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Adult/Ped Medicine Cumulative Final > Exam 6 > Flashcards

Exam 6 Flashcards

1
Q

Bladder Voiding FIlm

A

Voiding cystourethrogram (VCUG): Used with contrast

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2
Q

Functional unit of the kidney

A

Nephron

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3
Q

Most Common Urologic Problems

A
  1. UTI’s2. Prostate3. Renal Stones
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4
Q

When is recommended time to do surgery for undescended testicles?

A

after 6 mo.

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5
Q

Reason for surgery of undescended testicle

A

Fertility (Same fertility if unilateral, but bilateral is 50% fertility) and cancer risk.

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6
Q

When is the best time in life to do a scrotal exam

A

At birth

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7
Q

Most reliable way to identify an undescended testicle

A

1) Physical exam **2) MRI3) Scrotal US with doppler4) Scrotal US5) CT scan

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8
Q

Non palpable testicle has compensatory _________ >1.8cm. When kid has non palpable testicle must do a _________?

A

Hypertrophy, laparoscopy

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9
Q

Most hernias in kids are ____________ while in adults they are _______

A

Indirect, direct

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10
Q

Risks of hernias in kids

A

1) Incarceration (Premature 40%, overall 12%)2) <10% can be redced3) Bowel necrosis and strangulation is rare

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11
Q

2 types of hydroceles

A

1) Communicating: risks 2% hernias 0% incarceration. 85% spontaneous resolution by 18 mos.2) Non-communicating: risks=nil

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12
Q

Febrile UTI characteristics

A

1) Younger child2) Temp >38.53) Sick, back pain4) Usually anatomic problem present5) Workup: Renal US and in some a VCUG

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13
Q

Non-febrile UTI characteristics

A

1) Older child2) No fever3) No constitutional symptoms4) Usually has dysfunctional elimination syndrome with normal anatomy5) Work-up: KUB, voiding diary

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14
Q

What has surgical of vesicoureteral reflux been proven to decrease

A

1) Febrile UTIs- No other things

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15
Q

Antibiotic prophylaxis after a UTI decreases the risk of recurrent UTI by…

A

8%- Antibiotics can causes resistance in bowel flora

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16
Q

Classification of Hydronephrosis (SFU)

A

SFU 0= Normal SFU 1= Black (urine) at renal pelvisSFU 2= If you see calycesSFU 3= see all calycesSFU 4= Complete obstruction

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17
Q

Which children require immediate eval of hydronephrosis after birth

A

1) boy, history of oligodramnios (little amniotic fluid), bilateral grade 2 hydro2) Girl, bilateral ureteroceles3) Boy, bilateral grade 2 or more hydro

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18
Q

The diagnosis and treatment of vesicoureteral reflux in an asymptomatic child with prenatal hydro and no history of UTIs:

A

Has no proven benefits

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19
Q

Immediate postnatal evaluation

A

Bladder outlet obstruction, bilateral obstruction (SFU 4)

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20
Q

What is Mag 3

A

For SFU 3 and 4. Radiotracer study to show blockage

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21
Q

Causes of TRUE fecal incontinence (3)

A

1) Myelomeningocele2) Hirshprung disease3) Anorectal malformations

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22
Q

Cause of PSEUDO-fecal Incontinence

A

Due to constipation

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23
Q

Treatment of Encopresis

A

1) Desimpaction2) Maintenance3) Lifelong disease

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24
Q

Daytime urinary incontenence- what should you do?

A

In older kids consider Renal US to rule out neurogenic bladder, valves, anatomic problemsRX: Constipation, timed voiding and double voiding regimen-Anticholinergics? (relax bladder)

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25
Q

Monosymptomatic nocturnal enuresis treatment

A

1) General measures (Restrict fluids, go to bathroom before bed)2) Medicines (Don’t cure, and only 30% effective and <10% cure rate)3) Bedwetting alarm (80% success)

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26
Q

How are labial adhesions treated?

A

1) Observation2) Estrogen cream3) Break adhesion surgically

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27
Q

What is the recommended care of an uncircumcised penis from age 0 to age 8

A

Once the foreskin becomes retractable, teach children to retract their own foreskin during voiding or bathing-Phimosis- cannot retract foreskin

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28
Q

Soft penile adhesions involves what anatomically? What treatment is needed?

A

Do not involve the circumcision. Disappear on their own without treatment

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29
Q

Penile bridge involves what anatomically? What treatment is needed?

A

Usually involve circumcision. Require surgical treatment

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30
Q

Hypospadius

A

Dorsal hood. Hole on VENTRAL side

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31
Q

Patient reports with severe flank pain radiating to the lower abdomen, groin, testes. Patient also has hematuria. What are these symptoms for?

A

Kidney Stones- can be asymptomatic, cause restlessness, nausea, vomiting, ileus, “mirror pain”

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32
Q

Renal Colic

A

-severe flank pain radiation to lower abdomen, groin, or testes-restless, ambulatory-nausea, vomiting, ileus-mirror pain

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33
Q

Urolithiasis Stone Presentation

A

-asymptomatic-acute urinary obstruction - renal colic-hematuria

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34
Q

Stone Ingredients

A

CalciumOxalatePhosphateUric AcidCystineStruviteTriameterne

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35
Q

________ and _________ inhibit nucleation

A

Magnesium and Citrate

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36
Q

Calcium Phosphate Stones form in acidic/alkaline urine?

A

Alkaline - as pH increases more phosphates exist in ionic form

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37
Q

Uric Acid Stones form in acidic/alkaline urine?

A

Acidic - solubility of urate increases as pH increases

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38
Q

Diagnosis of Urolithiasis

A

Urinalysis - hematuria, cystine and struvite crystals are diagnosticPlain Abdominal FilmIVPUltrasound** Spiral CT - no contrast - very sensitive and specific

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39
Q

Most common stone ingredients

A

Calcium oxalate, calcium phosphate. Ingredients can be: Calcium, oxalate, phosphate, uric acid, cystine, struvite(Urea broken down), triamterene

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40
Q

What inhibits nucleation of kidney stones

A

Magnesium and citrate

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41
Q

What inhibits nuclei or larger structures to adhere to one another

A

Tamm-Horsfall protein in ascending limb of henle

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42
Q

Calcium phosphate stones form in ______ urine; uric acid stones form in _______ urine

A

Alkaline, acidic

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43
Q

Struvite stones process

A

Magnesium ammonium phosphate. Normal urine is under saturated with ammonium phosphate, UTI with urease-producing organism (Klebsiella or proteus)> Alkaline urine forms struvite

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44
Q

Colorless eight sided envelope crystal is

A

Calcium oxalate

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45
Q

Yellow or reddish brown diamond shaped or six sided stone is

A

Uric acid

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46
Q

Cystine crystals are

A

Colorless, hexagon shaped

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47
Q

Diagnosis of Kidney stone

A

Urinanalysis, plain abdominal film, IVP, ultrasound, SPIRAL CT

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48
Q

Abdominal flatplate: what stones are radiopaque and radiolucent

A

Radiopaque: Calcium oxalate, calcium phosphate, mixRadiolucent: Uric acid, xanthine, hypoxanthine

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49
Q

T/F: If stone is 10mm or more you normally need a urologist to take it out.

A

True

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50
Q

How to treat stone passage

A

80-90% pass spontaneously. Increase fluids. Strain urine. Analgesia (NSAID to normal creatinine levels)Calcium channel blocker/alpha blocker (Nifedipine/tamsulosin- Flomax)

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51
Q

When do you put someone in the hospital for kidney stone?

A

feverUTIoral analgesia ineffectiveintractable vomiting dehydration

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52
Q

Urologic management includes:

A

Shock wave lithotripsy (with stint)percutaneous nephrostolithotomyureteroscopyopen stone surgery

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53
Q

Risks for kidney stones

A

sweatingexcessive sun exposurerecurrent UTIneurogenic bladdergoutchronic diarrheafamily hx (Renal Tubular Acidosis (RTA) and cystinuria)medications

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54
Q

Medications that may cause kidney stones

A

Carbonic anhydrase inhibitors (eventually drops pH)triamterenesulfadiazoneascorbic acidIndinavir (HIV med)Topiramate (Topomax)Acetazolamide (Diamox)

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55
Q

What lab work could you order if someone had a kidney stone

A

Serum BUNSerum creatinine,calcium, PTH if hypercalcemicphosphorus, uric acid, Urinalysis (UTI, crystals, pH). Could do a 24 hour urine collection.

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56
Q

Preventative therapy for kidney stones

A

Drink more fluids (produce 2 liters of urine, 8 8oz.)Reduce salt intakelimit animal protein to 8 oz. daily

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57
Q

Why would low calcium intake increase urinary oxalate

A

Less calcium is available in intestinal lumen to bind oxalate and prevent its absorption

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58
Q

What drinks increase risk of stone

A

Apple juice, and grapefruit. Decrease risk: coffee, tea, beer, wine. Colas made no difference. Lemonade rich in citrate. OJ will increase urine pH and citrate

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59
Q

What food will increase urine uric acid

A

Red meat, fish, poultry

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60
Q

Foods rich in oxalate

A

Spinach, nuts, PB, strawberries, chocolate, rhubarb, brewed tea

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61
Q

What inhibits sodium reabsorption in distal renal tubules?

A

Thiazides (hydrochlorothiazide). Give potassium citrate to replace potassium

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62
Q

Medical management of uric acid stones

A

Alkalinize urine to pH 6 to 6.5. pH>7 is risk for calcium phosphate stones. Give potassium citrate. Increase fluids. Dietary restriction of purines. Allopurinol

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63
Q

What type of virus is HIV

A

A retrovirus: RNA virus, infects cell, forms DNA, makes more RNA

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64
Q

T/F: HIV is able to replicate continuously in their host cells despite a competent host immune response

A

True

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65
Q

Major cellular targets for HIV-1

A

Lymphocytesmononuclear phagocytes

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66
Q

HIV transmission factors

A

AIDSActive STDpresence of genital lesionsfrequency and type of unprotected sexcircumcisionviral load

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67
Q

How is HIV transmitted

A

Bodily fluids: blood, semen, breast milkNeedles

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68
Q

HIV pathogenesis and progression to AIDS

A

CD4 depletion in GALT in the acute phase of HIV. Selective loss of Th17, polyclonal B cell activation, increased CD4 and CD8 turnover with decreased half lives

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69
Q

T/F: Shingles is suggestive of HIV infection

A

True- also several other indications

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70
Q

AIDS indicators

A

CD4 count <14% of total lymphocytes

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71
Q

Diagnostic testing for HIV

A

Oral fluid testing, urine testing, home test kit, rapid HIV testing

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72
Q

Screening highest sensitivity for HIV

A

ELISA- detecting antibodies to HIV-1 and HIV-2

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73
Q

Confirmation- highest specificity for HIV

A

Western Blot

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74
Q

Acute HIV infection you should perform

A

HIV RNA by PCR

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75
Q

Specific tests used in HIV infection

A

Quantitative HIV RNA, CD4 cell count/percentage, Total lymphocyte count, HLA B5701 (always before abacavir), Resistance testing

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76
Q

Definition of success for HIV

A

HIV RNA <50 copies/mL

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77
Q

A 55 y.o. women has HIV with CD4 count of 344 cells.mm and viral load of 34000 copies/mL. What is treatment

A

2 nucleoside reverse transcriptase inhibitors and 1 non-nucleoside reverse transcriptase inhibitorOR2 nucleoside reverse transcriptase inhibitors and 1 protease inhibitor OR2 nucleoside reverse transcriptase inhibitors and an integrase inhibitor

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78
Q

What drug is used with all PIs to exploit CYP3A4 inhibition to allow for smaller doses

A

Ritonavir

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79
Q

Preferred initial treatments

A

1) Tenofovir (TDF)/ Emtricitabine (FTC) + Efavirenz 2) Abacavir/lamivudine + dolutegravir

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80
Q

Why is anti retrovirus treatment (ART) necessary?

A

Prevent transmission by lowering viral load

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81
Q

HIV in pregnancy- recommended regimen: All infected should be treated regardless of CD4 count with…

A

ZDV/#TC/lopinavir/ritonavir or TDF/FTC+Atazanavir/ritonavir

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82
Q

Protease inhibitors are associated with

A

Metabolic syndrome

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83
Q

Side effects of HIV medication:

A

Lipodystrophy, Bone disorders, etc…

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84
Q

HIV RNA in plasma: HIV RNA should be greater than

A

10,000 copies

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85
Q

Oral complications of HIV

A

Apthous ulceroral hairy leukoplakiacandidiasisKaposi’s sarcomaHSV

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86
Q

Frequent Dermatologic complications in HIV patients

A

Herpes zoster (More than 1 dermatome suggests HIV infection)Eosinophilic folliculitisMRSA relatedSeborrheic dermatitispurigo nodularisherpes simplexbacillary angiomatosismolluscum contagiosumcryptococcusscabies

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87
Q

Cardiovascular complications of HIV

A

Dilated cardiomyopathy pulmonary HTNTricuspid valve endocarditis

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88
Q

Chronic diarrhea in HIV patients is associated with a CD4<____

A

100

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89
Q

Two big neurologic complications in HIV patients

A

Cryptococcus and Bacterial Meningitis

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90
Q

T/F: CMV retinitis the CD4 count is usually less than 50 and fundoscopic exam looks like cottage cheese and ketchup

A

True

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91
Q

What type of pneumonia is associated with HIV patients

A

Pneumocystitis jirovecci pneumonia

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92
Q

What fungal infection is associated with HIV

A

Coccidioides immitis and Histoplasmosa Capsulatum (<150 CD4)

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93
Q

Pneumocytitis pneumonia prophylaxis should be started at CD4+ t cell count less than

A

200 cell/mm

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94
Q

Prophylaxis for toxoplasmosis in HIV patients. What drug and CD4 count?

A

Bactrim at CD4 <100

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95
Q

Definition of virologic management failure

A

HIV RNA> 200 copies/mL

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96
Q

Patients who cannot get HIV have what type of mutation

A

CCR5 mutation

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97
Q

Definition of Asymptomatic Microhematuria

A

No symptoms, greater than 3 RBCs per high power field on microscopy. Urine dipstick positive for heme no adequate (must have 3 negative micros for one positive dipstick)

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98
Q

Risk factors for urologic malignancy (10)

A

1) Smoking2) Males (BPH, prostate cancer prevalent)3) Age >354) Occupational exposures (benzene, aromatic amines)5) Analgesic abuse (phenacetin)6) H/o gross hematuria7) Hx pelvic radiation8) Hx of chronic UTI9) Hx alkylating chemo10) Hx of chronic indwelling foreign body

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99
Q

How many positive micro UA is sufficient for workup

A

1

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100
Q

Top 3 causes of benign causes of AMH

A

BPH, UTI, Stones. Others: Obstructions, medical renal disease, benign tumors.

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101
Q

Standard imaging for microhematuria

A

Multiphasic CT without and with IV contrastA) Non contrast: stones, hydronephrosis, fat lesionsB) Arterial phase: Tumors, inflammatory lesionsC) Venous stage: ScarringD) Excretory phase: pyelogram, ureters, bladder

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102
Q

Cant have a CT with contrast (Pregnant, Contrast allergy, renal insufficiency) what do you do?

A

1)MRI/MRU without and with gadolinium contrast: Not as good for stones, better for masses. Not good in renal insufficiency2) Retrograde pyelography: Safe with renal insufficiency. Plus Ultrasound.-Must need some contrast to see inside kidney

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103
Q

What is the best way to rule out bladder cancer?

A

Cystoscopy- May miss many many bladder tumors depending on how full bladder is.

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104
Q

Recommendation for cystoscopy

A

All patients over 35 or younger than 35 with risk factors

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105
Q

How many colonies on a culture indicate the presence of a UTI (microbiology definition)? How many colonies in a symptomatic patient before you start treatment?

A

100,000 org/ml (microbiology definition)In patients with symptoms: 100-10,000 to begin treatmentmultiple organism (3+) suggests contamination

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106
Q

Microbiology definition of UTI

A

100,000 org/ml. Symptomatic: 100-10,000Multiple organisms (3 or more) suggest contamination

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107
Q

Risk Factors for UTIs (8)

A

1) Gender2) Sexual activity and contraception3) Pregnancy4) Obstruction5) Neurogenic bladder dysfunction6) Vesicoureteral reflux7) Bacterial virulence factors8) Immunosuppressed states: Sickle cell

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108
Q

Clinical symptoms of UTI:

A

DysuriaFrequencyUrgencySuprapubic pain/pressure

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109
Q

With complaints of vaginal discharge, the dx of a UTI Increases/ Decreases by 20%

A

Decreases- vaginal symptoms may be causing dysuria

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110
Q

Who needs a urine C&S?

A

1) Seriously ill pts2) Recently hospitalized/ hospitalized pts3) Men and all children4) Women with relapse or reinfection5) Women with complicating factors6) Pregnancy

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111
Q

Etiology of UTI in women

A

1) E. coli (75-95%)2) Enterobacter3) Klebsiella4) Proteus-Gram negative causes 90-95%-Gram + cause 5-10%-Staph saprophyticus cause 10-15%

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112
Q

What drug for UTIs could you use for prophylaxis

A

Trimethoprim: Bacteriostatic

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113
Q

Drug of choice for UTI

A

Trimethoprim-Sulfamethoxazole

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114
Q

What is a drug for UTIs active against G+ and G- bugs which is contraindicated in pts with GFR <60 but safe in early pregnancy

A

Nitrofurantoin

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115
Q

What can you use for UTIs but is not first line?

A

Cephalosporins, FQ (resistance, contraindicated in kids and pregnancy)

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116
Q

What is first line in UTI is resistance to TMP/SMX is >20%

A

Quinolone

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117
Q

Fosfomycin is only indicated in what type of UTI

A

Uncomplicated UTI

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118
Q

For symptomatic UTIs, normally how long do you treat?

A

3 days

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119
Q

Urinary analgesics:

A

1) Phenazopyridine (Pyridium) - turns urine orange, stains2) Flavoxate (Uripas)3) Cranberry Juice?

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120
Q

Safe drugs for UTIs in pregnancy:

A

1) Penicillins2) Cephalosporins3) Nitrofurantoin4) Fosfomycin

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121
Q

T/F: If a pregnant women is suspected of having pyelonephritis, what should you do?

A

Hospitalize

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122
Q

Treatment for Pyelo outpatient

A

1) FQ or TMP-SMZ recommended2) Amox or Augmentin ok if gram + bug-10-14 days

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123
Q

DDX for Dysuria

A

1) Cystitis2) Painful Bladder Syndrome3) Vaginitis (Infectious, Chemical, PID)4) Prostatitis5) Urethritis6) Meatal strictures

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124
Q

T/F A UTI in a male patient is very rare and possibly pathologic and should undergo a work-up.

A

TRUEUTI’s are very common in females.

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125
Q

Protective Factors

A

Long urethraBladder emptyingAntibacterial properties of urineProstatic secretionsPMNs in bladder wall

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126
Q

UTI Urinalysis Findings

A

Cloudy urineMalodorousHematuria (microscopic)Dipstick Results: nitrite (+) or leukocyte esterase (+)Microscopic: WBC, Bacteria, casts

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127
Q

UTI Physical Findings

A

Vitals - document temperatureSuprapubic PalpationPalpation of CVALab - get a urine sample

128
Q

__________ is the most common etiologic agent of UTI’s and what what is the drug of choice.

A

E. Coli Trimethoprim-Sulfamethoxazole (TMP-SMZ)

129
Q

3 Drugs of Choice for Uncomplicated UTIs

A

NitrofurantoinTMP/SMX (depends on local resistance rates)Fosfomycin

130
Q

Helpful Suggestions for Patients with UTIs

A

Drink plenty of waterVoid frequentlyVoid after intercourse

131
Q

What is definition of recurrent UTI’s?What can be used for prophylaxis?

A

3 documented UTIs/yearProphylactic: Nitrofurantoin, Keflex, TMP-SMZ, Noroxin

132
Q

Most Common Etiology for Pyelonephritis

A

E. coliProteusKlebsiellaEnterobacterPsuedomonas

133
Q

Clinical Findings in Pyelonephritis

A

FeverFlank PainShaking ChillsVoiding Symptoms: dysuria, frequencyConstitutional Symptoms: nausea, vomiting, diarrheaPhysical Exam: fever, tachycardia, +/- CVA tenderness

134
Q

What finding on microscopic urinalysis is a strong indicator of pyelonephritis?

A

WBC casts

135
Q

UTI Symptoms in Newborns and Infants

A

non-specific signs: fever, poor feeding, irritability, vomiting, sepsis, hypothermiastrong, foul-smelling odor

136
Q

UTI Symptoms in Preschool

A

abdominal or flank pain, vomiting, fever, frequency, dysuria, enuresis

137
Q

UTI Symptoms in School-Age Children

A

classic signs and symptoms but CVA tenderness is uncommon

138
Q

Risk factors for prostate Cancer

A

1) Age2) Genetics3) African American men4) Diet5) Environmet

139
Q

Comparing 2 PSAs over time is called

A

PSA velocity

140
Q

Normal blood level of PSA

A

<4ng/ml

141
Q

A PSA >10 correlates with what?

A

Greater positive biopsy rate (66%)

142
Q

AUA guidelines for Prostate Cancer: Panel recommends against PSA screening in men

A

Under 40 and over 70

143
Q

AUA guidelines for Prostate Cancer: Panel does not recommend PSA screening in what age group

A

40-54

144
Q

Low Risk for Prostate Cancer

A

PSA <10 and gleason score 6 or less

145
Q

PSAV greater than what is useful in identifying PCA

A

0.4

146
Q

Risk Factors - Causes of Prostate Cancer

A

AgeRaceEnvironmentDietGenetics/Family History

147
Q

Assessing the Prostate

A

Men > 50 should have a PSA blood test and DRE once a year. (High risk groups > 45)

148
Q

Amount of PSA compared to the size of the prostate gland is called?

A

PSA Density

149
Q

Factors that can change PSA

A

1) Prostate Cancer2) BPH3) Prostatitis4) Trauma5) Instrumentation6) Mediciations

150
Q

Intermediate Risk for Prostate Cancer

A

PSA 10-20, Gleason Score 7

151
Q

High Risk for Prostate Cancer

A

PSA > 20, Gleason Score 8-10

152
Q

Goals of Active Surveillance for Prostate Cancer

A

1) Provide treatment for men likely to progress2) Reduce risk of treatment who are not likely to progress

153
Q

Prostate Cancer Treatment Options

A

Surveillance & watchful waitingRadiotherapy (external beam and interstitial)Radical ProstatectomyHormone Therapy

154
Q

BPH histological diagnosis:

A

Proliferation of smooth muscle and epithelial cells within the prostatic TRANSITION ZONE.

155
Q

LUTS - Storage Symptoms

A

frequencynocturia

156
Q

LUTS - Voiding Symptoms

A

hesitancyintermittencyweak streamdribbling

157
Q

urgency with or without urge incontinence usually with frequency and nocturia

A

Overactive Bladder Syndrome

158
Q

urodynamic observation of an involuntary detrusor contraction

A

Detrusor Overactivity

159
Q

Define Benign Prostatic . . .A) HyperplasiaB) EnlargementC) Obstruction

A

A) Hyperplasia - histological diagnosisB) Enlargement - gland enlargementC) Obstruction - obstruction is suspected based on flow rates/urodynamics

160
Q

Bladder Outlet Obstruction

A

any obstructive process

161
Q

Main drug classes used for treatment of LUTS

A

Alpha blockers (dynamic)5-alpha reductase inhibitors (static)

162
Q

Long Acting Alpha Blockers

A

Terazosin, Doxazosin, Alfuzosinrequire dose titration

163
Q

a1 Receptor Blockers

A

Tamsulosin (Flomax)Sildosin (Rapiflo)

164
Q

5 alpha reductase inhibitor action

A

blocks conversion of testosterone to DHT in prostate tissueaverage 50% reduction in PSA

165
Q

5 alpha reductase inhibitors are used in patients with a prostate > ______ grams or PSA > _____.

A

30 grams or PSA > 1.5

166
Q

Patient has a small prostate gland or low PSA. What type of treatment do you use?

A

alpha-blocker

167
Q

When to consult a urologist:

A

1) refractory to medical management2) recurrent urinary retention3) recurrent UTI4) renal insufficiency5) hematuria6) bladder calculi

168
Q

Cancer in the prostate occurs in what zone

A

Peripheral Zone

169
Q

Patient presentation of BPH (LUTS)

A

Lower Urinary Tract Symptoms1) Direct Bladder outlet obstruction (static component)2) Increased smooth muscle tone and resistance (dynamic component)-Frequency, nocturia (storage)-Hesitancy, intermittency, weak stream, dribbling (Voiding)

170
Q

Index patient according to AUA for BPH

A

Male aged 45 or older with LUTS-No history suggesting non-BPH causes-LUTS may or may not be due to enlarged prostate, BOO, or histological BPH

171
Q

A questionnaire given to patients with LUTS. What is it called, what does it include and ow is it scored?

A

AUA Symptom Index (AUA-SI). 7 question and 1 quality of life question. Mild: 0-7Moderate: 8-19Severe: 20-35

172
Q

Recommended tests for LUTS

A

1) Medical hx2) Assesment of LUTS3) Severity and bother (AUA-SI)4) DRE and PE5) UA6) Serum PSA7) Frequency/volume chart

173
Q

Polyuria is defined as:

A

> 3L in 24 hours

174
Q

Modifiable factors of LUTS

A

Fluid intake

175
Q

Alpha blockers:

A

Alfuzosin, doxazosin, Terazosin, Tamsulosin, Silodosin

176
Q

5ARIs

A

Avodart and Finasteride

177
Q

Patients with LUTS secondary to BPH whom an alpha blocker is offered, what syndrome do you need to worry about?

A

Intraoperative Floppy Iris Syndrome- If planned cataract surgery, hold alpha blocker until after

178
Q

A patient has LUTS secondary to BPH and without an elevated PVR and mainly irritative symptoms, what should you consider prescribing?

A

Anticholinergics- M3 receptor (Ex: Oxybutynon)

179
Q

Minimally invasive therapy for LUTS

A

Transurethral needle ablation-TUNATransurethral microwave thermotherapy- TUMT

180
Q

Surgery Treatments for LUTS

A

1) Transurethral: Incision of prostate (TUIP), Vaporization of Prostate (TUVP), Resection of Prostate (TURP).2) Open simple prostatectomy3) Robotic/Laparoscopic simple prostatectomy

181
Q

Domains for defining continence (4)

A

Symptoms: patient/caregiver descriptionSigns: objective demonstration of urine lossUDS observationCondition: lower urinary tract pathophysiology

182
Q

What is the involuntary loss of urine and is not necessarily a part of aging?

A

Incontinence

183
Q

The micturation control center in your frontal cortex does what?

A

Inhibitory signals to the detrusor.

184
Q

The pontine micturation center does what?

A

Coordinates Urinary Sphincter with detrusor

185
Q

The spinal cord had what role in micturation?

A

Communication between brainstem and sacral spinal cord. Sacral spinal cord is spinal reflex center.

186
Q

Classes of incontinence

A

Transient- Important in elderlyUrge- Variant overactive bladder syndromeStress- Leak with coughingMixed: Stress and urgeTotal/continuous: rareOverflow: neurogenic baldder

187
Q

Functional Classification of incontinence

A

1) Failure to empty (Bladder underactivity, obstruction) 2) Failure to store: (urethral incompetence, bladder overactivity)

188
Q

Urologist Referral for Incontinence

A

-Bothersome Stress Incontinence-Refractory Urge/Urge Incontinence-Recurrent symptomatic UTI’s with urinary incontinence-Pelvic floor prolapse-Prostate cancer-Bladder cancer-Hematuria-Urinary retention not responding to management

189
Q

Urethral sphincter Etiology: Urethral resistance- When will you see leakage of urine?

A

During filling of bladder with valsalva

190
Q

Results for post void residuals

A

400 consider intermittent catheterization or indwelling foley catheter and further urologic consult

191
Q

Testing for incontinence

A

Labs: UA with possible cultureUrodynamics testing: Stress testing, uroflow, postvoid residual, voiding cystometrogram, cystourethroscopy

192
Q

How should you begin therapy for incontinence?

A

-Begin with conservative therapy (Lifestyle changes- avoid caffeine, alcohol, etc.)-Bladder diary-Behavioral training: Timed, double voiding

193
Q

Pharmaceutical therapy for incontinence

A

1) Anticholinergic Agent- Promote urinary storage by blocking Mu receptor. SE: Dry mouth, constipation2) Beta 3 agonists- Mirabegron (Myrbetriq): Stimulates bladder relaxation promoting storage. SE: Occasional HTN3) Tricyclic antidepressants (Imipramine)- consider for mixed incontinence4) Estrogen: Elderly

194
Q

Treatment modalities for incontinence- Surgery for Overactive bladder:

A

1) Catheter (intermittent, indwelling)2) Surgery: Neuromodulation, Botulinum toxin, augmentation cytoplasty, denervation

195
Q

Surgery for Stress Incontinence

A

1) Retropubic suspensions2) Mid-urethral sling3) Pelvic organ prolapse repair4) Collaen injections5) Artificial urinary sphincter

196
Q

Barrier methods for Incontinence

A

Pads, Absorbant garments

197
Q

Risk factors for incontinence in women

A

Pregnancy and childbirthObesityEndocrine (diabetes, menopause)Pulmonary (persistent cough)Neurological (dementia)

198
Q

Risk factors for incontinence in men

A

Surgical interventionsNeurological (dementia)Endocrine (diabetes)

199
Q

Sympathetic Nervous Control of Micturation

A

Bladder Filling:-inhibits detrusor muscle through B receptors-activates internal urethral sphincter and proximal urethral constriction through hypogastric nerve

200
Q

Parasympathetic Nervous Control of Micturation

A

Micturation-suppression of sympathetics-stimulates detrusor smooth muscle through pelvic plexus from sacral segments (S2-S4)

201
Q

Transient Incontinence(DIAPPERS)

A

D - deliriumI - infectionA - atrophic vaginitisP - pharmacologicP - psychologicalE - endocrineR - restricted mobilityS - stool impaction

202
Q

Bladder Irritants

A

Acidic foodCitrusCaffeineEtOHSpicy foods

203
Q

Urologist Referral for Incontinece

A

-Bothersome Stress Incontinence-Refractory Urge/Urge Incontinence-Recurrent symptomatic UTI’s with urinary incontinence-Pelvic floor prolapse-Prostate cancer-Bladder cancer-Hematuria-Urinary retention not responding to management

204
Q

Signs and Symptoms of Acute Renal Failure

A

-Edema (Leg, pericardial, pleural)-HTN-Diminished urine output-Confusion-Symptoms of electrolyte abnormalities

205
Q

Signs and symptom of chronic renal failure

A

-Most common is no sign or symptom-Early symptoms include: Fatigue, weakness, anorexia/nausea/vomiting, irritability/mental status changes, pruritis, easy bruising, menstrual irregularities, libido

206
Q

Lab abnormalities with renal function decline

A

-High blood urea nitrogen-Elevated BUN and Creatinine-Proteinuria-Anemia

207
Q

Excess can be caused by

A

-Under excretion-Overproduction-Ectopic Source-Wrong place*1 of these 4 problems can cause abnormally high lab values

208
Q

Deficiency can be caused by

A

-Under production (Ex: hypothyroid)-Over-excretion (Ex: Basement membrane damage)-Inadequate intake (Ex: Lack of protein)-Wrong place (Ex: Sequestration)-Leakage, lysis or destruction (Ex: Hemolytic anemia)*1 of these 5 problems can cause abnormally low lab values

209
Q

What are the two major types of Renal Disease

A

Glomerular and Interstitial

210
Q

Proteinuria in Glomerular and Interstitial renal disease

A

Glomerular: >2.0 gm/dayInterstitial: <2.0 gm/day

211
Q

Urine sediment in Glomerular and Interstitial renal disease

A

Glomerular: Hematuria, RBC castsInterstitial: Pyuria, WBC casts

212
Q

Hypertension in Glomerular and Interstitial renal disease

A
  • Common in glomerular and less common in interstitial
213
Q

Edema in Glomerular and Interstitial renal disease

A

Usual in glomerular, rare in interstitial

214
Q

Quantitation of proteinuria on spot urine

A

Protein (mg/dL)/ Creatinine (mg/dL)= g protein/24 hour

215
Q

Nephrotic syndrome

A

-Proteinuria-Hypoalbuminemia-Edema-Hyperlipidemia-Lipiduria

216
Q

Most common glomerular disease in the US

A

Diabetic nephropathy- most common cause of end-stage renal disease in US.

217
Q

Microalbuminuria value

A

30-300mg/24 hrs

218
Q

Macroalbuminuria value

A

> 300 mg/24 hrs

219
Q

General history of glomerular nephropathy

A

Elevated glomerulofiltration rate and increased kidney size —–> Microalbuminuria—-> Proteinuria—-> Decreased GFR, ESRD

220
Q

With elevated GFR and increased renal size, what do you control and how would you treat

A

BP control (<130/80). ACE Inhibitor?

221
Q

With microalbuminuria, what do you control and how would you treat?

A

BP Control: ACE inhibitor, Glycemic control? (Statin)

222
Q

With proteinuria, what do you control and how?

A

BP control (<125/75): ACE inhibitor. Statin?

223
Q

Lab evaluation of glomerulonephritis

A

1) UA2) Spot urine for protein and creatinine3) Serum chemistries4) Hgb A1c5) ANA6) C3, C47) ANCA8) Blood culture

224
Q

Minimal change disease: Most common in what population? Presents how?

A

-most common in kids, presents with acute onset edema and nephrotic syndrome. Cell mediated immunity may play role in primary disease.

225
Q

How to treat minimal change disease

A

Steroids

226
Q

Most common primary glomerular disease in US blacks. Presentation from nephrotic syndrome to progressive kidney dysfunction. Can recur quickly following kidney transplant.

A

Focal and Segmental Glomerulosclerosis (FSGS)

227
Q

Treatment in Focal and Segmental Glomerulosclerosis (FSGS)

A

General: Blood pressure control, block Renin angiotensin system, Diuretics for edema, statin therapy-Idiopathic: Immune modulation with steroids and/or cyclosporine

228
Q

Clinical presentation of what: Progressive edema related to gradual worsening proteinuria. Overt nephrotic syndrome (80%). Microscopic hematuria (

A

Membranous Nephropathy

229
Q

Etiology of Membranous Nephrology

A

-Idiopathic- most common-Autoimmune disease (SLE)-Drugs (Gold, NSAIDS)-Infections (Hepatitis, syphilus)

230
Q

Membranous nephropathy treatment:

A

General: Blood pressure control, block Renin angiotensin system, Diuretics for edema, statin therapy-Idiopathic: Immune modulation with steroids and/or cyclosporine

231
Q

Most common glomerular disease worldwide

A

IgA Nephropathy- Most primary but can be secondary

232
Q

IgA Presentation

A

Microscopic hematuria, gross hematuria (SYNpharyngenitic), proteinuria, progressive renal dysfunction

233
Q

MPGN Type I Presentation

A

Microscopic hematuria and non-nephrotic proteinuria, LOW SERUM COMPLEMENT LEVELS, Hypertension

234
Q

Serum Complement levels: Low complement causes

A

-Lupus nephritis-MPGN-Post infectious glomerulonephritis (Strep, endocarditis)

235
Q

Serum Complement Levels: Anti-Neutrophil Cytoplasmic Antibodies

A

Wegener, microscopic polyangiitis, churg straus

236
Q

40 yo male who has noticed a little swelling in legs and urine is weird colored: How would you approach it?

A

1) Detailed History2) PE: Skin rashes, tenderness, BP3) Labs: UA, Creatinine, Serum Chemistries, Complements, blood culture, ANCA, ANA

237
Q

Anti-glomerular basement membrane disease clinical presentation

A

Hematuria and proteinuria. Progressive loss of kidney function.-Goodpasture’s Disease-when combined with lung involvement-Autoantibody to type IV collagen

238
Q

Treatment for Anti-GBM

A

Treated with plasmapheresis, steroids, cyclophosphamide

239
Q

Glomerulonephritis and ANCA

A

Renal limited ANCA disease: Hematuria and proteinuria. Progressive renal dysfunction.-As part of systemic disease (Wegener, MPA, Churg-Straus): Night sweats, wt. loss, fatigue (esp. elderly), pulmonary and Upper airway disease

240
Q

ANCA treatment

A

Steroids, cyclophosphamide. Plasmapheresis for severe renal disease or pulmonary hemmorrhage

241
Q

A systemic disease characterized by autoimmunity with antinuclear antibodies (ANA) and low serum complements

A

Systemic Lupus Erythematosis

242
Q

T/F: Lupus nephritis can present with multiple type of kidney lesions

A

True- immune complex glomerular disease

243
Q

Treatment of lupus nephritis

A

Steroids, cyclophosphamide, mycophenolate mofetil

244
Q

Definition of acute kidney injury

A

Abrupt (w/i 48 hours) reduction in kidney function defined as:-An absolute increase in creatinine of >0.3 mg/dL or a percentage increase more than 50%-Or a reduction in Urinary Output (UOP) (<0.5 ml/Kg/h for more than 6 hours)

245
Q

Major cause of acute renal failure in hospital setting

A

Acute tubular necrosis

246
Q

Prerenal presentation and treatment

A

Normal physiologic response to renal hypo perfusion to impair GFR. Renal parenchyma is normal. If not treated can lead to ATN.Treat: Fluid repletion

247
Q

Rate of rise of plasma creatinine in ATN vs. Prerenal

A

ATN: rise progressively at a rate greater than 0.3 to 0.5 mg/dL per day.Prerenal disease: Slower rate of rise with periodic downward fluctuation

248
Q

UA in ATN and Prerenal

A

-Normal in Prerenal disease-In ATN: Muddy brown granular and epithelial cell casts and free epithelial cells.

249
Q

Fractional excretion of sodium (FENa) in prerenal and ATN

A

Prerenal disease: 2%

250
Q

Fractional excretion of urea (FEurea) in prerenal patients

A

<35%

251
Q

Diagnosis of Prerenal Azotemia

A

-Normal renal US-UA-normal-Low urine Na, FENa<35%-No proteinuria, no albuminuria-Reversible with hydration

252
Q

Glomerular Disease as a cause of Acute Kidney Injury presentation

A

-Most of time rapidly progressive GN-Normal Renal US- large kidney-UA- hematuria, RBC CASTS, dysmorphic RBCs-Proteinuria ~1-2 g/day-FENa can be <1%

253
Q

Tubular Diseases- ATN presentation

A

Renal US: NormalUA: Muddy brown granular casts, epithelial cell, epithelial cell casts, hematuria- no dysmorphic RBCs-Subnephrotic proteinuria-FENA >2%

254
Q

ATN management

A

Conservative: Avoid hypotension, fluid depletion, nephrotoxic medication. Use renal replacement therapy when needed (dialysis).

255
Q

Interstitial Kidney Disease presentation

A

-Symptoms and/or signs of allergic-type reaction: Rash, fever, eosinophilia, or triad of three-Renal US: normal-UA: White cells, red cells, WBC casts. Mild increase in protein. EOSINOPHILURIA (75% in 1st week).-Nephrotic syndrome due to minimal change disease can be seen with NSAIDSFENa >2%

256
Q

AIN- Acute interstitial nephritis causes

A

Drugs with antibiotics responsible for 1/3 of these cases.-Infection related-Idiopathic-Tubulointerstitial nephritis and uveitis syndrome-sarcoidosis

257
Q

AIN management

A

Identify and stop medication causing disease.-Severe: prednisone- make sure infection has been excluded before starting therapy

258
Q

Tests to be ordered with acute renal failure

A

1) Renal Ultrasound with Doppler2) UA with microscopic exam3) Spot urine proteins/creatinine ratio4) Spot urine albumin/ creatinine ratio5) Urine Na, urea

259
Q

Postrenal causes

A

-Ureteral obstruction-Bilateral ureteral obstruction (stone, retroperitoneal fibrosis, pelvic masses)-Urethral obstruction: BPH, Prostate cancer

260
Q

Renal US with Doppler can tell you…

A

-Kidney size-Renal perfusion-Measures the resistive indexes-Renal echogenicity-Ureteral obstruction-Bladder obstruction, masses, postvoid residue-prostate size and shape-possible other organs pathology

261
Q

Increased renal echogenicity seen often in what?

A

Chronic renal disease

262
Q

UA with microscopic exam: 1) Glomerular problem2) Prerenal3) ATN

A

1) Hematuria (dysmorphic RBC) and proteinuria2) Normal3) Muddy brown granular casts

263
Q

Urine protein/creatinine and urine albumin/creatinine for glomerular (not NS), ATN, Interstitial disease

A

1-3.5 g of proteins/day

264
Q

> 3.5 g protein/day is

A

NS or nephrotic range proteinuria

265
Q

Indications to start RRT (Dialysis)

A

-Severe acidosis-Severe hyperK-Fluid overload not responding to diuretics-Uremic symptoms-Uremic pericarditis-BUN ~80 mg/dL

266
Q

3 stages of development of the kidney

A

Pronephros (nonfunctional), Mesonephros, Metanephros

267
Q

True/ False: Kidney produces amniotic fluid at a rate up to 1 ml/kg/h.

A

False: 10 ml.kg/h

268
Q

At what weight (kg) do you get adult like composition of fluids

A

15 kg- Water content decreases from 96% at EGA 8 weeks to 78% at term

269
Q

In a preterm baby, you have fewer production of glomeruli and because of the diluting and concentration capacity, baby is at risk for…

A

hyponatremia

270
Q

No cows milk up until 1 y/o because limited ability to excrete a high solute load: why is this

A

-Low GFR-Shorter loops of Henle-Increased medullary/cortical blood flow ratios

271
Q

One of the most common pediatric infections.

A

UTI

272
Q

Age 0-3 mos.: Boy/Girls have more UTIs

A

Boys: After 1 yr. girls more likely

273
Q

Most UTIs in the first year are Pyelonephritis/Cyctitis

A

Pyelonephritis (upper tract)

274
Q

WHAT REDUCES UTI incidence in boys in 1st year of life

A

Circumcision

275
Q

AAP: Infant with fever without focus. What do you obtain

A

Urine specimen by catheterization for both culture and UA. Treat constipation

276
Q

T/F: Grade III or less VUR may resolve without intervention

A

True

277
Q

What is hypoplasia, what is it proportional to, and what do you get?

A

Small kidneys, decreased glomeruli.-Directly proportional to BW.-Oligomeganephronia- Hyperfiltration injury

278
Q

Dysplasia:

A

Maturational arrest-Abnormal histology- primitive tubules and cartilageEx: Multicystic dysplastic kidney, obstructive dysplasia

279
Q

ARPKD: Autosomal recessive, infantile form

A

Fibrocystin, Chromosome 6-Hepatic fibrosis w/ portal HTN-Systemic HTN-Kidney Failure-Respiratory distress

280
Q

ARPKD: Autosomal Dominant, more frequent in adults

A

Polycystin-Bilateral macrocysts-Hepatic, splenic, and pancreatic cysts-Aneurysms of Circle of Willis

281
Q

Water excretion in the fetal and neonatal kidney

A

-Diminished capacity to rapidly excrete water.-Lower GFR-Elevated hormone levels suggest decreased ability of the neonatal kidney to respond to renin, aldosterone, atrial natriuretic peptide, and antidiuretic hormone.

282
Q

Increased renal mass after glomerular development is complete is due to tubular growth and maturation. So this means Preterm GFR is greater than what?

A

Tubular absorption- Fractional excretion of Na+ is greater in preterm- Hyponatremia

283
Q

Bicarbonate reabsorption threshold is directly related to ____ and most bicarbonate is reabsorbed in the ____.

A

Age, Proximal tubule- Same with glucose!

284
Q

Glucosuria can increase osmotic diuresis, risk for _________

A

Dehydration

285
Q

1) Phosphorous reabsorption is _________ in infants.2) ___________ related to age and GFR.

A

Higher, Inversely

286
Q

Chronic kidney disease stages

A

I: GFR>90II: GFR 60-90III: GFR 30-60IV: GFR 15-30V: GFR <15

287
Q

What is this: Many AR mutations, retinal degeneration, hepatic fibrosis, Brain and skeletal abnormalities.

A

Juvenile Nephronophthisis

288
Q

What is this: AD, typically presents later. HTN. Polyuria, hematuria in adults.

A

Medullary cystic disease

289
Q

Congenital nephrotic syndrome presents in the first ___ months. Fetal _____________ —-> elevated AFP. Placenta >25% birth weight. It is resistant to __________ treatment. Leads to end stage renal disease so need a __________. Abnormality in making ________.

A

1) 3 months2) Proteinuria3) Steroid4) Transplant5) Nephrin

290
Q

____________ nephrotic syndrome presents in the first 12 months. It is resistant to steroid treatment. ESRD, Transplant. An abnormality in _________.

A

Infantile, podocin

291
Q

A form on infantile nephrotic syndrome that presents with HTN, gonadoblastoma, wilms tumor, and male pseudohermaphroditism.

A

Denys-Drash

292
Q

Nephrotic Cystinosis: Renal fanconi syndrome

A

Proximal tuble: glucosuria, amino aciduria, phosphaturia, proximal RTA, secondary hypercalciuria.-AR- prototypic lysosomal membrane transport disease: cystine accumulates in lysosomes, causing crystal formation and cell death. Untreated leads to ESKD, CORNEAL crystals, hypothyroidism, and growth retardation.Rx: Cysteamine

293
Q

Basement membrane disease when it is less than 100nm in thickness

A

Thin basement membrane lesion. Normal is 100-300nm

294
Q

Abnormally split and laminated GBM

A

Alport syndrome- Problem with Collagen IV

295
Q

Posterior urethral valves

A

Obstructive Uropathy- Dilated ureters and prostatic urethra- Treat with catheter

296
Q

Early obstructive uropathy

A

10-12 weeks-Failure of UB branching, blastema induction-Dysplasia

297
Q

Late obstructive uropathy

A

-VUR-Inflammation-Fibrosis

298
Q

Triad of Prune belly syndrome (aka Eagle-Barrett sundrome)

A

1) Deficient abdominal musculature2) Bilateral Cryptorchidism3) Dilated nonobstructed urinary tract

299
Q

Symptoms of Prune belly syndrome

A

Dysplasia, VUR, UTIs common.-Pectus excavatum, hip dysplasia-97% male

300
Q

UPJ obstruction signs and symptoms

A

1) Dilated renal pelvis2) Flank pain with high urine flow3) May be bilateral-lead to renal failure4) Nephrostomy tube replacement

301
Q

A horseshoe kidney is fusion of the _______ poles and the ascent is blocked by the ______. The kidney is functional and malrotated.

A

Caudal, Inferior mesenteric artery

302
Q

What is this: Microangiopathic hemolytic anemia, thrombocytopenia, acute renal failure. What 2 types

A

Hemolytic Uremic Syndrome1) D +HUS: Hemorrhagic colitis, shigella, EHEC, 2) Atypical: Pneumococcus, complement abnormalities

303
Q

2 major causes of renal failure

A

Dibetes Mellitus and HTN

304
Q

Reversible causes of renal failure

A

-Hypovolemia-Infection-Obstruction-Exposure to drugs (Contrast or drugs that lower GFR)

305
Q

Definition of chronic kidney disease

A

GFR <60 or there is kidney damage manifested as proteinuria for greater than or equal to 3 months

306
Q

Signs symptoms of CKD

A

-HTN-Proteinuria-Edema-Electrolyte abn-Elevated BUN/ Creatinine-Elevated PT/INR-Fatigue, nausea, vomiting, pruritis, loss of appetite, amenorrhea, uremic smell, easy bruising or bleeding, muscle cramps

307
Q

Why do you start dialysis

A

-Hyperkalemia-Fluid overload-Pericardial effusion-Acidosis-Other electrolyte abnormalities-Bleeding

308
Q

Explain renal osteodystrophy/mineral and bone disorders

A

-Increased retention of phosphorous, body secretes calcium, increased parathyroid hormone, or vitamin D. -Abnormal bone turnover, mineralization, or linear growth.-Phosphorous abnormalities start with GFR <40 but can be sooner.

309
Q

Treatment of renal osteodystrophy/mineral and bone disorders

A
  • Restrict dietary source of phosphorous- Prescribe phosphorous binders to be taken at meals- Prescribe vitamin D supplementation which will decrease PTH levels- Draw a PTH
310
Q

A common problem in renal failure is hyperkalemia. How would patient present and how to treat and dietary restrictions.

A

-May have weakness, fatigue, muscle paralysis, SOB, palpatations, chest pain, nausea, vomiting, parasthesias.-Treat with dietary restrictions, drugs such as KAYEXALATE or with dialysis-Dietary restrictions: Potassium < 40-70 mEq/day. <2.4 grams Na+/day.

311
Q

Nutritional needs in CKD

A

-Nutritional needs: Protein restrictions (0.6g/kg/day) and fluid restrictions? Restrict Na+, K+, Phosphorous. If malnourished…eat!

312
Q

Acidosis with CKD: What causes it and treatment

A

-Hydrogen ions are retained and renal failure making the patient metabolically acidotic.-Treat by supplementing with sodium bicarbonate

313
Q

End Stage renal disease is fatal if not treated by:

A

Hemodialysis, peritoneal dialysis, renal transplantation

314
Q

A coronary heart disease risk equivalent is

A

Chronic kidney disease

315
Q

When can a patient be listed for a cadaveric kidney transplant

A

With a GFR of 20mL/min or less

Adult/Ped Medicine Cumulative Final (6 decks)

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