Renal/Urology Flashcards
Wilms Tumor Path: Pt: Dx: Tx:
Path: Neuroblastoma
MC abdominal malignancy in children (first 5 years of life)
Associated with cryptorchidism, hypospadias (opening of urethra is not at tip of penis), horseshoe kidney
Pt: Painless, palpable abdominal mass
Hematuria +/- HTN, anemia
Dx:
Abd U/S (initial test)
CT w/ contrast or MRI (more accurate)
Tx: Nephrectomy followed by chemotherapy
Renal cell carcinoma Path: Pt: Dx: Tx:
Path: 95% of tumors originating in the kidney
Risk factors: SMOKING, Dialysis, HTN, Obesity, male
Pt: Classic triad-> hematuria, flank/abd pain, palpable mass
L sided varicocele (blocks left testicular been drainage)
HTN an hyper-Ca++ (inc PTH)
Dx: CT
Tx: Stage 1-3: radical nephrectomy
Usually resistant to chemo and radiation
Bilateral involvement or pt w/ single kidney-> partial nephrectomy
Bladder cancer Path: Pt: Dx: Tx:
Path: Transitional cell (TCC) MC Risk factors: SMOKING Occupational exposure: dyes, rubber, leather Age >40 White male
Pt: 8th decade of life Painless gross/microscopic hematuria
Dx: Cystoscopy w/ bx
Abdominal U/S, CT or MRI for staging
Tx:
Superficial: transurethral resection
Invasive: radical cystectomy, irradiation, combo chemo
Good prognosis but highest rate of recurrence of all cancers
Prostate cancer Path: Pt: Dx: Tx:
Path:
Adenocarcinoma
Risk factors: family history prostate cancer, high fat diet, Africans American
MC located in peripheral zone
Pt: Asx; Obstructive symptoms
Dx:
Elevated PSA-> DRE: Asymmetric areas of induration or nodules
U/S with needle Bx
Tx: Active surveillance Prostatectomy Radiation therapy Hormonal therapy
BPH Path: Pt: Dx: Tx:
Path: Enlarged prostate
MC by stroll and epithelial cell growth in transitional zone of prostate
Pt: Obstructive sx
Dx:
DRE-> smooth and symmetrically enlarged “rubbery”
Bladder may be distended
Tx:
-Avoid antihistamines and anticholinergics
-Alpha-blockers-> doxazosin, terazosin, prazosin, tamsulosin
Relax smooth muscle of bladder neck
-5-alpha-reductase inhibitors-> finasteride, dutasteride
Shrink the prostate
-Surgery: Transurethral resection of the prostate (TURP)
Nephrolithiasis/Urolithiasis Path: Pt: Dx: Tx: Prevention:
Path: Decreased fluid intake, males, meds (loop diuretics, antacids, chemo), gout (uric acid stone), hyper-Ca++, polycystic kidney disease, UTIs (urea-splitting organisms)
4 types:
-Calcium oxalate (MC) and phosphate: inc protein and salt intake inhibit Ca++ reabsorption
-Uric acid: high protein foods-> inc purine -> uric acid
-Struvite stones (Mg ammonium phosphate)-> staghorn calculi in renal pelvis due to urea-splitting organisms: Proteus, klebsiella, pseudomonas, serratia, enterobacter
-Cystine: genetic disorder
Pt: Renal colic, CVA tenderness, hematuria
Proximal ureter: flank, CVAT
Mid-ureter: mid-abdominal
Distal ureter: groin pain
Dx:
- UA: hematuria, nitrites (if infectious); alkaline urine (pH >7.2) struvite stone
- Non-con CT Abd/pelvis
- KUB: only calcium and struvite stones are radiopaque
Tx: <5mm -80% pass spontaneously -IV fluids, analgesics, antiemetics -Tamsulosin
> 7mm
- Extracorporeal shock wave lithotripsy
- Ureteroscopy +/- stent: used to provide immediate relief to an obstructed or at-risk kidney
>10mm or struvite or other modalities have failed Percutaneous nephrolithotomy (most invasive)
Prevention:
- Increase fluid intake
- Decrease protein intake
Testicular Cancer Path: Pt: Dx: Tx:
Path: MC solid tumor in young men (15-40yr); white males; Klinefelter’s syndrome (males with an extra X chromosome)
Risk factors: cryptorchidism (both undescended and normal testicle)
Germinal cell tumors (97%)
- Seminoma: MC type in 30-40 y/o; simple (lack tumor markers AFP, B-hCG; sensitive to radiate, slower growing
- Nonseminomatous: boys <10y/o; inc AFP and B-hCG; radio-resistance
Pt: Painless testicular nodules, solid mass or enlargement
Dx:
Scrotal U/S: seminomas (hypoechoic mass)
AFP, B-hCG, LDH
Tx:
Low-grade (stage 1) : orchiectomy
Seminoma: +radiation
nonseminoma: retroperitoneal lymph node dissection
High-grade: debulking chemo -> orchiectomy and radiation
Cryptorchidism Path: Pt: Tx: Complications:
Path: Undescended testicle
Inc risk: prematurity, low birth weight
Pt: Empty, small scrotum
Tx:
- Orchiopexy: as early as 6m ideally within 1yr of age
- Observation: only if only <6m
Complications: Testicular cancer!!
- Sub-fertility
- Testicular torsion
- Inguinal hernia
Epididymitis and Orchitis Path: Pt: Dx: Tx:
Path: Ascending infection from the urethra, prostate or bladder
occasionally by hematogenous speed
*<35 y/o: Neisseria gonorrhoeae and Chlamydia trachomatis
*Older pts: E. Coli, klebsiella, enterobacter, citrobacter
*Chronic: >6w 2/2 inadequate tx
*Orchitis: usually viral; mumps
Pt: Gradually increasing dull, erythematous, swollen, unilateral scrotal pain
Fever, dysuria
Dx: localized epididymal edema and tenderness (posterior aspect for scrotum), +/- testicular tenderness, normal cremasteric reflex
+ Prehn sign: pain relieved w/ testicular elevation
+ cremasteric reflex (reflex present/normal): elevation of testicle after stroking inner thigh
Doppler U/S: enlarged, thickened epididymis w/ increased testicular blood flow
U/A: pyuria
Tx: Sexually transmitted (<35 yrs) -ceftriaxone/doxycycline Non-sexually transmitted (>35 yrs) -Fluoroquinolone: Levofloxacin, Ciprofloxacin -TMP-SMZ Chronic: abx x4-6w Orchitis: bed rest, scrotal elevation, cool compresses, NSAIDs
Testicular torsion Path: Pt: Dx: Tx:
Path: Twisting of spermatic cord causing reduced blood flow to testicle
Pt: Scrotal induration , edema, erythema and pain
Dx:
Absent cremasteric reflex
U/S w/ doppler: decreased blood flow
U/A to assess for pyuria and bacteriuria-> these would support epididymitis
Tx:
Manual detorsion -> “open book” rotation technique
Orchiopexy within 6hr of sx onset
Hydrocele Path: Pt: Dx: Tx:
Path: Cystic fluid collection in testicle
- Communicating: peritoneal/abd fluid enters scrotum via patent processus vaginalis failed to close
- Noncommunicating: collection of fluid between parietal and visceral layers of tunica vaginalis
Pt: Painless scrotal swelling
Communicating: worse with valsalva
Dx: + transillumination
Tx: Observe
Surgery: if persists >1yr of age, older pts with complications
Varicocele Path: Pt: Dx: Tx: Complications:
Path: Dilation of scrotal venous system
MC on left side
MC surgically correctable cause of male infertility
Pt: Dull ache
Dx: Clxl Palpable soft mass-> “bag of worms” superior to the testicle
Tx:
Observation vs surgery (spermatic vein ligation, varicocelectomy)
Complications:
- Sudden onset left side varicocele in older male-> possible renal cell carcinoma
- Right sided varicocele in children (<10)-> possible retroperitoneal malignancy
Cystitis and Pyelonephritis Path: Pt: Dx: Tx:
Path:
E. coli
Staph saprophyticus in adolescent females
Pt: Cystitis-> dysuria, frequency, urgency
Pyelonephritis -> High grade fever, chills; Flank pain, CVA tenderness, N/V
Dx: U/A: Leukocyte esterase, Nitrites, WBCs
Pyelonephritis: WBC casts
Urine culture
Tx: Uncomplicated cystitis: -Nitrofurantoin -Fluoroquinolones -TMP-SMX Complicated cystitis-> sx >7d, pregnancy, DM, immunosuppression, indwelling catheter, elderly, male -PO or IV: Cipro, levofloxacin -Aminoglycoside Pregnant: amoxicillin, augmentin, cephalexin, nitrofurantoin Pyelonephritis: -PO or IV: Cipro, levofloxacin -Aminoglycoside (amikacin, gentamycin)
Hyponatremia
Serum OSM ~280= 2Na + Glucose/18 + BUN/2.8
- High: correct for hyperglycemia; add 1.6 to Na for every 100 glucose
- Normal: pseudohyponatremia; hypertriglyceridemia or hyperproteinemia
- Low: assess volume status
Hypervolemic: Tx H20/Salt restriction
- Urine Na <20: CHF, nephrosis, cirrhosis
- Urine Na >20: acute/chronic renal failure
Euvolemic: Tx water restriction
- Renal tubular acidosis -> U/A
- Addison’s-> AM cortisol
- Thyroid (hypo)-> TSH
- SIADH-> psych meds, ecstasy
Hypovolemic: Tx IVF NS Renal loss Urine Na >20 -Diuretics: thiazides -ACEi, ARBs Extrarenal loss Na <10; FeNa<1 -Bleeding -Burns -GI (N/V/D) -Pancreatitis
Complication of rapid correction of hyponatremia
central pontine myelinolysis (demyelination)
correct no faster than 0.5 mEq/L per hour
Complication of rapid correction of hypernatremia
Cerebral edema
Hyperkalemia Path: Pt: Dx: Tx:
Path:
- Dec renal excretion: AKI, CKD, Hypoaldo
- Meds: K sparing diuretics, ACEi/ARB, digoxin, BB, NSAIDs
- Cell lysis: rhabdomyolysis, burns, hypovolemia, thrombocytosis, tumor lysis syndrome, leukocytosis
- K+ redistribution: metabolic acidosis (DKA)
- Pseudohyperkalemia: venipuncture MC, lab error
Pt:
Weakness, fatigue, paresthesias, flaccid paralysis
Palpitations, arrhythmias
Abd distention, diarrhea
Dx: K>5 Check glucose and bicarb CBC-> hemolysis CK-> rhabdomyolysis EKG: peaked T wave, QR shortening, wide QRS
Tx: Repeat lab unless sx present
- IV calcium gluconate-> severe sx (EKG changes)
- Insulin with D5W
- Sodium polystyrene sulfonate (Kayexalate): stool excretion
- B2 agonists: albuterol 12-20mg
- Bicarb: is metabolic acidosis present
- Loop directs, fludrocortisone
- Dialysis if severe
Hypokalemia Path: Pt: Dx: Tx:
Path:
- Urine/GI losses: diuretics, V/D, RTA
- Increased intracellular shift: metabolic alkalosis, B2 agonists, hypothermia, cholorquine use, Vit B12, insulin
- Hypomagnesemia
- Decreased K+ intake
Pt:
Severe muscle weakness (including resp), rhabdomyolysis, diabetes insipidus, dec DTRs
Palpitations, arrhythmias
Dx:
K<3.5
EKG: T wave flattening, prominent U-wave
Tx:
Tx hypomagnesemia if present
Replete oral»_space; IV
K+ sparing diuretics
