CEN GU

enuresis - loss of bladder control especially at night

children

teens

• HR increases 15-20 BPM
• increased total blood volume
• systolic BP decreases 0-15 & diastolic increases 10-20
• CO increases 30-50%

can mask hemorrhage

32-34% r/t dilutional anemia

can be normal up to 20,000

increased clotting factors and hypercoagulability

hypoxia r/t selective uterine vasoconstriction

• 1. upper airway engorgement
• 2. enlarging uterus elevates diaphragm and decreases lung capacity
• 3. RR and tidal volume increase
• 4. O2 consumption increases

pelvic veins engorged

progesterone relaxation of GI smooth muscle causes decreased gastric motility and emptying - can cause paralytic ileus

abd injuries may be masked

b/t T12 and L3

• 1. filter metabolic wastes and make urine\
• 2. regulate composition and volume of blood
• 3. balance acid/base
• 4. regulate BP:  aldosterone, ADH, and renin
• 5. activate Vitamin D

sperm and testosterone

semen

alkaline component of semen to neutralize vaginal secretions

stores sperm until it is mature

secretes alkline mucus that improves viability and motility of sperm

eggs, estrogen, and progesterone

low back, rectum, and perineum

vitmain B and some laxative

pyridium, rifampin

uric acid crystals

blue dye such as methylene blue

L-dopa or melanin secretion

copper or phenol poisoning

ingestion of lg amnt of rhubarb, blackberries, beets = dark brown/black

dark brown may be bilirubin

• rhabdo and myoblobinuria
• hyemoglobinuria

total number of pregnancies - include current pregnancy

number of pregnancies that have lasted at least 20 wks

primigravida

Nullipara

primipara

multipara

yellowish-grey:  renal failure

petechiae and bruising:  renal failure r/t platelet dysfunction

on either side of vertebral column b/t last rib and lumbar vertebrae

cyst may form and area becomes tender

infection

Rh neg women

knee-chest

110-160

detects fetal red cells in the maternal circulation

uti

circumcision

gram negative

may decrease intake to decrease need to urinate

• pyelonephritis
• sepsis, septic shock
• DVT, PE

• - take abx at night if possible so it stays in bladder longer
• - phenazopyridine:  orange/pink urine, may stain contacts/clothing, take after meals

upper UTI:  involves kidneys, tubules, glomeruli, and renal pelvis

• 1. infants, young sexually active women, older men with obstructive uropathy
• 2. GU abnormalites & neurogenic bladder
• 3. recurrent UTI
• 4. sex:  new partner, spermacidal use
• 5. DM
• 6. caths
• 7. pregnancy
• 8. stress incontinence
• 9. immunosuppression
• 10. GU obstruction
• 11. prostatic enlargement

reflux into one or both kidneys

abscess in kidney usually caused by staphylococcus aureus

scar tissue replaces infected/inflamed areas

major cause of renal failure and end-stage renal failure

may have decreased urination, bed wetting, irritability, and fatigue

irritability, cool skin, jaundice to gray skin, decrease in wet diapers, poor feeding

frequently will not have fevers

• 1. renal calculi
• 2. lower UTI
• 3. papillary necrosis
• 4. pernephric abscess
• 5. pretuerm labor in pregnant women

• - no improvement in 48-72 hrs may need eval for urinary obstruction or stone
• - fluid intake increase
• - foods/fluids to acidify urine:  meat, fish, eggs, cereals

• 1. previous calculi
• 2. gout or high-purine diet
• 3. Hx hypercalcemia
• 4. recent UTI
• 5. ingestion of increased minerals
• 6. dehydration
• 7. immobility
• 8. meds:  antacids, vit D, laxatives, high doses of asa
• 9. hyperparathyroidism
• 10. multiple myeloma

calcium, uric acid, struvite, and cystine

• hypercalcemia
• demineralization of bone:  immobility, bone malignancy

dehydration, gout, antineoplastic agents

interaction b/t protein breakdown products and infection causing bacteria in the urine

genetic disease called cystinuria

• >7 = struvite
• <5 = uric acid

helical CT

usually 1 L over 30-60min then reduce to 200-500mL/h

toradol

• 1. urethral obstruction:  BPH, urethral stricture
• 2. bladder neoplasm
• 3. neurogenic bleadder
• 4. meds:  anticholinergic or sympathomimetic (increase SNS and decrease PNS)
• 5. cauda equina syndrome:  compression of nerve root

urecholine - for urinary retention

500mL q3h to avoid micturition syncope

venous obstruction r/t distended urinary bladder

postrenal failure

• 1. age - neonate, 2/3 are 12-18
• 2. congenital abnormality
• 3. trauma
• 4. sex
• 5. undescended testicle
• 6. rapid mvmt
• 7. paraplegia
• 8. previous contralateral testicular torsion
• 9. more common in winter:  cold air associated with increased risk

• 1. severe, sudden unilateral scrotal pain and tenderness
• 2. NV
• 3. prior Hx of testicle pain that resolved on it's own
• 4. tachycardia
• 5. fever
• 6. scrotum erythematous and edematous
• 7. affected testis tender and elevated
• 8. absent cremasteric reflex

• - usually occurs with physical activity\
• - radiation to low abd/inguinal area
• - not relieved by elevation of testis

reduction in pain by manual elevation of testis - distinguish epididymitis from testicular torsion

stroking or pinching of medial thigh causes cremasteric muscle to contract causing testis to rise

r/o hydrocele

• -immediate urology consult
• - sedation or cord block
• - affected testis rotated laterally
• - confirmation of restored blood flow with ultrasound

4 hours

12 hours

• 1. age - men <40 usually STI
• 2. STI
• 3. UTI
• 4. prostatitis and urethritis
• 5. trauma:  surgical, caths, kick to groin

organism, usually Neisseria gonorrheae or Chlamydia trachomatis in young sexually active men

Enterobacteriaceae usually cause in older men with voiding dysfunction

• 1. slow or sudden onset
• 2. dysuria
• 3. scrotal pain- pos phren sign
• 4. fever/chills
• 5. tachycardia
• 6. duck waddle gait
• 7. urethral discharge
• 8. area swollen/tender
• 9. scrotal induration

• 1. elevation of scrotum
• 2. ice
• 3. bed rest X1-2 days
• 4. analgesics

inflammation of epididymis and testis - usually r/t infection

• 1. Recent GU instrumentation
• 2. STI
• 3. UTI
• 4. reflux of urine
• 5. mumps if bilateral orchitis

coomon causes:  staphylococcus, streptococcus, E. coli, streptococcus pneumoniae, psudomonas

• -can be made with Hx and s/s
• - serum immunofluorescence antibody testing

• 1. urethritis
• 2. hydrocele
• 3. abscess
• 4. hemospermia - blood in sperm
• 5. oligospermia - low sperm count
• 6. testicular atrophy and sterility

• 1. bed rest
• 2. meds
• 3. elevation of scrotum
• 4. ice on affected testis 10-15min qid until pain resolves
• 5. jock strap for support
• 6. follow up with urologist

inflammation of prostate gland

• 1. recent UTI
• 2. trauma
• 3. cath
• 4. cystoscopy
• 5. urethral dilation
• 6. TURP
• 7. transrectal biopsy
• 8. STI

• 1. low back, perineal, suprapubic, rectal, or ejaculatory pain - constant or intermittent
• 2. fever, chills, malaise
• 3. dysuria, frequency, urgency
• 4. urinary retention
• 5. hematuria
• 6. tender, warm, swollen prostate by rectal exam

PSA - prostate specific antigen

• stool softeners
• heat therapy
• suprapubic cath for severe retention
• control fever and pain

contraindicated - discomfort and potential for bacteremia

• doxy
• bactrim
• cipro

• 1. ABX X3-4 wks
• 2. analgesics
• 3. stool softeners
• 4. heat therapy
• 5. sitz bath
• 6. f/u with PCP

enlarged prostate gland

• 1. age:  50% of men at 60 and 90% at 85
• 2. diet high in fat and red meat
• 3. recent urinary stone or surgery
• 4. meds:  antihistamines, opioids, anticholinergics, TCA, muscle relaxers

increased estrogens and decreased testosterone with age

• 1. urinary frequency and urgency\
• 2. nocturia
• 3. dysuria
• 4. decreased force of stream
• 5. hesitancy initiating
• 6. intermittent stream, dribbling
• 7. low abd/suprpubic tenderness
• 8. enlarged or normal sized prostate
• 9. rubbery nodules on palpation
• 10. distended bladder

• sediment
• changes in urine pH r/t chronic residual urine

likely to be elevated with prostate cancer but normal level does not r/o cancer

• 1. cath
• 2. alpha 1 blockers:  terazosin/hytrin, tamsulosin/flomax, doxazosin/cardura
• 3. avoid anticholinergics, narcotics, and skeletal muscle relaxers
• 4. procedures:  TURP, TUMT

• 1. limit fluid intake in evening
• 2. avoid bladder irritants:  caffeine, alcohol
• 3. pelvic floor exercises to help with dribbling
• 4. NSAIDS daily may aid in prevention

erection lasting more than 4-6 hrs in absence of sexual stimulation

• 1. trauma
• 2. prolonged sex
• 3. hematologic & oncologic conditions:  sickle cell, leukemia
• 4. dehydration
• 5. meds:  prostaglandin E, phosphodiesterase inhibitors (for ED), psychotropic drugs:  phenothiazines, trazodone; antihypertensives, heparin
• 6. neurologic causes
• 7. tumors

obstructed/low-flow venous outflow

• often painless
• fistula b/t cavernosal artery and corporal tissue
• not associated with long-term erectile dysfunction

caused by clumping of erythrocytes leading to veno-occlusion in sinusoids of corpus cavernosum

short-lived and self-limiting

usually occurs at night

usually less than 3 hours

• 1. trauma, drug use, or hematologic probs
• 2. may be hypotensive r/t ED drugs
• 3. bladder distention
• 4. findings in low-flow priapism:  soft glans, painful penile shaft, aspirate is thick and dark
• 5. findings in high-flow priapism:  firm glans, spairate bright red

• low glucose:  low-flow priapism
• high glocose:  high-flow priapism

ice to penis

insert if need to maintain urinary flow

terbutaline/brethine

may inject sympathomimetics to constrict blood vessels for less flow in and more out

caused by ischemia -

• compartment syndrome
• ED

tightened foreskin of penis is unable to retract over glans

no sex until healing is complete

• 1. gender - usually in males
• 2. surgical trauma
• 3. childbirth
• 4. straddle injuries
• 5. pelvic fractures
• 6. intrumentation

urethral rupture

children

• 1. injury
• 2. pain especially with voiding
• 3. inability to void / bladder distention
• 4. hematuria
• 5. tachycardia
• 6. pallor
• 7. blood at meatus
• 8. butterfly-shaped hematoma of lower abd or perineum

hematocrit

suprapubic cath preferred

if foley cath - stop if any resistance and ask physician to insert

• 1. fistula
• 2. stricture
• 3. persistent urinary leakage
• 4. infection/sepsis

• 1. blunt/penetrating trauma - high incidence with vertebral and flank injuries
• 2. OB trauma
• 3. iatrogenic injury 2nd to surgical GYN, uroligic, and orthopedic procedures near bladder
• 4. spontaneous or idiopathic

peritonitis and sepsis

suprapubic preferred

• hypovolemic shock
• peritonitis, sepsis

back, chest, or abd

kidney

sits lower

11 or 12

• l kidney - spleen
• r kidney - liver

• 1. mechanism of injury
• 2. pain/tenderness:  CVA, renal colic
• 3. altered LOC
• 4. vomiting
• 5. oliguria, hematuria
• 6. abrasion/hematoma over posterior aspect of 11 or 12 rib
• 7. entrance/exit wound
• 8. abd and flank tenderness
• 9. palpated flank swelling/mass
• 10. abd distention or asymmetry
• 11. external genitalia ecchymosis

• 1. back pain
• 2. s/s of hemorrhage
• 3. Grey-Turner sign:  ecchymosis over flank

• 1. midline bulgin
• 2. lower quadrant, flank, or thigh distortion
• 3. low abd pain/mass
• 4. abd pain, rebound tenderness
• 5. hematuria
• 6. anuria

may be elevated

CT with IV contrast superior to IVP

• more common in young children
• sexual exploration and/or abuse

sexually active female especially with multiple partners

trauma

• pelvic exam
• urine pregnancy test to r/o ectopic pregnancy
• pelvic ultrasound

development of endometrial tissue outside the uterus

European American women of child-bearing age

genetic predisposition

endometrial tissue reacts to hormonal changes and sloughs off with menses

usually r/t mechanical blockage of fallopian tubes with endometrial implants

• 1. low back, intestinal, or pelvic pain
• 2. dysmenorrhea
• 3. dyspareunia
• 4. dysuria
• 5. heavy periods and bleeding b/t periods
• 6. tenderness with pelvic exam
• 7. may have other masses

hormone therapy to control growth

surgery to remove growths or control size

irregular menstruation without anatomic lesions of uterus

• 1. adolscents
• 2. oral contraceptives
• 3 thyroid, adrenal, or pituitary disease
• 4. adenosis
• 5. trauma or contact irritation (repeated intercourse)
• 6. endometriosis
• 7. polycystic ovary syndrome
• 8. intrauterine masses or functional cysts
• 9. liver disease
• 10 bleeding disorders
• 11. obesity
• 12. DM

carcinoma

• hormonal
• mechanical
• malignancies

• 1. prolonged/excessive bleeding
• 2. no PMS symptoms
• 3. painless bleeding
• 4. vulvar, vaginal, or cervical lesions

• 1. coagulation profile to detect bleeding disorder\
• 2. throid hormones
• 3. Beta hcg
• 4. ultrasound - ectopic pregnancy, miscarraige
• 5. LH-FSH ratio:  plycystic ovary syndrome
• 6. pap smear and colposcopy for malignancy

serum is quantitative and gives more accurate fetal development info

urine is qualitative

• pelvic exam
• possible surgery: D&C
• hormone replacement therapy

• 1. anemia
• \2. endometrial hyperplasia
• 3. endometrial carcinoma

3.8

trichamons

• candida- white
• trich - yellow-gray
• vaginosis - gray

trichomonas and vaginosis

normal

prepubertal and postmenapausal

vaginosis

candida

trichomonas

nitrazine paper

• blue - bacteria
• yellow - yeast

• PID
• sepsis

sharing needles, childbirth, breastfeeding

haemophilus ducreyi

• 1. ulceration on penis, anus, cervis, vag, vulva, or perineum - soft, dirtylooking, irregularly shaped ulcers with undefined margins, excavated depth, yellow to gray base
• 2. purulent hemorrhagic secretions
• 3. similar ulcers on opposing labia
• 4. progresses to painful inguinal adenopathy withing 3-14 days

antibiotics:  rocephin, azithromycin, cipro, - contraindicated in pregnancy and lactation

Tx of sexual partners

• 1. genital pain and discharge
• 2. may be asymptomatic
• 3. burning with urination
• 4. vaginal or penile discharge:  white, yellow, or green
• 5. swollen testicles
• 6. women may have mild/vague symptoms

syphilis and chlamydia

ABX:  rocephin, cefixim/suprax - fluoroquinolones no longer recommended r/t resistance

Tx partners

C. trachomatis

rectum, urethra, cervix, and throat

gohnorrhea

• 1. may be asymptomatic
• 2. abnormal vag discharge and/or dysuria
• 3. women:  low abd/back pain, nausea, fever, painful intercourse, bleeding b/t periods
• 4. men:  penile discharge, itching, or burning

HSV-2 usually

• 1. painful lesions with erythematous base - vesicles that ulcerate, crust over, then heal
• 2. fever, HA, photophobia, malaise, myalgia, lymphadenopathy, and waddling gait

• 1. acyclovir
• 2. warm baths
• 3. topicals
• 4. tx of sexual partners

16 and 18

cervix xsab bed with iodine solution healthy cells turn brown and abnormal cells turn white or yellow

• imiquimod 5% cream/aldara
• crysurgery- freezing
• trichloroactic acid

Treponema pallidum

• First:  painless ulcerations or pustules on genitals several wks after exposure
• Second: lasts 1-2 months; malaise, lethargy, fever, rash on palms/soles of feet, HA, bone/joint pain, white sore in mouth, anorexia

Third:  may not appear X20years; soft rubbery tumors attack all areas of body; coordination problems, paralysis, numbness, blindness, and dementia can occur;

in stage 3

lesion cultures positive

lumbar puncture and CSF testing in third stage

antibiotic therapy - PNC IM

if had >1 year may need additional doses

Tx of sexual partners

• other STI
• pyelonephritis
• PID
• infertility

RUQ pain occurring in PID r/t perihepatitis

• 1. infection, usually STI:  no use of barrier contraceptives, multiple sexual partners
• 2. intrauterine device
• 3. during or shortly after menses increased risk
• 4. douching
• 5. smokers have twice risk of nonsmokers
• 6. adolescents higher risk b/c seek health care later

C. trachomatis or N. gonorrheae

• 1. fever/chills
• 2. abd pain
• 3. vag discharge
• 4. irregular bleeding
• 5. NV
• 6. dysuria
• 7. stooped/shuffling gait
• 8. muscle guarding
• 9. pelvic mass
• 10. tenderness on palpation of cervix, uterus

• uterine tenderness or adnexal tenderness or cervical motion tenderness with one or more:
• - temp >101
• - abnormal cervical/vaginal mucopurulent discharge
• - elevated ESR
• - elevated CRP
• - Lab documentation of cervical infection

• infertility
• chronic pelvic pain
• ectopic pregnancy
• pelvic abscess

• 1. avoid sex until Tx comleted
• 2. eval of sex partners for STI
• 3. ABX prophylaxis with doxy may decrease infection r/t IUD insertion
• 4. f/u with PCP or GYN

bacteria from vagina enters gland

biopsy to r/o cancer

• recurring cyst
• nonhealing lesion
• scarring

• ketamine
• GHB - gamma-hydroxybutyric acid
• flunitrazepam - Rohypnol

if assault occurred <72 hours earlier

label with hospital name, pt name and ID number in approved evidence container

• date/time, signature of collector
• description of specimen and site it was collected from

try not to cut

cut around areas if must cut

air dry

Have patient stand on a white sheet and remove

glass, plastic to avoid mold growth

photograph site

• withing 72 hours
• ethinil estradiol/ovral - 2 tabs now, repeat in 12 hours

give with antiemetic to prevent NV

• 1. rocephin 125-250 mg IM
• 2. azithromycin 1 g po
• 3. metronidazole 2g po
• 4. doxy 100mg bid for 7 days
• 5. Hep B if not already immunized

2 to 4 wks to repeat STI and pregnancy testing

slight vag bleeding with mild uterine cramping, cervical os is closed, uterus enlarged and soft

moderate vaginal bleeding with mod cramping; cervical os open 3 cm or moere, gross rupture of membranes

appearance of s/s that signal impending loss of products of conception

slight vaginal bleeding, no craping or contraction, cervical os is closed; retention of dead products of conception

• heavy vag bleeding with severe cramping
• cervical os open some but not all uterine contents have been passed

• slight vaginal bleeding with mild uterine cramping\cervical os is closed
• products of conception have been completely expelled

• malodorous vag bleeding
•  no cramping
• cervical os closed
• fever
• ascending infection present