Urology Flashcards

1
Q

Renal colic vs peritonitis

A

Renal colic - unable to find comfortable position

Peritonitis - movement increases pain, lies still

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2
Q

Risk and Presentation of nephrolithiasis

A
Risk:
Diabetes
Gout
Renal tubular acidosis
Hypercalcemia
Hyperparathyroidism
Family or personal history
Drugs - loops and thiazide diuretics, acetazolamides, topiramate

Presentation:
Acute colicky flank pain radiates to ipsilateral LQ, genital pain
hematuria
N/V
Lower UTI sxs - urgency, frequency, discomfort while voiding

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3
Q

Diagnosis and treatment of nephrolithiasis

A

Imaging:
KUB - radiopaque Stones
CT abd/pelvis - noncontrast stone protocol; most sensitive, can detect uric acid stones
U/S if pregnant
IVP - get scout KUB, give contrast, serial XR

Tx:
Most resolve spontaneously 1-2 weeks

Small stones:
Pain control
Hydration
Urinary strainer - Chemical analysis
Tamsulosin - relaxes smooth muscle in distal ureters to help pass stone
Nifedipine - less commonly used, same mech as above, also impacts BP

Surgical intervention:
\+ fever - risk of sepsis
pain uncontrolled
Unable to pass after several weeks
Elevated creatinine
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4
Q

Surgical intervention - nephrolithiasis

A

Lithotripsy - upper ureter renal collecting system
-must be able to see Stone

ureteroscopy - distal ureter

Percutaneous nephrolithotomy - staghorn or over 3 cm

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5
Q

Most common site of renal stone impaction

A

ureterovesicular junction

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6
Q

Hydronephrosis

A
Dilation of renal pelvis and calyces
Urinary obstruction -> elevated intrarenal pressure
-kidney stones, B/l urgent
-BPH
-cancer
-posterior urethral valves
Presentation:
Usually asx
Vague flank pain
UTI sxs
Anuria

Dx:
r/o obstruction in anurial patient - cath

Tx: underlying obstructions
Ureteral stent
Nephrostomy tube if obstruction is high

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7
Q

Calcium oxalate stone

A

Causes:
Hyper calciuria
Hyperoxaluria
Ethylene glycol ingestion

MC stone type

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8
Q

Calcium phosphate stones

A

Causes:
Hyperparathyroidism
Renal tubular acidosis

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9
Q

Cystine stones

A

Causes: cystinuria

Staghorn calculi
Uncommon - difficult to treat
Hereditary

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10
Q

Uric acid stones

A

radiolucent

Causes:
Gout
Chemo - increase protein metabolism

Can be dissolve by alkalizing urine

  • potassium citrate
  • sodium bicarbonate
  • sodium citrate
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11
Q

Struvite stone

A

Mg-NH4-PO4

UTIs with urease-positive bacteria

  • klebsiella
  • Proteus mirabilis
  • staphylococcus saprophyticus

tend to form staghorn stones

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12
Q

Hematuria Causes

A

Infection, renal stones, trauma
Bladder or renal malignancy - painless, gross hematuria, smoker
Prostate pathology
Endometriosis in GU tract - cyclical
Rheumatic fever, Goodpasture’s syndrome, granulomatosis with polyangiitis, Henoch-Schonlein purpura
Glomerular disease
Sickle cell disease, hemophilia, thrombocytopenia
Simple renal cyst, polycystic kidney disease
Medications - anticoagulants, cyclophosphamide, salicylates, sulfonamides
Exercise-induced

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13
Q

Hematuria - dx

A

gross hematuria - blood is seen - post renal
Microscopic hematuria - more than 3-5 RBC on UA - glomerular

Labs:
UA, urine cytology, 24 hr urine protein, coagulation studies, CBC, BUN/Cr

Imaging: cystoscopy - evaluate for bladder CA
CT/US for stones, cysts, neoplasms

Bx: eval glomerular dz

Treat underlying cause

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14
Q

Red urine ddx

A
rifampin
nitrofurantoin
porphyrins
beets
menses
hematuria - gross
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15
Q

Cystitis

A

Complicated - diabetes, pregnancy, urinary obstruction, immunosuppression, indwelling catheter, abnormal anatomy of GU tract, sxs lasting >7 days, renal failure

Risk factors: female, recent sex, spermicide, hx of UTI

Presentation
Dysuria
Frequency
Urgency
Suprapubic pain
Hematuria - rare

UA: pyruia, bacteria

Bacteria: E. coli (MC), S. saprophyticus, Enterobacter, enterococcus, Proteus, Klebsiella

Tx:
Uncomplicated - nitrofurantoin x5 d, TMP-SMX x 3 d, or fosfomycin single dose

Complicated or pyelo - ciprofloxacin or levofloxacin

Pregnancy: amox, ampicillin, cephalosporins, nitrofurantoin

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16
Q

Most common causes of urethritis

A

Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma
Ureaplasma

17
Q

Urethritis

A
Presentation:
Dysuria
Urgency
Frequency
Purulent urethral discharge

Dx:
gram stain of discharge
DNA amplification

Tx:
Ceftriaxone IM x1
PO doxy or azythromycin

Treat partners

Complications:
Reinfection of partner
Urethral stricture or scarring
Narrowing of urethral lumen

18
Q

Urge incontinence

A

leakage of urine associated with strong urge to void

Cause: uninhibited bladder contractions

Dx: r/o UTI

Tx:
darifenacin
fesoterodine
oxybutynin
Solifenacin
Tolterodine
Trospium

S/E: constipation, Blurred vision, dry mouth, cNS/cognitive deficits in elderly

19
Q

Stress incontinence

A

Leakage of urine during increased abdominal pressure - cough, sneeze, exercise

Risk: obesity, multiparity, female, hx of urethral or prostate surgery in men

Dx: eval for pelvic organ prolapse, urodynamics

Tx:
Kegal exercises
Weight loss
Pessary
Meds: duloxetine
Surgery - midurethral sling
20
Q

Overflow incontinence

A

Leakage of urine from a overly distended bladder - incomplete emptying

Cause: bladder outlet obstruction (BPH), atonic bladder - spinal injury/disease, DM neuropathy

Presentation:
Constant urinary dribbling
Feeling of incomplete bladder emptying - fullness

Dx:
U/S assess bladder emptying
Cathereterized postvoid residual

Tx:
Decompress bladder with catheter
Address underlying cause

21
Q

Bladder cancer

A

Transitional cell carcinoma - MC in US

Squamous cell carcinoma - underdeveloped countries, Schistosoma haematobium, chronic irritation (indwelling cath)

Adenocarcinoma - dome, urachial remnant

Risk:
Tobacco
Schistosomiasis
anilin dye or petroleum byproducts
recurrent UTI
M>F
Cyclophosphamide
Presentation:
gross hematuria - painless
Hx smoking
UTI sxs - urgency, frequency, dysuria
Wt loss, fever, palpable suprapubic mass

Dx:
UA: RBCs, cytology
Cytoscopy to visual tumor

Tx: transurethral cytoscopic resection
Radical cystectomy w/ urinary diversion
Rad/chemo if mets

F/U surveillence cystoscopy and intravesicular chemo
If superficial, increased recurrences

22
Q

Varicocele

A

Dilation of veins in the spermatic cord in the pampiniform plexus in the scrotum

“bag of worms”

Right sided - r/o renal cell carcinoma

Color Doppler ultrasound - retrograde flow to scrotum

Tx: surgery - disrupt dilated vein

23
Q

Hydrocele

A

Collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis

Will transilluminate

Tx: surgical excision of hydrocele sac if symptomatic

Can occur in infants due to patent processus vaginalis

24
Q
Testicular torsion
Onset
Infection
Visual changes
Support
Cremasteric reflex
U/S
Treatment
A

Onset - acute, abrupt, and often associated with physical activity
Infection - no signs
Visual changes - raised and horizontal testicle
Support - no change in pain
Cremasteric reflex - absent
U/S - compromise blood flow
Treatment - surgical detorsion w/ b/l orchiopexy within 6 hrs

25
``` Epididymitis Onset Infection Visual changes Support Cremasteric reflex U/S Treatment ```
Onset - subacute and may be associated with STDs and/or anal intercourse Infection - urethral discharge, fever, dysuria, erythema Visual changes - normal position Support - lowers pain Cremasteric reflex - present U/S - normal blood flow Treatment: under 35 - G/C -> ceftriaxone IM + doxy x10 or azithromycin x1 over 35 or h/o anal sex - Enterobacteriaceae -> fluoroquinolone x10-14 day or TMP-SMX
26
Testicular cancer
15-35 yo MC solid cancer 95% germ cell tumors - seminomas, nonseminomatous (embryonal, choriocarcinoma, teratoma, yolk sac young boys) 5% stromal cells tumors - Leydig, Sertoli, granulosa Risk factors: Undescended testicle Prior history of testicular cancer Family history Presentation: Painless, firm testicular mass Gynecomastia (rare) sxs of mets - retroperitoneal LN -> mediastinal LN Labs: b-hCG - choriocarcinoma, nonseminomatous germ cell tumors AFP - Embryonal, yolk sac of nonseminomatous AFP never elevated in Coriocarcinomas or Seminomas Estrogen - stromal cell tumors ``` Dx: Scrotal US CT of abd/pelvis CXR Radial orchiectomy ``` Tx: Stage 1 seminoma - radical orchiectomy Stage 2 seminoma - chemo Early stage nonseminoma - active surveillance if no risk factors Later stage nonseminoma - retroperitoneal LN dissection and/or chemo NO RADIATION
27
Causes of erectile dysfunction
``` Surgery on prostate or retroperitoneum Diabetic neuropathy Vasculogenic - low blood flow, htn, hld, smoking Hypothyroidism Hypogonadism Psych Drug abuse heavy alcoholism ``` Dx: testosterone level, LH, and prolactin +/- MRI brain
28
Medication is known to cause erectile dysfunction
``` Most antidepressants - esp SSRIs Spironolactone Sympathetic blockers - clonidine, guanethidine, methyldopa thiazide diuretics (rare) ketoconazole cimetidine antipsychotics ```
29
Treatments available for erectile dysfunction
1st line: phosphodiesterase inhibitor - sildenafil, vardenafil, tadalafil 2nd line: penile self injectable drugs - papaverine, phentolamine, alprostadil -vacuums and constriction devices 3rd line - penile prosthesis implantation Androgen replacement if hypogonadal
30
Acute prostatitis
``` Bacterial: E. coli Proteus Klebsiella Enterobactor Serratia Pseudomonas G/C + urethritis ``` ``` Presentation: Fever, chills, myalgias Frequency, urgency Rectal pain Cloudy urine Pain at the tip of penis ``` DRE: warm, firm, edematous, tender prostate Labs: leukocytosis, pyuria, bacteruria, + blood cx, elevated PSA urine gram stain and cx Tx: empiric -> sensitivities TMP-SMX Fluoroquinolones - cipro, levo
31
chronic pelvic pain syndrome/chronic prostatitis
Presentation: Pain - perineum, low abd, testicles, back Difficulty voiding Sxs >3 mo Dx: by exclusion Tx: Alpha blocker - Tamulosin Cipro x6 weeks 5 alpha reductase inhibitor (older, not trying for kids)
32
Benign prosthetic hyperplasia
Central zone/transitional zone Dihydrotestosterone promotes prostate development and growth Presentation: Urinary frequency, hesitancy, Decreased urine stream Terminal dribbling Nocturia ``` Treatment: Alpha-1 adrenergic antagonists 5 alpha reductase inhibitors Phosphodiesterase 5 inhibitor Anti-cholinergics Surgery: transurethral resection of the prostate, plasma vaporization, radiofrequency ablation, Microwave thermotherapy, botox ```
33
Prostate cancer
Periphery MC non-dermatologic CA in men - 2nd MC cause of cancer deaths in men Presentation: asx sxs like BPH DRE: firm nodularity or irregular induration prostate Labs: PSA elevated UA: hematuria, pyuria Elevated alkaline phosphatase (bone mets) Dx: bx - adenocarcinoma Tx: Radical prostatectomy - risk ED d/t damage of cavernosal nerves, urinary incontinence Radiation therapy: external beam, brachytherapy (implanted seeds) -> ED, urinary retention/ frequency, urge incontinence Hormonal therapy - GnRH analog (leuprolide, goserelin) continuously to shut down HPG axis -> decreased testosterone - Chemical castration Adjuct - flutamide - androgen receptor blocker - less impact on libido and ED Mets to bone - osteoblastic