OBJECTIVES
Discuss the prevalence of Genitourinary problems
in family practice
Define the common genitourinary symptoms and
signs and discuss their etiology
Review the approach to the diagnosis and management
of UTIs and STDs in women
Review the approach to the diagnosis and management
of urethritis, epididymitis and
prostatitis in men
LECTURE OVERVIEW
Prevalence and Epidemiology: SV
Symptoms and Signs : JG
UTI’s in women: SV
Dysuria in men (Prostate/urethritis): JG
Kids and the elderly : SV
Cases on the world wide web : JG
Questions
PREVALENCE OF GU PROBLEMS IN FAMILY PRACTICE
Total visits 31,000
Female 20,000 : Male 12,000
Cystitis 500
Vaginitis “ unclassified” 243
Monilial Vaginitis 204
Frequency NYD 114
Dysuria NYD 89
Cervicitis 78
Prostatitis 31
Overall Relevance in Family Practice -
Most Common Reasons for Visits :
1. Hypertension
2. URI, Common Cold
3. Diabetes Mellitus
4. Depression
5. Well Baby Care
6. Skin Disorders
7. Prenatal Care
23 . UTI , Cystitis
24. Pneumonia
Epidemiology: UTI s alone
7 million visits to physician’s offices/yr
1 million hospital visits/yr
80 percent : e. coli
5 - 15 percent: staph. saprophytricus
klebsiella, proteus mirabilis and others
risk factors: sexual intercourse, use of diaphragm
or spermicide, delayed postcoital micturition, recent UTI
Asymptomatic Bacteriuria :
Two urine cultures with > 10 5 CFU/ml
No symptoms of UTI
Uncomplicated UTI :
Positive Urine Culture
Symptoms include dysuria, frequency, urgency,
suprapubic discomfort
No structural or functional GU abnormality predisposing
to UTI
Complicated UTI :
Positive Urine Culture
Fever, chills flank pain, abdominal pain
GU abnormality
Symptoms and Signs:
Consider:
Gender
Age
Concomitant Illness
GU Manipulation
Past History
Symptoms
Dysuria, frequency, nocturia, polyuria,
back ache, flank pain, incontinence, urgency, obstruction, post void dribbling,
dyspareunia
Vaginal Discharge
Urethral Discharge
Itching, skin changes ( lumps and bumps)
Sexual Dysfunction
Signs
Hematuria, Pyuria, Proteinuria, Leukocytosis
, Glucosuria
Prostate Mass, Prostate Hypertrophy, Scrotal
Mass
Pelvic Pain, Cervicitis,Vaginal Discharge, Urethral
Discharge
Fever, Flank tenderness
Skin lesions, erythema
Odour
Diagnostic Tests : Swabs
Elisa, DFA, urine test: Chlamydia
pH : Bacterial Vaginosis, Yeast
Microscopy in Office: Wet Preps, KOH Whiff test,
clue cells
Diagnostic Tests : Urine
Urinalysis : presence or absence of
PYURIA : UTI , URETHRITIS
HEMATURIA: UTI, PYELONEPHRITIS
PROTEINURIA : PYELONEPHRITIS
WBC CASTS : PYELONEPHRITIS
BACTERIA : UTI
GLUCOSE : DIABETES
Leukocyte Esterase Tests “ Dipstick”
Urine Culture : Gold Standard
Diagnostic Tests : Swabs
Gram Stain and Culture:
Neisseria Gonorrhea - Gram Negative Intracellular
Diplococci
Gardnerella Vaginalis - Gram Negative Rods on
Surface of Epithelial cells ( Clue cells)
Trichomonas Vaginalis - Flagellated Parasites
Candida Albicans - Yeast Mycelia and Spores
Dysuria in Women
History and Physical
Investigations: differentiate Cystitis, Urethritis
or Vaginitis
Acute UTIs : Rx
Vaginitis/Vaginosis
Acute UTIs
Acute dysuria in females is either acute cystitis;
acute urethritis due to chlamydia; gonorrhea or HSV; vaginitis due to candida
or vaginosis
Can be presumptively differentiated by history/
physical exam and urinalysis
Uncomplicated Cystitis
many studies looked at Rx options
3 day regimens = 7 day regimens
can use single dose but more likely to recur
or fail Rx
longer regimens for pregnancy, elderly, recurrent
UTIs
Rx Options
Vaginitis/ Vaginosis
Bacterial Vaginosis, Candidiasis, Trichomoniasis,
Gardenerella
50 % are asymptomatic
change in vaginal flora: anitbiotics, BCP
odour, pH, quality of vaginal discharge, microscopy,
culture
Yeast : antifungals
BV: Metronidazole
Dysuria and Frequency in Males
Describe the dysuria and quantitate the frequency
Other Symptoms ?
Other History ?
Investigations ?
Localization of problem
Prostatitis
Acute
Chronic
Non Bacterial
Benign Prostatic Hypertrophy (BPH)
Prostatodynia
*Antibiotics : 4 weeks for acute infection
Prostate assessment:
Urinalysis and culture - segmental
Rectal examination
Ultrasound
Biopsy
Prostatitis - Management
Manage the symptoms
Mechanical intervention
catheter, stent, surgery
Medical management
Alpha blockers
Finasteride
Antibiotics
? No treatment
Manage the infection
Antibiotic therapy, if indicated, should continue
for 4 weeks.
Choices include:
TMX (Bactrim/Septra)
quinolones
doxycycline
Rule out Cancer
Rectal examination
PSA
Ultrasound
Biopsy
( DO THESE TESTS AS INDICATED ONLY)
Urethritis
Urethral tenderness, irritation, dysuria, discharge,
meatal redness
Pus cells on Gram stain
Chlamydia, Gonorrhea, other bacteria
Culture
Antibiotics, Education
Rx Partner
Follow up
Testing for Urethritis
Gonorrhea - Swabs
Gram Stain - Gram neg intracellular diplococci
Culture
Chlamydia - Swabs
Culture
Elisa / DFA
Ligase Chain Reaction
Urine - Ligase Chain Reaction
Chlamydia
Chlamydia is the most common STD in North America
Canadian incidence 216 per 100,000 people per
year
3-5 x more prevalent than gonorrhea
women 15-25: rate 1.6-2%
5-7% in student health clinics
14% in family planning clinics
1/3-1/2 women develop PID
Gonorrhea
Swab C & S for Gonorrhea
Teenage women and men in 20s at highest
risk
Treat all as though resistant to penicillin
Cefixime 400 mg single dose or Ceftriaxone IM
125 mg single dose
Followed by seven days of doxycycline or single
dose Azithromycin
Children and the Elderly
Atypical Presentations
Children at Risk for Vesicourethral Reflux
Investigate all Boys with UTIs
STDs: Rule out Abuse
Commonest cause of bacteremia in the elderly
Dont Rx Asymptomatic Bacteriuria in the Elderly
Scrotal Masses
Location, Tenderness, Size, Consistency, Transillumination
Mechanical Causes: Hernia, Hydrocele,
Varicocele, Spermatocele, Torsion
Infections: Epididymitis, Orchitis
Tumours
What about other STDs ?
Chlamydia is the most common STD in North America
Canadian incidence 216 per 100,000 people per
year
3-5 x more prevalent than gonorrhea
women 15-25: rate 1.6-2%
5-7% in student health clinics
14% in family planning clinics
1/3-1/2 women develop PID
Genital Herpes
HSV Type 2
But can have Type 1 oral genital
infection
Clinical diagnosis plus ELISA swab/ Western
Blot test
Acyclovir, Valacyclovir, Famcyclovir
Barrier protection
Watch for lesions at Labour & Delivery
Genital Warts
HPV Type 6, 11, 16 ,18 etc
10 - 30 % adult population is infected but majority
are subclinical
Podophyllin, cryotherapy, laser surgery, interferon
etc
Barrier protection
DON’T FORGET
HEPATITIS
HIV
SYPHILIS