Tyler Pee Stuff DSAs + CIS Flashcards
What defines nocturia?
getting up to urinate more than 2x a night
What is the definition of urinary incontinence?
inability to control the urine flow
what are the 3 main cuases of nocturnal polyuria?
- age-related delay in urine excretion
- peripheral edema
- Medications (gabapentin, pregabalin, thiazolinediones, NSAIDs, CCBs)
What 5 meds are associated w/ nocturnal polyuria?
gabapentin
pregabalin
thiazolidinediones
NSAIDs
CCBs
What are internal and external dysuria?
internal: localized to the internal genital structures (urethra, bladder, suprapubic area)
external: localized to external genital structures (labia minora and majora) and occurs as urine exits the body
What is a complicated UTI?
UTI in individuals w/ functional or structural abnormalities of the urinary tract
at higher risk of tx failure
What is stress incontinence?
leakage of urine upon coughing, sneezing, or standing
due to urethral incompetence
common in older men - can be due to prostatic enlargement, urethral stricture, bladder neck contracture, or prostate cancer
in women - cystoceles or other anatomic problems
What is urge incontinence?
urgency and inability to delay urination
due to detrusor overactivity
most common cause of geriatric incontinence, usually idiopathic
What is overflow incontinence?
variable presentation
involuntary loss of urine caused by detrusor underactivity
idiopathic or due to sacral lower motor nerve dysfunction
What are the transient causes of urinary incontinence?
DIAPPERS
Delirium
Infection
Atrophic urethritis and vaginitis
Pharmaceuticals
Psychological factors
Excess urinary output caused by diuretics, excess fluid intake, metabolic abnormalities, peripheral edema
Restricted mobility
Stool impaction
What is DHIC?
detrusor hyperactivity with incomplete contractions
subtype of urge incontinence that can present with urgency w/ incomplete bladder emptying
Who gets stress incontinence most often?
women
(can be seen in men following prostatectomy)
What are sx of urethral obstruction?
dribbling, urge incontinence, and overflow incontinence
detrusor overactivity (coexists in 2/3 of cases) may cause sx of urgency
What distinguishes detrusor underactivity from detrusor overactivity and stress incontinence?
elevated post-void residual
generally over 450 mL
What are signs and sx of atrophic urethritis and vaginitis?
vaginal mucosal friability
erosions
telangiectasia (thread-like red lines on mucosa due to dilated small vessels)
petechiae
erythema
what lab tests should you run to evaluate incontinence?
review medications
check urinalysis and urine culture
consider tests for hyperglycemia, hypercalcemia, diabetes insipidus
What diagnostic test do you do for stress incontinence?
have pt relax her perineum and cough once while standing w/ full bladder
instant leakage –> stress incontinence if urinary retention has been excluded by postvoid residual determination using ultrasound
delay of several seconds or persistent leakage –> problem is caused by an uninhibited bladder contraction induced by coughing
What diagnostic procedures should you do for detrusor overactivity/urge incontinence and why?
detrusor overactivity may be due to bladder stones or tumor
if abrupt onset, esp if accompanied by perineal or suprapubic discomfort or sterile hematuria –> do cystoscopy and cytologic exam of the urine
What is the difference btw prostate hypertrophy and hyperplasia and its clinical management?
hypertrophy tends to have more malignant potential
hyperplasia tends to be more benign
ensure no cancer –> Sx management
What is the significance in tx choice of prostate cancer?
prostate cancer is super common in old men
always do risk benefit - are they going to die of this cancer or are there other co-morbidities that make the cancer less significant?
What are the two things that contribute to LUTS sx in BPH?
both size of prostate and also age-related detrusor dysfunction
“I like to think of the size of the bagel up someon’s butt vs the ability for them to adequately squeeze out pee” - Dr. Tyler
What are urine flow studies, bladder US, and Pressure-flow studies used for in BPH management?
urine flow studies: can ID those with normal flow rates who are unlikely to benefit from tx
bladder U/S: can id those w/ high postvoid residuals who may need intervention
pressure-flow (urodynamic) studies: detect primary bladder dysfunction
when would you do a cystoscopy in BPH/ LUTS sx?
if ther is hematuria
to assess urinary outflow tract before surgery
What are LUTS?
urinary frequency, urgency, retention, and incontinence
trouble starting urine stream
weak or interrupted stream
dribbling at end of urination
nocturia
pain after ejaculation or during urination
urine w/ unusual color or smell
How do you use the AUA symptom scale?
have pt fill out questionairre; 0-7 = mild, 9-19 = moderate, 20-35 = severe
What are the respective effects of alpha Receptor inhibitors and 5 ARIs in tx of BPH?
Alpha blockers: tx dynamic aspect of BPH by reducing sympathetic tone of bladder outlet
5 ARIs: treat static aspect by reducing prostate volume; delayed effect
(often used in combo to tx sx and delay progression)
What are the main pharm agents for tx of overactive bladder sx?
anticholinergics
When would you do surgery to tx BPH?
second line therapy done after a trial of medical therapy that has failed
why should you take a genitourinary family hx?
risk of being dx w/ prostate cancer increases 2.5-fold if one 1st degree relative is affected
fivefold if two or more are affected
(estimated 40% of early onset and 5-10% of all prostate cancers are hereditary)
How effective are DRE and PSA at detecting prostate cancer?
DRE = 3.2% detection
PSA = 4.6%
combined = 5.8%
How should you use DRE and PSA?
do not measure PSA in asymptomatic men with a short life expectancy
DRE and PSA not recommended in routine screening
determine risk for BPH and prostate cancer before getting PSA
for men w/ PSA of 4-7, refer to urology if sx score is moderate to severe
What is the difference btw UTI and ASB?
ASB = asymptomatic bacteruria
dont have to tx this w/ antibiotics
tx UTI bc this implies it is symptomatic
What makes the dx and tx of cystitis ambiguous?
What is the main distinguishing factor btw cystitis and pyelonephritis?
many elderly pts can’t mount a fever response
fever is the main distinguishing factor btw cystitis and pyelonephritis - fever in kidney infxn
What is emphysematous pyelonephritis?
severe form of dz associated w/ production of gas in renal and perinephric tissues
occurs almost exclusively in diabetic pts
often found thru U/S
What is xanthogranulomatous pyelonephritis?
occurs when chronic urinary obstruction (often by staghorn calculi), together w/ chronic infection, leads to suppurative destruction of renal tissue
residual tissue is often yellow w/ infiltration by lipid-laden macrophages
When should an intraparenchymal kidney abscess be suspected?
when a pt has continued fever and/or bacteremia despite antibacterial therapy
What can bethe first indication of rare bilateral papillary necrosis?
rapid rise in serum creatinine
which is more common, bacterial prostatitis or chronic pelvic pain syndrome?
chronic pelvic pain syndrome is much more common
How can heart failure lead to nocturia?
reduced renal perfusion during the day when pt upright –> normalizes only at night when pt is supine –> consequent diuresis
What are the essentials of diagnosis of urinary stones?
severe flank pain
nausea and vomiting
ID of stone on non-contrast CT scan or U/S
What are most urinary stones like?
85% contain calcim and are radiopaque
uric acid stones are radiolucent
What are hyperoxaluric calcium stones due to?
primary intestinal disorders, including chronic diarrhea, inflammatory bowel dz, or steatorrhea
What cause hypocitraturic calcium stones?
secondary to disorders associated w/ metabolic acidosis including chronic diarrhea, typ I tubular acidosis, and long-term thiazide tx
What are the contributing factos to uric acid calculi?
low urinary pH
myeloproliferative disorders
malignancy w/ increased uric acid production
abrupt and dramatic weight loss
uricosuric medications
What is the urine pH in struvite calculi?
7.2 or greater
What stones are suggested by peristent urinary pH < 5.5?
uric acid
or cystine
What is the most accurate imaging tool to evaluate pyelonephritis?
spiral CT
(plain film and renal u/s also work, but most ED docs will choose CT)
How do you prevent urinary stones?
increase fluid intake to void 1.5-2.0 L/day to reduce stone recurrence
reduce sodium intake
reduce animal protein intake
When do you admit someone w/ a urinary stone?
intractable nausea/vomiting or pain
obstructing stone w/ signs of infection (consult urology asap)
What are the usual and unusual causes of acute bacterial prostatitis?
usual: E coli and pseudomonas
unusual: enterococcus
What do you see on labs in acute bacterial prostatitis?
CBC: leukocytosis and left shift
Urinalysis: pyuria, bacteriuria, hematuria
urine culture: positive
What are your medication options for tx of acute bacterial prostatitis?
IV ampicillin and an aminoglycoside until afebrile for 24-48 hrs, then oral quinolone for 4-6 weeks
ampicillin, 1 g IV every 6 hours, gentamicin 1 mg/kg IV every 8 hrs for 21 days
ciprofloxacin BID for 21 days
ofloxacin BID for 21 days
trimethoprim-sulfamethoxazole BID for 21 days (increasing resistance noted)
What is the first step in management if a pt presents to you with red or brown urine?
must confirm gross hematuria with centrifuge unless sx are strongly suggestive
Should pts be routinely screened for microscopic hematuria?
no, US Preventive Health Services Task Force does not recommend it
What is the relationship of microscopic hematuria to bladder cancer?
low predictive value, even in high-risk elderly pts
no evidence that early detection improves prognosis
If there is a positive supernatant for hemoglobin by urine dipstick, what are the ddx?
hemoglobinuria (intravascular hemolysis)
myoglobinuria (breakdown of skeletal muscle)
If there is negative gross hematuria, neg hemoglobin, but positive red, brown or black supernatant, what are your ddx?
red: beet or blackberry, drugs (rifampin, sulfa, thiazines)
brown or black: liver dz, acute porphyria, ochronosis, melanoma
what is the definition of gross hematuria?
presence of blood in the urine in sufficient quantity to be visible to naked eye
95% of clinicians will only recognize when > 3500 RBCs per high-power field
What is the definition of microscopic hematuria?
2-3 RBCs per high-power field on urine microscopy
What are the 3 highlighted Ddxs for hematuria?
renal cell carcinoma
glomerulonephritis
medullary sponge kidney
What are risk factors for bladder cancer?
smoking
occupational exposure to chemicals
heavy phenacetin use
past tx w/ high dose cyclophosphamide
aristolochic acid found in some herbal weight-loss preparations
What should you consider with hematuria in pts on anticoagulants?
shouldn’t be attributed solely to the anticoagulant
How can hematuria be related to dysuria?
blood in urine can be an irritant –> can cause dysuria even in the absence of UTI or kidney stone
What should be considered with hematuria in older men?
gross or micro hematuria are more likely to be due to a GU malignancy
diagnostic eval should be pursued even in the presence of sx suggesting BPH
what upper UTI microbe can cause hematuria?
schistosoma haematobium
What are alarm sx associated w/ hematuria?
increased age + male sex –> cancer
constitutional sx –> cancer or chronic infection
personal and social hx risks –> cancer
pos fam hx of deafness or renal dz –> familial dz (alport syndrome)
What can a hx of irregular heartbeat and hematuria suggest?
renal embolus from atrial fibrillation
What can a hx of nephrotic syndrome and hematuria suggest?
renal vein thrombosis
What do visible blood clots within bloody urine suggest?
never due to a glomerular cause
indicate lower urinary tract source of hematuria
What pivotal points help distinguish glomerular hematuria from non-glomerular causes?
dysmorphic RBCs
red cell casts
new or acutely worsening HTN or proteinuria
increased creatinine
What are the essentials of dx of renal cell carcinoma?
gross or microscopic hematuria
flank pain or mass
systemic sx (fever, weight loss, etc)
solid renal mass on imaging
What are the best imaging studies to detect renal cell carcinoma?
CT and MRI - confirm character of the mass, stage the lesion
What are the prognosis of T1-4 renal cell carcinomas?
T1-T2 confined to renal capsule = 5 yr dz-free survival of 90-100%
T3-T4: extending beyond capsule = 50 - 60%; node-positive = 0-15%
Solitary resectable mets w/ radical nephrectomy and resection of mets = 15-30% 5 yr dz-free survival
What is the highlighted familial syndrome with renal cell carcinoma?
Von Hippel-Lindau syndrome
(autosomal dominant, see tumors in many places in the body)
What can IgA nephropathy be secondary to?
hepatic cirrhosis
celiac dz
HIV infection
cytomegalovirus infection
What is the most common primary glomerular dz in the world, esp in Asia?
Who gets it and what is the classic presentation?
IgA nephropathy
usually occurs in kids and young adults, males 2-3x more than females
episodic gross hematuria during URIs
What do you see on IF in IgA nephropathy?
mesangial IgA and C3 deposits
What intrisic kidney dzs most commonly present as gross hematuria?
IgA nephropathy
cyst rupture in ADPKD
What tests confirm IgA nephropathy?
serum IgA elevated in 50% of pts
dx confirmed by IgA deposits in mesangium on renal biopsy
What is the Oxford IgA nephropathy MEST classification?
standardized diagnosis tool for IgA nephropathy
Mesangial hypercellularity
Endocapillary hypercellularity
Segmental glomerulosclerosis
Tubular atrophy/ interstitial fibrosis
What genetics cause medullary sponge kidney (MSK)?
autosomal dominant mutations in:
MCKD1 on chr 1
MCKD2 on chr 16
Where are the cysts in MSK?
medullary and interpapillary collecting ducts`
How does MSK present?
gross or microscopic hematuria, recurrent UTIs, or nephrolithiasis
often found indidentally
What are common abnormalities/complications of MSK?
decreased urinary concentrating ability
nephrocalcinosis
What do you see on CT of MSK?
cystic dilation of distal collecting tubules
striated appearance in this area
calcifications in collecting sys
What imaging in the past and present detects MSK?
in the past, often made by IV pyelography
now CT urography has replaced, but its not as sensitive in detecting MSK
What kind of kidney stones are increased in freq in MSK (medullary sponge kidney)?
calcium phosphate
calcium oxalate
