B5.082 Prework 1: Hematuria: Benign Causes

Question 1

process of microscopic urinalysis

Answer 1

10 mL of midstream clean catch specimen is centrifuged for 10 min at 2000 rpm
3 or more rbc per hpf

Question 2

does excessive anticoagulation lead to hematuria?

Answer 2

no

but may make degree and duration worse

Question 3

overview of the steps taken when evaluating microscopic hematuria

Answer 3

1. dipstick
2. microscopic urinalysis
3. assess for UTI or benign causes
4. renal function testing
5. CT urography
6. cystoscopy

Question 4

categories of evaluation

Answer 4

medical history
physical exam
lab workup
upper tract imaging
lower tract imaging

Question 5

risk factors for urinary tract malignancy

Answer 5

> 35 years
analgesic abuse
chemicals/dyes
male sex
smoking
history of: indwelling foreign body, chronic UTI, known carcinogens, gross hematuria, irritative voiding, pelvic irradiation, urologic disorder/disease

Question 6

important components of physical in analysis of hematuria

Answer 6

BP
edema
cardiac arrhythmia
CVA tenderness
DRE
pelvic exam

Question 7

components of a urinalysis

Answer 7

RBCs
WBCs
presence of bacteria
nitrites

Question 8

what do you do if infection is suspected?

Answer 8

urine culture must be sent to confirm infection

UA must be repeated after treatment

Question 9

components of a lab workup for microscopic hematuria

Answer 9

UA
culture?
renal function studies
PSA

Question 10

alternatives to CT urography for imaging

Answer 10

MRI
US
non-contrast CT
retrograde pyelography

Question 11

mechanism for evaluation of lower urinary tract

Answer 11

cystoscopy

Question 12

most common benign etiologies of microscopic hematuria

Answer 12

idiopathic : 43-68%
UTI: 4-22%
urolithiasis: 4-5%
BPH: 10-13%

Question 13

uncomplicated UTI

Answer 13

infection in a healthy patient with functionally normal urinary tract

Question 14

complicated UTI

Answer 14

infection associated with anatomic/functional abnormality of urinary tract, immunocompromised host, or MDR bacteria

Question 15

risk factors for UTI

Answer 15

reduced urine flow
colonization
facilitation of ascent (catheter, incontinence)

Question 16

host factors that can predispose to UTI

Answer 16

changes in estrogen, low vaginal pH
high urine glucose
obstruction
vesicoureteral reflux
immunocompromised
pregnancy
SCI

Question 17

which bacterial factor is associated with pyelonephritis?

Answer 17

type P pili/fimbrae

Question 18

use of UA in suspected URI

Answer 18

catheterized urine is best
dipstick urinalysis rules infection out not in
nitrite positivity is very specific
pyuria (>10 WBC/hpf) is most sensitive for UTI

Question 19

quantitative urine culture in UTI

Answer 19

100,000 CFU is diagnostic

Question 20

indications for imaging in UTI evaluation

Answer 20

persistence after treatment
sepsis from urinary source
history of urolithiasis
neurogenic bladder
poor response to therapy
infections with urea-splitting bacteria
recurrence with same or unusual strain

Question 21

DOC for uncomplicated UTI

Answer 21

nitrofurantoin 100 mg BID x 5 days

TMP/SMX BID x 3 days

Question 22

outpatient management of complicated UTI

Answer 22

Cipro BID x 7 days
Levaquin x 5 days
TMP/SMX BID x 14 days
one time IV then 14 day oral ttx

Question 23

inpatient management of complicated UTI

Answer 23

IV fluoro
aminoglycoside + ampicillin
3rd gen ceph
extended spectrum pen
carbapenem
switch from parenteral to oral in 48 hours if clinical improvement, treat for 14 days

Question 24

pathophys of urolithiasis

Answer 24

soluble urine metabolites occur in amounts too high to stay dissolved in urine
supersaturation allows precipitation and aggregation to form crystalline concentrations
obstruction from a stone can cause pain via ureteral dilation

Question 25

common types of stones

Answer 25

``` calcium oxalate uric acid struvite calcium phosphate cystine ```

Question 26

calcium oxalate stones

Answer 26

most common urinary citrate is an inhibitor risk factors: dehydration, hypercalciuria, hyperoxaluria, hypernatriuria, hyperuricosuria treatment: fluids, decreased Ca in urine, increasing citrate

Question 27

uric acid stones

Answer 27

for in ACIDIC urine, 100 times more soluble at pH > 6 risk factors: persistently acidic urine from diet high in protein, hyperuricemia, hyperuricosuria, treatment of lymphoma/leukemia treatment: alkalization of urine

Question 28

urine alkalization agents

Answer 28

K+ citrate Na+ citrate Na+ bicarb

Question 29

struvite stones

Answer 29

magnesium ammonium phosphate stones caused by infections with urease producing organisms (proteus) form staghorn calculi treatment: surgical removal and aggressive treatment of infection

Question 30

calcium phosphate stones

Answer 30

form in ALKALINE unrine usually associated with metabolic disorders such as type 1 RTA (distal), primary hyperparathyroidism, or medullary sponge kidney treatment: managing the underlying disorder

Question 31

cystine stones

Answer 31

autosomal recessive disorder known as cystinuria microscopic hexagonal crystals cystine more soluble in alkaline urine treatment: alkalization of urine, treat with drug Thiola to break down sulfide bond

Question 32

clinical signs of urolithiasis

Answer 32

colicky flank pain radiating to groin or scrotum nausea and vomiting CVA tenderness hematuria

Question 33

imaging for urolithiasis

Answer 33

non-contrast CT

Question 34

lab workup for urolithiasis

Answer 34

UA + culture serum creatinine and electrolytes WBC count

Question 35

indications for urgent intervention for urolithiasis

Answer 35

concomitant UTI, fever, or signs of sepsis renal azotemia (high serum Cr) solitary kidney (impending renal damage) intractable pain, nausea, or vomiting despite treatment patient preference

Question 36

expectant management for urolithiasis

Answer 36

pain control with NSAIDs medical expulsive therapy with a blocker observation of 2-4 weeks

Question 37

options for urgent surgical intervention of urolithiasis

Answer 37

placement of ureteral stent placement of percutaneous nephrostomy tube don't break the stone in case of releasing bacterial endotoxins causing sepsis

Question 38

how to treat a kidney stone itself

Answer 38

oral dissolution therapy extracorporal shock wave lithotripsy ureteroscopy with intracorporal lithotripsy percutaneous nephrolithotomy

Question 39

what workup is necessary when someone has recurrent stones?

Answer 39

metabolic work up

Question 40

general dietary modifications to prevent kidney stones

Answer 40

increase fluid decrease dietary salt moderate animal protein increase dietary citrate

Question 41

what is BPH

Answer 41

histologic diagnosis | increase in number of prostatic stromal and epithelial cells in the transition zone

Question 42

lower urinary tract symptoms associated with BPH

Answer 42

phenotypic diagnosis | urinary frequency, urgency, slow stream, straining

Question 43

pathophys of BPH

Answer 43

transition zone hyperplasia leads to increased resistance via: - bladder outlet obstruction from tissue (static) - increased smooth tone and resistance within the gland (dynamic)

Question 44

storage symptoms

Answer 44

frequency urgency nocturia

Question 45

emptying symptoms

Answer 45

weak stream intermittent flow straining to urinate incomplete emptying

Question 46

indications for surgical management of BPH

Answer 46

``` gross hematuria UTI bladder stones urinary retention bladder diverticula ```

Question 47

drug therapy options for BPH

Answer 47

alpha blocker: relax prostatic smooth muscle by blocking a1 adrenergic receptors 5 alpha reductase inhibitor: block conversion of testosterone to DHT and decrease prostate volume by 30%

Question 48

surgical options in BPH

Answer 48

TURP (gold standard) open simple prostatectomy transurethral laser surgery minimally invasive therapy