B5.082 Prework 1: Hematuria: Benign Causes Flashcards
process of microscopic urinalysis
10 mL of midstream clean catch specimen is centrifuged for 10 min at 2000 rpm
3 or more rbc per hpf
does excessive anticoagulation lead to hematuria?
no
but may make degree and duration worse
overview of the steps taken when evaluating microscopic hematuria
- dipstick
- microscopic urinalysis
- assess for UTI or benign causes
- renal function testing
- CT urography
- cystoscopy
categories of evaluation
medical history physical exam lab workup upper tract imaging lower tract imaging
risk factors for urinary tract malignancy
> 35 years analgesic abuse chemicals/dyes male sex smoking history of: indwelling foreign body, chronic UTI, known carcinogens, gross hematuria, irritative voiding, pelvic irradiation, urologic disorder/disease
important components of physical in analysis of hematuria
BP edema cardiac arrhythmia CVA tenderness DRE pelvic exam
components of a urinalysis
RBCs
WBCs
presence of bacteria
nitrites
what do you do if infection is suspected?
urine culture must be sent to confirm infection
UA must be repeated after treatment
components of a lab workup for microscopic hematuria
UA
culture?
renal function studies
PSA
alternatives to CT urography for imaging
MRI
US
non-contrast CT
retrograde pyelography
mechanism for evaluation of lower urinary tract
cystoscopy
most common benign etiologies of microscopic hematuria
idiopathic : 43-68%
UTI: 4-22%
urolithiasis: 4-5%
BPH: 10-13%
uncomplicated UTI
infection in a healthy patient with functionally normal urinary tract
complicated UTI
infection associated with anatomic/functional abnormality of urinary tract, immunocompromised host, or MDR bacteria
risk factors for UTI
reduced urine flow
colonization
facilitation of ascent (catheter, incontinence)
host factors that can predispose to UTI
changes in estrogen, low vaginal pH high urine glucose obstruction vesicoureteral reflux immunocompromised pregnancy SCI
which bacterial factor is associated with pyelonephritis?
type P pili/fimbrae
use of UA in suspected URI
catheterized urine is best
dipstick urinalysis rules infection out not in
nitrite positivity is very specific
pyuria (>10 WBC/hpf) is most sensitive for UTI
quantitative urine culture in UTI
100,000 CFU is diagnostic
indications for imaging in UTI evaluation
persistence after treatment sepsis from urinary source history of urolithiasis neurogenic bladder poor response to therapy infections with urea-splitting bacteria recurrence with same or unusual strain
DOC for uncomplicated UTI
nitrofurantoin 100 mg BID x 5 days
TMP/SMX BID x 3 days
outpatient management of complicated UTI
Cipro BID x 7 days
Levaquin x 5 days
TMP/SMX BID x 14 days
one time IV then 14 day oral ttx
inpatient management of complicated UTI
IV fluoro aminoglycoside + ampicillin 3rd gen ceph extended spectrum pen carbapenem switch from parenteral to oral in 48 hours if clinical improvement, treat for 14 days
pathophys of urolithiasis
soluble urine metabolites occur in amounts too high to stay dissolved in urine
supersaturation allows precipitation and aggregation to form crystalline concentrations
obstruction from a stone can cause pain via ureteral dilation
common types of stones
calcium oxalate uric acid struvite calcium phosphate cystine
calcium oxalate stones
most common
urinary citrate is an inhibitor
risk factors: dehydration, hypercalciuria, hyperoxaluria, hypernatriuria, hyperuricosuria
treatment: fluids, decreased Ca in urine, increasing citrate
uric acid stones
for in ACIDIC urine, 100 times more soluble at pH > 6
risk factors: persistently acidic urine from diet high in protein, hyperuricemia, hyperuricosuria, treatment of lymphoma/leukemia
treatment: alkalization of urine
urine alkalization agents
K+ citrate
Na+ citrate
Na+ bicarb
struvite stones
magnesium ammonium phosphate stones
caused by infections with urease producing organisms (proteus)
form staghorn calculi
treatment: surgical removal and aggressive treatment of infection
calcium phosphate stones
form in ALKALINE unrine
usually associated with metabolic disorders such as type 1 RTA (distal), primary hyperparathyroidism, or medullary sponge kidney
treatment: managing the underlying disorder
cystine stones
autosomal recessive disorder known as cystinuria
microscopic hexagonal crystals
cystine more soluble in alkaline urine
treatment: alkalization of urine, treat with drug Thiola to break down sulfide bond
clinical signs of urolithiasis
colicky flank pain radiating to groin or scrotum
nausea and vomiting
CVA tenderness
hematuria
imaging for urolithiasis
non-contrast CT
lab workup for urolithiasis
UA + culture
serum creatinine and electrolytes
WBC count
indications for urgent intervention for urolithiasis
concomitant UTI, fever, or signs of sepsis
renal azotemia (high serum Cr)
solitary kidney (impending renal damage)
intractable pain, nausea, or vomiting despite treatment
patient preference
expectant management for urolithiasis
pain control with NSAIDs
medical expulsive therapy with a blocker
observation of 2-4 weeks
options for urgent surgical intervention of urolithiasis
placement of ureteral stent
placement of percutaneous nephrostomy tube
don’t break the stone in case of releasing bacterial endotoxins causing sepsis
how to treat a kidney stone itself
oral dissolution therapy
extracorporal shock wave lithotripsy
ureteroscopy with intracorporal lithotripsy
percutaneous nephrolithotomy
what workup is necessary when someone has recurrent stones?
metabolic work up
general dietary modifications to prevent kidney stones
increase fluid
decrease dietary salt
moderate animal protein
increase dietary citrate
what is BPH
histologic diagnosis
increase in number of prostatic stromal and epithelial cells in the transition zone
lower urinary tract symptoms associated with BPH
phenotypic diagnosis
urinary frequency, urgency, slow stream, straining
pathophys of BPH
transition zone hyperplasia leads to increased resistance via:
- bladder outlet obstruction from tissue (static)
- increased smooth tone and resistance within the gland (dynamic)
storage symptoms
frequency
urgency
nocturia
emptying symptoms
weak stream
intermittent flow
straining to urinate
incomplete emptying
indications for surgical management of BPH
gross hematuria UTI bladder stones urinary retention bladder diverticula
drug therapy options for BPH
alpha blocker: relax prostatic smooth muscle by blocking a1 adrenergic receptors
5 alpha reductase inhibitor: block conversion of testosterone to DHT and decrease prostate volume by 30%
surgical options in BPH
TURP (gold standard)
open simple prostatectomy
transurethral laser surgery
minimally invasive therapy
