Genitourinary Flashcards
What controls the bladder neck? What controls the bladder?
Bladder neck: Under adrenergic control
Bladder: Under cholinergic control
What are the treatment options for BPH?
Alpha blockers: Terazosin, tamsulosin
- SE: Hypotension, dizziness, asthenia
5 alpha reductase inhibitors
Gold standard for relieving bladder outlet obstruction: Transurethral resection of the prostate (TURP)
What male genital problem causes an increased risk of testicular cancer?
Cryptorchidism (40 times as likely to develop testicular CA)
(Most common genital problem encountered in pediatrics)
Also increases risk of testicular torsion and infertility
What is Cryptorchidism? what side is it most common?
Incomplete descent of the testes into the scrotum during fetal development
More common on the Right side
How do you test for functioning testicular tissue?
Hormonal challenge: HCG will confirm the presence of functioning testicular tissue (hcg is virtually identical to Pituitary LH)
If the FSH is 3X normall and no increase in testosterone in response to hCG, functional tests are not present
How do you treat Cryptorchidism?
Most will spontaneously descend by 3 months
Treat at 6 months
- hcG-identical to pituitary LH
- Agonist analogs of GnRH-Stimulate the release of LH and FSH
What is Prehn’s sign?
Elevation of the testicle–>
- Relieves pain in epidydimitis (positive prehn)
- No relief of pain in torsion
What are the symptoms and signs of Fournier’s Gangrene? Risk Factor?
RF: Indwelling catheter
Sxs: Fever, toxicity, sepsis
PE: scrotum reveals eschar, brawny, violaceous, bullous edema with a cellulitis extending into abdominal wall an perineum
Surgical Emergency!!
What is the most common type of bladder cancer? How does it present? RF? Diagnostics?
Transitional Cell carcinoma
Presents with gross hematuria
- If you see gross hematuria–>need a cystocopy and biopsy
RF: aniline dyes, smoking
Schistasomiasis–associated with Squamous cell
What is the most common renal malignancy? who does it most commonly affect? How is it diagnosed?
Renal cell carcinoma
Black men who smoke
Dx: CT scan
CXR (to exclude pulmonary metastasis)
What is the classic triad of Renal cell carcinoma? How do you treat it?
- Hematuria
- mass
- flank pain
Tx: Nephrectomy (if early), Radiation (if late, bad prognosis)
What medications can cause urinary retention in men?
Anticholinergics, OTC cold meds, Opiates, benzos, and general anesthesia
“I had surgery yesterday and now I can’t pee”
How do you treat acute urinary retention? What do you have to warn the patient about?
Alpha blockers : warn them that it may cause orthostatic hypotension
What controls Erection? What controls ejaculation?
- Erection requires intact parasympathetic
- also somatic nerve supply, unobstructed arterial flow, adequate venous constriction, hormonal stimulation, pyschological)
- ejaculation=sympathetic
“Point & Shoot”–>P=parasympathetic, S=sympathetic
What is Priapism?
Painful condition in which erect penis does not return to flaccid state.
What is the most common drug related cause of Priapism? What is the most common etiology in most emergency departments (and in boys)? Tx?
Trazadone most common drug related cause (hippa)
also Sildenafil (viagra)
Sickle cell disease-common cause in most ER
Dont miss leukemia in kids!
Tx: Phenylephrine
How does testicular cancer present? How do you diagnose?
Most common neoplasm in men 20-35 y/o
S/S: Painless unilateral mass (that cannot be separated from the testicle); Lung mets may be first symptom
Dx: UTZ for diagnosis, CT for staging
Testicular Torsion: S/S, Who?, Dx? Tx?
12-18 y/o; Testical is abnormally twisted on its spermatic cord–compromising arterial supply and venous drainage of testicles leading to testicular ischemia
PE: abnormal lie (high-lying painful testes), abnormal cremasteric reflex (neg. Prehn’s sign),
ass. with bell clapper deformity (Inadequate fixation of testes within the scrotum
Dx: If you think it’s torsion, immediately get US! US will show ischemia with abnormal flow
IF no access to urology attempt manual de-torsion with open book
Tx: SURGICAL EMERGENCY! Detorsion and ocrhiopexy
What is Balanitis/Balanoposthitis? What causes it?
Redness of the foreskin and penis with foul smelling discharge
Associated with lack of hygeine, usually found in uncircumscribed young boys
ORchitis: What is it? who does it most commonly affect? S/S?
- Commonly caused by ascending bacterial infection from Urinary tract.
- Occurs in 23% of postpubertal males who have mumps infection
(Typically follows Parotitis within 8 days)
- Sx: unilateral testicular swelling and tenderness
- Fever, tachycardia
Epididymitis: What is it? WHat organisms are involved?
- Infection of the epididymis acquired by retrograde spread of organisms through the vas deferens
- <35 y/o: Chlamydia and gonococci
- >35 y/: E. coli
- PE: warm tender erythematous enlarged scrotal mass
- Positive Prehn’s sign
Tx: <35 y/o: Ceftriaxone 250 mg IM + doxycycline 100 mg BID 10 days
> 35 y/o: Ciprofloxacine 500 mg BID PO x 10-14 days
What is Phimosis?
The inability to retract the foreskin over the glans penis
“Turtleneck tooo small to put over your head
circumcision may be a tx
What is Paraphimosis
entrapment of the foreksin behind the glans penis
“So now turtleneck is not only too small to put over your head, but its not strangling your gland)
EMERGENCY! may end up in edema or gangrene
What is a varicocele? What are the symptoms? Dx?
Formation of a venous varicosity within the spermatic vein (Paminiform plexus)
Left vein > Right vein
PE: Chronic, nontender mass that does not transilluminate
“Bag of worms”, increases in size with valsalva
Dx: Doppler Sonography
PE findings of hydrocele? of Spermatocele?
hydrocele: Soft, transluminating nontender mass
Spermatocele: Painless cystc mass containing sperm; Palpable, round firm cystic mass free floating above the testicle, which transilluminates; may be tender
Dx: Clinically
Name prerenal etiologies of acute renal failure and Labs
Decreased renal perfusion secondary to
- Hypovolemia
- hypotension
- CHF
Labs: Urine Na <20 mEq/L (The integrity of kidneys remain intact, So sodium is conserved as GFR declines in an attempt to reestablish volume and perfusion, resulting in a fractional excretion of sodium, FENa <1).
Name Post-renal etiologies of acute renal failure
Tubular obstruction, Obstructive uropathy, nephrolithiasis, BPH
Name intrinsic renal etiologies of acute renal failure; labs
- ATN
- Nephrotoxins
- Interstitial disease
- glomerulonephritis
- vascular disease
Labs: Increased urine Na > 40 mEq/L (when glomeruli are injured, the kidneys lose the ability to reabsorb sodium as the GFR decreases; FENa >1
Decreased BUN: Cr ratio
What are the symptoms of glomerulonephritis? What is seen on labs?
Sxs: Hematuria, tea/coloa-colored urine, oliguria, edema of face/eyes (classic, worse in AM), HTN
UA: Mishaped RBCs due to passage through glomeruli, RBC cast
+ antistreptolysin O if recent strep infection
Tx: depens on etiology, Steroids, immunosuppressive drugs
Defn of Nephrotic syndrome
>3.5 g of protein in 24 hours
What labs are seen in nephrotic syndrome?
Hypoalbuminemia, Proteinuria, Foamy urine (beer), RBC casts, Granular casts
Key finding: Oval fat body
What is Fibromuscular dysphagia? How do you dx? How do you tx?
Dz where renal artery has multipile areas of stenosis
On exam: 25 y/o female with HTN , abdominal bruits and renal failure
Dx: Renal US with doppler
tx: Angioplasty/stenting vs. Surgical repair
Hydronephrosis: what is it? Common cause? Dx? Tx?
Distention and dilation of renal collecting system (Calyces)
Common cause: obstruction of urine flow (Nephrolithiasis, BPH, mass, etc.)
Dx: abdominal US
Tx: Decompress kidneys
Must relieve obstruction–> percutaneous nephrostomy tubes
Respiratory Acidosis
Increased PCO2 (hypercapnia) caused by hypoventilation (seen in COPD,
Labs: Increased PCO2, Decrease PH, worsening MS
Kidneys slowly compensate over days leading to rise in serum HCO3
Complication: Hypercapneic Encephalopathy
Respiratory Alkalosis
decreased PCO2, caused by HYPERventilation
causes: sepsis, PE, anxiety, salicyclate toxicity, hypoxia, primary CNS disorders, Pregnancy
Sxs: Tetany-like syndrome secondary hyperventilation.
Compensation: decreased CO2 leads to renal excretion of HCO3
Tx: If anxiety breath in paperbag, otherwise tx underlying disorder
Metabolic Acidosis: Anion Gap vs NonAnion gap causes
Occurs when pt loses bicarb or adds H+ to the blood
Compensation: in acute metabolic acidosis, the resp response is immediate–>PCO goes down as you breath more to get rid of it.
Aniongap: Add acid to blood; Cause: MUDPILES
Non-Anion Gap: Loss of bicarb through GI tract; Common cause: Diarrhea and renal tubular acidosis
Metabolic Alkalosis: common cause
Increased serum bicarb concentration
Common causes: vomiting
What is the Diagnostic test used for Nephrolithiasis?
Helical CT
Treatment of Nephrolithiasis
<5 mm: Most likely pass spontaneously
5-10 mm: Less likely to pass spontaneously
Elective Lithotripsy or ureteroscopy
>10 mm: tx on inpt basis if unable to maintain adequate oral intake
Gold standard: Ureteral stent or percutaneous nephrostomy
The majority of Prostate cancers are what type?
Adenocarcinoma
When should a biopsy be done?
PSA > 4 ng/ml
How do you differentiate Seminoma Testicular cancer from Nonseminoma?
AFP elevated in Seminomas–Radiation sensitive
hCG elevated in nonseminomas–Radiation resistant (tx with chemo or surgery)
What is the most common solid renal tumor of childhood? What is the most common symptom?
WIlms Tumor, AKA Nephroblastoma
Sx: Asymptomatic Abdominal mass
What is the study of choice to diagnose WIlms Tumor? Tx?
Ultrasound
Tx: Surgery, chemo, radiation
What Is commonly seen on UA with pyleonephritis?
White blood cell casts
What UTI pathogen is most commonly seen in patients with recurrent UTI and in hospitalized patients?
Pseudomonas
What is Reiter syndrome?
Reactive arthritis as a result of untreated chlamydia infection.
Triad: Urethritis, Arthritis, and conjunctivitis
How do you treat acute bacterial prostatitis initially?
Bactrim + Fluoroquinolones x 4-6 weeks
What is urge incontinence? Tx?
Result of uninhibited urge sensations that are so strong that the patient experiences an involuntary urine loss; often seen with aging, weakened pelvic muscles secondary to childbirth, and estrogen depletion causing weakening of the detrusor muscle.
strong desire to void followed by loss of urine
Detrusor overactivity, results from blader contractions that cannot be controlled by the brain; Seen in inflammatory conditions or neurogenic disorders
Tx: Anticholinergics, Tolterodine and oxybutynin
What is stress incontinence?
Associated with increased intra-abdominal pressure (laughing, sneezing, coughing)
Dysfunction of the urethral sphincter
Females <70 y/o
what is overflow incontinence?
Associated with leaking small amounts of urine from mechanical factors that affect an already distended bladder; Detrusor underactivity
Also seen with chronic urinary retention (BPH, Urethral strictures)
Sxs: Nocturnal wetting, frequent loss of small amount of urine;
Complications: Hydronephrosis, obstructive neuropathy
What is Functional incontinence?
Associated with patients who exhibit cognitive impairment (Severe dementia)
Prevent pts from reaching toilet
How do you treat Overflow incontinence?
Cholinergic agents (Bethanechol): Increases bladder contractions
Alpha-blockers (Terazosin, Doxazosin): Decreases sphincter resistance
Catheterization
How do you treat stress incontinence?
Pessary, Topical estrogens
Surgery (Urethropexy)
What is associated with Suppressed levels of PTH and Hypercalcemia?
- Malignancy–most common
- Vitamin D intoxication
- hyperthyroidism
What do you see in the urine with acute tubular necrosis?
Epithelial cell casts
What medication class affects PSA levels?
5 alpha reductase inhibitors can lower a patients PSA levels by 50%
What is the most common primary source for metastatic bone disease in men?
What type of cancer commonly metastasizes to the lungs? lymph nodes along the renal hilum?
Prostate Cancer–metastatic bone dz
Renal cell CA, Bladder CA–lungs
Testicular CA–Lymph nodes along the renal hilum
When should a woman with recurrent UTIs be referred to a urologist?
A recurrence rate of more than 3 infections per year
What is the most common stone of Nephrolithiasis?
Which stone is associated with urease producing organisms?
Most common stone: Calcium oxalate
Struvite stones are associated with urease producing organisms (Proteus and Pseudomonas). Not usually associated with E. coli.
What is an absolute indication to begin hemodialysis in pateints with CKD?
Development of seizures
What is the most common cause of acute interstitial nephritis?
NSAIDS
What renal disease is ACE inhibitors contraindicated?
Significant renal artery stenosis
How do you diagnose renal artery stenosis?
Magnetic resonance angiography enhanced with gadolinium
Abnormal urinary protein excretion is defined as
>300 mg/24 hours
At what serum glucose level will glucsoe spill into the urine?
180 to 200 mg/dL
What renal disease result in a unilateral atrophied kidney? bilateral? An enlarged kidney?
- Unilateral atrophied kidney: Renal artery stenosis
- The unaffected kidney will generally enlarge in an attempt o compensate for the declining GFR
- Atrophy of both kidneys: Hypertensive nephrosclerosis and Diabetic nephropathy
- Enlarged kidneys–>Polycystic kidney disease
How does Insulin affect potassium levels?
Insulin helps drive potassium into the cell, but must be given with glucose to avoid signficant hypoglycemia.
Therefore, one way to tx hyperkalemia is
Insulin + D5W IV
What are the subtypes of Renal tubular acidosis?
Type I: Inability of the distal renal tubule to excrete hydrogen ions
Type II: Overexcretion of Bicarb into the urine
Type III: no longer used
Type IV: aldosterone deficiency or an inability of the distal tubule to response to aldosterone
The most serious consequence of rapid correction of hyponatremia is?
Central pontine myelinolysis
What is the most common electrolyte abnormality seen in hospitalized patients?
hyponatremia
What is the appropriate action prior to having a patient with CKD undergo a procedure involving IV contrast dye?
Administer 1,000 CC bolus of normal saline and Acetylcysteine pro
What is a common electrolyte abnormality in a patient who abuses alcohol? What are the symptoms
Hypomagnesemia;
Neuromuscular and CNS hyperirritability, weakness/muscle cramps, tremors, nystagmus, positive Babinski response, confusion, and disorientation
What is the treatment of choice for hypercalcemia associated with malignancy?
Bisphosphonates (IV zoledronic acid)
What are the signs and symptoms of Polycystic kidney disease?
- Abdominal fullness (due to enlarged kidneys)
- abdominal pain (due to bleeding into cysts)
- hematuria
- HTN
How is polycystic kidney disease diagnosed? what is a common complication?
- US
- <30 y/o: 3 or more cysts
- 30-59 y/o: 3 or more cysts in each kidney
- >60 y/o: 5 or more cysts in eache kidney
Complication: Cerebral Aneurysms (10-15% of PKD patients have arterial aneurysms in the circle of willis)
What are the stages of CKD?
Stage I: > 90 mL/min, persistent aluminuria
Stage II: GFR 60-89 mL/Min
Stage III: May start to see serum creatinine and BUN increase; Anemia, HTN, malnutrition, disorders of calcium and phosphorus metabolism, Reduced functioning and well-being neuropathy
Stage IV: GFR 15-29 ml/min; fluid, electrolyte, Acid-base abnormalities
Stage V: GFR <15 ml; initiateate dialysis or transplant when appropriate
