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Surgery Rotation > Genital/Urinary System > Flashcards

Genital/Urinary System Flashcards

0
Q

Prostate Carcinoma

A
  • Most common GU cancer
  • Most common cancer in men, usually seen in older men
  • 95% adenocarcinoma.
  • Sx: often asx, nodule found on routine rectal exam, cancer begins on the periphery and moves centrally (so obstructive sx occur late)
  • 40% of pts have metastatic disease at presentation
  • Sites of mets: osteoblastic bone lesions, lung, liver, adrenal
  • PSA should be checked in all men >50yo and in men with FH >40yo.
  • Imaging= Transrectal US (TRUS)
  • Dx: transrectal bx
  • Tx: Stage 1= radical prostatectomy(prostate, seminal vesicles, ampullae of vasa deferentia). Stage 2= radical prostatectomy +/- LN dissection. Stage 3= radiation +/- androgen ablation(b/l orchiectomy or LHRH agonists->decrease LH release from pituitary which then decreases testosterone production in the testes). Stage 4= androgen ablation, radiation.
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1
Q

Bladder Carcinoma

A
  • Second most common urologic malignancy
  • Histology: Transitional cell carcinoma is the most common
  • RFs: smoking, industrial carcinogens, schistosomiasis, truck drivers, petroleum workers, cyclophosphamide
  • Sx: HEMATURIA(usually painless), dysuria, frequency
  • Workup: UA, urine culture, IVP, cystoscopy with cytology and bx.
  • Tx: Stage 0=TURB (transurethral resection of the bladder) and intravesical chemo. Stage 1= TURB. Stage 2 and 3= radical cystectomy, LN dissection, removal of prostate/uterus/ovaries/anterior vaginal wall, urinary diversion, +/- chemo. Stage 4= +/- cystectomy with systemic chemo.
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2
Q

Renal Cell Carcinoma

A
  • Most common solid renal tumor
  • mostly in adults, m>f
  • RFs: male, tobacco use, von Hippel-lindau syndrome, polycystic kidney.
  • Sx: pain, hematuria, wt loss, flank mass, HTN.
  • Radiologic tests: IVP(intravenous pyelogram), abdominal CT with contrast.
  • Work up for mets: CXR, IVP, CT, LFTs, Ca level
  • Sites of mets: lung, liver, bone, brain
  • Tx: Radical nephrectomy (kidney and adrenal)
  • Tx for mets: alpha interferon, LAK cells, IL-2
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3
Q

Testicular Carcinoma

A
  • Rare
  • Most common solid tumor of young men (20-40yo)
  • RF: cryptorchidism
  • Sx: painless lump, swelling, firmness of the testicles
  • Tumor markers: B-HCG and AFP
  • Major classifications= seminomatous(less common, only 10% are AFP positive) vs nonseminomatous(more common, have positive AFP and/or B-HCG)
  • Workup: PE, US of scrotum, tumor markers, CXR, CT of chest/pelvis/abdomen
  • Tx: inguinal orchiectomy
  • Tx seminoma: Stage 1 and 2= inguinal orchiectomy and radiation. Stage 3= orchiectomy and chemo.
  • Tx nonseminoma: Stage 1 and 2= orchiectomy and retroperitoneal LN dissection. Stage 3= orchiectomy and chemo.
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4
Q

Wilms Tumor

A
  • Embryonal tumor of renal origin
  • Very rare, usually dx b/t 1-5yo
  • Sx: usually asx, abdominal mass, hematuria, HTN
  • Radiologic tests: abdominal and chest CT
  • Tx: radical resection followed by chemo (if low stage) and radiation (if high stage).
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5
Q

Incontinence

A
  • Stress incontinence: loss of urine associated with coughing/lifting, seen more in women, secondary to relaxation of pelvic floor. Tx: pelvic muscle exercises, pessaries, bladder neck suspension, surgery.
  • Overflow incontinence: failure of the bladder to empty properly. Can be due to impaired detrusor contractility or bladder outlet obstruction. More common in men, but least common type overall. Sx: feeling of incomplete emptying, dribbling, weak stream, intermittency, hesitancy, urinary retention, elevated post void residual. Tx: self catheterization, surgery to relieve obstruction, “double voiding”, alpha blockers.
  • Urge incontinence: Can occur secondary to detrusor instability in pts with stroke, dementia, etc. Detrusor overactivity= uninhibited bladder contractions. Most common cause of geriatric incontinence. Sx: intense urgency, leakage. Tx: bladder training, pelvic muscle exercises, anticholinergics ( oxybutynin, tolterodine), alpha agonists ( imipramine), beta agonists (mirabegron).
  • Dx: history, PE, UA, postvoid residual, urodynamics, cystoscopy/VCUG.
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6
Q

Urinary Retention

A
  • Enlarged urinary bladder
  • Caused by medications and spinal anesthesia
  • Dx: PE-will have palpable bladder, bladder residual volume upon placement of foley catheter
  • Tx: foley catheter
  • Drain 1L then clamp and drain the rest slowly over time to avoid vasovagal reaction.
  • Classic sign of urinary retention in an elderly pt is confusion.
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7
Q

Benign Prostatic Hyperplasia

A
  • Avg age= 60-65yo
  • Prostate gradually enlarges causing sx of urinary outflow obstruction
  • Occurs periurethrally
  • Sx: hesitancy, weak stream, nocturia, intermittency, UTI, urinary retention
  • Dx: history, DRE, elevated post void residual volume, UA, cystoscopy, U/S
  • Labs: UA, PSA, BUN, Cr
  • Tx: 1) alpha 1 blockers(terazosin, doxazosin, tamsulosin, alfuzosin). They cause relaxation of smooth muscle in the prostate and bladder neck. 2) 5-alpha reductase inhibitors (finasteride, dutasteride). Block transformation of testosterone to dihydrotestosterone which helps shrink the prostate. 3)TURP (trans urethral resection of prostate) 4)TUIP(trans urethral incision of prostate) 5)open prostate resection 6)trans urethral balloon dilation.
  • Surgery is indicated when: urinary retention, hydronephrosis, UTIs, and severe sx.
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8
Q

Hydrocele

A
  • Clear fluid in the process vaginalis membrane
  • Communicating: communicates with the peritoneal cavity, so becomes smaller as fluid drains and larger as fluid reaccumulates.
  • Non-communicating: hydrocele remains the same size.
  • Common in babies and older men
  • Sx: painless, swollen testicle, feels like a water balloon
  • Can be associated with inguinal hernias
  • Dx: PE, transillumination of testicles, US to confirm
  • Tx: aspiration, hydroceleectomy
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9
Q

Varicocele

A
  • Abnormal dilation of the pampiniform plexus to the spermatic vein in the spermatic cord
  • Appearance= “bag of worms”
  • Sx: painless, swollen, lump felt, enlarged/twisted veins
  • Infertility may be the first sign
  • Dx: PE, US
  • Tx: jock strap/snug underwear, varicocelectomy, varicocele embolization.
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10
Q

Testicular Torsion

A
  • Torsion of the spermatic cord, which causes venous outflow obstruction and subsequent arterial occlusion, which can lead to infarction of the testicle.
  • Hx: acute onset of scrotal pain.
  • Sx: pain in scrotum, suprapubic pain, tender/swollen/elevated testicle, nonillumination, absence of cremasteric reflex.
  • Dx: surgical exploration, US, doppler flow study
  • Tx: surgical detorsion, b/l orchiopexy
  • Need to perform surgery w/i less than 6 hrs for the best results.
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11
Q

Renal Vascular Disease

A
  • Stenosis of the renal artery resulting in decreased perfusion of the juxtaglomerular apparatus and subsequent activation of the renin-angiotensin-aldosterone system.
  • ACEi’s are contraindicated in pts with renal artery stenosis
  • Etiology: Most cases are due to atherosclerotic disease. Some due to fibromuscular dysplasia (young women with HTN).
  • RFs: FH, early onset of HTN, HTN refractory to treatment.
  • Sx: audible bruit on affected side, HA, diastolic HTN, decreased renal function.
  • Labs: BUN and Cr will be elevated.
  • Dx: Renal angiogram is the gold standard- will see beads on a string appearance in fibromuscular dysplasia. IVP-delayed nephrogram phase. Renal vein renin ratio- if greater than 1.5 diagnostic for unilateral stenosis. Captopril provocation test- will show drop in BP.
  • Tx: percutaneous renal transluminal angioplasty (PRTA)-use with stent in atherosclerosis. Surgery= resection, bypass, vein/graft interposition or endarterectomy.
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12
Q

Calculi

A
  • RFs: poor fluid intake, IBD, hypercalcemia, renal tubular acidosis, small bowel bypass.
  • 4 types: 1)calcium oxalate/calcium phosphate-caused by hypercalciuria 2)Struvite-high urine pH 3)uric acid-radiolucent stones, low urine pH 4)cystine
  • Struvite stones are associated with UTI
  • Sx: pain, pt cannot stay still, renal colic, hematuria, flank pain, stone on x-ray
  • Dx: KUB, IVP, UA with culture, BUN/Cr, CBC.
  • Tx: narcotics for pain, hydration
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13
Q

Chronic renal failure (shunts/access)

A
  • Increase serum creatinine and decrease in creatinine clearance, usually associated with decreased urine output.
  • Prerenal: inadequate blood perfusing the kidney=inadequate fluids, hypotension, CHF
  • Renal: kidney parenchymal dysfunction=acute tubular necrosis, nephrotic contrast or drugs
  • Postrenal: obstruction to outflow of urine from kidney=foley catheter obstruction, stone, ureteral/urethral injury, BPH, bladder dysfunction
  • Usually not reversible-progressive decline of renal function
  • CKD1=normal GFR >90, CKD2=GFR 60-89, CKD3=GFR 30-59, CKD4=GFR 15-29, CKD5=GFR130, acidosis, uremic complications.
  • Renal transplant: hemodialysis, peritoneal dialysis
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14
Q

Metabolic Alkalosis

A
  • Surgical causes: vomiting, NG suction, diuretics, alkali ingestion, mineralocorticoid excess
  • Etiology: Loss of H+ ion, addition of HCO3, fluid contraction, hypokalemia, blood transfusions.
  • Sx: paresthesias, carpopedal spasm, lightheadedness, muscle cramps, stupor, coma, hypoventilation, confusion, weakness
  • Dx: pH >7.45, HCO3/CO2 >24, PCO2>40.
  • Tx: If urine Cl 30= remove source of excess mineralocorticoid/give mineralocorticoid antagonist.
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15
Q

Metabolic Acidosis

A
  • Surgical causes: loss of bicarb(diarrhea, ileus, fistula, high-output ileostomy, carbonic anhydrase inhibitors), increase in acids (lactic acidosis, ketoacidosis, renal failure, necrotic tissue)
  • Etiology: Anion gap= MULE PAK (methanol, uremia, lactic acidosis, ethylene glycol, paraldehyde, aspirin, ketoacidosis). Non-anion gap= USED CARS (ureterosigmoidostomy, saline infusion, endocrinopathies, diarrhea, carbonic anhydrase inhibitors, acid infusion, RTA, spironolactone)

Sx: hyperventilation resulting from stimulation of the respiratory drive to blow off CO2, decreased CO and decreased tissue perfusion, ventricular arrhythmias, lethargy, coma

Dx: pH 12), low HCO3, normal Cl. Non-anion gap= low HCO3, high Cl.

Tx: reverse underlying cause, give sodium bicarb if pH <7.2, insulin therapy and volume repletion if DKA.

16
Q

Respiratory Alkalosis

A
  • Due to hyperventilation (anxiety, pain, fever, wrong ventilator settings)
  • Etiology: anything increasing the pulmonary rate (anxiety, sepsis, salicylate toxicity, pregnancy, progesterone, cirrhosis, CNS hemorrhage). Response of the kidneys is to gradually eliminate plasma bicarb.
  • Sx: hyperventilation, tetany, paresthesia, chest discomfort, light headedness, confusion, circumoral paraesthesia, acroparesthesias, giddiness, vasoconstriction, arrhythmias.
  • Dx: pH >7.45, PCO2 <40, HCO3 decreased.
  • Acutely: for each 10mmHg decrease in PaCO2, plasma HCO3 decreases by 2mEq/L and blood pH decreases by .08mEq/L.
  • Chronically: for each 10mmHg decrease in PaCO2, plasma HCO3 decreases by 5-6 mEq/L and blood pH decreases by .02mEq/L

-Tx: paper bag breathing

17
Q

Respiratory Acidosis

A
  • Due to hypoventilation, drugs, PTX, pleural effusion, parenchymal lung disease, acute airway obstruction.
  • Etiology: anything decreasing pulmonary function (pulmonary disease, neurologic disease, drugs, botulism, myasthenia gravis) Either CO2 overproduction or CO2 retention.
  • Normal compensatory response is gradual increase in plasma bicarb by the kidneys.
  • Sx:HA, confusion, stupor, coma
  • Dx: pH 40, HCO3 increased.
  • Tx: supplemental O2.
18
Q

Hypocalcemia

A

-Normal range= 9-10.5 mg/dl

  • Most common cause of low total serum Ca is hypoalbuminemia. Most common cause of low ionized Ca level is advanced chronic kidney disease.
  • Surgical causes: short bowel syndrome, intestinal bypass, Vit D deficiency, sepsis, acute pancreatitis, osteoblastic metastasis, aminoglycosides, diuretics, renal failure, hypomagnesemia, rhabdomyolosis.
  • Other causes: decreased intake or absorption of Ca, alcoholism, CKD, hypoparathyroidism
  • Sx: Chvostek’s sign(facial muscle spasm with tapping of facial nerve), Trousseau’s sign(carpal spasm after occluding blood flow in forearm), perioral paraesthesia, increased DTRs, confusion, abdominal cramps, laryngospasm with stridor due to airway obstruction, seizures, tetany, psychiatric abnormalities.
  • EKG findings: prolonged QT-risk for arrhythmias (also prolonged ST, possible peaked T waves)
  • Labs: need to check PTH, Mg, and Vit D levels.
  • Tx: Acute= calcium gluconate IV. Chronic= calcium PO Vit D.
19
Q

Hypercalcemia

A
  • Normal range= 9-10.5 mg/dl
  • If severely elevated (>14) likely due to malignancy.
  • Causes: Ca supplementation IV, hyperparathyroidism, immobility, iatrogenic, mets, milk-alkali syndrome, paget’s disease, addison’s disease, acromegaly, neoplasm, zollinger-ellison syndrome, excess Vit D, excess Vit A, sarcoidosis.
  • Sx: stones, bones, abdominal groans, psychic groans, and fatigue overtones. Polydipsia, polyuria, constipation, N/V, anorexia, drowsy, weak, lethargic, depressed
  • EKG findings: Short QT, prolonged PR interval
  • Tx: acute= volume expansion with NS(because pts become volume depleted due to nephrogenic DI), diuresis with furosemide. Can also use seroids, calcitonin, bisphosphonates(TOC for pts with malignancy), mithramycin, and dialysis(in emergency cases)
20
Q

Hypokalemia

A
  • Normal levels: 3.5-5 mEq/L
  • Surgical causes: diuretics, certain antibiotics, steroids, alkalosis, diarrhea, intestinal fistulae, NG aspiration, vomiting, insulin, insufficient supplementation/intake, amphotericin, hypomagnesemia.
  • Sx: fatigue, weakness, tetany, nausea, vomiting, ileus, paraesthesia, hypoventilation, hyporeflexia, arrhythmias, Can lead to metabolic alkalosis.
  • EKG changes: Flattened T waves, U waves present( also ST segment depression, PAC, PVC, atrial fibrillation)
  • Tx: rapid= KCl IV(max 10mEq/hr through peripheral line or 20mEq/hr through central line). RAPID KCl INFUSION CAN BE LETHAL!! Chronic tx= KCl PO.
  • It is the most common electrolyte mediated ileus in the surgical pt.
  • It exacerbaes digitalis toxicity.
  • Must first replace magnesium before replacing K.
21
Q

Hyperkalemia

A
  • Normal level: 3.5-5mEq/L
  • > 6.5-7 is a medical emergency!
  • Surgical causes: Iatrogenic overdose, blood transfusion, renal failure, diuretics, acidosis, tissue destruction
  • Sx: decreased DTRs, weakness, paraesthesia, paralysis, respiratory failure (hypoventilation), abdominal distention. Can result in metabolic acidosis.
  • EKG findings: Peaked T waves, wide QRS, bradycardia, V-fib.
  • Tx: Urgent= IV Ca, EKG monitoring, sodium bicarb IV, glucose, insulin, albuterol, sodium polystyrene sulfonate, furosemide, and dialysis. Non-acute= furosemide, sodium polystyrene sulfonate.
22
Q

Hyponatremia

A
  • Normal range: 135-145 mEq/L
  • Usually secondary to disorder of water balance. (usually reflects excess water retention than true Na depletion).
  • Hypotonic hyponatremia: need to assess volume status.
    • Hypovolemic- diuretic escess, hypoaldosteronism, vomiting, NG suction, burns, pancreatitis, diaphoresis
    • Euvolemic- SIADH, CNS abnormalities, drugs
    • Hypervolemic- renal failure, CHF, liver failure, fluid overload
  • Isotonic hyponatremia: can be caused by hyperproteinemia or hyperlipidemia.
  • Hypertonic hyponatremia: can be caused by elevated blood glucose, sugars, radioactive dyes. For every 100mg/dL rise in glucose above 100, the Na may fall approx. 2.4mEq/L.
  • Sx: seizures, coma, nausea, vomiting, ileus, lethargy, confusion, weakness.
  • Tx: Correction guideline is <12 mEq/L per day. Hypovolemic= NS IV, correct underlying cause. Euvolemic= furosemide and NS, fluid restriction. Hypervolemic= fluid restriction and diuretics.
  • Na deficit =TBW X (desired Na - actual Na)
  • TBW=.6 X wt in kg.

-The most common cause of post-op hyponatremia is Fluid overload.

23
Q

Hypernatremia

A
  • Normal range= 135-145 mEq/L
  • Surgical causes: inadequate hydration, DI, diuresis, vomiting, diarrhea, diaphoresis, tachypnea, iatrogenic, fever, burns
  • Labs: would expect a high urine osm because body is trying to conserve water.
  • Sx: seizures, confusion, stupor, pulmonary or peripheral edema, tremors, respiratory paralysis.
  • Tx: Give slowly over days: D5W, 1/4 NS or 1/2NS. Na should fall by no more than 12 mEq/L per day.
  • If sodium level is lowered too fast, can result in seizures.
  • Water deficit: [(Na-140) / 140] x TBW
  • TBW= .6 X wt in kg.
24
Q

Hypermagnesemia

A
  • Normal range: 1.5-2.5 mEq/L
  • Surgical causes: TPN, renal failure, IV over supplementation
  • Sx: respiratory failure, CNS depression, decreased DTRs, nausea
  • Tx: Ca gluconate IV, insulin + glucose, furosemide.
25
Q

Volume depletion

A
  • Problem with Na balance
  • Etiology: GI (vomiting, diarrhea, NG, fistula drainage), Third spacing (ascites, effusions, bowel obstruction, crush injuries, burns), inadequate intake, polyuria, sepsis, abdominal and retroperitoneal inflammatory processes, trauma, open wounds, sequestration of fluid into soft tissue injuries
  • Sx: fatigue, weakness, thirst, cramps, dizziness, syncope, coma, postural changes in BP and HR, orthostasis, wt loss, shock, decreased JVP, poor skin turgor, dry mucous membranes
  • Dx: monitor urine output and daily wts, elevated serum Na and low urine Na, BUN/Cr ratio >20:1 suggests hypoperfusion to the kidneys.
  • Tx: Fluid replacement
26
Q

Volume excess

A
  • Reflects excess Na and H2O.
  • Etiology: More Na ingestion than excretion. Cirrhosis, renal insufficiency, CHF, nephrotic syndrome
  • Sx: SOB, DOE, orthopnea, fatigue, edema, increased JVP, hepatojugular reflex, wt gain, rales.
  • Tx: Na restriction. If severe, fluid restriction. Diuretics.
27
Q

What is the triad of renal cell carcinoma?

A

1) Flank Pain
2) Hematuria
3) Palpable mass

28
Q

Hypomagnesemia

A
  • Normal range: 1.5-2.5 mEq/L
  • Surgical causes: TPN, hypocalcemia, gastric suctioning, aminoglycosides, renal failure, diarrhea, vomiting.
  • Sx: increased DTRs, tetany, asterixis, tremor, Chvosteks sign, ventricular ectopy, vertigo, tachycardia, dysrhythmias. Can cause low Ca and low K levels.
  • Tx: acute= MgSO4 IV. Chronic= Magnesium oxide PO.
  • Need to fix before hypokalemia can be fixed.

Surgery Rotation (10 decks)

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