Urology Flashcards
What is the normal Gfr range?
Less than 90
Patient presents with acute onset of high fevers, chills, dysuria, frequency, and unilateral flank pain. The flank pain is described as a deep ache. May complain of nausea with vomiting. And they have recent history of urinary tract infection.
Acute pyelonephritis
Infection of the upper urinary tract and renal parenchyma
Acute pyelonephritis
Untreated for undertreated UTI, urinary tract abnormalities, elderly, fecal incontinence, and pregnancy are all risk factors for
Acute pyelonephritis
CVA tenderness, fever, pyuria, white cells in urine, and casts are all findings associated with
Pyelonephritis
What are the diagnostic studies for pyelonephritis
Urine analysis which shows pyuria, possibly hematuria, and mild protein urea. Urine culture with sensitivity. CBC will show leukocytosis, CVA tenderness, fever, sed rate i.e. ESR
How is pyelonephritis treated
Culture before starting antibiotic. Quinolones are the only anti-microbial’s recommended for outpatient treatment. If Unable to take quinolone start Ceftriaxone 1 g. Plus Augmentin times 14 days i.e. Rocephin. Hospitalize if patient appears toxic
What is the antibiotic of choice for pyelonephritis
Quinolones
Infection of the upper urinary tract and renal parenchyma
Acute pyelonephritis
What might be the significance of white cell casts
Pyelonephritis
White blood cells in urine signifies
Inflammation which signifies pyelonephritis
If white blood cells are found in the urine is this consistent with a UTI
No
Patient presents with the abrupt onset of oliguria, edema, and weight gain i.e. fluid retention. Complains of lethargy, nausea, and loss of appetite. Rapid decrease in renal function. Elevated urinary and serum creatinine.
Acute renal failure
What is located in the retro peritoneal area
Kidneys
Why is the right kidney lower than the left
Displacement by the liver
What are the functional units of the kidney
Nephrons which contain the glomeruli
What is the body’s regulator of electrolytes and fluids
Kidneys
Urinary output that is less than 400 mL per day in adults
Oliguria
What part of the body excretes erythropoietin for red blood cell production, Renin and Bradykinin for blood pressure, prostaglandins for renal perfusion, and Calcitrol and vitamin D3 for the bones
Kidneys
What is related to muscle Mass in the kidneys
Creatinine production
What level decreases with age and loss of muscle mass by the age of 30
Creatinine
If a patient has high muscle mass that the creatinine maybe
Lad
Falsely normal but actually it’s low
What lab level is a better measure of kidney function
Creatinine clearance
When renal function decreases, the creatinine level well
Increase
Serum creatinine maybe falsely decreased in people with
Low muscle volume i.e. the elderly
Elevated values in creatinine are seen with
Renal damage or failure, nephrotoxic drugs.
What are some factors that affect the serum creatinine in people
Males as they have a higher level, race as African-Americans have more muscle mass, and muscle mass
What test is ordered to evaluate patients with protein urea, Albuminuria, and microalbumin urea.
Creatinine clearance 24 hour urine
When renal function decreases the creatinine clearance
Also decreases
Normal GFR rate is
Greater than 60 mL
What drugs can affect the GFR rate
Allopurinol, many antibiotics, digoxin, lithium, gabapentin, H2 blocker’s, anti-arrhythmic’s
What GFR level would mean renal failure
Less than 15 mL
Before getting a GFR what is it important for the patient to not eat
Patient should not eat me 12 hours before the blood test
If a patient has an abnormal BUN level what must be checked
GFR
Is the BUN as sensitive as the serum creatinine or the GFR
No
The BUN to creatinine ratio oh is used to classify
The type of renal failure such as Renal, infrarenal, or post renal
When do you do a urine culture
For recurrent infections, if refractory to treatment, and in children, women, and the elderly
What does it mean if if there is nitrates in the urine
Bacteria is present
What does it mean if they are nitrates in the urine
Nitrates are normal. Think A as is A-ok!! Normally found in urine
Nitrites equals
Infection. Think I as in infection. Abnormal never normal usually gram-negative bacteria such as E. coli.
Pyuria is
White blood cells in the urine which equals infection. Most reliable indicator of infection. 95% sensitive. Usually indicates UTI
What does leukocyte esterase test for
Test for enzyme present and white blood cell. Usually indicates UTI.
A large amount of epithelial cells in the urine sample indicates
Contamination as a few epithelial cells are considered normal
How many white blood cells in the urine is considered normal
Less than or equal to 10 white blood cells per milliliter
Presence of leukocytes in the urine or pyuria is
Always abnormal in males and means infection
In a urine culture greater than or equal to how many milliliters of bacteria is indicative of a UTI
10 to the fifth power CFU/ML of bacteria
How many red blood cells are considered normal in a urinalysis
Less than five cells
What conditions cause hematuria
Kidney stones, Pyelonephritis , and sometimes in cystitis
Protein in the urine indicates
Kidney damage i.e. chronic kidney disease
What may be present in the urine with acute pyelonephritis
Protein urea
Nitrates are indicative of
Infection with E. coli
Are hyaline casts normal in concentrated urine
Yes
With UTI and Pyelonephritis are white blood cell casts seen
Yes
Red blood cell casts and proteinuria are diagnostic for
Glomerulonephritis
Infection and inflammation of the bladder with presence of bacteria in the urine. E. coli is the most common bacteria
UTI
Back pain can also mean
Kidney infection
What is the first choice of treatment for uncomplicated UTI
Nitrofurantoin or Macrobid which is pregnancy category B
How long do you treat women with UTIs
Three day therapy if uncomplicated
How long do you treat a male for UTI
7 to 10 days
If it is a Complicated UTI or comorbidities how long to treat
Consider 7 to 10 days
What conditions make a UTI complicated
Pregnancy, fever, diabetes
What comfort measures can be taken for UTI
Anti-spasmodic for dysuria such as Phenazopyridine (Pyridium), Flavoxate (Urispas)
What medication can discolor urine orange
Anti-spasmodic
What are health promotion measures for UTI
Prompt treatment, hydration especially for elders, avoid bladder irritants such as caffeine, alcohol, carbonation and artificial sweeteners. Void after sexual intercourse extra lubrication and patient needs to follow up if blood is present on diagnosis
Other than E. coli what other bacteria can cause a UTI or cystitis
Staphylococcus saprophyticus, proteus mirabilis, and klebsiella pneumoniae
In what population is a UTI more likely to progress to pyelonephritis
Children younger than age 3 and pregnant women
In infancy are UTIs more common in boys or girls
Boys usually due to anatomic abnormality
Are males or females adolescent to adults at a higher risk for UTIs
Females of reproductive age
What are some risk factors for UTI
Female gender with Pregnancy, history of recurrent UTI or history of recurrent infections, diabetes mellitus or immunocompromise, failure to void after sex or increased sexual intercourse, spermicidal use within the past year, infected renal calculi, low fluid intake, poor hygiene, catheterization
A sexually active female complains of new onset of dysuria, frequency, frequent urge to urinate, and nocturia. May also complain of suprapubic discomfort. Not associated with fever. Urine dipstick will show moderate to large amount of leukocytes and will be positive for nitrates. May show a few red blood cells due to inflammation, negative for ketones and protein
Urinary tract infection or Cystitis
Symptomatic bacteriurua with leukocytosis, fever, chills, malaise is treated as
UTI
pyridium (phenazopyridine) Should be avoided for patients with
Liver or renal disease, G6PD anemia
If clinical symptoms persist for 48 to 72 hours after initiating antibiotics for her UTI
Order urine culture and sensitivity and urine analysis. Rule out pyelonephritis. Switch to another antibiotic drug class such as a quinolone and treat for 7 to 10 days
How long should complicated UTIs be treated
7 to 10 days
What patients would be considered a complicated UTI
Males, diabetics, pregnant women, children or elderly, immunocompromised, recurrent UTIs or reinfections, anatomic abnormality’s of the kidneys or ureters including kidney stones
What are the labs for complicated UTI’s
Urinalysis and urine culture and sensitivity before and after treatment to document resolution
Are UTIs ever normal in males
No. rule out ureteral stricture, infected kidney stones, anatomic abnormality, acute prostatitis, STI’s. Must be evaluated further. Refer to urologist
Three or more UTIs in one year or two infections within six months
Re-current UTI never normal in males
With recurrent UTIs what must be ruled out
Infected stones, reflux, fistulas, ureteral stenosis, urologic abnormalities
Long-term use of nitrofurantoin is associated with
Lung problems, chronic hepatitis, and neuropathy.
Nitrofurantoin is contra indicated with
Renal insufficiency
Acute bacterial infection of the kidneys most commonly due to gram-negative bacteria such as E. coli, Proteus Mirabilis, and klebsiella pneumonia. Outpatient treatment is only from milder cases that are uncomplicated i.e. immunocompetent adult female with normal urinary/renal system without comorbidities and compliant patients
Acute pyelonephritis
Adult patient presents with acute onset of high fever, chills, nausea/vomiting, and one sided flank pain. Some patients may have symptoms of cystitis such as dysuria, frequency, and urgency.
acute pyelonephritis
Physical exam shows fever equal or greater than 100°F, CVA tenderness on one kidney, urine dipstick with large amounts of leukocytes, hematuria, WBC casts, and protein urea. Urine culture and sensitivity shows presence of 10 to the fifth power ML of one organism. CBC shows leukocytosis, neutrophilia with shift to the left. Presence of bands noted.
Acute pyelonephritis
In order for a UTI to be diagnosed how many organisms need to be noted in a urine sample
Greater than 10,000 ML of one organism
White blood cell casts With protein urea is associated with
Pyelonephritis
What is a better measure of renal function compared with BUN or BUN and creatinine ratio.
Serum creatinine
Which kidney sits lower because of displacement of the liver
Right kidney
Large numbers of epithelial cells in the urine mean
Contamination
What is a normal white blood cell count and neutrophil or seg count
Normal white blood cell count is 10.5 and neutrophil/seg is greater than 80%
Neutrophils make up how much percent of all of the white blood cells in a sample
50 to 75%
If band forms are seen it is indicative of
A serious bacterial infection
Immature white blood cells
Neutrophil or band forms or secs
What two serum studies are preferred to BUN when checking renal function
Serum creatinine and GFR
Long term use of nitrofurantoin is associated with
Lung problems, chronic hepatitis, and neuropathy
The majority of kidney stones is made up of
Calcium oxalate
What are two risk factors for kidney stones or nephrolithiasis
Family history of stones, low fluid intake, gout, bariatric surgery
Adult with acute onset of severe colicky flank pain on one side that comes in waves. The pain builds up in intensity, then lessons and disappears. For some, the pain can be extreme and associate with nausea and vomiting. Majority have hematuria. Urine in maybe pink from blood.
Nephrolithiasis (kidney stones)
What labs are needed for kidney stone or nephrolithiasis diagnosis
Instruct patient to strain urine for several days and to bring a kidney stone to office if past for analysis by laboratory. Order renal ultrasound to determine location and stone size. Urinalysis until the episode resolves. Refer to urology if large stone and inability to pass it or acute renal failure. Refer to ED with high fever extreme pain and acute renal failure
What dietary measures should be taken with nephrolithiasis/kidney stones
Increase fluid and take up to 2 L per day. Avoid high oxalate foods such as rhubarb, spinach, beats, chocolate, tea, and meats
Involuntary loss of urine from the urethra
Urinary incontinence
What type of urinary incontinence is due to an unstable bladder
Urge incontinence
What type of urinary incontinence is due to laughing, coughing or jumping
Stress incontinence
What type of urinary incontinence has components of both urge and stress incontinence
Mixed incontinence which is most common
What should be avoided in urinary incontinence
Alcohol, carbonation, coffee or tea, citrus juices
What is the treatment for Urge, stress, and mixed urinary incontinence -behavioral therapy
Weight loss especially for stress incontinence, regular voiding but not frequent, pelvic floor muscles i.e. Kegel exercises at three sets of 10 to 12 contractions for five seconds each daily for three months, minimize fluids after dinner, take diuretics in the afternoon not at night
What pharmacologic measures can be taken for urinary incontinence
Anti-cholinergics for urge and stress urinary incontinence. Side effects include dry mouth, Eyes, & G.I. I.e. Vesicare RX. Estrogen for post-menopausal over active bad bladder, biofeedback, pelvic physical therapy, and Surgery for stress incontinence
What medication is best for urinary incontinence due to fewer side effects over the anti-cholinergics
Mirabegron Rx.
A patient with a history of kidney stones presents to your office. He has intermittent pain that is rated Four out of 10 but now has become nine out of 10. What describes his demeanor in the exam room
He is lying on the table and rolling from side to side
How do you treat kidney stone
Toradol injection if not contraindicated, Then refer to ER. Referral for hospitalization if infection is present, stone is greater than 6 mm in diameter, and excessive nausea and vomiting is present. Urological consult if obstruction suspected or symptoms persist greater than 3 to 4 days. Consider an alpha blocker such as Flomax for a calcium channel blocker such as Nifedipine as these medications are off label use
85% of bladder cancer presents with
Hematuria
What can cause hematuria in adults
Malignant neoplasm’s of the renal and bladder, infection, renal calculi, kidney stones, coagulopathy, glomerular disease, hydronephrosis, polycystic kidneys, trauma, medications, BPH, exercise-induced which results in 72 hours
What are risk factors for malignancy of the renal system and bladder
Age greater than 40, smoking history, occupational exposure, chronic cystitis, history of pelvic irradiation, history of analgesic abuse
Red blood cells are found in the urine what must be considered
Always pathological, consider glomerulonephritis, urinary tract injury
If a male presents with symptoms of burning with urination what part of the body would you not examine
Abdominal area
A symptom of scrotal heaviness in men is consistent with
Inguinal hernia
If a 76-year-old male patient presents with urethral irritation after voiding and STDs are ruled out what can be another etiology
Chronic prostatitis
If a 24-year-old female patient presents and is diagnosed with uncomplicated UTI which assessment is least important at this time
Vaginal exam
If a female patient is diagnosed with UTI and a bacteria count was collected midstream clean catch how many bacteria would be found in the sample
Greater than 100,000 bacteria
If a patient presents with flank pain that waxes and wanes what finding on urine analysis should direct the next action
Blood
A 72-year-old male patient has early renal insufficiency he. What laboratory test best assesses his kidney function
Glomerular filtration rate
What causes an insignificant increase in prostate specific antigen
Digital rectal exam
A patient with urolithiasis is most likely to
Be of male gender
A patient with dysuria has a urine specimen that reveals less than 10,000 bacteria and numerous trichomonads how should this patient be managed
Flagyl for seven days
Classical findings in a urinary tract infection in a urine sample are
Positive leukocytes and positive nitrates
If a patient takes her saw palmetto he is using it because he thinks it
Improves urine flow
A 25-year-old male patient with subacute bacterial epididymitis should be treated initially with
Doxycycline
Hey sexually active male patient presents with epididymitis What finding is likely
Recent history of heavy physical exercise
An example of a drug that targets the Renin– angiotensin – aldosterone system is
Ace inhibitor
What are symptoms of proctitis
Rectal pain, bleeding, and a continuous sensation to defecate (tenesmus)
Inflammation of the lining of the rectum leading to rectal pain etc.
Proctitis
A whitish sebaceous secretion that collects between the glans penis and foreskin or in the vulva is known as
Smegma
And then painful urination without frequency urgency suggests
Urethritis
What symptoms indicate a cute glomerulonephritis
Hematuria, protein urea, hypertension
At what point in a males life does BPH begin
Third decade of life
What condition usually coexists with epididymitis
Chlamydia infection
A 50-year-old male describes difficulty emptying his bladder. On exam a distended bladder is noted. this finding may be associated with
Functional incontinence
In a newborn what is the renal adaptation
The kidneys have an inability to concentrate urine and adapt to fluid and electrolyte stress
When examining the scrotum and a young male child, test the ceemasteric reflex by
Scratching the medial aspect of the thigh
Stress urinary incontinence is
Maybe aggravated by caffeine or alcohol
A 72-year-old man has chronic prostatitis. What is the initial drug treatment of choice for this patient
Ciprofloxacin or Bactrim
Is the prostate gland boggy with BPH
No it is rubbery
A patient post op TURP procedure should be monitoring
For bladder spasms
Will a U/A show protein in acute pyelonephritis
No. But it will show nitrates, white blood cells, and red blood cells
Micro albumin urea is a measure of
Protein lost in the urine
A nurse practitioner palpates a nodule during a prostate exam. What other clues may indicate prostate cancer?
Elevated PSA and hematuria
What is the most common early sign of colchicine toxicity
Diarrhea
When is asymptomatic protein urea seen in patients
It is often seen in patients who participate in strenuous exercise programs or who do physical labor.
