RC

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