Genitourinary Flashcards
acute kidney injury (AKI) - definition, risk factors
note: good summary table on side 14 of PPT
sudden dec. in renal fx (GFR) which causes build up of nitrogenous waste (uric acid)
- over hrs to days
- severity based on inc. in BUN and Cr and reduction of urine output (oliguria)
- can be pre-renal, intrinsic, or post-renal
risk factors:
- age, heart and liver dz
- exposure to nephrotoxins
- surgery, sepsis, vol. depletion
important nephrotoxins
IV contrast dye ACE-I and ARBs Loop and thiazide diuretics lithium NSAIDs statins some ABX
acute kidney injury (AKI) - sxs, dx
sxs: vary depending on cause
- +/- oliguria
- change in urine color
- N/V, malaise, abd pain, itching
dx:
- BUN/Cr ratio rises
- image/biopsy may be done
acute kidney injury (AKI) - pre-renal causes and tx
Pre-renal (most common):
- vol. depletion: dehydration, blood loss
- dec. effective circulating vol: CHF, ascites, nephrotic syndrome
- impaired renal blood flow: ACEIs, NSIADS, renal artery stenosis
- systemic vasodilation: sepsis
Tx: treat cause, maintain euvolumia, check K+
acute kidney injury (AKI) - intrinsic causes (3)
- acute tubular necrosis
- ischemia
- endogenous nephrotoxins: rhabdomyolysis, hemolysis
- exogenous nephrotoxins: amphotericin B, contrast dye
- sepsis/infection - interstitial nephritis
- drugs: Penicillin, cephalosporins, sulfa, NSAIDs - glomerularnephritis
- IgA nephropathy
- post strep (antibody against strep antigen that settled in kidney)
- Good pastures (antibody against basement membranes of kidney and lung
- HUS: hemolytic uremic syndrome (E. Coli)
acute kidney injury (AKI) - post-renal causes and tx
Post-renal (think obstruction; least common):
- BPH
- nephrolithiasis (bilateral)
- bladder outlet syndrome
tx: catheterization or stent
acute tubular necrosis - causes, dx, tx
most common intrinsic cause of AKI
causes:
- ischemia
- endogenous nephrotoxins: rhabdomyolysis, hemolysis
- exogenous nephrotoxins: amphotericin B, contrast dye
- sepsis/infection
dx:
- U/A: “muddy brown sediment” and granular casts
- Labs: hyperkalemia, high phase, FeNa>1, BUN:Cr<20:1
tx:
- remove toxin or tx cause to prevent further kidney injury!
- loop diuretic, correct electrolytes
- dialysis if needed
- low protein diet
interstitial nephritis - causes (drugs), sxs, dx, tx
inflammation of renal tubules and interstitial
- intrinsic cause of AKI
causes:
- DRUGS: Penicillin, cephalosporins, sulfa, NSAIDs
- infection: strep, CMV
- immune d/c: sarcoid, SLE (Lupus)
sxs: fever, maculopapular rash
dx:
- U/A: WBC casts, eosinophils
- CBC: peripheral blood eosinophils
Note: this is a hypersensitivity reaction to drug… why we see eosinophils
tx:
- address underlying cause
- urgent dialysis
glomerulonephritis - causes (many)
Note: only intrinsic cause list out on blueprint!
inflammatory lesions of glomerulus from immune complex deposition or development of antibodies against glomerulus
- intrinsic cause of AKI
causes:
- IgA nephropathy (aka Berger dz): assoc. w/ URI sxs, gastroenteritis; hematuria
- Post strep (immune complex deposition): occurs 2-6 wks post-impetigo and 1-3 wks post-strep pharyngitis; +ASO, inc. C3; steroids NOT helpful
- Good pastures: autoantibodies against basement membrane; tx is plasma exchange
- HUS (hemolytic uremic syndrome): uremia, low platelets, hemolytic anemia
glomerulonephritis - sxs, dx, tx
Note: only intrinsic cause list out on blueprint!
sxs:
- related to underlying cause
- hematuria, HTN and edema (periorbital and scrotal edema), flank pain
dx:
- U/A: tea or coca-cola colored urine w/ red cell casts
tx:
- treat underlying cause
- high dose corticosteroids (except if post-strep)
AKI - what medical calculation can help you determine cause?
FeNa
FeUrea - can be used on patients on diuretics
chronic renal failure - definition, sxs
destruction of nephrons leading to progressive decline in kidney fx
- common (1 in 9 adults)
- often with other chronic diseases
- most people die of other cause (CVD) and not ESRD
sxs:
- HTN (#1 sx)
- uremic syndrome
uremic syndrome
build-up of metabolic wastes w/ advanced chronic kidney dz
sxs:
- urinary changes
- fatigue, dec. appetite, pruritus, edema, SOB
chronic renal failure - dx, tx, prevention
Dx:
- renal fx: inc. BUN/Cr, inc. Cr, dec. GFR (< 60 for 3+ mo)
- hyper K, metabolic acidosis, proteinuria, etc.
tx:
- diet: protein restriction, also salt, water, potassium, and phosphate restriction
- dialysis or transplant
Prevent:
- treat HTN: ACE-I or ARB
chronic renal failure - stages
based on GFR
1: normal, but evidence of kidney dz; GFR 90+
2: mild; GFR 60-89
3: moderate: GFR 30-59
4: severe; GFR 15-29
5: failure (ESRD); GFR<15 (on hemodyalysis)
hydronephrosis - definition and cuases
distention of renal calyces and pelvis of kidney(s) by urine
- is the result of urinary blockage anywhere along urinary tract
- will see dec. GFR if bilateral
causes:
- BPH
- VUR
- nephrolithiasis (esp. at ureteropelvic jx)
- pregnancy
- large fibroids
- neurogenic bladder
hydronephrosis - sxs, dx, tx
sxs:
- pain, sxs related to cause
dx: U/S
- can also use IV urogram or CT
tx: treat cause!
- catheter for BPH
- anticholinergics for neurogenic bladder
- emergent stenting or nephrostomy for infection
nephrotic syndrome - definition, causes, sxs
increased permeability of glomerular capillary walls that allows passage of large amounts of protein into urine
- proteinuria + hypoalbuminemia + edema
Primary causes:
- minimal change dz
- focal glomerulosclerosis
- membranous nephropathy
- menbranous proliferative nephropathy (MPGN)
Secondary causes:
- DM
- amyloidosis
sxs:
- edema: periorbital and scrotal (also feet and ankles)
- pleural effusion: SOB
nephrotic syndrome - dx, management
Dx:
- proteinuria > 3g/day
- oval fat bodies: lipid passed into urine, as well (maltese crosses are signs of oval fat bodies under microscope)
Manage:
- diet: low protein, salt restriction
- tx hyperlipidemia and hypercoaguability
- diuretics (thiazide, loop) and ACE-I
polycystic kidney disease - definition, sxs, dx
genetic, cystic d/o of the kidneys often resulting in massive enlargement
- MOST common hereditary dz in US
sxs:
- present in 30-40’s; ESRD by age 60
- hematuria + abd/flank pain + 2ndary HTN
- large, palpable kidneys
- frequent UTIs and nephrolithiasis
dx:
- U/S for screening
- CT or MRI give anatomic details
polycystic kidney disease - complications, management
complications:
- pain from cyst and rupture
- renal infection
- nephrolithiasis
- HTN: must tx aggressively!
- cerebral aneurysms
- MVP (mitral valve prolapse)
- cysts in other locations
Management:
- treat complications
- aspirate cysts
- treat HTN aggressively
- VASOPRESSIN receptor antagonist delays ESRD
- renal transplant
renal artery stenosis
narrowing of 1 or both renal arteries
sxs:
- HTN onset <20 or >50 y/o
- HTN resistant to meds
- renal bruits
dx:
- U/S: screening
- renal arteriography: gold standard
tx:
- renal artery angioplasty +/- stent
- antihypertensives
renal vein thrombosis - definition, causes, sxs, dx, tx
acute or chronic thrombosis of renal vein
causes:
- Kids: severe dehydration
- Adults: infection, ascending thrombosis of vena cava, clotting d/o
sxs:
- flank pain
- palpable kidney
- nephrotic syndrome if bilateral
dx:
- renal U/S
- renal venography
tx:
- eliminate cause
- anticoagulation or thrombolytic therapy
Acid-Base Basics
acid-base balance is coordinated by lungs and kidneys to keep optimal pH
- goal pH: 7.35-7.45
- lungs regulate pCO2
- kidneys regulate HCO3-
Note: when one system fails, the other tries to compensate to bring back balance
acidosis
results when pH is too low (<7.35)
- pCO2 is HIGH (>40)
- HCO3 is LOW (<24)
Note: think of CO2 as Hydrogen
alkalosis
results when pH is too high (>7.45)
- HCO3- is HIGH (>24)
- pCO2 is LOW (<40)
acid-base question: approach
- identify if you have an acidic or basic state
- acidic: pH<7.35
- basic: pH>7.35 - identify if it is metabolic (HCO3-) or respiratory (pCO2) underlying the cause
- Consider underlying cause and correct
metabolic acidosis (w/ elevated anion gap) - causes
low pH, low HCO3-
anion gap > 16
causes: MUDPILERS
M: methanol U: uremia D: DKA P: propylene glycol, acetaminophen, I: iron, isoniazid (due to seizures), inborn errors of metabolism L: lactic acidosis E: ethanol (due to lactic acidosis), ethylene glycol R: rhabdomyolysis S: salicylates/ASA/Aspirin
anion gap
positive ions minus negative ions
anion gap = Na+ - (HCO3- + Cl-)
normal: 8-16 mEqu
metabolic acidosis (w/ normal anion gap) - causes
low pH, low HCO3-
anion gap b/t 8-16
causes:
- dec. bicarb with diarrhea
metabolic acidosis - what is compensation
increased ventilation to blow off CO2
- can get Kussmaul breathing
metabolic alkalosis - causes, compensation, other s/sx, tx
high pH, high HCO3-
causes: loss of H+ or excess HCO3-
- vomiting, suction gastric contents
- diuretics
- overcorrect metabolic acidosis
compensation: decreased ventilation (inc. pCO2)
other s/sx:
- hypocalcemia: paresthesias, confusion, coma
- hypokalemia: polyuria, polydipsia, weakness
tx: fix underlying cause, IV fluids
respiratory acidosis - causes, compensation, tx
low pH, high CO2
causes: anything that dec. respirations (COPD, narcotics OD)
compensation: inc. reabsorption of HCO3- by kidneys
tx:
- fix underlying cause, assist ventilation, naloxone (if all else fails)
respiratory alkalosis - causes, s/sx, compensation, tx
high pH, low CO2
causes: anything that inc. respirations and blows off too much CO2
- hysterical hyperventilation
- salicylate intoxication
- pulmonary embolism
s/sx: rapid breathing, lightheadedness
compensation: inc. elimination of HCO3- by kidneys
tx: underlying cause
hyponatremia - 1st step, s/sx
serum sodium <135
- can be due to excess total body water
s/sx: N/V, weakness, HA, dec. DTRs, delirium, coma
Must 1st determine volume status (hypo-, eu-, hyper volemic)
hyponatremia (hypovolemic): causes, sx, results of UA, tx
water and Na+ are lost; causes ADH to be released (for water retention)
causes: vomiting, diarrhea, diuretic use, Addisons dz
sx: dehydrated
UA: urine Na is LOW
tx: volume replacement to suppress ADH
hyponatremia (euvolemic): causes, sx, results of UA, tx
causes: SIADH (kidney conserves too much H2O), hypothyroidism, psychogenic polydipsia
sx: NO vol. overload
UA: urine sodium is HIGH
Tx: water restrict, correct cause
hyponatremia (hypervolemic): causes, sx, results of UA, tx
inc. extracellular water compared to Na+
causes: cirrhosis, CHF, nephrotic syndrome, renal failure
sx: edema, vol. OL
UA: urine Na LOW
tx: water restrict, diuretics
hyponatremia (hypertonic) - definition, cause, tx/correction
hypertonic: excess extracellular solute creates gradient so water moves out of cells
cause: hyperglycemia (most common)
tx: hypertonic saline
- BE CAREFUL - do not correct Na too rapidly = Central Pontine Myelinolysis
hypernatremia
serum Na >145
- can be due to low total body water
causes:
- impaired thirst mechanism, lack of access to water
- diabetes insipidus
s/sx: dehydration, hyperthermia, delirium, coma
tx: volume replace and rehydrate
- BE CAREFUL - do not dec Na too rapidly = cerebral edema (neuro impairment)
SIADH
syndrome of inappropriate secretion of ADH - leading to water retention
causes: MANY (CVA, trauma, infections, cancers, pneumonia, drugs and meds)
s/sx: hyponatremia
dx: diagnosis of exclusion
tx: fluid restrict, furosemide, tx cause
hypokalemia: causes, s/sx, EKG changes, tx
serum K < 3.5 (severe: <2.5)
causes:
- diarrhea (most common)
- vomiting, diuretics
s/sx: weakness, fatigue, muscle
- may cause arrhythmias
EKG: flattened or inverted T waves, U waves, frequent PVCs
Tx: oral or IV replacement
- monitor EKG
Recall: hypo K means hypo Mag
hyperkalemia: causes, s/sx, EKG changes, tx
serum K >5 (sever: >6.5)
causes:
- end stage renal dz (#1) - kidneys can’t excrete
- drugs: spirinolactone (K sparing diuretics), NSAIDs, ACE, ARBs
- burns, rhabdo
- lab erros
s/sx: muscle wekaness, hyperreflexia, flaccid paralysis
- life threatening arrhythmias (V-Fib –> death)
EKG: peaked T-waves, widened QRS, sine waves, death
tx: repeat lab
- stabilize heart: calcium gluconate
- drive K+ back into cells (insulin, albuterol, sodium bicarb)
- excrete K: kayexalate (stool), furosemide (urine) hemodialysis
hypocalcemia: causes, s/sx, EKG changes, tx
- recall: bound to albumin so much check ionized Ca to be sure not result of low albumin
serum Ca++ <8.5
- lowers neuromuscular and CV excitation thresholds (more sensitive to stimulation)
causes:
- chronic kidney dz (#1)
- hypoparathyroidism, hypoalbuminemia, vit D deficiency
s/sx:
- muscle cramping, inc. DTRs
- Chvostek sign: facial muscles contract when facial nerve tapped
- Trousseau sign: carpal spasm when BP cuff inflate for 3 min
EKG: prolonged QT –> ventricular arrhythmias
tx: oral of IV Ca++; replace Mg as needed
hypercalcemia
serum Ca++ > 10.5
- increases neuromuscular and CV excitation thresholds (less sensitive to stimulation)
causes:
- hyperparathyroidism (anything that makes high PTH)
s/sx: anorexia, constipation, polyuria, dehydration (only if >12)
EKG: shortened QT intervals
Tx: IV fluids, loop diuretics
hypomagnesemia: which patients, causes, s/sx, EKG tx
serum mag <1.5
patients: hospitalized, ICU
causes:
- chronic ETOH
- chronic diarrhea
- hypo PTH
- hyperaldosteronism
- diuretics, malnutrition
s/sx:
- can lead to hypo K and hypo Ca++
EKG: long QT leading to arrhythmia (TORSADES)
Tx: oral, IM, IV Mag
- monitor EKG
hypermagnesemia: what population does this occur in
rare - except in CKD patients
nephrolithiasis: definition, risk factors, s/sx
saturation of urine w stone-forming salts causes precipitation of crystals
risk factors:
- male, 3rd or 4th decade
- drugs: antacids, carbonic anhydrase inhibitors, loop diuretics, vit. C
- hyperparathyroidism
- diets high in oxalate-rich foods (leafy veggies, nuts, tea/coffee)
- diets high in purines
s/sx:
- SEVERE flank pain (radiates to abdomen or groin)
- hematuria, frequency, urgency, N/V
nephrolithiasis: dx, tx, prevention
Dx:
- imaging: spiral CT (gold standard); KUB (x-ray) helps to track stones
- U/A (culture), CBC, electrolytes
Tx:
- PAIN CONTROL: NSAIDs are best)
- Management depends on stone size and location
- <5mm: passable; 5-10mm (likely to pass), >10mm: admit for stent, nephrostomy, lithotripsy
Prevention:
- inc. FLUIDS, diet changes, tx underlying cause
nephrolithiasis: types of stones
calcium: most common (85%)
- radio-opaque
struvite: 15%
- assoc. w/ infections, staghorn
- urine pH<7.2
- ABX do not penetrate staghorn, so inc. risk of urosepsis (may ned surgery)
uric acid: 8%
- radiolucent (not seen on KUB)
- urine pH<5.5
cystine: <1%
- hereditary condition
urinary incontinence: definition, general categories of causes
NOT normal with aging
- women>men
can be caused by issues within and outside urinary tract
urinary incontinence: causes outside urinary tract
Outside: DIAPPERS (r/o first) D: delirium I: infection A: atrophic urethritis P: pharmaceuticals (alpha and beta blockers, diuretics, alcohol, anti-psych, narcotics) P: psychiatric illness E: excessive urinary output (hyperglycemia, CHF) R: restricted mobility S: stool impaction
urinary incontinence: 4 types of pathology within urinary tract
- Urge: “gotta go now”
- caused by overactive bladder
- most common in elderly
- tx: bladder training is 1st choice; Oxybutinin - Stress: due to inc. abdominal pressure / dysfx of urethral sphincter
- adult women
- leak w/ cough, sneeze, valsalva
- tx: Kegels - Overflow: due to outlet obstruction –> distention –> overflow
- leakage from BPH
- dx using post-void residual (large)
- tx: relieve obstruction w/ cath or foley - Functional: urine system is normal, but cannot get to bathroom in time (immobility, cognitive problem)
benign prostatic hyperplasia (BPH): pathophysiology, s/sx
increase in # of cells in prostate which surrounds urethra
pathophys:
- dihydrotestosterone causes hyperplasia and age increases sensitivity to DHT
- >90% of men over 80
s/sx:
- obstructive sxs: hesitancy, weak flow
- irritative sxs: frequency, urgency nocturia
- DRE: smooth, enlarged prostate
BPH: dx and tx
Dx: R/O other cases (UA, PSA, creatinine, post void residual, flow rate, cystoscopy)
Tx:
- watchful wait if very minor
- alpha blockers (tamulosin, doxazosin, terazosin): relaxes smooth muscle
- 5alpha reductase inhibitors (finasteride, dutasteride): block formation of DHT
- NOTE: these reduce PSA by 50% - Surgery:
- TURP, TUIP, TUNA, TUMT, prostatectomay
erectile dysfunction: definition, causes, dx, management
inability to attain or maintain erection
- >50% men 40-70 y/o
causes:
- medical conditions: DM, HTN, androgen deficiency, CAD, high chol
- surgery: complications of tx for prostate cancer
- drugs: alpha and beta blockers, diuretics, tobacco, ETOH
dx: good H&P; labs to r/o contributing conditions
tx:
- treat underlying cause / limit risk factors
- vasoactive therapy: oral PDE-5 inhibitors (sildenafil / Viagra); - Note: NEVER with nitro (severe hypotention)
priapism: causes, tx
painful, persistent erection lasting > 4 hours
- can lead to permanent penile necrosis!
causes:
- medical conditions: sickle cell dz, leukemia, multiple myeloma
- medications: anti-psychotics, sildenafil (rare)
- illicit drugs: cocaine, ecstasy
tx:
- terbutaline, if fails…
- aspiration of corpus cavernosum
peyronie’s: definition, cause, tx
fibrotic plaque of tunica albuginea leading to penile curvature
cause: unclear, repeat trauma (occurs in men >40)
tx:
- intra-plaque injection of Verapamil or interferon
- Surgery to remove plaque (NO guarantee of normal fx)
foreskin conditions - 3 main ones
balanitis
phimosis
paraphimosis
balanitis: definition, cause, tx
swelling of foreskin and glans penis
causes:
- poor hygiene
- more likely if uncircumcised
- can be fungal in DM
tx:
- kids: none (hygiene)
- adults: topical steroids or antifungals
phimosis: definition, cause, tx
foreskin unable to be retracted over glans penis
cause:
- kids: physiologic (no intervention)
- adults: chronic low grade infection (Lichen sclerosis)
tx:
- betamethazone cream
- stretch foreskin
- circumcision
paraphimosis: definition, cause, tx
foreskin trapped in retracted position
- edema, compromised blood supply
- can cause necrosis > EMERGENCY
cause:
- long-term foley
tx:
- manual reduction
- emergent dorsal slit
hypospadias: definition and tx
congenital abnormality when urethral meatus is ventral and proximal to normal position
tx: repair b/f 18 months
note: if hypospadias + bilateral cryptorchidism = think sex hormone abnormality
chordee: definition and tx
congenital abnormality resulting in ventral penile curvature, often associated with hypospadias
tx: surery 6-18 months
vesicoureteral reflux (VUR): definition, population, dx, tx, complication
congenital abnormality when urine passes retrograde from bladder to kidneys during voiding
- results from incompetent vesicoureteral sphincter
population: child with recurrent UTIs
dx: IVP (intravenous pyelogram), renal U/S, radionuclide cystogram, voiding cystourethrogram
tx:
- tx HTN (ACE-I)
- ABX for frequent urine cx
- surgery for severe reflux
complication:
- renal nephropathy: scarring associated w/ intra-renal reflux of infected urine
- can lead to HTN
cryptorchidism: definition, risks, PE, tx
congenital abnormality when testicle fails to descend from abdomen into scrotum
- normally, descent at 7 mo gestation but can get caught in inguinal ring
risks: premature, low birth weight, MOC exposure to estrogens in 1st trimester, FH
PE:
- empty hemiscrotum/absence of scrotal rugae
- must confirm not just retracted (pulled up into pubic area but can be “milked” into scrotum) - resolves by puberty w/o tx
tx:
- hCG IM daily for 3 days (25% will descend)
- surgical correction by 1 y/o (inc. in testicular cancer and infertility if not)
hydrocele: definition, tx
accumulation of serous fluid in membranes around testicle (not fluid in scrotum)
- benign and painless
- must transilluminate testicles
- no tx required
varicocele
varicosities in scrotum that feel like “bag of worms”
- may be achy
- increases with valsalva; dec. when supine
- rarely tx unless effecting fertility
testicular torsion: definition, clinical features, s/sx
testis rotates on spermatic cord causing vascular occlusion
clinical:
- 10-20 y/o males
- bell clapper deformity (testes not anchored)
s/sx:
- SUDDEN, SEVERE testicular pain, N/V
- neg. Phren’s sign: NO relief w/ elevation
- neg. cremasteric reflex: NO retraction of ipsilateral testis when medial tight is stroked
testicular torsion: Ddx, imaging, tx
Ddx:
- epididymitis (less acute, + Phren’s sign, + cremasteric reflex)
Image:
- doppler U/S shows dec. arterial flow
Tx:
- SURGICAL EMERGENCY!
- surgery in 4-6 hrs to save testicle
- manual detorsion: in to out (open book)
epididymitis: definition, pathogens, s/sx, dx, tx
infection of epididymis
- most common cause of adult scrotal pain
pathogens:
- < 35 y/o sexually active = GC/CT
- not sexually active (young or older): E. Coli (uropathogens)
s/sx:
- gradual, severe, unilateral scrotal pain
- scrotal inflammation, redness
- urethral D/C and irritative voiding sx possible
- Phren’s sign
- Cremasteric reflex
Dx: doppler U/S to r/o torsion
- labs: U/A, GC/CT, CBC
tx:
- bed rest, scrotal elevation, tight briefs, NSAIDS
- if E. Coli: Ofloxacin or Levofloxin ABX
- If STD: Ceftriaxone IM + Doxycycline for 10 days (cover for both GC and CT)
- treat partner!
orchitis: defintion, s/sx, tx, complications, prevention
inflammation of one or both testes
- associated with MUMPS
- can also be spread of epididymitis
s/sx:
- 1 week after onset of parotitis
- marked pain and swelling in 1 or both testes (large, tender, indurated)
- N/V, fever, urinary sxs
tx:
- bed rest, scrotal support, ice, analgesics
- ABX if due to epididymitis
complications:
- 1/2 develop testicular atrophy; 20% infertile
- abscess and chronic epididymitis
prevention: vaccine (MMR)!!
urethritis: causes, s/sx, dx, tx, complications
inflammation of urethra
- usually infectious cause (GC/CT)
s/sx:
- urethral d/c (purulent), dysuria
- may be asymptomatic
dx: urine or urethral swab for gram stain or PCR
tx: MUST treat BOTH GC and CT
- ceftriaxone IM + azithromycin (PO)
- ceftriaxone IM + doxycycline x 7 days
complications:
- men: epididymitis, disseminated GC infection, reactive arthritis
- women: PID, ectopic preg, infertility
cystitis: pathogen, s/sx, dx, tx (in pregnancy)
infection of bladder
- ascending infection, more common in women
pathogen: E. Coli
s/sx: dysuria, frequency, urgency, hematuria
- low back pain, public pain, malaise
Dx:
- clean catch U/A (w/ cx)
- urologic w/up if recurrent
tx: ABX for 3-7 days
- TMP/SMX, quinolones (cipro and levaquin), nitrofurantoin (only active in urinary tract)
Note: nitrofurantoin in pregnancy!
pyelonephritis: pathogen, s/sx, dx, tx
renal inflammation
pathogens: E/ Coli (most common)
s/sx:
- irritative voiding sx
- fever, chills, flank pain and CVA tenderness, N/V
- can develop sepsis!
dx:
- U/A: nitrites, WBC, RBC, WBC casts
- urine cx
- CBC: leukocytosis
- imaging: only if obstruction suspected
tx:
- Uncomplicated: oral ABX x 14 days (Cipro or quinolone)
- Admit: elderly, pregnant, etc. - IV ampicillin + aminoglycoside
prostatitis - 4 types
inflammation of prostate
- acute bacteria prostatitis
- chronic bacterial prostatitis
- non-bacterial prostatitis (chronic pelvic pain syndrome)
- prostatodynia
- condition of normal prostate with no abnormal labs
- thought to be due to musculature or spasm
acute bacterial prostatitis: pathogen, s/sx, what to avoid, dx. tx
pathogen: E. Coli
s/sx:
- perianal pain
- toxic appearing, fever, chills, body aches
DO NOT DO DRE - can become septic!
dx:
- fever, +U/A, + urine cx, DO NOT DO prostatic secretions
tx:
- 4-6 WEEKS TMP/SMX or fluoroquinolone
- analgesia, fluids, rest
chronic bacterial prostatitis: pathogen, s/sx, what to avoid, dx. tx
recurrent infection of prostate
Pathogen: usually gram neg rods (E. Coli)
s/sx: milder than acute, not systemic
- irritative voiding
- low back and perineal pain
- DRE: boggy and tender
dx:
- no fever, neg. U/A, positive urine cx, prostatic secretions w/ inc. WBCs
Tx (>50% relapse):
- TMP/SMZ, quinolones x 6-12 WEEKS
- NSAIDs, alpha-blockers, sitz baths
nonbacterial prostatitis (CPPS: chronic pelvic pain syndrome): definition, s/sx, dx, tx
sxs of chronic prostatitis w/o infection
s/sx:
- chronic pelvic pain (wax and wane)
- can be inflammatory or non inflammatory
- cause unknown / dx of exclusion
- NO hx of acute bacterial prostatitis
dx:
- no fever, neg. U/A, neg. urine cx, may have WBC in prostatic secretions if inflammatory
tx:
- ABX usually tried but do not help
- alpha blockers, NSAIDs, benzos??
testicular carcinoma: risks, population, tumor type, s/sx, dx, tx, prognosis
risks:
- cryptorchidism (40%!)
- FH or personal hx
- males 15-35 y/o (most common neoplasm)
tumor type: most are germ cell tumors (nonseminomas and seninomas)
- bHCG and LDH elevated in both
- AFP elevated in nonseminomas
s/sx:
- PAINLESS testicular mass
- usually does not MET (to lungs and brain if it does)
dx:
- scrotal U/S
- CT (abd, pelvis, chest) and MRI (brain) for mets
tx:
- radical orchiectomy
- radiation w/ seminomas
- no radiation w/ nonseminomas
prognosis: excellent (90-95% cure rate)
prostate cancer: risks, tumor type, s/sx, PE, mets
risks: age, AA, FH
tumor type: adenocarcinomas (95%)
s/sx:
- many asymptomatic
- pain, obstructive urinary sxs, erectile dysfunction
PE:
- DRE: indurated, hard prostate gland; may feel nodules
Mets: bone (axial skeleton - low back)
Prostate specific antigen (PSA)
Good for staging, trending dx, detecting recurrence
NOT for screening
- only if FH
Not: PSA is reduced by 50% by 5 alpha reductase inhibitors (used to tx BPH)
prostate cancer: dx, prognosis, tumor surveillance, tx
Dx: trans-rectal U/S-guided biopsy
Gleason score:
- evaluates tissue sample
- higher score = cells less differentiated/irregular = poorer prognosis
tumor surveillance:
- CT abd and pelvis
- bone scan
- MRI
Tx: many options
- prostatectomy
- radiation
- cryotherapy
- hormone therapy / androgen deprivation (LHRH agonists, antiandrogen meds, orchiectomy)
- chemotherapy (if hormone therapy failed)
bladder cancer: risks, s/sx,
risks:
- smoking (#1)
- industrial dyes, solvents
- male, > 40y/o
s/sx:
- PAINLESS hematuria (bladder cancer until proven otherwise)
- may have irritative voiding sxs
dx:
- cystoscopy w/ biopsy
tx: depends on penetration of bladder wall
- Ta, T1: does not invade wall - transurethral resection +/- intravesical chemo
- >T2: invades wall - radical cystectomy + pelvic lymphadenactomy +/- chemo and radiation
renal cell carcinoma: risk factors, s/sx, paraneoplastic syndrome, dx, tx
NOT common
Risks:
- smoking, male, obesity, HTN
Note: risk of producing occlusive thrombi in renal vein and IVC!!
s/sx:
- hematuria
- flank pain or mass
20% will have paraneoplastic syndromes (tumor produces ectopic hormones)
- hypercalcemia
- erythrocytosis
- HTN
- anemia
dx:
- imaging: CT w/ eval for mets (CXR, bone scan)
- labs: U/A, studies for paraneoplastic syndromes
tx:
- if localized, radical or partial nephrectomy
- if mets: palliative care
Wilms tumor (aka nephroblastoma): definition, population, s/sx, dx, tx, prognosis
cells meant to form kidney fail to develop properly
- peak incidence 2-3 y/o
- 5% childhood cancers
s/sx:
- PALPABLE ABDOMINAL MASS (60%)
- abdominal pain
- hematuria
- N/V, anorexia, fever
Dx:
- imaging
- biopsy is not done b/c could spill tumor cells
tx:
- surgical resection, nephrectomy, chemo, radiation
prognosis: 85% curable
