Exam 6 Flashcards
1
Q
Bladder Voiding FIlm
A
Voiding cystourethrogram (VCUG): Used with contrast
2
Q
Functional unit of the kidney
A
Nephron
3
Q
Most Common Urologic Problems
A
- UTI’s2. Prostate3. Renal Stones
4
Q
When is recommended time to do surgery for undescended testicles?
A
after 6 mo.
5
Q
Reason for surgery of undescended testicle
A
Fertility (Same fertility if unilateral, but bilateral is 50% fertility) and cancer risk.
6
Q
When is the best time in life to do a scrotal exam
A
At birth
7
Q
Most reliable way to identify an undescended testicle
A
1) Physical exam **2) MRI3) Scrotal US with doppler4) Scrotal US5) CT scan
8
Q
Non palpable testicle has compensatory _________ >1.8cm. When kid has non palpable testicle must do a _________?
A
Hypertrophy, laparoscopy
9
Q
Most hernias in kids are ____________ while in adults they are _______
A
Indirect, direct
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
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
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
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
14
Q
What has surgical of vesicoureteral reflux been proven to decrease
A
1) Febrile UTIs- No other things
15
Q
Antibiotic prophylaxis after a UTI decreases the risk of recurrent UTI by…
A
8%- Antibiotics can causes resistance in bowel flora
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
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
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
19
Q
Immediate postnatal evaluation
A
Bladder outlet obstruction, bilateral obstruction (SFU 4)
20
Q
What is Mag 3
A
For SFU 3 and 4. Radiotracer study to show blockage
21
Q
Causes of TRUE fecal incontinence (3)
A
1) Myelomeningocele2) Hirshprung disease3) Anorectal malformations
22
Q
Cause of PSEUDO-fecal Incontinence
A
Due to constipation
23
Q
Treatment of Encopresis
A
1) Desimpaction2) Maintenance3) Lifelong disease
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)
25
Monosymptomatic nocturnal enuresis treatment
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)
26
How are labial adhesions treated?
1) Observation2) Estrogen cream3) Break adhesion surgically
27
What is the recommended care of an uncircumcised penis from age 0 to age 8
Once the foreskin becomes retractable, teach children to retract their own foreskin during voiding or bathing-Phimosis- cannot retract foreskin
28
Soft penile adhesions involves what anatomically? What treatment is needed?
Do not involve the circumcision. Disappear on their own without treatment
29
Penile bridge involves what anatomically? What treatment is needed?
Usually involve circumcision. Require surgical treatment
30
Hypospadius
Dorsal hood. Hole on VENTRAL side
31
Patient reports with severe flank pain radiating to the lower abdomen, groin, testes. Patient also has hematuria. What are these symptoms for?
Kidney Stones- can be asymptomatic, cause restlessness, nausea, vomiting, ileus, "mirror pain"
32
Renal Colic
-severe flank pain radiation to lower abdomen, groin, or testes-restless, ambulatory-nausea, vomiting, ileus-mirror pain
33
Urolithiasis Stone Presentation
-asymptomatic-acute urinary obstruction - renal colic-hematuria
34
Stone Ingredients
CalciumOxalatePhosphateUric AcidCystineStruviteTriameterne
35
________ and _________ inhibit nucleation
Magnesium and Citrate
36
Calcium Phosphate Stones form in acidic/alkaline urine?
Alkaline - as pH increases more phosphates exist in ionic form
37
Uric Acid Stones form in acidic/alkaline urine?
Acidic - solubility of urate increases as pH increases
38
Diagnosis of Urolithiasis
Urinalysis - hematuria, cystine and struvite crystals are diagnosticPlain Abdominal FilmIVPUltrasound** Spiral CT - no contrast - very sensitive and specific
39
Most common stone ingredients
Calcium oxalate, calcium phosphate. Ingredients can be: Calcium, oxalate, phosphate, uric acid, cystine, struvite(Urea broken down), triamterene
40
What inhibits nucleation of kidney stones
Magnesium and citrate
41
What inhibits nuclei or larger structures to adhere to one another
Tamm-Horsfall protein in ascending limb of henle
42
Calcium phosphate stones form in ______ urine; uric acid stones form in _______ urine
Alkaline, acidic
43
Struvite stones process
Magnesium ammonium phosphate. Normal urine is under saturated with ammonium phosphate, UTI with urease-producing organism (Klebsiella or proteus)> Alkaline urine forms struvite
44
Colorless eight sided envelope crystal is
Calcium oxalate
45
Yellow or reddish brown diamond shaped or six sided stone is
Uric acid
46
Cystine crystals are
Colorless, hexagon shaped
47
Diagnosis of Kidney stone
Urinanalysis, plain abdominal film, IVP, ultrasound, SPIRAL CT
48
Abdominal flatplate: what stones are radiopaque and radiolucent
Radiopaque: Calcium oxalate, calcium phosphate, mixRadiolucent: Uric acid, xanthine, hypoxanthine
49
T/F: If stone is 10mm or more you normally need a urologist to take it out.
True
50
How to treat stone passage
80-90% pass spontaneously. Increase fluids. Strain urine. Analgesia (NSAID to normal creatinine levels)Calcium channel blocker/alpha blocker (Nifedipine/tamsulosin- Flomax)
51
When do you put someone in the hospital for kidney stone?
feverUTIoral analgesia ineffectiveintractable vomiting dehydration
52
Urologic management includes:
Shock wave lithotripsy (with stint)percutaneous nephrostolithotomyureteroscopyopen stone surgery
53
Risks for kidney stones
sweatingexcessive sun exposurerecurrent UTIneurogenic bladdergoutchronic diarrheafamily hx (Renal Tubular Acidosis (RTA) and cystinuria)medications
54
Medications that may cause kidney stones
Carbonic anhydrase inhibitors (eventually drops pH)triamterenesulfadiazoneascorbic acidIndinavir (HIV med)Topiramate (Topomax)Acetazolamide (Diamox)
55
What lab work could you order if someone had a kidney stone
Serum BUNSerum creatinine,calcium, PTH if hypercalcemicphosphorus, uric acid, Urinalysis (UTI, crystals, pH). Could do a 24 hour urine collection.
56
Preventative therapy for kidney stones
Drink more fluids (produce 2 liters of urine, 8 8oz.)Reduce salt intakelimit animal protein to 8 oz. daily
57
Why would low calcium intake increase urinary oxalate
Less calcium is available in intestinal lumen to bind oxalate and prevent its absorption
58
What drinks increase risk of stone
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
59
What food will increase urine uric acid
Red meat, fish, poultry
60
Foods rich in oxalate
Spinach, nuts, PB, strawberries, chocolate, rhubarb, brewed tea
61
What inhibits sodium reabsorption in distal renal tubules?
Thiazides (hydrochlorothiazide). Give potassium citrate to replace potassium
62
Medical management of uric acid stones
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
63
What type of virus is HIV
A retrovirus: RNA virus, infects cell, forms DNA, makes more RNA
64
T/F: HIV is able to replicate continuously in their host cells despite a competent host immune response
True
65
Major cellular targets for HIV-1
Lymphocytesmononuclear phagocytes
66
HIV transmission factors
AIDSActive STDpresence of genital lesionsfrequency and type of unprotected sexcircumcisionviral load
67
How is HIV transmitted
Bodily fluids: blood, semen, breast milkNeedles
68
HIV pathogenesis and progression to AIDS
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
69
T/F: Shingles is suggestive of HIV infection
True- also several other indications
70
AIDS indicators
CD4 count <14% of total lymphocytes
71
Diagnostic testing for HIV
Oral fluid testing, urine testing, home test kit, rapid HIV testing
72
Screening highest sensitivity for HIV
ELISA- detecting antibodies to HIV-1 and HIV-2
73
Confirmation- highest specificity for HIV
Western Blot
74
Acute HIV infection you should perform
HIV RNA by PCR
75
Specific tests used in HIV infection
Quantitative HIV RNA, CD4 cell count/percentage, Total lymphocyte count, HLA B5701 (always before abacavir), Resistance testing
76
Definition of success for HIV
HIV RNA <50 copies/mL
77
A 55 y.o. women has HIV with CD4 count of 344 cells.mm and viral load of 34000 copies/mL. What is treatment
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
78
What drug is used with all PIs to exploit CYP3A4 inhibition to allow for smaller doses
Ritonavir
79
Preferred initial treatments
1) Tenofovir (TDF)/ Emtricitabine (FTC) + Efavirenz 2) Abacavir/lamivudine + dolutegravir
80
Why is anti retrovirus treatment (ART) necessary?
Prevent transmission by lowering viral load
81
HIV in pregnancy- recommended regimen: All infected should be treated regardless of CD4 count with...
ZDV/#TC/lopinavir/ritonavir or TDF/FTC+Atazanavir/ritonavir
82
Protease inhibitors are associated with
Metabolic syndrome
83
Side effects of HIV medication:
Lipodystrophy, Bone disorders, etc...
84
HIV RNA in plasma: HIV RNA should be greater than
10,000 copies
85
Oral complications of HIV
Apthous ulceroral hairy leukoplakiacandidiasisKaposi's sarcomaHSV
86
Frequent Dermatologic complications in HIV patients
Herpes zoster (More than 1 dermatome suggests HIV infection)Eosinophilic folliculitisMRSA relatedSeborrheic dermatitispurigo nodularisherpes simplexbacillary angiomatosismolluscum contagiosumcryptococcusscabies
87
Cardiovascular complications of HIV
Dilated cardiomyopathy pulmonary HTNTricuspid valve endocarditis
88
Chronic diarrhea in HIV patients is associated with a CD4<____
100
89
Two big neurologic complications in HIV patients
Cryptococcus and Bacterial Meningitis
90
T/F: CMV retinitis the CD4 count is usually less than 50 and fundoscopic exam looks like cottage cheese and ketchup
True
91
What type of pneumonia is associated with HIV patients
Pneumocystitis jirovecci pneumonia
92
What fungal infection is associated with HIV
Coccidioides immitis and Histoplasmosa Capsulatum (<150 CD4)
93
Pneumocytitis pneumonia prophylaxis should be started at CD4+ t cell count less than
200 cell/mm
94
Prophylaxis for toxoplasmosis in HIV patients. What drug and CD4 count?
Bactrim at CD4 <100
95
Definition of virologic management failure
HIV RNA> 200 copies/mL
96
Patients who cannot get HIV have what type of mutation
CCR5 mutation
97
Definition of Asymptomatic Microhematuria
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)
98
Risk factors for urologic malignancy (10)
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
99
How many positive micro UA is sufficient for workup
1
100
Top 3 causes of benign causes of AMH
BPH, UTI, Stones. Others: Obstructions, medical renal disease, benign tumors.
101
Standard imaging for microhematuria
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
102
Cant have a CT with contrast (Pregnant, Contrast allergy, renal insufficiency) what do you do?
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
103
What is the best way to rule out bladder cancer?
Cystoscopy- May miss many many bladder tumors depending on how full bladder is.
104
Recommendation for cystoscopy
All patients over 35 or younger than 35 with risk factors
105
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?
100,000 org/ml (microbiology definition)In patients with symptoms: 100-10,000 to begin treatmentmultiple organism (3+) suggests contamination
106
Microbiology definition of UTI
100,000 org/ml. Symptomatic: 100-10,000Multiple organisms (3 or more) suggest contamination
107
Risk Factors for UTIs (8)
1) Gender2) Sexual activity and contraception3) Pregnancy4) Obstruction5) Neurogenic bladder dysfunction6) Vesicoureteral reflux7) Bacterial virulence factors8) Immunosuppressed states: Sickle cell
108
Clinical symptoms of UTI:
DysuriaFrequencyUrgencySuprapubic pain/pressure
109
With complaints of vaginal discharge, the dx of a UTI Increases/ Decreases by 20%
Decreases- vaginal symptoms may be causing dysuria
110
Who needs a urine C&S?
1) Seriously ill pts2) Recently hospitalized/ hospitalized pts3) Men and all children4) Women with relapse or reinfection5) Women with complicating factors6) Pregnancy
111
Etiology of UTI in women
1) E. coli (75-95%)2) Enterobacter3) Klebsiella4) Proteus-Gram negative causes 90-95%-Gram + cause 5-10%-Staph saprophyticus cause 10-15%
112
What drug for UTIs could you use for prophylaxis
Trimethoprim: Bacteriostatic
113
Drug of choice for UTI
Trimethoprim-Sulfamethoxazole
114
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
Nitrofurantoin
115
What can you use for UTIs but is not first line?
Cephalosporins, FQ (resistance, contraindicated in kids and pregnancy)
116
What is first line in UTI is resistance to TMP/SMX is >20%
Quinolone
117
Fosfomycin is only indicated in what type of UTI
Uncomplicated UTI
118
For symptomatic UTIs, normally how long do you treat?
3 days
119
Urinary analgesics:
1) Phenazopyridine (Pyridium) - turns urine orange, stains2) Flavoxate (Uripas)3) Cranberry Juice?
120
Safe drugs for UTIs in pregnancy:
1) Penicillins2) Cephalosporins3) Nitrofurantoin4) Fosfomycin
121
T/F: If a pregnant women is suspected of having pyelonephritis, what should you do?
Hospitalize
122
Treatment for Pyelo outpatient
1) FQ or TMP-SMZ recommended2) Amox or Augmentin ok if gram + bug-10-14 days
123
DDX for Dysuria
1) Cystitis2) Painful Bladder Syndrome3) Vaginitis (Infectious, Chemical, PID)4) Prostatitis5) Urethritis6) Meatal strictures
124
T/F A UTI in a male patient is very rare and possibly pathologic and should undergo a work-up.
TRUEUTI's are very common in females.
125
Protective Factors
Long urethraBladder emptyingAntibacterial properties of urineProstatic secretionsPMNs in bladder wall
126
UTI Urinalysis Findings
Cloudy urineMalodorousHematuria (microscopic)Dipstick Results: nitrite (+) or leukocyte esterase (+)Microscopic: WBC, Bacteria, casts
127
UTI Physical Findings
Vitals - document temperatureSuprapubic PalpationPalpation of CVALab - get a urine sample
128
__________ is the most common etiologic agent of UTI's and what what is the drug of choice.
E. Coli Trimethoprim-Sulfamethoxazole (TMP-SMZ)
129
3 Drugs of Choice for Uncomplicated UTIs
NitrofurantoinTMP/SMX (depends on local resistance rates)Fosfomycin
130
Helpful Suggestions for Patients with UTIs
Drink plenty of waterVoid frequentlyVoid after intercourse
131
What is definition of recurrent UTI's?What can be used for prophylaxis?
3 documented UTIs/yearProphylactic: Nitrofurantoin, Keflex, TMP-SMZ, Noroxin
132
Most Common Etiology for Pyelonephritis
E. coliProteusKlebsiellaEnterobacterPsuedomonas
133
Clinical Findings in Pyelonephritis
FeverFlank PainShaking ChillsVoiding Symptoms: dysuria, frequencyConstitutional Symptoms: nausea, vomiting, diarrheaPhysical Exam: fever, tachycardia, +/- CVA tenderness
134
What finding on microscopic urinalysis is a strong indicator of pyelonephritis?
WBC casts
135
UTI Symptoms in Newborns and Infants
non-specific signs: fever, poor feeding, irritability, vomiting, sepsis, hypothermiastrong, foul-smelling odor
136
UTI Symptoms in Preschool
abdominal or flank pain, vomiting, fever, frequency, dysuria, enuresis
137
UTI Symptoms in School-Age Children
classic signs and symptoms but CVA tenderness is uncommon
138
Risk factors for prostate Cancer
1) Age2) Genetics3) African American men4) Diet5) Environmet
139
Comparing 2 PSAs over time is called
PSA velocity
140
Normal blood level of PSA
<4ng/ml
141
A PSA >10 correlates with what?
Greater positive biopsy rate (66%)
142
AUA guidelines for Prostate Cancer: Panel recommends against PSA screening in men
Under 40 and over 70
143
AUA guidelines for Prostate Cancer: Panel does not recommend PSA screening in what age group
40-54
144
Low Risk for Prostate Cancer
PSA <10 and gleason score 6 or less
145
PSAV greater than what is useful in identifying PCA
0.4
146
Risk Factors - Causes of Prostate Cancer
AgeRaceEnvironmentDietGenetics/Family History
147
Assessing the Prostate
Men > 50 should have a PSA blood test and DRE once a year. (High risk groups > 45)
148
Amount of PSA compared to the size of the prostate gland is called?
PSA Density
149
Factors that can change PSA
1) Prostate Cancer2) BPH3) Prostatitis4) Trauma5) Instrumentation6) Mediciations
150
Intermediate Risk for Prostate Cancer
PSA 10-20, Gleason Score 7
151
High Risk for Prostate Cancer
PSA > 20, Gleason Score 8-10
152
Goals of Active Surveillance for Prostate Cancer
1) Provide treatment for men likely to progress2) Reduce risk of treatment who are not likely to progress
153
Prostate Cancer Treatment Options
Surveillance & watchful waitingRadiotherapy (external beam and interstitial)Radical ProstatectomyHormone Therapy
154
BPH histological diagnosis:
Proliferation of smooth muscle and epithelial cells within the prostatic TRANSITION ZONE.
155
LUTS - Storage Symptoms
frequencynocturia
156
LUTS - Voiding Symptoms
hesitancyintermittencyweak streamdribbling
157
urgency with or without urge incontinence usually with frequency and nocturia
Overactive Bladder Syndrome
158
urodynamic observation of an involuntary detrusor contraction
Detrusor Overactivity
159
Define Benign Prostatic . . .A) HyperplasiaB) EnlargementC) Obstruction
A) Hyperplasia - histological diagnosisB) Enlargement - gland enlargementC) Obstruction - obstruction is suspected based on flow rates/urodynamics
160
Bladder Outlet Obstruction
any obstructive process
161
Main drug classes used for treatment of LUTS
Alpha blockers (dynamic)5-alpha reductase inhibitors (static)
162
Long Acting Alpha Blockers
Terazosin, Doxazosin, Alfuzosinrequire dose titration
163
a1 Receptor Blockers
Tamsulosin (Flomax)Sildosin (Rapiflo)
164
5 alpha reductase inhibitor action
blocks conversion of testosterone to DHT in prostate tissueaverage 50% reduction in PSA
165
5 alpha reductase inhibitors are used in patients with a prostate > ______ grams or PSA > _____.
30 grams or PSA > 1.5
166
Patient has a small prostate gland or low PSA. What type of treatment do you use?
alpha-blocker
167
When to consult a urologist:
1) refractory to medical management2) recurrent urinary retention3) recurrent UTI4) renal insufficiency5) hematuria6) bladder calculi
168
Cancer in the prostate occurs in what zone
Peripheral Zone
169
Patient presentation of BPH (LUTS)
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
Index patient according to AUA for BPH
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
A questionnaire given to patients with LUTS. What is it called, what does it include and ow is it scored?
AUA Symptom Index (AUA-SI). 7 question and 1 quality of life question. Mild: 0-7Moderate: 8-19Severe: 20-35
172
Recommended tests for LUTS
1) Medical hx2) Assesment of LUTS3) Severity and bother (AUA-SI)4) DRE and PE5) UA6) Serum PSA7) Frequency/volume chart
173
Polyuria is defined as:
>3L in 24 hours
174
Modifiable factors of LUTS
Fluid intake
175
Alpha blockers:
Alfuzosin, doxazosin, Terazosin, Tamsulosin, Silodosin
176
5ARIs
Avodart and Finasteride
177
Patients with LUTS secondary to BPH whom an alpha blocker is offered, what syndrome do you need to worry about?
Intraoperative Floppy Iris Syndrome- If planned cataract surgery, hold alpha blocker until after
178
A patient has LUTS secondary to BPH and without an elevated PVR and mainly irritative symptoms, what should you consider prescribing?
Anticholinergics- M3 receptor (Ex: Oxybutynon)
179
Minimally invasive therapy for LUTS
Transurethral needle ablation-TUNATransurethral microwave thermotherapy- TUMT
180
Surgery Treatments for LUTS
1) Transurethral: Incision of prostate (TUIP), Vaporization of Prostate (TUVP), Resection of Prostate (TURP).2) Open simple prostatectomy3) Robotic/Laparoscopic simple prostatectomy
181
Domains for defining continence (4)
Symptoms: patient/caregiver descriptionSigns: objective demonstration of urine lossUDS observationCondition: lower urinary tract pathophysiology
182
What is the involuntary loss of urine and is not necessarily a part of aging?
Incontinence
183
The micturation control center in your frontal cortex does what?
Inhibitory signals to the detrusor.
184
The pontine micturation center does what?
Coordinates Urinary Sphincter with detrusor
185
The spinal cord had what role in micturation?
Communication between brainstem and sacral spinal cord. Sacral spinal cord is spinal reflex center.
186
Classes of incontinence
Transient- Important in elderlyUrge- Variant overactive bladder syndromeStress- Leak with coughingMixed: Stress and urgeTotal/continuous: rareOverflow: neurogenic baldder
187
Functional Classification of incontinence
1) Failure to empty (Bladder underactivity, obstruction) 2) Failure to store: (urethral incompetence, bladder overactivity)
188
Urologist Referral for Incontinence
-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
Urethral sphincter Etiology: Urethral resistance- When will you see leakage of urine?
During filling of bladder with valsalva
190
Results for post void residuals
400 consider intermittent catheterization or indwelling foley catheter and further urologic consult
191
Testing for incontinence
Labs: UA with possible cultureUrodynamics testing: Stress testing, uroflow, postvoid residual, voiding cystometrogram, cystourethroscopy
192
How should you begin therapy for incontinence?
-Begin with conservative therapy (Lifestyle changes- avoid caffeine, alcohol, etc.)-Bladder diary-Behavioral training: Timed, double voiding
193
Pharmaceutical therapy for incontinence
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
Treatment modalities for incontinence- Surgery for Overactive bladder:
1) Catheter (intermittent, indwelling)2) Surgery: Neuromodulation, Botulinum toxin, augmentation cytoplasty, denervation
195
Surgery for Stress Incontinence
1) Retropubic suspensions2) Mid-urethral sling3) Pelvic organ prolapse repair4) Collaen injections5) Artificial urinary sphincter
196
Barrier methods for Incontinence
Pads, Absorbant garments
197
Risk factors for incontinence in women
Pregnancy and childbirthObesityEndocrine (diabetes, menopause)Pulmonary (persistent cough)Neurological (dementia)
198
Risk factors for incontinence in men
Surgical interventionsNeurological (dementia)Endocrine (diabetes)
199
Sympathetic Nervous Control of Micturation
Bladder Filling:-inhibits detrusor muscle through B receptors-activates internal urethral sphincter and proximal urethral constriction through hypogastric nerve
200
Parasympathetic Nervous Control of Micturation
Micturation-suppression of sympathetics-stimulates detrusor smooth muscle through pelvic plexus from sacral segments (S2-S4)
201
Transient Incontinence(DIAPPERS)
D - deliriumI - infectionA - atrophic vaginitisP - pharmacologicP - psychologicalE - endocrineR - restricted mobilityS - stool impaction
202
Bladder Irritants
Acidic foodCitrusCaffeineEtOHSpicy foods
203
Urologist Referral for Incontinece
-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
Signs and Symptoms of Acute Renal Failure
-Edema (Leg, pericardial, pleural)-HTN-Diminished urine output-Confusion-Symptoms of electrolyte abnormalities
205
Signs and symptom of chronic renal failure
-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
Lab abnormalities with renal function decline
-High blood urea nitrogen-Elevated BUN and Creatinine-Proteinuria-Anemia
207
Excess can be caused by
-Under excretion-Overproduction-Ectopic Source-Wrong place*1 of these 4 problems can cause abnormally high lab values
208
Deficiency can be caused by
-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
What are the two major types of Renal Disease
Glomerular and Interstitial
210
Proteinuria in Glomerular and Interstitial renal disease
Glomerular: >2.0 gm/dayInterstitial: <2.0 gm/day
211
Urine sediment in Glomerular and Interstitial renal disease
Glomerular: Hematuria, RBC castsInterstitial: Pyuria, WBC casts
212
Hypertension in Glomerular and Interstitial renal disease
- Common in glomerular and less common in interstitial
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Edema in Glomerular and Interstitial renal disease
Usual in glomerular, rare in interstitial
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Quantitation of proteinuria on spot urine
Protein (mg/dL)/ Creatinine (mg/dL)= g protein/24 hour
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Nephrotic syndrome
-Proteinuria-Hypoalbuminemia-Edema-Hyperlipidemia-Lipiduria
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Most common glomerular disease in the US
Diabetic nephropathy- most common cause of end-stage renal disease in US.
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Microalbuminuria value
30-300mg/24 hrs
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Macroalbuminuria value
>300 mg/24 hrs
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General history of glomerular nephropathy
Elevated glomerulofiltration rate and increased kidney size -----> Microalbuminuria----> Proteinuria----> Decreased GFR, ESRD
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With elevated GFR and increased renal size, what do you control and how would you treat
BP control (<130/80). ACE Inhibitor?
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With microalbuminuria, what do you control and how would you treat?
BP Control: ACE inhibitor, Glycemic control? (Statin)
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With proteinuria, what do you control and how?
BP control (<125/75): ACE inhibitor. Statin?
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Lab evaluation of glomerulonephritis
1) UA2) Spot urine for protein and creatinine3) Serum chemistries4) Hgb A1c5) ANA6) C3, C47) ANCA8) Blood culture
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Minimal change disease: Most common in what population? Presents how?
-most common in kids, presents with acute onset edema and nephrotic syndrome. Cell mediated immunity may play role in primary disease.
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How to treat minimal change disease
Steroids
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Most common primary glomerular disease in US blacks. Presentation from nephrotic syndrome to progressive kidney dysfunction. Can recur quickly following kidney transplant.
Focal and Segmental Glomerulosclerosis (FSGS)
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Treatment in Focal and Segmental Glomerulosclerosis (FSGS)
General: Blood pressure control, block Renin angiotensin system, Diuretics for edema, statin therapy-Idiopathic: Immune modulation with steroids and/or cyclosporine
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Clinical presentation of what: Progressive edema related to gradual worsening proteinuria. Overt nephrotic syndrome (80%). Microscopic hematuria (
Membranous Nephropathy
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Etiology of Membranous Nephrology
-Idiopathic- most common-Autoimmune disease (SLE)-Drugs (Gold, NSAIDS)-Infections (Hepatitis, syphilus)
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Membranous nephropathy treatment:
General: Blood pressure control, block Renin angiotensin system, Diuretics for edema, statin therapy-Idiopathic: Immune modulation with steroids and/or cyclosporine
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Most common glomerular disease worldwide
IgA Nephropathy- Most primary but can be secondary
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IgA Presentation
Microscopic hematuria, gross hematuria (SYNpharyngenitic), proteinuria, progressive renal dysfunction
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MPGN Type I Presentation
Microscopic hematuria and non-nephrotic proteinuria, LOW SERUM COMPLEMENT LEVELS, Hypertension
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Serum Complement levels: Low complement causes
-Lupus nephritis-MPGN-Post infectious glomerulonephritis (Strep, endocarditis)
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Serum Complement Levels: Anti-Neutrophil Cytoplasmic Antibodies
Wegener, microscopic polyangiitis, churg straus
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40 yo male who has noticed a little swelling in legs and urine is weird colored: How would you approach it?
1) Detailed History2) PE: Skin rashes, tenderness, BP3) Labs: UA, Creatinine, Serum Chemistries, Complements, blood culture, ANCA, ANA
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Anti-glomerular basement membrane disease clinical presentation
Hematuria and proteinuria. Progressive loss of kidney function.-Goodpasture's Disease-when combined with lung involvement-Autoantibody to type IV collagen
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Treatment for Anti-GBM
Treated with plasmapheresis, steroids, cyclophosphamide
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Glomerulonephritis and ANCA
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
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ANCA treatment
Steroids, cyclophosphamide. Plasmapheresis for severe renal disease or pulmonary hemmorrhage
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A systemic disease characterized by autoimmunity with antinuclear antibodies (ANA) and low serum complements
Systemic Lupus Erythematosis
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T/F: Lupus nephritis can present with multiple type of kidney lesions
True- immune complex glomerular disease
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Treatment of lupus nephritis
Steroids, cyclophosphamide, mycophenolate mofetil
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Definition of acute kidney injury
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)
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Major cause of acute renal failure in hospital setting
Acute tubular necrosis
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Prerenal presentation and treatment
Normal physiologic response to renal hypo perfusion to impair GFR. Renal parenchyma is normal. If not treated can lead to ATN.Treat: Fluid repletion
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Rate of rise of plasma creatinine in ATN vs. Prerenal
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
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UA in ATN and Prerenal
-Normal in Prerenal disease-In ATN: Muddy brown granular and epithelial cell casts and free epithelial cells.
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Fractional excretion of sodium (FENa) in prerenal and ATN
Prerenal disease: 2%
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Fractional excretion of urea (FEurea) in prerenal patients
<35%
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Diagnosis of Prerenal Azotemia
-Normal renal US-UA-normal-Low urine Na, FENa<35%-No proteinuria, no albuminuria-Reversible with hydration
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Glomerular Disease as a cause of Acute Kidney Injury presentation
-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%
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Tubular Diseases- ATN presentation
Renal US: NormalUA: Muddy brown granular casts, epithelial cell, epithelial cell casts, hematuria- no dysmorphic RBCs-Subnephrotic proteinuria-FENA >2%
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ATN management
Conservative: Avoid hypotension, fluid depletion, nephrotoxic medication. Use renal replacement therapy when needed (dialysis).
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Interstitial Kidney Disease presentation
-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%
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AIN- Acute interstitial nephritis causes
Drugs with antibiotics responsible for 1/3 of these cases.-Infection related-Idiopathic-Tubulointerstitial nephritis and uveitis syndrome-sarcoidosis
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AIN management
Identify and stop medication causing disease.-Severe: prednisone- make sure infection has been excluded before starting therapy
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Tests to be ordered with acute renal failure
1) Renal Ultrasound with Doppler2) UA with microscopic exam3) Spot urine proteins/creatinine ratio4) Spot urine albumin/ creatinine ratio5) Urine Na, urea
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Postrenal causes
-Ureteral obstruction-Bilateral ureteral obstruction (stone, retroperitoneal fibrosis, pelvic masses)-Urethral obstruction: BPH, Prostate cancer
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Renal US with Doppler can tell you...
-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
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Increased renal echogenicity seen often in what?
Chronic renal disease
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UA with microscopic exam: 1) Glomerular problem2) Prerenal3) ATN
1) Hematuria (dysmorphic RBC) and proteinuria2) Normal3) Muddy brown granular casts
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Urine protein/creatinine and urine albumin/creatinine for glomerular (not NS), ATN, Interstitial disease
1-3.5 g of proteins/day
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>3.5 g protein/day is
NS or nephrotic range proteinuria
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Indications to start RRT (Dialysis)
-Severe acidosis-Severe hyperK-Fluid overload not responding to diuretics-Uremic symptoms-Uremic pericarditis-BUN ~80 mg/dL
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3 stages of development of the kidney
Pronephros (nonfunctional), Mesonephros, Metanephros
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True/ False: Kidney produces amniotic fluid at a rate up to 1 ml/kg/h.
False: 10 ml.kg/h
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At what weight (kg) do you get adult like composition of fluids
15 kg- Water content decreases from 96% at EGA 8 weeks to 78% at term
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In a preterm baby, you have fewer production of glomeruli and because of the diluting and concentration capacity, baby is at risk for...
hyponatremia
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No cows milk up until 1 y/o because limited ability to excrete a high solute load: why is this
-Low GFR-Shorter loops of Henle-Increased medullary/cortical blood flow ratios
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One of the most common pediatric infections.
UTI
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Age 0-3 mos.: Boy/Girls have more UTIs
Boys: After 1 yr. girls more likely
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Most UTIs in the first year are Pyelonephritis/Cyctitis
Pyelonephritis (upper tract)
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WHAT REDUCES UTI incidence in boys in 1st year of life
Circumcision
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AAP: Infant with fever without focus. What do you obtain
Urine specimen by catheterization for both culture and UA. Treat constipation
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T/F: Grade III or less VUR may resolve without intervention
True
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What is hypoplasia, what is it proportional to, and what do you get?
Small kidneys, decreased glomeruli.-Directly proportional to BW.-Oligomeganephronia- Hyperfiltration injury
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Dysplasia:
Maturational arrest-Abnormal histology- primitive tubules and cartilageEx: Multicystic dysplastic kidney, obstructive dysplasia
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ARPKD: Autosomal recessive, infantile form
Fibrocystin, Chromosome 6-Hepatic fibrosis w/ portal HTN-Systemic HTN-Kidney Failure-Respiratory distress
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ARPKD: Autosomal Dominant, more frequent in adults
Polycystin-Bilateral macrocysts-Hepatic, splenic, and pancreatic cysts-Aneurysms of Circle of Willis
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Water excretion in the fetal and neonatal kidney
-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.
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Increased renal mass after glomerular development is complete is due to tubular growth and maturation. So this means Preterm GFR is greater than what?
Tubular absorption- Fractional excretion of Na+ is greater in preterm- Hyponatremia
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Bicarbonate reabsorption threshold is directly related to ____ and most bicarbonate is reabsorbed in the ____.
Age, Proximal tubule- Same with glucose!
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Glucosuria can increase osmotic diuresis, risk for _________
Dehydration
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1) Phosphorous reabsorption is _________ in infants.2) ___________ related to age and GFR.
Higher, Inversely
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Chronic kidney disease stages
I: GFR>90II: GFR 60-90III: GFR 30-60IV: GFR 15-30V: GFR <15
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What is this: Many AR mutations, retinal degeneration, hepatic fibrosis, Brain and skeletal abnormalities.
Juvenile Nephronophthisis
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What is this: AD, typically presents later. HTN. Polyuria, hematuria in adults.
Medullary cystic disease
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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 ________.
1) 3 months2) Proteinuria3) Steroid4) Transplant5) Nephrin
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____________ nephrotic syndrome presents in the first 12 months. It is resistant to steroid treatment. ESRD, Transplant. An abnormality in _________.
Infantile, podocin
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A form on infantile nephrotic syndrome that presents with HTN, gonadoblastoma, wilms tumor, and male pseudohermaphroditism.
Denys-Drash
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Nephrotic Cystinosis: Renal fanconi syndrome
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
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Basement membrane disease when it is less than 100nm in thickness
Thin basement membrane lesion. Normal is 100-300nm
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Abnormally split and laminated GBM
Alport syndrome- Problem with Collagen IV
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Posterior urethral valves
Obstructive Uropathy- Dilated ureters and prostatic urethra- Treat with catheter
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Early obstructive uropathy
10-12 weeks-Failure of UB branching, blastema induction-Dysplasia
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Late obstructive uropathy
-VUR-Inflammation-Fibrosis
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Triad of Prune belly syndrome (aka Eagle-Barrett sundrome)
1) Deficient abdominal musculature2) Bilateral Cryptorchidism3) Dilated nonobstructed urinary tract
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Symptoms of Prune belly syndrome
Dysplasia, VUR, UTIs common.-Pectus excavatum, hip dysplasia-97% male
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UPJ obstruction signs and symptoms
1) Dilated renal pelvis2) Flank pain with high urine flow3) May be bilateral-lead to renal failure4) Nephrostomy tube replacement
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A horseshoe kidney is fusion of the _______ poles and the ascent is blocked by the ______. The kidney is functional and malrotated.
Caudal, Inferior mesenteric artery
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What is this: Microangiopathic hemolytic anemia, thrombocytopenia, acute renal failure. What 2 types
Hemolytic Uremic Syndrome1) D +HUS: Hemorrhagic colitis, shigella, EHEC, 2) Atypical: Pneumococcus, complement abnormalities
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2 major causes of renal failure
Dibetes Mellitus and HTN
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Reversible causes of renal failure
-Hypovolemia-Infection-Obstruction-Exposure to drugs (Contrast or drugs that lower GFR)
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Definition of chronic kidney disease
GFR <60 or there is kidney damage manifested as proteinuria for greater than or equal to 3 months
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Signs symptoms of CKD
-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
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Why do you start dialysis
-Hyperkalemia-Fluid overload-Pericardial effusion-Acidosis-Other electrolyte abnormalities-Bleeding
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Explain renal osteodystrophy/mineral and bone disorders
-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.
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Treatment of renal osteodystrophy/mineral and bone disorders
- 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
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A common problem in renal failure is hyperkalemia. How would patient present and how to treat and dietary restrictions.
-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.
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Nutritional needs in CKD
-Nutritional needs: Protein restrictions (0.6g/kg/day) and fluid restrictions? Restrict Na+, K+, Phosphorous. If malnourished...eat!
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Acidosis with CKD: What causes it and treatment
-Hydrogen ions are retained and renal failure making the patient metabolically acidotic.-Treat by supplementing with sodium bicarbonate
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End Stage renal disease is fatal if not treated by:
Hemodialysis, peritoneal dialysis, renal transplantation
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A coronary heart disease risk equivalent is
Chronic kidney disease
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When can a patient be listed for a cadaveric kidney transplant
With a GFR of 20mL/min or less
