Renal System/Urology/Male Reproductive System Flashcards
A 35-year-old man with history of sore throat three weeks ago, presents to the Emergency Department with a puffy face and decreased urine output for the past 48 hours. On examination, he has a blood pressure of 160/120 mmHg. His face is swollen especially in the periorbital area. On lung auscultation, bilbasal crepitations are heard. Which one of the following is correct regarding his condition?
A. Hematuria is a grave prognostic factor.
B. He is at immediate risk of death from left ventricular failure.
C. Increase in oral intake will result in diuresis.
D. If there is renal tenderness, a renal biopsy should be performed.
E. Dialysis is contraindicated during the acute phase of the illness.
Correct Answer Is B.
Facial edema, hypertension and oliguria are strong pointers towards glomerulonephritis. With the sore throat in the history, post-streptococcal glomerulonephritis (PSGN) is the most likely cause of this presentation.
PSGN is induced by infection with specific nephritogenic strains of group A streptococcus (GAS) such as type 12 and type 49. The clinical presentation can vary from asymptomatic, microscopic hematuria to full-blown acute nephritic syndrome, characterized by red to brown urine, proteinuria (which can reach the nephrotic range), edema, hypertension and acute renal failure.
A latent period always occurs between the streptococcal infection and the onset of signs and symptoms of acute glomerulonephritis. In general, the latent period is 1-2 weeks after a throat infection and 3-6 weeks after a skin infection. The onset of signs and symptoms at the same time as pharyngitis is points towards immunoglobulin A (IgA) nephropathy rather than PSGN.
Dark urine (brown-, tea-, or cola-colored) is often the first clinical manifestation of PSGN. Dark urine is caused by lysis of red blood cells that have penetrated the glomerular basement membrane and have passed into the tubular system.
Periorbital edema is typical. The onset of puffiness of the face or eyelids is sudden. It is usually prominent upon waking up and, if the patient is active, tends to subside toward the end of the day.
In some cases, generalized edema and other features of circulatory congestion, such as dyspnea, may be present. Edema is the result of a defect in renal excretion of salt and water. The severity of edema is often disproportionate to the degree of renal impairment. Nonspecific symptoms of PSGN can include general malaise, weakness, and anorexia that are present in 50% of patients.
Approximately 15% of patients complain of nausea and vomiting.
Early death is extremely rare in children (<1%) but is significantly more common in adults (25%).
This is secondary to congestive heart failure and azotemia. Left ventricular failure (congestive heart failure) is more common in adults (43%) than in children (<5%); therefore, this patient is potentially at immediate risk of congestive heart failure and death due to volume overload.
Nephrotic-range proteinuria is also more common in adults (20%) than in children (4-10%). Approximately 83% of adults have azotemia compared to 24-40% of children.
(Option A) Hematuria is seen in most patients with PSGN as in all other forms of glomerulonephritis. It can range from microscopic to gross (cola-or tea-colored urine). Hematuria is not associated with poor prognosis.
(Option C) Oliguria is present in 10-50% of cases. The oliguria is often transient and diuresis occurs within 1-2 weeks. Increased water intake does not result in diuresis.
(Option D) Kidney biopsy is not required, unless for those patient in whom other glomerular disorders are considered due to deviation from the natural course of PSGN or lack of a history of streptococcal infection. Recognition of PSGN in this patient is clear from the history and the clinical findings. Renal tenderness is not an indication for renal biopsy.
(Option E) Patients with PSGN have variable reduction in renal function, and some patients require dialysis during the acute episode.
A 72-year-old man presents with complaint of one episode of blood in the urine. Five years ago, he underwent colectomy after he was diagnosed with colon cancer. A while back, he developed back pain for which he was assessed and diagnosed with metastatic bone disease. Three months ago he was started on tramadol for management of the back pain. He has no urinary symptoms. Which one of the following is the most appropriate next best step in management?
A. Perform a pelvic and abdominal CT scan.
B. Perform a renal ultrasound.
C. Urine culture.
D. Stop tramadol.
E. Perform an intravenous pyelogram (IVP).
Correct Answer Is C.
Hematuria should be always considered as a sign; therefore, for established cases of hematuria an underlying cause should be investigated through history, physical examinations and laboratory/imaging studies. For established hematuria, the most common causes such as vigorous exercise, menstruation, trauma, viral illnesses, and infections should be excluded first.
One of the most common causes of hematuria even in the absence of symptoms is urinary tract infection (UTI), for which a urine analysis and culture should be performed.
(Option A) Genitourinary malignancies (either primary or metastatic) can cause hematuria. Malignancies should always be excluded and CT scan is one of the most accurate and commonly used means. However, other common causes of hematuria should be excluded first.
(Option B) Renal ultrasound may be later needed as further work-up but not as the first priority because the hematuria has been painless, making renal stones less likely. Small stones may cause painless hematuria, but since they almost always pass spontaneously, their detection on sonography does not change the management plan.
(Option D) Although hematuria has been reported as a rather rare adverse effect of tramadol, initial assessment should be focused on more common possibilities such as UTI. Even so, cessation of tramadol in an almost end-stage patient would not be recommended.
(Option E) If imaging studies are required during the evaluation process, CT scan is preferred over IVP. In the presence of more modern and convenient modalities, IVP is rarely done these days.
A 65-year-old man presents to your practice with complaint of blood in the urine. These episodes of hematuria have all been painless. Which one of the following is the least likely cause of painless hematuria?
A. Cancer within the kidney.
B. Anticoagulation therapy.
C. Glomerulonephritis.
D. Benign prostatic hyperplasia (BPH).
E. Use of cyclophosphamide.
Correct Answer Is E.
All the given options can present with painless hematuria except cyclophosphamide.
Cyclophosphamide use can result in hemorrhagic cystitis. With cystitis, the hematuria is more likely to be painful rather than painless.
The following can result in hematuria (painless or painful):
* Urothelial cancers (kidney cancers, bladder cancers, etc)
* Hydronephrosis/distention
* Renal vein thrombus / renal artery embolism
* Arteriorvenous malformation
* Papillary necrosis (sickle cell disease)
* Hypertension
* Glomerulonephritis
* Structural abnormalities (polycystic kidney disease, medullary sponge kidney, etc)
* Nephrolithiasis
* Urinary tract infections (pyelonephritis, cystitis, parasitic infections, etc)
* Ureteral strictures
* BPH
* Prostate cancer
* Prostatic procedures
* Trauma (including traumatic catheterization)
* Exercise-induced hematuria
* Bleeding diathesis / anticoagulation
* Urethritis
* Urethral diverticulum
* Hypercalciuria/hyperuricosuria
* Urinary tract fistulas
* Mimics of hematuria:
* Menstruation
* Drugs (phenazopyridine, pyriduim, rifampin, nitrofurantoin, etc)
* Pigmenturia
* Beeturia
A couple has presented to your office for infertility consult. They have been trying to start a family for over a year. The woman’s history and examination results are normal, but the man is found to have absent vas deferens. Which one of the following would be the most appropriate advice for
them?
A. They should have sperm donation.
B. The vas deferens should be fused to the ejaculatory duct.
C. Sperm aspiration and intrauterine fertilization should be tried.
D. Sperm aspiration for frozen sample and repeated tubal insemination.
E. In vitro fertilization.
Correct Answer Is E.
One to two percent of infertile men have congenital absence of the vas deferens. Most have mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Many infertile men with mutations of CFTR present with infertility in the absence of other typical features of cystic fibrosis (e.g. respiratory and pancreatic disease).
Using in vitro fertilisation is the most appropriate reproductive technique for this couple. Sperms are aspirated from epididymis or testis and then injected into the aspirated oocytes in vitro.
NOTE - Patients with congenital bilateral absence of the vas deferens may have genetic mutation commonly present in cystic fibrosis. Such men and their partners who are considering assisted reproductive techniques to achieve pregnancy should have genetic screening and counselling.
Screening the female partner may be more cost effective than screening the patient because if she
is negative, the risk that their children having cystic fibrosis is almost zero.
(Option A) Sperm donation, while the male sperms are retrievable, is not an appropriate treatment option.
(Option B) Fusion of vas deferens to ejaculatory duct is considered appropriate for male patients,
who have vas deferens but has undergone vasectomy.
(Options C and D) Aspirated sperms are not enough in number to make intrauterine infertilization
or tubal insemination acceptable methods.
A 65-year-old man, who is on chronic hemodialysis every other day due to chronic renal failure, presents to the Emergency Department with generalized weakness and dyspnea. He is noncompliant with his dialysis sessions and had his last session 5 days ago. Which one of the following would be the most appropriate **next action **to take?
A. Call the dialysis unit.
B. Arterial blood gas (ABG) analysis.
C. ECG.
D. Chest X-ray (CXR).
E. Furosemide.
Correct Answer Is A.
This patient has skipped dialysis sessions. Patients with end stage renal disease have volume overload and hazardous metabolic derangements such as metabolic acidosis and hyperkalemia, both of which can be fatal. Volume overload can cause congestive heart failure and pulmonary edema presenting with dyspnea as the most common manifestation. Hyperkalemia is also of great concern because it can cause lethal cardiac arrhythmias. No matter what the underlying cause of this presentation is, arrangement for urgent dialysis is the most appropriate next step in management as it shoud be arranged at earliest time. While the arrangements are in process,
investigations such as ECG (option C), CXR (option D) and ABG (option B) can be undertaken.
ECG is of paramount importance because with evidence of arrhythmias induced by hyperkalemia,
calcium gluconate should be administered promptly for cardiac protection.
Urgent dialysis can remove excess fluid and the congestion; in the mean time, standard protocols
should be used for such patients. In case of pulmonary edema, furosemide (option E) can be used in patients with preserved renal function as a component of acute management of pulmonary
edema.
A 70-year-old woman presents with increasing generalized abdominal pain for the past 2 hours. She is a known case of chronic renal failure and has been on peritoneal dialysis for the past 18 months. Her last dialysis session was hours ago. On examination, she appears toxic. Her blood pressure is 140/95mmHg, heart rate 110bpm, and temperature 39°C. Her abdomen is distended and diffusely tender to deep palpation. Rebound tenderness is also noted. Blood exam is significant for a white cell count of 18,000/mm3. Which one of the following is the most appropriate next step in management?
A. Erect and supine abdominal films.
B. Ultrasonography of the abdomen.
C. CT scan of the abdomen and pelvis.
D. Peritoneal fluid analysis and Gram stain.
E. Comparison of ascitic fluid amylase with serum amylase.
Correct Answer Is D.
In the setting of peritoneal dialysis (PD), **peritonitis ** is the most likely explanation to this presentation.
Peritonitis is a common complication of peritoneal dialysis (PD), and is associated with significant morbidity, catheter loss, transfer to hemodialysis, transient loss of ultrafiltration, possible permanent membrane damage, and occasionally death.
Among PD patients, peritonitis may be PD-related or secondary (enteric). PD-related peritonitis is due to touch contamination with pathogenic skin bacteria or to catheter-related infection.
Secondary peritonitis is caused by underlying pathology of the gastrointestinal tract. PD-related peritonitis is much more common than secondary peritonitis; the latter, however, is associated with higher rates of complications and mortality.
Conditions that may lead to secondary peritonitis include cholecystitis, appendicitis, ruptured diverticulum, treatment of severe constipation, perforation during endoscopy, bowel ischemia, and incarcerated hernia. Secondary peritonitis may also be caused by seeding from the blood or vagina but this is less common compared to intraabdominal causes.
The most common signs and symptoms of peritonitis among PD patients are abdominal pain and cloudy peritoneal effluent. Other signs and symptoms include fever, nausea, diarrhea, abdominal tenderness, rebound tenderness, and occasionally systemic signs, including hypotension.
The diagnosis of peritonitis should be suspected in a PD patient with characteristic clinical presentation. Analysis of the peritoneal fluid is the most appropriate next step when PD-related peritonitis is suspects.
A presumptive diagnosis is made if the peritoneal fluid white cell count is greater than 100cells/mm3 and the percentage of neutrophils is greater than 50%. The white cell count is greatly dependent on the dwell time of the dialysis catheter; therefore, with a white cell count of less than 100, but neutrophil percentage of greater than 50%, the diagnosis remains PD-related peritonitis untill proven otherwise.
Peritoneal fluid culture and Gram stain should also be performed. Although it is usually negative, the identification of any organisms is a helpful guide to therapy since the gram stain is predictive of the culture results. Gram stain may be particularly useful in the early diagnosis of fungal peritonitis.
Peritoneal fluid cultures are always indicated and performed, but empiric antibiotic therapy should not be delayed until culture results are available.
Culture of purulent drainage from the exit site should be performed since isolation of the same organism as from peritoneal fluid suggests that the exit site infection may be the cause of peritonitis.
Peritoneal fluid amylase and lipase should also be measured. The peritoneal fluid amylase and lipase concentrations are occasionally elevated (>50IU/L) among patients with secondary peritonitis, but not among patients with PD-related peritonitis. This may help to distinguish between PD-related and secondary peritonitis. Among patients with secondary peritonitis, the elevated amylase concentration may be due to a leak from a bowel perforation or directly from an inflamed pancreas. An elevated level of peritoneal lipase above 15IU/L suggests pancreatitis as the cause of the peritonitis.
NOTE – PD-related peritonitis is a different entity from spontaneous bacterial peritonitis (SBP).
(Options A, B and C) Radiographic manifestations of peritonitis are nonspecific and such studies are not routinely performed among patients with suspected PD-related peritonitis. However, they are indicated when secondary peritonitis is suspected.
(Option E) Amylase and lipase levels in peritoneal fluid are not used in comparison with their serum levels.
In the presence of systemic symptoms, blood cultures should be obtained, although they are seldom positive.
A 60-year-old man with end-stage renal failure presents to the dialysis unit for a session of hemodialysis. His current medications are enalapril, hydrochlorothiazide, and aspirin. He has a blood pressure of 140/95 mmHg. After the session, which was uneventful, his blood pressure is found to be 160/90mmHg. Which one of the following is more likely to be the cause of his increased blood pressure?
A. Allergic reaction to the dialysis fluid.
B. Overdialysis.
C. Enalapril overdose.
D. Hypokalemia.
E. Anemia.
Correct Answer Is B. Overdialysis.
While hemodialysis lowers blood pressure (BP) in most hypertensive end-stage renal disease patients, approximately 15% of patients show a paradoxical increase in BP during haemodialysis, termed intradialytic hypertension (IDH). IDH is defined as either of the following:
* An increase in mean arterial blood pressure (MAP) ≥ 15 mmHg during or immediately after hemodialysis
* An increase in systolic BP (SBP) >10 mmHg from pre- to post-dialysis
* Hypertension during the second or third hour of hemodialysis after significant ultrafiltration has taken place
* An increase in BP that is resistant to ultrafiltration
* Aggravation of pre-existing hypertension or development of de novo hypertension with erythropoietin stimulating agents.
Despite extensive investigations as to the mechanism and pathophysiology of IDH, the exact pathogenesis remains unclear. Numerous factors have been implicated, including:
1. Renin-angiotensin system activation because of ultrafiltration (UF) induced hypovolemia
2. Sympathetic overactivity
3. Intradialytic Ca++/k+ variations
4. Blood viscosity/haemoconcentration-induced vasoconstriction caused by erythropoietin treatment
5. Fluid overload
6. Increased cardiac output
7. Endothelin-driven vasoconstriction
8. Antihypertensive drug removal by dialysis treatment
Several studies and reports highlight the important role of fluid overload, hemodynamic changes and increased endothelin level. The importance of other hypothesis such as renin-angiotensin system activation, sympathetic overactivity and ionic variations seems secondary. Fluid removal remains the key point for treatment of IDH.
Of the options, overdialysis is the most appropriate one. In majority of dialysis patient, overdialysis results in hypotension as a complication; in some, however, this excess fluid removal leads to activation of compensatory mechanisms by which the blood pressure can increase. Also, excess removal of enalapril with dialysis can be an explanation.
(Option A) Allergic reaction to dialysis fluid has not been shown as a possible mechanism responsible for intradialytic hypertension.
(Option C) Enalapril overdose can cause hypotension, not hypertension.
(Option D) Hypokalemia induces vasoconstriction and increased blood pressure; however, it is does not appear to be a main contributor to IDH.
(Option E) Anemia, by itself, is not associated with hypertension during or shortly after dialysis, but erythropoietin stimulating agents used for treatment of anemia in patients with CKD during dialysis is among postulated causes of hypertension associated with dialysis.
A 64-year-old man with end-stage renal disease presents to the dialysis unit for a pre-scheduled
hemodialysis session. He proceeds through the session uneventfully, but his blood pressure reading is 80/60 mmHg at the end of the session. His pre-dialysis blood pressure was 150/90mmHg. A blood panel shows a hemoglobin level of 80 g/L. Which one of the following could be the **most likely cause **of this drop in blood pressure?
A. Allergic reaction to the dialysis fluid.
B. Overdialysis.
C. Anemia.
D. Hypokalemia.
E. Enalapril overdose.
Correct Answer Is B.
The scenario is a typical example of intradialytic hypotension. Intra- or post-dialysis hypotension is
a well recognized and common complication of hemodialysis.
The incidence of a symptomatic reduction in blood pressure during (or immediately following) dialysis ranges from 15-50% of dialysis sessions. In some patients, the development of orthostatic
hypotension necessitates intravenous fluid replacement before they are able to leave the dialysis
unit. This problem contributes to the excessive morbidity associated with the dialysis procedure.
There are two clinical patterns of dialysis-associated hypotension:
1. Episodic hypotension, which typically occurs during the later stages of dialysis and presents with vomiting, muscle cramps, and other vagal symptoms (such as yawning).
2. Chronic persistent hypotension, which may occur in patients with long-term dialysis. A predialysis systolic blood pressures of less than 100 mmHg is frequently observed.
The etiology of intradialytic hypotension is divers and includes:
* A rapid reduction in plasma osmolality, which causes extracellular water to move into the cells
* Rapid fluid removal in an attempt to attain “dry weight”, particularly among those with large inter-dialytic weight gains
* Inaccurate determination of true ‘dry weight’
* Autonomic neuropathy
* Diminished cardiac reserve
* Use of acetate rather than bicarbonate as a dialysate buffer
* Intake of antihypertensive medications that can impair cardiovascular stability
* Use of a lower sodium concentration in the dialysate
* Sudden release of adenosine during organ ischemia
* Ingestion of a meal immediately before or during dialysis
* Arrhythmias or pericardial effusion with tamponade, which are volume-unresponsive
* Reactions to the dialyzer membrane, which may cause wheezing and dyspnea as well as hypotension
* Increased synthesis of endogenous vasodilators, such as nitric oxide
* High magnesium concentrations in the dialysate
* Failure to increase plasma vasopressin levels
Overdialysis, by excess fluid removal, is an important, and probably the most common cause of intradialytic hypotension.
(Option A) Allergic reaction to dialyzer membrane (not fluid) can be a possible cause of hypotension in few cases. In addition to hypotension, wheezing and dyspnoea are also expected.
(Option C) Anemia has not been recognized as a cause of intradialytic hypotension.
(Option D) Hypokalemia induces vasoconstriction, with increased blood pressure being the expected result. Hypokalemia is unlikely to cause hypotension in this setting.
(Option E) Enalapril overdose can cause hypotension regardless of dialysis. Circulatiing enalapril is expected to decrease during dialysis; therefore, enalapril overdose, while the patient has not have hypotension before the session is very unlikely.
A 72-year-old woman has been on routine dialysis sessions for the past 6 months due to end-stage renal disease. At the beginning of each session, she is found to have a high blood pressure (BP).
During the session the BP normalizes, but goes up again after the session. Which one of the following would be the most appropriate management option for this patient?
A. Addition of hypertensive medications.
B. Addition of furosemide, daily.
C. Increasing the dialysis time.
D. Sedation before dialysis.
E. Decreasing the dialysis time.
Correct Answer Is C.
Paradoxical Hypertension During or After Dialysis:
Sometimes, instead of blood pressure dropping during or after hemodialysis (as expected when fluid is removed), a small number of patients (5-15%) experience high blood pressure (hypertension). This happens in the later stages of dialysis or right after coming off the dialysis machine, even though most of the excess fluid has already been taken out.
- Renin-Angiotensin System Activation: The body may activate a system that increases blood pressure in response to low blood volume caused by dialysis.
- Sympathetic Overactivity: The body’s “fight or flight” system may overreact, raising blood pressure.
- Calcium and Potassium Changes: Fluctuations in these minerals during dialysis might contribute to high blood pressure.
- Increased Blood Thickness: Erythropoietin (a drug used to treat anemia in dialysis patients) can make the blood thicker, leading to vessel constriction and higher blood pressure.
- Fluid Overload: If too much fluid is left in the body, it can cause high blood pressure.
- Increased Cardiac Output: The heart might pump more blood than usual, raising blood pressure.
- Endothelin-Driven Vasoconstriction: The blood vessels might constrict due to a substance called endothelin, leading to higher blood pressure.
- Removal of Blood Pressure Medications: Dialysis can sometimes remove medications that are meant to control blood pressure, causing it to rise.
- First-Line Treatment: The primary approach is to remove more fluid during dialysis (but carefully, to avoid dropping blood pressure too much). This can be done by increasing the time of dialysis or the rate at which fluid is removed, though these options can be challenging due to patient comfort or logistical limits.
- Gradual Weight Reduction: Slowly lowering the patient’s “dry weight” (the weight after dialysis when excess fluid is removed) is key. This includes encouraging patients to reduce their salt and fluid intake between dialysis sessions.
- Medications: Using antihypertensive drugs (like ACE inhibitors, ARBs, or beta-blockers) can be tried, but results have been inconsistent. Carvedilol, which blocks the release of endothelin-1, seems to be effective for some patients.
-
Avoid:
- Sedation: It has no role in managing this type of high blood pressure.
- Shortening Dialysis Time: Reducing dialysis time can worsen high blood pressure due to insufficient fluid removal.
In patients who experience high blood pressure during or after dialysis, the first step is usually to try to remove more fluid during the session. Medications might help, but their effectiveness varies. The focus should be on carefully managing fluid levels and considering medication adjustments as needed.
Although hypotension during hemodialysis is a frequent complication, some patients (5-15%) develop paradoxical hypertension in the later stages of dialysis or when the patients comes off the dialysis machine, a time at which most of the excess fluid has already been removed. The pathogenesis is unclear; however, the following mechanisms have been hypothesized as the cause:
1. Renin-angiotensin system activation because of ultrafiltration (UF) induced hypovolemia
2. Sympathetic overactivity
3. Intradialytic Ca++/k+ variations
4. Blood viscosity/hemoconcentration-induced vasoconstriction caused by erythropoietin treatment
5. Fluid overload
6. Increased cardiac output
7. Endothelin-driven vasoconstriction
8. Antihypertensive drug removal by dialysis treatment
The optimal therapy for this problem is not known.
While antihypertensive medications such as angiotensin converting enzyme inhibitors (ACE inhibitors) and alpha-blockers have been used before (or during) dialysis, they have not been predictably effective. Carvedilol, which blocks endothelin-1 release, appears to be effective.
Although there are no validated universal guidelines regarding management of such patients, fluid removal has been accepted as the first-line treatment for intradialytic hypertension (IDH).
Theoretically, increasing the time of the dialysis session and ultrafiltration (UF) rate would be efficient; however, this decision faces many difficulties such as patient refusal or the unit limitations. This treatment should be done with caution to avoid hazardous blood pressure drop that may occur in the elderly or patients with severe comorbidity.
The dry weight of patients should be gradually reduced by increasing the dialysis time and the UF rate. In addition, patients should be advised to decrease their daily salt and water intake in between their dialysis sessions.
(Options A and B) Addition of anti-hypertensive or other medications ACE inhibitors or angiotensin receptor blockers (ARBs), beta blockers, endothelin-1 receptor blockers, furosemide, etc has been associated with conflicting results. In some patients, hypertensive crises may occur. These hypertensive crises are not persistent and usually the blood pressure level quickly decreases spontaneously; however, addition of antihypertensive medications might be indicated. There is no comment regarding a hypertensive crisis in this patient to necessitate addition of antihypertensives. Furosemide is not the first-line option for management of hypertension crisis if it occurs.
(Option D) Sedation before dialysis has no role in management of IDH or post- dialytic hypertension.
(Option E) Decreasing the dialysis time results in insufficient excess fluid removal and hypertension due to volume overload.
A 50-year-old man presents with complaints of several episodes of painless gross hematuria and a mass he felt in his left loin recently. The significant finding on examination is a non-tender loin mass. Urine analysis shows blood in the urine. Urine culture is negative. Which one of the following is the most appropriate next step in management?
A. CT scan.
B. Cystoscopy.
C. MRI.
D. Intravenous pyelography (IVP).
E. Intravenous urogram (IVU).
Correct Answer Is A.
Gross hematuria is always concerning and warrants thorough investigations, because the prevalence of urinary tract malignancies among patients with macroscopic hematuria has been reported to be as high as 19%, but usually ranges from 3-6%.
Risk factors can help in determining which patients are at higher risk of urinary tract and bladder malignancies. Risk factors include:
* Age >40 years
* A history of smoking
* History of gross hematuria
* History of chronic cystitis or irritative lower urinary tract symptoms (e.g. frequency, urgency,
* dysuria, nocturia, hesitancy, sensation of incomplete emptying)
* History of pelvic irradiation
* Exposure to occupational chemical and dyes (e.g. heavy phenacetin use, treatment with high
* doses of cyclophosphamide, aristolochic acid)
One of the most common causes of hematuria is urinary tract infection, which can be investigated with urine microscopy, culture and sensitivity (MC&S). Ureteric and renal stones are another common cause, but these typically present with pain and microscopic or gross hematuria. In cases where macroscopic hematuria or risk factors are present, or if another cause cannot be determined, more extensive investigations are recommended to exlcude an underlying malignancy.
Despite extensive investigation, studies have shown that in up to 50% of patients with macroscopic hematuria and 70% with microscopic hematuria have no identifiable cause is found. This could be attributed to transient benign physiological conditions, including vigorous physical exercise, sexual intercourse or menstrual contamination.
In this patient, urinalysis is negative but for blood. There is no increase in WBC to indicate infection; furthermore, a urine culture is negative, excluding infections as a cause. There are also no red cell casts or other pathologic findings indicating conditions such as glomerulonephritis as the underlying pathophysiology. An enlarged or otherwise abnormal prostate would have come to attention on physical exam.
Given the presence of gross hematuria, the age (>40) and the loin mass, the most important concern would be a renal tumor until proven otherwise.
Such patients should undergo non-contrast CT scan of kidney, ureter and bladder (KUB) (first-line) or ultrasound (second-line). CT-KUB is a non-contrast study – the current gold standard in identifying ureteric and renal stones, with 94-98% sensitivity; however, the sensitivity is much lower for indentifying genitourinary malignancies.
CT scan findings associated with increased risk of urinary tract malignancies justify CT-KUP IVP. CT-KUB IVP (multidetector CT scanning of kidneys, ureter and bladder after intravenous contrast media is administered), also known as CT urography (CTU) is as accurate and diagnostic as a combination of ultrasonography, IVP and CT-KUB. This, however, should be performed by, or at least under consultation with an urologist. Sensitivity for detecting pathology in patients with hematuria varies from 94-100%, with a 97.4% specificity.
With the loin mass, the cause of hematuria is more likely to originate from upper parts of urinary tract that are beyond the reach of cystoscopy. Cystoscopy, however, can be considered somewhere along the diagnostic pathway, for patients with voiding symptoms or where there is suspicion of bladder cancer, but not as the next best step in this scenario.
IVP (intravenous pyelogram), also called IVU (intravenous urogram) is inferior to CT scan.
A 32-year-old man presents to the Emergency Department with left loin pain and hematuria. He is HIV positive and on an anti-HIV treatment regimen including indinavir. This is the first time he is having such problem. Urine dipstick is positive for blood but negative for urinary tract infection.
Which one of the following is the most appropriate next step in management?
A. Intravenous pyelogram (IVP).
B. Ultrasound (US).
C. Non-contrast CT scan.
D. KUB X-ray.
E. Triple-phase CT scan.
Correct Answer Is B. Ultrasound
Correct Answer: B. Ultrasound
Indinavir, a drug used to treat HIV, can cause kidney stones (nephrolithiasis) in about 12.4% of patients. If this happens, the drug should be stopped, and a different antiretroviral should be used.
Why Ultrasound?
- Ultrasound is a good initial test because it’s safe, readily available, cost-effective, and avoids radiation exposure.
- It can detect large, clinically significant stones and signs of obstruction, even though it may miss smaller stones caused by indinavir, which are not radiopaque (not visible on X-rays).
Why Not Other Options?
- Non-contrast helical CT scan (Option C) is the best test for most kidney stones because it can detect both stones and obstruction. However, indinavir stones are not radiopaque and may not show up on a CT scan.
- X-ray KUB (Option D) is less effective for indinavir stones for the same reason—they are not radiopaque.
- Contrast-enhanced CT scan and IVP (Option A) expose the patient to unnecessary radiation and contrast media. These are usually reserved for persistent symptoms or if another diagnosis is suspected.
- Triple phase CT scan (Option E) is mainly used for liver lesions, not kidney stones.
Ultrasound is the best initial test for suspected indinavir-induced kidney stones because it is safe and effective at detecting larger stones and obstruction without exposing the patient to radiation.
Indinavir sulfate is an HIV protease inhibitor. Indinavir-induced nephrolithiasis is a well-recognized adverse effect of this drug, occurring in almost 12.4% of patients. If indinavir-induced nephrolithiasis develops, the drug should be discontinued and an alternative antiretroviral be used.
Non-contrast helical CT scan (option C) is the criterion standard for evaluation of nephrolithiasis. This modality can detect both stones and urinary tract obstruction. Stones not visualized on IVP or KUB, usually are detected on CT scan; however, since stones secondary to indinavir are not radiopaque and signs of obstruction may be minimal, this modality may not be as accurate and miss the diagnosis. This holds true about x-ray KUB (option D) and ultrasound.
Although not accurate as non-contrast helical CT scan, ultrasound can detect obstruction caused by large, clinically significant stones and probably the stone itself. This modality has been recommended as the initial diagnostic option by many authors. It is safe, readily available, costeffective, and spares patients from the risk of radiation in most cases. Again, the accuracy is reduced in detection of stones secondary to indinavir.
In fact, studies have shown that contrast CT-scan is more likely to visualize indinavir-induced stones, but since most of such stones, especially if not large enough to cause obstruction and be detected on ultrasonography, will pass with conservative management, contrast enhanced imaging studies as contrast CT or IVP (option A) unnecessarily puts the patient at risk of radiation and/or contrast media.
Contrast CT scan, however, should be considered for patients in whom the symptoms persist or other diagnosis is suspected based on clinical grounds.
Triple phase CT scan (option E) is mostly used for diagnosis of liver lesions. It is not indicated diagnosis of renal stones but may be considered as an alternative diagnosis.
During a routine health assessment, a 43-year-old man is found to have established asymptomatic hematuria. Which one of the following is the most appropriate next step in management?
A. Ultrasonography of the renal system.
B. CT scan.
C. Cystoscopy.
D. Urine culture.
E. Intravenous pyelogram (IVP).
Correct Answer Is D.
Hematuria may be seen in a variety of situations including, but not limited to:
* Infections
* Renal stones
* Glomerulonephritis
* Urinary tract malignancies
* Trauma
Infections are the most common cause of hematuria in both symptomatic and asymptomatic patients. For this reason, the next best step in management of every patient with hematuria would be a urine analysis and culture. Urologic malignancies (mostly cancer of the bladder) should be considered and ruled out once urine culture is negative and renal stones are excluded using ultrasound (the best initial test) or spiral CT (the most accurate test).
A 75-year-old man presents to your practice after he noticed blood in his urine. A four-phase contrast CT scan is obtained that shows a 1cm mass in the left kidney, highly suggestive of renal cell carcinoma. His medical history is significant for acute myocardial infarction 1 month ago for which he underwent angioplasty and drug-eluting stent placement. Currently, he is on dual antiplatelet therapy (DAPT) with daily clopidogrel 75mg and aspirin 100mg. Which one of the following would be the most appropriate next step in management ?
A. Nephrectomy.
B. Heminephrectomy.
C. Repeat the CT scan in 12 months.
D. CT-guided percutaneous biopsy.
E. Repeat the CT scan in 3 months.
Correct Answer Is C.
Small renal masses can be found incidentally, or during evaluation for urinary symptoms, often by ultrasound. Once a mass is found in the kidney on ultrasound, a four-phase contrasted CT scan should follow for further evaluation, provided renal function allows use of contrast media. These four phases include: (1) arterial, (2) corticomedullary, (3) nephrographic and (4) excretory phases. This study allows a detailed examination of each aspect of the functional anatomy of the kidney.
The majority of renal lesions are benign simple cysts, which would require no further work-up. However, completely solid, mixed (solid and cystic), and cystic renal lesions that enhance with contrast are likely to be malignant.
A small renal mass is defined as a mass < 4 cm that has enhancement on abdominal contrast imaging. For such lesions, surgical resection of the mass is the most appropriate option if life expectancy is >5 years and the patient is a good candidate for surgery.
However, this patient has had an MI one month ago. Major surgery within the first 6 months after MI is associated with high risk of mortality; therefore, this patient is not a candidate for surgical resection of the mass. In such cases active surveillance of a small renal mass with CT or MRI in 6-to 12-month intervals is recommended.
Even if a small renal mass has imaging characteristics highly suspicious for RCC, active surveillance may be appropriate, particularly in patients with medical comorbidities that can increase the risk of active intervention such as surgery, in elderly patients, and in those with decreased life expectancy (≤5 years). Renal impairment may also be an indication for active surveillance in some patients. Active surveillance means that the patient will either have delayed treatment or no treatment at all.
NOTE - Active surveillance is not generally recommended for healthy younger patients because while there is some evidence to suggest such approach if the lesion is less than 1 cm; more data is needed before adopting this as a standard protocol in this patient group. Another issue of concern, when considering active surveillance in young patients, is the number of scans they will require over a lifetime, which is associated with considerable exposure to radiation.
(Options A and B) Tumor resection is the management of choice for small renal masses that are suspected of malignancy. Such masses are solid, mixed solid, or cystic renal lesions that enhance with contrast.
If possible, nephron-sparing surgery or partial nephrectomy rather than a total nephrectomy is performed to allow for preservation of renal function. However, in the following situation total nephrectomy is the treatment of choice:
* Tumor size ≥7 cm
* Those tumors that have a more central location
* Suspected lymph node involvement
* Tumor with associated renal vein or inferior vena cava (IVC) thrombus
* Direct extension into the ipsilateral adrenal gland
Even in the presence of the above, patients with any of the following conditions must have partial rather than total nephrectomy:
* A solitary kidney
* Multiple, small, and/or bilateral tumors
* Patients with or at risk for chronic renal disease
(Options D) The role of renal biopsy is controversial in the setting of a small renal mass. In particular, there is disagreement as to whether it is necessary to biopsy these lesions before planning management and in what settings. Circumstances under which a renal biopsy might be considered are where the patient is not a surgical candidate (controversial), life expectancy is ≤5 years (controversial), or the patient requests a definite diagnosis before proceeding with the surgery. Biopsy is not recommended for patients who are candidates for active surveillance.
NOTE - With available evidence, it may be safe to assume that routine discontinuation of the antiplatelet therapy is not necessary in low risk patients planned to undergo percutaneous renal biopsies.
(Option E) Recommended interval for active surveillance with CT scan or MRI is 6-12 months, not 3 months.
A 77-year-old man presents to your clinic with vague abdominal pain. Among initial laboratory tests, hematuria is notable. A repeated urinalysis confirms hematuria. You order a 4-phase contrasted abdominal CT scan that shows a 1cm complex mass in the lower pole of the right kidney. He is otherwise asymptomatic, enjoys a healthy life, and do not have any comorbidities.
Which one of the following is the most appropriate inital management option for him?
A. Repeat the CT scan in 12 months.
B. Nephrectomy.
C. CT-guided percutaneous biopsy.
D. Reassurance.
E. Thermal ablation
Correct Answer Is B.
Abdominal pain and hematuria in the presence of a renal mass is renal cell carcinoma (RCC) until proven otherwise. Small renal masses (< 4 cm) can be found incidentally, or during evaluation for urinary symptoms, often by ultrasound as the initial imaging modality. Once a mass is found in the kidney on ultrasound, a 4-phase contrasted CT scan should follow for further evaluation if contrast media is not contraindicated.
Solid or complex masses (a lesion demonstrating both cystic and solid structures), as well as cystic masses enhanced with contrast are suspected to be malignant and treatment is warranted.
NOTE - By definition, a renal lesion <4 cm in its largest diameter that shows contrast enhancement on abdominal imaging is a small renal mass. These lesions can be solid or complex cystic. Simple cysts not enhancing with contrast are excluded.
If the patient is a good candidate for surgical resection and has a life expectancy >5 years, surgical resection of the small renal mass would be the most appropriate initial management. This patient is otherwise fit and healthy with no comorbid condition precluding him from surgical tumor resection. Partial nephrectomy is the procedure of choice for masses less than 7cm that are not centrally located. This is to preserve as much renal function as possible.
(Option A) Active surveillance with CT scan or MRI in 6- to 12-months intervals is recommended for patients with small renal masses who are not good candidates for surgical resection (e.g., have a comorbid condition), or have a life expectancy of ≤5 years. Renal impairment may also be an indication for active surveillance in some patients. Active surveillance means that the patient will either have delayed treatment or no treatment at all. This patient has no comorbid condition precluding him from tumor resection.
(Option C) The role of renal biopsy is controversial in the setting of a small renal mass. There is disagreement as to whether it is necessary to biopsy such lesions before planning management and in what settings. Circumstances under which a renal biopsy might be considered are where the patient is not a surgical candidate (controversial), life expectancy is ≤5 years (controversial), or the patient requests a definite diagnosis before proceeding with the surgery. Biopsy is not recommended for patients who are candidates for active surveillance.
(Option D) With this clinical picture, the chances are that the tumor is malignant; therefore, reassurance cannot be given unless investigations exclude malignancy.
(Option E) Ablation of renal mass can be performed with either freezing (cryoablation) or heat (radiofrequency or microwave ablation). Using a percutaneous approach, a needle is used to ablate the tumor with heat of freezing. After ablation, all patients should undergo surveillance to assess for residual or recurrent tumor that would require additional therapy. Although initial studies have shown favorable short-term results with thermal ablation, long-term outcomes are yet to be studied. Thermal ablation is reserved for patients with a small RCC who are not candidates for surgery. In addition, ablation is a treatment option for RCC after partial nephrectomy, those with a unilateral or transplanted kidney, or for patients at risk for multiple RCCs over their lifetime.
A 62-year-old man is referred to your clinic for a health checkup by his insurance company. An ultrasound of the kidney, ureter, and bladder reveals a 3-cm heterogeneous mass in the upper pole of his right kidney. A contrast-enhanced CT scan is ordered that confirms the presence of a contrast-enhancing cystic mass. Which one of the following would be the most appropriate management for this patient?
A. Total nephrectomy.
B. Review in 12 months.
C. Percutaneous biopsy.
D. Partial nephrectomy.
E. Thermal ablation.
Correct Answer Is D.
Rising use of imaging studies as a means of diagnosis has increased the rate at which small renal masses are detected. Incidentally-found small renal masses (incidentalomas) are now a common clinical scenario. Recent data have revealed that over 50% of renal cell carcinomas (RCCs) are incidentally found, and the classic presentation with a triad of gross hematuria, flank pain, and abdominal mass is not commonly encountered.
The majority of incidentally-detected renal masses are benign simple cysts that require no further work-up. However the following renal masses are more likely to be malignant:
* Completely solid renal masses
* Mixed solid and cystic renal lesions
* Cystic lesions that enhance with contrast
By definition, a renal lesion <4cm in its largest diameter that shows contrast enhancement on
abdominal imaging is a small renal mass. These lesions can be solid or complex cystic. Simple cysts not enhancing with contrast are not considered renal small masses.
For small renal masses, surgical resection is the most appropriate option if life expectancy is >5 years and the patient is a good candidate for surgery. This man has a 3-cm complex tumor and needs surgical resection of the tumor as the most appropriate management option.
For renal masses smaller than 7-cm in size, nephron-sparing surgery, or partial nephrectomy rather than a total nephrectomy is performed to allow for preservation of renal function. This patient with a 1cm mass is most likely to benefit from partial nephrectomy as the most appropriate management option.
(Option A) Total nephrectomy is the treatment of choice in the following situations:
* Tumor size ≥7 cm
* Tumors with a more central location
* Suspected lymph node involvement
* Tumor with associated renal vein or inferior vena cava (IVC) thrombus
* Direct extension into the ipsilateral adrenal gland
Even in the presence of the above, patients with any of the following conditions must have partial rather than total nephrectomy:
* A solitary kidney
* Multiple, small, and/or bilateral tumors
* Patients with or at risk for chronic renal disease
(Option B) Active surveillance with CT scan or MRI in 6- to 12-month intervals is recommended for
patients with a small renal mass, who are not good candidates for surgical resection (e.g., have a comorbid condition), or have a life expectancy of ≤5 years. Renal impairment may also be an indication for active surveillance in some patients. Active surveillance means that the patient will either have delayed treatment or no treatment at all. This patient has no comorbid condition precluding him from tumor resection.
(Option C) The role of renal biopsy is controversial in the setting of a small renal mass. In
particular, there is disagreement about necessity to biopsy these lesions before planning management. Circumstances under which a renal biopsy might be considered are:
* The patient is not a surgical candidate (controversial)
* Life expectancy is ≤5 years (controversial)
* The patient requests a definite diagnosis before proceeding with the surgery.
NOTE - Biopsy is **not recommended **for patients who are candidates for active surveillance.
(Option E) Ablation of renal mass can be performed with either freezing (cryoablation) or heat
(radiofrequency or microwave ablation). Using a percutaneous approach, a needle is used to ablate the tumor with heat or freezing. After ablation, all patients should undergo surveillance for assessment of residual or recurrent tumor that would require additional therapy. Although initial studies have shown favorable short-term results with thermal ablation, long-term outcomes are yet to be studied. Thermal ablation is reserved for patients with a small RCC, who are not candidates for surgery.
Ablation is also considered for:
* Treatment of residual RCC after partial nephrectomy
* Those with a unilateral or transplanted kidney
* Patients at risk for multiple RCCs over their lifetime.
A 69-year-old man presents to your GP clinic with complaint of uriary incontinence. He explains that he cannot make it to the bathroom once he feels the urge to pass urine. He denies any dysuria.
Which one of the following could be the most likeky underlying cause to this presentation?
A. Benign prostatic hyperplasia (BPH).
B. Urinary tract infection (UTI).
C. Detrusor instability.
D. Increased intraabdominal pressure.
E. Nephrolithiasis.
Correct Answer Is C.
The incontinence described in the scenario is characteristic of urge incontinence. In this type of incontinence, there is sudden and strong urge to pass urine. The patient often is not able to make it to the bathroom and wet themselves. An overactive bladder caused by detrusor instability is the most common etiology of urge incontinence and the most likely cause to this presentation. An irritable or unstable bladder are synonymous terms used to describe the pathology. Patients with detrusor instability have involuntary bladder contractions, resulting in a sudden urge to urinate.
(Option A) BPH usually causes overflow urinary incontinence rather than urge incontinence.
(Option B) Although UTI is a cause of frequency and urgency due to irritation of the bladder, detrusor instability of unknown etiology is the most common cause of urge incontinence.
(Option D) Increased intraabdominal pressure is a cause of urine overflow in stress incontinence not in urge incontinence.
(Option E) A stone in the bladder can irritate the bladder and cause frequency, urgency, and urge incontinence but idiopathic detrusor instability remains the most common cause of urge incontinence.
A 68-year-old woman presents with complaint of urinary incontinence occurring when she laughs, sneezes, coughs, or when she lifts heavy weights or does exercise. She denies urgency or frequency. On examination, a rectocele is noted. A mid-stream urine exam is ordered which is unremarkable. Which one of the following is the most appropriate next step in management?
A. Surgical repair of the rectocele.
B. Pessaries.
C. Pelvic floor exercises.
D. Review in 4 weeks.
E. Bladder training program.
Correct Answer Is C. Pelvic floor exercises.
For women with mild to moderate stress, urge and mixed urinary incontinence, behavioral and physical therapy should be the initial treatment. It also can be an option for patients with more severe symptoms. These therapies include bladder training and pelvic floor muscle (Kegel) exercise. Although these two are often used in combination, pelvic floor muscles exercises are recommended initially for stress or mixed incontinence as the most important arm of treatment.
On the other hand, bladder training is the first line-treatment for urge incontinence or mixed incontinence when symptoms of urge incontinence predominate. It should be noted, however, that these two are usually advised in combination.
(Option A) Pelvic organ prolapse (e.g., rectocele) can have been caused by pelvic floor weakness which is often the same etiology of stress urinary incontinence. Surgical repair of pelvic organ prolapse is only indicated for patients who are symptomatic. Urinary incontinence is not a symptom of this condition. It is caused by the same etiology of pelvic organ prolapse.
(Option B) Continence pessaries are used as adjunctive therapy for women with pelvic organ prolapse or stress urinary incontinence. This method is inexpensive, effective and safe with no or rare serious complication or contraindication. This can be used adjunctive to pelvic floor muscle exercise, but not as the most appropriate method per se.
(Option D) Reviewing the patient in 4 weeks without considering any active management is not an appropriate option.
(Option E) Bladder training should be offered as first-line treatment for overactive bladder symptoms such as frequency or urgency in patients with urge and mixed incontinence. It also may be beneficial for patients with stress incontinence in combination with pelvic floor muscles exercise, but not as the most crucial portion of treatment of urinary stress incontinence.
TOPIC REVIEW
Urinary incontinence can be categorized as:
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A 25-year-old man presents with a painless right scrotal lump which he noticed while taking a shower three days ago. There is no tenderness or other abnormal findings except asymptomatic enlargement of the right testis. The epididymis and spermatic cord can be felt in their normal positions. An ultrasound scan is performed which is shown in the accompanying photograph.
Which one of the following is the most appropriate next step in management?
A. Reassurance.
B. Measurement of serum alpha phetoprotein (AFP).
C. Measurement of serum carcinoembryonic antigen (CEA).
D. Trans-inguinal excision of the right testis.
E. Trans-scrotal excision of the right testis.
Correct Answer Is B.
The photograph pictures the ultrasonographic view of the right testis, in which a lesion is seen. The lesion is combination of both cystic and solid structures. A testicular lump in a young man is testicular cancer until proven otherwise.
When testicular cancer is suspected on ultrasound, the next best step is always obtaining blood sample for serum tumor markers. Three serum tumor markers have established roles in patients with suspected testicular cancer: alpha fetoprotein (AFP), beta subunit of human chorionic gonadotropin (beta-hCG), and lactate dehydrogenase (LDH).
Tumor markers differ by histological subtype of testicular malignancies. In pure seminoma testicular cancers, AFP is never elevated and beta-hCG is elevated in fewer than 20% of patients. In other histological subtypes, AFP and beta-hCG are elevated in 85% of patients.
Of the options only measurement of serum AFP can be correct as the next best step in management. However, the best option would recommend both AFP ans beta-hCG.
Other measures to conisder prior to surgery are:
* High resolution CT scan of the abdomen, pelvis and chest
* Chest X-ray
* Chemistry profile and full blood count (FBC)
(Option A) No man with a testicular lump can be reassured unless thorough investigations exclude
testicular malignancies.
(Option C) CEA is not a tumor marker for testicular cancer.
(Options D and E) Tumor marker studies and imaging studies should be performed prior to surgical
management. If surgery is planned a trans-inguinal approach should be considered, as there is a risk of tumor spread and scrotal seeding when the testis is reached through scrotum.
