Urology/Renal Flashcards
1
Q
What are the average values for acid/base disorders?
A
“24/7 40/40”
-24 (HCO3, base)/ 7.40 (pH), 40 (CO2, acid)
2
Q
What is the three-step approach to acid-base disorders?
A
Look at your PH (7.35-7.45 normal)
- < 7.35 = acidosis
- > 7.45 = alkalosis
Next look at your PCO2 is it normal, low, or high (35 to 45 normal)
- increased CO2 and decreased PH = respiratory acidosis
-decreased CO2 and increased PH = respiratory alkalosis
-If you don’t see a change in the CO2 in relation to the PH then take a look at the HCO3
Finally look at the HCO3 is it normal, low, or high (20-26 normal)
-decreased HCO3 and decreased PH = metabolic acidosis
-Increased HCO3 and increased PH = metabolic alkalosis
3
Q
What is acute renal failure?
A
- Stage 1: Normal GFR (>90)
- Stage 2: Early GFR (60-90)
- Stage 3: Moderate GFR (3a 45-59) (3b 30-44)
- Stage 4: Severe GFR (15-29)
- Stage 5: Kidney failure (GFR < 15 = dialysis)
4
Q
What are the causes of renal vascular disease?
A
Diabetic kidney disease #1
- hypertension
- smoking
- vascular disease aka renal artery stenosis
- glomerular disease
- renal cysts
- genetics (autoimmune, SLE, polycystic kidney disease, Alport’s syndrome)
5
Q
What is the presentation of acute kidney injury or acute renal failure?
A
- an abrupt or rapid decline in renal filtration function
- elevated serum creatine and decrease GFR
- azotemia a rise in blood urea nitrogen (BUN) concentration
6
Q
What are the causes of acute renal failure?
A
prerenal, intrinsic, ans postrenal
7
Q
What are the causes of prerenal (before the kidneys) acute renal failure?
A
- this is due to decrease blood flow to the kidneys
- remember the nephrons are intact
- hypovolemia (most common)
- NSAIDs, IV contrast, ACEI, ARBS (renal artery stenosis)
- treatment = creatine improves with IV fluids
- low blood pressure
- heart failure
8
Q
What are the causes of intrinsic (in the kidneys) acute renal failure?
A
- renal aka intrinsic direct damage to the kidneys
- nephrotoxic drugs = aminoglycosides (Gentamicin)
- cyclosporine
- tumor lysis syndrome
- vasculitis (SLE, sarcoidosis)
- crystals from gout
- myoglobin from rhabdomyolysis
9
Q
What are the pearls of intrinsic renal failure?
A
cellular casts is the hallmark = RBC CASTS
-tx: IV fluids remove drugs if present and sometimes Lasix to get the kidneys moving
10
Q
What are the causes of post renal (downstream from the kidney) acute renal failure?
A
- there is some type of obstruction in the ureters such as kidney stones
- BPH, tumors
- congenital or structural abnormalities
- remove the obstruction or fix the structural abnormality
11
Q
What are the causes of acute renal failure?
A
rapid but usually reversible reduction in renal excretory function sufficient to cause azotemia
- ATN, interstitial nephritis, glomerulonephritis
- azotremia: retention of nitrogenous waste
- uremia: symptomatic azotemia, with n/v/lethargy
- acute: sudden, hours/days and is reversible
- chronic: progressive, irreversible
- oliguria: urine output < 400 ml/day
12
Q
How is acute renal failure dx?
A
CBC, BUN, Cr, electrolytes (Ca, phosphate), UA, postvoid residula bladder volume
-tx: depends on cause
13
Q
What is the prerenal mechanism?
A
perfusion (50%) - kidney working fine but things that perfuse it aren’t
- ex: volume loss, heart failure, loss of peripheral vascular resistance (espies/anesthesia)
- weak, decreased urine output, dizziness, sunken eyes, tachy, orthostatic
- fractioal excretion of sodium is normal
- urine specific gravity >1.030, Bun/Cr > 20, urine osm > 500
- tx: fluids, cardiac support, treat shock
14
Q
What is renal mechanism?
A
- RC casts = glomerulonephritis
- WBC casts = pyelonephritis
- muddy casts = ATN
- hyaline casts = normal
- waxy = chronic renal disease
- urine specific gravity <1.010, BUN/Cr <10, urine ism < 300
15
Q
What is post-renal mechanism?
A
obstructive - most likely prostate
- usually low/no urine output
- place foley Cath to find the source of obstruction; renal US to look for tumor/hydroephrosis
16
Q
What is ATN?
A
from kidney ischemia/toxins; UA shows muddy brown casts
- damaged tubules means can’t concentrate urine = high FENa
- prerenal failure is MC cause
- drugs: amp B, cisplatin, aminoglycosides, NSAIDs, ACE
- ischemic: dehydration, shock, sepsis
- fraction excretion of sodium > 2% + muddy, pigmented granular casts + high urine osm
17
Q
What is interstitial nephritis?
A
- immune-mediated response
- drugs: PCN, sulfa, NSAIDs, phenytoin
- US: WBC casts + eos + hematuria
- dx: renal biopsy, discontinue offending drug, steroids, dialysis if needed, usually self-limiting
18
Q
What is glomerulonephritis?
A
IGA nephropathy, post infectious, membranoproliferative
- UA: oliguria, hematuria, RBC casts
- causes: group A strep, IGA, anti-GBM, ANCA
- post-strep glomerulonephritis = MC infectious cause of acute glomerulonephritis: either from strep pharyngitis or strep skin infection (impetigo) = hematuria, HTN, periorbital edema
- dx: proteinuria + RBC in urine; usually caused by group A beta-hemolytic strep
19
Q
What is chronic kidney disease?
A
a progression on ongoing loss of kidney function (GFR) defined as less than 60 mL/min/1.73 m2 or presence of kidney damage (proteinuria, glomerulonephritis or structural damage from polycystic kidney disease) for > 3 months
-measurement of GFR is the gold standard - the Cockcroft - gault formules (requires age, body weight, and serum creatinine) or Modificationof diet in renal disease equation
20
Q
What is the etiology of chronic kidney disease?
A
diabetes, hypertension, glomerulonephritis
21
Q
What are the findings of chronic kidney disease?
A
fatigue, pruritus, Kussmaul respirations, asterisks (flapping tremor), muscle wasting, broad waxy casts
22
Q
What are the stages of chronic kidney disease?
A
- Stage 1: GFR > 90 mL/min
- asymptomatic
- Stage 2: GFR 60-89
- asymptomatic
- Stage 3: GFR 30-59
- Stage 4: GFR 15-29
- dialysis and kidney transplant
- Stage 5: GFR < 15
- kidney transplant
23
Q
What is the management of chronic kidney disease?
A
blood pressure control <130/80, ACE or ARB A1c 6.5-7.5%
-patients with chronic renal failure typically present with hypocalcemia, hyperphosphatemia, and metabolic acidosis
24
Q
What is acute interstitial nephritis?
A
- etiology: immune-mediated response
- drugs: PCN, sulfa, NSAIDs, phenytoin etc.
- Immunologic and infectious disease: strep, SLE, CMV, Sjogren’s, Sarcoidosis
- urinalysis: WBC casts and eosinophils
25
What are the characteristics of acute interstitial nephritis?
- eosinophils, WBC casts, and hematuria
- acute azotemia (accumulation of nitrogen waste)
- major causes - immune-mediated response
- drugs: PCN, sulfa, NSAIDs, phenytoin etc.
- Immunologic and infectious disease: strep, SLE, CMV, Sjogren's, Sarcoidosis
26
How is acute interstitial nephritis dx?
diagnose with renal biopsy - will see interstitial inflammatory cell infiltrates
27
How do you tx acute interstitial nephritis?
by discontinuing the offending drugs, corticosteroids, dialysis if needed, usually self-limiting if caught early
28
What is benign prostatic hyperplasia?
a disease of elderly men (average age is 60-65 years caused by hyperplasia of prostatic epithelial, stroll cells - formation of nodules in periurethral (transition) zone - narrowing of urethras canal - urethral compression - obstruction of the urinary outlet
29
What are the characteristics of benign prostatic hyperplasia?
- 50% of men develop BPH by 60 and >90% by age 85
- features: decreased force of urinary stream, hesitancy (stop and start) and straining, postvoid dribbling, incomplete empything, frequency, nocturia, urgency, recurrent UTIs
- in men with BPH avoid the use of anticholinergic and antihistamines
- this type of prostate enlargement isn't thought to be a precursor to prostate cancer
30
How is benign prostatic hyperplasia dx?
accurately diagnosing BPH is extremely important as more serious conditions, such as prostate cancer must be ruled out
- DRE = enlarged rubbery prostate
- urinalysis/culture - microscopic hematuria may be present - pyuria, bacteriuria in case of concomitant UTI
- blood tests - often PSA often elevated > 4 - electrolytes, blood urea nitrogen (BUN), and creatinine to evaluate for renal impairment
- ultrasound - evaluate bladder size, prostate size, degree of hydroenphrosis
- cystoscopy - reveal bladder diverticula/calculi before scheduled invasive treatment
31
How is benign prostatic hyperplasia tx?
includes medications that relax the bladder or shrink the prostate, surgery, and minimally invasive surgery, and minimally invasive surgery
- conservative measures; e.g decrease fluid intake before bedtime/going out; avoid caffeine, alcohol (mild diuretic effects)
- alpha-adrenergic receptor blockers (terazosin, tamsulosin) - decrease prostate, bladder, urethral muscle tone
- 5-alpha reductase inhibitors (finasteride) - decrease DHT synthesis - reduce prostate gland size
- Phosphodiesterase-5 enzyme inhibitors (e.g tadalafil) - induce smooth muscle relaxation
- TURP (transurethral resection of the prostate) if refractory to meds - removes excess prostate tissue to relieve obstruction - sexual dysfunction and urinary incontinence
32
What is bladder cancer?
- cigarette smoker; presents with painless gross hematuria
- transitional cell carcinoma is the most common type
- cystoscopy with biopsy is the gold standard for initial diagnosis
33
What is the tx for bladder cancer?
surgery, biological therapy, and chemotherapy
34
What is epididymitis?
acquired by the retrograde spread of organisms through vas deferens
- the pathogen is based on patient's age and risk factors:
- men < 35 chlamydia and gonorrhea
- men > 35 E.coli
35
How is epididymitis characterized?
dysuria, unilateral dull aching scrotal pain that can radiate up the ipsilateral flank
- swollen epididymis tender, fever/chills
- + Prehn's sign = relief with elevation is a classic sign
36
How is epididymitis dx?
urinalysis reveals pyuria and bacteriuria; cultures are positive for suspected organisms
37
How is epididymitis tx?
supportive care: bed rest, scrotal elevation, analgesics
- over 35 - E. coli:
- levofloxacin (Levaquin) 500 mg/day PO for 10 days (21 days if associated prostatitis)
- ofloxacin 300 mg PO BID for 10 days
- Unde 35 - gonorrhea and chlamydia
- doxyxycline 100 mg PO BID for 10 days PLUS ceftriaxone 250 mg IM x 1
- refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms
38
What is erectile dysfunction?
occurs when a man can't get or keep an erection firm enough for sexual intercourse
- psychological
- organic causes include hypertension, neurological problems from diabetes, and hormonal dysfunction
- medication side effects
- nocturnal penile tumesence used to evaluate sleep erections
- do not use with nitrates may cause hypotension
39
How is erectile dysfuntion tx?
phosphodiesterase 5 inhibitor Sildenafile (viagra), tadalafil (Cialis), vardenafil (levitra)
-weight loss, smoking and alcohol cessation, hormone replacement, and vacuum erection devices and surgery
40
What is glomerulonephritis?
damage of renal glomeruli by deposition of inflammatory proteins in glomerular membranes as a result of immunologic response
- 60% in kids; excellent prognosis in kids and worse in adults esp with preexisting renal disease
- cause: hematuria, Henoch-Schonlein purpura, postinfectious GN, IgA nephropathy, hereditary nephritis, and others
- features: hematuria, urine = tea/cola-colored, oliguria/anuria, edema of face and eyes in the morning and of the feet/ankles at night; HTN is common
41
How is glomerulonephritis dx?
hematuria, RBC casts, proteinuria, HTN, decreased GFR
- antistreptolysin-O titer is increased in 60-80% of cases; a common cause of GN is a streptococcal infection
- UA reveals hematuria (>3 RBCs/high power field) and misshapen RBCs, RBC casts, proteinuria (1-2g/24 hours)
- serum complement often decreased
- renal biopsy may be done to determine exact diagnosis or severity
42
What is the tx for glomerulonephritis?
steroids and immunosuppressive drugs to control inflammatory response; dietary management (salt and fluid intake decreased); dialysis if symptomatic azotemia present
- medical: ACE-I = renoprotective (reduce urinary protein loss) in chronic GN
- use meds as appropriate for hyperkalemia, pulmonary edema, peripheral edema, acidosis and HTN
43
What is a hydrocele?
a fluid-filled sac around a testicle, often first noticed as swelling of the scrotum
- common in newborns and usually disappears without treatment within the first year
- older men can develop hydroceles, sometimes due to inflammation or injury
- hydroceles are usually painless but may become large and inconvenient
- an ultrasound may be needed for diagnosis
- on physical exam mass will transilluminate
44
What is the tx for a hydrocele?
usually involves watchful waiting
| -In rare circumstances, surgery is needed
45
What is hydronephrosis?
caused by blockage int eh ureter
- causes include a kidney stones, an infection, an enlarged prostate, a blood clot or a tumor
- symptoms include difficulty urinating and pain in the side, abdomen, or groin
46
What is the tx for hydronephrosis?
antibiotics if there's an infection
| -In severe cases, the urine may need to be drained from the bladder or kidney
47
What is hypervolemia?
iatrogenic (parenteral over hydration); fluid retaining states: CHF, nephrotic syndrome, cirrhosis, ESR, hypoalbuminemia
- total body water increased
- total body sodium increased
- weight gain, peripheral edema (pedal or sacral), ascites
- signs: jugular venous distention, pulmonary edema (pulmonary rales)
48
How is hypervolemia dx?
pulmonary artery catheter (Swan-Ganz) to measure CVP (definitive): elevated CVP and PCWP Low hematocrit or hypoalbuinemia
- serum sodium may be low <135 mmol/L
- decreased BUN/CR
49
How is hypervolemia dx?
fluid restriction
- judicious use of diuretics
- monitor urine output and daily weights, consider Swan-Ganz catheter
50
What is hypovolemia?
inadequate fluid intake/excess water loss: no thirst, fluid loss, urinary loss, GI loss, burns, diuretics, osmotic diuresis (hyperglycemia), sodium excess, diabetes insipidus
-a decrease in ECF volume
51
What is the hx with hypovolemia?
blood loss, GI loss, excess sweating, diuretics
- polyuria, polydipsia, polyphagia (diabetes)
- thirst, salt craving
- desire to drink pickle juice or ingest salty foods (inherited salt wasting)
- weakness, LOC MS changes, sleepy, apahetics
52
What are the signs of hypovolemia?
tachycardia, postural hypotension JVD no visible
- dry mucous membranes (tongue) and decreased skin turgor
- hypothermia, pale extremities
- oliguria
53
How is hypovolemia dx?
- measure serum Na+, K+, Cl-, HCO3-
- high Na+ >145
- Increased hematocrit (3% for each liter lost)
- metabolic alkalosis
- BUN: Cr > 20:1
- FeNa: <1% (prerenal azotemia)
- pulmonary artery catheter (Swan-Ganz) to measure CVP (definitive): decreased CVP, PCWP, pulse pressure
54
What is diabetes insipidus?
- neurogenic (central) - caused by deficient secretion of vasopressin (ADH = anti-pee hormone) from the posterior pituitary
- nephrogenic: kidneys unresponsive to normal vasopressin levels a inherited x-linked or from lithium/renal disease
- low urine sodium and polyuria
- urine osmolality of less than 250 despite hypernatremia, indicated diabetes-insipidus
55
What is the tx for hypovolemia?
correct volume deficit
- bolus to achieve euvolemia, begin with an isotonic solution (NS or lactated ringers)
- monitor HR, BP, UOP, and weight
- maintain UOP at 0.5 to 1.0 mL/kg/h
- replace blood loss with crystalloid at 3:1 ratio
- maintenance fluid DS/NS solution with 20 mEq KCl/L (most common)
- beware with rapid fluid correction = pulmonary edema
56
What is nephritic syndrome?
the difference between nephrotic and nephritic syndrome are easily forgotten
- at the most basic level, remember that nephrotic syndrome involves the loss of a lot of protein, whereas nephritic syndrome involves the loss of a lot of blood
- nephritic syndrome is typically caused by inflammation that damages the glomerular basement membrane, leading to hematuria and red blood cell casts in the urine
- common causes are infections, immune system disorders and inflammation of the blood vessels
- eventually this damage can lead to renal failure, where the individual can present with oliguira (urine output below normal), arterial hypertension, due to sodium retention, and peripheral and periorbital edema
57
How is nephritic syndrome dx?
lab tests show high levels of BUN and creatinine and on urinalysis, there's hematuria, proteinuria and RBC casts in the urine
- a 24-hour protein collection is necessary to quantify how many proteins are lost through urine
- nephritic syndrome can be differentiated from nephrotic syndrome because the proteinuria is generally under 3.5 grams per day, or within the "subnephrtoic range"
- In order to determine the causes, a careful history and a kidney biopsy can help diagnose the particular disease
58
What are the different disorders that could cause nephritic syndrome?
- those caused by type III hypersensitivity:
- poststreptococcal glomerulonephritis
- IgA nephropathy (Berger's disease)
- diffuse proliferative glomerulonephritis (often caused by SLE)
- those with multiple potential causes:
- membranoproliferative glomerulonephritis (MPGN)
- rapidly progressive glomerulonephritis (RPGN)
- alport syndrome which affects collagen synthesis
59
What is the tx of nephritic syndrome?
depnd on cause
- steroids and immunosuppressive drugs may be used to control the inflammatory response
- dietary management: salt and fluid restriction
- dialysis should be performed if symptoatmic azotemia
- ACEI/ARBs (enalpril or losartan) are renoprotective - blood pressure goal < 130/80
- in poststreptococcal GN Nifedipine is used instead of ACEI (ACE may cause hyperkalemia)
- IgA nephropathy - glucocorticoids
- rapidly progressive glomerulonephritis - immunosuppressive therapy
- use medications to control hyperkalemia, pulmonary edema, peripheral edema, acidosis and hypertension
60
What is nephritis?
inflammation of the kidneys and may involve the glomeruli, tubules, or interstitial tissue surrounding the glomeruli and tubules
61
What is glomerulonephritis?
inflammation of the glomeruli
| -often implied when using the term "nephritis' without qualification
62
What is interstitial nephritis?
(or tubulointerstitial nephritis) is inflammation of the spaces between renal tubules
63
What is nephritis caused by?
caused by infections, and toxins, but is most commonly caused by autoimmune disorders that affect the major organs like kidneys
64
What is pyelonephritis?
an inflammation that results from a urinary tract infection that reaches the renal pelvis of the kidney
65
What is lupus nephritis?
inflammation of the kidney caused by systemic lupus erythematous (SLE)
66
What is athletic nephritis?
resulting from strenuous exercise
67
How is nephritis dx?
nephritis can produce glomerular injury - blood tests, x-rays and an ultrasound can help ascertain if the individual has the condition
- this can lead to reduced glomerular blood flow, leading to reduced urine output (oliguria) and retention of waste products (uremia)
- as a result, red blood cells may leak out of the damaged glomeruli, causing blood to appear in the urine (hematuria)
68
What is the tx of nephritis?
treatment of nephritis depends on what has provoked the inflammation of the kidney (s)
-in the case of lupus nephritis, hydroxychloroquine could be used
69
What is polycystic kidney disease?
autosomal dominant polycystic kidney disease (ADPKD) is a relatively common genetic condition resulting from mutation of the PKD1/PKD2 gene
70
What are the characteristics of polycystic kidney disease?
- growth of numerous cysts in kidneys made of epithelial cells from renal tubules; can = kidney failure/ESRD
- it results in often painful enlargement of the kidneys due to multiple cyst development
- one of the MC human genetic disorders (autosomal dominant)
- > 30 yo, +FH, abdominal mass
- the classic presentation is a young patient with back and flank pain, and HTN
- 10% have brain aneurysms (worry when they complain of the worst headache of life)
- cardiovascular abnormalities: mitral valve prolapse, LVH
71
How is polycystic kidney disease dx?
ultrasound will demonstrate many fluid-filled cysts
- CT shows large renal size and multiple thin-walled cysts
- anemia, UA = proteinuria, hematuria, pyuria, bacteriuria
72
How is polycystic kidney disease tx?
no cure, treatment is supportive, BP control
| -ACE-I/ARB for HTN, treat infections with antibiotics, dialysis/transplant with renal insufficiency
73
What are the characteristics of prostate cancer?
- symptoms include difficulty with urination, but sometimes there are no symptoms at all
- the most common area is the peripheral zone
- on DRE carcinoma is characteristically a hard, irregular, and nodular
- tumor marker is PSA (also elevated in BPH)
- PSA is considered normal < 4
- PSA > 4 think BPH, prostate CA, and prostatitis
- annual prostate cancer screening
- white male with average risk screen at 50 years old
- black male, positive family history or +BRCA mutations - screen at 40 years old
74
How is prostate cancer dx?
prostate-specific antigen, digital rectal examination, and transrectal ultrasonography
- if PSA level > 10 ng/mL, TRUS with biopsy is indicated, regardless of DRE findings
- If DRE is abnormal, TRUS with biopsy is indicated, regardless of PSA level
- if PSA is < 4.0 ng/mL and DRE is negative, annual follow-up is indicated
- if PSA is 4.1 to 10.0 and DRE is negative, a biopsy is usually recommended
75
What is the tx of prostate cancer?
some types of prostate cancer grow slowly
- in some cases, monitoring is recommended
- other types are aggressive and require radiation, surgery, hormone therapy, chemotherapy, or other treatments
76
What is prostatitis?
ascending infection of gram-negative rods into prostatic ducts
- acute: sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency and dysuria
- chronic: variable - asymptotic = acute symptomatolgy
- all forms present with irritative bladder symptoms (frequency, urgency, dysuria) and some obstruction
- physical exam reveals a tender and enlarged prostate on digital rectal exam
77
How is prostatitis dx?
urinalysis will reveal pyuria and hematuria
- prostatic fluid = leukocytosis, culture typically positive for E. coli in acute infections
- chronic usually have enterococcus
- if you suspect acute prostatitis DO NOT massage the prostate this can lead to sepsis
78
What is the tx for prostatitis?
- men < 35: Chlamydia and gonorrhea - cefriaxone and azithromycin (or doxycycline)
- E. coli and pseudomonas in men > 35 - treat with fluoroquinolone or Bactrim for six weeks to ensure eradication of the infection - culture urine 1 week after the conclusion of therapy
- hospitalization in acute - may need parenteral fluoroquinolones
- if fever doesn't resolve in 36 hours, suspect abscess and consult urology
- chronic prostatitis is treated with fluoroquinolone or Bactrim x 6-12 weeks
- NSAIDs = effective for analgesia; alpha 1 blocker may be helpful if lower UTI symptoms are present
- chronic, recurrent, resistant prostatitis with/without prostatic calculi may require transurethral resection of the prostate (TURP) for resolution
79
What is pyelonephritis?
irritative voiding + fever + flank pain + nausea and vomiting + CVA tenderness
- organism: E. coli
- urinalysis: bacteria and WBC casts
80
How is pyelonephritis dx?
- UA shows pyuria, bacteriuria, varying degrees of hematuria, WBC casts
- CBC shows leukocytosis and left shift
- complicated: ultrasound shows hydronephrosis secondary to obstruction
81
Whta is renal calculi?
- colicky flank pain radiating to the groin, hematuria, CVA tenderness, and nausea and vomiting
- CT scan (spiral CT) without contrast of the abdomen and pelvis is the gold standard for diagnosis
- urinalysis will often show microscopy hematuria
- BUN and Cr levels (for evaluation of renal function) and also calcium, uric acid, and phosphate levels
82
What are the four types of renal calculi?
- calcium oxlate (80%): most common, excess oxalate, hyperparathyroidism, radiopaque, - avoid grapefruit juice (makes calcium oxalate stones worse)
- struvite (10%): associated with chronic UTI with Klebsiella and proteus species, radiopaque
- Uric Acid (7%): form in individual with persistently acidic urine - excess meat/alcohol, gout, radiolucent
- cystine (1%): rare genetic, radiolucent (young boy with kidney stones)
83
What are the general measures (for all types of stones)?
- analgesia: IV morphine, parenteral NSAIDs (ketorolac)
- vigorous fluid hydration - beneficial in all forms of nephrolithiasis
- antibiotics - if UTI is present
- alpha-blocker therapy (Flomax) for patients with symptomatic ureteral stones > 5 mm and < 10 mm to facilitate ureteral stone passage (usually given to most patients independent of size)
- outpatinet management is appropriate for most patients, indications for hospital admission include:
- pain not controlled with oral medications
- anuria (usually in patients with one kidney)
- renal colic plus UTI and/or fever
84
What is the chance of spontaneous passage of renal calculi?
stones < 5 mm will have 80% chance of spontaneous passage
- stones > 5-10 mm have 20% chance of passage and may require elective lithotripsy - patient should be considered for early elective intervention
- stones > 10 mm are not likely to pass spontaneously
- ureteral stent or percutaneous nephrostomy (gold standard) should be used if renal function is jeopardized
- urgent treatment with extracorporeal shock wave lithotripsy can be used for renal stones of less than 2 cm or for ureteral stones of less than 10 mm
85
What is renal cell carcinoma?
triad of hematuria, flank pain, and abdominal mass (palpable)
- renal clear cell = MC (80) ; transitional cell = second MC
- r/f: smoking
86
How is renal cell carcinoma dx?
ultrasound or CT then biopsy
87
What is the tx of renal cell carcinoma?
surgery with radial neurectomy = curative
88
What is renal vascular disesae?
- narrowing of one or both of the renal arteries
- renal artery stenosis: narrowing of one or both renal arteries most often caused by atherosclerosis or fibromuscular dysplasia
89
What are the characteristics of renal vascular disease?
- narrowing of artery = impeded blood flow to kidney = renovascular HTN
- presentation: age < 30 with HTN or HTN with CAD/PVD, or HTN resistant to 3+ drugs
- patient placed on ACE who develops acute renal failure or a sharp rise in BUN/Cr = think renal artery stenosis
90
How is renal vascular disease dx?
ultrasound = first imaging in age < 60
- renal arteriography is gold standard for diagnosis
- may hear a renal artery bruit on auscultation
91
What is the tx of renal vascular disease?
percutaneous transluminal angioplasty (PTA) plus stent placement or with a surgical bypass of the stenotic segment
92
What is testicular torsion?
twisting of spermatic cord = compromised blood flow + ischemia (SURGICAL EMERGENCY)
93
What are the characteristics of testicular torsion?
- asymmetric high riding testicle "bell clapper deformity" negative Prehn's sign (lifting of testicle will not relieve pain), teenage males
- sudden, severe pain and swelling in the testicle are symptoms, associated with nausea and vomiting
- very tender to palpation, cremaster reflex absent
- blue dot sign: tender nodule 2 to 3 mm in diameter on the upper pole of the testicle
- more common in patients with a history of cryptorchidism
94
How is testicular torsion dx?
testicular doppler = best initial test; radionuclide scan demonstrates decreased uptake in affected testes = gold standard
95
What is the tx of testicular torsion?
- surgical emergency: repair within 4-6 hours, a longer wait may affect fertility
- followed by elective surgery on contralateral tests which is also at risk for torsion
96
What is a urinary tract infection?
an infection in any part of the urinary system, the kidneys, bladder, or urethra
- E. coli (most common)
- dysuria without urethral discharge, urgency, frequency, hematuria, new-onset incontinence (in toilet-trained children), abdominal or suprapubic pain
- absence of fever, chills or flank pain, change in urine color/odor
- urine dipstick: nitrite, leukocyte esterase
- urinalysis: pyuria, bacteriuria +/- hematuria +/- nitrites
- urine culture (gold standard)
- > 100 k CFU/mL (women)
- > 1000 CFU/mL men or Cath patients
- take 24 hour to obtain results
97
What is the tx of urinary tract infection?
nitrofurantoin (not over age 65), bactrim, fosfomycin
- ciprofloxacin - resevered for complicated cases
- posticoital UTI: single-dose TMP-SMX or cephalexin may reduce the frequency of UTI in sexually active women
98
What is the tx for a lower UTI in pregnancy?
- nitrofurantoin (Macrobid): 100 mg PO BID x 7 days
| - cephalexin (reflex): 500 mg PO BID x 7 days
99
What is interstitial cystitis?
symptoms relieved with voiding, diagnose of exclusion
| -Hunner's ulcer on cystoscopy
100
What is a varicocele?
is an enlargement of the veins within the scrotum (dilation of the pampiniform plexus)
101
What are the characteristics of varicocele?
- a varicocele may develop as a result of poorly functioning valves that are normally found in veins, in other cases, it may occur from compression of a vein by a nearby structure
- varicoceles often produce no symptoms but can cause low sperm production and decreased sperm quality, leading to infertility
- bag of worms in scrotum (made worse when patient is upright and improves when patient is supine)
- more common on left
102
What is the tx of varicocele?
varicoceles that cause no symptoms typically require no treatment
-cases in which symptoms occur can be repaired surgically
