Urology/Renal Flashcards
1
Q
balanitis
A
- balanitis xerotica obliterans (penile lichen sclerosis)
- occurs in males of all ages, average 42yo, SCC (4-6%), precancerous
- sxs: phimosis, painful erections, or obstructive voiding, itching, pain, bleeding → initial complaint of urinary retention
- hypopig lesion w/ skin similar to crinkled paper or cellophane, affects glans penis and prepuce, bullae, erosions, atrophy
- dx: bx if SCC suspected
- tx; mod to ultrapotent fluorinated topical steroids, surg for persistent dz or hx of SCC (circumcision of glans and prepuce), PO retinoids
2
Q
orchitis
A
- inflammation from epididymis spreads to adjacent testical; viral orchitis MC after mumps, but may be caused by viral or bact infxn
- sxs: abrupt onset test pain; if viral, 7-10d after mumps as parotitis resolves
- signs: test swelling and tenderness, + cremasteric reflex
- dx: hx, PE< UA, doppler, hyperechoic and hypervascular areas
- tx: supportive (NSAIDs, scrotal support), abx (cirpo, doxy, rocephin), viral resolves spontaneously after 3-10d
3
Q
epididymitis
A
- inflamm or infxn of epididymis → can spread to entire testicle → orchitis
- etiology: <35yo → Gonorrhea or chlamydia; >35yo → E. coli
- ho: UTI, urethritis, dc, sexual activity, foley cath; MCC scrotal pain in adults
- sxs: unilateral pain, dull ache, swelling, radiation to ipsilateral inguinal canal (flank), sxs of cystitis, fever, chills, urethral dc and pain at tip of penis
- signs: mass, erythema of scrotal skin, Prehn sign (+) → pain relief with elevation of scrotum, + cremasteric reflex, tachycardia
- dx: doppler (increased blood flow), CRP and ESR (elevated ro torsion)
- tx: rest, scrotal elevation, ice, NSAIDs; <35 ceftriaxone and doxy, >35 cipro and bactrim
4
Q
chlamydia
A
- MC bact STD, most coinfected with gonorrhea, incubation 1-3wk
- RF: lack of condom use, lower SES, living in urban area, having multiple sex partners, MC in F 15-19, then 20-24, independent RF for cervical CA
- sxs: mostly asx; men → dysuria, purulent urethral dc, itching, scrotal pain and swelling, fever; women → purulent urethral dc, intermentstrual or post-coital bleeding, dysuria
- signs: mucopurlent dc from cervical os, friable cervix
- dx: NAAT, wet mnt (leukorrhea), cx, enzyme immunoassay, PCR
- tx: azithro or doxy, tx all partners
- pregnant: azithro or amox
- complications: men → epididymitis, proctitis, prostatitis; women → PID, salpingitis, tubo-ovarian abscess, ectopic pregnancy, Fitz-Hugh Curtis syndrome, infert
5
Q
gonorrhea
A
- N. gonorrhoeae (gram neg)
- transmission: sexual or neonatal
- sxs: asx in women, sx in men → check pharynx, conjunctiva, and rectum
- M: 10% sxatic, contagious → urethral dc, dysuria, erythema, edema, frequ in urination
- F: most asxatic or few sxs → cervicitis or urethritis (purulent dc, dysuria, intermenstrual bleeding)
- disseminated, F: fever, arthralgias, tenosynovitis, migratory polyarth/septic arth, endocarditis, meningitis, skin rash
- dx: NAAT, gram stain, cx, test for syph . and HIV
- tx: empirically bc cx take 1-2d → ceftriaxon IM, add azithro or doxy to cover chlamydia, if disseminated hospitalize
- complications: PID, infer, epididymitis, prostatitis, salpingitis, tubo-ovarian abscess, Fitz-hugh-curtis, dissem gonococcal infxn
6
Q
Testicular carcinoma
A
- MC type = seminoma; MC 20-35yo
- RF: hx cryptorchidism or klinefelter syndrome
- sxs: painless enlarging testicular mass, lump, or firmness, gynecomastia
- signs: scrotal enlargement
- dx: US (1st line), tumor markers, CT chest/abd/pelvis and CXR for staging
- AFP (inc in embryonal tumors but chorio and seminoma never have elevated AFP)
- BhCG always elevated in choriocarcinoma
- tx: surg, radiation, chemo, orchiectomy
- nonsem: 2 rounds chemo
- sem (95% curable): orchiectomy and external beam radiation
- relatively high cure rate for cancer
- MC site of spread = retroperitoneal lymph nodes
- embryonal carcinoma (type of nonseminomatous) = highly malignant, hemorrhage, necrosis, mets to abd lymph and lungs
- choriocarcinoma (type of nonsem) = most aggressive, mets occur by dx
7
Q
BPH
A
- 70+
- associated: DM, cold/sinus meds, OSA, insomnia, hematuria
- occurs in the transition zone
- sxs: obstructive → decreased force of stream, hesitancy, post-void dribbling, sensation of incomplete emptying; irritative → dysuria, frequency, urgency, nocturia
- manifestations: UTI, hematuria, renal insuff, retention, lower urinary tract sxs
- dx: UA, PSA, renal US, urodynamics, uroflowmetry, postvoid residual
- tx: first line → reassurance, lifestyle mod (dec fluid before bed, dec caffeine/ETOH, time-void; alpha blockers (most effective with severe BPH and HTN; 5 alpha reductase inhib (finasteride, dutasteride), PDE5 inhib, saw palmetto, surg (TURP)
8
Q
acute prostatitis
A
- rare, class I “sick”, most community acquired, others occur after cath and cystoscopy, or after transrectal prostate bx
- cause: G neg orgs → E. coli, Klebsiella, Proteus, Enterobacter, Staph; peak 20-40
- sxs: acute onset pelvic pain (perineal, sacral, suprapubic pain; irritative UTI sxs (frequ, urg, dysuria)
- obstructive: striaining, hesitancy, poor or interrupted stream, incomplete emptying
- systemic febrile illness; fever/chills, malaise, N/V
- signs: toxic, febrile, sepsis, tachypnea, suprapubic pain
- dx: UA + cx → large WBC, + cx; postvoid residual, elevated WBC, tender, enlarged “boggy” prostate, prostatic massage contraindicated, CBC
- tx: outpt → FQ (cipro), bactrim BID; inpt (systemically ill or unable to urinate, unable to tolerate PO intake, or RF for resistance) → IV ampicillin + gentamicin, noncon pelvic CT if fever persists >36h post abx
9
Q
chronic prostatitis
A
- lasts longer than 3 mos
- causes: BPH, stones, foreign body, bladder cancer, prostatic abscess
- MCC: e. coli
- recurrent or relapsing UTI, urethritis or epididymitis, localized pain in lower back, perineal, testicular region, frequency, urgency, dysuria, NO FEVER
- signs: doesnt appear ill, afebrile
- dx: UA and cx → WBC + and culture +/-, 2-glass pre- and post- prostatic massage test, prostate enlarged and nontender
- tx: cipro, levo, bactrim
10
Q
nephrolithiasis
A
- MC types of stones: calcium ox, calcium phos, uric acid, struvite, cystine; M>F
- RF: family hx, hypercalciuria, wt gain, low urine output, sweet beverages, hot enviro, dieatery (animal protein, oxalate, sodium, sucrose, fructose)
- sxs: unilateral flank pain, radiates ant or ipsilateral testicle or labium; N/V, painless gross hematuria (90%)
- signs: CVAT
- dx: CMP, UA, KUB (cant see cystine or uric acid), helical CT w/out con
- tx: NSAIDs (ketorolac or toradol), PO fluids, alpha blockers, extracorporeal shockwave lithotripsy for stones >6mm up to 2cm; ureteral stent or percutaneous nephrolithotomy, 50% recur
11
Q
types of kidney stones and characteristics: calcium oxalate, calcium phosphate, uric acid, cystine, struvite
A
- calcium oxalate: visible on abd radio, bipyramidal and biconcave ovals; caused by inc calcium, oxalate, uric acid, citrate; tx → high dose thiazide diuretic, allopurinol
- calcium phosphate: pH >6.5MC in pt with RTA and 1ary hyperthy, visible on abd radio; tx → thiazide diuretics, potassium citrate
- uric acid: pH <5.5; RF = met syndrome, gout; CT noncon shows radiolucent stones, flat square plates, rhombic plates, or rosettes; tx → potassium citrate, allopurinol
- cystine: autosomal recessive; CT noncon shows radiolucent stones, stop signs, benzene rings, hexagons, tx → tiopronin and pencillamine, alkalinize urine w/ potassium citrate
- struvite: infxn w/ proteus mirabilis → inc urine pH >8; KUB shows staghorn calculi, coffin lids; hx of recurrent UTIs; tx → complete removal by urologist, acetohydroxamic acid
12
Q
glomerulonephritis
A
- caused by immune-mediated mechs, metabolic or hemodynamic disturbs
- dx: UA (hematuria, proteinuria, RBC casts), blood tests: renal fn tests, needle . bx of kidney
- 1ary disorders: minimal change, membranous, IgA neph (Berger dz)
- 2ary disorders: diabetic, mebranoproliferative, poststrep, Goodpasture
13
Q
Nephritic vs nephrotic syndromes
A
- Nephrotic: inc filtration of macromolecs, caused by membranous GN (MCC), DM, SLE, drugs, infxn, minimal change dz
- hypercoaguable, hypoalb, hyperlip (fatty casts in urine, hypercholest), proteinuria, edema (peripheral, periorbital in AM → pedal)
- dx: UA (oval fat bodies), 24hr urine, renal bx (REQUIRED FOR DX)
- tx: ACEi for HTN, sodium restriction, steroids and cytotoxic agents, statin for HLD, anticoag for hypoalbumin (hep followed by warf as long as nephrotic)
- inc risk VTE, inc risk infxn (PNA)
- Nephritic: inflamm dt poststrep (MCC), berger dz, hepC, SLE
- asx gross hematuria (smoke, tea, or coca cola colored), mild proteinuria, HTN, AKI (oliguria, azotemia), edema (generalized)
- dx: UA (dysmorphic RBC +/- RBC casts, C3 and CH50 dec in first 2 wk, +ASO titer, renal bx (not usually performed)
- tx: steroids and cytotoxic agents (methylprednisolone), loop diuretics and sodium/H2O restriction, ACEi for HTN enceph, oral nifedipine or IV nicardipine
14
Q
primary glomerular disorders
A
- minimal change: MC GN of kids, associated with Hodgkin and non-Hodgkin lymphoma
- sxs: proteinuria, edema, hypoalb, hyperlip, HTN, hematuria, fusion of foot processes, good prognosis
- tx: roids 4-8wk
- mebranous GN: nephrotic syndrome, thick glomerular cap walls
- causes: primary idiopathic, secondary dt infxn (hepC/B, syphilis, malaria), drugs (gold, captopril), or SLE
- prognosis fair, remission common, 1/3 renal failure
- tx: roids but wont change survival
- IgA (berger): asx recurrent hematuria/mild proteinuria common, MCC glomerular hematuria, gross hematuria after URI common, renal fn normal
- cause: mesangial deposition of IgA and C3, prognosis good
- tx: steroids for unstable dz
15
Q
secondary glomerular disorders
A
- diabetic nephropathy: MCC ESRD
- hx type 1 DM, M, AA, +FHx
- sxs: albuminuria, retinopathy or CVD, elevated SCr
- tx: annual screening for albuminuria, strict glycemic control, ACE/ARB, low sat/protein diet
- mebranoproliferative: dt hepC, associated with cryoglobulinemia, poor prognosis, 50% RF, tx rarely effective
- poststrep GN: MCC nephritic syndrome, occurs after GABHS infxn of URT (impetigo), develops 10-14d later, mainly children + ASO titer
- dx: RBC casts, dysmorphic RBCs
- sxs: hematuria, edema, HTN, low complement and proteinuria
- Goodpasture GN: classic triad → prolif GN, pulm hemorrhage, IgG antiglom basement membrane Ab
- features: rapidly progressive RF, hemoptysis, cough, dyspnea, lung dz before kidney dz
- dx: renal bx (linear immunofluorescence)
- tx: plasmapheresis to remove circ antiIgG Abs, cyclophsophamide, roids
16
Q
indirect inguinal hernia vs direct inguinal hernia
A
- sxs for both: asx, lump or swelling in gorin with sudden pain and bulge (after lifting or straining), “dragging” sensation, radiation of pain onto scrotum, with enlargement → discomfort, aching pain, must lie down to reduce
- indirect: obliteration of processus vaginalis fails to occur → hernial sac passes thorugh INTERNAL INGUINAL RING, sac located anteromedially to spermatic cord, descends into scrotum
- dx: mass may or may not be reducible, examine supine and standing, with cough and strain, tissue must be felt protruding the inguinal canal during cough in order for dx
- direct: weakness or defect in transversalis fascia, funicular type more likely to become incarcerated because it has distinct borders
- dx: symmetric, circular swelling at external ring with standing or straining, bulges forward through hesselback triangle, disappears when lying supine, post wall of inguinal canal is relaxed or absent
- tx: all sxatic groin hernias should be repaired surgically if pt can handle it
- nonsurg: truss (fit to provide external compression, take off at night)
17
Q
hiatal hernia
A
- congen or acquired (acquired may be nontraumatic or traumatic)
- portion of stomach herniates through diaphragmatic esoph hiatus
- RF: preg, obesity, ascites, mm weakness
- sxs: most asx, GERD sxs, pain radiates to chest, not back
- dx: upper GI series (barium), upper GI endoscopy (dx hiatal hern)
- tx: lifestyle mod, PPI, surg
- complications: intermittent bleeding, incarcerated hernia (rare), barrett esophagus, tumor
18
Q
femoral hernia
A
- acquired protrusion of peritoneal sac through fem ring (passes beneath iliopubic tract and inguin lig into upper thigh
- RF: small empty space between lacunar lig medially and fem vein laterally
- sxs: bulge near groin or thigh
- tx: highest incidence of strangulation and incarceration (>>> inguin hern)
19
Q
umbilical hernia
A
- gradual yielding of cicatricial tissue closing ring, F>M
- RF: mult pregnancies w/ prolonged labor, ascites, obesity, intra-abd tumors
- sxs: usually contain omentum, sharp pain on cough or strain (larger hernias . produce draggin or aching sensation)
- tx: obs, requires emergent repair if strangulated or incarcerated
- mesh = lowest recurrence rate
20
Q
epigastric hernia
A
- protrudes through linea alba above level of umbilicus, M>F, 20-50yo
- sxs: painless, sxatic → mild epigast pain and TTP, deep burning epigast pain radiation to back or lower abd quadrants, abd bloating, N/V, sxs occur after large meal and relieved by reclining
- signs: palpable
- dx: US, CT, XR
- tx: mesh for large hernias, high recurrence rate
21
Q
UTI (uncomplicated)
A
- definition of uncomplicated: nonpregnant women, healthy pts w/o underlying structural or neuro dz
- RF: recent use of diaphragm with spermicide, frequent interourse, hx of UTI
- in healthy postmen women → sex, DM, incontinence
- MCC: E. coli, proteus, Klebsiella, S. saprophyticus
- sxs: dysuria, urgency, frequency, hematuria
- signs: change in urine color/odor, suprapubic pain, NO fever
- dx: urine dip (nitrate, leuk esterase), UA (pyuria, bacteriuria, +/- hematuria, +/- nitrites), CBC (leukocytosis), urine cx (only get if sxatic → >100000 (F), >1000 (M))
- tx: nitrofurantoin (macrobid), bactrim DS PO x3d
- Recurrent: 2 uncomp in 6mo OR 3+ uncomp in previous year
22
Q
complicated UTI
A
- definition: pt with structural or fnal abnlity that would reduce efficacy of abx tx
- complicated: children, men, noscocomial or nursing home, kidney allograft, pregnancy, immunosuppressed
- MCC: e. coli, enterococci, PsA, S. epidermidis
- catheter associated: yeast, E. coli
- dx: urine cx
- tx: FQ or Bactrim (preg → nitro, ampicillin, cephalosporins) x7-14d
23
Q
urethritis (nongonococcal)
A
- inflamm of urethra cuased by infxs or noninfxs causes (trauma, foreign body)
- MC: M 20-24yo, AA, c. trachomatis, ureaplasma, trichomonas vag, mycoplasma genitalium, HSV
- sxs: urethral dc, dysuria, pruritis
- signs: proximal to distal “milking” of urethra
- dx: NAATs, gram stain, UA w/ cx (+) leukesterase, prostate exam
- tx: if no gonococci → azithro or doxy; if gonococci → ceftriaxone and doxy or azithro; recurrent infxn → flagyl or tinidazole plus azithro
24
Q
pyelonephritis
A
- RF: sex, new sex partner, UTI in previous 12 mos, maternal hx UTI, DM, incontinence; E. coli = MCC
- sxs: dysuria, urgency, frequency, fever + chills, N/V/D
- signs: flank or back pain, CVA tenderness
- dx: UA → pyuria, bacteriuria, WBC casts +/- hem, +/- nitrites; CBC → leukocytosis, left shift; urine cx 100000 W, 1000 M or cath pts; abd CT (ro abscess)
- tx: FQ (cipro) x7d OR bactrim x 14d
- inpt: IV ceftriax OR amp/sulbactam OR aminoglyc
- preg: IV amp +/- gent x14d
- men: FQ or bactrim x 7-14d
