AUA Updates

Question 1

Question:
What is the lifetime risk of developing prostate cancer (PCa) for men in the U.S.?

Answer 1

Answer:
Men in the U.S. have a 12% lifetime risk of developing prostate cancer (PCa).

Question 2

Question:
What is the risk of dying from prostate cancer (PCa) for men in the U.S.?

Answer 2

Answer:
Men in the U.S. have a 2%-3% risk of dying from prostate cancer (PCa).

Question 3

Question:
What do the guidelines recommend for low-risk and intermediate/high-risk prostate cancer (PCa)?

Answer 3

Answer:
Guidelines recommend active surveillance for low-risk PCa and treatment for men with intermediate or higher risk PCa based on the patient’s quality-of-life goals and life expectancy.

Question 4

Question:
What does Biochemical Recurrence (BCR) refer to in the context of prostate cancer (PCa)?

Answer 4

Answer:
Biochemical Recurrence (BCR) is defined as an abnormal value or change in serum PSA after primary treatment for PCa.

Question 5

“12-2-3 GUIDE”

Answer 5

12: 12% lifetime risk of developing PCa.
2-3: 2%-3% risk of dying from PCa.
G: Guidelines recommend active surveillance for low-risk PCa.
U: Undergo treatment for intermediate or higher risk PCa.
I: Importance of patient’s quality-of-life goals and life expectancy.
D: Definitions of BCR as abnormal PSA after primary treatment.
E: Emphasis on monitoring, evaluating, and treating BCR post-RP, post-RT, and post-focal therapy.

Question 6

Question:
What is PSA and where is it primarily expressed?

Answer 6

Answer:
PSA (Prostate-Specific Antigen) is a serine protease and arginine esterase that is almost exclusively expressed in prostatic tissue.

Question 7

Question:
What percentage of PSA in the serum is bound to alpha-1 antichymotrypsin?

Answer 7

Answer:
In the serum, 70% of PSA is bound primarily to alpha-1 antichymotrypsin, with the remainder being free.

Question 8

Question:

What is the significance of percent free PSA in the screen

Answer 8

Answer:
A percent free PSA <15% is associated with prostate cancer (PCa) in the screening setting.

Question 9

Question:

What was found in a study of over 800 post-RP and post-RT

Answer 9

Answer:
The study found that a percent free PSA >10% was associated with increased metastasis (hazard ratio [HR] = 1.7).

Question 10

Question:

Question:
What are the half-lives of PSA decline after radical cystoprostatectomy as found by Gregorakis et al.?

Answer 10

PSA concentrations dropped in a biphasic pattern: a sharper immediate decline with a half-life of 4.3 hours and a subsequent more gradual decline with a half-life of 63 hours.

Question 11

How long is the approximate half-life of PSA decline in the absence of residual cancer?

Answer 11

In the absence of residual cancer, 3 days is a fair approximation for the half-life of PSA decline.

Question 12

What general rule is used for checking responses to treatment changes based on PSA half-lives?

Answer 12

It is prudent to wait at least 5 half-lives before checking responses to treatment changes.

Question 13

What is the commonly used monitoring interval in practice for PSA changes?

Answer 13

The 3-month interval is commonly used in practice.

Question 14

Are changes in PSA specific for the location or severity of prostate cancer recurrence?

Answer 14

No, changes in PSA are not specific for the location or severity of recurrence, as both local and distant recurrences produce PSA.

Question 15

What did a meta-analysis find about the adjusted-R2 of BCR for PCa mortality compared to distant metastases?

Answer 15

The adjusted-R2 of BCR for PCa mortality was 0.38 compared to 0.78 for distant metastases.

Question 16

“PSA Monitor Has Two Rates, Two Free Tips, and Five Half-Lives”:

Answer 16

PSA: PSA is a serine protease and arginine esterase.
Monitor: PSA monitoring intervals form the basis.
Has Two Rates: 4.3 hours and 63 hours half-lives (sharper immediate and gradual declines).
Two Free Tips:
<15% free PSA associated with PCa in screening.
10% free PSA associated with increased metastasis (HR = 1.7).

Five Half-Lives: Wait at least 5 half-lives before checking treatment responses.

Question 17

What is PSA and where is it primarily expressed?

Answer 17

PSA (Prostate-Specific Antigen) is a serine protease and arginine esterase that is almost exclusively expressed in prostatic tissue.

Question 18

What percentage of PSA in the serum is bound to alpha-1 antichymotrypsin?

Answer 18

In the serum, 70% of PSA is bound primarily to alpha-1 antichymotrypsin, with the remainder being free.

Question 19

What was found in a study of over 800 post-RP and post-RT patients with BCR regarding percent free PSA?

Answer 19

The study found that a percent free PSA >10% was associated with increased metastasis (hazard ratio [HR] = 1.7).

Question 20

What is the commonly used monitoring interval in practice for PSA changes?

Answer 20

The 3-month interval is commonly used in practice.

Question 21

What is the PSA threshold for BCR after RP according to AUA guidelines?

Answer 21

AUA defines BCR as a post-RP PSA of at least 0.20 ng/mL with a confirmatory PSA.

Question 22

What are the risk-adapted PSA thresholds for defining BCR according to Mir et al.?

Answer 22

• Rising PSA >0.05 ng/mL with high-risk pathologic criteria
• Rising PSA >0.20 ng/mL with intermediate-risk pathologic criteria
• Rising PSA >0.40 ng/mL with low-risk pathologic criteria

Question 23

What is the significance of PSA persistence after RP?

Answer 23

PSA persistence using conventional assays carries a 47% 15-year risk of metastasis and is considered a more adverse prognostic factor than BCR.

Question 24

What is the risk stratification schema for BCR after RP according to EAU guidelines?

Answer 24

• Low Risk: PSA Doubling Time >12 months and ISUP Grade Group <4 at RP
• High Risk: PSA Doubling Time <12 months or ISUP Grade Group 4-5 at RP

Question 25

What are the guidelines for the use of next-generation PET imaging for evaluating PSA recurrence after local therapy?

Answer 25

The AUA, NCCN, and EAU guidelines allow for next-generation PET imaging to evaluate PSA recurrence after local therapy.

Question 26

Monitoring Frequency of PSA post treatment

Answer 26

First 2 Years: Every 3-4 months.
Next 3 Years: Every 6 months.
Thereafter: Annually if PSA remains undetectable.

Question 27

PSA Persistence:

Answer 27

AUA (<0.20 ng/mL), EAU (<0.10 ng/mL), NCCN (specific assay-dependent)

Question 28

BCR After RP:

Answer 28

AUA (PSA ≥0.20 ng/mL with confirmatory PSA), EAU (no confirmatory needed), NCCN (rising PSA on 2 or more occasions).

Question 29

Risk Stratification (EAU Guidelines):

Answer 29

Low Risk: PSA Doubling Time >12 months, ISUP Grade Group <4.
High Risk: PSA Doubling Time <12 months, ISUP Grade Group 4-5.

Question 30

Probability of Further PSA Rises (Figure 1):

Answer 30

Shows increasing probability with higher post-RP PSA levels.
Higher biochemical recurrence thresholds correlate with higher chances of further PSA rises.

Question 31

Pathological Risk-Adapted BCR Definitions (Figure 2):

Answer 31

Provides PSA thresholds and corresponding 5-year nomogram risk of recurrence based on pathological criteria.

Question 32

Risk Stratification Schema (Figure 3):

Answer 32

Differentiates between low and high risk for both RP and RT based on PSA doubling time and Gleason Grade Group.

Question 33

BCR Evaluation and Treatment Algorithm (Figure 4):

Answer 33

Outlines steps for evaluating and managing BCR after RP based on EAU guidelines, including imaging and treatment options.

Question 34

What is the typical half-life range of PSA decline after radiation therapy (RT)?

Answer 34

The half-life range of PSA decline after RT is 0.5 to 9.2 months, with a point estimate of 1.6 months.

Question 35

What is the nadir PSA value following modern RT treatments?

Answer 35

The nadir PSA value following modern RT treatments is frequently <0.5 ng/mL.

Question 36

What is PSA bounce and how is it defined?

Answer 36

PSA bounce is defined as a benign rise in PSA >0.2 ng/mL above a previous value followed by an eventual spontaneous decline to the level of that value.

Question 37

What is the mean amplitude and average timing of PSA bounce after RT?

Answer 37

The mean PSA bounce amplitude is 1.3 ng/mL, occurring on average 18 months after RT initiation and taking 33 months to return to nadir.

Question 38

How common is PSA bounce after brachytherapy compared to external beam radiation therapy?

Answer 38

PSA bounce is more common and pronounced after brachytherapy (incidence 32%-34%; mean amplitude 1.4-1.7 ng/mL) compared to external beam radiation (incidence 22%; mean amplitude 0.8 ng/mL).

Question 39

What impact does experiencing a PSA bounce have on BCR-free survival?

Answer 39

Patients experiencing a PSA bounce were noted to subsequently experience improved BCR-free survival in a meta-analysis of 10 studies.

Question 40

Changes in PSA after RT:

Answer 40

Prolonged Decline: PSA kinetics after RT can take a prolonged time to decline due to remaining prostate tissue and delayed tissue effects from RT.
Half-Life of PSA Decline: Range from 0.5 to 9.2 months, with an average of 1.6 months.
Nadir PSA Value: Typically <0.5 ng/mL following modern RT treatments.

Question 41

PSA Bounce:

Answer 41

• Definition: A benign rise in PSA >0.2 ng/mL above a previous value followed by an eventual spontaneous decline to the previous level.
• Mean Amplitude: 1.3 ng/mL.
• Timing: Occurs on average 18 months after RT initiation and takes 33 months to return to nadir.
• Incidence and Amplitude:
  
  • Brachytherapy: Incidence 32%-34%; mean amplitude 1.4-1.7 ng/mL.
  • External Beam Radiation: Incidence 22%; mean amplitude 0.8 ng/mL.
• Impact on BCR-Free Survival: Improved BCR-free survival noted in patients experiencing PSA bounce in a meta-analysis of 10 studies.

Question 42

What were the initial criteria defined by the American Society for Radiation Oncology in 1996 for biochemical recurrence (BCR) after radiation therapy (RT)?

Answer 42

The initial criteria defined BCR as either:
1. 3 consecutive PSA rises following a nadir, with the date of BCR being halfway between the nadir and the first rise.
2. 1 rise large enough to trigger initiation of therapy.

Question 43

Why was the Phoenix Criteria introduced in 2006 for defining BCR after RT?

Answer 43

The Phoenix Criteria were introduced to improve correlation with clinical progression by avoiding PSA bounces and forgoing backdating.

Question 44

What is the Phoenix Consensus definition for BCR after RT?

Answer 44

The Phoenix Consensus definition for BCR after RT is a rise in PSA of at least 2 ng/mL above the nadir value after radiation, regardless of whether ADT is administered with radiation.

Question 45

Definition of BCR after RT:

Answer 45

Initial Definition (1996):

Criteria 1: 3 consecutive PSA rises following a nadir, with the date of BCR being halfway between the nadir and the first rise.
Criteria 2: 1 rise large enough to trigger initiation of therapy.
Updated Definition (Phoenix Criteria, 2006):

Purpose: Improve correlation with clinical progression by avoiding PSA bounces and forgoing backdating.
Definition: A rise in PSA of at least 2 ng/mL above the nadir value after radiation, regardless of whether ADT is administered with radiation.

Question 46

Is BCR after RT specific for developing metastatic disease or PCa mortality?

Answer 46

No, BCR after RT is not specific for developing metastatic disease or PCa mortality.

Question 47

What does the heterogeneity of BCR after RT highlight?

Answer 47

The heterogeneity of BCR after RT highlights the European Association of Urology (EAU) risk stratification of BCR into low- and high-risk groups.

Question 48

What are the two risk groups for BCR after RT according to the EAU risk stratification?

Answer 48

The two risk groups for BCR after RT according to the EAU risk stratification are low-risk and high-risk groups.

Question 49

Impact of BCR after RT on Oncologic Outcomes:
Specificity: BCR after RT is not specific for developing metastatic disease or prostate cancer (PCa) mortality.
Heterogeneity: The heterogeneity of BCR after RT outcomes is underscored by the EAU risk stratification.
EAU Risk Stratification:
Low-Risk Group: Patients with favorable prognostic indicators.
High-Risk Group: Patients with adverse prognostic indicators.

Question 50

When should the evaluation for suspected recurrence be initiated in men who would benefit from earlier detection and management after RT?

Answer 50

The evaluation should be initiated sooner than when absolute criteria are met in men who would benefit from earlier detection and management.

Question 51

What imaging methods have become the standard of care for evaluating suspected recurrence after RT?

Answer 51

PSMA-based PET/CT and contrast-enhanced MRI have become the standard of care for evaluating suspected recurrence after RT.

Question 52

What percentage of recurrences were identified using C11-choline PET/CT scans in a cohort of 184 patients with PSA recurrences after RT?

Answer 52

Sites of recurrences were identified in 87% of patients with PSA recurrences after RT.

Question 53

What is necessary to establish locally recurrent disease prior to initiating salvage therapy for a patient with low competing risks?

Answer 53

Prostate biopsy is necessary to establish locally recurrent disease prior to initiating salvage therapy.

Question 54

What are some treatment options for isolated local recurrence after radiation therapy?

Answer 54

Treatment options include salvage radical prostatectomy (RP), androgen deprivation therapy (ADT), cryotherapy, high intensity focused ultrasound (HIFU), and re-irradiation.

Question 55

Is there a preferred salvage local treatment modality designated by guidelines for isolated local recurrence after radiation?

Answer 55

No, guidelines do not designate a preferred salvage local treatment modality. A shared decision-making approach should be undertaken based on patient preference and center expertise.

Question 56

What percentage of recurrences were in the pelvis and distant locations according to Parker and colleagues’ study using C11-choline PET/CT scans?

Answer 56

In the cohort, 54% had recurrences in the pelvis (prostate and soft tissue) and 33% had distant recurrences.

Question 57

Evaluation and Management of BCR After RT:

Answer 57

Evaluation and Management of BCR After RT:

• Early Evaluation: Initiate evaluation for suspected recurrence sooner in men who would benefit from earlier detection and management.
• Standard Imaging: PSMA-based PET/CT and contrast-enhanced MRI are the standard of care.
• C11-Choline PET/CT Scans:
  
  • Identified sites of recurrences in 87% of patients with PSA recurrences.
  • 54% had recurrences in the pelvis, 33% had distant recurrences.
• Algorithm for BCR Evaluation:
  
  • High Risk: PSMA PET/CT + pelvic MRI with IV contrast.
    
    • Any Distant Recurrence: Systemic therapy +/- metastasis directed therapy.
    • Local Only Recurrence: Local treatment options.
    • Negative Imaging: Prostate biopsy to confirm local recurrence.
      
      • Positive Biopsy: Salvage local therapy.
  • Low Risk: Observe with serial PSAs until individualized imaging threshold is met (clinical symptoms of metastatic disease, acceleration of PSA doubling time, PSA threshold [5, 10 ng/mL]).
• Treatment of Local Recurrence:
  
  • Salvage RP: Best pathological evaluation but higher toxicity.
  • Other Options: ADT, cryotherapy, HIFU, re-irradiation.
  • No Preferred Modality: Shared decision-making based on patient preference and center expertise.

By using these flashcards and summary, you’ll be able to efficiently memorize and understand the key points about the evaluation and management of biochemical recurrence after radiation therapy. If you need more detailed flashcards or further explanations, feel free to ask!

Question 58

How do the AUA and EAU guidelines currently consider primary focal therapy of localized prostate cancer (PCa)?

Answer 58

Primary focal therapy of localized PCa is considered investigational by the AUA and EAU guidelines.

Question 59

Why is PSA less accurate for measuring response to therapy after focal therapy compared to radical prostatectomy (RP)?

Answer 59

PSA is less accurate because the majority of the prostate gland remains in situ and is often untreated after focal therapy.

Question 60

What is needed to delineate the utility and optimal timing of PSA monitoring after focal therapy?

Answer 60

Rigorous study on PSA kinetics following various focal therapies is needed to delineate the utility and optimal timing of PSA monitoring.

Question 61

What remains the gold standard for identifying local recurrences and guiding subsequent therapies after focal therapy?

Answer 61

Post-treatment prostate MRI and per-protocol prostate biopsies remain the gold standard for identifying local recurrences and guiding subsequent therapies.

Question 62

Why is it important to establish standardized definitions of PSA recurrence after focal therapy?

Answer 62

Standardized definitions of PSA recurrence are important to facilitate cross-study comparison.

Question 63

Summary:

Monitoring for Disease Recurrence After Focal Therapy:

• Guideline Consideration:
  
  • Primary focal therapy of localized PCa is considered investigational by AUA and EAU guidelines despite its rising popularity.
• PSA Accuracy:
  
  • PSA is less accurate for measuring response to therapy compared to RP because the majority of the prostate gland remains in situ and is often untreated.
• Need for Study:
  
  • Rigorous study on PSA kinetics following various focal therapies is needed to determine the utility and optimal timing of PSA monitoring.
• Standardized Definitions:
  
  • Establishing standardized definitions of PSA recurrence is crucial for facilitating cross-study comparison.
• Gold Standard Monitoring:
  
  • Post-treatment prostate MRI and per-protocol prostate biopsies are the gold standard for identifying local recurrences and guiding subsequent therapies.

Question 64

What percentage of prostate cancer (PCa) patients will develop biochemical recurrence (BCR)?

Answer 64

Approximately 30% of PCa patients will develop BCR.

Question 65

Will the majority of patients who develop BCR also develop metastatic disease or die of PCa?

Answer 65

No, the majority of patients who develop BCR will not develop metastatic disease or die of PCa.

Question 66

What are the most popular definitions of BCR for RP and RT in the U.S.?

Answer 66

The AUA and Phoenix Criteria represent the most popular definitions of BCR for RP and RT, respectively.

Question 67

Why are risk-adapted thresholds for BCR considered useful?

Answer 67

Risk-adapted thresholds for BCR are useful to individualize decision-making.

Question 68

What does the EAU BCR risk stratification help determine?

Answer 68

The EAU BCR risk stratification helps determine the risk of metastasis after BCR in both post-RP and post-RT settings.

Question 69

What unique challenge does post-radiation PSA monitoring pose?

Answer 69

Post-radiation PSA monitoring poses the challenge of widely varying PSA decline, and 30% of patients may experience a prolonged yet benign PSA bounce.

Question 70

What imaging combination is currently the most sensitive for evaluating BCR in both post-RP and post-RT settings?

Answer 70

The most sensitive imaging combination is a PSMA-PET/CT and pelvic MRI with contrast.

Question 71

What should guide the choice of salvage treatments for isolated local recurrences after radiation?

Answer 71

The choice of salvage treatments for isolated local recurrences after radiation should be based on patient preference and center expertise.

Question 72

What is needed as focal therapy becomes more common?

Answer 72

Further study is needed on how to monitor PSA and evaluate patients for disease recurrence as focal therapy becomes more common.

Question 73

Summary:

Summary of Biochemical Recurrence (BCR) in Prostate Cancer:

• Incidence of BCR: Approximately 30% of prostate cancer (PCa) patients will develop BCR.
• Outcomes: The majority of patients with BCR will not develop metastatic disease or die of PCa.
• Definitions:
  
  • AUA Criteria: Most popular for post-radical prostatectomy (RP) BCR.
  • Phoenix Criteria: Most popular for post-radiation therapy (RT) BCR.
• Risk-Adapted Thresholds: Useful for individualized decision-making.
• EAU Risk Stratification: Helps determine the risk of metastasis after BCR in both post-RP and post-RT settings.
• Post-Radiation Monitoring:
  
  • PSA decline can vary widely.
  • 30% of patients may experience a prolonged yet benign PSA bounce.
• Evaluation and Imaging:
  
  • Early treatment of recurrent disease should be evaluated.
  • Most sensitive imaging combination: PSMA-PET/CT and pelvic MRI with contrast.
• Salvage Treatments:
  
  • sRT is routinely delivered after RP for the appropriate patient.
  • Choice of salvage treatments for isolated local recurrences after radiation should be based on patient preference and center expertise.
• Focal Therapy: Requires further study for PSA monitoring and evaluation of disease recurrence.

Question 74

What percentage of patients treated for localized prostate cancer (PCa) will develop biochemical recurrence (BCR)?

Answer 74

Thirty percent of patients treated for localized PCa will develop BCR.

Question 75

What percentage of patients with BCR will develop metastatic disease?

Answer 75

Approximately 30% of patients with BCR will develop metastatic disease.

Question 76

What is the AUA criteria for BCR after radical prostatectomy (RP)?

Answer 76

The AUA criteria for BCR after RP is a PSA ≥0.2 ng/mL with a second confirmatory PSA above this value.

Question 77

How can risk-adapted BCR thresholds individualize when to evaluate and treat BCR?

Answer 77

Risk-adapted BCR thresholds account for the patient’s surgical pathology grade, stage, and margin status, using lower thresholds for higher risk disease.

Question 78

What is the Phoenix Criteria for BCR after radiation therapy (RT)?

Answer 78

The Phoenix Criteria for BCR after RT is a rise of at least 2 ng/mL above the nadir value after radiation, regardless of whether androgen deprivation therapy (ADT) is administered with radiation.

Question 79

What is the lesion detection rate of PSMA-PET/CT when post-RP PSA is less than 0.5 ng/mL?

Answer 79

The lesion detection rate of PSMA-PET/CT is approximately 40%-60% when post-RP PSA is less than 0.5 ng/mL.

Question 80

What percentage of patients undergoing radiation therapy (RT) will experience a PSA bounce?

Answer 80

Approximately 31% of patients undergoing RT will experience a PSA bounce.

Question 81

Summary:

Key Facts About Biochemical Recurrence (BCR) and Prostate Cancer (PCa):

• Incidence of BCR:
  
  • 30% of patients treated for localized PCa will develop BCR.
  • Approximately 30% of these patients will develop metastatic disease.
• AUA Criteria for BCR After RP:
  
  • PSA ≥0.2 ng/mL with a second confirmatory PSA above this value.
  • Risk-adapted thresholds account for the patient’s surgical pathology grade, stage, and margin status to individualize evaluation and treatment.
• Phoenix Criteria for BCR After RT:
  
  • A rise of at least 2 ng/mL above the nadir value after radiation, regardless of whether ADT is administered with radiation.
• PSMA-PET/CT Detection Rate:
  
  • Lesion detection rate of approximately 40%-60% when post-RP PSA is less than 0.5 ng/mL.
• PSA Bounce After RT:
  
  • Approximately 31% of patients undergoing RT will experience a PSA bounce.

Question 82

What is the 15-year prostate cancer mortality after biochemical recurrence (BCR) following radical prostatectomy (RP)?

Answer 82

The 15-year prostate cancer mortality after BCR following RP is approximately 17%.

Multiple series have now documented the heterogenous, and most often prolonged, natural history of biochemical recurrence (BCR) following radical prostatectomy. For example, Pound et al reported that the majority of patients experiencing BCR after RP will not suffer distant progression or PCa mortality.14 Specifically, in a cohort of 304 patients with BCR who did not receive any adjuvant or salvage treatment until the development of metastases, they found that 34% developed metastasis, with a median time to metastasis of 8 years. Further, for patients who developed metastatic disease, the median time to death was then 5 years. This translates to a 15-year risk of prostate cancer mortality of approximately 15%-20%. Overall, these data are useful to counsel patients with biochemical recurrence regarding prognosis and expected timeline.

Question 83

Eight years after radical prostatectomy for Gleason 3+4 pT2N0R0 prostate cancer, a 78-year-old man with coronary artery disease and insulin dependent diabetes mellitus has a PSA increase to 0.30 ng/mL with a PSA doubling time of 36 months. The next step is:

Answer 83

Repeat PSA in 3 months.

PSMA-PET/CT.

Salvage radiation therapy with androgen deprivation.

Salvage androgen deprivation therapy alone.

Due to the patient’s age and comorbidities, he has an estimated life expectancy of less than 10 years. Moreover, his organ confined ISUP Grade 2 prostate cancer on surgical pathology with a doubling time of over 12 months puts him at low risk (<5%) for prostate cancer metastasis within 5 years using the EAU BCR risk stratification. While further evaluation with recurrence imaging or up-front treatment with salvage radiation are acceptable options for many patients with biochemical recurrence, for patients with significant competing risks of non-prostate cancer mortality and a low risk of prostate cancer metastasis, further evaluation and treatment are unlikely to benefit the patient but can lead to harm.

Question 84

A 63-year-old man undergoes low-dose brachytherapy for Gleason 3+4 cT1c prostate cancer with a pre-treatment PSA of 4 ng/mL. PSA nadir 9 months after completing treatment is 0.4 ng/mL. His PSA increases to 1.6 ng/mL over the subsequent 24 months, and then declines to 1.0 ng/mL in the following 6 months. The next step is:

Answer 84

Repeat PSA in 3 months.

Prostate MRI.

PSMA-PET/CT scan.

Prostate biopsy.

This patient is likely experiencing a PSA “bounce,” which has been reported to occur in over 30% of patients treated with brachytherapy. PSA bounce occurs on average 18 months after the initiation of radiation therapy and takes 33 months to return to nadir. Mean PSA bounce amplitude is 1.3 ng/mL. While it may be difficult to distinguish between a PSA bounce and biochemical recurrence for a patient with a rising PSA after radiation therapy, this patient is now experiencing a spontaneously declining PSA, consistent with a PSA bounce, as recurrent prostate cancer is unlikely to have sustained declines in PSA after an initial rise. Thus, rechecking the PSA is the best next step rather than initiating evaluation with imaging or biopsy.

Question 85

A 69-year-old man undergoes external beam radiation with androgen deprivation therapy for Gleason 4+4 cT2aN0M0 prostate cancer with a pre-treatment PSA of 12 ng/mL. Over the next year, his PSA increases from a nadir of 0.8 ng/mL to 2.8 ng/mL. PSMA-PET/CT scan demonstrates isolated uptake in the prostate and seminal vesicles, and a prostate MRI with contrast notes a mass at the base of the prostate involving the seminal vesicles. The next step is:

Answer 85

This patient has a rising PSA after prostate cancer radiation therapy with a doubling time of less than 12 months and post-radiation therapy nadir of over 0.4ng/mL, clinical features more consistent with biochemical recurrence as opposed to a PSA bounce. Imaging likewise supports local recurrence in the prostate and seminal vesicles. However, imaging alone is not able to definitively diagnose a local recurrence of prostate cancer in order to guide therapy. Thus, for a patient who may benefit from further local treatment, prostate biopsy should be performed to confirm viable recurrent prostate cancer before initiating further treatment.

Question 86

Eighteen months after radical prostatectomy for a Gleason 4+3 pT3R1N0 adenocarcinoma, a 62-year-old man has a PSA rise to 0.3 ng/mL with a doubling time of 24 months. PSMA-PET/CT is negative. The next step is:

Answer 86

Serial PSAs until PSMA-PET/CT demonstrates a PET-avid lesion.

Prostate fossa biopsy.

Salvage radiation therapy.

Androgen deprivation therapy alone.

Given the rising PSA, the negative PSMA-PET/CT, and the relatively slow PSA doubling time, the most appropriate next step would be:

Salvage radiation therapy.

Salvage radiation therapy is typically recommended in cases of biochemical recurrence after radical prostatectomy, especially when imaging is negative for distant metastasis, to target potential local recurrence in the prostate fossa.

Question 87

What percentage of visits do urological concerns account for in adults?

Answer 87

Up to 20% of visits.

Question 88

How common is microscopic hematuria in school-age children?

Answer 88

Population studies estimate that 4% of school-age children have microscopic hematuria on a single urinalysis and 1.1% on 2 or more tests.

Question 89

What is the incidence of gross hematuria in pediatric emergency room visits?

Answer 89

Gross hematuria has been estimated to account for 1.4 in 1,000 pediatric emergency room visits.

Question 90

What defines gross or macroscopic hematuria?

Answer 90

Gross or macroscopic hematuria occurs when red blood cells (RBCs) in urine are visible with the naked eye, resulting in an abnormal color.

Question 91

What is the definition of microscopic hematuria according to the most recent AUA guidelines?

Answer 91

Microscopic hematuria is defined as ≥3 RBCs per high-power field (HPF) on microscopic evaluation of a single, properly collected urine specimen.

Question 92

What is the primary goal of the hematuria workup in both pediatric and adult patients?

Answer 92

The primary goal is to identify the etiology and ensure that hematuria is not caused by a significant and potentially modifiable condition.

Question 93

What is the most concerning cause of hematuria in adults?

Answer 93

The most concerning cause of hematuria in adults is malignancy, which is present in 3%-10% of patients.

Question 94

What are the guidelines for the workup of adult hematuria?

Answer 94

The guidelines for adult hematuria include risk-stratified imaging and cystoscopy.

Question 95

Are there clear guidelines that dictate the workup of pediatric hematuria?

Answer 95

No, there are no clear guidelines that dictate the workup of pediatric hematuria.

Question 96

Flashcards for the Introduction

Flashcard 1:
```markdown
Question:
What percentage of visits do urological concerns account for in adults?

Answer:
Up to 20% of visits.
~~~

Flashcard 2:
```markdown
Question:
How common is microscopic hematuria in school-age children?

Answer:
Population studies estimate that 4% of school-age children have microscopic hematuria on a single urinalysis and 1.1% on 2 or more tests.
~~~

Flashcard 3:
```markdown
Question:
What is the incidence of gross hematuria in pediatric emergency room visits?

Answer:
Gross hematuria has been estimated to account for 1.4 in 1,000 pediatric emergency room visits.
~~~

Flashcard 4:
```markdown
Question:
What defines gross or macroscopic hematuria?

Answer:
Gross or macroscopic hematuria occurs when red blood cells (RBCs) in urine are visible with the naked eye, resulting in an abnormal color.
~~~

Flashcard 5:
```markdown
Question:
What is the definition of microscopic hematuria according to the most recent AUA guidelines?

Answer:
Microscopic hematuria is defined as ≥3 RBCs per high-power field (HPF) on microscopic evaluation of a single, properly collected urine specimen.
~~~

Flashcard 6:
```markdown
Question:
What is the primary goal of the hematuria workup in both pediatric and adult patients?

Answer:
The primary goal is to identify the etiology and ensure that hematuria is not caused by a significant and potentially modifiable condition.
~~~

Flashcard 7:
```markdown
Question:
What is the most concerning cause of hematuria in adults?

Answer:
The most concerning cause of hematuria in adults is malignancy, which is present in 3%-10% of patients.
~~~

Flashcard 8:
```markdown
Question:
What are the guidelines for the workup of adult hematuria?

Answer:
The guidelines for adult hematuria include risk-stratified imaging and cystoscopy.
~~~

Flashcard 9:
```markdown
Question:
Are there clear guidelines that dictate the workup of pediatric hematuria?

Answer:
No, there are no clear guidelines that dictate the workup of pediatric hematuria.
~~~

Summary

Hematuria in Children, Teenagers, and Young Adults: Introduction

• Prevalence:
  
  • Hematuria is common in both adults and children, with different etiologies and workup protocols.
  • Adults: Accounts for up to 20% of urological visits.
  • Children: 4% have microscopic hematuria on a single urinalysis, and 1.1% on 2 or more tests. Gross hematuria is less common but accounts for 1.4 in 1,000 pediatric ER visits.
• Definitions:
  
  • Gross Hematuria: Visible RBCs in urine causing discoloration.
  • Microscopic Hematuria: ≥3 RBCs per high-power field (HPF) on microscopic evaluation of a single, properly collected urine specimen.
• Workup Goals:
  
  • Identify the etiology of hematuria.
  • Ensure hematuria is not caused by significant and potentially modifiable conditions.
• Adult Hematuria:
  
  • Malignancy is a primary concern (3%-10% of patients).
  • Guidelines include risk-stratified imaging and cystoscopy.
• Pediatric Hematuria:
  
  • No clear guidelines exist for the workup.
  • The update reviews common causes and suggested workup based on risk factors and symptoms.

This summary and flashcards should help you understand the key points of the introduction to hematuria in children, teenagers, and young adults. If you need further details or have more questions, feel free to ask!

Question 97

What was the previous recommendation of the American Academy of Pediatrics (AAP) regarding screening urinalysis in children?

Answer 97

The AAP previously recommended screening urinalysis at multiple time points during childhood.

Question 98

Why did the AAP remove screening urinalysis from its health supervision guidelines in 2007?

Answer 98

The AAP removed screening urinalysis from its guidelines due to a lack of evidence of benefit in terms of early detection of chronic kidney disease (CKD) or other treatable conditions, and concerns about false-positives leading to costly, invasive, and anxiety-inducing evaluations.

Question 99

What did the 2018 AAP Choosing Wisely campaign recommend regarding universal screening urinalysis?

Answer 99

The 2018 AAP Choosing Wisely campaign recommended against universal screening urinalysis.

Question 100

What were the reasons for the AAP Choosing Wisely campaign’s recommendation against universal screening urinalysis?

Answer 100

The reasons included a high rate of false-positives, increased cost and familial anxiety, and the low prevalence of CKD and bladder cancer in children, leading to low rates of detection.

Question 101

Which children may benefit from screening urinalysis according to the AAP?

Answer 101

Children with risk factors such as prematurity or very low birth weight, congenital heart disease, recurrent urinary tract infections (UTIs), acute kidney injury (AKI), known urological congenital anomalies, history of organ transplant, malignancy, treatment with nephrotoxic medications, and family history of inherited renal disease.

Question 102

What percentage of patients were still undergoing urine screening at well-child visits despite the change in AAP guidelines?

Answer 102

Almost one-quarter of patients were still undergoing urine screening at well-child visits.

Question 103

Let’s create flashcards and a summary for the “SCREENING AND FOLLOW-UP OF MICROSCOPIC HEMATURIA” section.

Flashcards:

Flashcard 1:
```markdown
Question:
What was the previous recommendation of the American Academy of Pediatrics (AAP) regarding screening urinalysis in children?

Answer:
The AAP previously recommended screening urinalysis at multiple time points during childhood.
~~~

Flashcard 2:
```markdown
Question:
Why did the AAP remove screening urinalysis from its health supervision guidelines in 2007?

Answer:
The AAP removed screening urinalysis from its guidelines due to a lack of evidence of benefit in terms of early detection of chronic kidney disease (CKD) or other treatable conditions, and concerns about false-positives leading to costly, invasive, and anxiety-inducing evaluations.
~~~

Flashcard 3:
```markdown
Question:
What did the 2018 AAP Choosing Wisely campaign recommend regarding universal screening urinalysis?

Answer:
The 2018 AAP Choosing Wisely campaign recommended against universal screening urinalysis.
~~~

Flashcard 4:
```markdown
Question:
What were the reasons for the AAP Choosing Wisely campaign’s recommendation against universal screening urinalysis?

Answer:
The reasons included a high rate of false-positives, increased cost and familial anxiety, and the low prevalence of CKD and bladder cancer in children, leading to low rates of detection.
~~~

Flashcard 5:
```markdown
Question:
Which children may benefit from screening urinalysis according to the AAP?

Answer:
Children with risk factors such as prematurity or very low birth weight, congenital heart disease, recurrent urinary tract infections (UTIs), acute kidney injury (AKI), known urological congenital anomalies, history of organ transplant, malignancy, treatment with nephrotoxic medications, and family history of inherited renal disease.
~~~

Flashcard 6:
```markdown
Question:
What percentage of patients were still undergoing urine screening at well-child visits despite the change in AAP guidelines?

Answer:
Almost one-quarter of patients were still undergoing urine screening at well-child visits.
~~~

Summary:

Screening and Follow-Up of Microscopic Hematuria:

• AAP Screening Guidelines:
  
  • Previous Recommendations: Screening urinalysis at multiple time points during childhood.
  • Change in 2007: Removed from health supervision guidelines due to a lack of evidence for early detection benefits and concerns about false-positives leading to costly and invasive evaluations.
• 2018 AAP Choosing Wisely Campaign:
  
  • Recommendation: Against universal screening urinalysis.
  • Reasons: High rate of false-positives, increased cost and familial anxiety, low prevalence of CKD and bladder cancer in children, resulting in low rates of detection.
• Children Who May Benefit from Screening:
  
  • Risk Factors:
    
    • Prematurity or very low birth weight.
    • Congenital heart disease.
    • Recurrent UTIs.
    • Acute kidney injury (AKI).
    • Known urological congenital anomalies.
    • History of organ transplant.
    • Malignancy.
    • Treatment with nephrotoxic medications.
    • Family history of inherited renal disease.
• Current Practice:
  
  • Despite the change in guidelines, recent research shows that almost one-quarter of patients are still undergoing urine screening at well-child visits, leading to the incidental finding of microscopic hematuria.

This summary and flashcards should help you understand the key points about the screening and follow-up of microscopic hematuria in children. If you need further details or have more questions, feel free to ask!

Question 104

What should be done for patients where a cause of microscopic hematuria is identified?

Answer 104

Further workup and follow-up should be dictated by the etiology.

Question 105

What percentage of patients with microscopic hematuria will not have a clear causative diagnosis?

Answer 105

Up to 80% of patients with microscopic hematuria will not have a clear causative diagnosis.

Question 106

What are the long-term outcomes for patients with isolated microscopic hematuria?

Answer 106

The long-term outcomes are generally favorable.

Question 107

How should patients with isolated microscopic hematuria be monitored?

Answer 107

Patients can be safely observed with yearly follow-up by their pediatrician, including blood pressure measurement and urinalysis to assess for both persistent hematuria and proteinuria.

Question 108

What factors might warrant a referral to nephrology for a patient with persistent microscopic hematuria?

Answer 108

Risk factors such as proteinuria, elevated blood pressure, or family history of CKD may warrant a referral to nephrology for further workup and closer monitoring of renal function.

Question 109

Answer 109

Figure. Algorithm for the workup of pediatric hematuria. BMP indicates basic metabolic panel; Ca:Cr, calcium/creatinine; CT, computerized tomography; Mag3, mercaptoacetyltriglycine; MRU, magnetic resonance urography; RBCs, red blood cells; RBUS, renal bladder ultrasound; SLE, systemic lupus erythematosus; UA, urinalysis; UTI, urinary tract infection.

Question 110

What is the AUA definition of microhematuria?

Answer 110

Microhematuria is defined as ≥3 RBCs per high-power field (HPF) on a single, properly collected urine specimen.

Question 111

Why is a dipstick urinalysis not sufficient for diagnosing hematuria?

Answer 111

Dipstick urinalysis can result in false positives due to myoglobinuria, use of povidone iodine, hemoglobinuria, and dehydration.

Question 112

What should be done if a dipstick test is positive for hematuria?

Answer 112

A positive dipstick should prompt confirmatory testing with microscopy.

Question 113

What are some non-hematuria causes of discolored urine?

Answer 113

Non-hematuria causes include myoglobinuria, hemoglobinuria, certain foods (beets, blackberries, rhubarb, paprika), medications (nitrofurantoin, rifampin, phenazopyridine), and metabolites such as homogentisic acid.

Question 114

What physical characteristics of hematuria can help determine its origin?

Answer 114

• Upper tract pathology: Typically painless, brown or tea-colored hematuria.
• Lower tract cause: Often associated with dysuria, pink or red hematuria, sometimes with clots.
• Hematuria at the beginning or end of the stream suggests the urethra as the origin, while hematuria throughout the stream can be from any location along the urinary tract.

Question 115

What additional findings on microscopic urinalysis can suggest the etiology of hematuria?

Answer 115

• Proteinuria suggests a glomerular cause.
• Dysmorphic RBCs or RBC casts indicate a glomerular source.
• Intact RBCs suggest a nonglomerular origin.

Question 116

What should a careful history and physical exam include for a patient with hematuria?

Answer 116

• Associated signs or symptoms (pain, fevers, rashes, urinary symptoms)
• Association with trauma or exercise
• Family and personal history of hematuria, stones, or renal disease
• Palpation for flank and abdominal tenderness or mass
• Examination for bruising or blood at the urethral meatus
• Blood pressure measurement
• Evaluation for edema

Question 117

What is the most common initial imaging used for the workup of pediatric hematuria?

Answer 117

Renal bladder ultrasound (RBUS).

Question 118

What are the common initial labs beyond urinalysis for pediatric hematuria?

Answer 118

• Creatinine
• Albumin
• Complement component 3 (C3)
• Complement component 4 (C4)
• Complete blood count (CBC) if there is concern for significant blood loss or infection

Question 119

Are glomerular causes of hematuria more common in pediatric or adult patients?

Answer 119

Glomerular causes of hematuria are more common in pediatric patients.

Question 120

Is malignancy a common cause of hematuria in pediatric patients?

Answer 120

No, malignancy is less common in pediatric patients compared to adults.

Question 121

What percentage of pediatric patients with gross hematuria have a benign etiology or no cause identified?

Answer 121

The majority of pediatric patients with gross hematuria have a benign etiology or no cause identified.

Question 122

What were the most common diagnoses in a series of 342 pediatric patients presenting with gross hematuria?

Answer 122

• Benign urethrorrhagia in 19% of males
• UTI in 14%
• Trauma in 14%
• Congenital anomalies in 13%
• Stones in 6%
• Malignancy in 4 patients (3 bladder transitional cell carcinoma and 1 Wilms tumor)
• No etiology found in 34%

Question 123

What percentage of pediatric patients evaluated for microscopic hematuria had no specific cause identified?

Answer 123

80% of pediatric patients evaluated for microscopic hematuria had no specific cause identified.

Question 124

What percentage of pediatric patients evaluated for microscopic hematuria had hypercalciuria without stone disease?

Answer 124

16% of pediatric patients evaluated for microscopic hematuria had hypercalciuria without stone disease.

Question 125

Let’s create flashcards and a summary for the “CAUSES OF HEMATURIA” section.

Flashcards:

Flashcard 1:
```markdown
Question:
Are glomerular causes of hematuria more common in pediatric or adult patients?

Answer:
Glomerular causes of hematuria are more common in pediatric patients.
~~~

Flashcard 2:
```markdown
Question:
Is malignancy a common cause of hematuria in pediatric patients?

Answer:
No, malignancy is less common in pediatric patients compared to adults.
~~~

Flashcard 3:
```markdown
Question:
What percentage of pediatric patients with gross hematuria have a benign etiology or no cause identified?

Answer:
The majority of pediatric patients with gross hematuria have a benign etiology or no cause identified.
~~~

Flashcard 4:
```markdown
Question:
What were the most common diagnoses in a series of 342 pediatric patients presenting with gross hematuria?

Answer:
- Benign urethrorrhagia in 19% of males
- UTI in 14%
- Trauma in 14%
- Congenital anomalies in 13%
- Stones in 6%
- Malignancy in 4 patients (3 bladder transitional cell carcinoma and 1 Wilms tumor)
- No etiology found in 34%
~~~

Flashcard 5:
```markdown
Question:
What percentage of pediatric patients evaluated for microscopic hematuria had no specific cause identified?

Answer:
80% of pediatric patients evaluated for microscopic hematuria had no specific cause identified.
~~~

Flashcard 6:
```markdown
Question:
What percentage of pediatric patients evaluated for microscopic hematuria had hypercalciuria without stone disease?

Answer:
16% of pediatric patients evaluated for microscopic hematuria had hypercalciuria without stone disease.
~~~

Summary:

Causes of Hematuria in Pediatric Patients:

• Prevalence and Etiology:
  
  • Glomerular causes are more common in children, while malignancy is less common compared to adults.
  • Even with gross hematuria, most pediatric cases have benign etiologies or no identified cause.
• Series of 342 Patients with Gross Hematuria:
  
  • Diagnoses:
    
    • Benign urethrorrhagia: 19% of males
    • UTI: 14%
    • Trauma: 14%
    • Congenital anomalies: 13%
    • Stones: 6%
    • Malignancy: 4 patients (3 bladder transitional cell carcinoma, 1 Wilms tumor)
    • No etiology: 34%
• Series of 342 Patients with Microscopic Hematuria:
  
  • Findings:
    
    • No specific cause: 80%
    • Hypercalciuria without stone disease: 16%
• Diagnosis:
  
  • All malignancies in the gross hematuria series were diagnosed on renal bladder ultrasound (RBUS).

The next sections will discuss specific causes of hematuria and the associated findings that suggest these diagnoses. The Table (not provided here) lists common causes of pediatric hematuria and classic findings that should alert clinicians to these potential diagnoses.

This summary and flashcards should help you understand the key points about the causes of hematuria in pediatric patients. If you need further details or have more questions, feel free to ask!

Question 126

What are some common glomerular causes of pediatric hematuria?

Answer 126

• Postinfectious glomerulonephritis
• IgA nephropathy (Berger’s disease)
• Alport syndrome
• Thin basement membrane disease (benign familial hematuria)
• Membranoproliferative glomerulonephritis
• Focal segmental glomerulosclerosis
• Membranous nephropathy
• Acute interstitial nephritis

Question 127

Name some systemic glomerular causes of pediatric hematuria.

Answer 127

• Henoch-Schönlein purpura
• Hemolytic uremic syndrome
• Systemic lupus erythematosus
• Serum sickness
• Polyarteritis nodosa
• Goodpasture disease
• Thrombotic thrombocytopenic purpura

Question 128

List some systemic nonglomerular causes of pediatric hematuria.

Answer 128

• Sickle cell disease or trait
• Hemophilia
• Coagulopathies
• Strenuous exercise

Question 129

What are some nonglomerular infectious causes of pediatric hematuria?

Answer 129

• Cystitis
• Pyelonephritis
• Viral or bacterial infections
• Schistosomiasis

Question 130

Name some urolithiasis-related causes of pediatric hematuria.

Answer 130

• Kidney or ureteral stones
• Bladder stones

Question 131

What anatomical urinary tract anomalies can cause pediatric hematuria?

Answer 131

• UPJ obstruction
• UVJ obstruction
• Bladder diverticula
• Urinary tract polyps
• Renal cysts
• Calyceal diverticulum
• Urethral prolapse

Question 132

List some malignancies that can cause pediatric hematuria.

Answer 132

• Rhabdomyosarcoma
• Bladder tumors
• Renal masses (Wilms or other)

Question 133

What are some vascular anomalies that can cause pediatric hematuria?

Answer 133

• Renal vein thrombosis
• Nutcracker syndrome
• Arteriovenous malformations
• Hemangiomas

Question 134

What types of trauma can cause pediatric hematuria?

Answer 134

• Renal trauma
• Ureteral trauma
• Bladder trauma
• Urethral trauma

Question 135

Answer 135

Table. Causes of Pediatric Hematuria

Question 136

When should glomerular disease be suspected as the cause of hematuria?

Answer 136

Glomerular disease should be suspected when proteinuria, edema, or hypertension is present.

Question 137

What is the most common cause of acute nephritis in children worldwide?

Answer 137

Postinfectious glomerulonephritis.

Question 138

What is the incidence of postinfectious glomerulonephritis in children worldwide?

Answer 138

9.5-28.5 cases per 100,000 annually.

Question 139

What are common causes of postinfectious glomerulonephritis in industrialized countries?

Answer 139

• Streptococcal infections (25%)
• Staphylococcus infections (25%)

Question 140

How does IgA nephropathy (Berger’s disease) typically present?

Answer 140

It presents within 2-3 days of an upper respiratory tract or gastrointestinal infection, with intermittent hematuria.

Question 141

What percentage of patients with IgA nephropathy may develop chronic kidney disease (CKD)?

Answer 141

15%-30% of patients may develop CKD.

Question 142

What are the associated conditions and symptoms of Alport syndrome?

Answer 142

Alport syndrome is associated with high-frequency sensorineural hearing loss, ocular anomalies, and progressive CKD to end-stage renal disease (ESRD) before age 40.

Question 143

What is thin basement membrane disease (benign familial hematuria), and what is its prognosis?

Answer 143

Thin basement membrane disease is an autosomal dominant condition causing persistent microscopic hematuria, typically not progressing to CKD, though monitoring for proteinuria and hypertension is recommended.

Question 144

Let’s create flashcards and a summary for the “Primary Glomerular Causes” section based on the provided text.

Flashcards:

Flashcard 1:
```markdown
Question:
When should glomerular disease be suspected as the cause of hematuria?

Answer:
Glomerular disease should be suspected when proteinuria, edema, or hypertension is present.
~~~

Flashcard 2:
```markdown
Question:
What is the most common cause of acute nephritis in children worldwide?

Answer:
Postinfectious glomerulonephritis.
~~~

Flashcard 3:
```markdown
Question:
What is the incidence of postinfectious glomerulonephritis in children worldwide?

Answer:
9.5-28.5 cases per 100,000 annually.
~~~

Flashcard 4:
```markdown
Question:
What are common causes of postinfectious glomerulonephritis in industrialized countries?

Answer:
- Streptococcal infections (25%)
- Staphylococcus infections (25%)
~~~

Flashcard 5:
```markdown
Question:
How does IgA nephropathy (Berger’s disease) typically present?

Answer:
It presents within 2-3 days of an upper respiratory tract or gastrointestinal infection, with intermittent hematuria.
~~~

Flashcard 6:
```markdown
Question:
What percentage of patients with IgA nephropathy may develop chronic kidney disease (CKD)?

Answer:
15%-30% of patients may develop CKD.
~~~

Flashcard 7:
```markdown
Question:
What are the associated conditions and symptoms of Alport syndrome?

Answer:
Alport syndrome is associated with high-frequency sensorineural hearing loss, ocular anomalies, and progressive CKD to end-stage renal disease (ESRD) before age 40.
~~~

Flashcard 8:
```markdown
Question:
What is thin basement membrane disease (benign familial hematuria), and what is its prognosis?

Answer:
Thin basement membrane disease is an autosomal dominant condition causing persistent microscopic hematuria, typically not progressing to CKD, though monitoring for proteinuria and hypertension is recommended.
~~~

Summary:

Primary Glomerular Causes of Pediatric Hematuria:

• General Indications:
  
  • Hematuria from glomerular disease can be microscopic or gross.
  • Suspect glomerular causes when proteinuria, edema, or hypertension is present.
• Postinfectious Glomerulonephritis:
  
  • Prevalence: Most common cause of acute nephritis in children worldwide.
  • Incidence: 9.5-28.5 cases per 100,000 annually.
  • Causes:
    
    • 25% from streptococcal infections.
    • 25% from Staphylococcus infections.
  • Presentation: Variable; can range from asymptomatic microscopic hematuria to gross hematuria, proteinuria, edema, hypertension, and acute kidney injury (AKI).
  • Resolution: Hematuria and proteinuria usually resolve in weeks to months.
• IgA Nephropathy (Berger’s Disease):
  
  • Mechanism: Deposition of IgA in the glomerular mesangium.
  • Presentation: Intermittent hematuria, typically within 2-3 days of an upper respiratory or gastrointestinal infection.
  • Long-term Risk: 15%-30% may develop CKD. Older age, proteinuria, and hypertension are associated with poorer outcomes.
• Alport Syndrome and Thin Basement Membrane Disease:
  
  • Commonality: Both are related to defects in type IV collagen.
  • Alport Syndrome:
    
    • Inheritance: Most commonly X-linked.
    • Associated Conditions: High-frequency sensorineural hearing loss, ocular anomalies, progressive CKD to ESRD before age 40.
  • Thin Basement Membrane Disease (Benign Familial Hematuria):
    
    • Inheritance: Autosomal dominant.
    • Prevalence: Occurs in 1% of the population.
    • Prognosis: Persistent microscopic hematuria, typically does not progress to CKD. Monitoring for proteinuria and hypertension is recommended.

This summary and flashcards should help you understand the key points about the primary glomerular causes of pediatric hematuria. If you need further details or have more questions, feel free to ask!

Question 145

What is Henoch-Schönlein purpura (HSP) and what are its classic symptoms?

Answer 145

Henoch-Schönlein purpura (HSP) is a small vessel vasculitis that affects the skin, gut, and small vessels of the kidney due to IgA deposits. Classic symptoms include transient arthralgias, abdominal pain, a palpable purpuric rash of the lower extremities, and nephritis with hematuria (gross or microscopic) in 60% of cases.

Question 146

What is the usual treatment for Henoch-Schönlein purpura (HSP) and what percentage of patients progress to end-stage renal disease (ESRD)?

Answer 146

HSP is generally self-limited and treated with supportive measures and sometimes steroids. Approximately 1% of patients will progress to ESRD.

Question 147

What is the classic triad of symptoms for hemolytic uremic syndrome (HUS)?

Answer 147

The classic triad of symptoms for HUS includes anemia, thrombocytopenia, and acute kidney injury (AKI).

Question 148

What is the traditional infectious etiology of hemolytic uremic syndrome (HUS) and what additional symptom does it commonly cause?

Answer 148

HUS is traditionally caused by infection with Shiga toxin-producing Escherichia coli, which also causes bloody diarrhea.

Question 149

What is one of the leading causes of AKI in children under 3 years and what are the long-term risks for these patients?

Answer 149

Shiga toxin-producing E. coli-HUS is one of the leading causes of AKI in children under 3 years. Though most patients will recover their renal function, a small group will develop CKD and ESRD, requiring close monitoring and follow-up.

Question 150

What percentage of patients with systemic lupus erythematosus have renal involvement and what are common renal presentations?

Answer 150

Approximately 50% of patients with systemic lupus erythematosus have renal involvement. Common renal presentations include microscopic hematuria (80%), proteinuria, hypertension, and a decline in renal function. Gross hematuria is uncommon (<5%).

Question 151

What should raise suspicion for systemic lupus erythematosus in patients with renal manifestations?

Answer 151

Renal manifestations, along with involvement of multiple other organ systems (such as malar rash, fatigue, arthralgias, thrombocytopenia, and anemia), should raise suspicion for systemic lupus erythematosus.

Question 152

Why are children more likely than adults to sustain renal injuries in trauma?

Answer 152

Children’s kidneys are relatively larger and less well protected by their abdominal wall and rib cage.

Question 153

What imaging is recommended by AUA guidelines for evaluating renal injury in pediatric trauma patients?

Answer 153

CT scan with intravenous contrast is recommended in all abdominal blunt trauma patients with either microscopic hematuria and systolic blood pressure <90 mm Hg or gross hematuria. Delayed images should be obtained to evaluate for collecting system injury, often resulting in a CT urogram.

Question 154

What is the European Association of Urology pediatric guideline recommendation for imaging in children with abdominal trauma and hematuria?

Answer 154

Imaging is recommended in all children with either a blunt or penetrating abdominal injury and any degree of hematuria. Many pediatric groups suggest >50 RBCs/HPF as a reasonable cutoff without the use of hypotension.

Question 155

What imaging should be performed in pediatric patients with pelvic fractures and gross hematuria or clinical concern for bladder rupture?

Answer 155

A cystogram (standard radiography or CT) that includes both images with the bladder filled to capacity and after emptying should be performed.

Question 156

What percentage of pediatric patients with pelvic fractures and gross hematuria have bladder injuries?

Answer 156

Up to 45% of these patients will have bladder injuries.

Question 157

What is the prevalence of ureteral trauma in pediatric urological trauma cases, and how is it diagnosed?

Answer 157

Ureteral trauma comprises only 1% of pediatric urological trauma cases. It can be diagnosed using a CT urogram, with further information gained by retrograde or antegrade pyelograms at the time of stent or nephrostomy tube placement.

Question 158

What should raise suspicion for urethral injury in pediatric trauma patients, and what imaging should be performed?

Answer 158

Suspicion should be raised when there is a pelvic fracture with blood at the urethral meatus, gross hematuria, or pain or difficulty voiding. Retrograde urethrogram should be performed prior to catheter placement, or if a catheter is already placed and draining, a periurethral retrograde urethrogram can be performed.

Question 159

How are urethral injuries in females often evaluated?

Answer 159

They often require an exam under anesthesia for a pelvic exam to evaluate for concomitant vaginal injury and for visualization of the urethra and bladder neck with cystoscopy.

Question 160

Let’s create flashcards and a summary for the “Trauma” section based on the provided text.

Flashcards:

Flashcard 1:
```markdown
Question:
Why are children more likely than adults to sustain renal injuries in trauma?

Answer:
Children’s kidneys are relatively larger and less well protected by their abdominal wall and rib cage.
~~~

Flashcard 2:
```markdown
Question:
What imaging is recommended by AUA guidelines for evaluating renal injury in pediatric trauma patients?

Answer:
CT scan with intravenous contrast is recommended in all abdominal blunt trauma patients with either microscopic hematuria and systolic blood pressure <90 mm Hg or gross hematuria. Delayed images should be obtained to evaluate for collecting system injury, often resulting in a CT urogram.
~~~

Flashcard 3:
```markdown
Question:
What is the European Association of Urology pediatric guideline recommendation for imaging in children with abdominal trauma and hematuria?

Answer:
Imaging is recommended in all children with either a blunt or penetrating abdominal injury and any degree of hematuria. Many pediatric groups suggest >50 RBCs/HPF as a reasonable cutoff without the use of hypotension.
~~~

Flashcard 4:
```markdown
Question:
What imaging should be performed in pediatric patients with pelvic fractures and gross hematuria or clinical concern for bladder rupture?

Answer:
A cystogram (standard radiography or CT) that includes both images with the bladder filled to capacity and after emptying should be performed.
~~~

Flashcard 5:
```markdown
Question:
What percentage of pediatric patients with pelvic fractures and gross hematuria have bladder injuries?

Answer:
Up to 45% of these patients will have bladder injuries.
~~~

Flashcard 6:
```markdown
Question:
What is the prevalence of ureteral trauma in pediatric urological trauma cases, and how is it diagnosed?

Answer:
Ureteral trauma comprises only 1% of pediatric urological trauma cases. It can be diagnosed using a CT urogram, with further information gained by retrograde or antegrade pyelograms at the time of stent or nephrostomy tube placement.
~~~

Flashcard 7:
```markdown
Question:
What should raise suspicion for urethral injury in pediatric trauma patients, and what imaging should be performed?

Answer:
Suspicion should be raised when there is a pelvic fracture with blood at the urethral meatus, gross hematuria, or pain or difficulty voiding. Retrograde urethrogram should be performed prior to catheter placement, or if a catheter is already placed and draining, a periurethral retrograde urethrogram can be performed.
~~~

Flashcard 8:
```markdown
Question:
How are urethral injuries in females often evaluated?

Answer:
They often require an exam under anesthesia for a pelvic exam to evaluate for concomitant vaginal injury and for visualization of the urethra and bladder neck with cystoscopy.
~~~

Summary:

Trauma and Pediatric Hematuria:

• General Considerations:
  
  • Not all patients with urological trauma will have hematuria.
  • The presence of hematuria in the setting of trauma should prompt thorough evaluation for the source.
• Renal Injuries:
  
  • Children are more likely to sustain renal injuries due to the relative size and less protection of their kidneys.
  • AUA Guidelines: Recommend CT scan with intravenous contrast for blunt trauma patients with microscopic hematuria and systolic BP <90 mm Hg or gross hematuria. Delayed images are obtained to evaluate for collecting system injury, often resulting in a CT urogram.
  • European Association of Urology Guidelines: Recommend imaging for all children with blunt or penetrating abdominal injury and any degree of hematuria. Many pediatric groups suggest >50 RBCs/HPF as a reasonable cutoff without hypotension.
• Bladder Injuries:
  
  • Children are at higher risk due to the bladder’s higher location in the abdomen.
  • Gross hematuria in the setting of pelvic fracture or clinical concern for bladder rupture should be evaluated with a cystogram (standard radiography or CT) including images with the bladder filled to capacity and after emptying.
  • Up to 45% of patients with pelvic fractures and gross hematuria have bladder injuries.
• Ureteral Trauma:
  
  • Comprises only 1% of pediatric urological trauma cases.
  • Requires a high index of suspicion; only 46% of patients have gross hematuria, 38% microscopic.
  • Diagnosed using CT urogram, with further information from retrograde or antegrade pyelograms during stent or nephrostomy tube placement.
• Urethral Injuries:
  
  • Suspected with pelvic fracture, blood at the urethral meatus, gross hematuria, pain, or difficulty voiding.
  • Associated with perineal or scrotal hematoma and swelling.
  • Retrograde urethrogram should be performed before catheter placement or a periurethral retrograde urethrogram if a catheter is already placed and draining.
  • More common in males, but in females, they often require an exam under anesthesia for pelvic exam and visualization with cystoscopy.

These flashcards and summary should help you understand the key points about trauma-related causes of pediatric hematuria. If you need further details or have more questions, feel free to ask!

Question 161

What percentage of patients with acute UTI or pyelonephritis present with microscopic hematuria?

Answer 161

Up to 50% of patients with acute UTI or pyelonephritis present with microscopic hematuria.

Question 162

What are some symptoms associated with infection that suggest pyelonephritis?

Answer 162

Symptoms suggesting pyelonephritis include flank pain, fever, nausea, and vomiting.

Question 163

How is the diagnosis of a UTI confirmed?

Answer 163

The diagnosis of a UTI is confirmed with a urine culture that provides information regarding bacteria and antibiotic sensitivities.

Question 164

What are common viral causes of hemorrhagic cystitis in immunocompromised patients?

Answer 164

Common viral causes of hemorrhagic cystitis include BK virus, JC virus, cytomegalovirus, and adenovirus.

Question 165

What is the most common cause of gross hematuria in immunocompromised patients?

Answer 165

Viral UTIs are the most common cause of gross hematuria in immunocompromised patients.

Question 166

How is schistosomiasis diagnosed and treated?

Answer 166

Schistosomiasis is diagnosed with urine microscopy showing parasitic eggs and treated with praziquantel.

Question 167

What is the geographic area associated with Schistosoma haematobium, and why is travel history important?

Answer 167

Schistosoma haematobium is found in the water of sub-Saharan Africa, so travel history is important for diagnosis.