Bridge Exam 4 – Genitourinary & Oncologic Comprehensive Notes

Testicular Cancer

• Risk factors
  • Cryptorchidism (undescended testis) — even if corrected later, risk persists
  • Positive family history (especially first-degree male relatives)
  • Personal history of testicular cancer in contralateral testis
  • Caucasian ethnicity (incidence >4 times that of African-American men)
  • Age 15–35 years (peak incidence)
  • HIV infection (especially seminoma)
  • Gonadal dysgenesis/Klinefelter syndrome
  • Exposure to endocrine-disrupting chemicals (estrogens, pesticides) in utero
  • Infertility / poor semen parameters
• Prevention & screening
  • Monthly testicular self-exam (TSE) beginning at puberty
  • Prompt evaluation of painless testicular mass or swelling
  • Scrotal ultrasound followed by serum tumor markers: \alpha-fetoprotein, human chorionic gonadotropin (hCG), lactate dehydrogenase (LDH)

Post-Mastectomy Care (Lymphedema & Arm Precautions)

• Do NOT use the affected arm for:
  • Blood pressure measurements
  • Venipuncture or IV insertion
  • Subcutaneous or intramuscular injections
• Rationale: minimizes trauma, infection risk, and lymphedema exacerbation
• Interventions
  • Elevate arm above heart level; perform gentle ROM when approved
  • Compression sleeve or pneumatic device if prescribed
  • Avoid tight jewelry, sunburn, or heavy lifting > 4–6 kg
  • Educate on lifelong risk of lymphedema

Pelvic Organ Prolapse

• Manifestations
  • Sensation of vaginal pressure/fullness; “ball” in vagina
  • Stress urinary incontinence or urinary retention due to kinking of urethra
  • Constipation; difficulty with bowel evacuation (rectocele)
  • Low back/pelvic pain, dyspareunia
  • Visible bulge at introitus during Valsalva
• Management
  • Kegel exercises (strengthen pelvic floor)
  • Pessary insertion & routine follow-up for fit/cleaning
  • Estrogen therapy (post-menopausal atrophy)
  • Surgical: anterior/posterior colporrhaphy, hysterectomy with vault suspension

Benign Prostatic Hyperplasia (BPH)

• Pathophysiology
  • Non-malignant proliferation of peri-urethral (transition-zone) prostate tissue leading to bladder outlet obstruction
• Risk factors
  • Aging (prevalence >50\% at age >60)
  • Family history, obesity, metabolic syndrome, type 2 diabetes, Black ethnicity (earlier onset)
• Manifestations (“LUTS”)
  • Voiding: weak stream, hesitancy, intermittency, straining, dribbling
  • Storage: urgency, frequency, nocturia, incomplete emptying
• Complications
  • Acute urinary retention (AUR)
  • Hydronephrosis → renal insufficiency (post-renal CKD)
  • Recurrent UTIs, bladder stones, gross hematuria
• Diagnostics
  • Digital rectal exam (smooth, enlarged, rubbery gland)
  • Serum PSA (rule out prostate Ca; mild elevation possible)
  • Post-void residual, uroflowmetry, cystoscopy if hematuria or recurrent infections

Tamsulosin

• Class: \alpha-1A selective adrenergic blocker (uroselective)
• Indication: BPH LUTS; facilitates bladder/urethral smooth-muscle relaxation → improved flow
• Side effects / cautions
  • Orthostatic hypotension, dizziness, syncope (monitor BP, rise slowly)
  • Ejaculatory dysfunction, retrograde ejaculation
  • Nasal congestion, headache
  • Rare floppy iris syndrome during cataract surgery → inform ophthalmologist
• Nursing considerations: give at bedtime to minimize dizziness; do not crush; assess LUTS via International Prostate Symptom Score (IPSS)

Prostate-Specific Antigen (PSA)

• Glycoprotein produced by prostate epithelium
• Normal reference <4\,\text{ng/mL} (age-adjusted ranges exist)
• Uses
  • Screening (controversial) & early detection of prostate cancer
  • Monitoring response to therapy / recurrence
• Elevations also seen in BPH, prostatitis, after DRE or ejaculation; repeat if transient rise

24-Hour Urine Creatinine Clearance (Estimate of GFR)

• Purpose: measures endogenous creatinine filtration → approximates glomerular filtration rate (GFR)
• Collection
  • Discard first void, collect all urine for 24 h, keep on ice; draw serum creatinine during collection
• Formula (Cockcroft-Gault) for estimate without urine collection:
  \text{CrCl} = \frac{(140 - \text{age}) \times \text{weight (kg)}}{72 \times \text{Serum Cr (mg/dL)}} \times (0.85 \text{ if female})

Stress Urinary Incontinence

• Cause: urethral sphincter incompetence → leakage with ↑ abdominal pressure (cough, sneeze)
• Interventions
  • Pelvic floor muscle training (Kegels): 3 sets of 10 contractions, TID
  • Weight loss, smoking cessation, treat chronic cough
  • Topical estrogen (post-menopause)
  • Pessary, mid-urethral sling surgery for refractory cases

Urinary Tract Infection (UTI)

Clean-Catch Urine Technique

• Wash hands; clean periurethral area front-to-back with antiseptic wipe ×3
• Begin voiding, then collect midstream urine into sterile container without stopping flow
• Refrigerate or deliver to lab within 30 min
• Positive urinalysis (leukocyte esterase, nitrites, >10\,000 CFU/mL) → send urine culture automatically (“reflex culture”)

Primary Causative Organism

• \textit{Escherichia coli} (≈ 80–85\%)

Patient Education for Prevention

• Hydration: \geq 2–3\,L fluids/day unless contraindicated
• Void at least every 3–4 h; post-coital voiding within 15 min
• Wipe front-to-back; avoid douches, scented wipes
• Cotton underwear, avoid tight synthetic garments
• Limit spermicides/diaphragms which ↑ UTI risk
• Cranberry (unsweetened juice, capsules) may reduce bacterial adherence

CAUTI (Catheter-Associated UTI) Prevention Guidelines

• Use catheter only for appropriate indications; reassess daily
• Aseptic insertion, sterile closed drainage
• Secure catheter to prevent urethral traction
• Maintain unobstructed flow; keep bag below bladder, off floor
• Daily perineal hygiene with soap/water, no antimicrobial irrigation
• Sample from port with sterile syringe after alcohol swab

Phenazopyridine

• Urinary analgesic (azo dye)
• Education
  • Provides symptomatic relief (burning, urgency) — does NOT treat infection
  • Turns urine, sweat, tears orange-red → stain contacts/clothing
  • Take with food to ↓ GI upset
  • Limit to 2 days concurrent with antibiotics (masking symptoms may delay evaluation)

Pyelonephritis

• Acute bacterial infection of renal pelvis & parenchyma
• Manifestations
  • High-grade fever, chills, flank/costovertebral angle (CVA) pain
  • Nausea/vomiting, malaise
  • LUTS similar to cystitis (dysuria, frequency)
  • UA: pyuria, bacteriuria, WBC casts, mild proteinuria
• Management: IV/PO fluoroquinolones or broad-spectrum β-lactam; hospitalization if severe; hydration
• Complications: sepsis, renal scarring → CKD, perinephric abscess

Interstitial Cystitis (Bladder Pain Syndrome)

• Chronic sterile inflammatory condition
• Clinical picture
  • Suprapubic pain related to bladder filling, relieved by voiding
  • Urgency, frequency (up to >60 voids/24 h) without infection
  • Pain with sexual intercourse
• Diagnosis of exclusion; cystoscopy may show petechial hemorrhages (glomerulations)
• Management
  • Dietary avoidance of bladder irritants (caffeine, citrus, spicy food)
  • Amitriptyline, pentosan polysulfate sodium, antihistamines
  • Bladder instillations, pelvic floor PT

Urinary Incontinence Types (Comparison)

• Stress: outlet incompetence → leak with exertion
• Urge (overactive bladder): detrusor overactivity → sudden urge
• Overflow
  • Pathophysiology: impaired detrusor contractility or outlet obstruction → chronic retention, bladder over-distention
  • Manifestations: constant dribbling, high post-void residual >300\,mL
  • Management: intermittent self-catheterization, treat BPH/neurogenic causes, cholinergic agonist (bethanechol)
• Functional: incontinence due to cognitive, psychological, or mobility barriers despite intact urinary system
  • Examples: dementia, severe arthritis
  • Interventions: toileting schedules, assistive devices, environmental modifications

Glomerulonephritis

• Complications
  • Acute hypertension & hypertensive encephalopathy
  • Nephrotic syndrome (proteinuria >3.5\,g/24 h, edema, hyperlipidemia)
  • Rapid progression to acute kidney injury (AKI) or chronic kidney disease (CKD)
  • Pulmonary edema due to fluid overload

Polycystic Kidney Disease (PKD)

• Risk factors / etiology
  • Autosomal dominant inheritance (PKD-1 > PKD-2)
  • Positive family history in 75\% cases
• Manifestations
  • Bilateral enlarged kidneys with multiple cysts; palpable masses
  • Flank/abdominal pain, hematuria (ruptured cysts), recurrent UTIs
  • Hypertension (RAAS activation), nephrolithiasis
  • Extra-renal: liver cysts, intracranial berry aneurysms, mitral valve prolapse, diverticulosis
• Management: BP control (ACE/ARB), tolvaptan (slows cyst growth), dialysis/transplant for ESRD

Chronic Kidney Disease (CKD)

• Pathophysiology: progressive nephron loss → adaptive hyperfiltration & sclerosis → GFR decline for >3 months
• Risk factors
  • Diabetes mellitus (#1), hypertension (#2)
  • Recurrent pyelonephritis, glomerulonephritides, PKD
  • NSAID overuse, obstructive uropathy, systemic lupus erythematosus

Medications That Decrease Renal Function (Nephrotoxic)

• NSAIDs (inhibit prostaglandin-mediated afferent vasodilation)
• ACE inhibitors/ARBs (efferent vasodilation — beneficial long-term but may ↓ GFR acutely)
• Aminoglycosides (gentamicin), vancomycin
• IV contrast (iodinated), amphotericin B
• Tenofovir, cisplatin, cyclosporine/tacrolimus, lithium, methotrexate

Glomerular Filtration Rate (GFR)

• Definition: volume of plasma filtered across glomerular capillaries per minute — best overall index of kidney function
• Normal: \approx 90–120\,mL/min/1.73\,m^2 (declines with age)
• Estimated by creatinine-based equations (CKD-EPI, MDRD) or measured by inulin/^{51}\text{Cr} EDTA clearance

Hemodialysis Vascular Access — Arteriovenous (AV) Fistula

• Creation: surgical anastomosis of artery (usually radial) to vein (cephalic) in non-dominant arm
• Nursing Precautions: NO BP, venipuncture, IV, or constrictive clothing on affected arm; protect from injury
• Assessment: “feel the thrill, hear the bruit” each shift
• Complications
  • Thrombosis/stenosis (sudden loss of thrill, ↑ venous pressures)
  • Infection
  • Aneurysm formation of venous segment
  • Steal syndrome (see below)
  • High-output heart failure (rare)

Steal Syndrome

• Pathophysiology: arterial blood diverted (“stolen”) into low-resistance venous fistula → distal limb ischemia
• Symptoms: pain, pallor, reduced pulse, numb/cold fingers during dialysis or rest
• Management: surgical revision, banding, distal revascularization

Hemodialysis Complications (Systemic)

• Hypotension (rapid fluid removal): pause ultrafiltration, Trendelenburg, fluids
• Disequilibrium syndrome: cerebral edema from rapid solute shift → headache, nausea, seizures (prevent gradual dialysis)
• Muscle cramps, pruritus, anemia, bone disease

End-Stage Renal Disease (ESRD) Diet

• Goals: ↓ uremic toxin production, maintain nutrition, control electrolytes/fluids
• Recommendations (individualized)
  • Protein: 1.2–1.3\,g/kg/day when on hemodialysis (higher than pre-dialysis CKD)
  • Sodium: <2 g/day
  • Potassium: 2–3\,g/day (avoid high-K foods: bananas, oranges, tomatoes)
  • Phosphorus: \leq1\,g/day (binders with meals)
  • Fluid: urine output + 600 mL or 1–1.5\,L/day maximum
  • Adequate calories from carbohydrates/fats; vitamin D, calcium supplementation

Epoetin Alfa (rHuEPO)

• Indication: anemia of CKD (Hb <10\,g/dL)
• Administration
  • IV push at end of dialysis or SC 1–3 ×/week
  • Target Hb 10–11.5\,g/dL; do NOT exceed 13 due to ↑ stroke/HTN risk
• Nursing
  • Monitor BP (may precipitate/worsen hypertension)
  • Adequate iron stores essential: ferritin >100 ng/mL, transferrin sat >20\%; supplement PO/IV iron sucrose as needed

ACE Inhibitors

• Mechanism of Action
  • Block conversion of angiotensin I → angiotensin II by inhibiting angiotensin-converting enzyme
  • ↓ Ang II → vasodilation (arterial & efferent arterioles), ↓ aldosterone → natriuresis, ↓ cardiac remodeling
• Clinical utility: HTN, diabetic nephropathy (slow CKD); post-MI, heart failure (↓ mortality)
• Side effects: cough, hyperkalemia, angioedema, ↑ creatinine (initial), hypotension, contraindicated in pregnancy (teratogenic)

Prostate Cancer

• Risk factors
  • Age >50, African-American race
  • Family history (first-degree relative, early onset)
  • BRCA2 gene mutation, Lynch syndrome
  • High-fat/red-meat diet, low vegetables; obesity
  • Smoking, chemical exposure (Agent Orange, cadmium)
• Most common cancer diagnosed in men; screening: PSA ± DRE starting 45–50 yr depending on risk

BReast CAncer (BRCA)

• Most common tumor site: upper outer quadrant (tail of Spence) where glandular tissue dense, lymph drainage to axilla
• Risk factors
  • Female gender, age >50, white ethnicity
  • Early menarche (
  • Nulliparity or first birth after 30 yr
  • Hormone replacement therapy, oral contraceptives long term (>10 yr)
  • Family history (1st-degree relative), personal history, genetic mutations (BRCA1/BRCA2, p53, PTEN)
  • Radiation exposure (chest irradiation for Hodgkin’s)
  • Alcohol (>1 drink/day), obesity (post-menopausal estrogen), sedentary life

Cervical Cancer

• Labs/Diagnostics
  • Pap smear cytology (screening starts 21 yr; 3-yr or 5-yr intervals)
  • High-risk HPV DNA testing (types 16, 18) co-testing ≥30 yr
  • Colposcopy with biopsy for abnormal Pap/HPV
  • Endocervical curettage, cone biopsy (LEEP) for high-grade lesions

Overflow Incontinence (see above)

Breast Cancer Gene

• BRCA1 (chromosome 17q) & BRCA2 (13q) tumor-suppressor genes; autosomal dominant; lifetime breast Ca risk up to 65–80\%; ovarian Ca 15–40\%
• Counseling, prophylactic mastectomy/oophorectomy, MRI screening

Additional Formulas / Numbers

• eGFR staging (KDIGO)
  • \geq90 (G1) normal/high
  • 60–89 (G2) mild ↓
  • 45–59 (G3a) mild-mod
  • 30–44 (G3b) mod-severe
  • 15–29 (G4) severe
  • <15$$ or dialysis (G5) kidney failure

Linking Concepts & Ethical Considerations

• Cancer screening (PSA, mammography, Pap) requires shared decision-making to balance benefits (early detection) vs. harms (over-diagnosis, anxiety)
• Medication nephrotoxicity emphasizes principle of non-maleficence → monitor renal labs, adjust dosing, educate patients on OTC NSAID risks
• Dialysis access protection parallels post-mastectomy arm precaution — consistent patient education prevents irreversible harm (ischemia, lymphedema)
• Genetic testing (BRCA, PKD) raises confidentiality, insurability issues; provide genetic counseling & informed consent