AUA Updates Flashcards
(168 cards)
1
Q
Question:
What is the lifetime risk of developing prostate cancer (PCa) for men in the U.S.?
A
Answer:
Men in the U.S. have a 12% lifetime risk of developing prostate cancer (PCa).
2
Q
Question:
What is the risk of dying from prostate cancer (PCa) for men in the U.S.?
A
Answer:
Men in the U.S. have a 2%-3% risk of dying from prostate cancer (PCa).
3
Q
Question:
What do the guidelines recommend for low-risk and intermediate/high-risk prostate cancer (PCa)?
A
Answer:
Guidelines recommend active surveillance for low-risk PCa and treatment for men with intermediate or higher risk PCa based on the patient’s quality-of-life goals and life expectancy.
4
Q
Question:
What does Biochemical Recurrence (BCR) refer to in the context of prostate cancer (PCa)?
A
Answer:
Biochemical Recurrence (BCR) is defined as an abnormal value or change in serum PSA after primary treatment for PCa.
5
Q
“12-2-3 GUIDE”
A
12: 12% lifetime risk of developing PCa.
2-3: 2%-3% risk of dying from PCa.
G: Guidelines recommend active surveillance for low-risk PCa.
U: Undergo treatment for intermediate or higher risk PCa.
I: Importance of patient’s quality-of-life goals and life expectancy.
D: Definitions of BCR as abnormal PSA after primary treatment.
E: Emphasis on monitoring, evaluating, and treating BCR post-RP, post-RT, and post-focal therapy.
6
Q
Question:
What is PSA and where is it primarily expressed?
A
Answer:
PSA (Prostate-Specific Antigen) is a serine protease and arginine esterase that is almost exclusively expressed in prostatic tissue.
7
Q
Question:
What percentage of PSA in the serum is bound to alpha-1 antichymotrypsin?
A
Answer:
In the serum, 70% of PSA is bound primarily to alpha-1 antichymotrypsin, with the remainder being free.
8
Q
Question:
What is the significance of percent free PSA in the screen
A
Answer:
A percent free PSA <15% is associated with prostate cancer (PCa) in the screening setting.
9
Q
Question:
What was found in a study of over 800 post-RP and post-RT
A
Answer:
The study found that a percent free PSA >10% was associated with increased metastasis (hazard ratio [HR] = 1.7).
10
Q
Question:
Question:
What are the half-lives of PSA decline after radical cystoprostatectomy as found by Gregorakis et al.?
A
PSA concentrations dropped in a biphasic pattern: a sharper immediate decline with a half-life of 4.3 hours and a subsequent more gradual decline with a half-life of 63 hours.
11
Q
How long is the approximate half-life of PSA decline in the absence of residual cancer?
A
In the absence of residual cancer, 3 days is a fair approximation for the half-life of PSA decline.
12
Q
What general rule is used for checking responses to treatment changes based on PSA half-lives?
A
It is prudent to wait at least 5 half-lives before checking responses to treatment changes.
13
Q
What is the commonly used monitoring interval in practice for PSA changes?
A
The 3-month interval is commonly used in practice.
14
Q
Are changes in PSA specific for the location or severity of prostate cancer recurrence?
A
No, changes in PSA are not specific for the location or severity of recurrence, as both local and distant recurrences produce PSA.
15
Q
What did a meta-analysis find about the adjusted-R2 of BCR for PCa mortality compared to distant metastases?
A
The adjusted-R2 of BCR for PCa mortality was 0.38 compared to 0.78 for distant metastases.
16
Q
“PSA Monitor Has Two Rates, Two Free Tips, and Five Half-Lives”:
A
PSA: PSA is a serine protease and arginine esterase.
Monitor: PSA monitoring intervals form the basis.
Has Two Rates: 4.3 hours and 63 hours half-lives (sharper immediate and gradual declines).
Two Free Tips:
<15% free PSA associated with PCa in screening.
10% free PSA associated with increased metastasis (HR = 1.7).
Five Half-Lives: Wait at least 5 half-lives before checking treatment responses.
17
Q
What is PSA and where is it primarily expressed?
A
PSA (Prostate-Specific Antigen) is a serine protease and arginine esterase that is almost exclusively expressed in prostatic tissue.
18
Q
What percentage of PSA in the serum is bound to alpha-1 antichymotrypsin?
A
In the serum, 70% of PSA is bound primarily to alpha-1 antichymotrypsin, with the remainder being free.
19
Q
What was found in a study of over 800 post-RP and post-RT patients with BCR regarding percent free PSA?
A
The study found that a percent free PSA >10% was associated with increased metastasis (hazard ratio [HR] = 1.7).
20
Q
What is the commonly used monitoring interval in practice for PSA changes?
A
The 3-month interval is commonly used in practice.
21
Q
What is the PSA threshold for BCR after RP according to AUA guidelines?
A
AUA defines BCR as a post-RP PSA of at least 0.20 ng/mL with a confirmatory PSA.
22
Q
What are the risk-adapted PSA thresholds for defining BCR according to Mir et al.?
A
- Rising PSA >0.05 ng/mL with high-risk pathologic criteria
- Rising PSA >0.20 ng/mL with intermediate-risk pathologic criteria
- Rising PSA >0.40 ng/mL with low-risk pathologic criteria
23
Q
What is the significance of PSA persistence after RP?
A
PSA persistence using conventional assays carries a 47% 15-year risk of metastasis and is considered a more adverse prognostic factor than BCR.
24
Q
What is the risk stratification schema for BCR after RP according to EAU guidelines?
A
- Low Risk: PSA Doubling Time >12 months and ISUP Grade Group <4 at RP
- High Risk: PSA Doubling Time <12 months or ISUP Grade Group 4-5 at RP
25
What are the guidelines for the use of next-generation PET imaging for evaluating PSA recurrence after local therapy?
The AUA, NCCN, and EAU guidelines allow for next-generation PET imaging to evaluate PSA recurrence after local therapy.
26
Monitoring Frequency of PSA post treatment
First 2 Years: Every 3-4 months.
Next 3 Years: Every 6 months.
Thereafter: Annually if PSA remains undetectable.
27
PSA Persistence:
AUA (<0.20 ng/mL), EAU (<0.10 ng/mL), NCCN (specific assay-dependent)
28
BCR After RP:
AUA (PSA ≥0.20 ng/mL with confirmatory PSA), EAU (no confirmatory needed), NCCN (rising PSA on 2 or more occasions).
29
Risk Stratification (EAU Guidelines):
Low Risk: PSA Doubling Time >12 months, ISUP Grade Group <4.
High Risk: PSA Doubling Time <12 months, ISUP Grade Group 4-5.
30
Probability of Further PSA Rises (Figure 1):
Shows increasing probability with higher post-RP PSA levels.
Higher biochemical recurrence thresholds correlate with higher chances of further PSA rises.
31
Pathological Risk-Adapted BCR Definitions (Figure 2):
Provides PSA thresholds and corresponding 5-year nomogram risk of recurrence based on pathological criteria.
32
Risk Stratification Schema (Figure 3):
Differentiates between low and high risk for both RP and RT based on PSA doubling time and Gleason Grade Group.
33
BCR Evaluation and Treatment Algorithm (Figure 4):
Outlines steps for evaluating and managing BCR after RP based on EAU guidelines, including imaging and treatment options.
34
What is the typical half-life range of PSA decline after radiation therapy (RT)?
The half-life range of PSA decline after RT is 0.5 to 9.2 months, with a point estimate of 1.6 months.
35
What is the nadir PSA value following modern RT treatments?
The nadir PSA value following modern RT treatments is frequently <0.5 ng/mL.
36
What is PSA bounce and how is it defined?
PSA bounce is defined as a benign rise in PSA >0.2 ng/mL above a previous value followed by an eventual spontaneous decline to the level of that value.
37
What is the mean amplitude and average timing of PSA bounce after RT?
The mean PSA bounce amplitude is 1.3 ng/mL, occurring on average 18 months after RT initiation and taking 33 months to return to nadir.
38
How common is PSA bounce after brachytherapy compared to external beam radiation therapy?
PSA bounce is more common and pronounced after brachytherapy (incidence 32%-34%; mean amplitude 1.4-1.7 ng/mL) compared to external beam radiation (incidence 22%; mean amplitude 0.8 ng/mL).
39
What impact does experiencing a PSA bounce have on BCR-free survival?
Patients experiencing a PSA bounce were noted to subsequently experience improved BCR-free survival in a meta-analysis of 10 studies.
40
Changes in PSA after RT:
Prolonged Decline: PSA kinetics after RT can take a prolonged time to decline due to remaining prostate tissue and delayed tissue effects from RT.
Half-Life of PSA Decline: Range from 0.5 to 9.2 months, with an average of 1.6 months.
Nadir PSA Value: Typically <0.5 ng/mL following modern RT treatments.
41
PSA Bounce:
- **Definition:** A benign rise in PSA >0.2 ng/mL above a previous value followed by an eventual spontaneous decline to the previous level.
- **Mean Amplitude:** 1.3 ng/mL.
- **Timing:** Occurs on average 18 months after RT initiation and takes 33 months to return to nadir.
- **Incidence and Amplitude:**
- **Brachytherapy:** Incidence 32%-34%; mean amplitude 1.4-1.7 ng/mL.
- **External Beam Radiation:** Incidence 22%; mean amplitude 0.8 ng/mL.
- **Impact on BCR-Free Survival:** Improved BCR-free survival noted in patients experiencing PSA bounce in a meta-analysis of 10 studies.
42
What were the initial criteria defined by the American Society for Radiation Oncology in 1996 for biochemical recurrence (BCR) after radiation therapy (RT)?
The initial criteria defined BCR as either:
1. 3 consecutive PSA rises following a nadir, with the date of BCR being halfway between the nadir and the first rise.
2. 1 rise large enough to trigger initiation of therapy.
43
Why was the Phoenix Criteria introduced in 2006 for defining BCR after RT?
The Phoenix Criteria were introduced to improve correlation with clinical progression by avoiding PSA bounces and forgoing backdating.
44
What is the Phoenix Consensus definition for BCR after RT?
The Phoenix Consensus definition for BCR after RT is a rise in PSA of at least 2 ng/mL above the nadir value after radiation, regardless of whether ADT is administered with radiation.
45
Definition of BCR after RT:
Initial Definition (1996):
Criteria 1: 3 consecutive PSA rises following a nadir, with the date of BCR being halfway between the nadir and the first rise.
Criteria 2: 1 rise large enough to trigger initiation of therapy.
Updated Definition (Phoenix Criteria, 2006):
Purpose: Improve correlation with clinical progression by avoiding PSA bounces and forgoing backdating.
Definition: A rise in PSA of at least 2 ng/mL above the nadir value after radiation, regardless of whether ADT is administered with radiation.
46
Is BCR after RT specific for developing metastatic disease or PCa mortality?
No, BCR after RT is not specific for developing metastatic disease or PCa mortality.
47
What does the heterogeneity of BCR after RT highlight?
The heterogeneity of BCR after RT highlights the European Association of Urology (EAU) risk stratification of BCR into low- and high-risk groups.
48
What are the two risk groups for BCR after RT according to the EAU risk stratification?
The two risk groups for BCR after RT according to the EAU risk stratification are low-risk and high-risk groups.
49
Impact of BCR after RT on Oncologic Outcomes:
Specificity: BCR after RT is not specific for developing metastatic disease or prostate cancer (PCa) mortality.
Heterogeneity: The heterogeneity of BCR after RT outcomes is underscored by the EAU risk stratification.
EAU Risk Stratification:
Low-Risk Group: Patients with favorable prognostic indicators.
High-Risk Group: Patients with adverse prognostic indicators.
50
When should the evaluation for suspected recurrence be initiated in men who would benefit from earlier detection and management after RT?
The evaluation should be initiated sooner than when absolute criteria are met in men who would benefit from earlier detection and management.
51
What imaging methods have become the standard of care for evaluating suspected recurrence after RT?
PSMA-based PET/CT and contrast-enhanced MRI have become the standard of care for evaluating suspected recurrence after RT.
52
What percentage of recurrences were identified using C11-choline PET/CT scans in a cohort of 184 patients with PSA recurrences after RT?
Sites of recurrences were identified in 87% of patients with PSA recurrences after RT.
53
What is necessary to establish locally recurrent disease prior to initiating salvage therapy for a patient with low competing risks?
Prostate biopsy is necessary to establish locally recurrent disease prior to initiating salvage therapy.
54
What are some treatment options for isolated local recurrence after radiation therapy?
Treatment options include salvage radical prostatectomy (RP), androgen deprivation therapy (ADT), cryotherapy, high intensity focused ultrasound (HIFU), and re-irradiation.
55
Is there a preferred salvage local treatment modality designated by guidelines for isolated local recurrence after radiation?
No, guidelines do not designate a preferred salvage local treatment modality. A shared decision-making approach should be undertaken based on patient preference and center expertise.
56
What percentage of recurrences were in the pelvis and distant locations according to Parker and colleagues' study using C11-choline PET/CT scans?
In the cohort, 54% had recurrences in the pelvis (prostate and soft tissue) and 33% had distant recurrences.
57
Evaluation and Management of BCR After RT:
Evaluation and Management of BCR After RT:
- **Early Evaluation:** Initiate evaluation for suspected recurrence sooner in men who would benefit from earlier detection and management.
- **Standard Imaging:** PSMA-based PET/CT and contrast-enhanced MRI are the standard of care.
- **C11-Choline PET/CT Scans:**
- Identified sites of recurrences in 87% of patients with PSA recurrences.
- 54% had recurrences in the pelvis, 33% had distant recurrences.
- **Algorithm for BCR Evaluation:**
- **High Risk:** PSMA PET/CT + pelvic MRI with IV contrast.
- **Any Distant Recurrence:** Systemic therapy +/- metastasis directed therapy.
- **Local Only Recurrence:** Local treatment options.
- **Negative Imaging:** Prostate biopsy to confirm local recurrence.
- **Positive Biopsy:** Salvage local therapy.
- **Low Risk:** Observe with serial PSAs until individualized imaging threshold is met (clinical symptoms of metastatic disease, acceleration of PSA doubling time, PSA threshold [5, 10 ng/mL]).
- **Treatment of Local Recurrence:**
- **Salvage RP:** Best pathological evaluation but higher toxicity.
- **Other Options:** ADT, cryotherapy, HIFU, re-irradiation.
- **No Preferred Modality:** Shared decision-making based on patient preference and center expertise.
By using these flashcards and summary, you'll be able to efficiently memorize and understand the key points about the evaluation and management of biochemical recurrence after radiation therapy. If you need more detailed flashcards or further explanations, feel free to ask!
58
How do the AUA and EAU guidelines currently consider primary focal therapy of localized prostate cancer (PCa)?
Primary focal therapy of localized PCa is considered investigational by the AUA and EAU guidelines.
59
Why is PSA less accurate for measuring response to therapy after focal therapy compared to radical prostatectomy (RP)?
PSA is less accurate because the majority of the prostate gland remains in situ and is often untreated after focal therapy.
60
What is needed to delineate the utility and optimal timing of PSA monitoring after focal therapy?
Rigorous study on PSA kinetics following various focal therapies is needed to delineate the utility and optimal timing of PSA monitoring.
61
What remains the gold standard for identifying local recurrences and guiding subsequent therapies after focal therapy?
Post-treatment prostate MRI and per-protocol prostate biopsies remain the gold standard for identifying local recurrences and guiding subsequent therapies.
62
Why is it important to establish standardized definitions of PSA recurrence after focal therapy?
Standardized definitions of PSA recurrence are important to facilitate cross-study comparison.
63
**Summary:**
Monitoring for Disease Recurrence After Focal Therapy:
- **Guideline Consideration:**
- Primary focal therapy of localized PCa is considered investigational by AUA and EAU guidelines despite its rising popularity.
- **PSA Accuracy:**
- PSA is less accurate for measuring response to therapy compared to RP because the majority of the prostate gland remains in situ and is often untreated.
- **Need for Study:**
- Rigorous study on PSA kinetics following various focal therapies is needed to determine the utility and optimal timing of PSA monitoring.
- **Standardized Definitions:**
- Establishing standardized definitions of PSA recurrence is crucial for facilitating cross-study comparison.
- **Gold Standard Monitoring:**
- Post-treatment prostate MRI and per-protocol prostate biopsies are the gold standard for identifying local recurrences and guiding subsequent therapies.
64
What percentage of prostate cancer (PCa) patients will develop biochemical recurrence (BCR)?
Approximately 30% of PCa patients will develop BCR.
65
Will the majority of patients who develop BCR also develop metastatic disease or die of PCa?
No, the majority of patients who develop BCR will not develop metastatic disease or die of PCa.
66
What are the most popular definitions of BCR for RP and RT in the U.S.?
The AUA and Phoenix Criteria represent the most popular definitions of BCR for RP and RT, respectively.
67
Why are risk-adapted thresholds for BCR considered useful?
Risk-adapted thresholds for BCR are useful to individualize decision-making.
68
What does the EAU BCR risk stratification help determine?
The EAU BCR risk stratification helps determine the risk of metastasis after BCR in both post-RP and post-RT settings.
69
What unique challenge does post-radiation PSA monitoring pose?
Post-radiation PSA monitoring poses the challenge of widely varying PSA decline, and 30% of patients may experience a prolonged yet benign PSA bounce.
70
What imaging combination is currently the most sensitive for evaluating BCR in both post-RP and post-RT settings?
The most sensitive imaging combination is a PSMA-PET/CT and pelvic MRI with contrast.
71
What should guide the choice of salvage treatments for isolated local recurrences after radiation?
The choice of salvage treatments for isolated local recurrences after radiation should be based on patient preference and center expertise.
72
What is needed as focal therapy becomes more common?
Further study is needed on how to monitor PSA and evaluate patients for disease recurrence as focal therapy becomes more common.
73
**Summary:**
Summary of Biochemical Recurrence (BCR) in Prostate Cancer:
- **Incidence of BCR:** Approximately 30% of prostate cancer (PCa) patients will develop BCR.
- **Outcomes:** The majority of patients with BCR will not develop metastatic disease or die of PCa.
- **Definitions:**
- **AUA Criteria:** Most popular for post-radical prostatectomy (RP) BCR.
- **Phoenix Criteria:** Most popular for post-radiation therapy (RT) BCR.
- **Risk-Adapted Thresholds:** Useful for individualized decision-making.
- **EAU Risk Stratification:** Helps determine the risk of metastasis after BCR in both post-RP and post-RT settings.
- **Post-Radiation Monitoring:**
- PSA decline can vary widely.
- 30% of patients may experience a prolonged yet benign PSA bounce.
- **Evaluation and Imaging:**
- Early treatment of recurrent disease should be evaluated.
- Most sensitive imaging combination: PSMA-PET/CT and pelvic MRI with contrast.
- **Salvage Treatments:**
- sRT is routinely delivered after RP for the appropriate patient.
- Choice of salvage treatments for isolated local recurrences after radiation should be based on patient preference and center expertise.
- **Focal Therapy:** Requires further study for PSA monitoring and evaluation of disease recurrence.
74
What percentage of patients treated for localized prostate cancer (PCa) will develop biochemical recurrence (BCR)?
Thirty percent of patients treated for localized PCa will develop BCR.
75
What percentage of patients with BCR will develop metastatic disease?
Approximately 30% of patients with BCR will develop metastatic disease.
76
What is the AUA criteria for BCR after radical prostatectomy (RP)?
The AUA criteria for BCR after RP is a PSA ≥0.2 ng/mL with a second confirmatory PSA above this value.
77
How can risk-adapted BCR thresholds individualize when to evaluate and treat BCR?
Risk-adapted BCR thresholds account for the patient’s surgical pathology grade, stage, and margin status, using lower thresholds for higher risk disease.
78
What is the Phoenix Criteria for BCR after radiation therapy (RT)?
The Phoenix Criteria for BCR after RT is a rise of at least 2 ng/mL above the nadir value after radiation, regardless of whether androgen deprivation therapy (ADT) is administered with radiation.
79
What is the lesion detection rate of PSMA-PET/CT when post-RP PSA is less than 0.5 ng/mL?
The lesion detection rate of PSMA-PET/CT is approximately 40%-60% when post-RP PSA is less than 0.5 ng/mL.
80
What percentage of patients undergoing radiation therapy (RT) will experience a PSA bounce?
Approximately 31% of patients undergoing RT will experience a PSA bounce.
81
**Summary:**
Key Facts About Biochemical Recurrence (BCR) and Prostate Cancer (PCa):
- **Incidence of BCR:**
- 30% of patients treated for localized PCa will develop BCR.
- Approximately 30% of these patients will develop metastatic disease.
- **AUA Criteria for BCR After RP:**
- PSA ≥0.2 ng/mL with a second confirmatory PSA above this value.
- Risk-adapted thresholds account for the patient's surgical pathology grade, stage, and margin status to individualize evaluation and treatment.
- **Phoenix Criteria for BCR After RT:**
- A rise of at least 2 ng/mL above the nadir value after radiation, regardless of whether ADT is administered with radiation.
- **PSMA-PET/CT Detection Rate:**
- Lesion detection rate of approximately 40%-60% when post-RP PSA is less than 0.5 ng/mL.
- **PSA Bounce After RT:**
- Approximately 31% of patients undergoing RT will experience a PSA bounce.
82
What is the 15-year prostate cancer mortality after biochemical recurrence (BCR) following radical prostatectomy (RP)?
The 15-year prostate cancer mortality after BCR following RP is approximately 17%.
Multiple series have now documented the heterogenous, and most often prolonged, natural history of biochemical recurrence (BCR) following radical prostatectomy. For example, Pound et al reported that the majority of patients experiencing BCR after RP will not suffer distant progression or PCa mortality.14 Specifically, in a cohort of 304 patients with BCR who did not receive any adjuvant or salvage treatment until the development of metastases, they found that 34% developed metastasis, with a median time to metastasis of 8 years. Further, for patients who developed metastatic disease, the median time to death was then 5 years. This translates to a 15-year risk of prostate cancer mortality of approximately 15%-20%. Overall, these data are useful to counsel patients with biochemical recurrence regarding prognosis and expected timeline.
83
Eight years after radical prostatectomy for Gleason 3+4 pT2N0R0 prostate cancer, a 78-year-old man with coronary artery disease and insulin dependent diabetes mellitus has a PSA increase to 0.30 ng/mL with a PSA doubling time of 36 months. The next step is:
Repeat PSA in 3 months.
PSMA-PET/CT.
Salvage radiation therapy with androgen deprivation.
Salvage androgen deprivation therapy alone.
Due to the patient’s age and comorbidities, he has an estimated life expectancy of less than 10 years. Moreover, his organ confined ISUP Grade 2 prostate cancer on surgical pathology with a doubling time of over 12 months puts him at low risk (<5%) for prostate cancer metastasis within 5 years using the EAU BCR risk stratification. While further evaluation with recurrence imaging or up-front treatment with salvage radiation are acceptable options for many patients with biochemical recurrence, for patients with significant competing risks of non-prostate cancer mortality and a low risk of prostate cancer metastasis, further evaluation and treatment are unlikely to benefit the patient but can lead to harm.
84
A 63-year-old man undergoes low-dose brachytherapy for Gleason 3+4 cT1c prostate cancer with a pre-treatment PSA of 4 ng/mL. PSA nadir 9 months after completing treatment is 0.4 ng/mL. His PSA increases to 1.6 ng/mL over the subsequent 24 months, and then declines to 1.0 ng/mL in the following 6 months. The next step is:
Repeat PSA in 3 months.
Prostate MRI.
PSMA-PET/CT scan.
Prostate biopsy.
This patient is likely experiencing a PSA “bounce,” which has been reported to occur in over 30% of patients treated with brachytherapy. PSA bounce occurs on average 18 months after the initiation of radiation therapy and takes 33 months to return to nadir. Mean PSA bounce amplitude is 1.3 ng/mL. While it may be difficult to distinguish between a PSA bounce and biochemical recurrence for a patient with a rising PSA after radiation therapy, this patient is now experiencing a spontaneously declining PSA, consistent with a PSA bounce, as recurrent prostate cancer is unlikely to have sustained declines in PSA after an initial rise. Thus, rechecking the PSA is the best next step rather than initiating evaluation with imaging or biopsy.
85
A 69-year-old man undergoes external beam radiation with androgen deprivation therapy for Gleason 4+4 cT2aN0M0 prostate cancer with a pre-treatment PSA of 12 ng/mL. Over the next year, his PSA increases from a nadir of 0.8 ng/mL to 2.8 ng/mL. PSMA-PET/CT scan demonstrates isolated uptake in the prostate and seminal vesicles, and a prostate MRI with contrast notes a mass at the base of the prostate involving the seminal vesicles. The next step is:
This patient has a rising PSA after prostate cancer radiation therapy with a doubling time of less than 12 months and post-radiation therapy nadir of over 0.4ng/mL, clinical features more consistent with biochemical recurrence as opposed to a PSA bounce. Imaging likewise supports local recurrence in the prostate and seminal vesicles. However, imaging alone is not able to definitively diagnose a local recurrence of prostate cancer in order to guide therapy. Thus, for a patient who may benefit from further local treatment, prostate biopsy should be performed to confirm viable recurrent prostate cancer before initiating further treatment.
86
Eighteen months after radical prostatectomy for a Gleason 4+3 pT3R1N0 adenocarcinoma, a 62-year-old man has a PSA rise to 0.3 ng/mL with a doubling time of 24 months. PSMA-PET/CT is negative. The next step is:
Serial PSAs until PSMA-PET/CT demonstrates a PET-avid lesion.
Prostate fossa biopsy.
Salvage radiation therapy.
Androgen deprivation therapy alone.
Given the rising PSA, the negative PSMA-PET/CT, and the relatively slow PSA doubling time, the most appropriate next step would be:
Salvage radiation therapy.
Salvage radiation therapy is typically recommended in cases of biochemical recurrence after radical prostatectomy, especially when imaging is negative for distant metastasis, to target potential local recurrence in the prostate fossa.
87
What percentage of visits do urological concerns account for in adults?
Up to 20% of visits.
88
How common is microscopic hematuria in school-age children?
Population studies estimate that 4% of school-age children have microscopic hematuria on a single urinalysis and 1.1% on 2 or more tests.
89
What is the incidence of gross hematuria in pediatric emergency room visits?
Gross hematuria has been estimated to account for 1.4 in 1,000 pediatric emergency room visits.
90
What defines gross or macroscopic hematuria?
Gross or macroscopic hematuria occurs when red blood cells (RBCs) in urine are visible with the naked eye, resulting in an abnormal color.
91
What is the definition of microscopic hematuria according to the most recent AUA guidelines?
Microscopic hematuria is defined as ≥3 RBCs per high-power field (HPF) on microscopic evaluation of a single, properly collected urine specimen.
92
What is the primary goal of the hematuria workup in both pediatric and adult patients?
The primary goal is to identify the etiology and ensure that hematuria is not caused by a significant and potentially modifiable condition.
93
What is the most concerning cause of hematuria in adults?
The most concerning cause of hematuria in adults is malignancy, which is present in 3%-10% of patients.
94
What are the guidelines for the workup of adult hematuria?
The guidelines for adult hematuria include risk-stratified imaging and cystoscopy.
95
Are there clear guidelines that dictate the workup of pediatric hematuria?
No, there are no clear guidelines that dictate the workup of pediatric hematuria.
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Flashcards for the Introduction
**Flashcard 1:**
```markdown
**Question:**
What percentage of visits do urological concerns account for in adults?
**Answer:**
Up to 20% of visits.
```
**Flashcard 2:**
```markdown
**Question:**
How common is microscopic hematuria in school-age children?
**Answer:**
Population studies estimate that 4% of school-age children have microscopic hematuria on a single urinalysis and 1.1% on 2 or more tests.
```
**Flashcard 3:**
```markdown
**Question:**
What is the incidence of gross hematuria in pediatric emergency room visits?
**Answer:**
Gross hematuria has been estimated to account for 1.4 in 1,000 pediatric emergency room visits.
```
**Flashcard 4:**
```markdown
**Question:**
What defines gross or macroscopic hematuria?
**Answer:**
Gross or macroscopic hematuria occurs when red blood cells (RBCs) in urine are visible with the naked eye, resulting in an abnormal color.
```
**Flashcard 5:**
```markdown
**Question:**
What is the definition of microscopic hematuria according to the most recent AUA guidelines?
**Answer:**
Microscopic hematuria is defined as ≥3 RBCs per high-power field (HPF) on microscopic evaluation of a single, properly collected urine specimen.
```
**Flashcard 6:**
```markdown
**Question:**
What is the primary goal of the hematuria workup in both pediatric and adult patients?
**Answer:**
The primary goal is to identify the etiology and ensure that hematuria is not caused by a significant and potentially modifiable condition.
```
**Flashcard 7:**
```markdown
**Question:**
What is the most concerning cause of hematuria in adults?
**Answer:**
The most concerning cause of hematuria in adults is malignancy, which is present in 3%-10% of patients.
```
**Flashcard 8:**
```markdown
**Question:**
What are the guidelines for the workup of adult hematuria?
**Answer:**
The guidelines for adult hematuria include risk-stratified imaging and cystoscopy.
```
**Flashcard 9:**
```markdown
**Question:**
Are there clear guidelines that dictate the workup of pediatric hematuria?
**Answer:**
No, there are no clear guidelines that dictate the workup of pediatric hematuria.
```
Summary
Hematuria in Children, Teenagers, and Young Adults: Introduction
- **Prevalence:**
- Hematuria is common in both adults and children, with different etiologies and workup protocols.
- **Adults:** Accounts for up to 20% of urological visits.
- **Children:** 4% have microscopic hematuria on a single urinalysis, and 1.1% on 2 or more tests. Gross hematuria is less common but accounts for 1.4 in 1,000 pediatric ER visits.
- **Definitions:**
- **Gross Hematuria:** Visible RBCs in urine causing discoloration.
- **Microscopic Hematuria:** ≥3 RBCs per high-power field (HPF) on microscopic evaluation of a single, properly collected urine specimen.
- **Workup Goals:**
- Identify the etiology of hematuria.
- Ensure hematuria is not caused by significant and potentially modifiable conditions.
- **Adult Hematuria:**
- Malignancy is a primary concern (3%-10% of patients).
- Guidelines include risk-stratified imaging and cystoscopy.
- **Pediatric Hematuria:**
- No clear guidelines exist for the workup.
- The update reviews common causes and suggested workup based on risk factors and symptoms.
This summary and flashcards should help you understand the key points of the introduction to hematuria in children, teenagers, and young adults. If you need further details or have more questions, feel free to ask!
97
What was the previous recommendation of the American Academy of Pediatrics (AAP) regarding screening urinalysis in children?
The AAP previously recommended screening urinalysis at multiple time points during childhood.
98
Why did the AAP remove screening urinalysis from its health supervision guidelines in 2007?
The AAP removed screening urinalysis from its guidelines due to a lack of evidence of benefit in terms of early detection of chronic kidney disease (CKD) or other treatable conditions, and concerns about false-positives leading to costly, invasive, and anxiety-inducing evaluations.
99
What did the 2018 AAP Choosing Wisely campaign recommend regarding universal screening urinalysis?
The 2018 AAP Choosing Wisely campaign recommended against universal screening urinalysis.
100
What were the reasons for the AAP Choosing Wisely campaign's recommendation against universal screening urinalysis?
The reasons included a high rate of false-positives, increased cost and familial anxiety, and the low prevalence of CKD and bladder cancer in children, leading to low rates of detection.
101
Which children may benefit from screening urinalysis according to the AAP?
Children with risk factors such as prematurity or very low birth weight, congenital heart disease, recurrent urinary tract infections (UTIs), acute kidney injury (AKI), known urological congenital anomalies, history of organ transplant, malignancy, treatment with nephrotoxic medications, and family history of inherited renal disease.
102
What percentage of patients were still undergoing urine screening at well-child visits despite the change in AAP guidelines?
Almost one-quarter of patients were still undergoing urine screening at well-child visits.
103
Let's create flashcards and a summary for the "SCREENING AND FOLLOW-UP OF MICROSCOPIC HEMATURIA" section.
**Flashcards:**
**Flashcard 1:**
```markdown
**Question:**
What was the previous recommendation of the American Academy of Pediatrics (AAP) regarding screening urinalysis in children?
**Answer:**
The AAP previously recommended screening urinalysis at multiple time points during childhood.
```
**Flashcard 2:**
```markdown
**Question:**
Why did the AAP remove screening urinalysis from its health supervision guidelines in 2007?
**Answer:**
The AAP removed screening urinalysis from its guidelines due to a lack of evidence of benefit in terms of early detection of chronic kidney disease (CKD) or other treatable conditions, and concerns about false-positives leading to costly, invasive, and anxiety-inducing evaluations.
```
**Flashcard 3:**
```markdown
**Question:**
What did the 2018 AAP Choosing Wisely campaign recommend regarding universal screening urinalysis?
**Answer:**
The 2018 AAP Choosing Wisely campaign recommended against universal screening urinalysis.
```
**Flashcard 4:**
```markdown
**Question:**
What were the reasons for the AAP Choosing Wisely campaign's recommendation against universal screening urinalysis?
**Answer:**
The reasons included a high rate of false-positives, increased cost and familial anxiety, and the low prevalence of CKD and bladder cancer in children, leading to low rates of detection.
```
**Flashcard 5:**
```markdown
**Question:**
Which children may benefit from screening urinalysis according to the AAP?
**Answer:**
Children with risk factors such as prematurity or very low birth weight, congenital heart disease, recurrent urinary tract infections (UTIs), acute kidney injury (AKI), known urological congenital anomalies, history of organ transplant, malignancy, treatment with nephrotoxic medications, and family history of inherited renal disease.
```
**Flashcard 6:**
```markdown
**Question:**
What percentage of patients were still undergoing urine screening at well-child visits despite the change in AAP guidelines?
**Answer:**
Almost one-quarter of patients were still undergoing urine screening at well-child visits.
```
**Summary:**
Screening and Follow-Up of Microscopic Hematuria:
- **AAP Screening Guidelines:**
- **Previous Recommendations:** Screening urinalysis at multiple time points during childhood.
- **Change in 2007:** Removed from health supervision guidelines due to a lack of evidence for early detection benefits and concerns about false-positives leading to costly and invasive evaluations.
- **2018 AAP Choosing Wisely Campaign:**
- **Recommendation:** Against universal screening urinalysis.
- **Reasons:** High rate of false-positives, increased cost and familial anxiety, low prevalence of CKD and bladder cancer in children, resulting in low rates of detection.
- **Children Who May Benefit from Screening:**
- **Risk Factors:**
- Prematurity or very low birth weight.
- Congenital heart disease.
- Recurrent UTIs.
- Acute kidney injury (AKI).
- Known urological congenital anomalies.
- History of organ transplant.
- Malignancy.
- Treatment with nephrotoxic medications.
- Family history of inherited renal disease.
- **Current Practice:**
- Despite the change in guidelines, recent research shows that almost one-quarter of patients are still undergoing urine screening at well-child visits, leading to the incidental finding of microscopic hematuria.
This summary and flashcards should help you understand the key points about the screening and follow-up of microscopic hematuria in children. If you need further details or have more questions, feel free to ask!
104
What should be done for patients where a cause of microscopic hematuria is identified?
Further workup and follow-up should be dictated by the etiology.
105
What percentage of patients with microscopic hematuria will not have a clear causative diagnosis?
Up to 80% of patients with microscopic hematuria will not have a clear causative diagnosis.
106
What are the long-term outcomes for patients with isolated microscopic hematuria?
The long-term outcomes are generally favorable.
107
How should patients with isolated microscopic hematuria be monitored?
Patients can be safely observed with yearly follow-up by their pediatrician, including blood pressure measurement and urinalysis to assess for both persistent hematuria and proteinuria.
108
What factors might warrant a referral to nephrology for a patient with persistent microscopic hematuria?
Risk factors such as proteinuria, elevated blood pressure, or family history of CKD may warrant a referral to nephrology for further workup and closer monitoring of renal function.
109
Figure. Algorithm for the workup of pediatric hematuria. BMP indicates basic metabolic panel; Ca:Cr, calcium/creatinine; CT, computerized tomography; Mag3, mercaptoacetyltriglycine; MRU, magnetic resonance urography; RBCs, red blood cells; RBUS, renal bladder ultrasound; SLE, systemic lupus erythematosus; UA, urinalysis; UTI, urinary tract infection.
110
What is the AUA definition of microhematuria?
Microhematuria is defined as ≥3 RBCs per high-power field (HPF) on a single, properly collected urine specimen.
111
Why is a dipstick urinalysis not sufficient for diagnosing hematuria?
Dipstick urinalysis can result in false positives due to myoglobinuria, use of povidone iodine, hemoglobinuria, and dehydration.
112
What should be done if a dipstick test is positive for hematuria?
A positive dipstick should prompt confirmatory testing with microscopy.
113
What are some non-hematuria causes of discolored urine?
Non-hematuria causes include myoglobinuria, hemoglobinuria, certain foods (beets, blackberries, rhubarb, paprika), medications (nitrofurantoin, rifampin, phenazopyridine), and metabolites such as homogentisic acid.
114
What physical characteristics of hematuria can help determine its origin?
- Upper tract pathology: Typically painless, brown or tea-colored hematuria.
- Lower tract cause: Often associated with dysuria, pink or red hematuria, sometimes with clots.
- Hematuria at the beginning or end of the stream suggests the urethra as the origin, while hematuria throughout the stream can be from any location along the urinary tract.
115
What additional findings on microscopic urinalysis can suggest the etiology of hematuria?
- Proteinuria suggests a glomerular cause.
- Dysmorphic RBCs or RBC casts indicate a glomerular source.
- Intact RBCs suggest a nonglomerular origin.
116
What should a careful history and physical exam include for a patient with hematuria?
- Associated signs or symptoms (pain, fevers, rashes, urinary symptoms)
- Association with trauma or exercise
- Family and personal history of hematuria, stones, or renal disease
- Palpation for flank and abdominal tenderness or mass
- Examination for bruising or blood at the urethral meatus
- Blood pressure measurement
- Evaluation for edema
117
What is the most common initial imaging used for the workup of pediatric hematuria?
Renal bladder ultrasound (RBUS).
118
What are the common initial labs beyond urinalysis for pediatric hematuria?
- Creatinine
- Albumin
- Complement component 3 (C3)
- Complement component 4 (C4)
- Complete blood count (CBC) if there is concern for significant blood loss or infection
119
Are glomerular causes of hematuria more common in pediatric or adult patients?
Glomerular causes of hematuria are more common in pediatric patients.
120
Is malignancy a common cause of hematuria in pediatric patients?
No, malignancy is less common in pediatric patients compared to adults.
121
What percentage of pediatric patients with gross hematuria have a benign etiology or no cause identified?
The majority of pediatric patients with gross hematuria have a benign etiology or no cause identified.
122
What were the most common diagnoses in a series of 342 pediatric patients presenting with gross hematuria?
- Benign urethrorrhagia in 19% of males
- UTI in 14%
- Trauma in 14%
- Congenital anomalies in 13%
- Stones in 6%
- Malignancy in 4 patients (3 bladder transitional cell carcinoma and 1 Wilms tumor)
- No etiology found in 34%
123
What percentage of pediatric patients evaluated for microscopic hematuria had no specific cause identified?
80% of pediatric patients evaluated for microscopic hematuria had no specific cause identified.
124
What percentage of pediatric patients evaluated for microscopic hematuria had hypercalciuria without stone disease?
16% of pediatric patients evaluated for microscopic hematuria had hypercalciuria without stone disease.
125
Let's create flashcards and a summary for the "CAUSES OF HEMATURIA" section.
**Flashcards:**
**Flashcard 1:**
```markdown
**Question:**
Are glomerular causes of hematuria more common in pediatric or adult patients?
**Answer:**
Glomerular causes of hematuria are more common in pediatric patients.
```
**Flashcard 2:**
```markdown
**Question:**
Is malignancy a common cause of hematuria in pediatric patients?
**Answer:**
No, malignancy is less common in pediatric patients compared to adults.
```
**Flashcard 3:**
```markdown
**Question:**
What percentage of pediatric patients with gross hematuria have a benign etiology or no cause identified?
**Answer:**
The majority of pediatric patients with gross hematuria have a benign etiology or no cause identified.
```
**Flashcard 4:**
```markdown
**Question:**
What were the most common diagnoses in a series of 342 pediatric patients presenting with gross hematuria?
**Answer:**
- Benign urethrorrhagia in 19% of males
- UTI in 14%
- Trauma in 14%
- Congenital anomalies in 13%
- Stones in 6%
- Malignancy in 4 patients (3 bladder transitional cell carcinoma and 1 Wilms tumor)
- No etiology found in 34%
```
**Flashcard 5:**
```markdown
**Question:**
What percentage of pediatric patients evaluated for microscopic hematuria had no specific cause identified?
**Answer:**
80% of pediatric patients evaluated for microscopic hematuria had no specific cause identified.
```
**Flashcard 6:**
```markdown
**Question:**
What percentage of pediatric patients evaluated for microscopic hematuria had hypercalciuria without stone disease?
**Answer:**
16% of pediatric patients evaluated for microscopic hematuria had hypercalciuria without stone disease.
```
**Summary:**
Causes of Hematuria in Pediatric Patients:
- **Prevalence and Etiology:**
- Glomerular causes are more common in children, while malignancy is less common compared to adults.
- Even with gross hematuria, most pediatric cases have benign etiologies or no identified cause.
- **Series of 342 Patients with Gross Hematuria:**
- **Diagnoses:**
- Benign urethrorrhagia: 19% of males
- UTI: 14%
- Trauma: 14%
- Congenital anomalies: 13%
- Stones: 6%
- Malignancy: 4 patients (3 bladder transitional cell carcinoma, 1 Wilms tumor)
- No etiology: 34%
- **Series of 342 Patients with Microscopic Hematuria:**
- **Findings:**
- No specific cause: 80%
- Hypercalciuria without stone disease: 16%
- **Diagnosis:**
- All malignancies in the gross hematuria series were diagnosed on renal bladder ultrasound (RBUS).
The next sections will discuss specific causes of hematuria and the associated findings that suggest these diagnoses. The Table (not provided here) lists common causes of pediatric hematuria and classic findings that should alert clinicians to these potential diagnoses.
This summary and flashcards should help you understand the key points about the causes of hematuria in pediatric patients. If you need further details or have more questions, feel free to ask!
126
What are some common glomerular causes of pediatric hematuria?
- Postinfectious glomerulonephritis
- IgA nephropathy (Berger’s disease)
- Alport syndrome
- Thin basement membrane disease (benign familial hematuria)
- Membranoproliferative glomerulonephritis
- Focal segmental glomerulosclerosis
- Membranous nephropathy
- Acute interstitial nephritis
127
Name some systemic glomerular causes of pediatric hematuria.
- Henoch-Schönlein purpura
- Hemolytic uremic syndrome
- Systemic lupus erythematosus
- Serum sickness
- Polyarteritis nodosa
- Goodpasture disease
- Thrombotic thrombocytopenic purpura
128
List some systemic nonglomerular causes of pediatric hematuria.
- Sickle cell disease or trait
- Hemophilia
- Coagulopathies
- Strenuous exercise
129
What are some nonglomerular infectious causes of pediatric hematuria?
- Cystitis
- Pyelonephritis
- Viral or bacterial infections
- Schistosomiasis
130
Name some urolithiasis-related causes of pediatric hematuria.
- Kidney or ureteral stones
- Bladder stones
131
What anatomical urinary tract anomalies can cause pediatric hematuria?
- UPJ obstruction
- UVJ obstruction
- Bladder diverticula
- Urinary tract polyps
- Renal cysts
- Calyceal diverticulum
- Urethral prolapse
132
List some malignancies that can cause pediatric hematuria.
- Rhabdomyosarcoma
- Bladder tumors
- Renal masses (Wilms or other)
133
What are some vascular anomalies that can cause pediatric hematuria?
- Renal vein thrombosis
- Nutcracker syndrome
- Arteriovenous malformations
- Hemangiomas
134
What types of trauma can cause pediatric hematuria?
- Renal trauma
- Ureteral trauma
- Bladder trauma
- Urethral trauma
135
Table. Causes of Pediatric Hematuria
136
When should glomerular disease be suspected as the cause of hematuria?
Glomerular disease should be suspected when proteinuria, edema, or hypertension is present.
137
What is the most common cause of acute nephritis in children worldwide?
Postinfectious glomerulonephritis.
138
What is the incidence of postinfectious glomerulonephritis in children worldwide?
9.5-28.5 cases per 100,000 annually.
139
What are common causes of postinfectious glomerulonephritis in industrialized countries?
- Streptococcal infections (25%)
- Staphylococcus infections (25%)
140
How does IgA nephropathy (Berger’s disease) typically present?
It presents within 2-3 days of an upper respiratory tract or gastrointestinal infection, with intermittent hematuria.
141
What percentage of patients with IgA nephropathy may develop chronic kidney disease (CKD)?
15%-30% of patients may develop CKD.
142
What are the associated conditions and symptoms of Alport syndrome?
Alport syndrome is associated with high-frequency sensorineural hearing loss, ocular anomalies, and progressive CKD to end-stage renal disease (ESRD) before age 40.
143
What is thin basement membrane disease (benign familial hematuria), and what is its prognosis?
Thin basement membrane disease is an autosomal dominant condition causing persistent microscopic hematuria, typically not progressing to CKD, though monitoring for proteinuria and hypertension is recommended.
144
Let's create flashcards and a summary for the "Primary Glomerular Causes" section based on the provided text.
**Flashcards:**
**Flashcard 1:**
```markdown
**Question:**
When should glomerular disease be suspected as the cause of hematuria?
**Answer:**
Glomerular disease should be suspected when proteinuria, edema, or hypertension is present.
```
**Flashcard 2:**
```markdown
**Question:**
What is the most common cause of acute nephritis in children worldwide?
**Answer:**
Postinfectious glomerulonephritis.
```
**Flashcard 3:**
```markdown
**Question:**
What is the incidence of postinfectious glomerulonephritis in children worldwide?
**Answer:**
9.5-28.5 cases per 100,000 annually.
```
**Flashcard 4:**
```markdown
**Question:**
What are common causes of postinfectious glomerulonephritis in industrialized countries?
**Answer:**
- Streptococcal infections (25%)
- Staphylococcus infections (25%)
```
**Flashcard 5:**
```markdown
**Question:**
How does IgA nephropathy (Berger’s disease) typically present?
**Answer:**
It presents within 2-3 days of an upper respiratory tract or gastrointestinal infection, with intermittent hematuria.
```
**Flashcard 6:**
```markdown
**Question:**
What percentage of patients with IgA nephropathy may develop chronic kidney disease (CKD)?
**Answer:**
15%-30% of patients may develop CKD.
```
**Flashcard 7:**
```markdown
**Question:**
What are the associated conditions and symptoms of Alport syndrome?
**Answer:**
Alport syndrome is associated with high-frequency sensorineural hearing loss, ocular anomalies, and progressive CKD to end-stage renal disease (ESRD) before age 40.
```
**Flashcard 8:**
```markdown
**Question:**
What is thin basement membrane disease (benign familial hematuria), and what is its prognosis?
**Answer:**
Thin basement membrane disease is an autosomal dominant condition causing persistent microscopic hematuria, typically not progressing to CKD, though monitoring for proteinuria and hypertension is recommended.
```
**Summary:**
Primary Glomerular Causes of Pediatric Hematuria:
- **General Indications:**
- Hematuria from glomerular disease can be microscopic or gross.
- Suspect glomerular causes when proteinuria, edema, or hypertension is present.
- **Postinfectious Glomerulonephritis:**
- **Prevalence:** Most common cause of acute nephritis in children worldwide.
- **Incidence:** 9.5-28.5 cases per 100,000 annually.
- **Causes:**
- 25% from streptococcal infections.
- 25% from Staphylococcus infections.
- **Presentation:** Variable; can range from asymptomatic microscopic hematuria to gross hematuria, proteinuria, edema, hypertension, and acute kidney injury (AKI).
- **Resolution:** Hematuria and proteinuria usually resolve in weeks to months.
- **IgA Nephropathy (Berger’s Disease):**
- **Mechanism:** Deposition of IgA in the glomerular mesangium.
- **Presentation:** Intermittent hematuria, typically within 2-3 days of an upper respiratory or gastrointestinal infection.
- **Long-term Risk:** 15%-30% may develop CKD. Older age, proteinuria, and hypertension are associated with poorer outcomes.
- **Alport Syndrome and Thin Basement Membrane Disease:**
- **Commonality:** Both are related to defects in type IV collagen.
- **Alport Syndrome:**
- **Inheritance:** Most commonly X-linked.
- **Associated Conditions:** High-frequency sensorineural hearing loss, ocular anomalies, progressive CKD to ESRD before age 40.
- **Thin Basement Membrane Disease (Benign Familial Hematuria):**
- **Inheritance:** Autosomal dominant.
- **Prevalence:** Occurs in 1% of the population.
- **Prognosis:** Persistent microscopic hematuria, typically does not progress to CKD. Monitoring for proteinuria and hypertension is recommended.
This summary and flashcards should help you understand the key points about the primary glomerular causes of pediatric hematuria. If you need further details or have more questions, feel free to ask!
145
What is Henoch-Schönlein purpura (HSP) and what are its classic symptoms?
Henoch-Schönlein purpura (HSP) is a small vessel vasculitis that affects the skin, gut, and small vessels of the kidney due to IgA deposits. Classic symptoms include transient arthralgias, abdominal pain, a palpable purpuric rash of the lower extremities, and nephritis with hematuria (gross or microscopic) in 60% of cases.
146
What is the usual treatment for Henoch-Schönlein purpura (HSP) and what percentage of patients progress to end-stage renal disease (ESRD)?
HSP is generally self-limited and treated with supportive measures and sometimes steroids. Approximately 1% of patients will progress to ESRD.
147
What is the classic triad of symptoms for hemolytic uremic syndrome (HUS)?
The classic triad of symptoms for HUS includes anemia, thrombocytopenia, and acute kidney injury (AKI).
148
What is the traditional infectious etiology of hemolytic uremic syndrome (HUS) and what additional symptom does it commonly cause?
HUS is traditionally caused by infection with Shiga toxin-producing Escherichia coli, which also causes bloody diarrhea.
149
What is one of the leading causes of AKI in children under 3 years and what are the long-term risks for these patients?
Shiga toxin-producing E. coli-HUS is one of the leading causes of AKI in children under 3 years. Though most patients will recover their renal function, a small group will develop CKD and ESRD, requiring close monitoring and follow-up.
150
What percentage of patients with systemic lupus erythematosus have renal involvement and what are common renal presentations?
Approximately 50% of patients with systemic lupus erythematosus have renal involvement. Common renal presentations include microscopic hematuria (80%), proteinuria, hypertension, and a decline in renal function. Gross hematuria is uncommon (<5%).
151
What should raise suspicion for systemic lupus erythematosus in patients with renal manifestations?
Renal manifestations, along with involvement of multiple other organ systems (such as malar rash, fatigue, arthralgias, thrombocytopenia, and anemia), should raise suspicion for systemic lupus erythematosus.
152
Why are children more likely than adults to sustain renal injuries in trauma?
Children's kidneys are relatively larger and less well protected by their abdominal wall and rib cage.
153
What imaging is recommended by AUA guidelines for evaluating renal injury in pediatric trauma patients?
CT scan with intravenous contrast is recommended in all abdominal blunt trauma patients with either microscopic hematuria and systolic blood pressure <90 mm Hg or gross hematuria. Delayed images should be obtained to evaluate for collecting system injury, often resulting in a CT urogram.
154
What is the European Association of Urology pediatric guideline recommendation for imaging in children with abdominal trauma and hematuria?
Imaging is recommended in all children with either a blunt or penetrating abdominal injury and any degree of hematuria. Many pediatric groups suggest >50 RBCs/HPF as a reasonable cutoff without the use of hypotension.
155
What imaging should be performed in pediatric patients with pelvic fractures and gross hematuria or clinical concern for bladder rupture?
A cystogram (standard radiography or CT) that includes both images with the bladder filled to capacity and after emptying should be performed.
156
What percentage of pediatric patients with pelvic fractures and gross hematuria have bladder injuries?
Up to 45% of these patients will have bladder injuries.
157
What is the prevalence of ureteral trauma in pediatric urological trauma cases, and how is it diagnosed?
Ureteral trauma comprises only 1% of pediatric urological trauma cases. It can be diagnosed using a CT urogram, with further information gained by retrograde or antegrade pyelograms at the time of stent or nephrostomy tube placement.
158
What should raise suspicion for urethral injury in pediatric trauma patients, and what imaging should be performed?
Suspicion should be raised when there is a pelvic fracture with blood at the urethral meatus, gross hematuria, or pain or difficulty voiding. Retrograde urethrogram should be performed prior to catheter placement, or if a catheter is already placed and draining, a periurethral retrograde urethrogram can be performed.
159
How are urethral injuries in females often evaluated?
They often require an exam under anesthesia for a pelvic exam to evaluate for concomitant vaginal injury and for visualization of the urethra and bladder neck with cystoscopy.
160
Let's create flashcards and a summary for the "Trauma" section based on the provided text.
**Flashcards:**
**Flashcard 1:**
```markdown
**Question:**
Why are children more likely than adults to sustain renal injuries in trauma?
**Answer:**
Children's kidneys are relatively larger and less well protected by their abdominal wall and rib cage.
```
**Flashcard 2:**
```markdown
**Question:**
What imaging is recommended by AUA guidelines for evaluating renal injury in pediatric trauma patients?
**Answer:**
CT scan with intravenous contrast is recommended in all abdominal blunt trauma patients with either microscopic hematuria and systolic blood pressure <90 mm Hg or gross hematuria. Delayed images should be obtained to evaluate for collecting system injury, often resulting in a CT urogram.
```
**Flashcard 3:**
```markdown
**Question:**
What is the European Association of Urology pediatric guideline recommendation for imaging in children with abdominal trauma and hematuria?
**Answer:**
Imaging is recommended in all children with either a blunt or penetrating abdominal injury and any degree of hematuria. Many pediatric groups suggest >50 RBCs/HPF as a reasonable cutoff without the use of hypotension.
```
**Flashcard 4:**
```markdown
**Question:**
What imaging should be performed in pediatric patients with pelvic fractures and gross hematuria or clinical concern for bladder rupture?
**Answer:**
A cystogram (standard radiography or CT) that includes both images with the bladder filled to capacity and after emptying should be performed.
```
**Flashcard 5:**
```markdown
**Question:**
What percentage of pediatric patients with pelvic fractures and gross hematuria have bladder injuries?
**Answer:**
Up to 45% of these patients will have bladder injuries.
```
**Flashcard 6:**
```markdown
**Question:**
What is the prevalence of ureteral trauma in pediatric urological trauma cases, and how is it diagnosed?
**Answer:**
Ureteral trauma comprises only 1% of pediatric urological trauma cases. It can be diagnosed using a CT urogram, with further information gained by retrograde or antegrade pyelograms at the time of stent or nephrostomy tube placement.
```
**Flashcard 7:**
```markdown
**Question:**
What should raise suspicion for urethral injury in pediatric trauma patients, and what imaging should be performed?
**Answer:**
Suspicion should be raised when there is a pelvic fracture with blood at the urethral meatus, gross hematuria, or pain or difficulty voiding. Retrograde urethrogram should be performed prior to catheter placement, or if a catheter is already placed and draining, a periurethral retrograde urethrogram can be performed.
```
**Flashcard 8:**
```markdown
**Question:**
How are urethral injuries in females often evaluated?
**Answer:**
They often require an exam under anesthesia for a pelvic exam to evaluate for concomitant vaginal injury and for visualization of the urethra and bladder neck with cystoscopy.
```
**Summary:**
Trauma and Pediatric Hematuria:
- **General Considerations:**
- Not all patients with urological trauma will have hematuria.
- The presence of hematuria in the setting of trauma should prompt thorough evaluation for the source.
- **Renal Injuries:**
- Children are more likely to sustain renal injuries due to the relative size and less protection of their kidneys.
- **AUA Guidelines:** Recommend CT scan with intravenous contrast for blunt trauma patients with microscopic hematuria and systolic BP <90 mm Hg or gross hematuria. Delayed images are obtained to evaluate for collecting system injury, often resulting in a CT urogram.
- **European Association of Urology Guidelines:** Recommend imaging for all children with blunt or penetrating abdominal injury and any degree of hematuria. Many pediatric groups suggest >50 RBCs/HPF as a reasonable cutoff without hypotension.
- **Bladder Injuries:**
- Children are at higher risk due to the bladder's higher location in the abdomen.
- Gross hematuria in the setting of pelvic fracture or clinical concern for bladder rupture should be evaluated with a cystogram (standard radiography or CT) including images with the bladder filled to capacity and after emptying.
- Up to 45% of patients with pelvic fractures and gross hematuria have bladder injuries.
- **Ureteral Trauma:**
- Comprises only 1% of pediatric urological trauma cases.
- Requires a high index of suspicion; only 46% of patients have gross hematuria, 38% microscopic.
- Diagnosed using CT urogram, with further information from retrograde or antegrade pyelograms during stent or nephrostomy tube placement.
- **Urethral Injuries:**
- Suspected with pelvic fracture, blood at the urethral meatus, gross hematuria, pain, or difficulty voiding.
- Associated with perineal or scrotal hematoma and swelling.
- Retrograde urethrogram should be performed before catheter placement or a periurethral retrograde urethrogram if a catheter is already placed and draining.
- More common in males, but in females, they often require an exam under anesthesia for pelvic exam and visualization with cystoscopy.
These flashcards and summary should help you understand the key points about trauma-related causes of pediatric hematuria. If you need further details or have more questions, feel free to ask!
161
What percentage of patients with acute UTI or pyelonephritis present with microscopic hematuria?
Up to 50% of patients with acute UTI or pyelonephritis present with microscopic hematuria.
162
What are some symptoms associated with infection that suggest pyelonephritis?
Symptoms suggesting pyelonephritis include flank pain, fever, nausea, and vomiting.
163
How is the diagnosis of a UTI confirmed?
The diagnosis of a UTI is confirmed with a urine culture that provides information regarding bacteria and antibiotic sensitivities.
164
What are common viral causes of hemorrhagic cystitis in immunocompromised patients?
Common viral causes of hemorrhagic cystitis include BK virus, JC virus, cytomegalovirus, and adenovirus.
165
What is the most common cause of gross hematuria in immunocompromised patients?
Viral UTIs are the most common cause of gross hematuria in immunocompromised patients.
166
How is schistosomiasis diagnosed and treated?
Schistosomiasis is diagnosed with urine microscopy showing parasitic eggs and treated with praziquantel.
167
What is the geographic area associated with Schistosoma haematobium, and why is travel history important?
Schistosoma haematobium is found in the water of sub-Saharan Africa, so travel history is important for diagnosis.
168
