Genitourinary 6% Flashcards
Benign prostatic hyperplasia
Enlargement of transitional zone.
Benign prostatic hyperplasia, diagnosis
PSA is often elevated; < 4 considered normal.
PSA > 4 think BPH, prostate CA and prostatitis.
Benign prostatic hyperplasia, treatment
Symptomatic: Alpha blocker (Tamsulosin = Flomax).
Decrease prostate size: 5 alpha reductase inhibitors (Finasteride = Proscar).
Definitive: TURP
Congenital abnormalities
Vesicoureteral reflux (VUR) - retrograde passage of urine from the bladder back into the ureter and collecting system - diagnosed with a Voiding CystoUrethroGram (VCUG). Hypospadias and Epispadias urethra opens onto the underside/topside of the penile shaft.
Cryptorchidism
A condition in which one or both of the testes fail to descend from the abdomen into the scrotum.
If still non-palpable at 6 mo well-child exam, refer to urology/surgery for evaluation and possible orchiopexy.
↑ Risk in premature infants 30%.
If not repaired risks infertility and malignancy.
Treatment: Orchiopexy by age 1.
Erectile dysfunction
The most common vascular cause is atherosclerosis. Consider psychological cause.
Nocturnal penile tumescence used to evaluate sleep erections.
Phosphodiesterase 5 inhibitors Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra).
Do not use with nitrates may cause hypotension.
Hydrocele/varicocele
Hydrocele: On physical exam mass will transilluminate. Varicocele: Dilation of the pampiniform plexus. Bag of worms in scrotum (made worse when patient is upright and improves when patient is supine). More common on left.
Incontinence, Stress
Urine leakage due to abrupt increases in intra-abdominal pressure (eg, with coughing, sneezing, laughing, bending, or lifting).
Treatment: strengthen pelvic floor or surgery.
Incontinence, Urge
Results from an overactive detrusor muscle. Increased frequency. Vaginal delivery.
Treatment: Oxybutynin
Incontinence, Overflow
Cannot empty bladder, just leaks. High PVR.
Treatment: Self catheterization.
Incontinence, Functional
Mobility issue .
Incontinence, Mixed
Combo of stress and urge; most common.
Nephrolithiasis/urolithiasis, symptoms
Flank pain radiating to groin, hematuria, CVA tenderness.
Nephrolithiasis/urolithiasis, types
Calcium oxalate (80%): Most common, excess oxalate, hyperparathyroidism, radiopaque.
Struvite (10%): Associated with UTI with Klebsiella and Proteus species, radiopaque.
Uric Acid (7%): Excess meat/alcohol, gout, radiolucent.
Cystine (1%): Rare genetic, radiolucent.
Nephrolithiasis/urolithiasis, treatment
Lithotripsy: Stones > 1 cm unlikely to pass. Lithotripsy is indicated in patients with stones > 6 mm in size or intractable pain.
Hydration: Stones < 5 mm likely to pass.
Paraphimosis
Inability to return foreskin to normal position causes tourniquet effect, is a medical emergency.
Entrapment of the foreskin behind glans.
More acute than phimosis.
Phimosis
Inability to retract the foreskin, usually resolves by age 5, betamethasone topically, if no improvement circumcision.
Unable to retract foreskin.
More chronic than paraphimosis.
Testicular torsion
Teenage males.
Asymmetric high riding testicle; “bell clapper deformity”.
Testicular torsion, symptoms; signs
Very tender to palpation. Cremaster reflex absent.
Prehn’s sign: negative (lifting of testicle will not relieve pain).
Blue dot sign: Tender nodule 2 to 3 mm in diameter on the upper pole of the testicle.
Testicular torsion, diagnosis; treatment
Radionuclide study and ultrasound.
Surgical emergency: Repair both testes within 4-6 hours.
Cystitis
Infection of the bladder and is characterized by dysuria without urethral discharge.
E. coli (most common).
Cystitis, treatment
Nitrofurantoin (Macrobid) (not over age 65), Bactrim, Fosfomycin.
Ciprofloxacin- reserved for complicated cases.
Cystitis, Postcoital UTI, treatment
Single-dose TMP-SMX or cephalexin (Keflex) may reduce frequency of UTI in sexually active women.
Cystitis, Lower UTI in pregnancy, treatment
Nitrofurantoin (Macrobid): 100 mg PO BID × 7 days
Cephalexin (Keflex): 500 mg PO BID × 7 days
Epididymitis, presentation
Epididymitis is characterized by dysuria, unilateral scrotal pain and swelling.
+ Prehn’s sign: relief with elevation is a classic sign.
Epididymitis, etiology; treatment
< 35yo chlamydia and gonorrhea;
Doxycycline 100mg PO BID for 10 days + Ceftriaxone 250 mg IM × 1.
> 35yo E.coli;
Levofloxacin x 10 days.
Orchitis, presentation
Unilateral swollen testicle with erythema and shininess of the overlying skin. Orchitis is rarely seen without epididymitis unless patient has mumps.
25 % are associated with MUMPS
Orchitis, etiology; treatment
<35: Gonorrhea and chlamydia;
Ceftriaxone + doxycycline/azithromycin.
> 35: E. coli;
Levofloxacin.
Prostatitis, presentation
Sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency and dysuria.
Prostatitis, etiology; treatment
< 35: Chlamydia and Gonorrhea;
ceftriaxone and azithromycin (or Doxycycline).
> 35 - E. coli;
Fluoroquinolones or bactrim x 1 month
If you suspect acute prostatitis DO NOT massage the prostate this can lead to sepsis
Prostatitis, Chronic prostatitis, treatment
Fluoroquinolones or bactrim x 6-12 weeks.
Pyelonephritis, presentation
Irritative voiding, fever, flank pain, nausea and vomiting, CVA tenderness.
Pyelonephritis, diagnosis; etiology; treatment
Urinalysis: Bacteria and WBC casts.
E. coli.
Outpatient: ciprofloxacin/levofloxacin +/- ceftriaxone IM.
Inpatient: Ciprofloxacin/levofloxacin or imipenem for more severe disease.
Urethritis, symptoms
Dysuria and,
primarily in men, urethral discharge.
Urethritis, diagnosis; etiology
Nucleic Acid Amplification Test (NAAT)
N. gonorrhoeae (gram negative diplococci) and C. trachomatis.
Urethritis, treatment
Ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infection PLUS Azithromycin (1 gram in a single oral dose) for possible additional activity against N. gonorrhoeae and for treatment of potential chlamydia coinfection.
Doxycycline (100 mg orally twice daily for seven days) is an alternate option for a second agent to administer with ceftriaxone.
Bladder cancer
Painless hematuria in a smoker, transitional cell carcinoma is the most common type.
Prostate cancer, findings
Most common area: Peripheral zone.
Digital Rectal Exam: hard, irregular, nodular prostate.
Tumor marker: PSA (also elevated in BPH).
PSA is considered normal < 4.
PSA > 4 think BPH, prostate CA and prostatitis.
Prostate cancer, screening
Annual prostate screening:
White male average risk: 50 years old.
Black male + Family History or + BRCA mutations: 40 years old.
Renal cell carcinoma, presentation
Classic triad of flank pain + hematuria + painless abdominal/renal mass.
Smoking is the most significant risk factor.
Renal cell carcinoma, etiology
Renal clear cell carcinoma is the most common type (80%).
Transitional cell is the second most common type (20%)
Testicular cancer, presentation
Presents as a firm, painless, non tender testicular mass.
Risk factors include history of cryptorchidism.
Testicular cancer, etiology
Seminoma is the most common type (60%).
Testicular cancer, diagnosis
Diagnostic studies: Initial-Ultrasound.
Tumor markers: AFP, βHCG.
Wilms tumor
Child with painless, unilateral abdominal mass with no other signs of symptoms, also known as nephroblastoma.
Acute renal failure, Acute Tubular Necrosis (ATN), Etiology
Kidney ischemia or toxins
Acute renal failure, Acute Tubular Necrosis (ATN), urinalysis; labs
Muddy brown casts. Renal tubular epithelial cells + high urine osmolality.
FENa > 2%.
Acute renal failure, interstitial nephritis, etiology
Immune-mediated response:
Drugs: PCN, sulfa, NSAIDs, phenytoin etc.
Immunologic and infectious disease: strep, SLE, CMV, Sjogren’s, Sarcoidosis.
Acute renal failure, interstitial nephritis, urinalysis
WBC casts and eosinophils
Acute renal failure, glomerulonephritis, etiology
IGA nephropathy (Berger disease), postinfectious, membranoproliferative.
Acute renal failure, glomerulonephritis, urinalysis
Oliguria, hematuria and RBC casts.
Chronic kidney disease
CKD is a progression of ongoing loss of kidney function (GFR) defined as < 60 mL/min/1.73 m² or presence of kidney damage (proteinuria, glomerulonephritis or structural damage from polycystic kidney disease) for > 3 months.
Chronic kidney disease, diagnosis
Measurement of GFR is the gold standard.
The Cockcroft - Gault formula (requires age, body weight, and serum creatinine) or
Modification of Diet in Renal Disease equation.
Chronic kidney disease, etiology
Diabetes, hypertension, glomerulonephritis
Chronic kidney disease, findings
Fatigue, pruritus, Kussmaul respirations, asterixis (flapping tremor), muscle wasting, broad waxy casts.
Glomerulonephritis (Nephritic Syndrome)
Immune-mediated glomerular inflammation results in glomerular damage which results in urinary protein and RBC loss.
Glomerulonephritis (Nephritic Syndrome), findings
Proteinuria, HTN, azotemia, oliguria (<400 ml urine/day), hematuria (RBC casts) hallmark, edema is not as much as nephrotic syndrome.
Glomerulonephritis (Nephritic Syndrome), diagnosis
Urinalysis: proteinuria < 3.5 grams per day, hematuria, RBC casts.
Biopsy: hypercellular, immune complex deposition.
Acute Glomerulonephritis (Nephritic Syndrome), etiologies
IgA Nephropathy (Berger disease).
Postinfectious.
Membranoproliferative glomerulonephritis.
Rapidly progressive glomerulonephritis (Nephritic Syndrome), findings; etiologies
Crescent formation on biopsy due to fibrin and plasma protein deposition.
Goodpasture’s syndrome.
Vasculitis.
Glomerulonephritis (Nephritic Syndrome), IgA Nephropathy (Berger disease)
Most common cause of acute glomerulonephritis worldwide - often affects young males within days (24-48 hours) after URI or GI infection.
Glomerulonephritis (Nephritic Syndrome), Postinfectious
Group A strep: 10-14 days after infection - diagnosed with ASO titers and low serum complement.
Glomerulonephritis (Nephritic Syndrome), membranoproliferative glomerulonephritis
Due to SLE, viral hepatitis.
Rapidly progressive glomerulonephritis (Nephritic Syndrome), due to Goodpasture’s syndrome
(+) anti-GBM antibodies, dx linear IgG deposits, treat with high dose steroids, plasmapheresis + cyclophosphamide.
Rapidly progressive glomerulonephritis (Nephritic Syndrome), due to vasculitis
Lack of immune deposits (+) ANCA antibodies.
Hydronephrosis
Urine outflow obstruction causes renal distention.
Treat underlying cause.
Nephrotic syndrome
Glomerular damage results in increased urinary protein loss.
Nephrotic syndrome, findings
Proteinuria, hypoalbuminemia, edema, hyperlipidemia, edema is predominant feature, transudative pleural effusion.
Nephrotic syndrome, diagnosis
Urinalysis: proteinuria >3.5 grams on 24-hour urine, fatty casts, oval fat bodies.
Biopsy: hypo-cellular minimal change disease loss of podocytes on microscopy.
Nephrotic syndrome, most common primary causes
Membranous nephropathy.
Minimal change disease.
Focal segmental glomerulosclerosis.
Nephrotic syndrome, membranous nephropathy
Most common in non-diabetic adults associated with malignancies.
Nephrotic syndrome, minimal change disease
80% of nephrotic syndrome in kids. Responds to corticosteroids.
Nephrotic syndrome, focal segmental glomerulosclerosis
Obese patients, heroin, and HIV black males.
Nephrotic syndrome, most common secondary causes
Lupus
Diabetes.
Preeclampsia.
Nephrotic syndrome, lupus
Both nephritic and nephrotic.
Nephrotic syndrome, diabetes
Common cause of nephrotic syndrome and subsequent renal failure.
Polycystic kidney disease
Autosomal dominant genetic disorder presents as back and flank pain. Associated with cerebral aneurysms.
Polycystic kidney disease, diagnosis; treatment
Ultrasound will demonstrate many fluid-filled cysts.
No cure, treatment is supportive; BP control.
Renal vascular disease
Narrowing of one or both of the renal arteries, most often caused by atherosclerosis or fibromuscular dysplasia.
Renal vascular disease, diagnosis
May hear a renal artery bruit on auscultation.
Renal Arteriography is Gold Standard for diagnosis.
Renal vascular disease, treatment
Percutaneous transluminal angioplasty (PTA) plus stent placement or surgical bypass of the stenotic segment.
Hyponatremia, defined; presentation
Serum sodium of < 135 mmol/L.
Muscle cramps and seizures.
Hypervolemic hyponatremia
CHF, nephrotic syndrome, renal failure, cirrhosis, water excess.
Euvolemic hyponatremia
SIADH, steroids, hypothyroid.
Hypovolemic hyponatremia
Sodium loss (renal, non-renal).
Hyponatremia, treatment
Serum Na should be corrected slowly—by ≤ 10 mEq/L over 24 h to avoid osmotic demyelination syndrome.
Hypernatremia
Serum sodium of > 145 mmol/L.
Hypernatremia, etiologies
Diarrhea, burns, diuretics, hyperglycemia, deficit of thirst, hypovolemia, diabetes insipidus.
Hypernatremia, treatment
Rapid overcorrection causes cerebral edema and pontine herniation.
Hypernatremia, due to diabetes insipidus
Low urine sodium (but high serum sodium) and polyuria usually indicate diabetes insipidus.
Acid/Base values
Average values “24/7 40/40”
24 (HCO3, base) / 7.40 (pH) / 40 (CO2, acid)
Respiratory Acidosis
pH < 7.35, pCO2 > 45, HCO3 > 26
Lungs fail to excrete CO2.
Breathing too slow (holding onto CO2), pulmonary disease, neuromuscular disease, drug-induced hypoventilation - opiates, barbiturates.
Respiratory Alkalosis
pH > 7.45, pCO2 < 35, HCO3 < 22
Excessive elimination of CO2.
Breathing too fast (blowing off CO2), pulmonary embolism, fever, hyperthyroid, anxiety, salicylate intoxication, septicemia.
Metabolic Acidosis
pH <7.35, pCO2 < 35, HCO3 < 22
Need to calculate anion gap: Anion Gap = Na – (Cl + HCO3-) = 10-16
Increased ion gap (>16): Addition of hydrogen ions (lactic acidosis (think metformin), diabetic ketoacidosis, aspirin overdose).
Metabolic Acidosis, increased ion gap (>16), etiologies
Methanol Uremia Diabetic Ketoacidosis Paraldehyde Infection Lactic Acidosis Ethylene Glycol Salicylates
Respiratory Alkalosis, low anion gap (<16), etiologies
Loss of bicarbonate (diarrhea, pancreatic or biliary drainage, renal tubular acidosis).
Metabolic Alkalosis
pH > 7.45, pCO2 > 45, HCO3 > 26
Loss of hydrogen (vomiting), bulimia, overdose of antacids, addition of bicarbonate (hyperalimentation therapy).
