Urology/Renal Flashcards
DDX for dysuria
PID Trichomoniasis Chlamydia / gonorrhea UTI Epididymitis and orchitis Pyelonephritis Prostatitis Urethritis
DDX for hematuria
Acute glomerulonephritis Polycystic kidney disease Cystitis Pyelonephritis BPH Bladder CA Renal cell CA Wilms Tumor Nephrolithiasis Urethritis Chlamydia Gonorrhea
DDX for suprapubic/flank pain
Glomerulonephritis Nephrolithiasis Pyelonephritis Polycystic kidney disease Cystitis
DDX for incontinence
Hydrocephalus
Spinal cord injury
Cauda equina
Tertiary syphilis
Most common types of stones in nephrolithiasis
- Calcium oxalate
- Calcium phosphate
Other types: uric acid, struvite stones, cystine stones
Characteristics of struvite stones in nephrolithiasis
Staghorn appearance
Caused by urea splitting bacteria (proteus)
Risk factors for nephrolithiasis
Decreased fluid intake
Medications (loop diuretics, chemo drugs)
Gout
Signs/symptoms of nephrolithiasis
Renal colic - acute flank pain that radiates to groin
Pain over CVA
N/V
unable to find comfortable position
Diagnosis of nephrolithiasis
- Urinalysis - will show hematuria in 80%
- Non-contrast helical CT scan - test of choice
- KUB - will only visualize calcium stones
- Intravenous pyelography - gold standard
Treatment of nephrolithiasis < 5 mm in diameter
80% chance of spontaneous passage
- IV fluids, analgesics, antiemetics
- Tamsulosin - may facilitate passage
Treatment of nephrolithiasis > 7 mm in diameter
Extracorporeal shock wave lithotripsy
Ureteroscopy +/- stent
Percutaneous nephrolithotomy - used for stones > 10 mm
Prevention of future nephrolithiasis
- Adequate hydration
- Decrease animal protein intake
- Thiazide diuretics are used for recurrent calcium stones
Spermatic cord twists and cuts off testicular blood supply due to congenital malformation which allows the testicle to be free floating in the tunica vaginalis causing it to twist on itself
Testicular torsion
If nausea/vomiting if present in the setting of abrupt onset of scrotal or inguinal pain, suspect
Torsion
Usually absent in epididymitis
Physical exam signs for testicular torsion
Negative Prehn’s sign
Negative cremasteric reflex
Blue dot sign at upper pole
Bell clapper deformity
Pain relief of scrotal elevation
Prehn’s sign
Diagnosis of testicular torsion
- Testicular doppler ultrasound - best initial
- Emergency surgical exploration required if US unable to exclude
- Radionuclide scan (not used frequently)
Management of testicular torsion
- Detorsion and orchiopexy within 6 hours and in obvious cases (testicle fixation in the scrotum)
- Orchiectomy if testicle not salvageable
Risk factors for cystitis (women)
Sexual intercourse
Spermicidal use
Pregnancy
Postmenopausal
Risk factors for cystitis (men0
Rare - should have workup
> 50 y/o
BPH
Prostate CA
Most common etiology for cystitis
E. coli
Staph, saprophyticus (sexually active women)
Enterococci for indwelling catheters
Dysuria (burning), increased frequency, urgency, hematuria, suprapubic discomfort
Acute cystitis
Fever and tachycardia, back/flank pain, + CVAT, n/v
Pyelonephritis
Diagnosis of cystitis/pyelonephritis
- Urinalysis
- Dipstick
- Urine culture
If urinalysis shows WBC casts
Pyelonephritis
Indications for urine culture with cystitis/pyelonephritis
Complicated UTI Infants/children Elderly Males Urologic abnormalities Refractory to tx Catheterized pts
Conservative treatment for cystitis
Increase fluid intake, void after intercourse
Management of cystitis
- Phenazopyridine (Pyridium) turns urine orange
- Nitrofurantoin, ciprofloxacin, bactrim, fosfomycin
- Pregnant: amoxicillin, augmentin
Management of pyelonephritis
Fluoroquinolones IV or PO aminoglycosides
Epididymal pain and swelling thought to be secondary to retrograde infection or reflux of urine
Epididymitis
Epididymitis is usually __________, while orchitis is usually ___________
Bacterial
Viral
Most common causes of orchitis and epididymitis in men < 35 y/o
Chlamydia, gonorrhea
Most common causes of orchitis and epididymitis in men > 35 y/o and children
Enteric organisms most common
E. coli, Klebsiella
1/3 of postpubertal men with __________ whave concomitant orchitis
Mumps
Gradual onset of scrotal pain, erythema and swelling. Most commonly unilateral. +/- groin or abdominal pain. Fever, chills, irritative symptoms
Epididymitis and orchitis
Relief of pain with elevation of the affected scrotum
Positive Prehn’s sign
Epididymitis and orchitis
Elevation of the testicle after stroking the inner thigh
Positive cremasteric reflex
Epididymitis and orchitis
Diagnosis of epididymitis / orchitis
- Scrotal ultrasound - increased testicular blood flow, enlarge epididymitis
- UA: pyuria (WBC), bacteriuria
- CBC: leukocytosis
- Urine culture
- STD testing
Symptomatic treatment for orchitis
Bed rest, scrotal elevation, cool compresses and analgesics (NSAIDs)
Management of acute epididymitis
Gonorrhea and chlamydia: doxycycline plus ceftriaxone IM
Enteric organisms: fluoroquinolones
Children: cephalexin or amoxicillin
Management of chronic epididymitis
4-6 week trial of abx
Prostate gland inflammation secondary to an ascending infection
Prostatitis
Most common causes of prostatitis when > 35 y/o
E. coli (MC)
Pseudomonas
Klebsiella
Proteus
Most common causes of prostatitis when < 35 y/o
Chlamydia and gonorrhea MC
Most common cause of chronic prostatitis
E. coli
Enterococci
Trichomonas
Fever/chills, malaise, arthralgias, irritative and obstructive urinary symptoms, lower back/abdominal pain, perineal pain
Prostatitis
Chronic prostatitis usually presents as:
Recurrent UTIs
Intermittent dysfunction
Physical exam for acute prostatitis
Exquisitely TENDER, normal or hot, boggy prostate
Physical exam for chronic prostatitis
Usually non tender boggy prostate
Diagnosis of prostatitis
- Urinalysis and urine culture
- Avoid prostate massage in acute prostatitis
- Transrectal ultrasound
Management of acute prostatitis > 35 y/o
Fluoroquinolones or TMP-SMZ
If hospitalized, IV fluoro
Management of acute prostatitis < 35 y/o
Tx for gonorrhea and chlamydia
Ceftriaxone plus Doxy/Azithro
Management of chronic prostatitis
Fluoroquinolones, TMP-SMZ
Transurethral resection of the prostate for refractory chronic prostatitis
Most common cause of urethritis in men < 30 y/o
Gonorrhea
Anal, vaginal, penile or pharyngeal discharge, may cause septic arthritis
Urethritis and cervicitis - gonorrhea
Culture shows gram negative diplococci in polymorphonuclear leukocytes
gonorrhea
Management of gonorrhea
Ceftriaxone IM plus doxy or azithromycin
Purulent or mucopurulent discharge, pruritus, dysuria, dyspareunia, hematuria
Urethritis - chlamydia
Most common causes of urethritis
Chlamydia
Gonococcal (2nd most common)
Urethritis with abrupt onset of symptoms (especially within 3-4 days). Opaque, yellow, white, or clear thick discharge, pruritus
Gonococcal urethritis
Urethritis of 5-8 days with purulent or mucopurulent discharge, pruritus. Hematuria, pain with intercourse
Chlamydia urethritis
Complications of men with urethritis
Epididymitis, prostatitis, infertility, reactive arthritis
Complications of women with urethritis
Pelvic inflammatory disease, infertility, ectopic pregnancy, premature delivery, septic arthritis
Diagnosis of urethritis
Nucleic acid amplification
Acute renal failure is described as: (2)
- Increased serum creatinine > 50% OR
2. Increased BUN (azotemia)
Phases of AKI
- Oliguric phase (decreased urine output, hyperkalemia, azotemia, metabolic acidosis)
- Diuretic phase (increased urine output, hypotension, hypokalemia)
- Recovery
3 types of acute renal failure
- Prerenal (rapidly reversible)
- Postrenal (rapidly reversible)
- Intrarenal
Causes of prerenal acute renal failure
Reduced renal perfusion
Hypovolemia
Management of prerenal acute renal failure
Volume repletion to restore volume and renal perfusion (rapidly responds to tx)
Causes of postrenal acute renal failure
Obstruction of the passage of urine (stones, BPH)
Management of postrenal acute renal failure
Removal of obstruction
Cause of intrinsic acute renal failure
Direct kidney damage - nephrotoxic, cytotoxic, prolonged ischemic, inflammatory insults to the kidney
Structural/functional nephron damage (cellular cast formation) - hallmark
Most common type of intrinsic acute renal failure
Acute Tubular Necrosis
Overall cause of intrinsic acute renal failure
NSAIDs, contrast, aminoglycosides, infections, penicillins, sulfa drugs, ciprofloxacin, allopurinol, etc.
Management of intrinsic acute renal failure
Remove offending agents
IV fluids
Furosemide if p euvolemic and not urinating
If glomerulonephritis - give corticosteroids
Immunologic inflammation of the glomeruli causing protein and RBC leakage into the urine
Glomerulonephritis
HTN, hematuria (RBC casts), dependent edema (proteinuria), and azotemia (nitrogen in blood) are hallmarks
Glomerulonephritis
Types of glomerulonephritis
- IgA Nephropathy (Berger’s Dz)
- Post infectious
- Membranoproliferative / Mesangiocapillary
- Rapidly progressive
- Goodpasture’s dz
- Vasculitis
Most common cause of acute glomerulonephritis in adults worldwide
IgA nephropathy (Berger’s dz)
Glomerulonephritis that often affects young males within days (24-48 hours) after URI or GI infection
IgA nephropathy
Diagnosis of IgA nephropathy
IgA mesangial deposits on immunostaining
Management of IgA nephropathy
ACEI +/- corticosteroids
Glomerulonephritis that is most common after GABHS
Post infectious
Glomerulonephritis that classically presents as a 2-14 yo boy with facial edema up to 3 weeks after Strep with scanty, cola-colored dark urine (hematuria and olguria)
post infectious glomerulonephritis
Diagnosis of post infectioius glomerulonephritis
Increased antistreptolysin (ASO) titers, low serum complement Biopsy: hypercellularity, increased monocytes/lymphocytes, immune humps
Management of post infectious glomerulonephritis
Supportive, +/- antibiotics
Glomerulonephritis due to SLE, viral hepatitis (HCV, HBV), hypocomplementemia, cryoglobulinemia
Membranoproliferative / mesangiocapillary glomerulonephritis
Glomerulonephritis associated with poor prognosis (progresses to end stage renal failure within weeks/months)
Rapidly progressive glomerulonephritis (RPGN)
Crescent formation on biopsy
Rapidly progressive glomerulonephritis
Due to collapse of crescent shape of Bowman’s capsule
Management of rapidly progressive glomerulonephritis
Corticosteroids + cyclophosphamide
Two types of glomerulonephritis that only present with RPGN:
Goodpasture’s disease
Vasculitis
Glomerulonephritis with + anti-GBM antibodies
Goodpasture’s disease
Diagnosis of goodpasture’s disease
Linear IgG deposits
Management of goodpasture’s disease
High dose corticosteroids + cyclophosphamide + plasmapheresis
Glomerulonephritis that is characterized by lack of immune deposits and + ANCA antibodies
Vasculitis
Can either have p-ANCA or C-ANCA
The presence of ______________ in nephritis distinguishes nephritic from nephrotic
Gross hematuria
Signs/Symptoms of glomerulonephritis
Hematuria Edema HtN Fever, abdominal pain, flank pain Oliguria
Diagnosis of glomerulonephritis
- Urinalysis
- Increased BUN, creatinine
- Renal biopsy gold standard
Proteinuria, hypoalbuminemia, edema, hyperlipidemia
Nephrotic syndrome
Edema is the predominant feature in:
Nephrotic syndrome
Diagnosis of nephrotic syndrome
- Urinalysis - protein > 3.5
2. Biopsy - hypocellular
Complications of nephrotic syndrome
Transudative pleural effusion
DVTs
Frothy urine
Disorder that may cause hypernatremia
Diabetes insipidus
In surgical patients, hypernatremia may result from
Loop diuretics
Also from gastrointestinal losses
In the acute setting, rapid hypernatremia can cause
Intracerebral hemorrhage
Causes of hypervolemic hyponatremia - patient will usually have edema
Renal failure
CHF
COPD
Severe liver disease
Causes of normovolemic hyponatremia
SIADH
Causes of hypovolemic hyponatremia
Renal losses of sodium Diuretic use Aldosterone deficiency Renal failure Subarachnoid hemorrhage
Treatment of hypervolemic hyponatremia
Volume restriction and loop diuretic
Treatment of normovolemic hyponatremia
SIADH - fluid restriction
How do you correct hypernatremia?
D5W
Treatment of hypovolemia hyponatremia
Salt and water replacement
Should not increased serum sodium concentration faster than _________ mEq/L/hr
0.5
Hyperkalemia can result from
Renal or adrenal insufficiency
Metabolic acidosis
Iatrogenic causes
Most important results of severe hyperkalemia
Myocardial effects
Peaked T wave is first sign
Finally: complete heart block, ventricular tachycardia, cardiac standstill can occur
Treatment of hyperkalemia
10-20 mL of 10% calcium gluconate
Can give Kayexalate (takes longer)
Most effect method: hemodialysis
Hypokalemia is common in surgical pts due to :
GI losses - vomiting, diarrhea, fistula
Use of diuretics
Treatment for hypokalemia
- Oral potassium unless severe or pt is symptomati
Treatment for hypercalcemia (when not due to parathyroidism)
Saline diuresis
Furosemide
Calcitonin - reduces bone resorption
Signs of hypocalcemia
Trousseau’s
Chvostek Sign
Trousseau’s Sign
Seen in hypocalcemia
BP cuff inflated - spasm in muscles of hand/forearm
Chvostek Sign
Seen in hypocalcemia
Tap facial nerve - twitch on same side of face
Treatment of hypocalcemia if symptomatic/severe
IV calcium therapy
Diseases that cause hypermagnesemia
Renal failure
Addison’s disease
Treatment for hypermagnesemia
Calcium infusion followed by immediate dialysis
In surgical pts, hypomagnesemia is a result of
GI losses
Reduced absorption
Treatment for hypomagnesemia
Magnesium infusion
If treatment not urgent, give oral supplements
Most common causes of hyperphosphatemia
Renal insufficiency
Treatment of hyperphosphatemia
Treat underlying renal failure
Phosphate-binding antacids
Treatment of hypophosphatemia
Oral or parental phosphate
Metabolic acidosis formula
Decreased pH
Decreased bicarb
Decreased CO2
Metabolic alkalosis formula
Increased pH
Increased bicarb
Increased CO2
Respiratory acidosis formula
Decreased pH
Increased bicarb
Increased CO2
Respiratory alkalosis formula
Increased pH
Decreased bicarb
Decreased CO2
An anion gap over _____ is considered an elevated anion gap
12
MUDPILERS
Methanol Uremia Diabetic/alcoholic ketoacidosis Paraldehyde/propylene glycol Isoniazid / iron Lactic acidosis Ethylene glycol Rhabdomyolysis Salicylates
When can you treat an acidotic pt with sodium bicarb?
If pH < 7.2
Life-threatening ventricular arrhythmia
Inadequate compensatory response
Risks fo sodium bicarbonate therapy
Hypernatremia
Hyperosmolarity
Volume overload