Urology/Renal Flashcards
1
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
2
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
3
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)
4
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
5
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
6
Q
Prostate cancer
A
- second MC cancer in men worldwide, 95% adenocarcinomas
- RF: age 65+ (most important), AA, high fat diet, + FHx, exposure to herbicides and pesticides
- sxs: early - asxatic, cancer begins in periphery and moves centrally
- late - obstructive sxs (difficulty voiding, dysuria, inc urinary frequency)
- late-late - bone pain from mets (MC vertebral bodies, pelvis, and long bones in legs), wt loss
- dx: DRE (hard, nodular, irreg) - if indurated, asymm or nod = bx especially if >45yo
- when palpable, 60-70% have spread beyond prostate
- TRUS with bx regardless of PSA level (PSA not cancer specific)
- tx: localized dz (radical prostatectomy) or watchful waiting in older men who are asxatic
- complications: erectile dysfn and urinary incontinence (locally invasive - radiation tx + androgen deprivation)
- metastatic dz: orchiectomy, antiandrogens, LH agonists (leuprolide), GnRH antag (degarelix)
7
Q
acute urinary retention
A
- inability to void in presence of a full bladder
- RF: male gender, prostatic enlargement; epidural, spinal or prolonged anesthesia; antihistamine and narcotic use; pelvic and perineal procedures, M > F
- sxs: suprapubic discomfort with urgency and inability to void, unable to void within 8h after surgery or 8h after catheter removal, painful, vomiting
- signs: palpable bladder on exam, hoTN, bradycardia, cardiac dysrhythmias
- complication: infxn, ischemia, long-term bladder dysfn
- dx: bladder US (500 mL urine), postvoid residual (500mL or greater), urine cx, CBC if suspected infxn
- tx: immediate sterile cath (place for 24h, then void trial), identify and treat underlying cause
8
Q
chronic urinary retention
A
- painless, develops gradually, frequent urination of small amounts or overflow incontinence (sensation of fullness)
- signs: suprapubic dullness, rounded midline mass
- dx: postvoid residual bladder volume by cath or US, abd US or CT indicated to identify suspected masses, stones, or hydronephrosis
- tx: same as acute urinary retention
9
Q
detrusor (bladder) sphincter dyssynergia
A
- consequence of neurological pathology: SCI or multiple sclerosis; urethral sphincter m. dyssyndergically contracts during voiding causing flow to be interrupted and bladder pressure to arise, obstructive cause
- sxs: daytime and nighttime wetting, urinary retention, hx of UTI/bladder infxn
- associated: constipation and encopresis
- dx: postvoid residual urine volume (PVR) >150mL
- tx: botulinum A toxin injections, surgical incision of bladder neck (can result in incontinence)
10
Q
wilms tumor
A
- MC primary malig tumor of kidney in children, peak age 3, 97% are sporadic
- sxs: asxatic mass (flank or upper abdomen, discovered while dressing or bathing), HTN, hematuria, obstipation, wt loss
- dx: abd and chest CT (characterize mass, identify mets, look at opposite kidney), abd US to evaluate renal vein and vena cava
- tx: surgery (radical nephroureterectomy if unilateral), if bilat bx both and start chemo after nephron-sparing procedure; chemo = 97% 4y survival rate
11
Q
edema
A
- lower extrem (either inc venous or lymphatic pressures, dec intravasc oncotic pressure, inc capillary leak or infxn/local injury)
- MCC: chronic venous insuff, common complication of DVT
- sxs: MC sx = sensation of “heavy legs”, itching, pain
- signs: hyperpig, stasis dermatitis, lipodermatosclerosis (thick, brawny skin), atrophie blanche (small depigmented macules), measure size of calves 10cm below tibial tuberosity, check for tenderness and pitting, ulcer located over medial malleolus (hallmark finding)
- dx: if low suspicion D dimer indicated, use Wells criteria to rule out DVT, color duplex US as well as ABI, urine dip to ro nephrotic syndrome, SCr to check kidney fn
- tx: treat underlying cause, if chronic venous insufficiency without volume overload, avoid diuretics (may enhance sodium retention through inc secretion of renin and angiotensin - AKI and oliguria)
- supportive care = leg elevation above heart x 30min TID and during sleep, compression stockings, ambulatory exercise
12
Q
orthostatic hypotension
A
- volume depletion, medication, autonomic dysfn, cerebral hypoperf, and syncope in standing position
- primary: shy-drager syndrome, parkinson, rare dysautonomias
- secondary: DM, anemia, amyloidosis, MS, HIV
- meds that commonly cause OH - diuretics, antihypertensives (ACE inhib, BB, CCB), and ethanol
- sxs: 20mmHg decline in SBP or 10mmHg dec in DBP when standing
- precipitating factors: micturition, cough, exertion
- premonitory sxs: aura
- associated: palpitations, CP, HA
- activity: at rest or with exercise
- position: standing, sitting, changing position
- injury, incontinence, rapid recovery vs. postictal state
- dx: EKG, tox screens, if cardiac hx - echo, stress test, holter monitor, tilt-test (+ if syncope or presyncope), electrophysiolgoy study (EPS)
- tx: treat the cause (SVTs - BB, K/Na channel blockers, CCB), neurocardio and situation - avoid precipitants, ephedrine, midorine, metoprolol, pindolol, scopolamine
13
Q
bladder carcinoma
A
- white males 65-75yo
- RF: smoking (2-4x), chronic cyclophosphamide, schistosoma haematobium exposure, protective = vitA supplements, >95% are transitional cell in origin, most tumors are superficial, MC sites of hematogenous spread = lung, bone, liver, brain
- sxs: gross hematuria, irritative sxs = dysuria and frequency, obstructive sxs if near urethra or bladder neck
- signs: flank pain
- dx: UA and cx, urine cytology, CT scan of pelvis or MR urogram or IV pyelogram, cystoscopy with bx, histology (required for dx - bladder barbotage for cytology), selective cath and visualization of upper tracts if cytology +
- tx: nonmuscle invasive dz = complete endoscopic resection (transurethral surg, for solitary papillary lesions, add intravesical tx for CIS and recurrent dz, monitor q3mo), muscle invasive dz (radical cystectomy = standard and removal of pelvic lymph nodes, including prostate, seminal vesicles, and urethra, impotence)
14
Q
renal cell carcinoma
A
- M 2x > F, 85% of primary renal cancers in adults
- cause unknown
- RF: smoking, phenacetin analgesics, adult polycystic kidney dz, chronic dialysis, exposure to heavy metals, HTN
- sxs: hematuria (MC), abd or flank pain (50%), abd flank mass, wt loss, fever, paraneoplastic syndromes (polycythemia, hypercalcemia, HTN, cushing’s syndrome, feminization, or masculinization
- dx: renal US, abd CT with and w/o contrast (optimal test for dx and staging)
- tx: radical nephrectomy (remove kidney and adrenal gland) for stages I-IV, metastasis (liver, lung, brain, bone)
15
Q
renovascular hypertension (renal artery stenosis)
A
- MCC = atherosclerosis (elderly men, smoking, high cholesterol), 1-2% pts with hypertension, cause in most young individuals is fibromuscular dysplasia
- sxs: HTN (sudden onset wo family hx, age <20 or >50, severe and refractory to 3+ drugs)
- signs: abdominal bruit (RUQ, LUQ, epigastrium) in 50-80% of pts, atherosclerotic dz of aorta or peripheral arteries, pulm edema with increase in blood pressure
- dx: hypoK, dec renal fn, abrupt inc in serum Cr after use of ACE inhib, renal arteriogram = gold standard but contrast is nephrotoxic
- MRA = high sens and spec, can be used in renal failure - for medium to low suspicion
- duplex US and con enhanced CT
- tx: revasc with percut transluminal renal angio (PRTA) initial tx, surg (bypass), ACEI or CCB may be tried alone or in combo
