GU Flashcards
Risk factors for complicated UTI
Males poorly controlled DM pregnant kids older adults immunocompromised recurrent anatomic abnormalities recent instrumentation indwelling catheter
Definition of recurrent UTI
3 or more culture positive UTI in one year
OR
2 within 6 months
First line treatment of uncomplicated UTI?
- nitrofurantoin (macrobid) 100 mg BID x 5 days
- TMP-SMX (bactrim, septra) BID x 3 days
- fosfomycin 3 g po x single dose
Lifestyle (non-pharm) counselling for treatment of uncomplicated UTI
- increase fluid intake to 2-3 L/day
- restrict dietary oxalate (beans, spinach, beets, chips, fries, nuts, tea)
First line treatment of complicated UTI?
- cipro 500 mg BID or 1000 mg ER once daily
- levofloxacin 750 mg once daily
-treat for 7 days or longer 7 days
If high risk of multidrug resistant organisms: macrobid 100 mg BID
UA and urine C+S before and after treatment
Adverse effect from long term nitrofurantoin use?
- lung problems
- chronic hepatitis
- neuropathy
contraindications to nitrofurantoin use?
renal insufficiency (avoid if CrCl 40-60)
cipro side effects:
- MSK
- neuro
- derm
- endo
- QTc
MSK: tendinitis, tendon rupture (increased risk age > 60, corticosteroids, strenuous physical activity, renal failure, previous tendon disorder, kidney/heart/lung transplant recipients), exacerbation muscle weakness in myasthenia gravis
NEURO: seizures, toxic psychosis, increased intracranial pressure, polyneuropathy
DERM: phototoxicity: clothing & sunscreen protection;
ENDO: hyperglycemia or hypoglycemia
QTc prolongation: concomitant medications that prolong QT and/or cause torsades de pointes
Pyelonephritis
Lab findings
- urine culture
- urinalysis
- CBC
Urine C&S: 100,000 CFU/mL
Urinalysis: pyuria (>2-5 leukocytes/HPF)
• WBC casts
CBC
Leukocytosis (WBC >11,000), neutrophilia (>80%), shift to left (bands of immature neutrophils)
Treatment approach for pyelonephritis: which can be treated as outpatient vs hospitalization?
Outpatient only for compliant healthy patients with milder infections
Complicated pyelo: renal disease, male, kidney stone, anatomic abnormality, immunosuppression –> refer for hospitalization
First line treatment for uncomplicated pyelonephritis (eg healthy adult female, not pregnnat)
ciprofloxacin 500 mg BID x 7 days
- must treat minimum 7 days or longer
- close follow up for 12-24 hours
Nephrolithiasis
Risk factors?
- Family hx (double the risk)
- Dehydration, hyperuricosuria, acidic urine –> increase risk for uric acid stones.
- Chronic obstruction
- Diet high in calcium, vit C, oxalate, sodium, protein, purine
- Pregnancy
- Chronic infections
- Foreign bodies
- IBD, bowel resection, ileostomy –> excessive oxalate formation
- Medications (Vitamins A,C,D, loop diuretics, calcium-containing medications, sulfa drugs, acyclovir)
- Obesity
- Gastric bypass
- DM
Nephrolithiasis
imaging of choice?
Noncontrast CT abdo/pelvis
KUB ultrasound if pregnant
Nephrolithiasis
Classic symptoms?
acute onset severe colicky flank pain (unilateral)
lasting 20-60 min
-can be severe with nausea and vomiting
Majority will have. hematuria
Kidney stones
majority are made of ______?
calcium oxalate (60-70%)
remainder are struvite (7%), uric acid (7%), cystine (1%)
Nephrolithiasis
Treatment?
pain control with NSAIDs and opioids, fluids (hydration)
if stone is small (<5 mm), most people will pass stone within 24-48 hours
If large: lithotripsy
AKI
KDIGO definition?
increase in serum Cr by _____ within ____
urine volume less than _______
- Increase in serum Cr by 0.3+ mg/dL within 48 hours
- Increase in serum Cr by 1.5+ mg/dL from baseline (known or presumed in last 7 days)
Urine volume <0.5 mL/kg/hr for 6 hours
Causes of AKI
- prerenal usually due to?
- postrenal usually due to?
- intrinsic usually due to?
Prerenal: hypoperfusion
eg hypovolemia, decreased cardiac output, third spacing, meds (ACEI, ARB, NSAIDs)
Postrenal: obstruction
eg bladder/urethal/renal obstruction, neurogenic bladder
Intrinsic: acute tubular necrosis
eg ischemia, prolonged hypoperfusion, sepsis, hemorrhage
Definition of microscopic hematuria
3 or more RBC/hpf on urine microscopy
urine microscopy must be done at lab **must be analyzed within 2-3 hours
First line imaging for microscopic hematuria?
KUB ultrasound
Risk factors for urothelial (bladder) cancer?
age (40+) sex (male) SMOKING is most important risk factor (past, present, second hand) occupational exposure to chemicals exposure to pelvic radiation chronic lower urinary tract inflammation schistosomiasis
if microscopic hematuria detected, next step in workup?
serum Cr, urine ACR
BP
Kidney/bladder ultrasound
Microscopic hematuria
cystoscopy recommended for what categories?
Recommended for
- all patients age >40 with microscopic hematuria
- any age with risk factors for urothelial cancer
- any age with suspicious imaging
post-strep glomerulonephritis
symptoms?
timing?
- acute onset dark red/brown urine
- edema
- proteinuria
- fatigue
- decreased urine output
timing:
- 10-21 days after strep throat, scarlet fever, impetigo
Oliguria is defined as…..?
urinary output <400 mL/day for adults
Proteinuria is defined as …..?
Excretion of >150 mg/day of protein
Microscopic hematuria is defined as …..?
presence of 3 or more RBCs/hpf
Asymptomatic bacteriuria is defined as …..?
presence of one or more species of bacteria (100,000 CFU/mL) in absence of UTI irrespective of pyuria
What is the definition of a UTI on urine culture?
100,000 CFU/mL of single organism
or
100,000 CFU/mL of one AND 50,000 CFU/ml of second organism
What are some benign causes of proteinuria?
fever, intense exercise, acute illness, dehydration, emotional stress
What are some serious causes of proteinuria?
○ Diabetic nephropathy, hypertensive nephropathy, polycystic kidneys, sarcoidosis, lupus, rhabodomyolysis, pre-eclampsia, eclampsia
symptoms of acute kidney injury?
WOE with LAN
- weight gain
- oliguria
- edema
- lethargy
- anorexia
- nausea
cause of high BUN? low BUN?
High BUN • Acute kidney failure • High protein diet • Hemolysis • CHF • Drugs
Low BUN
• Liver disease
eGFR is less reliable in these situations?
- drastic increase/reduction in muscle mass (bodybuilder, amputee, wasting disorder)
- pregnancy
- acute renal failure
- elderly
what do large amount of squamous epithelial cells indicate?
contamination
what is normal cutoff for WBC in urine?
< or equal to 10 WBCs/mL
urine dipsticks only detect ____ for proteinuria
albumin
*does not capture microalbumin
Hyaline casts are seen in …..?
WBC casts seen in …..?
RBC casts seen in ……?
Hyaline: “normal” in concentrated urine and after strenuous exercise
WBC: infections (UTI, pyelo)
RBC casts and proteinuria diagnostic of glomerulonephritis
true or false
asymptomatic bacteriuria should not be treated in pregnant women
false
always treat pregnant women
up to 30% risk of pyelo
true or false
UTIs are common in males
false
UTIs in males must have follow up evaluation
r/o ureteral stricture, infected kidney stones, anatomical abnormality, acute prostatitis, STI
Glomerulonephritis
Etiology/cause?
-3 broad categories
• Infection (eg post-strep, bacterial endocarditis, viral infections HIV HBV/HCV)
○ Timing: 1-2 weeks after GBS pharyngitis
- Immune disease (eg lupus, Goodpastrue’s syndrome, IgA nephropathy)
- Vasculitis (eg polyarteritis, Wegener’s granulomatosis)
Glomerulonephritis
Symptoms?
Symptoms: • Pink/cola-coloured urine (hematuria) • Foamy urine (proteinuria) • HTN • Edema of face, hands, feet and abdomen • Anemia maybe
Sequelae of glomerulonephritis
Sequelae
• Kidney failure
• HTN
• Electrolyte imbalance
• syndromeTreatment of glomerulonephritis
Treatment
• Acute glomerulonephritis: usually self-limiting. Goal to identify cause, protect from further damage
○ Antihypertensive: to lower BP
○ Antimicrobial: if infection suspected
○ Systemic steroids and immunosuppressives: to reduce inflammation
• If severe case due to immune disease: plasmapheresis to remove Ab and toxic proteins
• If acute kidney failure: dialysis
Chronic glomerulonephritis most commonly seen in what population?
young men who also have hearing and vision loss
diagnostic workup of glomerulonephritis?
Diagnosis
• Urinalysis: RBC and RBC casts, WBC, elevated protein
• Bloodwork: Elevated serum Cr and BUN
• Imaging: CT or kidney ultrasound
• Renal biopsy needed to confirm diagnosis
Nephrotic syndrome is characterized by what lab findings?
symptoms?
lab: heavy proteinuria, hypoalbuminemia, hyperlipidemia, lipiduria
symptoms:
- edema (peripheral and periorbital)
- elevated BP
What are lab findings in acute renal failure?
- increased Cr and BUN
- hyperkalemia
- hypercalcemia
- hypernatremia
Anemia in chronic renal failure
eGFR for stage 4 CKD?
stage 5 CKD?
stage 4: GFR 15-29 mL/min
stage 5: <15 mL/min
what type of anemia is seen in CKD?
- normocytic
- normochromic
- low reticulocyte count
