Exam 3 Renal Disorders Flashcards
S/ SX of Dysuria
- 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
Dysuria: Differential Diagnosis
- 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
Dysuria: Diagnostic Testing
- 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.
Hematuria: Clinical presentation
- Color of the urine
- Concurrent symptoms?
Hematuria: History
- Medications & dietary history
- Menstrual history
Hematuria: Differential diagnosis
- UTI / pyleo
- Cancers
- BPH
Hematuria: Physical exam
- Abdominal exam – tenderness, masses, CVA tenderness, pelvic / prostate exam
Hematuria: Diagnostic tests
- Urinalysis, C&S
- ANA, CMP, CBC,
- IVP, cystoscopy
- Ultra sound
- CT scan
Hematuria: Management and follow-up
- Antibiotic therapy if bacterial infection found
- Refer for further evaluation – urology or nephrology
Lower Urinary Tract Infection (UTI) differentiate between acute, chronic and complicated UTI
- 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
Type of Lower Tract UTI
o Urethra: urethritis
o Bladder: cystitis
o Bladder wall: interstitial cystitis (IC)
o Prostate gland: prostatitis
Lower UTI: Clinical Presentation
- 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
Lower UTI: Clinical Presentation UA
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
Lower UTI: Diagnostic Testing
- 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)
Lower UTI: Differential Diagnosis
- Differential diagnosis
o Tumors
o Upper UTI
o Vaginitis
o STDs - Lower UTI does not exhibits signs of sepsis (fever, chills, WBC casts, CVAT)
Lower UTI: Management Uncomplicated
- 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
Lower UTI: Management Complicated UTI
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
Lower UTI: Management Pregnancy
- 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
Lower UTI: Management
Fungal
fluconazole 200 mg qd 7–14 days
Lower UTI: Management
Chronic UTI
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)
Lower UTI: Follow-up and Referral
- 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
Lower UTI: Patient Education
- 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
UTI Males: Clinical presentation
-dysuria
-urgency/frequency
-cloud urine
UTI Males: Treatment
- 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
UTI Males: Differential Diagnosis
- Prostititis
- BPH
- STI
UTI Males: Diagnostic Testing
o UA/C+S
o Consider IVP or cystoscopy
Interstitial Cystitis (IC): Clinical Presentation
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
Interstitial Cystitis (IC): Aggravating Factors
intercourse
perimenstrual status
Interstitial Cystitis: Diagnostic Testing
- Lab: diagnosis of exclusion
GYN, U/S, IVP, Cystoscopy - PUF Symptom Scale (>5, IC likely)
*Intravesical Potassium Sensitivity Test
Interstitial Cystitis: Management
- 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
Pyelonephritis: Clinical Presentation Acute vs Chronic
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
Pyelonephritis: Clinical Presentation- Physical exam
o Marked tenderness on deep abdominal palpation
o May be hypertensive
Pyelonephritis: Diagnostic Testing
- 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
Pyelonephritis: Differential Diagnosis
- 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
Pyelonephritis: Differential Diagnosis
- 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
Pyelonephritis: Management
- 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
Pyelonephritis: Follow-up and Referral
- 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
Pyelonephritis: Patient Education
- 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
Kidney Stones: Different Kinds
Stones form from
o Calcium *
o Struvite
o Uric acid
o Cystine
Kidney Stones: Clinical Presentation
- Sudden flank pain
- Can radiate to abdomen, groin, perineal, and inner thigh
- Nausea/vomiting
- Urinary frequency
- Diaphoresis
- Dysuria
- Hematuria
- Weakness
Kidney Stones: Physical Exam
Vital signs
* Elevated BP, tachycardia, tachypnea
Systemic
* fever
Abdomen
* Distended
* Guarding
* Decreased/absent bowel sounds
* CVA tenderness
Kidney Stones: Diagnostics
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
Kidney Stones: Differential Diagnosis
Appendicitis
UTI
Pyelonephritis
PUD
Ovarian cyst
Tubal pregnancy
Renal/bladder cancer
Kidney Stones: Treatment
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
Chronic Kidney Disease: Clinical Presentation
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
CKD: Diagnostics
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
CKD: Management
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
Urinary Incontinence:
Stress Clinical Presentation
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
Urinary Incontinence:
Stress Incontinence Management
- 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
Urge Incontinence:
Urge Incontinence
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
Urge Incontinence:
Urge Incontinence Management
Anticholinergic medications Tricyclic antidepressants
Urge Incontinence:
Overflow Incontinence
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
Urge Incontinence:
Overflow Incontinence Management
Treatment of underlying cause Indwelling catheterization
Overactive Bladder (OAB): Clinical Presentation
Unable to postpone–urgency
Overactive Bladder (OAB) Management Non-Medication
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
Overactive Bladder (OAB) Management Medication
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)
