MDT's Part 1 Flashcards
What is hematuria?
Presence of blood in urine
Gross vs microscopic hematuria?
- Gross: visible to naked eye
- Microscopic: only detectable my microscopy
- Both require further evaluation
Gross hematuria from the lower tract (bladder/urethra) is most commonly found from what?
Urothelial carcinoma of the bladder
What is microscopic hematuria most commonly from?
Benign prostatic hyperplasia
In gross hematuria, what is the presence of blood at the beginning of the urinary stream called and what area of the urinary tract is the source?
- Initial hematuria
- Anterior (penile) urethral source
In gross hematuria, what is the presence of blood at the end of the urinary stream called and what area of the urinary tract is the source?
- Terminal hematuria
- Bladder neck or prostatic urethral source
In gross hematuria, what is the presence of blood throughout the urinary stream called and what area of the urinary tract is the source?
- Total hematuria
- Bladder or upper tract source
When would hematuria indicate Ureteral stone?
Hematuria associated with renal colic
Irritating voiding symptoms in a young woman with hematuria may suggest?
Acute bacterial infection and associated cystitis
In UA for hematuria, what does proteinuria and casts suggest?
Renal origin
Imaging/Referral for hematuria?
- CT scan without contrast of Upper tract
- Cystoscopy
- Urology (anatomic abnormality, urolithiasis, recurrent cystitis)
General considerations for Urinary Tract Infection?
- Coliform bacteria most common (E. coli)
- Ascending infection most common route
- Hematogenous spread to urinary tract is uncommon
- Lymphatic spread is rare
What is acute cystitis?
- Infection of the bladder
- Most commonly due to coliform bacteria (E. coli)
- Uncomplicated cystitis in men is rare and implies pathologic process
S/S of acute cystitis?
- Irritating voiding symptoms
- Suprapubic discomfort (tenderness with palpation)
- Women experience hematuria and Sx’s appear post sex
- Usually afebrile
Imagining for acute cystitis?
- Abdominal ultrasonography or cystoscopy
- CT scan is warranted if pyelonephritis are suspected
Treatment of acute cystitis?
- Women:
- Cipro
- Nitrofurantoin (Macrobid)
- Bactrim
- Men:
- Depends on underlying etiology
- Urinary analgesics
- Pyridium (Phenazopyridine)
Prevention of cystitis in women who have 3 or more episodes in one year?
- Thorough urologic evaluation
- Prophylactic antibiotic therapy
- Bactrim
- Nitrofurantoin
- Cephalexin
- Single dose at bedtime or after intercourse
What is pyelonephritis?
- Infectious inflammatory disease involving kidney parenchyma and renal pelvis
- Gram-negative bacteria most common causative agent
- E. coli
- Proteus
- Pseudomonas
- Infection usually spreads from lower urinary tract (except S. aureus)
S/s of Pyelonephritis?
- Fever
- Flank pain
- Irritative voiding Sx’s
- Shaking chills
- Nausea/vomiting
- Diarrhea
- Tachycardia
Differential Dx for pyelonephritis?
- Acute cystitis
- Acute Intra-abdominal disease
- Males:
- Epididymitis
- Acute prostatitis
Imaging for pyelonephritis?
Renal ultrasound
Inpatient treatment for pyelonephritis?
- Ampicillin IV and gentamicin continued for 24 hours after fever resolved
- Then oral antibiotics to 14 day course of antibiotics
Outpatient treatment for pyelonephritis?
- Ciprofloxacin
- Levofloxacin
- Phenazopyridine
Complications of pyelonephritis?
- Sepsis and shock
- Abscess formation from inadequate therapy
- Catheter drainage might be necessary
MEDEVAC to Urology or infectious disease for pyelonephritis when?
- Evidence of complicating factors
- Severe infections
- Evidence of sepsis
- Need for parental antibiotics
- Absence of clinical improvement in 48 with oral antibiotics
What is acute prostatitis?
Inflammation and infection of prostate gland usually caused by gram-negative rods (E. coli and Pseudomonas)
Most likely routes of infection for prostatitis?
- Ascent up the urethra
- Reflux of infected urine
S/s of prostatitis?
- Perineal, suprapubic, or sacral pain
- Fever, high
- Irritative voiding symptoms
- Obstructive symptoms that may lead to urinary retention
- Warm and tender prostate
Lab findings prostatitis?
- Leukocytosis and a left shift on UA
- Pyuria, Bacteriuria, and hematuria on UA
- Urine cultures demonstrate offending pathogen
Rad for prostatitis?
No
Inpatient treatment of prostatitis?
Ampicillin and gentamicin until 24-48 hours resolution of fever
- oral antibiotics for 4-6 weeks
Outpatient treatment of prostatitis?
- Cipro
- Levofloxacin
- Bactrim
- Acetaminophen/NSAIDS
- Stool softeners
What to do if urinary retention develops with prostatitis?
- Percutaneous Suprapubic tube is required
- Urethral catheterization is CONTRAINDICATED
MEDEVAC for prostatitis?
- Evidence of urinary retention
- Signs of sepsis
- Surgical drainage of bladder prostatic abscess
- Evidence of chronic prostatitis
- Absence of clinical improvement in 48 with oral antibiotics
Chronic bacterial prostatitis?
- May evolve from acute prostatitis
- Many men have no Hx of acute infection
- Gram negative rods are most common
- Enterococcus only gram positive organism
- Not to be managed by IDC alone
S/Sx’s of chronic bacterial prostatitis?
- Irritating voiding symptoms
- Low back and perineal pain
- Suprapubic discomfort
- Hx UTI
- PE unremarkable
- Prostate may be:
- Normal
- Boggy
- Indurate
Tx of chronic bacterial prostatitis?
- Bactrim
- Cipro
- Levofloxacin
- Duration lasts 6-12 weeks
- NSAIDS
- Sitz baths
What is Epididymitis?
- Inflammation and/or infection of epididymitis
- Can be divided into two categories:
- Sexually transmitted forms
- Non-sexually transmitted forms
- Route of infection is probably urethra to ejaculatory duct
Information on sexually transmitted epididymitis?
- Typically occurs in men under 40 year
- Associated with urethritis
- Results from chlamydia or gonorrhea
Information of non-sexually transmitted epididymitis?
- Typically occur in older men
- Associated with UTI and prostatitis
- Caused by gram negative rods ( E. Coli, Klebsiella)
S/Sx’s of epididymitis?
- May follow acute physical strain, trauma, or sexual activity
- Associated Sx’s of urethritis and cystitis
- Pain develops in scrotum and may radiate along spermatic cord or to flank
- Fever
- Scrotal swelling
- epididymis might be distinguishable from testes early on**
Later S/Sx’s of epididymitits?
- Epididymis and testes can appear as one mass
- Prostate may be tender on rectal exam
- Prehn sign
What is Prehn sign?
Elevation of scrotum above pubic symphysis may relieve pain from epididymitis
Imaging for epididymitis?
Scrotal U/S
Tx for sexually transmitted epididymitis?
- Ceftriaxone IM
PLUS - Doxycycline
Tx for non-sexually transmitted epididymitis?
- Trimethoprim/sulfamethoxaz (Bactrim)
- Ciprofloxacin
- Levofloxacin
Symptomatic relief for Epididymitis?
- Bed rest
- Scrotal support
- Ice packs
- NSAIDS
Complications of epididymitis?
- Delayed or inadequate Tx may result in:
- Epididymo-orchitis
- Decreased fertility
- Abscess formation
Follow up for epididymitis?
Refer to Urology if:
- Persistent symptoms or infection despite antibiotic therapy
- Signs of sepsis or abccess formation
General considerations for renal calculi/urolithiasis/kidney stones?
- Men are more frequently affected than woman (2.5:1 ratio)
- Initial presentation predominantly between 3rd and 5th decade
- There are five types urinary stones (calcium most common)
What are some contributing factors to renal calculi/urolithiasis?
- High humidity
- Elevated temperatures
- Sedentary lifestyle
- HTN
- Carotid calcification
- Cardiovascular disease
- High protein and salt diet with inadequate hydration
What are some sign/symptoms of renal calculi/urolithiasis?
- Sudden pain (may be episodic)
- Pain localized to the flank
- Pt constantly moving to find comfort
- Pain may radiate anteriorly over abdomen
- Stone size does not correlate to severity of symptoms
How do obstructing urinary stones present?
Acute, unremitting and severe colic
Urinalysis finding for urolithiasis/urinary stones?
- Microscopic or gross hematuria (absence does not exclude)
- Urinary pH is a valuable clue
Imaging for renal caculi/urinary stone?
- Plain abdominal radiograph
- Renal U/S
- Spiral CT with Pt in prone position
Tx for urinary stone?
- Forced IV fluids or diuresis in counterproductive
- Medical expulsive therapy (Alpha blockers, NSAIDS, corticorsteroids)
- Surgical Tx
Prevention of renal calculi?
- Dietary modification:
- Increased fluid intake
- Restrict sodium intake
- Spread animal protein throughout day
Complications of urolithiasis?
Obstructing stone with an associated infection is a medical emergency
** MEDEVAC **
Referral to urology for urolithiasis is warranted when?
- Obstructing stone with associated infection
- Stone fails to pass after 4 weeks
- Fever
- Intolerable pain
- Persistent Nausea/vomiting
