Urology/Renal Flashcards
1
Q
cryptorchidism
A
- inc risk for testicular cancer, 1-2% males after 1yo, underlying hypogonadism, including hypogonadic hypogonadism
- sxs: one or both testes absent from scrotum at birth, distinguish from retractile testes (which requires tx)
- dx: MRI > US, 1500 units IM hCG x3d should cause significant rise in testosterone if testes are present
- tx: tx with hCG works in 25%, surg (orchipexy) reduces risk of infert, decreses risk of neoplasia
2
Q
paraphimosis
A
- dt chronic inflamm under redundant foreskin, leading to contracture of preputial opening and formation of tight ring of skin when foreskin is retracted behind the glans
- RF: frequent cath without reducing foreskin, forcibly retracting constricted foreskin, vigorous sexual activity
- sxs: pain, edema, tenderness, erythema of glans and foreskin
- signs: skin ring causes venous congestion leading to EDEMA and enlargement of the GLANS, arterial occlusion and necrosis of the glans may also occur
- dx: none required
- tx: manual reduction (firmly squeeze glans for 5min to reduce edema and size), surg (may require incision under local anesthesia), emergent urologic referral and circumcision, abx and circumcision should be completed after inflamm goes away
3
Q
phimosis
A
- foreskin that cannot be retracted
- congenital = children, adolescents, physiologic; acquired = adults with poor hygiene and chronic balanitis
- sxs: EDEMA, erythema, tenderness of prepuce, presence of purulent discharge, inability to retract foreskin over glans penis, obstructed urinary stream, hematuria, pain of prepuce
- dx: non required
- tx: if asxatic watch and wait; if sxatic refer for circumcision
- initial infxn txed with broad spectrum abx, circumcision should be avoided in <2y until reach age when general anesthesia can be administered
4
Q
hypospadias
A
- associated with chordee: ventral curvature of penis, both genetic and environmental
- RF: subfert in father, maternal age, IUGR, fetal exposure to oral progestins or combined progestins and estrogens
- sxs: urethra is abnormally placed where meatus is proximal and ventral to its normal or anterior location
- dx: bilat renal US to r/o ascending pathology; if severe, evaluate gonadotropin, AMG, inhibin B, testosterone secretion . at 1-3mo or response to hCG
- tx: do not circumcise, refer to ped urologist
5
Q
testicular torsion
A
- twisting of spermatic cord leading to arterial occlusion and venous outflow obstruciton → ischemia → testicular infarction
- adolescent male patients mostly 12-18yo
- sxs: acute severe unilateral testicular pain worse with physical activity, radiates to lower abd, N/V, absent dysuria or bladder sxs
- signs: absent cremasteric reflex on affected side, affected testis higher than opposite, swollen and tender scrotoum, elevated high-riding testicle, bilateral “bell clapper” deformity, horixontal orientation, phren’s signs neg (lift up testicle, no relief)
- dx: collor doppler shows reduced flow, definitive = scrotal exploration
- tx: manual detorsion (rotate caudal to cranial and medial to lateral), immediate surgical deterosion and orchiopexy to the scrotum (bilateral), SURGICAL EMERGENCY - if delayed >6h infarction may not be salvagable → infert
- orchiectomy if nonviable testicle found
6
Q
hydrocele
A
- accumulation of fluid in tunica vaginalis, recurs with drainage
- sxs; painless, fluctuates in size, smaller in the morning, increases size while upright
- dx: US to r/o testicular cancer (transilluminates)
- tx: watch/wait (small, scrotal support), hydrocelectomy (painful or large)
7
Q
vesicoureteral reflux (VUR) etiology and sxs
A
- abnl retrograde flow of urine from bladder into one or both ureters and kidneys d/t mislocated and incompetent ureterovesical valves
- cause: recurrent UTI, high pressure sterile reflux impaires growth of kidneys + recurrent UTIs (patchy interstitial scarring and tubular atrophy), loss of functioning nephrons → hypertrophy of remaining glomeruli
- MCC: weakness of the trigone and its contiguous intravesical ureteral musculature
- young children, girls > boys
- sxs: prolonged bed wetting or recurrent UTIs, renal insuff, HTN, mild to mod proteinuria, unremarkable urine sediment
8
Q
VUR dx and tx
A
- dx: VCUG (voiding cystourethrogram) - clubbed calyces and dilated tortuous ureters entering the bladder
- RNC (radionuclide cystography), renal US, DMSA (first UTI in all children <5, febrile UTI any child, any boy with UTI)
- tx: spont resolution common in younger children, less with puberty/severity (watch and wait), aggressive control of BP with ACE or ARB to reduce proteinuria
- health maint: long-term abx proph recommended if recurrent UTI
- neonates: amox
- child/adult: bactrim, nitro
- 1/4 dose at PM, dc once CUR resolved, corrected or outgrows need
- FU renal US/VCUG/RNC q1-1.5y
- surg as needed (breakthrough febrile UTI, severe reflux, persistent in females, poor med compliance, poor renal growth
- complications: pyeloneph, hydroureteronephrosis
9
Q
enuresis
A
- urination into the clothing during day and into bed at night by child who is chonologically and developmentally oder than 5yo
- RF: boys, first-degree relative
- sxs: must occur at least 2x/w for 3mos
- dx:
- primary: r/o UTI, constipation, polyuria from DM or renal fail
- daytime: UA, cx +/- US of bladder, XR of spine
- secondary: UA, cx
- tx: behavioral strategies (star chart, no excess fluid during evening, void before bed)
- if no improvement, alarm devices (conditioning tx, most effective long-term tx, first line if no response to behavioral strats)
- desmopressin - response in 2wk (monitor fluid intake dt hyponatremia, children 5+ (CI in hyponat, hx of hyponat), AE = dilutional hyponatremia
- third line = TCAs (imipramine, amitryptaline, desipramine)
- if UTI, PO bactrim, cefixime x7d
10
Q
primary vs secondary enuresis
A
- primary: nocturnal, one bedwetting incident . weekly for boy >6yo or girl >5yo
- secondary: previously dry, emotional upset/family stress, child previously dry for >6mo
- dx for both: voiding diary, UA (first morning void), renal sonogram or voiding cystourethrogram (for children with daytime complaints, hx of UTI, or possible structural abnlity)
11
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
12
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
13
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
14
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
15
Q
UTI in neonates (<30d) etiology, RF, sxs, dx
A
- presents in 2-3rd wk after birth, MC pathogen (term) = E. coli, MC pathogen (preterm) = coagulase-neg staph and klebsiella, M = 75% of cases
- RF: preterm, low birth weight (<1000g), uncircumcised males (10x), kidney and urinary tract anomalies (pelviectasis, mild hydronephrosis)
- sxs: fever, FTT, jaundice, V, poor feeding, lethargy, irritabiliy
- in preterm infants <30d old: feeding intol, lethargy, abd distention
- signs: tachypnea, cyanosis, ill-appearing, jaundice (may be initial sign)
- in preterm infants <30d old: apnea, bradycardia, hypoxia, tachypnea
- associated: bacteremia, congen anomalies of the kidney and urinary tract (CAKUT), conjugated hyperbilirubinemia
- dx: CBC with diff, UA (not sens or spec enough for dx, 10-50k, +leukocyte esterase), blood cx (get in every infant w/ suspected UTI, ro sepsis), renal US (all neonates with UTI to ro structural anomalies, obtain after abx initiated), VCUG recommended in all neonates with UTI
