Ch. 54 - Blood in Urine Flashcards
1
Q
Acute cystitis
A
Bladder infection most commonly caused by enteric bacteria such as E. coli
+frequency, urgency, burning
+pyuria
2
Q
Bladder cancer
A
Mainly urothelial carcinoma (transitional cell carcinoma)
PAINLESS hematuria
Risk factors: tobacco, exposure to automobile exhaust, industrial solvents
3
Q
BPH
A
Obstruction of urethra by enlarged prostate
Frequency, urgency, hesitancy, slow stream, nocturia
4
Q
Nephrolithiasis (kidney stones)
A
May be made of calcium, uric acid, cysteine, struvite
Severe pain often in the flank
5
Q
Prostatitis
A
Infection of prostate gland, most commonly by urinary pathogens;
Fever, dysuria, perineal/back pain
Avoid vigorous prostate exam**
6
Q
Renal cancer
A
Most common subtype is RCC
Most are asymptomatic;
Small minority may present w flank pain, flank mass, hematuria
Smoking = risk factor
7
Q
Pyelonephritis
A
Mainly ascending infection of kidney from lower UTI
May cause systemic symptoms
CVA tenderness on percussion
8
Q
Prostate cancer
A
Most common non-skin malignancy in males
Diagnosed via DRE, PSA and/or biopsy
Gross hematuria = rare
9
Q
Urethral stricture
A
Similar sx to BPH
Caused by scarring from infection, instrumentation, trauma, cancer
Usually benign
10
Q
Trauma
A
Injury to GU tract
eg., Foley placement, penetrating injury to kidney
11
Q
Polycystic Kidney Disease
A
Flank pain, enlarged liver, kidney stones, HTN
+risk of SAH
Often +family hx
12
Q
Menstruation
A
Blood can mix with urine
13
Q
How do the Age of the pt and the chronicity of the hematuria alter the likely differential dx?
A
14
Q
Other than blood, what can make urine appear red?
A
- Certain foods (beets, rhubarb)
- Drugs (rifampin, sulfonamides, phenazopyridine, nitrofurantoin, phenytoin, levodopa, chloroquine, adriamycin, metronidazole)
- Rhabdomyolysis from crush injuries
- Elevated levels of conjuated bilirubin
15
Q
What is the importance of pain in association with hematuria?
A
Strongly suggests infection or urinary obstruction
Therefore, UTI, pyelonephritis, nephrolithiasis = higher on differential
16
Q
What is the classic presentation for nephrolithiasis?
A
Ureteral stones present with acute colicky flank pain, +n/v/dysuria
+periods of severe pain during which the pt will not be able to stay still and will shift positions –> temporary resolution of pain
Helps to differentiate from peritonitis as these pts prefer to remain rigid
17
Q
Risk factors for nephrolithiasis (12)
A
- Previous episodes of nephrolithiasis
- Fam hx
- High protein diet
- M>F
- Low fluid intake
- Dehydration
- Recurrent UTI
- Diabetes
- Gout
- RTA
- Electrolyte abnormalities (e.g. hypercalcemia)
- Meds (acetazolamide, furosemide, allopurinol)
18
Q
Classic presentation for kidney cancer?
A
Triad (but only seen in 10-15% pts):
- Flank pain
- Abdominal mass
- Hematuria
19
Q
What are the main risk factors for renal cancer?
A
- SMOKING
- Male gender
- Older age
- Obesity
Fam hx - Exposure to certain heavy metals/chemicals
20
Q
What is the most common presentation for bladder cancer? What are the risk factors?
A
- Painless gross hematuria
- Similar risk factors to renal cancer (smoking, male gender, older age, fam hx, etc…) + chronic bladder irritation and inflammation (from recurrent UTI, indwelling Foley, pelvic irradiation)
21
Q
What is the most common presentation for prostate cancer? What are the risk factors?
A
Most prostate cancers discovered incidentally b/c of PSA screening
With metastatic disease, pt may present with:
- Bone pain
- Obstructive renal failure
- Weight loss
Main risk factors:
- Age >50
- AA
- High fat diet
- Family hx
22
Q
What comprises the urinary tract and where along the tract can bleeding arise?
A
Upper tract:
- Kidneys
- Ureters
Lower tract:
- Bladder
- Urethra
Bleeding can arise from anywhere along the tract, from glomerulus to distal urethra
23
Q
What is the difference between glomerular and non-glomerular hematuria? Why is it important to distinguish them?
A
Glomerular hematuria implies that blood is coming from kidney itself. Most common causes:
- IgA nephropathy (Berger’s disease)
- Thin GBM disease
- Hereditary nephritis (Alport’s syndrome)
Non-glomerular causes can originate from upper (kidney, ureter) or lower (bladder, urethra) urinary tract
Glomerular causes are within purview of nephrologists, whereas non-glomerular causes concern the urologist.
24
Q
Where do renal stones develop and in what circumstances do they lead to symptoms?
A
Stones can develop anywhere in the urinary tract but typically originate from the kidney or the renal pelvis. Many of these tsones (<5 mm) pass freely into bladder and eventually exit body during micturition.
Stones do NOT cause sx unless they get LODGED somewhere in the urinary tract and cause obstruction.
Most common locations to get stuck:
URETEROPELVIC JUNCTION (UPJ) where ureter crosses iliac vessels
URETEROVESICAL JUNCTION (UVJ)
25
Types of stones
Etiology
Radiology
Features
26
Why do high protein diets increase risk of developing renal stones?
Breakdown of protein (e.g., fish, red meat, chicken) **lowers urinary pH and increases excretion of uric acid** --\> formation of stones
Decreasing dietary protein, oxalate, and sodium intake dec. risk of developing renal calculi
27
1. What is the most common type of kidney cancer?
2. Where does it arise from?
3. What are the most common histologic subtypes?
4. What % are bilateral?
5. What are the risk factors?
6. Sx?
1. RCC
2. Arises from **proximal renal tubular cells,** and nearly 1/3 of pts have metastatic disease at time of presentation
3. Most common histologic subtypes:
1. clear cell (70%), papillary (15%), chromophobe (5%)
4. 1% bilateral
5. Male sex, tobacco, VHL syndrome, polycystic kidney
6. Pain (40%), hematuria (35%), weight loss (35%), flank mass (25%), HTN (20%)
28
Where is the most common location for RCC metastasis?
Lung
29
What genetic syndromes are associated with RCC?
Most cases of RCC are sporadic but several familiar syndrome are associated w/ RCC:
* **VHL** (AD, mutation of xsome 3p)
* **Tuberous sclerosis** (AD, mutation of xsome 9)
* **Birt-Hogg-Dube** (AD, mutation of xsome 17)
30
What paraneoplastic syndromes are associated with RCC (5)?
* **Polycythemia** --\> inc. erythropoietin production
* **Hypercalcemia** --\> PTH-like hormone production
* **Hypertension** --\> inc. renin production
* **Cushing's syndrome** --\> Ectopic cortisol production
* **Stauffer's syndrome** --\> Reversible liver dysfunction; inc. ALP, inc. GGT, inc. ESR, hepatosplenomegaly
31
What is the most common type of bladder cancer?
Urothelial cell carcinoma (UCC) formerly referred to as transitional cell carcinoma
Can arise from renal collecting system, ureters, bladder, or urethra
Staged based on depth of invasion
32
What is the most common type of prostate cancer?
Prostatic adenocarcinoma
33
Work Up:
What is the first step in the workup of a pt with gross hematuria
What is the second step in the workup?
Dipstick Urinalysis to confirm that there are, in fact, RBCs in urine
False +s can result from **myoglobinuria (eg., muscle breakdown 2/2 intense exercise, rhabdomyolysis)**
F/U w Microscopic urinalysis --\> provide # of RBCs/HPF, # WBCs, and presence of bacteria... presence of dysmorphic RBCs and RBC casts suggest glomerular source
34
What additional lab tests should be ordered during hematuria workup?
35
What is the best diagnostic test for nephrolithiasis?
Non-contrast CT-KUB --\> can detect majority of stones and is more acurate than X-ray or sonogram
U/S = procedure of choice in pregnant women and women of childbearing age, though stones are poorly visualized by U/S
36
What is a **radical nephrectomy?**
What is a **radical cystectomy?**
Radical nephrectomy: removal of kidney, perinephric fat, Gerota's fascia, ureter, lymph nodes, possibily, **ipsilateral adrenal gland**
Radical cystectomy: Removal of entire bladder and pelvic lymph nodes... in a male, prostate and seminal vesicles also removed... in a female cervix, uterus, fallopian tubes, and part of vagina are also removed
37
A 60 y/o man sees a urologist for what he describes as **bloody urine**. A urine sample is + for cytologic evidence of malignancy. Cystoscopy confirms presence of **superficial transitional cell carcinoma.** Which of the following is the recommended tx for **stage A (superficial/submucosal) TCC** of the bladder?
a. Topical (intravesicular) chemo
b. Radical cystectomy
c. Radiation therapy
d. Local excision and topical (intravesicular) chemo
e. Systemic chemo
d. Local excision and topical (intravesicular) chemo
When disease is still superficial, transurethral resection of visible lesions and intravesicular chemo = most often recommended... more radical surgical resection, systemic chemo, and radiation reserved for advanced stages of disease
38
A 36 y/o man presents to the ER with renal colic. His vital signs are normal and UA shows microscopic hematuria. Radiograph reveals a **1.5 cm stone.** Which of the following is the most appropriate mgmt of this pt?
a. Hydration and analgesics
b. alpha-adrenergic blocker
c. Extracorporeal lithotripsy
d. Percutaneous nephrostomy tube
e. Open surgery to remove the stone
c. Extracorporeal lithotripsy
Most appropriate tx given size of stone (1.5 cm)... this procedure is **completely noninvasive and uses a device that delivers convergent shock-wave energy under fluoroscopic guidance**
Many pts with renal stones smaller than 1 cm can be managed with **hydration and analgesics until stone passes spontaneously.**
Percutaneous nephrostomy tubes reserved for unstable pts who present with urinary infection coexisting with an obstructing stone
39
An 8 m/o boy is seen by pediatrician for first time. The physician notes that there are no testes in the scrotum. Which of the following is the optimal mgmt of bilateral undescended testicles in an infant?
a. Immediate surgical placement into scrotum
b. Chorionic gonadotropin therapy for 1 mo; operative placement into scrotum before age 2 if descent has not occurred
c. Observation until age 2; operative placement into scrotum if descent has not occurred
d. No therapy
**b. Chorionic gonadotropin therapy for 1 mo; operative placement into scrotum before age 2 if descent has not occurred**
Chorionic gonadotropin is occasionally effective in patients with bilateral undescended testes. If there is no testicular descent after 1 mo of endocrine therapy, surgical intervention consisting of inguinal orchidopexy should be performed before age of 2. After 2 y/o, testicle not in cooler environment of scrotal sac will begin to undergo histologic changes characterized by reduced spermatogonia.
40
A 32 y/o man presents with asymptomatic mass in his R testicle. On exam, the mass cannot be transilluminated. U/S shows a solid mass in the R testicle. Which of the following is the most accurate method in obtaining a diagnosis of testicular cancer?
a. Serum levels of AFP and bHCG
b. Percutaneous biopsy of the testicular mass
c. Incisional biopsy of testicular mass through scrotal incision
d. Excisional biopsy of testicular mass through scrotal incision
e. Radical inguinal orchiectomy
e. Radical inguinal orchiectomy
The most accurate method to obtaining a dx of any cancer is with **histologic confirmation.** In the case of testicular cancer, a radical inguinal orchiectomy with high ligation of spermatic cord near internal inguinal ring is procedure of choice to provide histologic evaluation of the tumor. Violation of the scrotum must be avoided b/c it may alter lymphatic drainage of the testis.
41
A 10 y/o boy presents to ER with pain in L testicle. The pain was acute in onset and began 1 hr ago. On exam, he is noted to have a high-riding, firm, and markedly tender L testis. The R testis is normal. Urinalysis is unremarkable. Which of the following is the most appropriate mgmt of this pt?
a. Manual detorsion of the L testicle with external rotation toward the thigh; orchiopexy if the condition recurs
b. Manual detorsion of the L testicle with internal rotation toward the thigh; orchiopexy if the condition recurs.
c. Orchiopexy of the L testicle
d. Orchiopexy of bilateral testicles
e. Orchiectomy of L testicle
d. Orchiopexy of bilateral testicles
Pt's presentation consistent with testicular torsion --\> needs surgery immediately
During surgery, affected testicle is rotated to its normal position (external) rotation). If it is viable, orchiopexy is performed on both the affected and unaffected testes b/c unaffected testes has greater-than-normal chance of torsion in the future. If the affected testicle is nonviable, orchiectomy is performed with orchiopexy of the nonaffected testicle.
42
A 45 y/o woman presents with a 7 cm RCC with radiologic evidence of abdominal lymph node involvement with no distant metastases. Which of the following is the most appropriate mgmt of this pt?
a. Radical nephrectomy
b. Radiation
c. Chemo
d. Radiation followed by nephrectomy
e. Chemo followed by nephrectomy
**a. Radical nephrectomy**
RCC is NOT responsive to radiation and chemo; therefore, radical nephrectomy should be offered as a possible curative procedure in this pt b/c many nodes initially suspected of having metastatic disease on imaging are enlarged due to reactive inflammation.
43
A 58 y/o man is found to have a high serum PSA concentration with a normal prostate exam. A biopsy of the prostate confirms low-grade carcinoma. The patient wishes to avoid therapy involving any risk for impotence. Which of the following is the most appropriate mgmt of this patient?
a. Observation
b. Chemo
c. Prostatectomy
d. Radiation therapy
e. Hormonal therapy
**a. Observation**
Most early prostate cancers are slow-growing tumors and will remain confined to prostate gland for a significant length of time. Active surveillance involves frequent visits to the doctor (every 3-6 mo) with questions about new or worsening symptoms and DREs for any changes in the gland.
In addition, blood tests are done to watch for a rising PSA, and imaging studies can be conducted to detect spread of cancer.
Chemo is most often given to pts with metastatic disease who no longer respond to hormonal therapy.
44
A 60 y/o man seeks medical attention b/c of recurrent UTIs. The patient also reports a hx of increasing difficulty in urination (decreased flow, straining, and hesitancy) over the last several months. A PSA level is midly elevated and prostate biopsy proves benign. Which of the following is the most appropriate initial mgmt of this pt with BPH?
a. alpha-adrenergic blocker
b. 5-alpha reductase inhibitor
c. alpha-adrenergic blocker + 5-alpha reductase inhibitor
d. Transurethral resection of prostate
e. Open prostatectomy
d. Transurethral resection of prostate
Recurrent UTI = ABSOLUTE INDICATION FOR SURGERY in pts with BPH
Other indications for surgery in pts with BPH include urinary retention refractory to medical therapy, upper tract dilation, renal insufficiency 2/2 outflow obstruction, bladder stones
TURP = surgery of choice with proven long-term efficacy and safety
Open prostatectomy is more invasive and is reserved for pts with very large prostates (\>100 g)
Medical tx = first-line therapy for pts with symptomatic uncomplicated BPH
45
The L ureter is partially transected (50% of circumference) during the course of a difficult operation on an unstable, critically ill pt. Which of the following would be the most appropriate mgmt of this injury given the pt's unstable condition?
a. Placement of external stent through proximal ureteral stump with delayed reconstruction
b. Ipsilateral nephrectomy
c. Placement of a catheter from distal ureter through abdominal wall stab wound
d. Placement of closed-suction drain adjacent to the injury
e. Bringing the proximal ureter up to the skin as a ureterostomy
a. Placement of external stent through proximal ureteral stump with delayed reconstruction
This will allow reconstruction to be performed later.
46
A pedestrian is hit by a speeding car. Radiologic studies obtained in the ER, including retrograde urethrogram (RUB) are consistent with pelvic fracture with a rupture of the urethra superior to the urogenital diaphragm. Which of the following is the most appropriate next step in the pt's mgmt?
a. Immediate percutaneous nephrostomy
b. Immediate placement of Foley through urethra into bladder to align and stent the injured portions
c. Immediate reconstruction of the ruptured urethra after intiial stabilitization of the pt
d. Immediate exploration of the pelvis for control of hemorrhage from pelvic fracture and drainage of pelvic hematoma
e. Immediate placement of suprapubic cystostomy tube
e. Immediate placement of suprapubic cystostomy tube
This should be done before any attempts are made to place Foley, as efforts to do so may result in creation of multiple false passages or conversion of partial laceration into complete rupture.
Definitive repair is delayed 4 to 6 mo, at which time the hematoma will have resolved and the prostate will have descended into the proximity of the urogenital diaphragm.
Percutaneous nephrostomy has no role in the mgmt of this problem.
47
A 55 y/o man presents with fever and pain in the perineal region. Upon further questioning, he also complains of frequency, urgency, dysuria, and a decreased urinary stream. On exam, his abdomen is soft, nondistended, and nontender. DRE demonstrates exquisite tenderness on anterior aspect. Lab exam reveals leukocytosis and findings on UA are consistent with bacterial infection. Which of the following is the most likely diagnosis?
a. UTI
b. BPH
c. Prostatitis
d. Pyelonephritis
e. Nephrolithiasis
c. Prostatitis
Tx = broad spectrum IV abx until pt is afebrile and hemodynamically stable (not hypotensive, tachy) --\> then continue abx tx for 3 weeks PO
UTI has similar sx but no perineal pain or pain on rectal exam
BPH does not present with fever or pain
Pyelonephritis/nephrolithiasis are not associated with pain in perineum
