Urology/Renal from PANCE Pearls Flashcards
What is Incontinence
Involuntary loss of urine
What is Stress Incontinence
Increased intraabdominal pressure leads to urinary leakage
How does Stress Incontinence occur
Increased intrabdominal pressure is greater than the urethral resistance to blood flow
Laxity of pelvic floor muscles caused by childbirth, obesity, estorgen
Sx of Stress Incontinence
Sneezing, Coughing, Laughing all lead to increased intrabdominal pressure which leads to leakage
Tx of Stress Incontinence
Pelvic Floor Exercises: Kegel, Biofeedback
Alpha Agonists: Midodrine, Pseudoephedrine (increase urethral sphincter tone)
Surgery: Increase urethral outlet resistance
What is Urge Incontinence
Urine leakage accompanied by or preceding urge
What causes Urge Incontinence
Detrusor muscle overactivity
Remember, detrusor muscle is stimulated by muscarinic Ach receptors
Contraction of detrusor causes release of urine
Sx of Urge Incontinence
Urgency, frequency, small volume voids, nocturia
Tx of Urge Incontinence
Bladder training (timed, frequent voids)
Anticholinergics are 1st line (Tolterodine, Propantheine, Oxybutynin)
TCA’s (Imipramine)
What is Overflow Incontinence
Urinary Retention
Incomplete bladder emptying
What leads to Overflow Incontinence
Decreased Detrusor Muscle activity
“Underactive bladder”
Bladder outlet obstruction: BPH
Sx of Overflow Incontinence
Small volume voids, frequency, dribbling
Increased Post void residual >200mL
Tx of Overflow Incontinence
Intermittent or indweling catheter 1st line
Cholinergics (Bethanacol)
BPH: Alpha-1 Blockers (Tamsulosin)
What is Chronic Kidney Disease
Chronic Kidney damage for > 3 months evidence by: Proteinuria Abnormal Urine Sediment Abnormal Serum/Urine Chemistries Abnormal Imaging Studies Inability to buffer pH Inability to make urine Inability to excrete nitrogenous waste Decreased Synthesis of Vitamin D/Erythropoietin
What are the different stages of Chronic Kidney Disease
Stage 0: At risk patients (DM, HTN, Chronic NSAID) State 1: Normal GFR with kidney damage Stage 2: GFR 60-89 Stage 3: GFR 30-59 Stage 4: 15-29 Stage 5: GRF
What interventions occurs with end stage renal disease
Uremia requiring dialysis and/or transplant
What is a normal GFR
120-130
What is common causes of end stage renal disease
DM #1
HTN
Glomerulonephritis
Dx of Chronic Kidney Disease
Proteinuria: Can test with spot Microalbumin/Microcreatine Ratio or 24 hour urine collection Urinalysis: See broad waxy casts GFR BUN/Cr ratio Renal Ultrasound: Small Kidney
What are dietary modifications for Chronic Kidney Disease
Protein Restriction
Water Restriction
Potassium and phosphate restriction
What are the two most important modifications to prevent Chronic Kidney Disease
Reduce blood pressure to
What is the gold standard for Dialysis access
AV fistula which connects an artery to a vein
What is the primary regulator of water secretion and what does it do
ADH
It conserves water by concentrating urine
What are 4 ways to regulate water
ADH
Thirst
Aldosterone
Sympathetics
What happens in the environment of high ADH
The kidney excretes small volumes of concentrated urine
ADH makes aquaporins to preserve water
What stimulates ADH
Hyperosmolarity
Decreased Arterial Volume (Hypovolemia) which reduces blood pressure
What happens in the environment of low ADH
Kidney generates large volumes of dilute urine
What inhibits ADH
Hypoosmlarity, which increases free water
Note that hypovolemia always takes precedence over hypoosmalarity (so ADH will be stimulated)
What stimulates thirst
Dehydration = Decreased free water
Hyerosmolarity which increases serum osmolarity
What does Aldosterone do
Causes sodium to be reabsorbed which in turn, water follows
What role does the sympathetic nervous system have in water regulation
Alpha-1 activation causes arteriole constriction
Afferent Arteriole constriction decreases renal perfusion (decreases GFR) which leads to less urine formation
How is sodium regulated in the body
Aldosterone
How is Aldosterone stimulated
Hypovolemia = low blood pressure = decreased intravascular volume (sodium + water)
Hyperkalemia
Water homeostasis is determined by ____
Sodium homeostasis is determined by ___
Water = ADH Sodium = Aldosterone
What is Hyponatremia
Increased free water = Decreased serum sodium
What is Hypernatremia
Decreased free water = Increased serum sodium
What makes up extracellular volume
Sodium and Water
What is hypovolemia
Hypervolemia
Euvolemia
Total body sodium is decreased
Total body sodium is increased
Normal total body sodium
Sx of Hypervolemia
Peripheral edema
Pulmonary edema
Jugular venous distension
HTN
Sx of Hypovolemia
Poor skin turgor Dry mucous membranes Flat neck veins Hypotension Increased BUN:Cr ratio
What is True Hyponatremia
Kidney unable to excrete free water to match oral free water intake
Associated with increased free water
What is Hypovolemic Hyponatremia
Decreased volume (water and sodium) AND increased free water Usually due to impaired free water excretion, leads to increased ADH
Sx of Hyponatremia
CNS dysfunction due to cerebral edema
Tx of Hyponatremia
Isovolemic: Water restriction
Hypervolmeic: Sodium and water restriction
Hypovolemic: Normal saline
What is Hypernatremia
Due to net water loss
Sustained hypernatremia is seen when appropriate water intake is not possible
Sx of Hypernatremia
CNS dysfunction due to shrinkage of brain cells
Confusion, lethargy, coma, muscle weakness, seizures
Tx of Hypernatremia
Hypotonic fluids to replace water deficit
Oral route is best (pure water)
D5W, 0.45%NS, o.2% saline
What is Magnesium essential for
DNA and protein synthesis
Parathyroid hormone production
Cardiovascular and neurologic function
What is Hypomagnesemia and what causes it
GI Loss: Malabsorption, Alcoholics, Celiac
Renal Loss: Diuretics, PPI, DM
Sx of Hypomagnesemia
Neurovascular: AMS, lethargy, weakness, Increased DTR
Hypocalcemia: Increasd DTR, Trousseau’s and Chvostek’s sign
Cardiovascular: Arrhythmias, Palpitations
What do you see on EKG with Hypomagnesemia
Prolonged PR and QT intervals
Tx of Hypomagnesemia
IV Magnesium Sulfate if Torsades de pointes or severe
Oral Magnesium
What causes Hypermagnesemia
Renal insufficiency or Increased Mg intake
Sx of Hypermagnesemia
N/V
Skin flushing
Weakness
Decreased DTR, Muscle Weakness
What do you see on EKG with Hypermagnesemia
Bradyarrhythmias, Prolonged PR or QT intervals
Tx of Hypermagnesemia
Mild to Moderate: IV fluids + Furosemide
Severe: Calcium Gluconate (antagonizes toxic effects and stabilizes cardiac membranes)
What is Hypokalemia
Increased urinary/GI losses usually due to vomiting, diarrhea, diuretic therapy
Sx of Hypokalemia
Neuromuscular: Severe muscle weakness, Rhabdomyolysis
Cardiovascular: Palpitations, Arrhythmias
What do you see on EKG with Hypokalemia
T wave flattening, prominent U waves
Tx of Hypokalemia
Potassium replacement
Potassium sparing diuretics
What leads to Hyperkalemia
Decreased renal excretion usually due to acute or chronic renal failure
Potassium supplements, Potassium sparking Diuretics
Cell Lysis: Rhabdomyolysis, burns, hypovolemia
Sx of Hyperkalemia
Neuromuscular: Weakness, fatigue, parasthesias
Cardiovascular: Palpitations, Cardiac Arrhythmias
GI: Abdominal distention, diarrhea
What do you see on EKG with Hyperkalemia
Tall Peaked T waves with eventual QR interval shortening, Wide QRS
Tx of Hyperkalemia
IV Calcium Gluconate
Insulin with glucose
Beta-2 Agonist
Kayexalte (enhances GI potassium excretion, lowers total body potassium)
What is Metabolic Alkalosis and what causes it
Increased pH Increased Bicarbonate Loss of protons from GI/Kidneys: Vomiting/N Tube Exogenous: Diuresis Post Hypercapnia: Mechanical Ventilation
What is Respiratory Acidosis and what causes it
Decreased pH
Increased CO2
Anything that decreases respiration
CNS Depression: Opiates, Sedatives, Trauma
Chronic Diseases: COPD, Obesity, Neuromuscular Disorders
What is Respiratory Alkalosis and what causes it
Increased pH
Decreased CO2
Due to Hyperventiation
What is Testicular Cancer
Most common solid tumor in young men 15-40yrs
What are risk factors for Testicular Cancer
Cryptochidism, usually right sided
What are the different forms of Testicular Cancer
Germinal Cell Tumor (most common)
Nongerminal Cell Tumors
Germinal Cell
- Seminoma: Most common type
- Nonseminoma: Embryonal cell, tratoma, choriocarcinoma (bad prognosis)
Non-Germinal
-Leydig, Sertoli, Gonadoblastoma
Sx of Testicular Cancer
Painless testicular nodule, solid mass or enlargement
Hydrocele is sometimes present
Gynecomastia
Dx of Testicular Cancer
Scrotal Ultarsound and Serum Studies (alpha-fetoprotein, HCG, LDH)
Seminomas are radiosensitive and lack tumor markers
Nonseminomas are radioresistant and tumor markers are noted (increased apha-fetoprotein and HCG)
Tx of Testicular Cancer
Low rade Nonseminoma: Orchiectomy with retroperitoneal lymph nodes
Low grade seminoma: Orchiectomy followed by radiation
High Grade Seminoma: Debulking chemo followed by orchiectomy and radiation
What are the pathogens involved in Cystitis and Pyelonephritis
E.Coli is most common in complicated and uncomplicated
Staph. Saprophyticus in sexually active women
Enterococci with indwelling catheter
Sx of Acute Cystitis
Dysuria, Frequency, Urgency, hematuria, Suprapubic Discomfort
Sx of Pyelonephritis
Fever, Tachycardia, Back/Flank Pain, CVA tenderness, N/V
Dx of Acute Cystitis
What is the definitive dx
Urinalysis: Pyuria and Leukocyte Esterase, Nitrites, Hematuria
Dipstick: Leukocyte Esterase, Nitrites, Hematuria, WBC
Cultures: Definitive
Dx of Pyelonephritis
What is the definitive dx
Urinalysis: Pyuria, Leukocyte Esterase, WBC Casts, Nitrites, Hematuria
Dipstick: Leukocyte Esterase, Nitrites, Hematuria, WBC
Cultures: Definitive
Tx of Uncomplicated Cystitis
Increased fluid itake
Fluoroquinolones are tx of choice (Cipro)
Nitrofurantoin (Macrobid)
TMP-SMX (Bactrim)
Tx of Complicated Cystitis
Pregnancy
Fluoroquinolone
Aminoglycoside
Pregnancy: Amoxicillin, Nitrofurantoin
Tx for Pyelonephritis
Fluoroquinolones
What is Bladder Cancer
Most are Transitional Cell or Uroepithelial Cell
Most present early and respond to treatment
What are risk factors for Bladder Cancer
Smoking
Occupational Exposures such as dyes, rubber, leather, white males
Sx of Bladder Cancer
Painless microscopic or gross hematuria
Dysuria, Urgency, frequency, Hesitancy if locally advanced
Dx of Bladder Cancer
Cytoscopy with Biopsy
Tx of Bladder Cancer
If Localized or Superficial: Transurethral Resection with cautery
If Invasive (involves muscular layer): Cystectomy, Chemi
Recurrent: BCG Immune Therapy
What is Renal Cell Carcinoma
Tumors originating in the kidney
Tumor of proximal convoluted renal tubule cells
Usually no warning signs
Risk factors for Renal Cell Carcinoma
Smoking, Dialysis, HTN, Obesity, Men
Sx of Renal Cell Carcinoma
Hematuria
Flank/Abdominal Pain
Palpable Mass
Malaise, Weight Loss, Left sided varicocele, HTN and Hypercalcemia
Dx of Renal Cell Carcinoma
CT scan
Tx of Renal Cell Carcinoma
Localized: Radical Nephrectomy
Bilateral Involvement or patient with solitary kidney: Partial Nephrectomy
What is Wilms Tumor
Nephroblastoma
See in kids within first 5 yrs of life
Usually associated with other GU abnormality (cryptochidism, hypospadias)
Sx of Wilms Tumor
Painless, Palpable abdominl mass
Hematuria, HTN, Anemia
Tx of Wilms Tumor
Nephrectomy followed by Chemo
If beyond Renal Capsule, Pulmonary METS or large tumor, radiation post surgery
What is the most common site for METS for Wilms Tumor
Lungs
What is Renovascular Hypertension
HTN due to renal artery stenosis
Due to increased RAAS activation
What can cause Renovascular HTN
Atherosclerosis in eldery
Fibromuscular dysplasia in women less than 50
Sx of Renovascular HTN
Severe/Refractory HTN
Adominal Bruit
Dx of Renovascular HTN
What is the gold standard
Renal Angiogram: Gold Standard
Renogram (best non-invasive): Captopril Test
Tx of Renovascular HTN
Angioplasty with stent is definitive
Ace-I, however contraindicated in patients with bilateral stenosis or solitary kidney because Ace-I reduces renal blood flow and GFR in these patients
What is Nephrolithiasis and what is their composition
Stones Calcium is most common Uric Acid (high protein foods) Struvite Stones (Mg Ammonium Phosphate) Cystine
Sx of Nephrolithiasis
Renal Colic: Sudden onset of constant upper/lateral back pain over CVA, radiating to groin
+ CVA tenderness
Dx of Nephrolithiasis
What is most common 1st line
What is gold standard
Urinalysis: Microscopic hematuria
pH7.2=Struvite stones
Noncontrast CT: Only will see Calcium and Struvite stones (most common 1st line)
IV Pyelography is gold standard
Tx of Nephrolithiasis
If 7mm: Shock wave lithotripsy, Uretoscopy with stent, Percutaneous Nephrolithotomy (used for large stones or struvite)
