Urology Flashcards
Renal colic vs peritonitis
Renal colic - unable to find comfortable position
Peritonitis - movement increases pain, lies still
Risk and Presentation of nephrolithiasis
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
Diagnosis and treatment of nephrolithiasis
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
Surgical intervention - nephrolithiasis
Lithotripsy - upper ureter renal collecting system
-must be able to see Stone
ureteroscopy - distal ureter
Percutaneous nephrolithotomy - staghorn or over 3 cm
Most common site of renal stone impaction
ureterovesicular junction
Hydronephrosis
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
Calcium oxalate stone
Causes:
Hyper calciuria
Hyperoxaluria
Ethylene glycol ingestion
MC stone type
Calcium phosphate stones
Causes:
Hyperparathyroidism
Renal tubular acidosis
Cystine stones
Causes: cystinuria
Staghorn calculi
Uncommon - difficult to treat
Hereditary
Uric acid stones
radiolucent
Causes:
Gout
Chemo - increase protein metabolism
Can be dissolve by alkalizing urine
- potassium citrate
- sodium bicarbonate
- sodium citrate
Struvite stone
Mg-NH4-PO4
UTIs with urease-positive bacteria
- klebsiella
- Proteus mirabilis
- staphylococcus saprophyticus
tend to form staghorn stones
Hematuria Causes
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
Hematuria - dx
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
Red urine ddx
rifampin nitrofurantoin porphyrins beets menses hematuria - gross
Cystitis
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
Most common causes of urethritis
Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma
Ureaplasma
Urethritis
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
Urge incontinence
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
Stress incontinence
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
Overflow incontinence
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
Bladder cancer
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
Varicocele
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
Hydrocele
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
Testicular torsion Onset Infection Visual changes Support Cremasteric reflex U/S Treatment
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
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
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
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
Medication is known to cause erectile dysfunction
Most antidepressants - esp SSRIs Spironolactone Sympathetic blockers - clonidine, guanethidine, methyldopa thiazide diuretics (rare) ketoconazole cimetidine antipsychotics
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
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
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)
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
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
