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R5 - Internal Medicine > Urology/Renal > Flashcards

Urology/Renal Flashcards

1
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
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2
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
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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)
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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
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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
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6
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
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7
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
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8
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
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9
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
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10
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
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11
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
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12
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
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13
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
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14
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)
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15
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
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16
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)
17
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
18
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)
19
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)
20
Q

chronic renal failure

A
  • renal failure or insuff (stages 2-5)
  • RF: DM, HTN; independent risk factor for CV dz
  • sxs: abnl elevated SCr for 3+mos, abnl GFR <60 mL/min for 3+ mos, persistent proteinuria or abnormalities on renal maging, even if GFR normal
  • dx: UA, spot urine sample for albumin or protein:Cr ration, SCr level (broad waxy casts), GFR estimation, anemia, hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, hyperuricemia, met acidosis with high anion gap, renal US (symmetrically small echogenic kidneys)
  • tx: aggressive glucose and BP control, low salt, target BP <130/80, avoid nephrotoxic agents, dose adjust meds, refer for stage 3+ (GFR <30), ACE/ARBs
    • diet and med: protein restriction, sodium 2g/d), K restriction if hyperK, kidney transplant with dialysis (CKD stage 5)
  • prognosis: 80% with CKD die, from CVD mostly before getting dialysis
21
Q

acute kidney injury

A
  • abrupt, typically reversible decline in GFR, usually within 48h, MC dt acute tubular necrosis, changes lag behind and underestimate decline in GFR - by the time serum Cr rises, GFR has fallen significantly
  • sxs: INCREASE in SCr level of >/= 0.3 mg/dL, % inc in SCR >/= 50%, DECREASE in urine output of 6+h
  • signs: JVD, orthostatics, periorbital edema, pedal edema, rash, thick skin, mucus ulcers, fever, pleural rub, crackles, S3, prostate masses, bladder distention
  • associated: arthritis, foot drop
  • dx: serum electrolytes, phosphate, Ca and albumin, uric acid, mag, CBC
    • if obstruction suspcted, US - prerenal: no obst, no evidence of intrarenal causes or acute renal failure; intrinsic = kidney dz or normal, no obstruction; postrenal: hydronephrosis
  • tx: r/o reversible causes (hoTN, volume depletion, obst, hyperkalemia, volume overload), identify cause and determine complic ations that require immediate action, if not responsive to tx, consider urgent dialysis
22
Q

signs of uremia

A
  • skin: pale, hyperpig, ecchymosis, hematoma, pruritus, skin necrosis, bullous lesions
  • cardio: volume overload, HTN, atherosclerosis, LVH, HF, rhythm disturbances, uremic pericarditis
  • neuro: CVA, encephalopathy, Szs, peripheral autonomic neuropathy
  • GI: anorexia, N/V, malnutrition, uremic fetor, inflammatory/ulcerative lesions, GI bleed
  • heme: anemia, increased infections, bleeding diathesis
  • bone: renal osteodystrophy, growth retardation, muscle weakness
  • endo: sexual dysfn, infertility, glucose intolerance, hyperlipidemia
  • labs: hyoNa, hypoCa, hyperK, hyperMg, hyperuricemia, met acidosis
23
Q

acute interstitial nephritis

A
  • inflammation involving the intersitium (surrounds glom and tubules)
  • causes: acute allergic rxn to meds (PCN, ceph, sulfa, diuretics, anticoagulants, allopurinol, PPI), inxn (strep, legionella), sarcoidosis, SLE, Sjogren’s
  • sxs: AKI with associated sxs (wt gain, edema, oliguria, dry mucous membranes, hyoptension, tachycardia, decreased turgor), recent infxn or start of new meds, general aches and pains, rash, fever, eosinophilia, +/- pyuria, hematuria
  • dx: renal fn tets (high BUN/Cr), UA eosinophils, proteinuria
  • tx: remove offending agent, steroids, treat infxn if present
24
Q

polycystic kidney disease

A
  • family hx; autosomal dominant, MC GENETIC cause of CKD, ESRD develops in 50% of pts
  • sxs: microscopic or gross hematuria, abd or flank pain, resistant HTN
  • signs: palpable abd mass, palpable kidneys on exam
  • associated: kidney stones, infxn
  • dx: US CONFIRMATORY, multiple cysts, CT and MRI alternatives
  • tx: no curative tx, drain cysts if sxatic, tx infxn with abx, control HTN
  • complications: intracerebral berry aneurysm, infxn of renal cysts, renal filaure, kidney stones, mitral valve prolapse, cysts in other organs, hernias, diverticula
25
Q

hydronephrosis

A
  • MCC congenital bl hydronephrosis = post urethral valves (males), MC acquired causes = pelvic tumors, renal calculi, urethral stricture; common in pregnancy
  • sxs: sudden or new onset HTN, severe steady pain, radiates down to lower abd, testicles, or labia, disturbed excretory fn or difficulty voiding (oliguria, anuria vs polyuria, nocturia, dysuria with UTI
  • signs: fever, distention of kidney or bladder, DRE enlarged prostate or rectal/pelvic mass, pelvic exam enlarged uterus or pelvic mass
  • dx: UA hematuria, pyuria, proteinuria, or bacteriuria; BUN/Cr azotemia dt impaired excretion of Na, urea, and H2O; urodynamic testing for neurogenic bladder; US imaging (sensitive and specific if no diuresis occurs with cath - IV urogram and or CT scan, MR pyelogrphy, VCUG if VUR)
  • tx: bladder cath if diuresis occurs, the obst is below the bladder neck (frequent voiding or catheterization), abx 3-4wks +/- percutaneous nephrostomy, anticholinergics for neurogenic bladder, VUR (surgical repair)
26
Q

erectile dysfn

A
  • M 40-70; CVD risk factors = smokers, HTN, DM, 2x risk of heart attack, cannot dilate cavernosal artery (smooth muscle relaxation OR venous leakage)
  • sxs: consistent or recurrent inability of a man to attain and/or maintain an erection for sexual performance
  • dx: clinical
  • tx: PDE-5 inhibitors, vacuum constriction device, intracavernosal injection, transurethral system: alprostadil, penile prosthesis
27
Q

varicocele

A
  • left-sided (90%), may be infertile, left spermatic vein enters left renal vein, right spermatic vein enters IVC, majority not associated with fertility
  • sxs: asxatic (adolescent males), vague testicular pain
  • signs: bag of worms - decompresses while supine
  • dx: US
  • tx: NSAIDs, scrotal support, rarely surgery

R5 - Internal Medicine (10 decks)

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