Genitourinary Flashcards
An upper urinary tract infection involves what structures?
kidney and/or ureters
A lower urinary tract infection involves what structures?
bladder and/or urethra
What is the most common pathogen that causes a UTI?
Escherichia Coli (E. Coli)
S/S of Lower Urinary Tract Infection
(cystitis, urethritis, prostatitis)
-NO FLANK OR CVA TENDERNESS
- dysuria
- frequency/urgency
- suprapubic pain
- hematuria w/ bacteruria
- fever
- chills
S/S of Upper Urinary Tract Infection
(Pyelonephritis, abscess)
- FLANK PAIN and/or CVA Tenderness
- fever
- hematuria
- N/V
- malaise
- rigors
- tachypnea
- tachycardia
What is the diagnostic gold standard test to diagnose a UTI?
Positive Urine Culture - detection of bacteria in the culture
How long does it take for urine culture results to be available after collection?
24 hrs
What is the term for the presence of
> 10 leukocytes/ml in urine?
pyuria
Bacteriuria is when there is > __?__ bacteria/ml of urine?
> 100,000
- indicates active infection
Leukocytosis with a shift to the left is indicative of what urinary tract disorder?
Pyelonephritis
- shift to the left means increased number of immature WBCs, usually band cells which are immature precursors
What tests are done to r/o obstruction, calculi or urinary retention?
- post void residuals
- CT abd/pelvis w/ and w/o contrast
- Pelvic Ultrasound
- MRI pelvis w/ and/or without contrast
What should be suspected in a patient with a UTI related fever lasting longer than 3 days?
obstruction or abscess
- abd imaging (CT, US, MRI)
- urology consult
What labs should be done if a UTI is suspected?
- Clean catch midstream Urinalysis
- Urine dipstick test
- CBC (leukocytosis w/ shift to left)
- blood culture (pyelonephritis, sepsis)
What are the 4 first line ABX used to treat acute cystitis?
- Fosfomycin
- Macrobid
- Sulfonamides
- TMP-SMX aka Bactrim DS
- Trimethoprim
What is the generic name for Nitrofurantoin monohydrate/macrocrystal?
Macrobid
When should Fluoroquinolones be used in the treatment of acute cystitis?
As a second line therapy and should only be used when there is no other option due to the severity of adverse effects
- end in -oxacin
- cause tendonitis, tendon rupture, disorientation
What is the treatment for an uncomplicated upper UTI (pyelonephritis)?
Treated as an outpatient
- Fluoroquinolones (ciprofloxacin)
- Sulfonamides (TMP-SMX aka Bactrim DS)
- Oral B-lactams (amoxicillin-clavulanate)
Sulfonamides should be used with caution in patients with _______ when treating an UTI?
impaired renal function
- sulfonamides are nephrotoxic
Levofloxacin is used to treat what kind of UTI?
- Cystitis -complicated lower UTI
- Acute pyelonephritis
- other complicated and uncomplicated UTI’s
What are the fluoroquinolone ABX?
- ciprofloxacin
- levofloxacin
Ciprofloxacin and levofloxacin are what classification of ABX?
Fluoroquinolones
What is the treatment for a complicated lower UTI (cystitis)?
- Levofloxacin
- ceftriaxone
- piperacillin/tazobactam (zosyn)
- aminoglycoside with ampicillin
What is the treatment for a complicated upper UTI (pyelonephritis)
- Fluoroquinolones (ciprofloxacin)
- Sulfonamides (TMP-SMX aka Bactrim DS)
- Oral B-lactams (amoxicillin-clavulanate)
- piperacillin/tazobactam (zosyn)
- aminoglycosides (not use as monotherapy)
What are common s/s of a UTI in the elderly?
- altered LOC
- lethargy
- delirium
Cause(s) of pre-renal AKI?
Decreased renal perfusion d/t:
(1) Volume depletion:
- hemorrhage
- GI loss (diarrhea, vomit, pancreatitis)
- increased UO (diabetes insipidus, diuretics)
- edema or 3rd spacing (burns, wounds)
(2) Vasodilation decreases blood flow
- sepsis
- anaphylaxis
- pancreatitis (increase cytokine release = increase premeability)
- drugs (ACEI, NSAIDs, diuretics)
(3) decreased CO decreases renal perfusion
- severe systolic HF
- MI
- cardiogenic shock
(4) Vasoconstriction or arterial occlusion
Lab findings indicative of a Pre-renal AKI?
- oliguria (little to no UO)
- urine sodium < 20 mEq/L (low)
- urine osmolality > 500 mOsm/L (high)
- urine specific gravity > 1.020 (high)
- BUN/creatinine ration > 20:1 (high)
- hyperuricemia
- increased ADH secretion
Will Urinary sodium be high, low, or normal in a patient with a Pre-renal AKI?
low (< 20 mEq/L)
Will Urinary osmolality be high, low, or normal in a patient with a Pre-renal AKI?
high (> 500 mOsm/L)
Will Urinary specific gravity be high, low, or normal in a patient with a Pre-renal AKI?
high (> 1.020)
What are the 3 types of Intrinsic or Intra-renal AKIs?
- acute glomerulonephritis
- acute tubular necrosis
- vascular
What are the causes of acute glomeruloneprhitis?
- autoimmune
- Systemic Lupus Erythematosus (SLE)
- Sjogrens syndrome
- sarcoidosis
- idiopathic
What are the causes of acute tubular necrosis (ATN)?
- conditions that cause decreased renal perfusion and eventual ischemia and necrosis
- sepsis
- infection
- low CO
What is the term for the build up of nitrogenous products in the blood r/t to renal insufficiency?
Azotemia
- increased BUN/creatinine
Furosemide is what type of diuretic?
Loop
Bumetidine is what type of diuretic?
Loop
Torsemide is what type of diuretic?
Loop
What is the drug of choice to treat volume overload in a patient with an AKI?
Furosemide (lasix)
- 20-200mg q6hrs
- double dose after 1hr if response is not adequate
Which drug is given to temporarily reverse the neuromuscular effects r/t to hyperkalemia?
IV Calcium, is cardioprotective
Why is IV Calcium given to hyperkalemic patients?
to temporarily reverse the neuromuscular effects r/t to hyperkalemia
What are the drugs that treat hyperkalemia by pushing K+ into the cells?
- 10 Units of IV Regular insulin
- give 25gm of dextrose if BG < 250
- Inhaled Beta-2 agonist (onset w/in 30min)
Which drug binds K+ in the GI tract preventing absorption?
Sodium Polystyrene Sulfonate (SPS)
- aka Kayexalate
- 15-30gm orally
- adds 1mEq Na for q 1mEq K+ removed
What are methods for treating hyperkalemia?
- Insulin
- hInhaled Beta-2 agonist
-Sodium Polystyrene Sulfonate (SPS) aka Kayexalate - Lasix (takes longer)
- dialysis
What is the definition of CKD?
- GFR < 60mL/min with or w/out renal damage
- Kidney dysfunction w/ one or more of:
- albumineria
- urine sediment abnormalities
- elyte abnormalities r/t tubular disorders
What are the causes of CKD?
- Diabetes
- glomerular disease
- polycystic kidney disease
- HTN
- renal artery stenosis
- recurrent kidney infections
What is the normal GFR value?
80-120 mL/min
Renal replacement therapy is started when the GFR is?
5-10mL/min
Management of CKD?
- tx fluid overload
- tx HTN (ACE-I or ARBs are 1st choice)
What is the 1st line drug for treatment of HTN in a patient with CKD?
ACE-I or ARB if cannot tolerated ACE-I
What are common issues r/t to CKD?
- fluid overload
- HTN
- hyperkalemia
- hyperphosphatemia
- hypocalcemia
- hypermagnesemia (reduced excretion)
- anemia (decreased erythropoietin)
S/S of BPH?
- frequency/urgency
- dysuria
- nocturia
- incontinence
- hesitancy
- straining
- dribbling
- retention
sensation of incomplete emptying
What are the tests/diagnostic/lab tests if BPH is suspected?
- UA
- Urine culture to r/o infection
- BUN/creatine to r/o renal insuffiency
- Prostate-specific antigen (PSA)
- Transrectal US for elevated PSA or palpable nodule
Management of BPH?
- wait and watch (may recover on own)
- avoid nightly fluid intake
- surgery (TURP)
Meds - alpha 1 blockers (preferred for mild-mod) (terazosin, tamsulosin)
- 5-alpha reductase inhibitors (finasteride, dutasteride)
- muscarinic receptor antagonist
-phosphodiesterase 5 (PDE5) inhibitors (sildenafil, end in afil)
Terazosin (Hytrin) is what class of medication and is used to treat what condition?
alpha-1 blocker used to treat BPH
- relaxes muscle fibers in the prostate gland and i n the internal urethral sphincter
Prazosin (Minipress) is what class of medication and is used to treat what condition?
alpha-1 blocker used to treat BPH
- relaxes muscle fibers in the prostate gland and i n the internal urethral sphincter
What are the most common side effects r/t to alpha-1 blockers?
hypotension and dizziness
Tamsulosin is what class of medication and is used to treat what condition?
alpha-1 blocker used to treat BPH
- relaxes muscle fibers in the prostate gland and i n the internal urethral sphincter
Tadalafil (Cialis) is what class of medication and is used to treat what condition?
phosphodiesterase 5 (PDE5) inhibitor used to tx:
- BPH
- erectile dysfunction
- lower urinary tract symptoms (LUTS) that are not responsive to alpha-adrenergic antagonists
What is the medical term for kidney stone?
nephrolithiasis
What are the most common types of kidney stones?
calcium oxalate and calcium phosphate
What are the different types of kidneys stones?
- calcium oxalate
- calcium phosphate
- uric acid
- struvite
- cystine
What is the main risk factor for calcium oxalate and calcium phosphate stone development?
high urine pH
What is the difference between nephritic and nephrotic syndromes?
- Nephritic - damage to glomerular basement membrane
- proteinuria < 3.5 g/day
- hematuria
- Nephrotic - damage to podocytes
- proteinuria > 3.5 g/day
- lipidurea (fat oval bodies)
What are causes of uric acid stone formation?
- dehydration and low urine pH
What are causes of calcium phosphate and struvite kidney stone formation?
high urine pH
What are causes of calcium oxalate kidney stone formation?
- decreased urinary citrate
- increased urine calcium
- increased uric acid
What are causes of cystine kidney stone formation?
- low urine pH
- increased urine calcium
- increased uric acid
S/S of kidney stones
- flank pain, can radiate to the groin
- renal colic
hematuria - CVA tenderness
- hydronephrosis
What are complications of having kidney stones?
Urine backs up = decreased bacteria out
- hydronephrosis
- pyelonephritis
- urosepsis (if gets into blood)
What is the relationship between calcium and oxalate and how does it relate to a kidney stone formation?
- oxalate binds to calcium in the GIT for excretion in stool
- low calcium in diet leads to higher levels of free oxalate that are absorbed into the blood via the GIT
- increased blood oxalate means higher level in urine to bind to urine calcium = stone formation
Low urine pH is conducive to the formation of which type(s) of kidney stones?
- Uric acid
- cystine
- calcium oxalate
High urine pH is conducive to the formation of which type(s) of kidney stones?
- calcium phoshate
- struvite
Which stone is aka a staghorn?
struvite
What does urease do?
- converts urea into ammonia
- produced by bacteria such as
) helicobacter pylori
) proteus sp
) klebsiela sp - high ammonia levels can cause changes in LOC, tremors, coma
What are the diagnostic tests if a kidney stone is suspected?
- CT Abd and pelvis (gold standard)
- renal us
- kidney ureter bladder xr (KUB)
- UA w/ microscopy
- 24hr UA for recurrent stones
Which stones will be radiopaque (can be seen) on a KUB XR?
- Calcium oxalate
- calciumphosphate
- struvite (staghorn)
Which stones will be radiolucent (can not be seen) on a KUB XR?
- uric acid
- cystine
What is the treatment for a struvite kidney stone)
Abx
Are the following symptoms associated with a complicated or uncomplicated UTI:
- dysuria
- urgency
- frequency
- CVA tenderness
- fever
- n/v
Complicated UT
What is/are the 1st line agent(s) to treat an uncomplicated UTI?
- sulfamethoxazol/trimethoprim (Bactrim) DS 1 tab BID x3days (treats both gram (-) and (+) bacteria)
- if resistance is < 20% in your area
- can cause confusion in the elderly
- nitrofurantoin (macrobid) 100mg BID x 5 days
What is/are the 1st line agent(s) to treat an complicated UTI?
One of the following:
- ciprofloxacin 500 mg PO BID x 7-14 days
- ciprofloxacin 400 mg IV Q12hrs x 7-14 days
- levofloxacin (levaquin) 750mg PO x7-14 days
- levofloxacin (levaquin) 750mg IV x7-14 days
What is the 1st line treatment for a patient with a complicated UTI and is at high risk of multi drug resistance or systemic illness?
- cefepine 2 grams IV BID
- zosyn (piperacillin- tazobactam) 3.375 grams IV QID
- Ertapenem 1 gram IV QD
