Exam 3 Renal Disorders

Question 1

S/ SX of Dysuria

Answer 1

• Subjective experience of pain or a burning sensation on urination
• Frequency, urgency, hesitation
• Can be secondary to several medical conditions or certain medications
• Most commonly associated with lower urinary system infections

Question 2

Dysuria: Differential Diagnosis

Answer 2

• Most often associated with a bladder problem and rarely with renal disease
• Inflammatory lesions of the prostate, bladder, and urethra
• Other conditions associated with dysuria
  o Bladder tumors
  o Chronic renal failure
  o Nephrolithiasis
  o Disease of upper urinary system
• Outside the renal system
  o STIs
  o Vaginitis and prostatitis
• Women should be questioned about vaginal discharge or irritation
• Symptoms may lead to other diagnoses
  o Urethral strictures
  o Prolapsed uterus
  o Pelvic peritonitis
  o Cancer of the cervix or prostate

Question 3

Dysuria: Diagnostic Testing

Answer 3

• Urinalysis is the easiest, most noninvasive, and most economical way to identify UTIs and other renal problems.
• Once the associated condition is identified, appropriate treatment can begin.

Question 4

Hematuria: Clinical presentation

Answer 4

• Color of the urine
• Concurrent symptoms?

Question 5

Hematuria: History

Answer 5

• Medications & dietary history
• Menstrual history

Question 6

Hematuria: Differential diagnosis

Answer 6

• UTI / pyleo
• Cancers
• BPH

Question 7

Hematuria: Physical exam

Answer 7

• Abdominal exam – tenderness, masses, CVA tenderness, pelvic / prostate exam

Question 8

Hematuria: Diagnostic tests

Answer 8

• Urinalysis, C&S
• ANA, CMP, CBC,
• IVP, cystoscopy
• Ultra sound
• CT scan

Question 9

Hematuria: Management and follow-up

Answer 9

• Antibiotic therapy if bacterial infection found
• Refer for further evaluation – urology or nephrology

Question 10

Lower Urinary Tract Infection (UTI) differentiate between acute, chronic and complicated UTI

Answer 10

• Acute infections
  Characterized by the onset of UTI in a previously symptom-free individual
• Chronic infections
  Caused by obstructions, antibiotic-resistant bacteria, presence of multiple strains of bacteria
• Complicated UTI
  Accompanied by factors that complicate the infection

Question 11

Type of Lower Tract UTI

Answer 11

o Urethra: urethritis
o Bladder: cystitis
o Bladder wall: interstitial cystitis (IC)
o Prostate gland: prostatitis

Question 12

Lower UTI: Clinical Presentation

Answer 12

• Most frequently reported symptoms
  o Dysuria
  o Urinary frequency or urgency
  o Nocturia
  o Hematuria
  o Low back or suprapubic pain
  o Urinary incontinence
  o Cloudy, foul-smelling urine
  o Altered mental status in elderly

Question 13

Lower UTI: Clinical Presentation UA

Answer 13

Urinalysis may exhibit
o Cloudy appearance
o Alkaline pH
o Hematuria
o Elevated levels of nitrites
o Leukocyte esterase
Urine sediments of
o RBCs, WBCs, mucus, and bacterial overgrowth

Question 14

Lower UTI: Diagnostic Testing

Answer 14

• Urinalysis
  o Clean-catch, midstream urine sample
  o Sample showing more than 100,000 organisms/mL is indicative of infection
  o PLUS presence of characteristic clinical symptoms
• Urine culture is considered the gold standard for laboratory confirmation of UTI
• Urinalysis with microscopy
• Urine culture and sensitivity
• IC: potassium sensitivity test (PST)

Question 15

Lower UTI: Differential Diagnosis

Answer 15

• Differential diagnosis
  o Tumors
  o Upper UTI
  o Vaginitis
  o STDs
• Lower UTI does not exhibits signs of sepsis (fever, chills, WBC casts, CVAT)

Question 16

Lower UTI: Management Uncomplicated

Answer 16

• Pharmacological antimicrobial management is the mainstay of treatment
  o Nitrofurantoin (Macrobid) seems to be the most effective on gram-negative and gram-positive cocci;100 mg BID 7-day regimen 🡪 does not work in males!
  o Trimethoprim-sulfamethoxazole (Bactrim DS/Septra DS) is also effective; 1 DS x 3-day regimen for uncomplicated UTI
  o Amoxicillin; 500mg BID x 3 days
  o The fluoroquinolones have widespread efficacy
   BLACKLISTED for female patients, male patients be cautious…typically reserved for serious infections
• Ampicillin and sulfonamides are becoming increasingly resistant

Question 17

Lower UTI: Management Complicated UTI

Answer 17

o Ciprofloxacin 500mg po BID x 7-14 days
o Levaquin 250 mg po daily x 10 days or 750 mg daily x 5 days
* Do NOT use the same medication if one has been used in the last 3 months

Question 18

Lower UTI: Management Pregnancy

Answer 18

• During pregnancy
  o Especially important as an established link exists between premature delivery and UTI
  o Empirical therapy: amoxicillin 500mg po QID, nitrofurantoin 100 mg po BID x 7 days, or cephalexin (Keflex) 500 mg po QID x 7 days
  o Most treatment is 1 week
  o No Fluoroquinolones!!
  o No Bactim or Septra in the 1st or 3rd trimester of pregnancy!
  o History of UTI: postcoital prophylaxis

Question 19

Lower UTI: Management
Fungal

Answer 19

fluconazole 200 mg qd 7–14 days

Question 20

Lower UTI: Management
Chronic UTI

Answer 20

o Who should receive prophylaxis?
 2 or more symptomatic UTIs w/in 6 months
 3 or > within 12 months
* Prophylaxis should be initiated after previous UTI resolution is confirmed
* Daily dosing for 6 months
* Post-coital prophylaxis
* Self-medication (3-4 days of therapy when symptoms begin)

Question 21

Lower UTI: Follow-up and Referral

Answer 21

• Midstream, clean-catch urine sample for urinalysis
• Indwelling catheters should be changed every 4–6 weeks
• Maintain adequate hydration and monitor urine output
• Obstructions must be identified and removed
• Prescribe analgesics for patients to reduce pain associated with UTI

Question 22

Lower UTI: Patient Education

Answer 22

• Instruct patient to notify clinician if flank pain, hematuria, or lack of response to treatment occurs
• Advise patient to
  o Complete full course of antibiotic therapy
  o Increase fluid intake to eight 8-ounce glasses of H2O
  o Take cranberry supplement and drink cranberry juice
  o Wear cotton underclothes
  o Avoid harsh soaps or feminine hygiene productsUse condoms
  o Use proper self-catheterization techniques
  o Empty bladder frequently, completely, and after sexual intercourse
  o Take showers instead of tub baths
  o Self-medicate as indicated
  o Keep a diary of urinary symptoms
  o Proper hygiene

Question 23

UTI Males: Clinical presentation

Answer 23

-dysuria
-urgency/frequency
-cloud urine

Question 24

UTI Males: Treatment

Answer 24

• Treat 10 to 14 days:
• No macrolide
  o can still use Macrobid 100 mg po BID (as long as there is NO Prostatitis)
  o Bactrim DS 1 tab po BID
  o If associated with prostatitis
• Ciprofloxacin 500 mg po BID or 1000 mg ER po daily
• Levaquin 750 mg po Qday is only used for severe cases

Question 25

UTI Males: Differential Diagnosis

Answer 25

* Prostititis * BPH * STI

Question 26

UTI Males: Diagnostic Testing

Answer 26

o UA/C+S o Consider IVP or cystoscopy

Question 27

Interstitial Cystitis (IC): Clinical Presentation

Answer 27

Chronic inflammatory condition of the bladder clinically characterized by irritable voiding symptoms or urgency and frequency, in the absence of objective evidence of another disease

Question 28

Interstitial Cystitis (IC): Aggravating Factors

Answer 28

intercourse perimenstrual status

Question 29

Interstitial Cystitis: Diagnostic Testing

Answer 29

* Lab: diagnosis of exclusion GYN, U/S, IVP, Cystoscopy * PUF Symptom Scale (>5, IC likely) *Intravesical Potassium Sensitivity Test

Question 30

Interstitial Cystitis: Management

Answer 30

* Oral Pentosan polysulfate sodium: 100mg TID or 200mg BID * Course duration: 2-4 months minimum * Intravesical DMSO bladder instillation * Bladder training (reduce eliminations) * Hydro-distension of the bladder * laser * low acid diet * NSAIDS, antidepressants, muscle relaxants

Question 30

Pyelonephritis: Clinical Presentation Acute vs Chronic

Answer 30

Acute o May present with sudden onset of fever, shaking, chills, nausea, vomiting, unilateral or localized flank pain, fatigue, diarrhea o Otherwise may be largely asymptomatic o Elderly patients may present with altered mentation Chronic o fatigue, nausea, decreased appetite with weight loss, nocturia and/or polyuria, symptoms of renal failure o Usually first diagnosed when patient presents with impaired renal function caused by damage to the kidneys

Question 31

Pyelonephritis: Clinical Presentation- Physical exam

Answer 31

o Marked tenderness on deep abdominal palpation o May be hypertensive

Question 32

Pyelonephritis: Diagnostic Testing

Answer 32

* Diagnosis confirmed through urinalysis & CNS, which is positive for bacteria, proteinuria, leukocyte esterase, urinary nitrites, hematuria, pyuria, and WBC casts * Urine culture, which typically demonstrates greater than 100,000 cfu/mL * Blood cultures * Cystoscopy with ureteral catheterization * Renal ultrasound or IVP

Question 33

Pyelonephritis: Differential Diagnosis

Answer 33

* Difficult to differentiate from cystitis; however, presence of WBC casts is diagnostic for pyelonephritis * Definitive diagnosis for chronic disease is made by identifying persistent pyuria and by positive urine cultures * Kidney biopsy is sometimes appropriate for diagnosis

Question 33

Pyelonephritis: Differential Diagnosis

Answer 33

* Difficult to differentiate from cystitis; however, presence of WBC casts is diagnostic for pyelonephritis * Definitive diagnosis for chronic disease is made by identifying persistent pyuria and by positive urine cultures * Kidney biopsy is sometimes appropriate for diagnosis

Question 34

Pyelonephritis: Management

Answer 34

* Aggressive therapy is necessary to prevent permanent damage * Oral antibiotics for mild cases o Septra DS or Cipro (cautiously!) * Hospitalization of patients who are pregnant, vomiting, or dehydrated should be considered * Treatment courses should typically last 7–10 days for mild to moderate, 14 days for severe, and 21 days for particularly slow responders * If patient does not respond within 48 hours o Reevaluate patient and cultures o Consider hospitalization o Ultrasound, IVP, or dimercaptosuccinic acid (DMSA) renal scan o IV antibiotics o Increase fluid intake and maintain an accurate intake and output record o Surgery may be indicated o Diagnostic studies requiring insertion of instruments should be delayed

Question 35

Pyelonephritis: Follow-up and Referral

Answer 35

* Patient should be assessed 48 hours later to assess responsiveness to therapy and consideration for discharge * Recurrent pyelonephritis o Reculture at 2, 6, and 12 weeks after antibiotic therapy is initiated * Chronic pyelonephritis: refer to nephrologist

Question 36

Pyelonephritis: Patient Education

Answer 36

* Focus is on preventing recurrence o Complete antibiotic therapy o Prevent lower UTIs * Increase fluid intake * Report recurrence of any symptoms immediately * Take cranberry supplements and drink cranberry juice * Control hypertension with medications

Question 37

Kidney Stones: Different Kinds

Answer 37

Stones form from o Calcium * o Struvite o Uric acid o Cystine

Question 38

Kidney Stones: Clinical Presentation

Answer 38

* Sudden flank pain * Can radiate to abdomen, groin, perineal, and inner thigh * Nausea/vomiting * Urinary frequency * Diaphoresis * Dysuria * Hematuria * Weakness

Question 39

Kidney Stones: Physical Exam

Answer 39

Vital signs * Elevated BP, tachycardia, tachypnea Systemic * fever Abdomen * Distended * Guarding * Decreased/absent bowel sounds * CVA tenderness

Question 40

Kidney Stones: Diagnostics

Answer 40

UA o Normal to hematuria and leukocytes o Crystals and cast o Pus o Alkaline or acidic pH CBC-infection? CMP Renal/bladder ultrasound Bladder x-ray Noncontrast CT

Question 41

Kidney Stones: Differential Diagnosis

Answer 41

Appendicitis UTI Pyelonephritis PUD Ovarian cyst Tubal pregnancy Renal/bladder cancer

Question 42

Kidney Stones: Treatment

Answer 42

 Pain relief * Oral NSAIDs * Oral Opiates * Antispasmodics * Warm compresses * Focused breathing/diversional therapy Thiazide diuretics-calcium Allopurinol-uric acid D-penicillamine-cystine Increase water intake Noninvasive and invasive surgical interventions May need hospitalization for severe symptoms/referral Avoid medications that can cause stone formation * TUMs * Loop diuretics * Vitamin supplements

Question 43

Chronic Kidney Disease: Clinical Presentation

Answer 43

Usually asymptomatic until GFR declines 10-15% from normal  Anorexia  Lassitude  Fatigability  Weakness  Pruritus and dry skin  N/V  Hiccups  Emotional lability  Depression  Insomnia  Confusion  Bruising  Peripheral Neuropathy  Edema  Headaches  Urine odor to breath  Metallic taste  Impotence  Nocturia  Muscle cramps  Gout  Pale  Frost appearance to urine  Ascites  Proteinuria  Crackles in lungs  Pericardial rub  Elevated BP

Question 44

CKD: Diagnostics

Answer 44

 BMP  BUN, creatinine, and creatinine clearance  GFR Staging:  Stage 1 * Persistent Albuminuria, normal GFR  Stage 2 * Persistent Albuminuria, GFR between 60 and 89  Stage 3 * GFR between 30 and 59  Stage 4 * GFR between 15 and 29  Stage 5 * ESRD, GFR less than 15  CBC o Anemia  UA o Proteinuria  24-hour urine studies  Renal ultrasound  Renal CT, CT angiography  MRI/MRA  Duplex Doppler ultrasonography

Question 45

CKD: Management

Answer 45

 Control any underlying comorbidities * HTN – Target BP 125/75 (JNC 8 says <140/90?)  DM  Anemia  Fluid restriction  Sodium restriction  Protein restriction (0.58g/kg daily)  Adequate caloric daily intake (40-50cal/kg daily)  Referrals  Nephrology  Nutritionist

Question 46

Urinary Incontinence: Stress Clinical Presentation

Answer 46

 Increase in abdominal pressure results in loss of urine  Urethral sphincter muscle is weak  Weakness in pelvic floor muscles (preg, menopuas)  Brought on by coughing, sneezing, straining  Small Leakage

Question 47

Urinary Incontinence: Stress Incontinence Management

Answer 47

* Kegels: 40 to 60 contractions daily o Slow tighten for 10 seconds, hold for 10 seconds, release over 10 seconds  Pelvic floor muscle training (PFMT)  Vaginal cones or pessaries o Must be measured, have to be resized after baby or weight changes  Lose weight  Limit fluids and diuretics in evening  Dietary changes and quit smoking  Meds: vaginal estrogen  Surgical intervention

Question 48

Urge Incontinence: Urge Incontinence

Answer 48

 Detrusor instability  Involuntary leakage of urine resulting from inability to delay voiding  Patient has sensation of a full bladder, but cannot store urine long enough to reach the bathroom

Question 49

Urge Incontinence: Urge Incontinence Management

Answer 49

Anticholinergic medications Tricyclic antidepressants

Question 50

Urge Incontinence: Overflow Incontinence

Answer 50

 Involuntary leakage of small amounts of urine  Caused by over-distended bladder in an individual who does not feel sensation to void  Caused by outlet obstruction, BPH, medications

Question 51

Urge Incontinence: Overflow Incontinence Management

Answer 51

Treatment of underlying cause Indwelling catheterization

Question 52

Overactive Bladder (OAB): Clinical Presentation

Answer 52

 Unable to postpone--urgency

Question 53

Overactive Bladder (OAB) Management Non-Medication

Answer 53

 Behavioral therapy techniques: bladder training, urgency control strategies  Avoid bladder irritants o Common bladder irritants: cold remedies (Sudafed), chocolate, carbonation, colas, citrus, cranberry juice or pills, vitamin C, certain wines and beers, Crystal Light, candy and high sugar foods, smoking

Question 54

Overactive Bladder (OAB) Management Medication

Answer 54

 Anticholinergic /Antimuscarinic Medications o Oxybutynin – Ditropan and Ditropan XL po and patch o Trospium Chloride – Sanctura o Tolterodine - Detrol and Detrol LA o Solifenacin – Vesicare o Fesoterodine - Toviaz  Major side effects: dry mouth, urinary retention, constipation, blurred vision (caution in elderly and in glaucoma)