Genitourinary

Question 1

Urinary tract infection

Answer 1

Up to 90% of UTIs are caused by E. Coli, which belongs to the family of Enterobacteriaceae

Risk factors:
- Poor hygiene, diabetes, immunocompromised, frequent, sexual intercourse, pregnancy, spermicide use

Presentation:
- Uncomplicated UTI
- Polyurea, dysuria, urgency, super pubic pain, occasionally gross hematuria, and in the absence of vaginal pruritus and/or discharge
- Complicated UTI
- systemic symptoms, such as fever, chills, or costovertebral (CVA) tenderness, male, gender, poorly control, diabetes, pregnancy, children, elderly, immunocompromise, recurrent UTIs, presence of kidney stones or an obstruction, or if there is an indwelling catheter in place.

Diagnosis:
- positive markers for a UTI include nitrates, white blood cells, and leukocyte esterase.

Question 2

Uncomplicated UTI Treatment

Answer 2

• Beta-Lactam (5-7 days)
  
  • Cephalexin, Cefuroxime
• Nitrofurantoin
  
  • Avoid if pylon nephritis is suspected or CrCl <30
  • avoiding first trimester of pregnancy, unless no other alternatives
  • contraindicated >36 weeks gestation due to increased risk of neonatal hemolytic anemia
• TMP/SMX (3-5 days)
• Fosfomycin (3g PO Once)
• Fluoroquinolone (3 days)
  
  • Consider risk and benefit

Question 3

Complicated UTI treatment

Answer 3

• Beta-Lactam (7-10 days, if no recent antibiotic exposure and low risk for resistance)
• TMP/SMX (7-10 days)
• Fosfomycin (3g PO Q48 hours for 3 doses)
• Fluoroquinolone (5-7 days)
• Do not treat a symptomatic bacteriuria, unless patient is pregnant.

Question 4

Hematuria

Answer 4

• Gross hematuria: visible to “ naked eye”
• microscopic hematuria: detectable only with microscopy.

Risk factors:
- < 35 years, low risk
- 85% of bladder cancer presents with hematuria
- Tobacco smoking is a big risk factor

Causes:
- include UTI, glomerular, bleeding, pylonephritis, kidney stones, a mass, recent instrument use, malignancy, trauma, and exercise induced hematuria.

Unexplained hematuria :
- abdominal pelvic CT scan with and without contrast for urography: high risk for malignancy
- cystoscopy: gold standard for diagnosing and staging bladder cancer

Question 5

Nephrolithiasis

Answer 5

• 80% are calcium stones.
• Other types: your acid, struvite and cystine stones.

Presentation:
- Pain (renal colic or flank pain) and gross or microscopic hematuria
- Other symptoms include nausea, vomiting, dysuria, and urinary urgency

Diagnosis:
- lower radiation dose, computed, tomography of the abdomen and pelvis without contrast
- Ultrasound of the kidneys and bladder, in combination with abdominal pelvic radiography is the second line for imaging modality

Treatment:
- Patients with stones less than 5 mm typically do not require specific treatment; most will pass spontaneously
- patients with stones greater than five and less than 10 mm in diameter, research suggest treatment with tamsulosin for up to four weeks to facilitate stone passage
- patient with stones greater than 10 mm should be referred to urology for management

Question 6

Urinary incontinence

Answer 6

Risk factors:
- Obesity, vaginal parity, older age, and family history

Stress urinary incontinence
- you’re in loss with an increase in intra-abdominal pressure

Urgency urinary incontinence (overactive bladder)
- Frequent, small volume voids, with sudden urge to urinate, maybe unable to make it to the bathroom in time

Overflow incontinence
- Detrusor muscle under activity
- Loss of urine with no warning or triggers and often occurs with a change in position and/or with activity
- Urinary outlet obstruction
- intermittent, or slow stream, difficulty getting urine stream started, and a sensation of incomplete emptying

Treatment options:
- avoid alcohol and caffeine
- Pelvic floor exercises, for example Kegels
- Continence pessaries
- Bladder training
- topical vaginal estrogen

Question 7

Acute kidney injury

Answer 7

• sudden decline in the glomerular filtration rate
  
  • reduced GFR <60 (chronic kidney disease is a GFR <60 for a minimum of three months)

Presentation:
- sudden oliguria, Adema, weight gain, lethargy, nausea and loss of appetite
- Oliguria is < 0.3ml/kg per hour or < 500ml a day
- Anuria is < 50 ml a day

Diagnosis:
- increase in serum creatinine by >0.3mg/dl within 48 hours
- Or an increase in serum creatinine to > 1.5 times baseline (which is known or presumed to have occurred within the prior seven days)
- Or urine volume < 0.5 ml/kg/hour for 6 hours

Treatment:
- Consult nephrology
- Indications for ER: stage two or three AKI, uncontrolled comorbidities, signs of sepsis, stage one with unclear etiology
- Discontinue any inciting medications (NSAIDs or ACE), treat hypovolemia, or hypovolemia if present, treat electrolyte imbalances.

Question 8

Rhabdomyolysis

Answer 8

Characterized by muscle cell death, and the release of these intracellular muscle constituents into the circulation

Potential causes:
- traumatic or muscle compression injury
- non-traumatic, exertional injury (extreme exertion in untrained individuals)
- non-traumatic, non-exertional injuries (drugs, infections or electrolyte disorders)

Presentations:
- creatine kinase (CK) levels that are markedly elevated and symptoms of muscle pain, weakness, and dark urine as a result of myoglobinuria.

Treatment:
- Managed in the hospital