NR 601 wk 6 Genitourinary problems Summary Notes Rated A+

NR 601 wk 6 Genitourinary problems Summary Notes Rated A+ NR 601 wk 6 Genitourinary problems Genitourinary problems Dysuria Subjective experience of pain or burning on urination Hematuria - Blood in urine; more than 3 RBC=> direct relationship to quantity of blood and the probability of pathology - Two types (Transient: sometimes, Persistent: more often) - Differentials: trauma, cancer, coffee, chocoholic, alcohol, citrus, antibiotics, anticoagulation, - glomerulonephritis, urolithiasis, menses - Pathophysiology-depends on the cause Diagnostic tests - UA: Blood - Urine culture with sensitivities - Microscopic urine exam: if more than 3 RBC <3- explore hemoglobinuria >3- test for cause ANA, immunoglobulins, CMP Causes are varying Proteinuria - renal pathology, most often glomerular in origin - Due to illness, stress, exercise or benign - Can develop from overproduction of filterable plasma proteins, may be associated with multiple myeloma - If continues associated with pathology - Best test for this is 24 hour urine; >165mg is abnormal, 3.5 grams is nephrotic disease Differentials Benign or functional causes: orthostatic proteninuria, Bence jones protein-> multiple myeloma Diagnostic tests - 24 hr urine; measure protein and Cr (if excretion rate> 3-3.5g/d, pt has nephrotic syndrome) - Full Chemistry panel-FBS - LIPID PROFILE - Un/uc with ID and sensitivity - CBC WITH DIFF - Test specifically for Bence Jones. It characterizes the free monoclonal light chain of protein. And again, if this test is positive, we're thinking multiple myeloma. And it's only used for low-risk patients-- nondiabetic, not pregnant. And if this test is positive, do with serum protein electrophoresis. Management - With positive nephrotic syndrome per 24-hour urine, refer your patient to a nephrologist. - With 2 grams of protein in 24-hour urine, test renal function.  With normal renal function, test urine on awakening before upright for 1 minute and after standing for 2 hours. - If the first test is normal, and the second shows protein, refer. - With abnormal renal function, refer for biopsy. - It may be managed with an ACE inhibitor, by nephrology, and primary care. But I think you're going to want to pull the nephrologist in, with any of this complicated management. With coexisting, existing hypertension and hyperlipidemia, aggressive treatment is warranted for all conditions to prevent renal failure. urinary incontinence. The definition is the involuntary loss of urine from the bladder. It's so common in women that many consider it normal and then common in older men with enlarging prostates. And it certainly can affect quality of life and especially in our older adult patient. So the significance of urinary incontinence is that it's one of the most common complaints among older adults in the U.S. It may cause distress and embarrassment. There's a big market for those adult pullups and pads, et cetera. And it may cause a cost burden to individuals and society as a whole. My patients tell me all the time how expensive it is to continue to buy those pads, but they just won't live without them. They're afraid to go out without them. And although it's not life threatening, it may impact one's quality of life greatly. And the primary care providers are essential to educating patients about urinary incontinence. The epidemiology of urinary incontinence, it increases in prevalence as both men and women age. The prevalence is half that of women in all ages. However, it also increases in aging men. The prevalence of UI in the nursing-home population ranges from greater than 40% to over 70% and is often a factor in the decision for nursing-home placement. And the prevalence of urgency UI is greater in men, and the prevalence of stress UI is greater in women. So some terminology is common in both genders. The terms below describe lower urinary tract symptoms. urinary incontinence, which is the unintentional voiding, loss, or leakage of urine, continuous incontinence continuous loss of urine or leakage of urine. There's no control over the bladder. increased daytime urinary frequency, this urination occurs more frequently during the day than what would be considered normal. nocturia is the interruption of sleep one or more times due to the need to urinate. And this increases in frequency after age 50. urgency, that's the sudden compelling desire to pass urine that's difficult to prevent-- like got to go, got to go kind of thing. overactive bladder syndrome, this is urgency, frequency nocturia, with or without incontinence. And with the older adult patient, you're going to be commonly being exposed to these types of situations. risk factors for urinary incontinence-- aging is the top factor. Obesity, smoking and caffeine intake, uncontrolled diabetes, constipation, and use of diuretics risk factors for UI by gender. Women-- aging, obesity, smoking, caffeine intake, diabetes. And if you note under men, those are also the risk factors as well, but then there are some risk factors gender specific following diabetes. For women, it's pregnancy, multiparity, estrogen deficiency, history of pelvic surgery, and diuretics. Men- prostate disease, history of prostate surgery, history of UTIs, and diuretics. Physical changes with aging that contribute to urinary incontinence in both men and women. Well, the primary changes that occur is to the lower urinary tract. There is detrusor muscle overactivity. There's a decrease in detrusor contractility. There's increase in postvoid residual, and a decrease in urethral blood flow. Women can experience a decreased urethral closure pressure as well. The low estrogen following menopause may lead to atrophy of urethral mucosal epithelium and an increase in your urethral sensation. Men can experience a construction of the urethra due to benign prostatic hypertrophy, BPH, which may result in bladder outlet obstructing symptoms. Here's a nice table that depicts the types of incontinence, and their definition, and cause and pathology. And so functional environmental incontinence, definition is the incontinence results when the person is unable to get to the toilet or use the bedpan. And this occurs frequently in impaired mobility and also patients who have dementia. Urge incontinence, definition is involuntary leakage preceded by sudden need to void. So this is due to detrusor overactivity, and that exact mechanism is not exactly known. And then stress incontinence, definition is involuntary leakage of urine during increased abdominal pressure and the absence of a detrusor contraction. Cause of that is urethra hypermobility caused by weakness in the pelvic floor muscle, pelvic fascia, and pubourethral ligaments and intrinsic sphincter deficiency, caused by the pudendal nerve damage and damage to the intrinsic and extrinsic urethral sphincter. So basically, weakening over all those area. Mixed incontinence, involuntary leakage of urine with activity or exertion and preceded by a sudden need to void. And that's a combination of detrusor overactivity, urethral hypermobility due to weakness in the pelvic floor, or nerve damage. So your initial clinical workup for urinary incontinence in men, the initial workup includes a complete past medical history review, physical exam, and urinalysis. The physical exam includes a digital rectal exam for the male and an evaluation of the prostate. And then a PSA is also suggested with new onset of UI in men. Now, the initial workup in women for a urinary incontinence, the initial workup is to exclude any underlying causes for the lower urinary tract dysfunction and to confirm the diagnosis of urinary [INAUDIBLE] UI. Essential elements of a workup include a complete history review, complete physical exam, and a urinalysis. And then the physical exam includes a pelvic exam, as a perineal and vaginal exam are needed to identify the estrogen status of the patient and for any pelvic prolapse or fistula. A cough test may be performed to assess the integrity of the pelvic musculature and for any leaking of urine. The woman needs to have a full bladder, and is in place in a standing position, and then asked to cough to increase pressure. If urine leakage is observed, then stress incontinence is confirmed. Here are some specific red flags in males. Since the prevalence of incontinence is lower in men than women, maintain a higher level of suspicion for other diseases causing a urinary incontinence in men. So we've got to put on a different hat when we're thinking about a male. Men need a referral to urology if there is a history of previous pelvic surgery or pelvic radiation, pelvic pain, severe incontinence, severe lower urinary tract symptoms, recurrent urologic infections, abnormal prostate on exam, or an elevated PSA level. So be alert to the following symptoms with new onset and a underlying new onset-- urinary incontinence, hematuria, pelvic pain, abdominal mass, dysuria, proteinuria, glucosuria, CVA tenderness, nodular prostate, and any neurological symptoms. Goals of treatment for urinary incontinence, the treatment goals should be individualized and are similar for men and women. So goals to consider, we want to reduce the symptoms of urgency, frequently, and/or nocturia and reduce the number of incontinence episodes. We want to improve quality of life, increase their social activities, reduce linkage volume, increase dryness, and use less protection-- such as pads-- avoid leakage during certain activities, increase independence in incontinence management, and decrease caregiver burden. Urinary incontinence and OAB treatment So first-line management guidelines, take a look at the AHRQ 2014 guidelines for the management of urinary incontinence in women. It emphasizes behavioral therapy and lifestyle modification. Behavioral therapy, lifestyle modifications, including bladder training and prompted voiding, these have been shown to produce symptoms of stress, urge, and mixed incontinence and can be recommended as a noninvasive treatment in most women. Attempted first-line treatment includes attempted first-line treatment options for 3 months before considering pharmacological management. So that's a great rule of thumb here. So again take a look at those guidelines.And then first-line management strategies-- lifestyle changes, behavioral management, weight loss, decreases stress UI. Smoking cessation, tobacco is a bladder irritant, and there is less coughing with smoking, which equals less stress continence. 15:56 stop smoking. Dietary changes, eliminate bladder irritants like alcohol, sodas, coffee with or without caffeine, acidic foods, and spicy food. And then maintain adequate fluid balance in order to reduce constipation and to provide adequate flow to the kidneys. Some behavioral strategies-- bladder training, bladder control strategies, timed voiding, Kegel exercises, and pelvic floor training. All of the options could be recommended to your patient. OK, so first-line management was the lifestyle modification and behavioral modification. second-line management for urinary incontinence and overactive bladder OAB is medication. So your antimuscarinic medication, these are the first pharmacological agents to be used with women. In general, the response to pharmacologic treatment is unpredictable, and side effects are common. Antimuscarinic drugs block the parasympathetic muscarinic receptors and exert their effects on urinary incontinence and overactive bladder through the M2 and M3 receptors by inhibiting involuntary detrusor contraction. The effects on these and other muscarinic receptors are responsible for the side effects associated with these agents. The most common side effect of anticholinergic therapy is dry mouth. Others include blurred vision, constipation, nausea, dizziness, and headache. The mechanism of action for the antimuscarinics, it blocks acetylcholine at the muscarinic receptors, relaxes bladder smooth muscle, and inhibits involuntary detrusor some muscle contraction. And these are CYP3A4 substrate. Indications of these medication for urgent continence and overactive bladder. Contraindicated in untreated or uncontrolled narrow-angle glaucoma, gastric retention, or urinary retention. Precaution, a CNS depression can occur. So use with caution in elderly individuals. Renal dosing is required. Creatinine clearance less than 30 milliliters with trospium, tolterodine, and solifenacin. Your beta-3 adrenergic agonists, mirabegron or myrbetriq, which everybody's probably heard of. In addition to the antimuscarinics, myrabegron is also approved for the treatment of UI and OAB. It's been shown in clinical trials to have significant reductions in incontinence and micturations, compared with placebo without anticholinergic side effects. So that's a good thing. The mechanism of action for this is selectively stimulates beta-3 adrenergic receptor, which relaxes the bladder smooth muscle. It's contraindicated and cautions in hypertension. Do not use if the systolic blood pressure is greater than 180, or the diastolic is greater than 100. Also avoid if there's severe renal or liver disease. The dose can be 25 to 50 PO daily. Creatinine clearance, less than 30. The maximum should be 25 milligrams a day. Second-line management of urinary incontinence in males, your alpha-1 blockers. Pharmacological agents for men with urinary incontinence differ from women. So that's a piece of information that you need to tuck away when you are working with your preceptor, and you're trying to manage your patients with urinary incontinence. So is it a male or female, and then revert to these kinds of guidelines. So your alpha-1 antagonize peripheral alpha-1 adrenergic receptors and commonly referred to as alpha-1 blockers. Lifestyle changes and behavioral management are again our first line, but when those are not effective, that's when you initiate your alpha-1 blockers. This difference in choice of medication for men is due to the high incidence of benign prostatic hypertrophy associated in aging men. So your alpha-1 adrenergic receptor antagonists, alpha-1A, when that antagonized, you get prostatic smooth muscle relaxation. Alpha-1B, vascular smooth muscle contraction. And then alpha-1D, bladder muscle contraction sacral spinal cord innervation. Adrenergic, again, going on, here's a list of those. So your doxazosin with the dosing thing and side effects as dizziness, dyspnea, edema, fatigue, and somnolence. Terazosin, there's your dosing again. Asthenia, side effects, dizziness, postural hypotension. Tampsulosin, there's your dosing. Abnormal ejaculation is a side effect, as well as asthenia, back pain, dizziness, increased cough. Alfuzosin, 10 milligrams per day. And there's a mention of creatinine clearance there. If it's less than 30, use with caution. Side effects is dizziness, upper respiratory tract infection. And then the silodosin, 8 milligram PO Q day, give with food, and retrograde ejaculation is a side effect. So with these, you can understand why some people would be noncompliant with the medication or not take it regularly, due to the side effects. All right, we're shifting gears over to interstitial cystitis. The definition is a chronic bladder inflammation syndrome, characterized by pelvic pain and irritative voiding symptoms. The pathology is unknown. It's related to an autoimmune, allergic, or infection etiology. And it really is a diagnosis of exclusion. It occurs mostly in women. 10% may be men. Onset between ages 30 to 70 years of age. And it does occur in children and is underdiagnosed. Symptoms is pain really by voiding small amounts, uncomfortable constant urge to void. It may worsen the week before menstruation. Differential diagnosis include a urinary tract infection, prostatitis, cystitis. Or it could be a GYN condition, such as vaginitis and endometriosis, or neuropathic bladder dysfunction, neoplasm, or an overactive bladder. Diagnostic tests, a UA urine culture and maybe potassium sensitivity test, a slow installation of 40 milliliters of sterile water into the bladder. The patient grades the pain from 0 to 5. This is the baseline. And then empty the bladder and repeat with the potassium chloride solution. Interstitial cystitis is suggested when there is a 2-point increase in pain or urgency after that. And then cystoscopy and hydrodistention under anesthesia confirms the diagnosis. So for a plan for interstitial cystitis, education. It's not a malignancy, and it does have an organic basis. There's no specific cure. It's chronic. Basically, we'll just treat the symptoms. We'll avoid acidic food, caffeine, alcohol, artificial sweeteners, chocolate, cigarettes, and drink plenty of water, and then do some bladder retraining, and that may help. Medication treatment for interstitial cystitis is tricyclic antidepressant, anti-histamine, nonsteroidal drugs, pyridium, ditropan, procardia may help. And then they require some long-standing opioids. So you can refer for further treatment to a urologist. urinary tract infection, the definition is inflammation and infection of the urinary bladder. Their urethra may be involved. Etiology and incidence, the most common causative organisms are E. coli in women and proteus species in men. Contributing factors in women for developing a urinary tract infection is sexual intercourse, pregnancy, diabetes, a catheterization, instrumentation, retaining urine in bladder despite urge to go, constipation, diaphragm use, meatal stenosis, and bowel incontinence. Urinary tract infections FYI, oral antibiotic treatment cures 85% of uncomplicated urinary tract infection, although the rate of recurrence remains high. There is some debate over whether to treat young sexually active women with high bacterial count, but they're having no symptoms, which we call a asymptomatic bacteriuria. So given growing bacterial resistance to antibiotics-- this is why this is even coming up-- and the benign nature of this condition, many experts don't recommend routine treatment. This is a really good point to discuss with your preceptor. Talk to your preceptor about their thinking on this and would they treat under these circumstances. And then the most common antibiotics used for uncomplicated UTIs are either TMP-SMX or an antibiotic known as fluoroquinolone. Pregnant women should not take the fluoroquinolone. For uncomplicated UTIs, better options or in pregnancy may be sulfisoxazole or a cephalosporin. You're going to get lots of experience in clinical managing-- UTIs are something that you're commonly going to see, and so hopefully you're going to become very comfortable with the management of UTIs. So for duration of treatment, studies are now reporting that uncomplicated female UTIs can often be successfully diagnosed over the phone. So in such cases, the provider provides the patient with a 3-day day antibiotic regimen without even requiring a urine test. A single oral dose of antibiotics-- usually bactrim, cotrim, Septra, or fluoroquinolone-- is sometimes prescribed in mild cases, but cure rates are generally lower than the 3-day regimen. So longer term therapy, given 7 to 10 days, is now mostly limited to men, children, the elderly, people with diabetes with any UTI, and then women with pyelonephritis or who are pregnant. So after a week of antibiotic treatment, most patients are free of infection. If the symptoms do not clear up within the first few days of therapy, physician or providers generally suggest that women submit a urine sample for culturing in order to identify the specific organism that causes it. Treating relapsing UTIs, you'll sometimes have your patients come back in frequently-- that it didn't clear up. So a relapsing infection is caused by the same organism as the first episode. And it usually occurs within 3 weeks in about 10% of women. The relapse is treated similarly to a first infection, but the antibiotics are continued for at least 2 weeks. A relapsing infection may be due to structural abnormalities, abscesses, or other problems that might require surgery. And all these conditions should be ruled out, so you have to just go a little bit deeper with your investigation, if they're coming in with a relapsing UTI. So it is very prudent to discuss bacterial resistance to antibiotics. And that's a major concern for primary care providers, nurse practitioners, physicians, PAs, and the public. I mean, this is the emergence of strains of common bacteria, including E. coli that are resistant to specific antibiotics. And the prevalence of such bacteria has dramatically increased worldwide, in large part due to the widespread use of antibiotics in people and then animal feeds. They're feeling their animals' antibiotics. So this is something that you really have to have a conversation with your patient about. They feel like that they needed antibiotics, so they can get to feeling better, and going back to work, or to get their symptoms alleviated, but you'll run into that. And then I do urge you to talk with your preceptor about how to manage that, how they manage it in their practice, because it will be a great learning experience for you. So UTI preventive antibiotics, this is prophylaxis. This is an option for women who experience two or more symptomatic UTIs within 6 months or three or more over the course of a year. So a woman's own perception of discomfort should guide her decisions on whether to use preventive antibiotics or not. The increasing use of antibiotics for many common infections is causing concern, because again of the emerging strains of common bacteria that have become resistant to standard antibiotics. Let's shift and talk about antibiotics for urethritis in men. Urethritis in men has typically been treated with a 7-day regimen of doxycycline. Some research is showing that a small dose of azithromycin may be just as effective, while causing fewer side effects. A one-dose treatment also improves compliance, so cure rates may be even better than with a long-term regimen. But there is a concern, however, that it's an infection that spreads to the prostate gland, which is harder to treat. So most primary care providers still prefer the longer regimen. Again, learn as much as you can in clinical, and ask your preceptor how would they treat this. And it should be noted that azithromycin and similar antibiotics do not cure the infection. And they mask the symptoms of an accompanying sexually transmitted disease, such as gonorrhea. So tests for such diseases should be conducted if urethritis is diagnosed, because it's really not common for men to have these type of infections. So men always need to be cultured and treated for all STDs on the day of service, as well as for urethritis. UTI contributing factors in men, usually, they are the residual urine due to a prostatic enlargement. They have a naturopathic bladder. There's calculi, or they have prostatitis. They've had catheterization or some type of instrumentation. There are meatal stenosis. Signs and symptoms would be a dysuria, frequency, urgency, suprapubic discomfort, and fowl smelling urine. Differential diagnoses, whether male or female, vaginitis in females, prostatitis in males, gonorrhea, chlamydia, renal calculi, pyelonephritis, and epididymitis. UTI physical findings, the urinary meatus may be erythematous or edematous. Or there may be negative costovertebral angle tenderness, may be negative pelvic or prostate exam, and may have suprapubic tenderness on palpation. So diagnostic test and findings, pyuria may be seen. That's 10 white blood cells per high power. And then a complete urinalysis, clean catch with culture and sensitivity testing. Bacteria count over 100,000 organisms per milliliter in fresh, clean catch midstrength specimen is a reliable indicator of active urinary tract infection. Women with acute cystitis may have more than 10 to the third, but less than 10 to the fifth per milliliter in midstream urine cultures. You'll get used to this, interpreting those results and knowing how to treat. Dipstick results interpretation + Leukocyte esterase WBC cells in urine + nitrate gram-negative infection + protein, blood nitrates UTI So a CBC with diff, maybe a blood culture, SR, STD screen for all males and females when indicated. And then a male with UTI, a VCUG or IVP and a renal ultrasound. Treatments for UTIs, management treatment in uncomplicated female, this is basically a repeat of what was just said. So your single dose regimens of your Septra DS, or amoxicillin 3-day regimens, or you can go with the fluoroquinolones used in area with high resistant rates to sulfa drugs and so forth-- also used when a sulfa has been used in the last six months or used for women who were recently in the hospital. And then nitrofurantoin and monurol useful if resistance to others increases. And then treatment complicated female, it's based on culture results. So if it's a gram-negative organism, Septra DS 10 to 14 days or the fluoroquinolone for 14 days. Or gram-positive organism, it's best to culture the urine before and after treatments. And if it's a urinary recurrent UTI in females, culture before and after. Consider treating longer, up to 8 weeks. Test BUN creatinine, IVP, or VCUG, electrolytes. Explore causes. Look at their timely voiding. Advice to increase water and decrease carbonated drinks, and refer to a specialist. Just send them straight to a urologist. And then another disease process that's prevalent in men is acute bacterial prostatitis. Definition is the inflammation, infection of the prostate gland. The etiology, E. coli or other gram-negative bacteria, it's common.Occasionally, acute urinary retention develops, which requires suprapubic drainage. Usually, you're not going to use any cath in this situation. Absence of zinc and prostatic fluid can predispose the male to prostatitis. And then young men are more prone to nonbacterial. White blood cells are present in expressed prostatic secretions, but no organisms culture out. Causative agents include mycoplasma, gonorrhea, and chlamydia. Physical findings, there could be maybe a fever. Could be bladder distention is present on exam. Prostate is edematous. It could be firm or body, warm and tender. Avoid a vigorous massage, as it may lead to bacteremia when we release some of the bacteria into the bloodstream. Chronic bacterial prostatitis, this is an older adult, older male situation. It's the most uncommon type-- men 50 to 80 years. Symptoms are slow in onset and varying degrees of bladder obstruction, can be some dribbling, hesitancy, loss of stream form. Hematuria, hematospermia, or painful ejaculation may be prevalent there. The hallmark feature, though, is recurrent UTI, asymptomatic between episodes. And chronic nonbacterial prostatitis and chronic pelvic pain syndrome is the most common type of urinary condition for men. And men 30 to 50, symptoms are indistinguishable from a bacterial type II. In men with type IIIB, pelvic pain is the predominant complaint. Asymptomatic inflammatory prostatitis, diagnosed incidentally with the evaluation of other disorder-- basically by accident. Limited research on natural history and clinical presentation. There's just not a whole lot out there. But just FYI, all types can have dangerous sequelae and lead to urinary retention. Renal parenchymal infection, or bacteremia, chronic infection, and they produce prostatic stones. So with your prostatitis, there's several classifications. Type I is acute infection. Type II, chronic or recurrent. Type III, chronic genitourinary pain in absence of infection and uropathogenic bacteria in gland. Type IIIA, inflammatory WBCs in any secretion. Type IV, asymptomatic inflammatory, no subjective symptoms, diagnosis by biopsy or white blood cells in secretion. And you're probably not going to get down to that kind of level of diagnosis with the patient. If you're having to do all this, then it's probably best to send them to the urologist. Signs and symptoms, for men in the 40 to 60 year range, may have painful intercourse, fever, chills, malaise, myalgias, lower back pain, dysuria, urgency, nocturia, frequency, perineal pain with defecation. Abscess is a complication, and consider that possibility if they're responding to the treatment. Differential diagnoses for prostatitis, all of these here are listed. And so that's why I think it may be a good idea to send them on to a urologist. Again, speak with your preceptor, and see what they would do in this case. Diagnostic tests, findings, urine culture will be positive.Prostatic excretions expressed, prosthetic secretions on the white blood cell greater than 20 cells, that's abnormal. And diagnosis is best made by performing simultaneous quantitative cultures. And then of your urethral urine, bladder urine, in expressed secretions, the glass test. And the patients are often treated based only on physical exam and urine culture, rather than doing a lot of these tests. Management and treatment of prostatitis, if it's acute bacterial. With severe symptoms, they have to go in the hospital with the IV antibiotics aggressive, especially a very aggressive, if they have an abscess. With chronic bacterial prostatitis, 3- to 4-month bactrim BS, BID. Consider prophylactics. Evaluate prn for stones with X-ray, do cultures every 4 to 6 weeks, and then prostatic massage once or twice a week for 4 weeks may be helpful. Chronic nonbacterial, there's no effective treatments available. You can try meds like doxycycline, erythromycin, or bactrim. Reassure, counseling, nonsteroidal, ditropan, and some alpha-adrenergic blocking drugs. Asymptomatic inflammatory prostatitis, there's really limited research to guide the treatment in this area.You may try some antibiotics, education, just have them avoid the usual-- alcohol, coffee, or tea. Discontinue and avoid over-the-counter drugs with anticholinergic properties, such as cold meds. And recheck them 4 to 6 weeks later. And then there's epididymitis. You'll come across this. Diagnostic test and findings, men STD testing, urinalysis, do a culture of the urine, scrotal ultrasonography. In older men, search for obstruction at the bladder outlet. And then benign prostatic hyperplasia. The definition, this is a progressive benign hyperplasia of the prostate gland tissue. You're going to see this very frequently in working with your older adult male. Etiology and incidence, the causes is uncertain. About 50% of men will have BPH by age 60. By age 85, 90% will have BPH. So you're definitely going to be treating it, diagnosing, treating it. Most common cause, the bladder outlet obstruction in men over age 50. The symptoms are attributed to mechanical obstruction of the urethra by the enlarged prostate gland. Signs and symptoms, gradual worsening of the following. They'll have gradual worsening of frequency, urgency, urge incontinent. More nocturia, more dysuria, a weak urinary stream, dribbling, hesitancy, sensation of full bladder even after voiding, and then urinary retention. Here's a lot of differential diagnoses for the BPH. And depending on the situation or the male-- the severity of the symptoms-- again, you may be sending them to urology. Physical findings, abdomens may have distended bladder secondary to retention. The prostate could be nontender with asymmetrical or symmetrical enlargement. Growth enlargement is atypical. So you can have various enlargement there. Consistency is smooth and rubbery, like an eraser. Nodules may be present. So then in that case, differentiation from BPH and cancer, so you'd need a biopsy on that in that case. Tests and findings, UA-NO, no hematuria or UTI is found in the urine. The urinary flow rate, the voided volume, and peak urinary flow rate may detect an obstructed flow. There might be an abdominal ultrasound that rules out of upper tract pathology. PSA levels should be normal in BPH. Consider post void residual urine volume. Creatinine to assess renal function. Elevated levels suggest urinary retention or underlying renal disease.Definitely refer this patient. Treatment and management. Refer men who have the following-- refractory urinary retention who failed one attempt at cath removal, if it's a recurrent infection, recurrent retention, refractory hematuria, bladder stone, large bladder, diverticula, or a renal insufficiency related to BPH. And then consider referral if complications exist, or if patients have severe symptoms. For your management, for men who have no indications for surgery, discuss risk and benefits of all options. Sometimes it's just watchful waiting. You're observing the patient, and they're telling you how they're feeling. And then behavioral techniques to reduce the symptoms. Limit fluid after dinner. Avoid medications, such as anti-, antiparkinson agents, antipsychotic, antispasmodic, cold meds, and diuretics as much as possible. So your medication treatments is your alpha adrenergic blocker for smaller prostates and your 5-alpha adrenergic blocker for larger prostates. Combination therapy is an alpha adrenergic blocker. And finasteride is used now for men with large prostates. And surgery has the best chance for relief of symptoms, but has greater risk. So that's something that you discuss with your patient or their urologist. Discuss with the patient. Follow up. Teach signs and symptoms of retention and obstruction. If observing for now, recheck them every 6 to 12 months. Bring them back in for follow up. If they're on meds, recheck them in 4 to 6 weeks. Got to bring them back sooner in that case, and that makes sense. And if postsurgery, follow up is at the discretion of the urologist.Thank you. I know that this is chock full of information regarding men and women with genitourinary problems, but as we've gone through these and you've been in clinical-- this is your second course in clinical-- hopefully, some of this is familiar. And you've been able to work with your preceptor in diagnosing and managing a patient with a GU problem.And so I hope that this has been helpful. I hope that you can pull some of the concepts out of the presentation, and take the clinical, and be that proactive student that is seeking information, asking questions. How does your preceptor handle a certain situation? What antibiotic do they order? Or do they order an antibiotic? Get all the information that you can. So these are just some great tips on how you can maximize your learning at your clinical site. Please continue exploring, and you can feel free to ask questions in the weekly Q & A area. And continue to ask your instructor questions. And I do wish you well in your clinical and hope you see lots of patients that come in with these conditions. Thank you.