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Rosens > 85. Urologic disorders > Flashcards

85. Urologic disorders Flashcards

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1
Q

UTI - lower vs upper?

A

lower - confined to bladder
upper - to kidneys//ureters

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2
Q

Complicated UTI catch all includes who?

A

nderlying functional or structural abnormality, history of uri- nary instrumentation or organ transplantation, or systemic disease, such as renal insufficiency, diabetes, and immunodeficiency

also typically men

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3
Q

Urethritis typical cause

A

gonorrhea

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4
Q

cystitis can be bacterial or ?

A

not - ie radiation

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5
Q

why do women have more UTIs?

A

shorter yrethra and opens close to vulvar/perirectal area

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6
Q

Name 3 major causes of dysuria and what differentiates them (Rosen’s box 85.1)

A

UTI - internal dysuria, freq/urgency/small void vol/abrupt onset, suprapubic pain with pyruia and 50% of pt hematura

vs
STD - gradual onset, hx of new/mult sexual partners vaginal discharge

vs

vaginitis - external dysuria, gradual onset with vaginal discharge/odor/prutitis

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7
Q

RF for cystitis and pyelo

A

sexual intercourse, use of spermicides, previous UTI, new sex partner, and history of UTI in a first-degree female relative

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8
Q

MC UTI bug

A

ecoli

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9
Q

list 4 bugs causing uti

A

ecoli
Staphylococcus saprophyt- icus and other members of the Enterobacteriaceae family (Klebsiella pneumonia and Proteus mirabilis)

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10
Q

Name 5 unusual organisms for UTI in patients institutionalized/ hospitalized

A

R Escherichia, Klebsiella, Proteus, and Enterobacter, as well as Pseudomonas, Enterococcus, Staph- ylococcus, Providencia, Serratia, Morganella, Citrobacter, Salmonella, Shigella, and Haemophilus spp., Mycobacterium tuberculosis, and fungi.

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11
Q

Which 2 common bugs causing uti may not cause nitrate into nitrite + UTI?

A

S. saprophyt- icus and Enterococcus,

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12
Q

Which patients with acute cystitis and pyelonephritis need imaging?

A
  • suspicion for structural abnormalities
  • complicating factors: abscess/urolithiasis/emphysematous pyelo
  • worsening pyelo illness or persistent fever 48- 72 hours after initiating antimicrobials
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13
Q

Ultrasound - when is this useful in cystitts?

A

assess for potential urinary obstruction. Ultrasound is a sensitive tool for detecting postvoid resid- ual bladder volume, intrarenal and perinephric abscess, and presence of hydroureter and hydronephrosi

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14
Q

What is the most comprehensive test to assess kidneys/ureter/bladder in suspected cystitis patients?

A

ct kub -high sensitivity for detecting abscess, obstruction, and acute inflammation.

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15
Q

3 abx options and doses for acute cystitis

A

Trimethoprim- sulfamethoxazole
160/800 mg bid
3 days

Nitrofurantoin
100 mg bid
5 days

Fosfomycin
3 g as a single dose

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16
Q

Men recommended treatment of uti +/- prostatits

A

In men, if there are no signs of toxicity, the patient can be treated on an outpatient basis with any of the urinary antibacterial agents (e.g., TMP-SMX, nitrofurantoin, fluoroquinolones) for 7 to 14 days. If concomitant prostatitis is suspected, TMP-SMX or a fluoroquino- lone is recommended for 14 days

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17
Q

Name 3 antibiotic options and doses, duration for uncomplicated pyelo

A

Ciprofloxacin
500 mg bid
7 days

Levofloxacin
750 mg once daily
5 days

Trimethoprim- sulfamethoxazole
160/800 mg bid
10–14 days

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18
Q

Name 3 antibiotic options and doses, duration for
complicated pyelo

A

Cefepime
1–2 g every 8 h
Ceftriaxone
1 g every 24 h
Piperacillin- tazobactam
3.375 g every 6 h
Aztreonam
1 g every 8–12 h
Ciprofloxacin
400 mg every 12 h
Levofloxacin
500 mg every 24 h

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19
Q

Name 3 medication options for prostatic enlargement

A

Alpha-adrenergic receptor antagonist:
Alfuzosin
10 mg once daily
Doxazosin
1 mg once daily
Tamsulosin
0.4 mg once daily
Terazosin
1 mg once daily or at bedtime

5-Alpha-Reductase Inhibitors
Dutasteride
0.5 mg once daily
Finasteride
5 mg once daily

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20
Q

Reasons for hospitalization of cystitis/pyelo

A

presence of clinical toxicity (e.g., fever, tachycardia, hypotension, vomiting), inability to take oral medications, an immunocompromised state, third-trimester preg- nancy, failure of oral outpatient therapy, urologic abnormalities, or patients with significant comorbid conditions, including heart failure and renal insufficiency

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21
Q

Why is pyelonephritis mc in pregnancy but not cystitis?

A

physiologic changes that occur within the urinary tract of pregnant women, which include ureteral and renal pel- vis dilation.

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22
Q

What are untreated UTI in pregnancy more at risk of?

A

premature labor, low birth weight, perinatal mortality, maternal anemia, and maternal pyelonephritis

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23
Q

When to admit pregnant patients with UTI?

A

last trimester, who appear ill, or who have evidence of pyelonephri- tis and would benefit from treatment with parenteral antibiotics and IV fluids

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24
Q

Antibiotic options for bacteruria in pregnancy

A

Amoxicillin-clavulanate
500 mg tid
3–7 days
Cefpodoxime
100 mg bid
5–7 days
Nitrofurantoin
100 mg bid
5–7 days
*CI in First trimester and 38 weeks to delivery

Fosfomycin
3 g as a single dose
Trimethoprim-sulfamethoxazole
160/800 mg bid
3 days
* CI First trimester and term

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25
Which two antibiotics are contraindicated in first trimester and 38 weeks-delivery or term
Nitrofur (including 38 wks to delivery) septra first trim and term
26
Parenteral antibiotic options for pyelo in pregnancy and dose
Ceftriaxone 1 g every 24 h Cefepime 1 g every 8 h Piperacillin-tazobactam 3.375 g every 6 h Aztreonam 1 g every 8–12 hours
27
Catheter associated UTI - defintion
urine containing greater than 1000 CFU/ml of one or more bacterial species in a cath- eterized patient with suggestive symptoms, such as pelvic discomfort, flank pain, fever, rigors, malaise, altered mental status or lethargy with no other identified cause, costovertebral angle tenderness, or acute hematuria.
28
Indwelling catheter assoc UTI tx
abx catheter exchange
29
Acute bacterial prostatits bugs
E. coli, Klebsiella, Enterobacter, Pro- teus, or Pseudomonas spp.
30
Chronic bacterial prostatitis defn
persistent bacterial infection of the prostate lasting more than 3 month
31
Chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS) defn
urologic pain in the pelvic region asso- ciated with urinary symptoms or sexual dysfunction lasting for at least 3 of the previous 6 months
32
Asymptomatic inflammatory prostatitis
painless inflammation of the prostate gland in the absence of infection. It is a common finding in men with benign prostatic hyperplasia and a diagnosis of exclusion in the ED.
33
MC complications of acute prostatits
acute uri- nary retention (AUR) and prostatic abscess
34
Tx of acute prostatits
Antibiotic options include ciprofloxacin 400 mg IV every 12 hours, levofloxacin 500 mg IV every 24 hours, or ceftriaxone 2 g IV every 24 hours. Ciprofloxacin 500 mg every 12 h (PO) Levofloxacin 500 mg once daily (PO) Trimethoprim-sulfamethoxazole 160/800 mg bid (PO) Minimum 2 weeks to 4-6 weeks
35
Renal calculi RF
older age, male gender, obesity, and family histor
36
MC 3 compositions of stones
calcium, struvite, or uric acid
37
MC stone composition
calcium oxalate, alone or in combination with calcium phosphate
38
MC hyperexcretion of ca in ca oxalate ston formation
hyperparathyroidism
39
Medical conditions increasing ca forming ca oxalate stones
Hyperparathy- roidism. Other medical conditions that lead to increased calcium levels include hypercalcemia of malignancy, sarcoidosis, and excessive cal- cium ingestion or increased absorption from the gut.
40
What conditions can cause hyperoxaluria
small bowel disease, bariatric surgery, Crohn disease, ulcerative colitis, and radiation enteritis.
41
What makes up a struvite stone?
mag ammonium phosphate
42
Struvite stones - why do they form?
struvite stones occur almost exclusively in patients with UTIs and are sometimes referred to as infection stones. They form as a result of the presence of urea-splitting organisms, such as Proteus, Providencia, Klebsiella, Pseudomonas, and Staphylococcus. Patients with anatomic abnormalities that predispose them to recurrent UTIs a
43
What is associated with uric acid calculi
symptomatic gout
44
RF for urolithiasis
Metabolic disease or disturbance Crohn disease Milk-alkali syndrome Primary hyperparathyroidism Hyperoxaluria Hyperuricosuria Sarcoidosis Recurrent UTI Renal tubular acidosis (type I) Gout Laxative abuse Positive family history Hot arid climates (southeast United States) Male gender (white men affected more commonly than black men) Previous kidney stone Dehydration
45
What is a distinctive feature of uric acid stones?
radiolucency
46
What is the major cause of progressive renal damage in a renal calculi
assoc infection also size and location
47
3 primary predictors of stone passage without need for surgical intervention
calculus size (<5mm pass spontatneous within 4 weeks); >8mm need lithotripsy/surgery, location, and degree of patient pain.
48
When can a stone >8mm be surgically removed as outpatient?
patient is able to tolerate oral intake and has adequate pain con- trol unless the stone is infected, renal damage is considerable, there are bilateral obstructing stones, or there is obstruction of a solitary or transplanted kidney.
49
What are the 5 spots along a ureter at which calculi can become impacted
calyx of kidney or UPJ renal pelvis narrowin near pelvis brim where ureter has to pass over iliac vessels posteriorly into true pelvis (MC UVJ)
50
DDX pain associated with urolithiasis - name 5 sites
upper urinary tract ureter lower urinary tract non uro idsease: intra abdo, vsacular, retroperitoneal, gyne, msk
51
name 10 ddx urolithiasis
Urologic Disease Upper Urinary Tract Renal infarct Renal parenchymal tumors Urothelial tumors Papillary necrosis Pyelonephritis Hemorrhage (blood clot) Ureter Urothelial tumors Hemorrhage (blood clot) Previous surgery (e.g., stricture) Metastatic tumors Lower Urinary Tract Urothelial tumors Urinary retention Nonurologic Disease Intra-abdominal Peritonitis (especially appendicitis) Biliary colic Intestinal obstruction Vascular Abdominal aortic aneurysm Superior mesenteric artery occlusion Retroperitoneal Retroperitoneal lymphadenopathy Retroperitoneal fibrosis Tumor Gynecologic Cervical cancer Endometriosis Ovarian vein syndrome Musculoskeletal Muscle strain or bony injury
52
page dx diagnostic testing
53
Priapism - low flow vs high flow
low flow = ischemic abnormal vbg with decrease ph and incr lactate PAINFUL - ddx idiopathic, drugs, wtoh, scc, intracavernosal inf, leukemic infiltration nonischmeic high flow - uncontrolled incr artrerial flow - no VBG, not painful secondary to trauma, avm/cavernosal injury/vascular erosions
54
Ischemic priapism management
!!!!!emergent aspiration and irrigate with 19g butterfly inject phenyl (add 1 ml to 100ml NS bag --> 100mcg/ml --> 2-5cc per uro resident 1g/hour safe) - 2-10cc unilaterally, max 1g/hour, call uro for shunt goal within 4-6 hours
55
Non-ischemic priapism
observe ice pack 60% with conservative management
56
Paraphimosis pathophys
incarceration glans due to inability to reduce retracted foreskin
57
Paraphimosis cause
improper hygeine trauma chronic balanphismosis
58
Paraphimosis reduction
Penile block vs procedural sedation distal to proximal coban x10m vs death grip maneuver manual compression Successful reduction can go home after trial of void and uro f/u 2-3 weeks
59
Paraphimosis emergent consult uro
ischemia >12 hours failed manual reduction
60
Phimosis defn and when is this a problem?
cannot restract foreskin back = only issue if cannot pee
61
If can pee and have phimosis
conservative tx: hygeine, forcible retraction, prepuce stretching x3 min CS triaminoclone
62
Defn penile frature
tunica albuigneoa for one or both cavernosa flexion of a pressureized corpora and rigid, thinned outb wrapper
63
Penile fracture dx
clinical eggplant defomirty and angulation away from tear
64
Penile fracture - must r/o
urethrtal injury *** needs to pee/ or rretrograde urethrogram negative before foley
65
Penile tx
operative repair vs hematoma nd no fracture = outpt, nsaids, uro f/u
66
Anterior vs posterior urethra trauma
both surgery post prostatic utrethra = anterior, straddle injury vs posterior = prostatic urethra, blunt trauma/massive decel with pelvic fracture --> suprapubic cath then delayed dx
67
Fournier's gangrene defn
nec fasc of peritoneum
68
Fournier's gangrene cause
GI tract mc, GU <40% cut SSTI
69
Fournier's gangrene why spead so quickly
colles fascia continue with abdo wall/scarpa and duck's/dartos of scrotum
70
Fournier's gangrene RF
diabetes obese >50 smoking hx HTN
71
Fournier's gangrene hx/physical
insiduous onset with rapid progression fluctuance, crepitus fever, tachycardia, pain redness
72
Fournier's gangrene mc bugs
ecoli kleb protecus enterococcus
73
Fournier's gangrene abx
tazo/mero and vanco or linezolid can also do ctx flagyl with vanco/linezolid +/0 clinda if worried TSS, doxy for water bus or fluc/amphotericin
74
Testicular torsion: what is twisted?
spermatic cord
75
Testicular torsion: RF?
not a lot may be am/trauma/strenuous activity
76
Testicular torsion: what matters in terms of success rates
degree of torsion time <6 hours = 80% salvagble
77
Testicular torsion: score?
twist
78
Testicular torsion: manual detort
try away from medline x2-3 twists if not relief untwist past 360 degree other direction if worse
79
Torsion of testicular appendage - what is this?
[aratesticular nodule/remannt at superior pole between testis and epidydimis prone to torting
80
Torsion of testicular appendage: hx/physical
focal tender spot and firm nodule 2-3 nodule at superior pole entire tesitcle not tender blue dot "ischemic appendage' on exam
81
Epidydmitis: common bugs
c trach gonorrhea tneric bugs/anal
82
Epidydmitis: feels better when
held up
83
Epidydmitis: tx
abx depending on source bed rest/scroital elevation/ice pack/nsaid - poor evidence just treat infection
84
Epidydmitis: crp?
high vs low in torsion/tumor
85
Epidydmitis: tests
ua/urineculture ultrasound - preserved flow (moreso to r/o torsion)
86
Epidydmitis tx abx specific
ceftiraxon or cefixime or azithro and chlyamida: azithro/doxy/levo
87
Epidydmitis: causes - list 5
sti behcet disease fungal amiodarone treponema pallidum congenital neurogenic bladder predispoistion in older people - bph, prostatitis, immunosuppression, recentGU instrumentations/surgery/cath
88
Orchitis causes
mumps - pain swell, fever, post parotitis *public health report bacterial - fever/swell/constit sx, mc bilateral
89
Testicular rupture hematoma what is this?
tear of tunica albuinea and extrusion seminiferus tubules tender lage blood filled scortu, with swell ultasound rapid evac
90
Intra-testicular hematoma --> needs?
ultrasound then rapid evac
91
Extra testicular with or without testicular rupture - needs?
ultrasound then rapid evac
92
Scrotal masses: ddx testciular
cannot separate from testicle erm cell mc painless ultasound
93
scrotal masses paratesitcular ddx
inguinal hernia hydroceyle varicoele spermatocele
94
Incarcerated inguinal hernia signs
tender, edema, erythema, n/v abdo pain --> reduce and surgery
95
Hydrocele defn
fluid between 2 layers tunica transilluminates ultrasound, benign outpt uroV
96
Varicocele tx
u/s, outpt uro
97
Spermatocele findings
sperm containing cyst usually not painful ultrasound dx outpt uro f/u
98
Post vasectomy pain - concern?
compartment syndrome!!!! yikes.
99
Which stone needs urinary alkalinzation
uric acid
100
Go to imaging for nephrolithiasis
noncontrast enhanced celical ct scan
101

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