Ch. 18 Renal/GU Flashcards
Proteinuria + RBC casts +hematuria = ______
Glomerulonephritis
Proteinuria + fatty casts or oval bodies = _____
nephrotic syndrome
proteinuria + WBCs, WBC casts without bacteria = _____
interstitial nephritis
proteinuria + hyaline casts = _____
benign causes
How is nephrotic syndrome diagnosed?
clinical and lab findings:
1. peripheral edema and/or ascites
2. proteinuria: 3+ or 4+ on dipstick, or 3.5g protein per 24 hours
How should nephrotic syndromes be treated?
fluid restriction
IV diuretics
BP control with ACE inhibitors
Corticosteroids may reverse or delay disease progression
What is a complication of nephrotic syndrome?
increased risk of thrombosis – DVTs and renal vein thrombosis
What are some things that can cause pseudohematuria?
- foods: beets, berries, rhubarb
- meds: rifampin, phenazopyridine, nitrofurantoin
- Porphyrias (heme precursors enter urine)
Hematuria + hearing loss… diagnosis?
Alport syndrome
hematuria + recent URI.. what two things should be on your differential?
Glomerulonephritis
IgA nephropathy
hematuria + petechiae/purpura +/- schistocytes on smear
In a child?
In an adult?
in a child, think HUS
in an adult, think TTP
Hematuria in a developing country, what should you consider?
Schistosomiasis
What serum BUN/Cr ratio suggests prerenal source of AKI?
> 20:1
What serum BUN/Cr ratio suggests post-renal source of AKI?
> 20:1
What serum BUN/Cr ratio suggests acute tubular necrosis as cause for AKI?
<20:1
What do you see on urinalysis in prerenal AKI?
normal or hyaline casts
In what type of AKI would you see granular (muddy brown) casts on UA?
acute tubular necrosis
In what type of AKI would you see dysmorphic RBCs, RBC casts, and proteinuria on UA?
intrinsic AKI: renal acute glomerulonephritis
In what type of AKI would you see WBC, WBC casts, eosinophils on UA?
Acute interstitial nephritis
How is FENa calculated?
(urine sodium X plasma Cr) / (plasma sodium X urine Cr) x 100
What types of medicines may contribute to prerenal AKI?
NSAIDs, ACE inhibitors
What are 4 causes of intrinsic AKI?
- GN
- AIN
- ATN
- Vascular disease
What diseases fall under GN?
- poststrep GN
- lupus
- Goodpasture
- systemic vasculitis
How is GN diagnosed?
hematuria, dysmorphic RBCs, proteinuria (may or may not be nephrotic range), and RBC casts
Renal biopsy is definitive
What is the treatment for GN?
supportive care, control BP
steroids/immunosuppressives to treat an underlying disease; but not for poststrep GN
What medications cause AIN?
penicillins, diuretics, anticoagulants, NSAIDs
What are symptoms of AIN?
vary – 35% have fever, 30% arthralgias, 20% rash
How is AIN diagnosed?
elevated BUN/Cr
presence of eosinophils, WBCs, and WBC casts on UA
Renal biopsy is definitive
What is the treatment for AIN?
supportive care
discontinue offending agents
Steroids only if no improvement after 3-7 days – no indication in ED
What is the most common etiology of hospital-acquired AKI?
Acute Tubular Necrosis
What are some nephrotoxic agents that can cause acute tubular necrosis?
aminoglycosides (Gentamycin, tobramicin)
radiocontrast agents
What type of AKI does rhabdo cause?
ATN
How is ATN diagnosed?
loss of urinary concentrating ability.
Urinalysis: Granular (muddy brown) casts and renal tubular casts.
or presence of rhabdo
What is the treatment for ATN?
Treat underlying precipitating cause or discontinue offending age
What conditions may put you at higher risk of ATN?
diabetes
pre-existing renal insufficiency
that will be receiving contrast agents
In those with DM or renal insufficiency, what could you pretreat with to prevent ATN?
N-acetylcysteine
and/or sodium bicarbonate, and IV hydration with normal saline
How is CKD defined?
permanent loss of renal function of > 3 months duration
How is CKD staged?
based on the
estimated glomerular filtration rate (GFR)
How is ESRD defined?
End-stage renal disease (ESRD, or kidney failure) is the final endpoint where GFR is < 10% of normal,
& clinical sx of uremia will ensue without dialysis or transplant
What are symptoms of uremia?
anorexia, nausea, vomiting, and decreased mental function
What do you call the deposition of urea from evaporated sweat; fine white powder on skin?
Uremic frost
What is renal osteodystrophy?
Due to loss of vitamin D3 production and secondary hyperparathyroidism
■ Bone pain, muscle weakness, fractures
What dx should you consider in any ill-appearing patient with ESRD?
Cardiac Tamponade
What do you call the D\deposition in the tunica media of small arteries leading
to thrombosis, ischemia, and necrosis of skin and soft tissues?
calciphylaxis
What type of anemia does ESRD typically cause and why?
Normocytic, normochromic
■ Due to decreased erythropoietin production and RBC survival time
Why are ESRD patients at higher risk of bleeding?
Multifactorial: Decreased platelet function, altered von Willebrand factor (vWF)
What is asterixis?
hand flapping
with dorsiflexion
What is first line treatment for acute bleeding in ESRD patients?
DDAVP: First line, stimulates release of vWF from endothelial cells
What is second line treatment for acute bleeding in ESRD patients?
Cryoprecipitate: Contains factors I (fibrinogen), II (fibronectin), VIII,
XIII, and vWF
What are the indications for dialysis?
A: Severe acid-base disturbance (metabolic acidosis)
E: Severe electrolyte disturbance (hyperkalemia, hypercalcemia)
I: Certain toxic ingestions (eg, lithium, alcohols, barbiturates, salicylates)
O: Volume overload (pulmonary edema, severe HTN)
U: Symptomatic uremia (pericarditis, twitching, nausea/vomiting, encephalopathy)
What do you call cerebral edema due to rapid changes in body fluid composition and osmolality in setting of dialysis?
Dialysis Disequilibrium Syndrome
What is the treatment for Dialysis Disequilibrium Syndrome?
supportive;
no indication for mannitol or hypertonic saline
What is the treatment for suspected infection of vascular access sites?
IV Vanc
+
Gentamycin or 3rd generation cephalosporin
What bacteria is most commonly associated with vascular access infections?
staph
What 2 organisms most commonly cause peritoneal dialysis-related peritonitis?
staph and strep
How is peritoneal dialysis-related peritonitis diagnosed?
PD fluid with > 100 WBC/mm3 with > 50% neutrophils or a positive Gram stain.
(This is a lower cutoff than the 250 neutrophils/mm3 for SBP)
What is Branham sign with regards to fistulas?
The drop in heart rate with occlusion of the dialysis access site
** indicates a high output
heart failure from excess flow
through the AV fistula.
The diagnosis can be confirmed with Doppler ultrasound.
What is the treatment from PD peritonitis?
Intraperitoneal (IP) antibiotics (may give IV if IP not immediately available):
Vancomycin or third-generation cephalosporin
What is the most common site of urolithiasis?
UV junction (ureterovesicular)
With what types of bacteria do you see struvite kidney stones?
Urea-splitting bacteria such as:
- pseudomonas
- klebsiella
- staphylococcus
- proteus
What type of stone typically makes up staghorn calculi?
struvite stones
Struvite stones are typically present with what acidity of urine?
alkaline, pH >7.6
Uric acid stones are typically present in what acidity of urine?
acidotic, pH <5.0
When you are thinking of urolithiasis due to flank pain, what other diagnosis MUST be considered in patient >50 years old?
AAA
What is first line treatment for urolithiasis?
Analgesia– NSAIDs are first line, then +/- opioids
What are the 4 admission criteria for Urolithiasis?
- Obstruction with concomitant infection
- Intractable pain or vomiting
- Solitary kidney
- Acute Renal Insufficiency
What makes a UTI complicated?
- men
- elderly
- pregnant
- serious medical condition
- immunosuppression
- recent hospitalization
- treatment failure
- structural abnormalities
- pyelo
- indwelling catheter
- recent instrumentation
Most common organism to cause UTIs?
E coli
Second most common organism in UTIs?
Staph saprophyticus
How is pyuria defined?
> 2-5 WBC/hpf
When is a urine culture positive?
> 100 CFU/mL in males or symptomatic females
100,000 CFU/mL in asymptomatic patients
What is the most common cause of dysuria or pyuria in sexually active young male?
urethritis or prostatitis
What is first line treatment for acute uncomplicated cystitis?
Bactrim (TMP/SMX), Macrobid (Nitrofurantoin), second gen cephalosporin, or fluoroquinolone
for 3-5 days
What is first line treatment for Acute uncomplicated
cystitis with comorbid
conditions?
Bactrim (TMP/SMX), Macrobid (Nitrofurantoin), or fluoroquinolone (Ciprofloxacin)
for 7 days
What is first line outpatient treatment for Acute uncomplicated
pyelonephritis?
- Oral fluoroquinolone 7d or
- Bactrim (TMP/SMX) 14d
What is first line INpatient treatment for Acute uncomplicated
pyelonephritis?
IV fluoroquinolone or
Ampicillin/Gentamycin
14 days
What is first line treatment for outpatient treatment of complicated UTI?
14d Oral fluoroquinolone (Cipro) or trimethoprim/
sulfamethoxazole (Bactrim)
What is first line treatment for inpatient treatment of complicated UTI?
■ IV ampicillin/gentamycin or imipenem/cilastatin or fluoroquinolone
What is the treatment for UTI in pregnancy?
second gen cehalosporin (cefpodoxime or cefuroxime)
or Nitrofurantoin
7d
What is the treatment for pyelonephritis in pregnancy?
IV ceftriaxone
14d
When should you consider perinephric abscess?
pyelonephritis not responsive to initial therapy
What is emphysematous pyelonephritis? Who is at higher risk?
High-mortality necrotizing infection of renal
parenchyma,
primarily in diabetic females
What is the treatment for emphysematous pyelonephritis?
often requires nephrectomy
How is urethritis diagnosed?
nucleic acid amplification test (NAAT) or culture
What is the empiric treatment for urethritis?
Ceftriaxone or cefixime for GC, and doxycycline or azithromycin for chlamydia
What is the most common organism implicated in acute bacterial prostatitis in patients <35 yrs old?
C trachomatis and/or
N gonorrhoeae
What is the most common organism implicated in acute bacterial prostatitis in patients >35 yrs old?
Most often caused by gram-negative organisms, predominantly E coli
What is the treatment for acute bacterial prostatitis in males <35 years old?
Ceftriaxone (IM × 1) or ofloxacin (× 10 days) and doxycycline
(× 10 days)
What is the treatment for acute bacterial prostatitis in males >35 years old?
Fluoroquinolone (Ciprofloxacin) or trimethoprim/sulfamethoxazole for
2-4 weeks ***
What is the treatment for CHRONIC bacterial prostatitis?
4 WEEKS of fluoroquinolone
OR
1-3 MONTHS of TMP/SMX (Bactrim)
What do you call PAINFUL, sharply demarcated ulcer with undermined edges, often MULTIPLE, with suppurative INGUINAL NODES?
Chancroid
What organism causes chancroids?
Haemophilus ducreyi
What disease and organism causes PAINFUL grouped vesicles on red base, also form shallow ulcers?
Herpes / Herpes Simplex Virus
What do you call penile lesion that is PAINLESS, indurated ulcer, heals spontaneously?
Syphilis
(no nodal involvement)
What do you call penile lesion that initially presents transiently as a painless ulcer; followed bby unilateral (mostly) inguinal adenopathy which may suppurate?
Lymphogranuloma
venereum
What organism causes Lymphogranuloma
venereum?
Chlamydia trachomatis
Describe the microbio of chlamydia
nonmotile gram negative coccoid bacteria that are obligate intracellular parasites
Describe the microbio of gonorrhea
Gram negative diplococci aerobic
What do you call the penile lesions (diagnosis?) described as Subcutaneous nodule(s), becomes beefy red, highly vascular ulcer(s)?
Granuloma inguinale
(donovanosis)
What bacteria causes Granuloma inguinale
(donovanosis)?
Calymmatobacterium
granulomatis
What is the treatment for chancroid?
Azithromycin or ceftriaxone or ciprofloxacin
What is the treatment for herpes?
Acyclovir
What is the treatment for syphilis?
Benzathine penicillin
What is the treatment for Lymphogranuloma venereum?
Doxycycline
What is the treatment for Granuloma inguinale?
Doxycycline or trimethoprim/sulfamethoxazole
How is syphilis diagnosed?
a combination of a nontreponemal test (VDRL or
rapid plasma reagin [RPR]) followed by confirmatory testing with a treponemal
test (TPHA or FTA-Abs).
What causes epididymitis?
urinary reflux or obstruction
What bacteria causes epididymitis in prepubertal boys?
gram negative bacteria
What bacteria causes epididymitis in men <35 years?
gonorrhea and chlamydia
What bacteria causes epididymitis in >/= 35 years?
e coli
What do you call relief of pain with elevation of the scrotum?
Prehn sign
How is epididymitis diagnosed?
Mostly clinical
50-90% will have pyuria
obtain urethral swab if <35, urine culture if >35
Ultrasound can show enlarged epididymis with increased vascularity
What is the treatment for epididymitis in prepubertal boys?
Supportive care with analgesia, bed rest, elevation of scrotum
AND
Augmentin or Bactrim
What is the treatment for epididymitis in men <35 yrs old?
Supportive care with analgesia, bed rest, elevation of scrotum
AND
Cetriaxone 500mg IM + Doxy 10d
What is the treatment for epididymitis in men >35?
Supportive care with analgesia, bed rest, elevation of scrotum
AND
Fluoroquinolone (Levofloxacin 500 mg daily x10 d)
What are contraindications to fluoroquinolones?
myasthenia gravis (worsens muscle weakness)
risk of AAA
causes QT prolongation
tendinopathy
hypo/hyperglycemia?
What is the most common cause of orchitis?
secondary spread of bacterial epididymitis, but may be viral in nature (like in mumps)
What is the treatment of orchitis?
if viral –> supportive
if bacterial –> treat as epididymitis
What layer attaches the testicle to the scrotal wall and epididymis?
tunica vaginalis
What deformity puts boys at higher risk for torsion?
bell-clapper deformity - the tunica vaginalis attaches higher up on the spermatic cord, leaving a redundant spermatic cord and a mobile testicle
Is torsion most commonly due to venous or arterial occlusion?
venous
(but rarely arterial)
What are classic exam findings of testicular torsion?
elevated or high-riding testicle with a transverse lie
loss of cremasteric reflex
tender, firm, swollen testicle
Prehn sign is usually NOT present
What antibiotics should be initiated for Founiers?
Carbapenem or Zosyn
+
Vanc
+
Clindamycin
How is balantitis defined?
inflammation of the glans penis
How is balanoposthitis defined?
inflammation of the glans penis AND foreskin
How is phimosis defined?
constriction of the foreskin, resulting in an inability to retract the prepuce over the glans
(phimos means muzzle in greek)
How is paraphimosis defined?
when the proximal foreskin cannot be reduced distally
over the glans penis, resulting in distal vascular congestion and ischemia
What is the treatment of balanitis and balanoposthitis?
usually due to candida
tx with topical antifungal for 1-3 weeks
if severe sx, add oral fluconazole 150mg x1 dose
What is the treatment of phimosis?
pathologic when causes urinary or sexual dysfunction
- gentle stretching
- improved hygiene
- Topical steroids for 4-6 weeks
+/- dorsal slit procedure
What is the treatment of paraphimosis?
- analgesia
- manual reduction - firm circumferential pressure at glans for 5-10 min
- traction with forceps - constant stead pressure with forceps at 9 and 3 oclock positions
How is priapism defined?
An erection lasting >4 hours
Where does pooling occur in priapism?
corpora cavernosa
WHat are some risk factors for priapism?
-sickle cell disease
-malignancy –leukemia, multiple myeloma
-substance abuse – cocaine, ecstasy
-meds – antihypertensives (hydralazine, CCBs, prazosin, psych meds (trazodone, chlorpromazine, risperidone), ED meds (sildenafil, tadalafil)
What is the treatment for priapism?
- analgesia/ice packs
- aspiration of the corpus cavernosum – use butterfly needle to drain n5mL
- injection of 1mL of dilute phenylephrine (100-500ug/mL) q3-5m until resolution
(terbutaline SQ/PO and pseudoephedrine PO have been used with some success and may be tried while preparing for aspiration/injection)
- emergent urology consult if unsuccessful
What is the treatment of nonischemic/high flow priapism (ie from saddle injury, painless & semierect)?
urology consultation for eval and possible surgical ligation of fistula
Penile fractures are caused by rupture of the ______.
Tunica Albuginea
How is penile fracture diagnosed?
primarily clinical
retrograde urethrogram to assess for urethral injury
A hydrocele is a collection of fluid in the tunica ______.
vaginalis
Communicating hydroceles occur when the ________ fails to obliterate and leaves a potential space between the peritoneum and scrotum.
processus vaginalis
Noncommunicating hydroceles result from an imbalance between the production and absorption of fluid by the _____.
tunica vaginalis
What is the treatment for hydroceles?
supportive care
– if disabling –> Urology referral
Varicocele is a collection of venous varicosities of the spermatic veins due to
incomplete drainage of the ______.
pampiniform plexus
In adults with new varicocele, what should you suspect?
IVC compression; thrombosis if R sided, or obstruction of the L renal vein from Renal cell carcinoma if L sided
What is the classic appearance of a varicocele?
“bag of worms”
What classic sign is seen with transillumination of scrotal skin in cases of appendageal torsion?
“blue dot sign”
What is the treatment for appendageal torsion?
supportive care only with analgesia, bed rest, and scrotal elevation – resolved in 7-10 days
surgical excision in cases of severe pain
When are inguinal hernias most common?
bimodal distribution: before 1 year of age then after 40 years of age
Describe course/landmarks of an indirect hernia.
Indirect hernia protrudes through the internal ring, lateral to the inferior epigastric vessels
What is the most common cause of indirect hernias?
congenitally patent processus vaginalis
Describe course/landmarks of a direct hernia.
protrudes directly through the transversalis fascia and the external inguinal ring medial to the inferior epigastric vessels.
What amount of post-void residual urine is abnormal?
> 50-100ml
