Urology_Nephrology Flashcards
Initial lab test for nephrolithiasis
UA<div>CBC</div><div>Lytes</div><div>BUN/Creat</div><div>Ca</div><div>Po4</div><div>Uric acid</div><div>Preg test</div>
Stone imaging
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IVP features of stone
Direct stone visualization<div>Unilateral ureteral dilation</div><div>Delayed nephrogram appearance</div><div>Lack of normal peristalsis</div><div>Perirenal contrast extravasation</div>
<p>Indications for Admission of urinary stone</p>
<ul> <li>Septic stone (stone + fever/UTI)</li> <li>Solitary kidney and complete obstruction</li> <li>Severe pain requiring parenteral analgesics</li> <li>Intractable nausea/vomiting</li> <li>Large stone:–>6 mm stones pass 10% of the time, 1 cm stones will not pass</li> <li>Concomitant acute renal insufficiency</li> <li>Ruptured renal capsule with urine extravasation</li> <li>Special populations: pregnant, pediatric, renal transplant patients</li> </ul>
<p>Renal Colic Treatment</p>
<ul> <li>Medical expulsive therapy: Alpha-1 receptor antagonist (tamsulosin)</li> <li>Extracorporeal shock wave lithotripsy (ESWL)</li> <li>Ureteroscopy +/- stent placement</li> <li>Percutaneous nephrolithotomy</li> <li>Open stone surgery</li> </ul>
Risk factors for nephrolithiasis
Chronic dehyfration<div>Diet</div><div>Obesity</div><div>FHx</div><div>Medications</div><div><br></br></div>
Sites of stone impaction
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Causes of urinary retention
Mechanical:<div> BPH</div><div> Meatal stenosis</div><div> Urethral stricture</div><div> Malignant tumers to prostate/bladder</div><div> Bladder stones</div><div><br></br></div><div>Neurogenic:</div><div> Stroke</div><div> SC injuries</div><div> MS</div><div> DM (advanced)</div><div><br></br></div><div>Drugs:</div><div> OTC sympathomimetics (cold remidies)</div><div> TCA</div><div> Anticholinergics (oxybutynin)</div><div> Antihypertensives</div><div> Opioids</div><div><br></br></div><div>Infection</div><div> acute prostatitis</div><div> Urethral herpes</div><div> Peri-urethral abscess</div><div> TB</div><div> Cystitis</div>
Important things to do in urinary retention
Bedside U/S (bladder vol, R/U AAA)<div>Neurological exam (sph tone & sensation, LE strength, DTRs)</div><div>Labs: (U/A & culture, creat)</div>
Risk factors for urologic malignancies
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<p>Acute Kidney Injury: Renal</p>
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<p>Acute Kidney Injury: Urinalysis</p>
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<p>What are indications for emergent hemodialysis? List 5.</p>
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ESRD electrolytes dist
HyperK<div>HypoK<br></br><div>HypoCa</div></div><div>HypoMg</div>
Renal Transplant Complications
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Urinalysis in UTI Criteria for Rx
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False negative nitrite test
Vit C ingestion (cranberry juice)<div>Insuff time between last void and collection</div><div>Delay occur between collection and testing the sample</div>
DDx of pyuris
GU TB (sterile pyuria)<div>Epididymitis</div><div>Prostatitis</div><div>Infected stone</div>
What are the features of complicated UTI
All patients are regarded as complicated UTI except young, healthy nonpregnant woman<div><br></br></div><div>Fever, chills, rigors</div><div>Significant fatigue, malaise</div><div>Flank pain</div><div>CVAT</div><div>Pelvic/perineal pain in men</div>
Indications of admission in UTI
Septic patient<div>Uncontrolled pain</div><div>Unable to tolerate oral intake</div><div>Functional decline</div><div>Associated urinary obstruction</div>
Surgical complications of UTI
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Rx of UTI in Peds
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Risk factors of Prostatitis
Cystitis<div>Urethritis (STI)</div><div>Epididymitis</div><div>Instrumentation (TURP, cystoscopy, catheterization)</div>
Rx of Prostatitis
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Complications of prostatitis
Sepsis<div>Chronic prostatitis</div><div>Prostatic abscess</div><div>Urinary retention</div><div>Chronic pelvic pain syndrome</div>
Priapism risk factors
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Types of priapism
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What to give in a case of dialysis AV fistula bleeding?
Desmopressin (DDAVP)<div>It increases factor 8 an vWF which enhances activity of the (Uremic platelets)</div>
Complications of AV fistula
thrombosis,<div>infection,</div><div>formation of true aneurysms or pseudoaneurysms,</div><div>high-output heart failure, and</div><div>venous hypertension</div>
Treatment of low-flow (ischemic) priapism
Monitored bed<div>Analgesia (opioids, penile block, procedural sedation)</div><div>Urology consult</div><div>Corporal aspiration at 10 and 2 oclock</div><div>Corporal irrigation with saline and/or alpha-agonist (phenylephrine)</div><div><br></br></div><div><b>In case of SCA:</b></div><div>Iv fluids</div><div>Oxygenation</div><div>Alkalinization</div><div>Exchange transfusion</div><div><br></br></div>
DDx of unilateral testicular pain
“Torsion<div>Orchitis</div><div>Epididymitis</div><div>Incarcerated hernia</div><div>Testicular tumor</div><div>Fournier’s gangrene</div>”
Diagnostic tests for testicular pain
Urethral swab for NAAT (chlamydia and GC)<div>Ultrasound (? abcess, torsion)</div>
Epididymitis Rx
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“Features of fournier’s gangrene”
Abn lie<div>Absent cremasteric reflex</div><div>Severe pain</div><div>N/V</div><div>significant swelling/erythema</div><div>Abn vital signs</div>
<p>Fournier’s Gangrene: Management</p>
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<p>Genital Ulcers – History</p>
<ul> <li>Sexual partners (male, female or both)</li> <li>Type of intercourse (oral, vaginal, anal)</li> <li>Barrier contraception use</li> <li>Painful vs. painless lesion</li> <li>Constitutional symptoms</li> <li>Rash</li> <li>Urinary symptoms</li> <li>Urethral discharge</li> </ul>
DDx of penile ulcer
Syphilis<div>Genetal herpes</div><div>Chancroid</div><div>LGV</div><div>Donovanosis</div>
Syphilis
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Chancroid
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LGV
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Significance of eosinophilia in urine
Interstitial nephritis due to drug reaction
DDx of genital ulcers
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Priapism,List 5 additional historical features that would be important to elicit?
Duration of erection<br></br>Duration of pain<br></br>Similar prior episodes<br></br>Genitourinary trauma<br></br>Recent urologic surgery<br></br>Medication use (intracavernosal injections of papaverine/ prostaglandin E1, antihypertensives, neuroleptics, or oral agents for erectile dysfunction)<br></br>Substance abuse (esp. cocaine)<br></br>Medical history (eg, sickle cell disease)<br></br>History of malignancy (eg, prostate cancer, bladder cancer)
Define priapism
Persistent (>4hrs), usually painful, pathologic erection in which both corpora cavernosa are engorged with stagnant blood
“<span>What confirmatory investigation and with what results would differentiate between the two types of <b>priapism</b>?</span>”
<b>Investigation</b>: <br></br><i>blood gas analysis of the first corporal aspirate</i><br></br><b>Result</b>: <br></br><i>Red sample, consistent with arterial sample = <b>high-flow priapism. </b><br></br>Dark, acidic sample = <b>low-flow priapsim</b></i>
“<span>Describe how to perform regional anesthesia of the penis</span>”
<b>Dorsal penile nerve block:</b><br></br>-Position the patient supine/ allowing exposure of the dorsal penis<br></br>-Prep the skin with iodine/chlorhexidine<br></br>-Prep analgesic (lidocaine/xylocaine 1-2% +/- bupivacaine 0.5-1%)<br></br>-Landmark insertion sites (10 and 2 o’clock positioning for two point landmark OR mid-pubic arch for one point landmark at penis base)<br></br>-Insert needle at landmark site/s, aspirate, direct towards each dorsal penile nerve, and inject 5-7cc anaesthetic bilaterally
“<span>Describe the procedure of manually reducing the foreskin (minimally invasive technique). Include any pre-treatment that may aid in the reduction (excluding pain control / sedation).</span>”
<b>Preparation</b><br></br><i>Hold manual pressure on glans OR wrap glans penis in compression gauze, for at least five minutes<br></br>Consider topical ice, osmotic agents (sugar)<br></br></i><br></br><b>Manual Reduction</b><br></br><i>Lubricate glans<br></br>Hold foreskin with both hands/ fingers of the hand<br></br>Use thumbs to push glans penis through paraphimosis</i>
“<span>Describe 2 invasive methods that can be performed in the ED if the above is unsuccessful. Your urologist is unavailable</span>”
<b>Needle decompression of foreskin</b><br></br><i>Perform penile block/ conscious sedation<br></br>Insert 21 gauge needle in several locations through foreskin<br></br>Milk to remove fluid from the edematous foreskin<br></br>Attempt manual reduction<br></br></i><br></br><b>Dorsal slit</b><br></br><i>Perform penile block/ conscious sedation<br></br>Indicated if refractory to all other reduction methods<br></br>Identify the dorsal midline of the foreskin<br></br>Clamp with a hemostat for 30-60 sec<br></br>Cut a dorsal slit of foreskin to allow foreskin reduction<br></br>Oversew the edges with absorbable suture<br></br>Urologist consultation - commits patient to circumcision</i>
“<span>What clinical presentations may raise concern for UTI in children?</span>”
-Dysuria<br></br>-Urinary frequency<br></br>-Hematuria<br></br>-Abdominal pain<br></br>-Back pain<br></br>-Nausea and/or vomiting<br></br>-New daytime incontinence<br></br>-Unexplained fever
“<span>List risk factors for developing UTI in children.</span>”
-Female gender<br></br>-Uncircumcised males<br></br>-Younger age<br></br>-Fever >39°C or fever duration >24-48 h<br></br>-Previous UTI<br></br>-Sexual activity<br></br>-Urinary tract pathology<br></br>-Recent urologic instrumentation<br></br>-Neurogenic bladder
“<span>List bacteria associated with pediatric UTIs. Of these, which is the most common?</span>”
-E. coli (most common)<br></br>-Klebsiella spp.<br></br>-Proteus spp.<br></br>-Enterobacter spp.<br></br>-Enterococcus spp.<br></br>-S. aureus (neonates)<br></br>-Group B streptococci (neonates)<br></br>-S. saprophyticus (adolescents)<br></br>-Chlamydia trachomatis (adolescents)
“<span>How should a urine sample be obtained for this patient? (1) How would your approach differ for an infant?</span>”
<b>Toilet-trained children:</b><br></br><i>Midstream urine sample for urinalysis and culture</i><br></br><br></br><b>Non-toilet trained children:</b><br></br><i>Urethral catheterization<br></br>Suprapubic aspiration<br></br>Clean-catch urine</i><br></br><br></br><b>Pediatric urine collection bag (PUC)</b><br></br>For urinalysis only; don’t culture (high rates of contamination)<br></br>Useful to screen/rule out for UTI (unlikely if completely normal urinalysis). Unable to rule in UTI
“<span>You determine that this patient has a UTI. What antimicrobial would you choose for empiric treatment? Include the weight-based dose and duration of therapy</span>”
“<span><b><u>Antibiotic treatment for two to four days in uncomplicated cystitis</u></b></span><br></br><span>–Note: 7-10 day course is recommended for febrile UTI</span><br></br><span>–Note: oral antibiotics can be chosen for initial treatment (even if febrile) if the child is not seriously ill and likely to receive and tolerate every dose</span><br></br><br></br><br></br>Amoxicillin: 50 mg/kg/day (divided in three doses)<br></br>Amoxicillin/clavulanate: (7:1 formulation) 40 mg/kg/day (divided in three doses)<br></br>TMP-SMX: 8 mg/kg/day of the trimethoprim component, divided in two doses<br></br>Cefixime: 8 mg/kg/day (given as a single dose)<br></br>Cefprozil: 30 mg/kg/day (divided in two doses)<br></br>Cephalexin: 50 mg/kg/day (divided in four doses)”
“<span>UTI in children. <br></br>What follow-up investigations are warranted, if any? In which situations is follow-up indicated?</span>”
-No specific follow-up is indicated in this case<br></br>-Children <2 years should be investigated after their first febrile UTI with a renal/bladder ultrasound to identify any significant renal abnormalities<br></br>-Voiding cystourethrogram (VCUG) is not required for children with a first UTI unless the renal/bladder ultrasound reveals findings suggestive of vesicoureteral reflux, renal anomalies or obstructive uropathy
“Renal transplant with complications.<br></br><span>What factors will determine your disposition for this patient? What follow-up should be arranged, if any?</span><br></br>”
Factors:<br></br>-Creatinine level (acute renal failure defined as >20% increase from baseline in renal transplant patients)<br></br>-Sub- or supra-therapeutic immunosuppressant levels<br></br>-Other abnormal lab or imaging findings<br></br>-Urine output<br></br>-Ability to tolerate oral rehydration<br></br><br></br>Critical to discuss disposition with the on-call transplant team (admission vs. discharge with close outpatient monitoring and follow-up)
<p>Indications for hospital admission with a kidney stone</p>
<p><strong>Absolute</strong></p>
<p><em>Obstructing stone with signs of infection</em></p>
<p><em>Intractable nausea & vomiting</em></p>
<p><em>Severe pain requiring parenteral analgesics</em></p>
<p><em>Urinary extravasation</em></p>
<p><em>Hypercalcemic crisis</em></p>
<p><em>Pregnant woman</em></p>
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<p><strong>Relative</strong></p>
<p><em>Significant comorbidities complicating outpatient management</em></p>
<p><em>High grade obstruction</em></p>
<p><em>Leukocytosis</em></p>
<p><em>Size of stone</em></p>
<p><em>Solitary kidney/intrinsic renal disease</em></p>
<p><em>Psychosocial disease</em></p>
