/o a lumen. A 3ml ballon hold in place and plugs urethra. Ex: Reliance, Viva Plug and FemSoft. Absorbent material: skin irritation/ breakdown, last resort or as backup. Other: Last resort: indwelling cath. Intermittent cath: for urinary retention, q3-6hr, 20% get urethritis, UTI, stricture, epididymitis, bladder stones. Indwelling: bacteriuria in 2-4wks, with inc in urosepsis. Pelvic Floor Electrical Stimulation: an electric current to sacral and pudendal nerves to inhibit bladder (detrusor) instability. Covered by Medicare. Stimulate the somatic/sacral autonomic nerves, leads to hypertrophy of skeletal muscle fibers. Extracorporal Magnetic Innervation: uses the NeoControl Pelvic Floor Therapy System. Done in the office, based on magnetic induction of pelvic floor muscle contraction. Protocol of two 20-30min session/wk for 8wks. Surgical: A last resort in pts with severe sxs or not responding to the above conservative measures. Females can achieve 85-90% cure rate with Pubovaginal sling (retropubic suspension) or a Burch procedure, both usually outpatient surgery. Periurethral bulking injections can cure 50%. Artificial sphincters can cure 77% of women and 66% males with intrinsic sphincter deficiency. Males with moderate-severe stress incontinence are usually best treated with an artificial urinary sphincter. Denervation techniques: to achieve a low-pressure bladder in pts with complete suprasacral spinal cord lesions. Bladder augmentation: increase the bladder capacity utilizing intestinal segments. Prevention: Good bladder hygiene --> empty bladder when needed, holding it is harmful. Prepare for childbirth with Kegal exercises before & after. Start bladder retraining as soon as any incontinence occurs. **Ref: (Overactive bladder. Clinical Geriatrics 2001;9:2) (Postgrad Med 1998;103:4) (J Urol 1995;154:1727-31) (Incontinence. Smiths General Urology, by Tanagho, 15th ed, 2000, McGraw Hill, pp538-53) (Promoting continence in older people. Elder Care 1999;11:34-8) (Definition of overactive bladder and the epidemiology of urinary incontinence. Urology 1997;50:S4-14) (The overactive bladder: an overview for primary care health providers. Int J Fertil Womens Med 1999;44:56-66) (Urinary incontinence in the older man. Med Clin North Am 1999;83:1247-66) (Neurogenic bladder dysfunction. Curr Opin Urol. 1999;9:303-7) Catheterized Patients: Links: Types: Intermittent: Care of Chronic Cath: Complications: Pediatric Sizes: Bladder Tap: Indications: Short Term use --> urinary retention, urologic or other surgery, to measure output in

illness. Long Term use --> terminally ill or impaired whom bed and clothing changes are uncomfortable, pt or caregiver preference, skin breakdown caused by incontinence, neurogenic bladder or retention. Other Types: External --> condom catheter, for men w/o urinary retention who have severe functional disability. More comfortable than indwelling, less bacteriuria, but more skin breakdown. Suprapubic --> Less microbes on abd wall, but risk cellulitis, hematoma, leakage. Much more comfortable than urethral catheter, avoids urethral damage, decreases risk of prostatitis is men. Intermittent Self Catheterization Technique: Preferable to long term indwelling in pt with bladder-emptying dysfunction. Insert with clean (not sterile) technique. Use the smallest tube, 14-16 F. Step #1: wash hands meticulously with soap and water. Rinse hands & cath with tap water. Step #2: Apply lubricant to untouched lower of catheter. Expose meatus with nondominant hand. Cleanse area gently, beginning with meatus with a disposable wipe. Step #3: Leave nondominant hand in position, insert catheter until urine flows, slowly remove, rinse meatus, wash hands. Step #4: Clean catheter in soap and water, soap needs to flow through the inside. Store in ventilated container until dry, then place in a clean container or zip lock bag. Plastic catheter --> boil for 10min, let cool, remove with tongs, let dry on paper towels. Can last up to 2mo. Discard if cracks. Red rubber cath --> cant be boiled, scrub with soap and water and irrigate with catheter tipped syringe. Discard when stiff or >6wks old. Technique for Care of Chronic Indwelling Catheter: Use 14-18F, 5ml balloon. Secure to anteromedial thigh if female, to abd if male. Cleansing perineum BID with Hibiclens soap and applying topical Abx ointment to meatus BID have not proven to be effective. Maintain closed drainage system (open only at bag). Minimize duration of catheterization, replace indwelling with clean intermittent or spontaneous voiding. Avoid suppressive Abx. Irrigate only if have infection (0.25% acetic acid or bladder irrigation with chlorhexidine 1/10,000). Always keep collection bag below bladder. Maintain at least 2L fluid intake/d. If need to check a urine culture, aspirate the catheter with a 21g needle after Betadine prep. Catheters usually replaced every 4-6 weeks, more frequent changes needed if obstruction or concretions are demonstrated. Renacidin bladder irrigations can decrease bladder stone formation. Separate catheterized patients from each other whenever possible. Always obtain postcatheterization urine cultures. Administer prophylactic Abx during insertion and removal if pt is predisposed to endocarditis. Complications: Links: Balloon Fails to Deflate: Infection: Urethral --> false passage, ballon inflation in urethra, hematuria from traumatic insertion, erosions on the glans of the penis, urethral necrosis, urethral stricture. Bladder --> polypoid cystitis, hematuria from irritation/ infection, bladder perforation, rectovesicular fistula. If bladder spasms -->dec water in the ballon or use anticholinergic such as Propantheline 15mg q8h or an anticholinergic such as Oxybutrin, Flavoxate, Dicyclomine, Hyoscyamine or Tolterodine. Catheter --> inability to remove, knot formation, obstruction by clots, encrustation, lubricating gel. Irrigation may prevent repeated

obstruction if not responding to inc&61472;fluid intake or urinary acidification. Catheter Balloon will not deflate: May be due to inflation valve damage (kink, clamping, crush or obstruction with crystallized fluids. Catheter balloons should be filled with sterile water-NOT saline. Step #1 Advance the catheter to ensure that the ballon is within the bladder. Step #2: Cut the balloon port proximal to the inflation valve. Step #3: Pass a lubricated fine guage wire stylet through the inflation channel to relieve any obstruction. Step #4: If that does not work, pass a lubricated 22g central venous catheter over that guidewire using the Seldinger technique. Once advanced, remove the guidewire. Step #5: Rupture the balloon. Do not overinflate it with air or saline as this is painful and may rupture the soft tissue. Can try instilling 10ml of mineral oil via the inflation port as a chemical to dissolve the balloon. First instill 200ml of sterile water into the bladder to dilute the mineral oil when it enters so as to reduce the risk of a chemical cystitis. An additional 10ml of mineral oil can be added if the balloon does not rupture in 10min. It should rupture by 30min. Once removed, the catheter should be inspected and if there is any possibility of a retained fragment, prompt urologic consultation is indicated. Step #6: if still unable to remove consult urology ASAP. Various puncture techniques can be employed ranging from transurethral, endoscopic to percutaneous (transabdominal, transvaginal, transperitoneal, transrectal). Bacteriuria & Infection: Asymptomatic: With a closed drainage system, bacterial colonization develops in ~10days. Asymptomatic bacteriuria develops in 20% within one week (3-10% per day), by 30d, 90% have significant bacteriuria. Vs 4d in open drainage system. If chronic indwelling or suprapubic will have bacteria/ WBC/ RBC and epithelial cells on U/A. Will also see sediment, turbidity, dislocation and cloudiness (sludge). Even if use clean, intermittent catheterization, get colonization in 60-90 days. Consider other urine-collection devices such as condom catheter or disposable diapers for pts with uncomplicated urinary incontinence. S/s of infection: Temp >38.3C (100.9F) (if only an isolated incidence, do not tx as mild pyrexia is common), back pain, mental status change, unusually cloudy urine, more frequent blockage, new or worsening bladder spasms. Tx: observe, culture several days after catheter is removed and give Abx if still positive. Symptomatic: cystitis, periurethral or prostatic abscess, acute/ chronic pyelo, urosepsis. If sxs (temp <102F and normotensive) >24hr, give Abx, get blood and urine Cx. Dx of UTI: symptoms and Cx with >100 CFU/ml. Only symptomatics need to be tx, considered complicated as have Fb infection. Often polymicrobial. Tx: Remove catheter if possible. If short term catheter, probably a single organism that can be tx with Bactrim, Quinolone or Nitrofurantoin X 10d. If long term catheter, probable polymicrobial, if noncritical illness give Bactrim or 2nd gen ceph. If critical illness give Ampicillin + either 3rd gen Ceph or Aztreonam or Aminoglycoside or Quinolone to make a 2 drug combo. Based on Cultures: G-: Ceftriaxone or quinolone (Levofloxacin). Amp/Amox + Gent if G+. Piperacillin & Tazobactam. If

G+ cocci give Vanc. Catheter Sepsis --> F/C, leukocytosis, glucose intolerance. Culture tip of catheter. IV Abx. Pediatric Catheter size: Infants --> 5-8F feeding tube. 1-3yr --> 8F feeding tube. 4-6yr --> 10F feeding tube. 7-12yo --> 10-12F red rubber catheter (Robinson). >12yo --> 14F red rubber catheter. Bladder Tap: To obtain sterile urine sample in infants or to release acute urinary retention. Contra: GU tract anomalies, infection over entry sight, coagulopathy, previous abdominal surgery (may need U/S guidance), bladder tumor, gross hematuria. PE: distended bladder, no urinary output in past 30min. Step#1: Pt supine in frog leg position (or with thighs and hips together) If infants use direct penile pressure in male or anterior rectal pressure in female to prevent urination during procedure. Step #2: Sterile technique, Betadine X3 to lower abd. Use 22g needle and 10-20cc sterile syringe. Insert 2cm above pubic symphysis perpendicular to 200 caudal. Use slight negative pressure on the syringe as enter. Step #3: Advance needle instill see urine enter the syringe. Cover area with sterile dressing. Complications: may have transient hematuria for 1-2 days. Penetration of bowel (pain, but no adverse outcome expected). **Ref: (Managing the Foley catheter. Am Fam Physician. 1993;48:829-36) (J Am Geriatr Soc 1996;44:1235-41) (Am Fam Phys 2000;61:2) (Catheter associated urinary tract infection. Infect Dis Clin NA 1997;11:609) (Managing the nondeflating urethral catheter. J Am Board Fam Pract 2000;13:116-9) Interstitial Cystitis: Links: S/s: Dx: Lab: Tx: Chronic , often debilitating painful bladder syndrome that is characterized by pelvic/perineal pain with urinary urgency/frequency. A dx of exclusion (must r/o infectious causes, stones, uninhibited bladder ctxs, radiation/ chemical cystitis, bladder cancer ), ?from alteration in glycosaminoglycan mucous layer in bladder --> secondary inflammation. Ulcers and linear tracks on mucosa (Hunners ulcer on cysto) F:M 9:1. Usualy age 40-50 yo. Two types, ulcerative and nonulcerative. S/s: urg/ freq/ nocturia at least 8X/d for 9mo. Pain in bladder, lower abdomen (suprapubic), perineum, pelvis, vagina, low back and thighs. Dx: above S/s, age >18, bladder capacity <350ml and urge to void when distended with 150ml. No recent dx of prostatitis or cystitis. No alternative explanation. + Dysuria, small volume. Lab: U/A with C&S, urine cytology, cystoscopy, pelvic exam. Consider urethral/ cervical Cx, urine for AFB. Dx: Hx and cystoscopy, labs.

Tx: Dietary and behavior modification. Bibliotherapy with www.ichelp.org. Consume a low-potassium, low-acid (avoid tomatoes, fruit juices, carbonated drinks) diet for two weeks, avoid spicy and acidic foods, caffeine, alcohol and chocolate. Keep a voiding diary, gradually increase their voiding interval by 15min q1-2wks so that the frequency decreases and bladder capacity increases over a 3-4mo period. Increase water intake. Physical therapy with biofeedback and electrical stimulation with a therapist who specialized in pelvic floor dysfunction to re-train the levator ani muscles. Behavioral therapy for the development of coping & problem solving skills, sex-therapy, self-hypnosis, deep breathing and medication may help. Pentosan Polysulfate (Elmiron): 100mg TID or 200 BID one hour before or two hours after a meal, it augments GAG protective layer of bladder with fibrinolytic/ anticoagulant effects, can take 3-6 months to achieve affect. Antispasmodics such as Tolterodine (Detrol) or Ditropan XL: for overactive bladder sx of freq/ urge/ and urge incontinence. OTC meds such as phenazopyridine (Pyridium) 200mg PO TID or chondroitin sulfate 1g/d may help. L-Arginine: trial @ 500 mg TID with meals --> causes the body to make nitric oxide, which reduces the spasms, 50% sx improvement (J Urol 1999;161). Other: A TCA such as Amitriptyline (Elavil) or Doxepin @ 10-75mg qHS can be very helpful. Hydroxyzine (Atarax): 25-50mg qHS. Bladder hydrodistention during cystoscopy (20-50% improve for 3mo), intravesical installation of DMSO (Dimethylsufoxide) + Heparin (anti-infl/ analgesic) --> 60% get sx relief, but 40% relapse --> TENS unit. **Ref: (Interstitial cystitis. Curr Opin Urol. 1999;9:297-302) (Urology 1997;49:SA) (Interstitial nephritis. Postgrad Med J. 1997;73:151-5) (Treating interstitial cystitis. Womens health in Primary Care 2001:4:2) (Interstitial cystitis 2001: an evolving clinical syndrome. Urology 2001;57:S6A) Male Infertility: Links: Hx: PE: Lab & W/u: Tx: Vasectomy: Oligospermia --> the presence of less than 20 million sperm/mL of the ejaculate. Azoospermia --> the absence of sperm. Spermatogenesis takes approximately 74 days, it is thus important to review events from the past 3 months. Hx: Sexual habits, frequency and timing of intercourse, use of lubricants, and each partner's previous fertility experiences are important. Loss of libido and headaches or visual disturbances may indicate a pituitary tumor. Testicular insults --> torsion, cryptorchism, trauma. Infections --> mumps orchitis, epididymitis. Environmental factors (Gonadotoxins) --> excessive heat, radiation, chemotherapy agents. Chemicals such as carbamates, heavy metals, herbicides, organic solvents, organophosphates. Meds --> anabolic steroids, cimetidine, and spironolactone all affect spermatogenesis. Phenytoin may lower FSH. Sulfasalazine and nitrofurantoin affect sperm motility. Macrobid, Nitrofurantoin, Drugs --> alcohol, marijuana. PMHx & PSHx --> thyroid or liver disease (abnormalities of spermatogenesis), diabetic neuropathy (retrograde ejaculation), radical pelvic or retroperitoneal surgery (absent seminal emission secondary to sympathetic nerve injury), or hernia repair (damage to the vas deferens or testicular blood supply). PE: features of hypogonadism --> underdeveloped secondary sexual characteristics, diminished

male pattern hair distribution (axillary, body, facial, pubic), eunuchoid skeletal proportions (arm span 2 > ht, upper to lower body ratio < 1.0), gynecomastia. The scrotal contents should be carefully evaluated. Testicular size (normal ~4.5 2.5 cm, volume 18 mL). Varicocele should be looked for in the standing position and on occasion may only be appreciated with the Valsalva maneuver. The vas deferens, epididymis, and prostate should be palpated. Lab: Semen analysis should be performed after 72hr of abstinence. The specimen should be analyzed within 1 hour after collection. Normal: opaque, cream colored. PH 7-8, concentration >40million/ml, morphology --> >60% normal, motility >50%, viscosity --> liquefies within one hour, volume of 2-5ml. Concentration --> Normal = >20 x 10 to the 6th /mL / Inadequate = <5 million/ mL. Motility --> Normal = >50% forward progression / Inadequate = <10%. motility. Progression --> Normal = >50% rapid / Inadequate = <25%. Morphology --> Normal = >50% normal / Inadequate = <4% normal. Ejaculate volume --> Normal = >2cc / Inadequate = <2 cc. Leukocytes --> Normal = <1mil/ml. pH --> Normal = 7.2-7.8. Semen volumes <1.5 mL may result in inadequate buffering of the vaginal acidity and may be due to retrograde ejaculation or androgen insufficiency. Abnormal motility may result from antisperm antibodies or infection. Abnormal morphology may result from a varicocele, infection, or exposure history. Inc WBCs may indicate prostatitis. Immature germ cells may suggest a defect in spermatogenesis. If any parameter is abnormal, two additional analyses should be performed 2 weeks apart. The functional sperm fraction (quantity & quality) peaks at age 31-40yo. If abnormal --> serum FSH, LH, and free testosterone. +TSH & prolactin (exclude pituitary prolactinoma). Inc FSH and LH and dec&61472;testosterone (hypergonadotropic hypogonadism) are associated with primary testicular failure, which is usually irreversible. Dec FSH and LH with dec&61472;testosterone occur in secondary testicular failure (hypogonadotropic hypogonadism) and may be of hypothalamic or pituitary origin. Such defects may be correctable. Treat any infections and surgically correct any varicocele. Intrauterine insemination with or without sperm washing is frequently used to treat men with impaired semen parameters, this can be performed during natural cycles or cycles in which the ovaries are hyperstimulated with CC or gonadotropins. Endocrinologic evaluation is warranted if sperm counts are low or if there is a clinical basis (H&P) for suspecting an endocrinologic origin.

Imaging: Scrotal U/S may detect a subclinical varicocele. Vasography may be required in selected patients with suspected ductal obstruction. Other Tests: Azoospermia patients should have postmasturbation urine samples centrifuged and analyzed for sperm to exclude retrograde ejaculation. Azoospermia patients and patients with ejaculate volumes less than 1 mL should have fructose levels determined on the ejaculate. Fructose is produced in the seminal vesicles and if absent in the ejaculate implies obstruction of the ejaculatory ducts. Tx: Links: Endocrine: IVF: Retrograde Ejaculation: Varicocele: Azoospermia: Ductal Obstruction: Education with respect to the proper timing for intercourse in relation to the female's ovulatory cycle as well as the avoidance of spermicidal lubricants should be discussed. In cases of toxic exposure or medication-related factors, the offending agent should be removed. Patients with active genitourinary tract infections should be treated with appropriate antibiotics. Endocrine Therapy: Hypogonadotropic hypogonadism may be treated with chorionic gonadotropin once primary pituitary disease has been excluded or treated. Dosage is usually 2000 IU intramuscularly three times a week. If sperm counts fail to rise after 12 months, FSH therapy should be initiated. Menotropins (Pergonal) is available as a premixed vial of 75 IU of FSH and 75 IU of LH. The usual dosage ranges from one-half to one vial intramuscularly three times per week. Clomid can often increase sperm counts. Two Step IVF: extract as few a 1-2 sperm from men whose samples previously showed no sperm count. Need 3-4 samples in 24h period using multiple ejaculate suspension and centrifugation. Next use intracytoplasmic sperm injection (ICSI) as inject sperm into womans egg, if fertilizes, transfer to womb. Retrograde Ejaculation Therapy: Oligospermia patients with retrograde ejaculation may benefit from alpha-adrenergic agonists (pseudoephedrine, 60 mg orally three times a day) or imipramine (25 mg orally three times a day). Medical failures may require the collection of postmasturbation urine for intrauterine insemination or electroejaculation in the case of absent emission. Varicocelectomy if have varicocele will increase rate of conception 30%. Surgical approaches to varicocele may be accomplished via a scrotal, inguinal, or laparoscopic approach. More recently, percutaneous venographic approaches have been developed, obviating the need for an anesthetic. Men with azoospermia & <1.5ml ejaculate volume --> transrectal US to r/o congenital anomaly or obstructive defect of the distal genital tract, so long as not having retrograde ejaculation, neuro d/o or DM. Ductal Obstruction: The level of obstruction must be delineated via a vasogram prior to operative treatment. Mechanical obstruction of the ejaculatory duct may be corrected by transurethral resection and unroofing of the ducts in the prostatic urethra. Obstruction of the vas deferens is best managed by a microsurgical approach, and a vasovasostomy or vasoepididymostomy may be required. Vasectomy: Currently 12% of married males age 20-39 choose this as their method of preventing

pregnancy. Overall 76% are done by Urologists, 15% by family physicians and 9% by general surgeons. About 1/3 of urologists and half of FPs use the no scalpel vasectomy (NSV) technique. Pre-op: examine pt with focus on genitals. Palpate testes for abnormalities. There is a unilateral absence of the vas deferens in 1/500 males (assoc with agenesis of ipsilateral kidney). Discuss ramifications of the permanent sterilization. Explain the procedure. Takes 30-40min. With the NSV an extracutaneous fixation ring clamp encircles the vas w/o penetrating the skin, next a sharp curved hemostat punctures and dilates the skin. A hook delivers the vas to the puncture site. The vas can be occluded in a number of ways (ligation & cautery, interpose the facial sheath over the end). The contralateral vas is delivered through the same site. Only takes 5-11 min. 40% less time than standard vasectomy, smaller wound (2cm). Has a higher learning curve. Hematoma in 0.09%. Wound infection in 0.16-2.7%, usually easily controlled with Abx. Sperm granuloma seen in 15% due to leakage of sperm from the proximal end, most are asymptomatic. Failure to achieve azoospermia seen in 0.2-0.5% due to spontaneous recanalization (most in the 1st 3mo), test by getting post-vasectomy semen analysis ~10 ejaculations and 45d after surgery. Vasectomy Reversal: 75-80% successful if < 3yrs old, 55% if 3-8yrs, 45% if 9-14yrs., 30% if >15yrs. **Ref: (Urol Clin North Am 1994;21:3) (Eval of the male, Assit Reprod Rev 1998;8:36-9) (Postgrad Med 2000;107:2) (Relative incidence of etiologic disorders in male infertility. In Male Reproductive Dysfunction. By Santen, 1986, pp341. Maarcel Dekker, NY.) (Male sterilization. The Female Pt 2000;25:24-33) Microhematuria: Links: Hx: W/u: Nephrology Eval: Etiology: Drug Induced: Gross: References: Found in up to 5-10% of asymptomatic normal adults in the general population. Normally up to 2 million RBCs are excreted in the urine daily. Definition: >3 RBCs/ HPF (some labs vary) on 2 of 3 properly collected specimen. <3 RBCs = normal regardless of +dipstick, which has more False +s (= micro with no RBCs, seen in rhabdomyolysis and hemolytic anemia.). False Negatives: seen with air exposed strips, ascorbic acid (>2g/d), pH<5.1, formaldehyde. Risk factors for significant dz should always be taken into account. Hx: clots: large = bladder, small stringy -upper tract. Gross hematuria: suggests distal urethra to the urogenital (UG) diaphragm. >100 RBC/ HPF --> red. Pinks up at 30-30 RBCs. If long Hx of smoking, then inc risk for neoplasia. The old Three Glass Test was historically used before cystoscopy. #1: Terminal: prostate or bladder neck, urethritis, trigone irritation. #2: Total: bladder or upper tract: stone, tumor, TB, nephritis. #3: Initial: anterior urethral lesions, urethritis, stricture, meatal stenosis. W/u: If low clinical suspicion for disease --> Repeat the UA with micro (look at sediment) to see if 2 of 3 UAs are positive. If gross with dysuria/ pyuria/ WBC casts, get culture and give Abx empirically for cystitis, re-check in 14 days. Lab: BUN/Cr, U/A & C&S, + Chem 18, +24hr Ur Protein if 2-3+ on dipstick, IVP (IVP:) has been the

gold standard as the best initial functional and anatomical study. By itself it has limited sensitivity in detecting small renal masses and thus it is being replaced by spiral CT and U/S. Get a renal U/S if renal insufficiency (Cr> normal) or contrast allergy. Start with a spiral CT if any acute abd process. If have a noncontrast scan demonstrating urolithiasis in a pt with low risk of malignancy, can stop the eval, if no calculus detected then need a contrast study or U/S. If complex cyst or solid renal mass on U/S get CT of Abd/ pelvis. Cystoscopy is routinely checked if no current infection and age >40yo or if <40 with risk factors (smoker, occupational chemical exposure, irritative voiding sxs). Get cytology if >50yo to r/o TCC (grade 1-25% yield, grade 4-75% yield), will need to repeat q6mo until hematuria resolved or 3yrs have passed. W/u is Neg: follow q6-12mo X3yrs (@6, 12, 24, 36mo) with U/A, BP, BUN/Cr, +cytology. (Nephron 1996;72) Confounding: rhubarb, Vit-C, Pyridium, Coumadin (high INR, nl level may unmask lesion), clots = nonglomerular origin. Get Nephrology Eval If: Renal insufficiency or proteinuria >500mg/ 24hr, RBC casts (pathognomonic for glomerular bleeding), dysmorphic RBCs (often >80%) --> Glomerular dz labs. Get 24hr protein. Check a serum IgA fibronectin level as 60% positive if IgA nephropathy. If find dysmorphic RBCs, RBC casts and / or proteinuria --> get ANA, ANCA, anti-GBM, ASO, anti-hyaluronidase, RPR, HIV, Chem 17, 24hr urine, cryoglobulins, C3, C4, CH50, hep serology. Consider SPEP and SIEP. May need renal Bx especially if abnormal renal function or proteinuria >1.5g/d. Consider --> throat Cx, ANA, serum complement (GN), renal Bx. Most cases are idiopathic, Benign Familial Hematuria (= thin basement membrane nephropathy, nonprogressive), Bergers dz (IgA nephropathy), post-Step GN or Alports (chronic hereditary nephritis). 70% of cases of Alports are discovered by age 6yo, 70% have proteinuria, 50% with SNHL (4,000-8000Hz), all males progress to ESRD. Isolated hematuria: consult Urology if age> 40-45, Nephrology if <40yo, r/o AV fistula (renal), Burgers dz (IgA nephropathy). If Etiology: 1. Nonglomerular: (exercise sports hematuria --> bladder trauma, up 18% of normals may have after prolonged exercise, re-check post cessation of exercise X3d), polycystic kidney (up to 10% have cerebral aneurysm), papillary necrosis (low blood flow --> necrosis, in DM, TB, SS, obstruction, analgesics, pyelo), Medullary sponge kidney, Ca, Vascular dz (malignant HTN, renal v thrombosis, artheroemboli), loin pain hematuria, hypercalciuria (young adult/ child). 2. Glomerular: have systemic illness with fatigue/ arthralgias see dysmorphic RBCs/ casts and proteinuria check ANA, complements, anti GBM, ANCA, ASO, cryoglobulins, (+RPR, HIV, HBsAg, anti-HCV, SPEP). Need ASAP Nephrology consult if nephrotic or have impaired renal function. IgA Nephropathy --> gross hematuria within 1-2 days of URI/ skin infection. Thin BM Dz (variable thickness, AD, good prognosis), Alports Syndrome (Hereditary Nephritis, X-linked defect in collagen, hearing loss (HL), lens abnormalities, often ESRD by 16-35), also: Post infectious GN --> hematuria 6-21 days after URI/ skin infection. Other -->

membranoproliferative, RPGN, SLE, HSP, Goodpastures, DM, FSGN. 3. Extrarenal: Infection, calculi, neoplasm, BPH, Meds (cyclophosphamide --> hemorrhagic cystitis), trauma, extra-GU (anal fissure, vaginal prolapse, endometriosis), Schistosoma haematobium. 4. Hematologic: coagulopathy, SS, anticoagulants. 5. Malignancy: risks: age >40, tobacco use, h/o pelvic irradiation, exposure to cyclophosphamide or occupational toxins such as dyes, benzene, aromatic amines, chimney sweepers. Analgesic abuse. Drug Induced Hematuria: Pseudohematuria (Rare) --> phenytoin, ibuprofen, levodopa, nitrofurantoin, rifampin, quinine. Glomerulonephritis --> mercury, gold, penicillamine, heroin, probenecid, antivenom. Vasculitis --> allopurinol, colchicine, diphenhydramine, furosemide, hydantoins, isoniazid, penicillins. Thrombotic microangiopathy --> chemo agents, cyclophosphamide. Interstitial nephritis --> penicillins (Methicillin 10%, Nafcillin 3%), rifampin, ibuprofen, sulfonamides, phenindione, phenytoin, cyclophosphamide, danazol, mitotane, busulfan, chloroform, NSAIDs, olsalazine, Silvadene, TMP/ SMX, Furosemide, Cipro, cephalosporins, Omeprazole. Chronic interstitial nephritis --> analgesics, Li, chemo agents. Intrarenal obstruction --> methotrexate, sulfonamides, tumor lysis syndrome. Extrarenal obstruction --> methysergide. Hemorrhagic cystitis --> Cyclophosphamide, Ifosfamide, Mitotane. Nephrolithiasis --> triamterene, Vit-D, acetazolamide, Ritonavir, Indinavir, Mirtazapine, Dichlorphenamide. Urinary tract carcinoma --> analgesic abuse. (Am Fam Phys 1999; 60:4) Ddx: myoglobinuria (muscle fiber necrosis, has inc CPK, nl haptoglobin), porphyria, oxidizing agent (bleach), provodone Iodine, narcotic seeker, munchausenss, red diaper syndrome, drugs (rifampin, phenothiazenes, Flagyl), fruits and veges with plant dyes (beets, berries, rhubarb), hypotonic urine (sg <1.010), urine left out >30min. Gross Hematuria: Need urgent consult if RBC casts, renal dysfunction or high grade proteinuria is present. W/u: r/o infection, especially if female. Check IVP if normal renal function. Consider CT scan +cystoscopy. If h/o bone marrow transplant r/o hemorrhagic cystitis from adenovirus. Labs: CBC, BUN, Cr, UA with micro, Urine C&S. Consider PT, PTT, peripheral smear, urine cytology, ANA, anti-dsANA, C3, C4, anti-GBM, ANCA, renal U/S, 24h protein and creatinine, renal Bx. Trauma: if gross hematuria or >10 RBC/ HPF, follow closely re-check U/S in 6wks, if still + --> IVP. ***Ref: (Evaluation of asymptomatic hematuria in adults. Urology 2001;57:599) (Evaluation of asymptomatic microscopic hematuria. Urol Clin North Am. 1998;25:661-76) (Workup and management of traumatic hematuria. Emerg Med Clin North Am. 1998;16:145-64) (Med Clin NA

1997;81:641) (Kidney Int 1996;49:222) (Nephron 1996;72:125) (Management of nephropathy, Kidney Int 1999;70:S56-70) (Exercise induced hematuria. Am Fam Phys 1996;53:3) (A practical primary care approach to hematuria in children. Pediatr Nephrol. 2000;14:65-72) (The patient with hematuria. Practitioner. 1999;243:564-70) (Evaluation of asymptomatic microscopic hematuria in adults. Am Fam Physician. 1999;60:1143-52) Proteinuria: Links: Quantity: Definitions: Microalbuminuria: W/u: Tx: Etiology: Orthostatic: Overflow: Tubular: Glomerular: Child: References: Urinary protein excretion of >150 mg/d. 3-5%pop. About 40% of the protein excreted is high molecular weight (albumin), 40% Tamm-Horsfall mucoprotein secreted by the distal tubule and 20% is LMW (immunoglobulins). Dipstick is insensitive to 50% @ 30mg/dL, picks up albumen only (not Bence Jones). Results: Negative (<10 mg/dL), Trace (10-20 mg/dL), 1+ (30+ mg/dL), 2+ (100 mg/dL), 3+ (300 mg/dL), 4+ (1,000mg/dL). Quantity of Daily Protein Excretion: 15-30 mg/24 hr --> Normal Urine Protean level (<20ug/min timed collection, <30ug/mg Cr, spot collection. 150-2000 mg/ 24 hr --> mild glomerulonephritis, tubular proteinuria or overflow proteinuria. 2,000-4,000 mg/ 24 hr --> usually glomerular. >4g/ 24 hr --> always glomerular proteinuria. Definitions: Dipstick albuminuria: >250-300mg/d (>200ug/min timed, >300ug/mg Cr, spot collection). Nephritic range Proteinuria: >3g/d. False + may be seen occasionally if pH>7 (seen if urine alkalinized with heavy contaminants such as mucus, blood, pus, semen or vaginal secretions). Sulfosalicylic Acid (SSA) Turbidity Test: 2-3 ml of 20% solution into 5ml of voided centrifuges urine. Precipitates both albumen and globulins (Bence Jones) (+ turns milky white color if 4mg/dL 0.04g/L protein). (F+ presence of radiocontrast in past 3 days, pt taking PCN, Ceph or Sulfa), (F- if urine is dilute --> sg<1.010 or alkaline urine). Microalbuminuria (MA): =30-300mg Protein/24hr or 20-200ug/min if timed collection, or 30-300 ug/mg creatinine for spot collection = A/C). Albumin appears in urine before other renal problems surface, check for qyear to asses renal function. Screening: can be performed by one of three methods: 1) measurement of the albumin-to-creatinine ratio in a random spot collection. This method is often found to be the easiest to carry out in an office setting and generally provides accurate information. First-void or other morning collections are preferred because of the known diurnal variation in albumin excretion. 2) 24hr collection with creatinine, allowing the simultaneous measurement of creatinine clearance. 3) timed (e.g., 4-h or overnight) collection. Normal level is 15-30 mg/24hr (<20ug/min timed collection, <30ug.mg Cr, spot collection. Clinical albuminuria: = Urinary-Albumin-Excretion (UAE): >300mg/d (>200ug/min timed, >300ug/mg Cr, spot collection).

Use Chemstrip Micral (or Chemstrip with SSA test) for spot UA or 3 separate samples in 1 wk. If + get 24hr to quantify loss. 30-300= incipient nephropathy, >300= overt (clinical). 30% with micro--> overt nephropathy. 2-3 consecutive measurements spaced 3-6mo apart will confirm. In diabetics, the albumin -to- creatinine ratio is the preferred screening test in diabetics. MA is the earliest clinical sign of Diabetic Nephropathy:. W/u: if Urine A/C >30 mg/g--> re-check 2X in next 3mo. If >300--> refer to Nephrology. If 30-300--> dx as microalbuminuria--> --> Tx: Tx for HTN If BP >15/10 mmHg above 130/80. If serum Cr <1.8 mg/dL use ACEi + Thiazide. If ?1.8 use ACEi + Loop diuretic. If still not at BP goat add a long-acting calcium channel blocker. If still not at goal after ACEi, diuretic and CCB add low-dose bets-blocker if Hr >84 or another CCB. If still not under control add a qHS alpha blocker, consider w/u for secondary HTN or refer. Tight glycemic control (dec HbA1C by 2%) in diabetic. Add an ACEi in any diabetic with >1 risk factor, even if normotensive. Aim for a BP <130/80. Re-check q4-6mo, if progresses, then refer. Can add CCB or an ARB for additive effects. Prevent progression--> Smoking cessation. Caution if use radiocontrasts. Maintain hydration. Maintain BP ~125/75, reduce proteinuria to <1g/d. Restriction of dietary protein has no good data and only mild effect on progression (aim for <0.8g/kg/d). Avoid renal damage via infections (UTIs) or drug use (NSAIDs, antifungals, nephrotoxic Abx), control dyslipidemia. If have an underlying RTA 4 tx acidosis with bicarb. W/u if >2-3 samples abnormal: lytes, BUN/ Cr, Albumin, total Protein, CBC, C3, spot AM UPr/Cr. If normal and >6yo test --> orthostatic proteinuria. If <6yo check renal US to look for congenital malformation. 24hr collection --> quantify with 24hr Urine Protein, Cr and volume (start after am void, end with am void) + if >150 mg/d for adult. The pt should refrain from vigorous exercise for 24h (as get a transient inc in Alb) The creatinine level provide an estimate of the adequacy of the urine collection. Creatinine Index (content in 24hr UR): Male age 20-50yo --> 18.5-25 mg/kg body weight/day, age 50-70 @ 15.7-20.2 mg/kg Ur-creatinine. Female age 20-50yo --> 16.5-22.4, age 50-70 @ 11.8-16.1 mg/kg. Will tell if over collection or inadequate collection. Micral II-Test Dipstick: good for screening for microalbuminuria. Very low false neg. For random urine specimens. Costs $4-7, can be done in the office, get immediate results. Random AM (spot) Urine Protein (albumen) to Urine Cr ratio: (Upr / Ucr in mg/dL): +if >0.03 mg/mg as this suggests the albumin excretion is >30 mg/d. Check an ECMP (Chem 17) in the AM when pt turns in urine sample. Easier (compliance) to get than 24hr Ur collection. Strong correlation to g/24hr protein excretion, thus UPr/Cr more reliable than 24hr as no problem with compliance. Age 2--Adult: <0.2 mg/dL = 0.2 g/d = normal. Child age 3-24mo old: <0.5mg/dL =normal. >3.5 --> = 3.5 g/d and is nephrotic range, if age <6yo --> steroids, if >6yo --> Nephrologist (or if hematuria and dec C3 or abnormal renal U/S). Test not valid if severe malnutrition or very low GFR. Can convert to Total Protein (g/m2/d) --> = 0.63 X (UPr/Cr). Albumin-to-Creatinine Ratio (Serum A-C ratio): This has been suggested as a way to screen for

proteinuria using serum blood. An normal urine albumin excretion rate is <20ug/min (<30mg/d) and corresponds to an serum A-C ratio of <1.98 g/mol in men and 2.81 g/mol if women. An excessive albumin excretion rate of 200ug/min (>250mg/d) corresponds to A-C ratio of 19g/mol in men and 28 in women. A screening test for diabetics. Pt should be off ACEi, NSAIDs and CCB as they will mask early microalbuminuria. Need to prove by repeating 2X or get a 24h urine. If >600-800 mg protein/ 24hr --> check split 24hr to dx. Orthostatic (Postural) Proteinuria: Accounts for 60% of proteinuria in children & adolescents. All other labs will be normal. --> urinate just before going to bed and discard, remain supine all night and urinate immediately when get up in morning, this sample labeled supine. Additional samples collected until pt goes to bed again as pt maintains normal daily activity. Labeled active. The supine sample should be free of Protein. Long term prognosis good, but re-check annually. (AM + late night urine volume ~=10%) + if significant proteinuria during the ambulatory period and <75mg during supine. True glomerular dz will not return to normal (<50 mg/ 8hr) with supine position. Other labs to consider: Check urine immuno-electrophoresis UIEP (spreads the immunoglobins, not the same as UPEP = urine protein electrophoresis that spreads the prteins) (r/o MM, amyloid, plasma cell dyscrasia), Ur sed (nephrotic vs nephritic), ESR (if very high --> vasculitis), C3 & C4 (dec in hypocompliment GNs, SLE, post inf, MPG, HbsAg, HCV). Check ANA, RF, HIV, HCV Ab, HbsAg, RPR, serum urate (stones causing tubulointerstitial dz), ASO titer (strep), serum albumen & lipids (nephrotic), cryoglobulins, renal U/S (enlarged in DM nephropathy, renal vein thrombosis, amyloidosis, obstruction). CXR (r/o sarcoid). Tx: fix underlying d/o, Protein restriction, ACEi, Statins for lipids, NSAIDs may reduce but at the expense of GFR. 20% of those with isolated proteinuria are at risk of progression to renal insufficiency in 10 yrs. Confounding Factors: Inc Albuminuria --> blood in urine, CHF, heavy exercise in past 48hr, fever, excessive protein intake, uncontrolled DM, uncontrolled HTN, UTI, vaginal fluid in specimen. Dec Albuminuria --> ACEi tx, malnutrition, NSAIDs. Benign Causes of Proteinuria: 1. Functional: acute illness (febrile), CHF, viral, dehydration, emotional stress, heat injury. Resolves. 2. Idiopathic Transient: after intense activity or an inflammatory process. Negative on repeat. Pt has nl BP and orthostatics. 3. Intermittent: off and on, nl BP and orthostatics. 4. Orthostatic: Benign, found in 4% of adolescents and young adults, usually remits spontaneously. Check split 24 hr urine. 5. Persistent Isolated: watch closely, 50% HTN, may need Bx, renal U/S, 20% with CRI in 10yrs. 3 Etiologies of Proteinuria: (overflow, tubular, glomerular)

Glomerulopathy due to systemic dz: DM, CVD, amyloid, heavy metals, IgA nephropathy, infection (HIV, HBV, HCV, post strep, endocarditis), GI & lung malignancies, lymphoma, transplant rejection. Glomerulopathy due to Meds: NSAIDs, gold, Penicillamine, ACEi, Li. 1. Overflow Proteinuria: Overproduction of immunoglobulins via paraproteinemia (MM, amyloid, light chain dz, leukemia). --> light chains spilling into the urine, nl kidneys. Dx: UPEP. 2. Tubular Proteinuria: Inability to reabsorb small MW Protein, usually <1g, from ATN or tubulointerstitial dz due to uric acid, heavy metals, sickle cell, NSAIDs, Abx. HTN nephrosclerosis --> ischemia or drug induced damage to the endothelial cells lining the tubes. 3. Glomerular Proteinuria: May be primary or secondary increase in glomerular capillary permeability of protein. From damage to the BM (holes in filter or loss of neg charge that normally repels protein). Acute Glomerular nephritis: an immunological response to infection (Strep, viral), hypocomplementemic/ hematuria/ RBC casts/ mild proteinuria/ HTN/ edema/ azotemia. See in 8% strep (1-2 weeks after pharyngitis), 1-2% of pyoderma (2-4 wks after impetigo). Lab: ANA, Cr, culture throat/ lesions, ASO titer (inc in 75%, highest @ 3-5 wks), C3,4. Tx: Most pts can be safely followed as outpatient so long as BP under control. See Chronic renal disease. Many nephrologist would recommend a Bx to more accurately define the prognosis. Decrease fluid intake to insensible loss plus 2/3 of urine output until diuresis. Add ACEi such as 40-80mg Monopril, consider adding ARG as effects are additive. Primary Glomerular Dz: (unknown cause, has 4 kinds) A. Minimal Change Dz (MCD): Lipoid Nephrosis. 90% of peds cases, dont Bx., caused by change in charge to BM Clinical: rapid/ overnight onset of periorbital/ extremity edema, normo-hypotensive. Nephrotic. Hallmark is rapid response to Prednisone 2mg/kg/d X 1mo (60mg/m2/d) if respond cont 2 more weeks then qod for 4 weeks, then taper over 4mo. May respond in 10d. In adults (start at 1.5mg/kg/d) tend to relapse more often and need to r/o Hodgkins Lymphoma, NSAIDs use. B. Focal & Segmental Sclerosis ( FSGS): Can be divided into primary problems (immune mediated) and secondary (wear and tear etiology). Nephrotic, HTN, progressive renal insufficiency. R/o: HIV, IVDU (from contaminates such as talc), obese, SS. May be more common in Africans. Hyperfiltration model in obese as having a 6 cylinder engine that runs on 2 cylinders. C. Membranous GN: Immune mediated from anti IgG & complement. The most common GN in adults. Few sxs, but have the heaviest proteinuria (8-20g), Nephrotic, +HTN. 40% with hematuria. See below under ARF. D. Membranoproliferative GN (MPGN): Nephritic/Nephrotic, r/o SLE, HCV. Proteinuria in Children: Child varies --> Childs excretion level varies with age: Age 5-30 days

preemie --> 26mg/d (or 182 mg/m2/d), 7-30d term --> 32mg (145/m2), 2-12mo --> 38 (109/m2), 2-4yo --> 46 (91/m2), 4-10yo --> 71 (85/m2), 10-16yo --> 83mg/d (or 63 mg/m2/d). Etiology: Transient --> fever, strenuous exercise, extreme cold exposure, epi administration, emotional stress, CHF, abdominal surgery, sz. Isolated Asymptomatic --> orthostatic, persistent fixed. Secondary to Renal Dz --> HSP, lupus, MPGN, post infectious GN, minimal change, FSGN, chronic interstitial nephritis. Congenital/ Acquired Urinary Tract Abn --> hydronephrosis, PCKD, reflux nephropathy, renal dysplasia. Diabetic Nephropathy: Diabetes has become the most common single cause of end-stage renal disease (ESRD) in the U.S. and Europe. 35% of type 1 and 20% of type 2 progress to End Stage Renal Dz (ESRD). May occur as early as 5ys after onset of DM. Once microalbuminuria develops, 65% of type 1 and 30% of type 2 progress to overt proteinuria, then ESRD. Microalbuminuria: Predictors of Progression: HTN, smoking, hyperlipidemia, poor glycemic control, genetics (the only non-remediable factor) 3 Stages of ESRD: 1. Hyperfiltration with sustained microalbuminuria. 2. Loss of GFR, inc albumin, variable HTN. 3. Nephrotic. W/u: if Urine A/C >30 mg/g--> re-check 2X in next 3mo. If >300--> refer to Nephrology. If 30-300--> dx as microalbuminuria--> --> Stages of Diabetic Nephropathy: Histology: starts with nodular glomerulosclerosis, then diffuse, then exudative lesions of the glomeruli. Stage I (Preclinical): (0-5yrs). Renal hypertrophy (size> 14cm,) GFR >150 ml/min, Albumin excretion <30mg/d, BP normal. 30% progress. II: renal hypertrophy, GFR 150-200, albumin excretion <30mg/d, no HTN. III (Incipient Nephropathy): (5-20yrs after onset of DM). Normal renal size (~12cm), GFR 130-150, excretion 30-300mg/d, inc BP. 20-80% progress. IV (Overt Nephropathy): dec renal size (<10cm), GFR <120, albumin excretion >300mg/d, very high BP. Creatinine rises, GFR deteriorates 10-14ml/min/yr. V (ESRD): atrophic kidneys (<8cm), GRF <20, albumin excretion >3.5g/d, very high BP. Uremia if untreated, needs dialysis or transplant. Suspect Non-diabetic Kidney Dz when: Have proteinuria w/o nephropathy, especially if DM 1. If have overt nephropathy with 5yrs of onset of DM. If have renal failure w/o significant proteinuria. If have sudden onset nephrotic syndrome. If have rapid decline in GFR (>1ml/min/mo, r/o MM). If have persistent gross and microscopic hematuria (consider lower tract dz). If have RBC casts.

Tx of Proteinuria: Tx for HTN If BP >15/10 mmHg above 130/80. If serum Cr <1.8 mg/dL use ACEi + Thiazide. If ?1.8 use ACEi + Loop diuretic. If still not at BP goat add a long-acting calcium channel blocker. If still not at goal after ACEi, diuretic and CCB add low-dose bets-blocker if Hr >84 or another CCB. If still not under control add a qHS alpha blocker, consider w/u for secondary HTN or refer. Tight glycemic control (dec HbA1C by 2%) in diabetic. Add an ACEi in any diabetic with >1 risk factor, even if normotensive. Aim for a BP <130/80. Re-check q4-6mo, if progresses, then refer. Can add CCB or an ARB for additive effects. Prevent progression--> Smoking cessation. Caution if use radiocontrasts. Maintain hydration. Maintain BP ~125/75, reduce proteinuria to <1g/d. Restriction of dietary protein has no good data and only mild effect on progression (aim for <0.8g/kg/d). Avoid renal damage via infections (UTIs) or drug use (NSAIDs, antifungals, nephrotoxic Abx), control dyslipidemia. If have an underlying RTA 4 tx acidosis with bicarb. ***Ref: (Diabetes Care. 1999;22) (Am Fam Phys 1998;58;5) (Proteinuria. Ann Int Med 1983;98:186) (Management of idiopathic membranous nephropathy. Kidney Int 1999;70:S47) (Nephropathic nature of proteinuria. Curr Opin Nephrol Hypertens. 1999;8:655-63) (A practical approach to proteinuria. Pediatr Nephrol. 1999;13:697-700) (Microalbuminuria in essential hypertension. Curr Opin Nephrol Hypertens. 1999;8:359-63) (Proteinuria in adults. Am Fam Phys 2000;62:6) (Kidney Int 1999;55:1-28) (J Am Soc Neph 1998;9:2157-69) (Am J Kidney dz 1995;25) (Diabetes Care 1999;22:S1) (Nephropathy in patients with Type 2 DM. N Engl J Med 1999;341:15) (Micoralbuninuria: what is it, why is it important. What should be done about it. J of Clin Hyperten 2001;3:2) Female Sexual Dysfunction (FSD): Links: Hx & W/u: Hypoactive: Arousal: Anorgasmia: Dyspareunia: Vaginismus: Tx: Up to 33% of all women age 18-59 have a disorder of desire. 15% of premenopausal and 35% of postmenopausal women have difficulty reaching orgasm. 38% with anxiety/ inhibitions associated with sex. 15% have lubrication problems. The 4 categories of problems are desire, arousal, orgasm and sexual pain disorders. The w/u starts with a detailed sexual Hx: Onset (primary or lifelong vs secondary or acquired), frequency (situational or generalized), location of pain (insertional or superficial vs deep or deep thrust). Did anything happen in your life that may have causes this problem? Is your partners sexual functioning satisfactory for you? Have you had this problem with other partners? Have you ever had any sexual experiences that were negative or upsetting? If you masturbate, do you have the same problem? Tell me about your lifestyle and childhood. Medication SE. How can I best be of help to you? Exam & W/u: Inspect the external genitalia for lesions, leukoplakia or erythema. Examine the Bartholin & Skenes glands, the urethra, meatus, vestibulitis using a moistened cotton-tipped applicator. Ascertain muscular pain by inserting one well-lubricated finger into the introitus as have the pt perform relaxations and contractions of the pubococcygeus (teach them to identify this muscle to perform Kegal exercises at home with eventually two fingers for 5-15min/d). Inspect the inner wall of the vagina for fissures, friable mucosa, lubrication problem, atrophic changes from aging (pubic hair, skin elasticity, labial fullness and depth). Check for hymenal scarring. Inspect the cervix and adnexa, look for endometriosis, fibroids, PID. Lab: Obtain PAP, Cx, KOH and Wet Prep. Consider as TSH and serum testosterone (free and total).

Hypoactive sexual desire d/o (HSDD): low or no sexual fantasies or desire, 81% are female. Essentially a loss of libido. Many factors may play a role in this and other disorders. There are many major emotional transitions seen with advancing age: empty nest syndrome, change in body habitus and retirement (self or spouse). Med SE: Li, SSRI, TCA, benzo, antilipid, Clonidine, digoxin, spironolactone, beta-blocker, danazol, H2 blocker, ketoconazole, Phenytoin, Indomethacin. Sexual aversion d/o: avoidance of genital sexual activity due to anxiety, fear or disgust. This is a phobic psychological disorder best treated by a mental health professional. Female Sexual Arousal d/o (FSAD): Characterized by both the physiological and psychological inhibition of sexual arousal. May be lifelong or acquired, intermittent or continual. Inability to attain or maintain a physical response (no lubrication/ vasocongestion). This is an end-organ problem due to lack of sufficient blood flow or a deficiency of genital and somatic responses in the clitoris, labia, vagina and pelvic region. It may not be an issue unless the pt is experiencing subjective distress from the problem. Med SE: anticholinergics, antihistamines, antihypertensive, benzo, TCA, SSRI. Female orgasmic d/o: inability to experience orgasm despite adequate arousal. The pt feels like building to a plateau and then getting stuck. This may be manifested as difficulty, delay or an absence of orgasm. One must first determine if there was sufficient desire, stimulation and arousal to achieve an orgasm. Once these are adequate, focusing on the pts capacity for fantasy is the next step. Need to change the conception that sex equals intercourse as it leads to a pressure to obtain an orgasm. Inadequate sexual techniques may also contribute. Some women are afraid to provide specific guidance to their partner as to their preferred method of stimulation. Med SE: sympathomimetics/ diet aids, benzo, SSRI, trazodone, TCA, narcotics, methyldopa. Sexual Pain Disorders: May be due to problems with lubrication, vaginal atrophy or physical scarring. Dyspareunia --> pain before/ during/ after sexual intercourse. Often due to a combination of physical and psychological factors. Up to a 7% prevalence in primary care clinics. Entry --> Vulvodynia, vulvar vestibulitis, vaginismus, vaginitis, urethritis. Deep --> endometriosis, pelvic adhesions, adnexal pathology, retroverted uterus, chronic cervicitis, PID, endometriosis, pelvic congestion, urethral disorders. Both --> Dyspareunia, inadequate lubrication (usually entry pain), vaginal atrophy, postpartum. Ddx Dyspareunia: Abd d/o (PID, endometriosis), congenital (hymenal stenosis, vaginal agenesis/ duplication/ septation), GI (constipation, diverticular dz, hemorrhoids, IBD, proctitis), lubrication inadequacy (past/ present abuse, arousal d/o, insufficient foreplay, vaginal atrophy, progesterone-only contraception), pelvic scarring (episiotomy, surgery), psychological (anxiety, depression), urologic (cervicitis, interstitial cystitis, lichen sclerosis, urethral diverticulum, urethritis), vaginal (vaginitis, vaginismus, atrophic vaginitis), vulvar (chemical irritation, HSV, lichen sclerosis, vulvodynia, vestibulitis), other (adenomyosis, leiomyoma, ovarian mass, prolapsed adnexa). Chronic Pelvic Pain: Postpartum Dyspareunia: very common, 45% have entry pain. More common in those with vaginal delivery and those lactating. Median time to resolution is 5- mo, mild tenderness persists for up to 1yr.

Vaginismus --> involuntary vaginal muscle spasm (outer 1/3) accompanied by pain, often preventing completed intercourse. Tx: self dilation using a lubricated finger or test tubes of graduated sizes. She should always be the one to control the depth of insertion. Other Causes of a Sexual Disorder --> d/o do to substance abuse, medical condition, paraphilia, gender identity, discordant timing with partner, coital H-A. Tx of Sexual Disorders: Biopsychosocial Approach: learning theory suggests these pts have erroneous or negative expectations of sexual intercourse. Cognitive Treatments: control of vaginal muscles, self-exploration of sexual anatomy, insertion of a trainer under controlled relaxation, sharing of control with partner, insertion of penis with the woman in control. Deep thrusting pain may be minimized with the use of the woman-superior positions or other position changes. Enhance stimulation by encouraging erotic material (videos, book) and recommend the use of vibrators. Encourage both erotic and nonerotic fantasy. Encourage noncoital behaviors such as sensual massage and sensate focus (no involvement of sexual areas as one partner massages and the other provides feedback as to what feels good. 4-Step Homework: Daily Kegal Exercises: advise repetition during routine activities such as standing in line, at stop lights etc. Home Kegal exercises with inserted fingers daily with eventually inserting two fingers for 5-15min/d. #1: 1st 2wks engage in daily intimacy with partner that does not involve contact with breasts or either partners genitalia. #2: Week #3, guide partner to insert a lubricated index finger into vagina as pt breathes slowly, relaxes pubococcygeus muscle and counts to four Include extragenital foreplay. #3: Cont prior, include pt guiding partners fingers and then lubricated soft penis (just after ejaculation) into her vagina. #4: As pain & anxiety subside, experiment with inserting the tip of the erect penis, add more until pain-free coitus. Suggestions For Enhancing Sexual Satisfaction: Take responsibility for your own sensual and sexual pleasure, your partner should not have to guess what you want, say what makes you happy. Talk about sex with your partner. Make regular time for togetherness with your partner, Do not let sex become routine, avoid boredom with too much of the same thing, try new things. Keep romance in your life, continue unexpected surprises and kindness. Dont always wait to be in the mood before agreeing to sex, your enjoyment may rise when you least expect it. Keep you sexual expectations realistic, not every orgasm is atomic. Consider Sex Therapy If: Sexual problem has persisted at least 2-3mo. Problem is likely caused or maintained by psychological factors. The couples general relationship is reasonable harmonious. No current active major psychiatric d/os, drug, ETOH abuse. Female partner is not pregnant. Conjugated Estrogen Cream: 1/8 applicatorful qd X 10d, then QOD. Use finger to apply cream directly to most tender area. Other: HRT, Viagra?. Testosterone Cream 1-2%: micronized methyltestosterone @0.25mg, titrate up to 0.8mg/d or Estratest with .625mg est + 2.5-1.25mg methyltestosterone. SE: reversible masculinization, lipids. Best for low libido and postmen on ERT (also relieves vasomotor sxs), surgical menopause or high risk osteoporosis. Testosterone therapy for disorder of desire --> In women who have undergone oophorectomy and hysterectomy, transdermal testosterone improves sexual function and psychological well-being. Labs: serum testosterone (free and total), lipid profile, baseline LFTs, mammography, Pap smear.

Tx with Methyltestosterone (Android): 1.25-2.5mg qd. Micronized testosterone: 5 mg PO qd. Estratest PO qd. Per to the lowest effective dose. Monitor lipids, LFTs 1-2X/d. When to Refer: longstanding dysfunction, multiple dysfunctions, current or past abuse, unknown etiology, no response to therapy, psychologic disorder. **Ref: (Evaluation of dyspareunia. Am Fam Phys 2001;63:8) (Female sexual dysfunction. Postgrad Med 2000;5:S35-39) (Dyspareunia and vaginismus. Clin Obstet Gyneco. 1984;27:750-9) (Female Pt 1999;8:suppl) (Female sexual problem. WJM 1999;171:358-60) (Female sexual dysfunction. Am Fam Phys 2000;62:1) (Dyspareunia. Post Grad Med 2000;108:2) (Transdermal testosterone treatment in women. N Engl J Med 2000;343) Sexually Transmitted Diseases (STDs): Links: Herpes Simplex Virus: Genital Ulcer Ddx: LVG: Chancroid: Granuloma Inguinale: Syphilis: Gonorrhea: NGU: Chlamydia: Pelvic Inflammatory: Genital Warts: 1g of Azithromax single dose will tx Chlamydia, GC, syphilis, NGU, and chancroid. (Ann IM 1999;131:434-7). Give Hep B vaccination to all, as likely high risk. Other STDs: Bacterial --> BV, enteric dz (Salmonella, Shigella), PID. Viral --> AIDS, hepatitis, Condylomata acuminata (HPV), molluscum contagiosum (poxvirus, may be from nonsexual), Mononucleosis, enteric viruses. Fungal --> tinea, vaginal candidiasis, candidal balanitis (erythematous scaly rash, KOH +, need to treat partner as well). Protozoan --> enteric dz (Cryptosporidium, E. histolytica, PCP..), Giardiasis, pinworms (E. vermicularis), trichomoniasis (T. vaginalis). Ectoparasites --> pediculous pubis, scabies. Herpes Simplex Virus (HSV): Links: Primary Infection: Oral: Genital: Other: Pregnancy: Tzanck: Zoster: Any mucocutaneous surface or visceral site may be infected by Herpesvirus hominis. Types 1&2 clinically indistinct lesions orally and genitally. 80% who test + for virus by Western Blot will never have had sxs. Humans the only natural host. Primary HSV infection: gingivostomatitis, herpetic whitlow, vulvovaginitis, cervicitis, genital infection, keratoconjunctivitis, eczema herpeticum (Kaposiss varicelliform eruption from widespread cutaneous HSV infection in those with preexisting skin dz such as eczema), generalized cutaneous herpes, disseminated HSV (newborns, immunodeficiency states), meningoencephalitis, traumatic herpes. Recurrent manifestations in carriers: fever blisters, genital herpes, encephalitis, herpetic whitlow, dendritic corneal ulcers. Human Herpes-Viruses family includes HSV, VZV, CMV and EBV.

HSV-1: 60% prevalence. Most acquire as child and manifest with reactivation in adulthood. Majority of primary infections are asymptomatic, in adults primary infections are explosive and febrile with ulcerative lesions diffusely in the oral cavity with predilection for lips and gingiva. Tx: maintain hydration, NSAIDs, viscous lidocaine and Benadryl elixir, lesions resolve in 10-14d. Oral Recurrent HSV-1: presents as a crop of vesicles that are limited to the palate, gingiva or alveolus (rather than buccal or lips) (anywhere in immunocompromised). Has a preliminary vesicular phase, (unlike apthous ulcers), tend to be smaller than apthous (<0.5cm) and occur in clusters rather than singly. Tx: PO Acyclovir may help, 400mg TID will help reduce relapse in HIV. Herpes labialis (cold sore): Latent HSV-1, on lips at vermilion border, precipitated by trauma, sunlight, stress, febrile illness. Prodromal burning & itching 2-24hr before. (5 or 10%). Vesicular lesions and membranes coalesce into yellowish plaques, often associated with fever, malaise and regional lymphadenopathy. Tx: No decreased duration of viral shedding nor promotes healing. Oral Acyclovir pills only reduce the duration of pain, no improved healing. Docosanol (Abreva): 10% cream, OTC, 2g tube. AAA 5X/d. Blocks viral entry and subsequent replication. May shorten episodes. $17. Penciclovir (Denavir): 1% cream, 2g, AAA q2hr at prodromal Sx while awake X4d. Will reduce shedding, pain and lesion. $27. Acyclovir (Zovirax): 5% oint, 3g tube, not very effective, AAA 6X/d, $24. Topical steroid are a great additive treatment as much of the discomfort is from inflammation. Genital HSV: Links: Primary: Dx: Tx 1st: Counseling: Recurrent: Tx Recur: Suppressive: 2-7 day incubation, primary lesion is a vesicle, multiple, may coalesce, 1-2mm D, erythematous base, superficial, tender, tender adenopathy with 1st episode. Any recurrent anogenital s/s in th speedo area is Herpes until proven otherwise. Usually HSV 2 (22% prevalence overall --> 26% F, 18% M. 46% blacks), indistinguishable clinically from HSV-1 (20% of cases). Even with 1st clinical episode, may already be seropositive both one or both types. Painful multiple edematous erosions with yellow-whit membranous coating. Primary lasts 2-6 wks, recurrent lasts 7-10d. Also have bilateral tender inguinal adenopathy (rare in recurrent). Checks in, but doesnt check out. May come down to the lobby to visit, but always goes bach to its room in the dorsal root ganglion. Primary infection: After 1st exposure (1-26d incubation period), followed by latency period of viral dormancy in nerve ganglion. Women more likely than men to have symptomatic primary infection. S/s: Grouped or solitary vesicles on erythematous base progressing to ulceration. May have flu like sxs, especially if 1st time. Lesions painful and persist 2-3d before forming honey colored crust.

Lesions last for 15-23 days, healing is usually complete within 3 weeks. Women commonly have vulvodynia and dysuria. Atypical presentations such as fissures, ulcerative lesions, and cervicitis occur. Dx: By H&P if have the classic cluster of vesicular lesions on an erythematous base, but only seen in 65%. Lab confirmation with viral culture is the classic gold standard. See the characteristic cytopathic morphology within 24-96h, can subsequently type them with monoclonal Ab staining. Isolation is most successful when culture lesion in the vesicular stage, during a primary infection and in the immunocompromised. Immunfluorescent assay (ELISA, only 70% accurate at this time). Western Blot is the new gold standard, best tested at 4mo after new sxs (UofW: www.viridae.com). Up to 70% of pts that have serum Abs to HSV-2 have no h/o outbreaks. Positive serology does not indicate the duration of infection (new Vs old) or the presence of active infection. First Episode Tx: PO Acyclovir (Zovirax) @ 400mg TID or 200mg 5X/d X 7-10d or until clinically resolved. SE: N/V/ rash, rare H-A., adjust for renal insufficiency. Valacyclovir (Valtrex) @ 500mg, two (1g) PO BID X 7d. Prodrug of acyclovir. Famciclovir (Famvir) @ 250 TID X 7d. Adjust for Cr clearance (>60ml/min --> 500 TID, 40-59 @500 BID, 20-39 @500qd). Converted to Penciclovir via oxidation. Severe infection or nonhealing in immunocompromised --> Acyclovir IV 5-10mg/kg/d q8hr X5-7d. Neonatal: 30-60mg/kg/d X10-21d. Other Tx: analgesics, sitz baths, keep area clean and dry with corn starch/ baby powder or a hair dryer. Pyridium for dysuria. Warn pt of autoinoculation, infected sites should be patted dry rather than wiped, abstain from sexual activity while lesions are present. Encourage condoms as asymptomatic viral shedding common. Risk of neonatal transmission. Check GC, chlamydia, RPR, HIV, HPV. Give HBV vaccine. Counseling: 20% of sexually active persons are infected, just a matter of luck. No good or bad type, only oral or anogenital. Incidence of HSV- 1 in genital area inc as from oral sex. Asymptomatic shedding occurs on 1% of all days, risk of transmission to uninfected partner is 5-10%/yr. The transmission and acquisition of HSV may be asymptomatic. May be hard to tell who gave it to who, but do not rely upon presence of sxs or lesions in taking precaution against transmitting. The risk of transmission during childbirth is extremely low unless active lesions are present. Recurrent Infections: prodromal burning or itching, usually just a mild/transient nuisance compared to initial episode. Lesions last 9-10 days only. 90% HSV 2 and 60% HSV 1 recurs in 1yr. Variable recurrance rate from none to every 2-3 wks. Average annual rate of 4 recurrent episodes/yr. Men 20% more recurrences. Over time the recurrences become less frequent. They are precipitated by stress, menstruation, sun, cold, local trauma. Sunscreen and lip balm recommended. In men, have dysuria out of proportion to discharge. Shingles usually only recurs once, if recurs 2X, consider HSV, not VZV. Tx of recurrent Episodes: Must initiate tx at prodromal sxs or w/in on day of onset of lesions. Acyclovir @ 800mg BID or 400mg TID or200mg 5x/d X5 days (10d if immunocompromised) or Famvir @ 125mg BID X 5d, or Valtrex 500mg BID X 5d. Acyclovir-resistant strains: Foscarnet (Foscavir): 40mg/kg qd-TID for 3-4 wks. Cidofovir (Vistide). Suppressive Tx dosing if >6/yr: Acyclovir 400mg BID-TID or 200mg TID or Famvir 250mg BID or

Valtrex 500-1000mg qd. Can consider suppressive dosing during periods of inc stress or optimal protection desired (wedding, vacations). Will dec recurrance by 75%. After one year, stop and reassess risk of recurrance, as start to give meds for episodic tx. Herpes Gladiatorum: skin to skin contact (wrestlers), 1-2 wks after exposure, Acyclovir 200mg 5X for 7d, Px: hygiene. No evidence of fomite transfer. Herpetic Whitlow: Infection of distal digit or nail fold by HSV I or II. Painful inflammation with erythema and vesicles. Dx: clinical, Tzanck smear. Tx: PO Acyclovir 600mg 5X/d for 5-7d, TID soaks with 1:40 Burrows solution, topical Abx ointment to prevent bacterial superinfection. Kaposis Sarcoma: HHV-8, visceral dz often asymptomatic. Roseola infantum (Exanthem subitum): HHV 6 --> T-cell lymphotrophic virus. 90% children are seropositive by age 2yo. Shed in saliva and urine. In adult --> fever, lymphadenopathy, hepatitis, encephalitis. (Mayo Clin 1999;74) & HHV 7. Eczema Herpeticum: widespread cutaneous herpes lesions that develops in eczematous skin. Systemic sxs vary. Rash may simulate chickenpox lesions. Tx: PO Acyclovir. Pregnancy: has a 0.03% incidence for all deliveries. 50% transmission rate if have a primary active lesion and vaginal delivery. 4-5% transmission if have a recurrent active lesion at delivery. %0% of all neonatal infections occur in infants whose mother has no h/o HSV. ACOG recommends that so long as no active lesions seen at the time of labor, vaginal delivery is safe. **Ref: (Medical Letter 1999;41:1062) (Recurrance rates, Ann IM 1994;121:847-54) (New infections with HSV, N Engl J Med 1999;341;1432-8) (Modern Medicine 2000;68:61-65) (J Am Acad Derm 1996;35:4) (Postgrad Med 2000;107:3) (Dx and tx of HPV, Clin Obstet Gynocol 1999;42:206-20) Tzanck Prep/ Smear: Step #1: take cells from base of an early lesion via scalpel scraping or CTA/ Dacron swab moistened in saline. #2: Dab/ roll gently onto slide, air dry. #3: Stain via above Wright stain.

Or If using Giemsa stain, 1st fix in methyl alcohol for 1-2 min before staining. Can also use H & E

stain, PAP, toluidine blue. #4: Look for multinucleated giant cells and epithelial cells containing acidophilic intranuclear inclusions. Cannot tell VZV from HSV. **Ref: (J Am Acad Dermat 1999;41:1 p5) Herpes Zoster (VZV): Links: S/s: Tx: Complications: Eye: Ramsay Hunt: Neuralgia: Prophylaxis: Varicella-Zoster Virus. Reactivation of latent Chickenpox virus. 15% of pop gets during lifetime, can occur despite Ab titers. Mean age 42yo, with inc frequency after age 55, any age can be affected (10% of cases in age <20yo). Elderly at greater risk for postherpetic neuralgia (33% if >66yo). Second attacks seen in 4%. Check HIV if protracted, recurrent, multiple dermatones. S/s: Heralded by dermatomal pain (1-3 days before in 90%), then explosive, diffuse vesicular rash that is usually pruritic. 5% may have fever, malaise and H-A. Shingles can occur only if reactivated. New lesions continue to appear for 2-3d. Can be in any dermatome, usually unilateral in T3-L2 region or facial (V1). ( 9th or 10th CN (Vs herpangina, diffuse). Erythematous macules & papules progress to vesicles in 12-24hr, then pustules in 3-4 days, crusting in 7-10 days. (J Am Acad Derm 1999;7) Tx: Local care (Wet dressings/ compresses Burrows solution (Domeboro). Analgesics/narcotics PRN. If age >60yo give PO Acyclovir @ 800mg (20mg/kg/d) 5X/d (q4hr while awake) X7-10d or Valtrex 1g TID X7d or Famvir 500 TID X7d, to hasten the resolution of the rash, best if initiated within 24hr onset of rash. If immunocompromised give 10mg/kg IV q8hr X7-10d. Contact precautions as infectious up to 7 days after appearance of the rash. Age >50yo --> Prednisone 60mg/d X7, then 30mg/d X 7d, then 15mg/d X 7d, over 21d total (if not immunocompromised). Calamine lotion, Aspercreme (10% Salicylate). Complications: meningoencephalitis, cerebrovasculopathy, CN syndromes (ophthalmicus, Ramsay Hunt), peripheral motor weakness, transverse myelitis, cutaneous dissemination, superinfection of lesions, visceral involvement (pneumonitis, hepatitis, pericarditis, myocarditis, pancreatitis, esophagitis, enterocolitis, cystitis, synovitis). Dissemination: >20 vesicles outside of primary and immediately adjacent dermatomes. Risk visceral involvement in 10%. Herpes zoster ophthalmicus (HZO): Involvement of the trigeminal nerve in zoster occurs in 15% of cases, seen as a burning of scalp and skin in dermatomal distribution several days before vesicular eruption. Spread to the ophthalmic division of the trigeminal nerve leads to HZO. The ophthalmic division of trigeminal nerve supplies the forehead, temple, palate, tip of nose and eye. Usualy develops within 3 wks of zoster rash. Nasociliary nerve may affect skin of forehead, eyebrow, cornea, sclera, ciliary body and optic nerve. Signs: conjunctivitis (transitory, X 1wk), corneal edema 2-3 d after rash, eyelid edema, eye pain, keratitis, uveitis, iridocyclitis, neck lymphadenopathy.

Pupils may be asymmetric. Hutchinsons sign is a vesicles on the lateral / tip of the nose, pathognomonic for corneal involvement. Tx: If any opthalmic involvement, need Acyclovir to prevent blindness, f/u with ophthalmologist. Refer all as may cause blindness or secondary glaucoma (10%). **Ref: (Mayo Clin 1999;74:983-998) (Hospital Physician 1999;9:45-49) Ramsay Hunt Syndrome: involvement of both facial and auditory nerves. Ipsilateral facial palsy in combination with lesions of external ear, TM or anterior 2/3 or tongue. Can result in tinnitus, vertigo, deafness, otalgia or loss of taste. Refer to ENT as soon as dx. Postherpetic Neuralgia (PHN): Pain >1mo after the rash. Up to 15% of pts (3% at 1yr if age <60yo), but in up to 50% if age >60. Most have a significant reduction in pain by 6mo. Avoid by starting antivirals within 72hr. Prednisone at time of diagnosis reduces acute pain, not chronic. TCAs 1st line tx for constant pain, consider starting with acute shingles. Amitriptyline 10-25mg/d X 3mo to prevent. If cardiovascular dz or if not improving after 3 mo, consider Gabapentin 300mg/d divided TID, then increase gradually to 3.6g divided TID. CMZ for lancinating pain. Zostrix (Capsaicin): 0.25-075% cream qHS. Lidocaine Patch (Lidoderm): up to 12hr/d, up to 3 patches to intact skin, can cut to fit. Or 5% Lido gel. Or EMLA cream. Or TENS unit. Homemade Capsaicin Cream: cup cold cream + 3-4 tsp Cayenne Pepper (start with 2 and work up if you can tolerate it), Mix well, apply thin coat to painful area 2-4d. Use gloves to apply, avoid open wounds, massage in well until no residue remains. Cover area at bedtime (sock or plastic wrap). Burning sensation improves in 2-3d, take a few weeks for cream to take effect. Chickenpox: persons born and raised in temperate climates such as Europe most often have immunity by adulthood as there is a higher incidence of childhood chickenpox. Prophylaxis after exposure: VZIG if --> Exposure Criteria (Chickenpox or Zoster) --> continuous household contact, playmate contact (>1hr indoor play), hospital contact (same 2-4 bedroom, adjacent ward beds), immunocompromised, pregnant w/o Hx of varicella and neg Abs, newborn contact (infants born to mothers infected with varicella 5d before or 2d after delivery), hospitalized premature infant and no maternal Hx/ no Abs, preemie <28wk or <1kg regardless of mothers Ab status. 1% of pregnant women with chickenpox have infants with congenital varicella syndrome (low birth-weight, cutaneous scarring, limb hypoplasia, chorioretinitis, microcephaly, cataracts. Acyclovir if given within 48hrs of sh onset beneficial. **Ref: (MMWR 1998;47:1-111) (Drug Tx of common STDs, Am Fam Phys 1999;60;5) (Medical Letter 1999;41:1062) (Postherpetic neuralgia, N Engl J Med 1996;335:1) Genital Ulcer Ddx: Behcets, trauma, fixed-drug eruption, Crohns, Yaws, typhus eschar, leprosy, anthrax, cutaneous

leishmaniasis, desert sore (C. diptheria), HSV 1 or 2 (erythematous base, nonpurulent, tender bilateral adenopathy), Apthous ulcer (larger & more irregular than oral, painful, on modified mucous membranes of vulva, and scrotum/penis.) Primary -secondary syphilis (painless, single), LVG, Chancroid, Granuloma inguinale. Management if pt has acute genital sore/ ulcer --> Tx for syphilis and chancroid, educate, partner management, RTC 7d. Buboes = Tender, enlarged lymph nodes, Lymphogranuloma Venereum (LVG) = Chlamydia, Chancroid = Hemophilus ducreyi, HSV, Syphilis =T. pallidum, Donovanosis. Management if pt c/o painful lymph nodes, no ulcers present --> Tx for LGV & Chancroid, educate, manage partner, RTC 7d. Lymphogranuloma Venereum (LVG): C. trachomatis. 3d-6wk (ave 21d) incubation, lasts 2-6 days. Primary lesion is a papule, pustule or vesicle. Single genital lesions (rarely see an ulcer), suppurative unilateral regional lymphadenopathy (+Groove sign), or hemorrhagic proctitis. Ulcer 2-10mm D, superficial or deep. Obliterative destruction of lymph. Dx: Isolation of C. trachomatis, inclusion bodies in leukocytes of an inguinal lymph node (bubo) aspirate. Complement fixation test. Tx: Doxy 100mg BID X21d or Emyc 500mg QID X 21d or Sulfisoxazole 500mg QID X21d. Chancroid: Haemophilus ducreyi. 2-5d (1-14d) incubation. Primary lesion is a small papule that rapidly vessiculates to form a pustule, the ulcer. Usually have multiple lesion, may coalesce, lasts months. Hurts and Smells like Hell Painful deep genital ulcerations, friable, ragged border, little induration, purulent exudate, single or multiple. Inflammatory inguinal adenopathy (buboes) (unilateral, rare bilateral). May have mild fever and malaise. Dx: Isolation of H. ducreyi from a clinical specimen (smear, Cx, Bx) or smear from aspirated, unruptured lymph node. Presumptive dx made by scraping the edge of the ulcer and Grams staining to see short, chain forming G- bacilli in clusters (false + may be from colonization) seen as a school of fish appearance. Check HIV & RPR. Tx: Azithromax 1g PO X1 or Ceftriaxone 250mg IM or Emyc base 500mg QID X7d or Augmentin 500mg TID X7d or Cipro 500mg BID X3d. Highly infectious, treat all secondary contacts. Granuloma Inguinale (Donovanosis): Calymmatobacterium granulomatis. Incubation 1-16wks, lasts years. Encapsulated G-. S/s: Primary lesion is a papule. Slowly progressive ulcerative disease of the skin and lymphatics, minimally painful. Beefy-red granular lesion with rolled raised, sharply defined border, has firm induration. Can be in the anogenital area. Perilymphatic granulomatous lesions (pseudobuboes). No lymph adenopathy. Dx: intracytoplasmic Donovan bodies (G- in monocyte) in Wright or Giemsa-stained smears or biopsies.

Tx: Rocephin 1g qd X7d or Bactrim DS BID X 3wks or Doxy 100mg BID X3wks or Cipro. Syphilis (Louies Dz): A complex STD that has a highly variable clinical course. Due to the spirochete Treponema pallidum. Primary: Primary lesion is a papule, then get one + chancres (ulcers), have rolled, indurated edges, Non tender, appear 9-90 days incubation and lasts 2-8wks, regional lymphadenopathy. Dx: darkfield microscopy, direct fluorescent ab (DFA-TP), a reactive serologic test --> nontreponemal: Venereal (VDRL or RPR). On CSR check FTA-ABS, not WDRL. treponemal: FTA-ABS or microhemagglut assay for ab to [MHA-TP]) (False + RPR in low titers (<1:8): SLE, Hep, chronic inf, lepr, pregn, old age, malaria, recent immunize), prozone phenomena = high ab levels in secondary syphilis giving a false - unless diluted, Four fold drop in titer is a two-dilution change e.g. 1:16 to 1:4 or 1:8 to 1:32. Tx: primary to early latent (<1yr duration) --> Benzathine PCN-G 2.4mil U IM X1. If PCN Allergy --> Doxy 100mg BID X 14d or TCN 500mg QID X14d, Doxy 100mg BID X14d, Emyc 500mg QID 14d. Azithromax 1g PO. Check titer at 6&12mo. If titer not dec 4X by 6mo, need to re-treat with 3 weekly IM PCN-G 2.4 mil U. Cure = Titer <1:32, if higher --> LP to check VDRL in CSF. If HIV+, must desensitize if PCN allergic. Jarisch-Herheimer reaction common --> fever, H-A, hypotension, myalgias. Secondary: 4-6wks after primary, lasts 2-6wks. Localized or diffuse scaly macular rash with mucocutaneous lesions (rash on palms/soles, mucous membrane lesions), condyloma lata (resemble acuminata, except it has a smooth surface area), often with generalized lymphadenopathy, malaise, fever, sore throat, arthralgia. The primary chancre may still be present. --> Latent --> asymptomatic. Tertiary: 15% progress to this stage. Best screening test is FT-ABS. Can present 25yr after initial infection. PARESIS --> Personality changes, Affect abnormalities, Reflex hyperactivity, Eye abnormality, Sensorium changes, Intellectual impairment, Slurred speech. Subdivided into early, late, and unknown categories based on the duration of infection, destructive gummas anywhere, obliterative endarteritis, 10% CV-ascending aorta, 8% CNS lesions may include inflammatory lesions of the cardiovascular system, skin, and bone, RPR usualy NR. Tabes dorsalis. Argyle-Robertson pupils. Tx: Benzathine PCN-G IM 2.4mil U qwkX3. Or Doxy 100 BID X 4wks. Need 4X dec titer by 12mo for early latent Neurosyphilis: CNS infection, reactive serologic test for syphilis and reactive VDRL CSF. Tx: Aqueous crystalline PCN-G 3mil U q4hr IV X 10d, then Benzathine PCN 2.4 mil U IM/wk X3. Follow CSF q6mo until cell count is normal, if not dec in 6mo or normal in 2yr re-treat. Congenital: (in utero), wide spectrum of severity, only severe cases are clinically apparent at birth, HSM, rash, condyloma lata, snuffles, jaundice (nonviral hepatitis), pseudoparalysis, anemia, or edema (nephrotic syndrome and/or malnutrition). An older child may have stigmata (e.g., interstitial

keratitis, deafness, anterior bowing of shins, frontal bossing, mulberry molars, Hutchinson teeth, saddle nose). Serology in Syphilis: Nonspecific Treponemal --> VDRL & RPR (reactive plasma antigen): screening tests (low specificity), wanes over time. Become +4-6wks after infection or 1-2wks after the primary lesion. of latent syphilis neg. Good for monitoring response to tx. False+ --> any pneumonia, hepatitis, TB, mono, chancroid, chickenpox, HIV, measles, malaria, immunization, pregnancy, liver dz, malignancy, IV drug user, aging, CTD, mulitple blood transfusions. Specific Treponemal Ab tests --> FTA-ABS, MHA-TP, TPHA, TPI: high specificity, used to confirm all +RPR/VRDL and negatives whom you still strongly suspect syphilis clinically. Stays + (not correlate with dz activity) and become + earlier in the coarse of the dz. False + --> mono, Lyme, leprosy, malaria, SLE. Ex: 1. +RPR/VDRL --> check FTA, if + need tx. 2. +RPR/VDRL , FTA neg, then a false + due to nonspecific reaction. Dark-field microscopy: see corkscrew-like organisms moving around. CSF Exam: not needed if primary or secondary with no neurological S/s. Indicated if: tertiary/ latent syphilis of unknown duration, any neurological finding, HIV+ latent/unknown duration, treatment failure, pt preference, high titer, PCN allergy, >1yr sxs. **Ref: (Ann IM 1999;131:434-7) (Med Clin NA 1990;74:1389-1416) (Syphilis Serology, Infect Dis Clin Pract 1996;5:351-58) Neisseria gonorrhea (GC): Incubation: 2-14d (ave is 3-4d). S/s: In females have pelvic pain, or acute urethral syndrome or PID (15%) or asymptomatic with a mucopurulent d/c. In males get a spontaneous purulent urethral exudate with dysuria. May cause prostatitis, epididymitis, urethral strictures. Anorectal infection may cause pruritis ani, pain with deification, mucopurulent d/c and constipation. Usually have a thick, creamy, yellow d/c. Pharyngitis, nonexudative may be asymptomatic. Proctitis presents with tenesmus, discharge and constipation. Conjunctivitis presents with erythema and mucopurulent d/c. Dx: grows on chocolate agar enriched by 5-10% CO2. Gram stain reveals G- intracellular diplococci, has sens/ spec of 93/ 98%, usually have >5 WBCs/ HPF in gonococcal urethritis. New antigen detection methods are quicker and easier to handle, however do not allow for Abx sensitivity testing. Have ELISA and direct immunofluorescent tests (DFA). Also have amplification tests such as PCR and ligase chain reaction (LCR) with sens/spec of 99% on cervical and urethral specimens, but slightly less on urine specimens. Tx: Ceftriaxone 125mg IM X1 --> DOC, ok for pregnancy. If allergic to PCN give Cipro 500mg X1 PO. Cefixime 400mg PO X1. Ofloxacin 400mg PO X1. Azithromycin 2g PO X1 (inc GI SEs, but txs

chlamydia as well). All pregnant cases need repeat testing after treatment (test of cure). Pregnant and allergic --> Spectinomycin 2g IM X1. Cefoxitin 2g IM X1 + Probenecid 1g PO X1. Disseminated (adults) --> Ceftriaxone 1g IM/IV qd, once improved switch to 1 week of PO Cipro/ Cefixime/ Ofloxacin. Rx for chlamydia as well as 30-50% co-infected. Treat partners in past 30d for a symptomatic index case and 60d if asymptomatic at time of dx. Disseminated GC (DGI): Arthritis-dermatitis-tenosynovitis syndrome, seen in 0.5%. Most common in females during menstruation or 2nd-3rd trimester. It is the most common cause of infectious arthritis in young adults. Have fever, skin lesions, polyarticular arthralgias, tenosynovitis. Non-GC Urethritis & Cervicitis (NGU): Due to Chlamydia, Ureaplasma urealyticum are the usual causes. Also from Trichomonas vaginalis, HSV, and Mycoplasma genitalium. S/s: Usually the sxs of urethritis last longer (>4d), have a scantier d/c that is nonspontaneous and mucoid. Commonly asymptomatic. Dx: GC is absent. Have any 1 of 3: urethral d/c or >15 PMNs/ HPF of 1st 15ml voided urine or >5 PMNs/ HPF of urethral exudate or swab specimen. Tx: Azithromax 1g PO X1. Or Doxy 100mg BID X7d. If pregnant give Emyc base 500mg QID X7d or Amox 500mg TID X7d. If child <8yo give Emyc base @50mg/kg/d divided QID for 10-14d. Chlamydia trachomatis: S/s: 50% of men and 70% of women are asymptomatic. See above. Have a yellow d/c, angry, reddened cervix. Dx: ELISA, PCR or DFA Ab detection, need a high quality specimen. Tx: Azithromax 1g PO X1. Or Doxy 100mg BID X 7d. or Oflox 300mg BID X 7d. Pregnancy --> Emyc base 500 QID X 7d, 250mg QID X14d or Amoxicillin 500mg PO TID X7d. or Emyc ethylsuccinate 800mg QID X7, 400mg QID X14. Or Azithromycin 1g X 1. If pregnant need to re-check Cx to prove cure as transmission to infant in 50% of vaginal deliveries as a conjunctivitis or pneumonia. (Emyc estolate, Doxy and Oflox are contraindicated in pregnancy). All pregnant cases need repeat testing after treatment. Test of cure can be reliably done in 1wk if using a Cx, 2wks if using Ag-Ab (DFA, EIA) and delayed for 3 wks if using nucleic acid tests (LCR, PCR) to avoid false positives. Male NGU: if still c/o dysuria after tx, give Emyc or Azitho to tx for Ureaplasma. Pelvic Inflammatory Disease (PID): GC, Chlamydia, trichomonas, other organisms such as H. influenza, facultative and anaerobic bacteria in 50% of cases. S/s: PID Shuffle no lift feet up and hold lower abdomen so not shaking peritoneum. Pain is always

bilateral (Vs appy or ovarian cysts lateralize) Tx: Outpatient --> Oflox 400mg PO BID X14d + Flagyl 500mg BID X14d. Or Ceftriaxone 250mg IM X1 or Cefoxitin 2g IM X1 (with Probenecid 1g PO) + Doxy 100mg PO BID X14d. If do not respond in 720, hospitalize. Inpatient Regimen A --> Cefoxitin 2g IV q6hr or Cefotetan 2g IV q12hr. Plus Doxycycline 100mg PO BID X14d Regimen B --> Clindamycin 900mg IV q8hr Plus Gentamicin 2mg/kg IV/IM load, then 1.5mg/kg q8hr, then Doxy 100mg PO BID X14d or Clinda 450mg PO QID X14d. Regimen C --> Azithromycin 500mg IV X 2d, then 500mg PO X 8d. Parenteral therapy discontinues 24hr after clinical improvement. If tubo-ovarian abscess, best to use Clinda regimen. Genital Warts (HPV) (Condyloma acuminatum): External Genital Warts (EGW). Enter epidermal tissue through inflamed and macerated skin or microscopic abrasions that occur during intercourse. Incubation of 4-100 weeks. 25% of pt's partners will become infected, 12-34% associated with gonorrhea, chlamydia, or syphilis. S/s: painless, nonpruritic, pedunculated or sessile wart. 4 types of lesions: Moist exophytic (cauliflower), papular lesions, flat/ erythematous, and keratotic masses. Variable size. STD. Female partner needs PAP. Give HBV vaccine. Practice safe sex X 6mo w/o lesion until consider cured. Majority of cases are subclinical and asymptomatic. Aceto-white lesions are visible on colposcopic exam when treated with mild acetic acid (vinegar) --> squamous intraepithelial lesions of the cervix. Use on the external genitalia not recommended. small, <1yr old respond better to tx. Ddx: sebaceous (Tysons) gland, anal skin tag, pearly penile papule (angiofibroma), vestibular papillae, molluscum, seborrheic keratosis, lichen nitidus, melanocytic nevus, condyloma lata (syphilis). Imiquimod (Aldera): 5% cream, home use --> qHS 3X/wk max 16wks. Spread thin coat over the entire effected area with finger. Wash off with soap in 10hrs. Works in 72% F, 33% M, 40% have a complete response. SE: teratogen, erythema, itch, flaking, edema. Can also tx refractory warts on other areas. Alpha-interferon & TNF stimulated. LN2: 10 sec with CTA, frost extending 2-3mm, repeat q2wk until resolve. Avoid scrotal skin. Safe in pregnancy. Can then use podophyllin. Podophyllin: Condylox (Podofilox): 0.5% solution/ gel, a plant extract, inhibits cell mitosis (avoid pregnancy), apply to wart only, BID for 3 consecutive days followed by 4 days off X 4 cycles (or 4-6 weeks), wash off in 4-6hr, works 50%, but recurs 50%, may have local irritation, N/V, fever, renal fail. Avoid in pregnancy, do not put on vagina. Paint healthy skin with Abx ointment/ Vaseline via CTA prior to application to protect normal skin from irritation. Or 10-25% in tincture of benzoin,

wash off in 1-4 hr, repeat weekly. TCA (trichloroacetic acid/ BCA (bichloroacetic acid): 80-90%, chemical cauterize, apply with toothpick/ CTA 3X/wk for 3 wks or 3 applications 1 week apart. Excess neutralized with baking soda or talc, works 70% but recurs 50%. Can be used in pregnancy, on vagina, urethral meatus, anal or cervix. Avoid if large area or friable warts. Safe in pregnancy & lactation. 5-FU: 5% cream qhs 1-2X/wk for 10 wks, wash off in am (if penile wash off in 3hr, apply 3X/wk X 4 wks). Laser ablation: $$, works 70-80%, recurs 5-10%. Loop electrosurgical excisional procedure (LEEP): avoid if penile. **Ref: (MMWR 1998;47:1-118) (Drug Tx of common STDs, Am Fam Phys 1999;60;5) (Medical Letter 1999;41:1062) (Diagnosis and sxs of STDs, Scientific America Medicine 1999;7:22, pp1-15) (Anogenital warts, Clin Dermatol 1997;15:355)

Preamble and List of Abbreviations Used: Links: Disclaimer: Common Lab Values: Abbreviations: Written by Carl G. Weber MD, Internal Medicine. Any feedback is appreciated: CGWEBER@POL.NET. Remember, paying the nominal download fee contributes to the ongoing improvement of this text and entitles you to free email upgrades for 1 year. Purchase at PalmGear.com, look under clinical. If you have any pearls, illustrations or knowledge that you wish to add send it to me. If it is good, I will add it and send the update back to you as soon as possible and subsequently include it in further updates. If it is a significant contribution, I will prolong your update period (possible indefinitely). Lets make this book our own, we can save trees and the weight of carrying books around. Please include any citations as evidence-based medicine is our ultimate goal. Preamble to Book: Thank you for supporting the production of this text. It is called shareware, not because you can share it freely with other, but in order to simplify the transmittal of my frequent email updates to those who purchase it. I hope you find it useful. This text is designed as a quick and yet extensive reference for the diagnosis and treatment of the majority of problems that may present in a primary care physicians practice. It is intended to aid providers in their pursuit of optimal patient care. This book provides concise, quick information that can be used during a busy clinical day with the goal of efficient work-ups, accurate diagnosis, and effective treatment that hopefully leads to well-informed, healthy patients, healthy families and a satisfied physician. The information in this guide (the ultimate peripheral brain) has been culled from peer-reviewed articles and manuscripts, key textbooks and review courses published within the last few years.The goal is for these texts is to have 95% of clinical info you need at your fingertips. If you have any pearls, illustrations or knowledge that you wish to add send it to me. If it is good, I will add it and send the update back to you as soon as possible and subsequently include it in further updates. If it is a major contribution, I can prolong your update period. Lets make this book our own, we can save trees and the weight of carrying books around. Purpose of Book: I believe this is the first electronic textbook available that adequately summarizes medical information in a concise and easy to read format. This book is directed at

practicing clinicians. It is also useful to residents and medical students doing clinical rotations. It includes differential diagnosis, basic pathophysiology, clinical pearls, physical diagnostic findings as well as evaluations and treatments of a multitude of medical conditions. This book will allow primary care physicians to interface with the specialist, and assist in deciding when referral is necessary. Book Disclaimer: Medicine is a constantly changing science with a continuing better understanding of disease processes and newer and diagnostic and treatment modalities emerging almost every day. The authors, editors, and publisher of this text have given their best efforts to provide accurate, up-to-date, information that is considered to be within current medical standards. The approaches to medical problems are referenced with supporting studies, and further reading is encouraged. Human error is always possible and the authors, editors, and publisher of this text do not warrant the information as being absolutely complete, nor are they responsible for omissions or errors in the text or for the results of using this information. This book should not take the place of your own clinical judgment or the advice of specialists. We have tried with great fervor to limit errors, misinformation, and copyright infringement in the text. We would greatly appreciate feedback regarding any problems you discover while perusing these pages. Other Available titles: 23 Titles: Clinical Endocrinology, Neurology, Orthopedics, Nephrology, Dermatology, Gastroenterology, ENT, Psychiatry, Urology, Infectious Disease, Womens Health, Hematology/ Oncology, Geriatrics-Death & Dying, Rheumatology, Pulmonology, Allergy, Pediatrics, Pain Management, Ethics-Alternative Medicine-Evidence Based Medicine-Communication (Compendium), Cardiology, Ophthalmology and the Clinical Medicine Consult (includes all 23 titles). The goal is for these texts is to have 95% of clinical info you need at your fingertips. Common Laboratory Values: Chem 7 = basic metabolic panel, 17 = comprehensive, which includes electrolytes, renal and liver function tests. New Medicare Labs: **Electrolyte Panel (#4): Na, K, Cl, CO2. **BMP: #8: Chem 7 with Ca. **Renal Panel: #10 BMP + Alb & PO4. **CMP #14: BMP + Alb, AP, AST, ALT, Tb, Dbili. **ECMP #17: CMP +Mg, P, LDH. **Hepatic: Alb, Tbili, Dbili, AP, Tp, ALT, AST. Acid Phosphatase: 0-5.5 U/L, Albumin (Alb): 3.5-5.5 g/dL Alk Phosphatase (AP): 30-120 U/L Aminotransferases: AST (SGOT): 0-35 U/L, ALT (SGPT): 0-35 U/L Ammonia: 80-110 mcg/dL Amylase: 60-80 U/L Lipase: 49-220 U/L Bilirubin Direct: 0.1-0.3 mg/dL, Indirect: 0.2-0.7 mg/dL Calcium: 8.6-10.5 mg/dL CO2: 22-30 mEq/L

Chloride (Cl): 98-106 mEq/L Cholesterol Total: <200 mg/dL, HDL: 30-90 mg/dL, LDL: 50-160 mg/dL CPK: 25-145 U/L Creatinine (Cr): 0.4-1.5 mg/dL Ferritin: 15-200 ng/mL Glucose (blood sugar = BS): 70-140 mg/dL Iron (Fe): 80-180 mcg/dL, Iron Binding: 250-450 mcg/dL, Iron Saturation: 20-45 LDH: 25-100 U/L Magnesium (Mg): 1.6-2.6 mg/dL Osmolality: 285-295 Phosphorus (P): 2.5-4.5 mg/dL Protein: 5.5-8.0 mEq/L Sodium (Na): 136-145 mEq/L Triglycerides (Trig): <60 mg/dL Uric Acid: Males: 2.5-8.0 mg/dL, Females: 1.5-6.0 mg/dL Renal Labs: Cr Clearance (CC): Males: 125 mL/min, Females: 105 mL/min Ur Creat (UCr): 1.0-1.6 g/d, Ur Protein: <0.15 g/d, Ur K: 25-100 meg/d, Ur Na: 100-260 meg/d. Commonly Used Abbreviations: Links: E: J: N: S: 1/2 NS = 0.45% saline solution 5-HIAA = 5-hydroxyindoleacetic acid 5-HT = serotonin 17-OHCS = 17-hydroxcorticosteroids AAA = apply to affected area, abd aortic aneurysm ac = ante cibum (before meals)

ABG = arterial blood gas Ab = antibody ABI = ankle brachial index (in PVD) Abx = antibiotics ac = before meals ACD = anemia of chronic dz ACT = activated clotting time ACTH = adrenocorticotropic hormone Ad = R ear (aurio dextra) ad lib = as needed or desired AD = autosomal dominant ADH = antidiuretic hormone ADL = activities of daily living AF = atrial fibrillation AFB = acid fast bacillus AK = actinic keratosis AP = alkaline phosphatase AR autosomal recessive ALL = acute lymphocytic leukemia ALT = alanine amino-transferase am = morning AMA = against medical advice AMI = acute myocardial infarction AML = acute myelogenous leukemia amp = ampule

AMV = assisted mandatory (mode) ventilation ANA = antinuclear antibody ante = before AP = anteroposterior, alk phos AR = autosomal recessive ARB = angiotensin receptor blocker ARDS = adult respiratory distress syndrome ARF = acute renal failure ASA = acetylsalicylic acid, aspirin ASO = antistreptolysin AST = aspartate amino-transferase AVB = atriovenous block AVM = atrial venous malformation AVN = avascular necrosis BAL = blood alcohol level BBB = bundle branch block BCC = basal cell carcinoma BID = bis in die (twice a day) B12 = vitamin B-12 BM = bowel movement, bone marrow BMD = bone mineral density BMR = basal metabolic rate BMT = bone marrow transplant BP = blood pressure

BPH = benign prostatic hypertrophy BS = bowel sounds BUN = blood urea nitrogen BSA = body surface area Bx = biopsy CA = cancer Cal = calorie (kilocalorie) c/o = complaint of c cum (with) C/ S or C & S = culture and sensitivity C = centigrade Ca = calcium CAD = coronary artery disease cap = capsule CBC = complete blood count CBZ = carbamezapine cc = cubic centimeter, creatinine clearance CCB = calcium channel blocker CCU = coronary care unit CF = cystic fibrosis CFU = colony forming units Chem 7 = basic metabolic panel, 17 = comprehensive, which includes electrolytes, renal and liver function tests. New Medicare Labs: **Electrolyte Panel (#4): Na, K, Cl, CO2. **BMP: #8: Chem 7 with Ca. **Renal Panel: #10 BMP + Alb & PO4. **CMP #14: BMP + Alb, AP, AST, ALT, Tb, Dbili. **ECMP #17: CMP +Mg, P, LDH. **Hepatic: Alb, Tbili, Dbili, AP, Tp, ALT, AST.

cm = centimeter CMV = cytomegalovirus CNS = central nervous system CO2 = carbon dioxide COPD = chronic obstr pulm dz CP = chest pain CPK-MB = myocardial-specific CPK Cr = creatinine CrCl = creatinine clearance CRF = chronic renal failure CSF = cerebrospinal fluid CT = computerized tomography CTA = cotton tip applicator CTD = connective tissue disease CTX = contraction CV = cardiovascular CVA = cerebrovascular accident, costovertebral angle CVD = cardiovascular disease. CVP = central venous pressure Cx = culture CXR = chest x-ray DA = dopamine d/c = discharge or discontinue D5W = 5% dextrose water solution DBP = diastolic blood pressure

DIC = dissemin. Intravasc. coagulation Diff = differential cell count DHP = dihydropteridine DJD = degenerative joint disease DKA = diabetic ketoacidosis dL = deciliter DM = diabetes mellitus DNR = do not resuscitate DOC = drug of choice DOE = dyspnea on exertion DOT = directly observed therapy Doxy = doxycycline DTs = delirium tremens DTR = deep tendon reflex DVT = deep vein thrombosis Dx = diagnosis Ddx = differential diagnosis DUB = dysfunctional uterine bleeding Dz = disease EBV = Epstein Barr virus ECG = electrocardiogram = EKG ECT = electroconvulsive therapy EDC = estimated date of confinement (due date) EE = ethinyl estradiol

EEG = electroencephalogram EGA = estimated gestational age ELISA = enzyme-linked immunoabsorbant assay EM = erythema multiforme EMB = endometrial biopsy Emyc = erythromycin EPO = erythropoietin EPS = extra pyramidal symptoms ERCP = endoscopic retrograde cholangiopancreatography ERT = estrogen replacement therapy ESR = erythrocyte sedimentation rate ET = endotracheal tube ETD = eustachian tube dysfunction ETOH = alcohol Fb = foreign body FBS = fasting blood sugar F/C = fever and chills FEV1 = forced expiratory volume (1 sec) FHT/ FHR = fetal heart tones/ rate FiO2 = fractional inspired oxygen FOB = fecal occult blood FSP = fibrin split product FVC = functional vital capacity Fx = fracture G = gram(s)

GC = gonococcal; gonococcus GBS = GBBHS = Group B Beta Hem Strep GFR = glomerular filtration rate GH = growth hormone GI = gastrointestinal gm = gram GN = glomerular nephritis gt = drop gtt = drops GU = genitourinary h or hr = hour H20 = water HA = headache Hb = hemoglobin concentration HCO3 = bicarbonate HCG = human chorionic gonadotropin HCT hematocrit HCTZ = hydrochlorothiazide or hydrocortisone HCW = Health Care Worker HDL = high-density lipoprotein HF = heart failure Hg = mercury HI = homicidal ideation HIV = human immunodeficiency virus

hr = hour HOCM = HCM = hypertrophic cardiomyopathy HR = heart rate HRT = hormone replacement therapy HS = hora somni (bedtime) HSM = hepato-splenomegaly HSP = Henoch-Schonlein purpura HTN = hypertension HUS = hemolytic uremic syndrome Hx = history ICP = intracranial pressure IBD = inflammatory bowel disease IBS = irritable bowel syndrome ICP = intracranial pressure IDA = iron deficiency anemia ILD = interstitial lung disease IM = intramuscular I & D = incision and drainage I & O =intake and output IOP = intraocular pressure IU = international units ICU = intensive care unit IgM = immunoglobulin M IMV = intermittent mandatory ventilation INH = isoniazid

INI = if not improved, RTC. INR = International normalized ratio IV = intravenous or intravenously IVD = intravenous drug IVF = intravenous fluids, in-vitro fertilization IVP = intravenous pyelogram, intravenous piggyback JRA = juvenile rheumatoid arthritis K = potassium kcal = kilocalorie KCL = potassium chloride KOH = potassium hydroxide KUB = x-ray of abdomen L = liter LBBB = left bundle branch block LPB = lower back pain LDH = lactate dehydrogenase LDL = low-density lipoprotein LE = lower extremity LFT = liver function tests liq = liquid LLSB = left lower sternal border LLQ = left lower quadrant LMN = lower motor neuron LMP = last menstrual period

LN2 = liquid nitrogen LOC = loss of consciosness LP = lumbar puncture, LR = lactated Ringer's LV = left ventricle LVH = left ventricular hypertrophy mEq = milliequivalent MD = muscular dystrophy Mg = magnesium, milligram, myasthenia gravis MgSO4 = Magnesium Sulfate MI = myocardial infarction MIC = minimum inhibitory concentration mL = milliliter mm = millimeter, multiple myeloma MOM = Milk of Magnesia MR = mitral regurg MRI = magnetic resonance imaging MS = mitral stenosis, multiple sclerosis, mental status, morphine sulfate MSE = mental status exam MTX = methotrexate MVP mitral valve prolapse Na = sodium NaHCO3 = sodium bicarbonate NE = norepinephrine Neuro = neurologic

NCV = nerve conduction velocity NGT = nasogastric tube NKA = no known allergies NM(J) = neuro muscular (junction) NMT = no more than (maximum dose) NLT = no less than (minimum age to use drug) NPH = neutral protamine, normal pressure hydrocephalus NPO = nulla per os (nothing by mouth) NS = normal saline solution (0.9%) NSAIDs = nonsteroidal anti-inflammatory drugs NTG = nitroglycerine N/V/D = nausea, vomiting, diarrhea NWB = non-weight bearing. OCD = obsessive compulsive disorder OCP = oral contraceptive pill OD = right eye, overdose, optometrist oint = ointment OS = left eye (oculus sinister) Osm = osmolality OT = occupational therapy OTC = over the counter OU = each eye oz = ounce p = post after, Phosphate

pc = post cibum (after meals) PA = posteroanterior, pulmonary artery PAC = premature atrial contraction PaO2 = arterial oxygen pressure pAO2 = partial pressure of oxygen pc = after meals PCA = patient controlled anesthesia PCN = penicillin pCO2 = partial pressure of carbon dioxide PE = pulmonary embolism, physical exam PEEP positive end-expiratory pressure per = by PFS = patella-femoral syndrome PFT = pulmonary function test PG or PGE = prostaglandin pH = hydrogen ion concentration (H+) PID = pelvic inflammatory disease pm = afternoon PND = paroxysmal nocturnal dyspnea PO = orally, per os pO2 = partial pressure of oxygen Post cib = after meals (post cibos) polys = polymorphonuclear leukocytes PP = pathophysiology PPD = purified protein derivative

PPI = proton pump inhibitor PR = per rectum prn = pro re nata (as needed) PT = physical therapy, pro-thrombin time PTCA = percutaneous transluminal coronary angioplasty PTT = partial thromboplastin time PV or Px = prevention PUD = peptic ulcer disease PVC = premature ventricular contraction PVD = peripheral vascular disease q = (every) q6h, q2h every 6 hours, every 2h QID = quarter in die (four times a day) qAM = every morning qd = quaque die (every day) qh = every hour qHS = every night before bedtime QID = 4 times a day Ql = as much as desired (quantum libet) QOD = every other day qs = quantity sufficient qt = quart R = right RAD = right axis deviation RAE = right atrial enlargement

R/O = rule out RA = rheumatoid arthritis, room air, right atrial RAST = radioallergosorbent test RF = rheumatic fever RMSF = rocky mountain spotted fever RPR = syphilis test RR = Respiratory rate ROM = range of motion RSD = reflex sympathetic dystrophy RTA = renal tubular acidosis RTC = return to clinic (pt to come back) RV = right ventricle, residual volume s = sine (without) s/p = status post sat = saturated SBE: subacute bacterial endocarditis SBP = systolic blood pressure SC = subcutaneously SE = side effect SED = SE discussed (chart if start a new med), ESR SES = socioeconomic status SI = suicidal ideation SIADH = syndrome of inappropriate antidiuretic hormone SJS = Stevens Johnson syndrome SK = seborrheic keratosis

SL = sublingually under tongue SLE = systemic lupus erythematosus, slit lamp exam SMA-7, 10, 17 = sequential multiple analysis SMX = sulfamethoxazole SOB = shortness of breath = DOE sol = solution SPEP = serum protein electrophoresis SQ = under the skin SR = sustained release S(S)RI = selective serotonin reuptake inhibitor S/s = signs and symptoms of disease SSC = squamous cell carcinoma STAT = statim (immediately) STD = sexually transmitted disease susp = suspension T- = half life (of a drug) TCN = tetracycline TID = ter in die (three times a day) T4 = Thyroxine level tab = tablet TB = tuberculosis Tbsp = tablespoon TCA = tricyclic antidepressant Temp = temperature

TIA = transient ischemic attack TKO = to keep open, an infusion rate (~500 mL/24h) just enough to keep the IV from clotting TL = toxic level TMJ = temporomandibular joint TMP = trimethoprim TMP-SMX = trimethoprim-sulfa-methoxazole TPA = tissue plasminogen activator TS/ TR = tricuspid stenosis/ regurge TSH thyroid-stimulating hormone tsp = teaspoon TPN = total parenteral nutrition TSS = toxic shock syndrome TT = thrombin time TTP = tender to palpation Tx = treatment U = units UA = uric acid U/A or Ua = urinalysis UC = ulcerative colitis UD = as directed UDS = urine drug screen (tox) ug = microgram UFH = unfractionated heparin ULN = upper limits of normal

um = micrometer UO = urine output URI = upper respiratory infection UPEP = urine protein electrophoresis U/S = ultrasound UTI = urinary tract infection UV = ultraviolet light V = vitamin, V-C, V-E, V-B6 etc VAC vincristine, adriamycin, and cyclophosphamide vag = vaginal VC = vital capacity VDRL = Venereal Disease Research Laboratory V fib = ventricular fibrillation VGE = viral gastroenteritis VLDL = very low-density lipoprotein Vol = volume VS = vital signs VSD = ventricular septal defect VT = ventricular tachycardia WBC = white blood count X = times Zn = zinc