Nephrology, Male GU Flashcards
Kidney functions (7)
- Acid-base regulation
- Water balance
- Electrolyte balance
- Toxin excretion
- BP
- EPO production
- Vit D & renin secretion
Risk factors for AKI
- HTN
- CHF (low-flow)
- DM
- MM
- Chronic infection
- Myeloproliferative disorder
What is RIFLE criteria?
Assess AKI based on SCr elevation & urine output
What does RIFLE stand for?
Risk
Injury
Failure
2 outcomes - Loss of renal fx (>4wks), ESRD (>3 mo)
Pre-renal causes of AKI
- Hypovolemia
- Decreased CO
- NSAIDs
- ACEI/ARBs
Intrinsic causes of AKI
- Ischemia
- Toxins
- Vascular (renal a./v. obstruction)
Most common post-renal causes of AKI
- BPH
- Malignancy
- Neurogenic bladder
- Pregnancy
- Med crystals (acyclovir, methotrexate, idinavir)
Labs for pre-renal AKI
- BUN:Cr >20:1
- FeNa <1%, FeUrea<35% or FeUA <9%
- Hemoconcentration
What would you see in pre-renal AKI urine?
Hyaline casts & high specific gravity
Tx for pre-renal AKI
- IVF
- Diuretics, nitrates, dobutamine if decr. CO
- Dose-adjust/hold meds cleared by kidney
Intrinsic renal diseases (6)
- Acute interstitial nephritis
- Acute tubular necrosis
- Post-streptococcal glomerulonephritis
- IgA nephropathy
- Henoch-Schonlein Purpura
- Nephrotic syndrome
Labs for acute tubular necrosis
- Elevated BUN/Cr
- HyperK+, hyperPO4, hyperuricemia
- FeNa >2%
What would you see in acute tubular necrosis urine?
Pigmented granular casts (muddy-brown casts)
Tx for acute tubular necrosis
- Aggressive volume replacement
- Consider high dose loop diuretic if oliguria
- Protein restriction
- Dialysis
Etiology of post-streptococcal glomerulonephritis
Strep-A containing immune complex deposition in glomerulus
Presentation of PSGN
- AKI 7-12 days s/p sore throat/impetigo
- HTN
- Oliguria
Tx for PSGN
- Antibiotics (usually PCN)
- Anti-HTN meds, salt restriction, diuretics
IgA nephropathy urine
Red or coca-cola
Dx IgA nephropathy
Renal biopsy
Tx for IgA nephropathy
- ACEI/ARB
- Steroid
- Renal transplant if needed
Who is commonly affected by HSP?
Children ~6 y/o
Classic presentation of HSP
- Rash esp. LE, butt
- Abd pain, vomiting
- Arthralgias
- Edema
Tx HSP
Supportive (immunosuppressants and/or plasmapharesis)
Etiology of HSP
IgA complex deposition
Classic presentation of nephrotic syndrome (4)
- Heavy proteinuria (>3.5g/24hr)
- Hypoalbuminuria (<3g/24hr)
- Peripheral edema
- Lipiduria (foamy urine)
How do cells in minimal change dz look?
Diffuse effacement (flat) of epithelial cell foot processes
Tx for minimal change dz
Prednisone
Presentation of postrenal AKI
Anuria!
Tx for postrenal AKI
- Tx underlying cause
- Catheterization (Foley, suprapubic)
2 components of polycystic kidney disease
Multisystem & Cyst formation
What’s so bad about polycystic kidney dz?
- 50% need transplant/dialysis by age 60
- Intracranial aneurysm
Si/Sx of polycystic kidney dz
- Pain
- Bleeding
- HTN
- Nodular hepatomegaly
Dx polycystic kidney dz
U/S
Tx for polycystic kidney dz
- ACEI/ARBs
- NO NSAIDs (bleeding)
- Surgical cyst decompression
- Nephrectomy
- Transfusions prn
Indications for dialysis
- Acidosis (hyperK+, hyperPO4, hypoCa2+)
- OD
- Volume overload
- Uremia
Acute vs. chronic kidney disease
Acute = rapid & reversible Chronic = progressive & irreversible
Normal GFR
≥90
GFR of ___ indicates kidney dysfunction
<60
GFR of ___ indicates ESRD
<15
Approach to pt with new renal dysfunction
- Consider etiologies (pre-renal, renal, post-renal)
- GFR/SCr
- Urine dipstick (protein, RBC)
- US or CT w/out contrast
- Urinalysis (casts)
- Consider MM via serum/urine protein electrophoresis
GFR of _____ for _____ indicates CKD
<60mL/min for >3 months
3 risk factors for CKD
- Diabetes
- HTN
- African ancestry
Sx’s of CKD
- Asx until Stage 3 or 4
- Anemia, fatigue
ESRD sx’s
- Encephalopathy
- Muscle twitches/cramps
- LE edema
- Pruritus
- Uremic syndrome (sx’s associated w/ azotemia)
Labs for CKD
- 24hr urine
- Elevated BUN, SCr
- HyperK+, hyperphosphatemia, hypocalcemia
- Proteinuria on UA
- RBC/WBC casts
Complications of CKD
- Anemia (decr. EPO)
- Metabolic acidosis (decr. HCO3 reabsorption)
- Poor Vit D, Ca2+, phosphorus metabolism
- Fractures
- Volume overload
- Hyperkalemia
- Uremia
- CV issues (HTN, athero, CHF)
Tx for CKD
- Tx underlying disorder
- Dialysis (ARF or ESRD)
- Eventual transplant for ESRD (kidney-pancreas for T1DM)
When would you refer CKD pt to nephrologist?
- GFR <30
- Rapidly progressing
- Poorly controlled HTN on 4 agents
- Rare/genetic causes of CKD (polycystic)
- Suspected RAS
Staging of CKD
Stage 0: GFR>90 Stage 1: Kidney damage w/ normal GFR Stage 2: GFR 60-89 Stage 3: GFR 30-59 Stage 4: GFR 15-29 Stage 5: GFR <15
Microalbuminuria
30-300mg/L of albumin in urine
Macroalbuminuria
> 300mg/L of albumin in urine
Leading cause of ESRD
DM
First sign of diabetic nephropathy
Microalbuminuria
Tx for diabetic nephropathy
ACEI/ARB +/- diuretic (for HTN)
What is the BP goal for diabetic nephropathy?
<130/80
What is the BP goal for hypertensive nephropathy
<140/90
First line for hypertensive nephropathy
ACEI/ARB - may cause AKI (d/c if doesn’t improve), hyperkalemia (reduce K+ retaining drugs if >6mmol/L)
___% pts will have recurrent urinary calculi (kidney stones)
50%
Types of kidney stones
- Ca2+ (most common)
- Struvite
- Uric acid
- Cystine
Risk factors for Ca2+ stone
- Dehydration
- Increased oxalate absorption (short bowel syndrome)
- Grapefruit, tomato, apple juice
- Sodas w/ phosphoric acid
- High salt & protein intake
- Loop diuretics (esp. thiazides)
- TONS of antacids
- Long-term steroids
- Vit D/C
- Hyperparathyroidism
- Malignancy
Risk factors for uric acid stones
- Gout
- Hyperuricosuria
- Chronic diarrhea
- HTN, DM, obesity
Risk factors for struvite stones
UTI’s - esp. Proteus
Presentation of nephrolithiasis
- Waxing/waning, colicky pain
- Constant writhing
- N/V, diaphoresis
- Tachycardia, hypotn
- Dysuria, frequency, urgency, hematuria (distal stones)
- CVA tenderness
Top imaging choices for nephrolithiasis
Non-contrast CT UNLESS pregnant/child (US instead)
CT findings consistent with nephrolithiasis
- Ureteral, collecting system dilatation
- Perinephric, periureteric stranding (inflammation)
- Nephromegaly
- “Rim sign” around stone
Pros/cons of US for kidney stones
(+) Pregnant, child, signs of obstruction (hydroureter, loss of ureteric jet)
(-) Poor visualization unless at UPJ or UVJ, can’t measure size of stone
Besides CT & US, what are 2 other imaging options for kidney stone dx
- IV pyelography (measure SCr first b/c uses contrast)
- KUB
Pros/cons for IV peylography
(+) Size, location, radiodensity, degree of obstruction
-) Not for RF, poor visualization of non-GU stuff (can’t r/o other d/o
KUB’s not really the best option for nephrolithiasis. Name 3 reasons.
- Only sees radiolucent stones
- Stones can be covered by stool, gas, bones
- Non-urologic radiopacities may be mistaken as stones (calcified LNs, gallstones, stool, phleboliths)
Management of nephrolithiasis
- IVF, NSAIDs (bridge w/ narcotics?), metoclopramide (anti-emetic), tamsulosin?, abx?
- Can alkalnize w/ K+ citrate if uric acid stone
- If able to tolerate PO, stay home → strain urine, bring back for analysis
What’s so great about NSAIDs for kidney stones?
- Analgesic
- Antispasmodic
- Antiemetic
Indications for referral of kidney stones to urology
> 5mm
1 stone
Hydronephrosis
Pregnant
3 options for >5mm kidney stone mgmt
- Extracorporeal shock wave lithotripsy (proximal stones)
- Ureteroscopy (mid-distal stones)
- Percutaneous nephrolithotomy (>2cm, complex stones)
Criteria for extracorporeal shock wave lithotripsy
- Radiopaque <2cm renal or <1cm ureteral
- Not morbidly obese
- No hard/cystine stones
- C/I pregnancy, tightly impacted stones, untreatable bleeding d/o
Complications of extracorporeal shock wave lithotripsy
- Perinephric hematoma
- Requires spontaneous passage of fragments, which can obstruct
Struvite = _____
Staghorn
Most common bacteria that causes struvite stones
Proteus
Tx for struvite stones
Percutaneous nephrolithiotomy +/- ESWL
Medication not enough
When would you want to send someone w/ kidney stones for metabolic evaluation?
Recurrent stones (usually uric acid, cystine) or strong FHx
What kind of cells are involved in bladder cancer?
Transitional cells
Risk factors for bladder cancer
- Smoking
- Occupational exposures
- Chronic urinary inflammation (SCI, indwelling catheter)
- Previous pelvic radiation
Si/Sx of bladder cancer
- Painless hematuria +/- LUTS
- Advanced = LE edema, bony/pelvic/flank pain, palpable mass
Gold standard for dx bladder cancer
Cytoscopy w/ bx (also therapeutic)
Typical metastatic destinations of bladder cancer
- Bone
- Brain
- Lung
Tx for non-muscle invasive bladder cancer
- Endoscopic transurethral resection of bladder tumor or radical cystectomy
- Intravesicle instillation (catheter) of BCG vaccine or chemo
Tx for muscle-invasive bladder cancer
Neoadjuvant chemo followed by radical cystectomy w/ regional LN dissection +/-radiation
Risk factors for RCC
- Smoking
- Obesity
- HTN
- Renal transplant/dialysis w/ cystic renal dz
Si/Sx for RCC
- “Classic” triad: Hematuria, flank pain, flank mass
- Paraneoplastic syndromes (hyperCa2+, non-met liver dysfunction, HTN, erythrocytosis)
Diagnostic imaging of choice for RCC
CT w/ contrast (alternative = US)
Which is more common, cystitis or pyelonephritis?
Cystitis
Risk factors for cystitis in men
Insertive intercourse, uncircumcised
Most common bacterial cause of cystitis
E. coli (also Klebsiella, Proteus)
Risk factors for cystitis
- Recent sex
- Spermicide
- Diaphragms
- Indwelling catheters
- Diabetes, obesity
- Short urethra syndrome
What kind of urine sample do you want for cystitis assessment?
Midstream, unspun
Tx for cystitis
Bactrim, cipro or Macrobid
+/- Pyridium (phenazopyridine) bladder analgesic (orange urine ADR)
Most common bacterial causes of pyelonephritis
E. coli (also Klebsiella, Proteus)
Pseudomonas in healthcare exposures
In addition to LUTS similar to cystitis, what else might pyelonephritis sx’s include?
Fever, chills, N/V
Indications for hospitalization in pyelonephritis
- Sepsis
- Persistent fever
- Unable to tolerate PO
- Urinary tract obstruction
Tx for pyelonephritis
- Outpatient → Cipro or levo
- Inpatient → Augmentin, Bactrim, cefpodoxime
+/- Pyridium, Motrin, Tylenol, Zofran, IVF
Sx’s of cystitis in pregnant pt
Usually asx - cystitis found incidentally on routine UA
Tx for cystitis in pregnancy
Macrobid, Augmentin, cefpodoxime, or fosfomycin
Tx for pyelonephritis in pregnancy
- Beta lactams
- PCN derivatives
- Cefazolin
- Ceftriaxone
+/- admission
Tx for asx bacteriuria
Don’t treat in elderly
Bactrim, Macrobid, cipro (same as cystitis)
Most common causes of RAS
- Atherosclerosis (most common)
- Fibromuscular dysplasia
Angiogram of atherosclerosis vs. fibromuscular dysplasia
- Atherosclerosis = narrowing of contrast at renal artery
- FMD = “string of beads”
Risk factors for RAS
- CKD
- DM
- Tobacco
- HTN
When should you consider revascularization in RAS
> 70% angiographic stenosis OR 50-70% angiographic stenosis associated with resting mean pressure gradient >10mmHg, systolic hyperemic pressure gradient >20mmHg or renal fractional flow reserve <0.8
2 components of RVHTN
HTN d/t RAAS + RAS
Si/Sx’s that may indicate RAS
- Severe/refractory/sudden-onset HTN (e.g. <160/100)
- Flash pulmonary edema
- Atherosclerosis
- Retinopathy
- Abdominal bruits
Lab findings associated w/ RAS
- Hypokalemia (hyperaldosteronism)
- Azotemia s/p ACEI/ARB
+/- incr. Cr, proteinuria
Gold standard for RAS dx
Renal artery angiography
Alternatives to renal artery angiography for RAS dx
- MRA (C/I if CrCl <30)
- CTA (C/I if CrCl <60) → preferred for FMD
- Duplex US (operator dependent)
1st line tx for RAS
Medications → anti-HTN (ACEI/ARB) + statins + antiplatelet
When would you prefer CCB over ACEI/ARB in RAS tx
- Bilateral RAS
- Single kidney w/ RAS
- Can’t monitor SCr, electrolytes
2nd line tx for RAS
Percutaneous renal angioplasty +/- stenting → preferred for FMD (w/ stent), refractory, intolerance to meds, bilateral RAS or single kidney
What is the last line tx for RAS? Indications?
Renovascular bypass → pts w/ unsuccessful PTRAS or extensive atherosclerosis in aorta
What is Wilm’s tumor?
2nd most common abdominal tumor in children
Common metastatic locations for Wilm’s tumor
- IVC
- Lungs
- Liver
Is Wilm’s tumor curable?
Yes! 90% cure rate w/ resection +/- chemo/radiation
Risk factors for cryptorchidism
- Low birth weight
- Premature baby
What is cryptorchidism?
Undescended testis mostly d/t gubernaculum defect
Most intra-abdominal testes are found ______ in cryptorchidism
Within a few cm of internal inguinal ring
Cryptorchidsm hx increases future risk of ____ and ____ and ____
Testicular cancer
Infertility (esp. if bilateral)
and indirect hernia
Refer infants w/out spontaneous testicular descent by _____
6 months (corrected for gestational age)
Surgery needed for cryptorchidsm by ____
age 1
Pediatric hydroceles are…..
Normal - resolve by age 1
Noncommunicating vs communicating hydrocele
- Noncommunicating d/t trauma, inflammation
- Communicating d/t patent processus vaginalis
How do you differentiate hydrocele from other penile d/o’s?
Transillumination!
Tx for hydrocele
Mostly observation
Surgical closure of patent processus vaginalis if communicating hydrocele
Varicocele is more common on the….
left side
Grading of varicoceles
Grade I → palpable only w/ Valsalva
Grade II → palpable at rest but invisible
Grade III → easily visible
What differentiates varicocele from other penile d/o’s?
Bag of worms
Tx for varicocele
Nothing or embolization
Tx for hypospadias
Nothing or surgery (make sure not to circumcise - need that skin for repair) +/- testosterone pretx
Risk factor for hypospadias
Low birth weight
Is phimosis normal?
In newborns, yes - usually resolves by adolescence
Pathological if difficulty urinating or abdnormal sex
Causes of phimosis
- Tip of foreskin too narrow to pass over glans
- Inner surface of foreskin fused w/ glans
- Frenulum too short to allow for complete foreskin retraction
Tx for phimosis
Manual stretching, change masturbation, preputioplasty, circumcision
Paraphimosis is….
Urological emergency!!
Ischemia can turn to gangrene or autoamputation
Higher incidence of paraphimosis in ____
uncircumcised men (but can happen in circumcised w/ external objects)
Tx for paraphimosis
- Gental retraction
- If severe, dorsal split procedure w/ eventual circumcision
Testicular torsion is ……
A urological emergency!
Irreversible damage after _____ in testicular torsion
12 hrs of ischemia
What kind of irreversible damage can occur d/t testicular torsion?
Infertility, even in contralateral testis
Manifestation of testicular torsion
- Severe testicular pain
- Negative cremasteric reflex
- “Bell clapper” sign (high-rising horizontal testis)
What kind of imaging can be used to confirm testicular torsion?
US w/ Doppler flow
Managment of testicular torsion
Manual/surgical detorsion (most torsions are medially rotated) → bilateral gubernacular fixation after
Most prostate cancers are located in ______
Peripheral zone
Most common bacterial causes of acute bacterial prostatitis
GNR - most common E. coli & Psuedomonas
Risk factors for acute bacterial prostatitis
- UTIs
- Prostate bx
- Catheter
- Structural abnormalities
Presentation of acute bacterial prostatitis
- Fever
- Dysuria
- Perineal, suprapubic, or back pain
- Extremely tender, warm, edematous prostate on DRE
+/- Urinary retention
Labs for acute bacterial prostatitis
Leukocytosis w/ left shift UA - pyuria, bacteriuria, hematuria UCx Elevated inflammatory markers (CRP, ESR) Elevated PSA
Imaging for acute bacterial prostatitis
Usually none unless doesn’t improve in 48hrs w/ abx → CT, MRI
Indications for admission for acute bacterial prostatitis
- Sepsis
- Cant tolerate PO
- Concern for adherence
- Multiple comorbidities
Tx for acute bacterial prostatitis
Bactrim, cipro, levo, gentamycin
Si/Sx of chronic bacterial prostatitis
Asx or subtle
- LUTS
- Low grade fever
- Dull pelvic, perineal, testicular pain
- Prostate usually not tender
Labs for chronic bacterial prostatitis
- UA frequently normal → UCx
- Expressed prostate secretions = WBC, bacteria
Imaging for chronic bacterial prostatitis
Usually none - if super chronic, may see prostate calculi on x-ray
Tx for chrnoic pbacterial prostatitis
Bactrim (if resistant, quinolones or cephalexin)
Inflammatory prostatitis
Prostate pain w/out bacteria; dx of exclusion
Labs for inflammatory prostatitis
- UA/UCx normal
- Expressed prostate secretions → leukocytosis, incr. macrophages
- Prostate bx → inflammatory tissue
Tx for inflammatory prostatitis
Tamsulosin or cipro
+/- dutasteride (5-alpha reductase inhibitor) → only in older men b/c affects sperm
Classification of epididymitis
Sexually transmitted vs. non-sexual transmitted
Most common causes of sexually transmitted epididymitis
Gonorrhea & Chlaymdia
Most common causes of non-sexually transmitted epididymitis
E. coli
Presentation of epididymitis
- Unilateral pain/swelling
- Urethral discharge
- Dysuria
- Fever
- Normal cremasteric reflex
Imaging for epididymitis
Scrotal US
Tx for epididymitis
- Bed rest, scrotal elevation, ice
- Sexually transmitted → azithro, ceftriaxone, doxy
- Non-sexually transmitted/low-risk → levo
Orchitis is most often associated with _____
Mumps
Bacterial causes of orchitis
N. gonorrhea in age 14-35
E. coli in age <14, >35
Presentation
- Associated parotitis 4-7 days prior
- Unilateral swollen red testis
- Fever, malaise, myalgia
Imaging for orchitis
Scortal US to differentiate from epididymitis
Tx for orchitis
Supportive - scrotal elevation, NSAIDs, ice
Urethritis is most common in ______
Young, sexually active men
Causes of urethritis
Gonococcal vs. non-gonococcal (mostly chlamydia)
Presentation of urethritis
- Dysuria, pruritus, burning at urethral meatus
- Discharge (purulent = gonorrhea, watery = chlamydia)
- Non-gonococcal commonly asx
- Inguinal LAD
Labs for urethritis
- First catch UA → leukocytes
- Gram stain of urethral dischrage (PMN = chlamydia, G- diplococci = gonorrhea)
Tx for urethritis
Azithro + doxy + ceftriaxone
Classification of testicular ca
- Germ cell tumors → NSGCT vs. seminoma
- Sex cord-stromal tumors
Risk factor for testicular ca
Cryptorchidism hx
Testicular ca is slightly more common on ________
Right side
Presentation of testicular malignancy
- Asx
- Painless nodule/enlargement of testis
- Gynecomastia if GCT
- Supraclavicular LNs
Order of operations for dx testicular cancer
Scrotal US → cryopreservation of sperm → CT → serum tumor markers → radical inguinal orchioectomy + retroperitoneal LN dissection to determine histology, staging, tx
Scrotal US finding for malignancy
Cystic or fluid-filled mass
Hypoechoic w/out cystic area = seminoma
Non-homogenous w/ cystic area/calcifications = NSGCT
Serum tumor markers for testicular ca
- AFP, HCG elevated in NSGCT
- LDH in any GCT
Why do you need to do retroperitoneal LN dissection for testicular ca?
Only reliable method for finding micromets, important for staging, decr. relapse risk
Risk factors for prostate Ca
- African ancestry
- High dietary fat
- FHx
Presentation of prostate ca
Most are asx
- Abnormaly prostate (nodules, asymmetry, indurated)
- LUTS (might be d/t BPH)
- Boney pain
- LE edema
- Urinary retention
Screening for prostate ca
DRE + PSA (but PSA not specific)
Diagnosis of prostate ca
Abnormal DRE + High PSA + transrectal US-guided bx → can repeat bx 1-2x if negative but PSA high
Imaging for staging prostate ca
MRI > TRUS
Gleason staging
Prognosis of prostate cancer
Main tx for metastatic prostate ca
Palliative androgen deprivation tx (ADT)
ED is associated with ___
CAD → ED w/o obvious cause should be screened for CVD
peyronie’s dz
Penile deformity/curvature d/t subtle trauma/fibrosis
Diagnostic studies for Peyronie’s dz
- Nocturnal penile tumescence testing (normal = psychogenic/hormonal; impaired = vascular or neurogenic)
- Duplex doppler or angio (venous leak or artery obstruction)
Tx for Peyronie’s dz
PDE-5 inhibitors (sildenafil, vardenafil, tadalfafil, avanafil)
C/I for PDE5 inhibitors
Nitrates
Relative C/I w/ alpha-adrenergic antagonists (-zosin)
If medical tx didn’t work for Peyronie’s and your pt doesn’t want to resort to surgery yet, what options are there?
- Vacuum-assisted erection device
- Penile self-injection/intraurethral prostaglandin-E1
Surgical options for Peyronie’s
- Penile prosthesis
- Penile revascularization (super strict criteria)
Criteria for priapism
prolonged erection >4 hrs unresolved by ejaculation
Priapism is….
Urological emergency
Tx for priapism
Nerve block w/ lidocaine → phenylephrine injection → aspirate blood +/- saline irrigation → surgery
