GU: Block 2 Flashcards
1
Q
Most simple renal cysts are at ? originating from ?
What are the three US criteria for a benign cyst
A
Outer cortex from renal tubule dilation
Demarcated/smooth walls
Enhanced back wall
Anechoic
2
Q
What are the CT criteria for a simple renal cyst?
What is the next step if the cyst meets or does not meet criteria?
A
Thin, sharp demarcation
No contrast enhancement
Meets= periodic eval Fails= urology referral
3
Q
What are the essentials for Dx of PKD
What are compelling but not required parts of PKD?
A
Multiple bilateral cysts HTN+Mass= suggestive
FamHx
Palpable kidneys
4
Q
What is the MC inherited kidney dz?
What are the genetic mutations that lead to this dz?
A
Auto Dom PKD
ADPKD1
ADPKD2- slower/longer life
5
Q
How does ADPKD present
How is it Dx and what criteria is needed by age for Dx
A
HTN
Abdominal/flank pain
Hematuria
US w/ 2 or more (<59) or 4 or more (>60)
6
Q
What will ADPKD present and be seen on labs?
What class of medications can and can NOT be used for chronic pain in these PTs
A
Low pH
HTN
Dec GFR w/ + FamHx
\+= TCAs - = NSAIDs
7
Q
What is the MC cause of hematuria in ADPKD PTs
What Dx is considered if hematuria is persistent?
A
Cyst ruptures into renal pelvis
Renal cell carcinoma, especially men >50y/o
8
Q
How does a ADPKD infection present?
When does PT w/ ADPKD need to be screened for cerebral aneurysms?
A
Flank pain Fever Leukocytosis
FamHx
Elective surgery
Profession, high risk
9
Q
Medullary Sponge Kidney Dz is AKA ?
What type of genetic defect causes this?
A
Lenarduzzi kidney
Cacchi Ricci dz
Auto Dom MCKD1/2 mutation
10
Q
When is Medullary Sponge Kidney Dz present and dx
Although mostly ASx and benign, what can PTs present w/?
What may be seen on lab results due to the decreased ability to concentrate urine?
A
Present at birth
Dx 40-50y/o
Hematuria UTIs Nephrolithiasis
High urine pH
HyperCa
11
Q
What may be seen on x-rays of PTs w/ Medullary Sponge Kidney?
How is this condition Dx?
A
Calculi beyond calyces
CT showing DCT dilation and calcification in collecting system
12
Q
Define ‘bouquet of flowers’ seen in Medullary Sponge Kidney
Define the ‘paint brush appearance’
A
IV pyelogram- ectatic DCDs w/ micro calcification
Dilated tubules in medulla
13
Q
How are PTs w/ Medullary Sponge Kidney Tx
What PTs are likely to develop acquired renal cystic dz?
A
Thzd- dec HyperCa
Alkali therapy- tubular acidosis
Dialysis
Long standing RF
14
Q
Acquired renal cystic dz has a higher rate of ? than other cystic d/ox
How/why does this progress to ESRD?
A
Conversion to malignancy
Loss of nephron mass/fibrosis
15
Q
How does Acquired Renal cystic dz present, Dx and Tx
How can you differentiate between acquired renal dz or PCKD?
A
Pain/hematuria
Dx: US/CT scan
Tx: Transplant/nephrectomy
FamHx/genetics
GFR
16
Q
What kidney dz is common in younger PTs and almost universally progresses to ESRD?
What is the difference between the two types?
What do they both have in common?
A
Juvenile Nephronophthisis- Medullary Cystic Dz
Juvenile- auto recessive
Medullary- auto dom
Multiple cysts at corticomedullary junction/medulla
17
Q
What happens as JNMCDz progresses in severity?
How does the adult/child form of JNMCDz present?
What is a later presentation of JNMCDz?
A
Interstitial inflammation and glomerular sclerosis
Polyuria Pallor Lethargy,
Reqs salt/water d/t wasting
HTN
18
Q
What does juvenile nephrolithisis form cause?
What will be seen on US/CT images?
A
Growth retardation
ESRD by 20y/o
Small scarred kidney w/ medullary cysts
19
Q
Ca of ureter/renal pelvis are rare but are more common in ? PT populations?
The majority of these that do develop are ? type
A
Smokers* Thorotrast exposure Lynch syndrome Analgesic abuse Bladder Ca Balkan nephropathy
Urothelial cell Ca
20
Q
What are the clinical findings of UT Cas?
What will be seen on CT/Urography
A
Hematuria
Less common: bleeding/pain
Pos urine cytology
Hydronephrosis
Unilateral non-visualization of collecting system
Filling defects
21
Q
How are Cas of the UT Tx?
What are the essentials of Dx for these conditions?
A
Laparoscopic excision
Open nephroureterectomy
Ureter excision (distal lesion)
Triad: Mass Pain Hematuria
Fever/weight loss- prominent
22
Q
Renal cell Ca peak during ?, are more predominant in ? and may be associated w/ ?
What are the RFs?
What is the only known environmental RF for renal cell Ca?
A
6th decade
M>F
Paraneoplastic syndromes
Physical inactivity
Obesity
DM
Smoking
23
Q
Where do Renal Cell CA originate from within the kidney?
A
Proximal tubule cells
24
Q
What lab findings may be seen during renal cell Ca?
Some PTs may develop Stauffer Syndrome which is ?
A
Hematuira
Anemia
HyperCa
Reversible hepatic dysfunction w/ inc tests, no metastatic dz
25
What four images may be ordered to assess PTs w/ renal cell CA and why
CT/MRI w/ contrast- most valuable- staging, pre-op planning and contralateral kidney eval
CXR/CT- pulm metastases
Bone scan- bone pain/elevated AlkPhos
Brain images- high metabolic burden/neuro deficits
26
Any discovered solid renal mass is ? until Dx
What are the possible solid masses that could be present?
Renal cell Ca
Angiomyoplipoma- fat density
Pelvis urothelial Ca- central involvement of collecting system, + urinary cytology
Oncocytomas- indistinguishable from Ca pro-operatively
Abscess/Tumor- superoanterior to kidney
27
How are different types of renal cell Ca Tx
Nephrectomy- primary Tx, >7cm carcinomas
Partial- single kidney, bilateral lesion or significant renal dz
Radiofrequency/cryosurgical ablation- tumors <4cm
Percutaneous biopsy- histology/grade for Tx
28
What Tx combo has the best benefit for renal cell Ca PTs?
Where are different renal cell Cas referred to?
Surgery w/ ImmunoTherapies
Solid mass/renal cell Ca- urologist
Metastatic dz- oncologist and urologist
29
# Define Benign Oncocytoma
This type of tumor can be seen in ? other organs
Primary kidney tumor indistinguishable w/out surgery
Salivary glands
Adrenals
Para/thyroids
30
# Define Angiomyolipomas
What PT population is more likely to have these?
Rare benign tumors of fat, smooth muscle and vessels
Tuberous sclerosis
Middle age women
31
What image finding is Dx of angiomyolipomas?
Most don't require intervention if under ? size
CT identification of fat component
ASx and <5cm diameter
>5cm= prophylactically Tx w/ emoblization Tx
32
If angiomyolipomas start to bleed how are they Tx
What types of Cas are likely to metastases to kidneys?
Angiographic embolization
Nephrectomy
```
Lung Ca- MC
Breast
Stomach
Contralateral kidney
Lymphoma= enlarged, not mass
```
33
What paraneoplastic Sxs can be present w/ renal cell Cas?
```
HyperCa
Fever
Cachexia
Liver dysfunction
Amyloidosis
Polymyalgia rheumatica
Anemia
```
34
# Define Nephroblastoma
What is the MC site for metastases?
MC primary malignant renal tumor of Peds <15y/o
2nd MC malignant abdominal tumor of childhood after neuroblastoma
Lung Nodes Liver
35
Nephroblastoma is AKA ? and almost all are located ?
? PT population is at higher risk for this type of tumor?
Wilm's Tumor, Unilateral
AfAm
36
Classic Wilm's Tumor is made up of ? cells
How are these Tx?
Blastemal Stromal Epithelial
Surgery and Chemo, possibly radiotherapy
37
What is the MC presentation of Wilm's Tumor
What other findings can be seen at presentation
ASx abdominal mass
Constitutional Sxs
HTN
Abdominal pain
Painless hematuria
38
What are two rare facts about Wilm's Tumors
Any abdominal mass in Peds is considered ? and ? is sequence of images ordered
Anemia- microcytic, ACDz
Thrombus to IVC
Ca
Doppler US of renal vein/IVC
CT defines extent
39
When are partial nephrectomys preferred for Tx of Wilm's Tumors
Wilm't Tumor is associated w/ ? dzs
What types of poorer outcomes and how are they Tx?
Unilateral tumor
Predisposing syndromes- Denys-Drash/WAGR
WAGR
Denys-Drash
Beckwith-Wiedemann
Anaplastic- chemo
40
What would be seen on PE of Wilms Tumor
What images are ordered for Dx purposes?
Non-tender firm mass that rarely crosses mid-line
US- initial
CT/MRI
Surgical excision/biopsy- definitive
41
? is the MC solid renal tumor seen in neonates and is the MC benign renal tumor of childhood
What is the difference between this MC and WIlms Tumors
What is the TxOC for mesoblastic nephomas?
Mesoblastic nephroma
MN- dx before 3mon
Wilms- rarely dx before 6mon
Radical nephrectomy
42
? is the prevalent renal malignancy during 2nd decade of life
What process causes GU pain?
What type of pain presents late and is a poor indicator?
RCC
Distension (obstruct/distend)
Inflammation on capsule
Malignancy
43
? is infection pain
How does it present?
Pyelonephritis/Peritonitis
Constant pain w/ PT laying still
44
? is obstruction pain?
How does it present?
Renal colic- ureter paristalsis against obstruction
Wax/waning pain causing PTs to move
45
How/where is renal colic pain assessed?
Where can this pain radiate to?
CVA tenderness
Umbilicus
Ipsilateral testicle/labia
46
If ureter becomes obstructed, how does the type/location of pain indicate the site of the obstruction?
Upper- referred pain to scrotum/labia
Mid- R/LLQ pain
Lower- bladder irritability; UVJ stone
47
How does prostatic pain present?
What are three causes of flaccid penile pain?
What are two causes of erect penile pain?
Inflamed perineum radiating to lumbar, inguinal or LE
Balanitis
Paraphimosis
STI
Priapism
Peyronie's Dz
48
What are the irritative voiding Sxs
What are the obstructive Sxs
Frequency inc Urgency Nocturia Dysuris
```
Hesitancy
Weak
Intermittent
Double void
Dribbling
```
49
# Define Incontinence
What are the different categories
Involuntary loss of urine
Urge Stress Overflow Functional Atonic
50
# Define Hematospermia
What can cause this condition?
Blood in ejaculate
Inflamed prostate/seminal vesicles, normally benign
51
# Define Pneumaturia
What can cause this to happen?
Gas/air in urine causing bubbly/malodorous urine
Bladder/GI fistula due to colon Ca, Diverticulitis, Crohns
52
What is the MC Sx of an STI
What DDx needs to be r/o in elderly PTs w/ bloody d/c?
Urethral d/c w/ dysuria
Urethral carcinoma
53
What type of urinary tract issues do and don't present w/ fevers?
What are 3 DDxs that the fever could possible be associated w/?
```
+= pyelonephritis
- = acute cystitis
```
Prostatitis Malignancy Epididymitis
54
Urology PTs complaining of malaise may be due to ?
Any type of hematuria is worked up w/ ?
Cancer
CKDz
Upper tract imaging
Cytoscopy
55
Analgesic use causes ? etiology of hematuria?
ABX cause ? etiology of hematuria
What drug used for Chemo/ImmSupp can cause hematuria?
Papillary necrosis
Interstitial nephritis
Cyclophophamide
56
Other than analgesics, what other issues can cause papillary necrosis?
Lower tract sources of gross hematuria, w/out presence of infections, is MC due to ?
DM, Sickle Cell
Urothelial Ca of bladder
57
Microscopic hematuria in male PTs is MC from ?
PTs on ? class of drugs is concerning and requires full work up?
BPH Stricture Stone
Antiplatelets/coags
58
What is the lab criteria to Dx hematuria
Gross hematuria in adults is ? until disproven
>3 RBC/HPF
Malignancy
59
Gross hematuria w/ >3 RBCs/HPF can be seen in ? conditions
What type of urine sample is best for evaluating hematuria?
What criteria can be detected by dip stick and what is the f/u tests?
Urinary calculi
UTIs
Kidney/Bladder Ca
1st morning void
2 RBCs/HPF
3 samples 1wk apart for confirmation
60
What can cause false-pos dipstick results during hematuria work ups?
Bacteria
Oxidizing agents
Menses
Beets/Rhubarb
Myo/Hbgglobinuria
Exercise
Concentrated urine
HCl
61
What can cause false-neg dipstick results during hematuria work ups?
+ hematuria with proteinuria, dysmorphic RBCs and casts suggest ?
High Vit-C levels
Renal origins
62
What hematuria presentation suggests a UTI
What is recommended for these PTs after Tx to ensure hematuria resolution?
Positive urine culture
Irritative voiding Sxs
Bacteruria
Test of cure
63
What is the f/u test for a positive dipstick UA?
Why would culture/sensitivity be performed?
Why would urine cytology be performed?
Urine microscopy
ID/Tx infections w/ repeat UA in 4-6wks
Persistent/unexplained hematuria
R/o Ca
64
What are the 3 types of hematuria in reference to presence during flow?
How do these correlate to the cause of the blood?
Initial: blood at beginning; urethritis, stricture
Terminal: blood at end; posterior urethral polyps, vesicle neck tumors
Total: bladder, upper tract, TB
65
What imaging modality is used for evaluating the upper GU tract?
What type may be ordered for evaluating for other conditions?
Helical/spiral CT for stones
CT-IVP
Pelvic CT w/ and w/out contrast
66
What is cystoscopy used to assess?
This procedure ordered for ? PTs
Bladder/urethral neoplasms
Benign prostatic enlargement
Radiation/chemical cystitis
Gross hematuria
>35y/o w/ ASx micro hematuria
67
When do PTs w/ hematuria need to be referred?
```
Absence of clear benign etiology:
Infection
Menstruation
Exercise
Medical renal dz
Viral illness
Trauma
Recent urological procedure
```
68
Why would a PT w/ hematuria be referred to nephrology?
Why would they be referred to urology?
Renal parenchymal etiology
Calculi/Ureter/Cystic/Urethral origin
69
What are the 5 ROS questions asked for hematuria?
What is the DDx for hematuria acronym
```
Fever/Pain
Sxs of bladder irritability
Trauma/menses
Urethral d/c
Dysuria
```
```
PP ON THIS
Period
Prostate/Papillary necrosis
Obstructive uropathy
Nephritis syndrome
Trauma Tumor TB Thrombosis
Hematological
Infection**/Inflammation
Stones*- 1st MC
```
70
# Define Pseudohematruia
What can cause this?
Dipstick +, Microscopic -
```
Hgburia- black urine
Mgburia- rhabdo
Food- beets, berries
Artificial coloring
Drugs: Levodopa Ibuprofen Phenytoin Sulfameth Pyridium Rifampin Nitro
```
71
Acute UTIs usually have ? microbes while chronic UTIs usually have ?
What two microbes are responsible for most non-nosocomial, uncomplicated UTIs?
Single
Two or more
E Coli
Coliform
72
What test is recommended for PTs w/ suspected UTIs?
What is the intrinsic defense mechanism for defending against UTIs?
Urine culture
Efficient bladder emptying
73
What part of the bladder is a natural protection against bacterial adherence?
What are the antimicrobial properties of urine?
Glycosaminoglycan layer
High osmolality
Extremes of pH
74
What part of the female GU tract are natural defenses against UTIs?
What part of the male GU tract is a natural defense?
Vaginal flora
Prostatic fluid contains Zinc, prevents ascending infections
75
What are the RFs for UTIs?
What is the MC route for UTIs to begin?
Retention Stasis Reflux
Pregnancy Obstruction
Neuro condition DM
Foreign bodies
Ascending from urethra, MC as pyelonephritis from E Coli
76
What is an uncommon route for UTIs to begin?
What is a rare route?
What are conditions could cause direct extension infections?
Hematogenous spread
Lymphatic spread
Intraperitoneal abscess from IBD/PID
77
What microbes cause uncomplicated UTIs?
What microbes cause nosocomial/hospital acquired infections?
E Coli- MC
Klebsiella Enterobacter Enterococci Proteus
Pseudomonas
Staph
78
ASx bacteriuria does not require Tx unless ?
What are the essentials of Dx for acute cystitis?
Pregnant- Amox/Cephalexin
Invasive procedure
Catheter/imaging
Afebrile
Pos urine culture
Irritative Sxs (FUND)
79
Acute cystitis is MC from ? microbe introduced via ?
What virus can rarely cause acute cystitis?
E Coli
Urethra
Adenovirus
80
Uncomplicated cystitis in men is rare and implies ?
What are the common S/Sxs of acute cystitis
Anatomic defect
Prostatitis
Infected stone
Chronic urine retention
Irritative voiding Sxs
Gross hematuria
Sxs after intercourse
81
What may be seen on labs of acute cystitis
What two results are suggestive?
What is the criteria for a positive culture but not required for Dx
Bacteriuria Pyuria Hematuria
Leukocyte esterase
Nitrates
10^5/mL CFUs
82
What PT populations are expected to be colonized w/ bacteria?
Since uncomplicated cystitis in males is rare, what tests are done when assessing acute cystitis?
When/why would a follow on CT be needed?
Indwelling Foley
Suprapubic catheters
Cystoscopy
Abdominal US
Postvoid residual tests
Recurrent infection
Anatomic abnormality
Pyelonephritis
83
What are the 6 non-infectious causes of cystitis-like Sxs?
Bladder Ca
Chemo- cyclophos
Pelvic irradiation
Voiding dysfunction
Interstitial cystitis
Psychosomatic d/o
84
How can UTI risks be reduced?
How can these risks be reduced in female PTs who get UTIs after intercourse?
Post-menopause women w/ recurrent UTIs >3x/year may benefit from ?
Hydrate, frequent voids
Void before/after
Post-coital ABX
Topical estrogens
85
Criteria to be labeled uncomplicated UTI
What cases are labeled as a complicated UTI?
Acute cystitis in otherwise healthy non-pregnant adult woman
Everyone else
86
How are uncomplicated acute cystitis PTs Tx
Which one is the DOC for Tx of pregnant Pts
Nitrofurantoin
Trimeth/Sulfameth
Nitrofurantoin
87
What is the urinary analgesic used for acute cystitis Tx?
What PT education has to go w/ this Rx?
Phenazopyridine
Discoloration of urine, fabric and contacts
88
How are female PTs w/ recurrent (>3/year) acute cystitis' managed?
What meds may be used?
Candidate for prophylaxis ABX
Uro refer/consult first
Trimeth/Sulfameth
Nitrofur
Cephalexin
Single dose at bed/prior to intercourse
89
What is the first line med used for Tx of ASx Bacteriuria and simple cystitis in pregnant PTs?
Define Acute Pyelonephritis
Amoxicillin
Cephalexin
Infection of renal parenchyma and renal pelvis
90
What microbes can cause acute pyelonephritis?
What are two less common microbe etiologies?
Gram Neg- MC (KEEPP)
Enterococcus
Staph via hematogenous
91
What would be seen on microscopy of pyelonephritis?
What would be seen on CBC results
White cell casts
Leukocytosis
L-shift
92
What images are ordered fr pyelonephritis?
When would an abscess be suspected in these PTs?
Renal US- uncertain etiology/complicated dz
CT- dec perfusion
No improvement w/ continued fever/bacteremia
93
# Define Emphysematous Pyelonephritis
When can pyelonephritis PTs be Tx outpatient?
Gas producing organisms causing complications after pyelonephritis in DM PTs
F/u <48hrs
Uncomplicated
Non-pregnant
Compliant
94
What meds are used for Tx of pyelonephritis
What are the 3 parts of Tx covered by these meds?
FQ- Levo/Cipro
Alt: Trimeth/Sulfameth
Augmentin
PO ABX
Pain
Anti0-emetics
95
When Tx pyelonephritis, if susceptibility is unknown and TMP/SMX is used, what med is added to Tx regime?
When do PTs w/ pyelonephritis need to be admitted?
1g IV Ceftriaxone
```
Pregnant
RF
IV ABX
Multi-resistant microbes
Obstruction
Severe/complicated- septic,
```
DM
Imaging needed
No improvement after 48hrs
96
How long are PTs being Tx for pyelonephritis Tx w/ ABX
What meds are used while admitted?
What drugs are used for initial IV dose?
InPT/IV- 24hrs after fever resolution then PO ABX X 14days
Ceftriax Cipro Piper-Tazo
Ceftriax Cipro Genta
97
PTs being Tx for pyelonephritis in patient may be d/c after 72hrs and placed on ? ABX
PTs w/ this Dx may have fevers x __Hrs but imaging is ordered after __hrs
TMP/SMX Levo Cipro
x72, 48hrs
98
What lab order is mandatory after pyelonephritis Tx
What are the two categories of acute epididymitis?
Urine culture- test of cure
Sex/Anal transmitted
Non-sexually transmitted
99
PTs <35y/o w/ epididymitis have ? until proven otherwise?
PTs >35y/o w/ epididymitis usually have?
Men participating in insertive anal intercourse may have ? microbes
STI- G/C
UTI, Prostatitis from enteric Gram-neg rods
Enteric organisms
100
Cardiac PTs on ? drug can have medication induced epididymitis?
What PE findings of acute epidiymitis is usually apparent?
Amiodarone
Scrotal swelling/tenderness
101
PTs w/ epididymitis that have white cells w/out a visible organism seen on smears represent ? due to ?
What will be seen on UA results in PTs w/ non-sexual transmitted forms?
Nongonoccoccal urethritis
C trachomatis
Bacteriuria Pyuria Hematruia
102
What is the gold standard of Dx acute epididymitis?
What images may be ordered to r/o more severe causes of PTs Sxs?
Gram stain
US, r/o torsion
103
What are 3 DDx for acute epididymitis and how are the r/o as primary Dx?
Tumor- painless enlargement of testis, neg UA, normal epidiymis
Torsion- acute onset in younger PTs, + Prehn sign
Distal ureter stone- referred pain to ipsilateral scrotum, w/ norm US
104
How are acute epididymitis cases Tx
Acute phase: rest elevate ice
Sex transmitted: Ceftriax and PO DOxy
Insertive anal: Ceftriax and PO Cipro
Non-sex transmitted- FQN
105
When do PTs being Tx for epididymitis need to be re-evaluated
What is the gold standard for Dx urethritis
S/Sxs not resolving after 3 days
Urine culture of Gram-Neg diplococci
106
# Define Urethral Syndrome in Women
What are the two types
G/C/HSV causing Sx urethritis
Internal dysuria: no pathogen, urgency
External dysuria: vulvular herpes/candidiasis causing pain w/ contact w/ urine
107
Female PTs w/ acute onset of urine urgency/frequency, hematuria and bladder tenderness suggest ?
How are PTs w/ G/C Tx and how long do they need to avoid sex
Bacterial cystitis
Chla: Azith 1g or Doxy
Gon: Ceftriax plus Chla Tx
7days
108
When is a Dx of vesicoureteral reflux considered
What images may be ordered?
This condition may present w/ ? indicative Sx
Any child UTI prior to toilet training
US/VCUG w/ referral
Fever
109
# Define Interstitial Cystitis
What Dx findings may be seen on PE imaging?
Pain w/ bladder filling, urgency and frequency
Submucosal petechiae/ulcers on cystoscopic exam
110
What is the key take away to interstitial cystitis?
Although an unknown etiology, what is this Dx associated w/?
Dx of exclusion:
Neg UA culture cytology
Severe allergies
IBS/IBDz
111
What is the pathophys behind interstitial cystitis development?
What will these PTs present complaining of?
Disrupted glycosaminoglycan layer, urine irritants enter nerves/tissue of bladder
Bladder pain relieved w/ voiding
112
What part of PTHx needs to be assessed for suspected interstitial cystitis?
What are the names of the lesions seen on cystoscopy and required for Dx?
Cyclophos usage
Hunner lesion
113
How is interstitial cystitis Tx
```
Amitriptyline- first line
Nifedipine
IV Dimethyl Sulfoxide
TENS
Last, surgery0 cystourethrectomy w/ urinary diversion or SCS
```
114
Urinary stone dz is the third most prevalent behind ?
What are the essentials for Dx and images of this condition?
Infections
Prostatic dzs
Flank pain w/ N/V
US
Non-contrast CT* Gold standard
115
# Define Urolithiasis
Define Nephrolithiasis
Define Ureterolithiasis
Stone formation anywhere in urinary tract
Stone in kidney
Stone in ureter
116
Urinary stone formation requires saturated urine that is dependent upon ?
pH
Ionic strength
Complexation
Solute concentration
117
What are the 5 types of urinary stones
Struvite- Mg Ammonium phosphate (stag horn)
Uric acid- may also have CaOx
Cystine
MC: Ca oxalate/phosphate
118
What are the most important RFs leading to stone development?
What two geographic factors can contribute to formation?
High protein/Na diet
Inadequate hydration
Sedentary lifestyle
High humidity/temps
119
What genetic factor can increase prevalence?
What types of stones develop due to acidic/alkaline urine?
Cystinuria- AutoRec d/o, homozygous PTs have inc cysteine excretion leading to stone formation
Acidic: uric acid, cystine
Alkaliine: struvite
120
Alkaline urine w/ ? 2 microbes have inc stone development
CaOx stones develop between what pHs and w/ ? RFs?
Proteus
Klebsiella
5.5-6.8
Hypercalciura
Inc Na, protein
Dec water, urine citrate
121
CaPhos stones develop between ? pH
? PT populations are at inc risk of oxalate stone formation?
What other RF increases chances of oxalate formation?
>7.5
IBD- dec gut Ca to bind w/ oxalate
>2g/day ascorbic acid
122
What is the strongest promoter for urinary stone formation?
What is the most important inhibitor of formation?
Urinary oxalate
Urinary citrate- binds to Ca and dec amount available for stone formation
123
What impacts the amount/level of urinary citrate available for regulation?
Women w/ recurrent UTIs are MC to produce ? stones
Acidosis- dec
Alkalosis- inc
Struvite stones, but overall Ca is more common in women
124
What pH and microbes promote the formation of struvite stones?
Define a Staghorn Calculi
>7.2
Urease producing bacteria (Proteus Pseudomonas Providencia Klebsiella Staph Mycoplasma)
Upper tract stone involving renal pelvis and extends x 2 calyces, usually struvite
125
What is the only amino acid not soluble in urine?
Cystine stones develop at ? pH
Cystine
<5.5
126
Stone appearance on x-ray
Ca- opaque
Phos- opaque
Struvite- opaque/dense
Cystine- lucent
Uric acid- lucent
127
What are the RFs for uric acid stones
What is the most important contributor to this type of stone formation?
Hyperuricemia
Myeloproliferative d/o
Malignancy
Abrupt/dramatic weight loss
pH <5.5
128
How do PTs w/ obstructing urinary stone present?
If stone becomes lodged at the uretovesical junction, how will PT present?
Sudden/wakes from sleep
Severe flank pain w/ N/V
Constantly moving
Urinary urgency/frequency
Testicular/penile tip pain
129
What labs are ordered for urinary stone work up?
What pH ranges are stones seen in?
Chem 17
<5.5: uric acid, cysteine
5.5-6.8: Ca oxalate
>7.2: struvite
>7.5: Ca phosphate
130
What is the gold standard imaging for Dx of urinary stones?
What is the alternative if this is not available but ? is the con?
Non contrast spiral/helical CT
KUB, does not exclude if negative
131
Most stones ? size will pass spontaneously
What meds may be given to the PT
6mm or less
Analgesic
Antiemetic
Alpha blocker to facilitate passage
132
What type of urinary stone presentation requires emergent urology consult?
Stones that are bigger than ? or don't pass w/in ? need referral
Obstructive urinary calculi w/ fever and infected urine (pus under pressure)
>6mm
4wks
133
How are stones extracted if located in lower 1/3 of tract?
What is the TxOC for 75% of cases that can't pass?
Ureteroscope
Extracorporeal Shock Wave Lithotripsy
134
ESWL Tx works well for stones that are ? size or location
How do PTs get ready for this procedure?
Renal pelvis
Upper 2/3 of ureter
<1.5cm
D/c NSAIDs 3d prior
135
When would a percutaneous nephrolithotomy procedure be conducted?
What is done during this procedure?
Stone in renal collecting system
Upper 2/3 of ureter
>2cm
Needle insertion into calyx, dilation for stone to pass into kidney
136
When are open stone surgery procedures conducted?
What are the 5 steps to Tx of acute stones
Complex anatomy
Obstructions
Large infected struvites
```
Inc fluid intake
Pain control
Confirmation
Admit- failure to control pain, infection, comorbidity
Refer- infection, large, comorbidity
```
137
How are PTs that recurrently form stones managed?
What dietary prevention strategies can be done?
24hr urine q6mon
Serum PTH
Uric acid
CT q12mon
Maintain Ca intake
Avoid soda/Vit C
Inc bran/water
Dec salt/protein
138
PTs that are recurrent stone makers are managed w/ ? meds
Erection is a neurovascular event based on ? triad
High urine Ca: Tzd
Low urine citrate/pH: K citrate therapy
Autonomic/Somatic nerves
Cavernosal arteries
Corpora cavernosa/pelvis relaxation
139
What neurotransmitter is responsible for initiating/maintaining erections?
What other ones help?
NO
Vasoactive intestinal peptide
ACh
Prostaglandins
140
What are the 7 steps needed for an erection?
Nerve impulse
Messenger release
Inflow inc
Outflow dec
Cavernous filling
Accumulation
Erection
141
What two muscles control rigidity to penis?
Organic ED may be an early sign of ?
Bulbocavernosus
Ischiocavernosus
CV dz
142
? is a common benign fibrotic d/o of penis causing pain, deformity and dysfunction
What is the MC cause of ED?
Peyronie
Dec arterial flow due to vascular dz
143
Psychogenic ED can be categorized as what two types?
Generalized: unresponsiveness, inhibition
Situation: partner, performance, distress/adjustment
144
How can organic ED be simply classified?
What can cause this type of ED?
No evening/morning wood
Neuro Hormonal Arterial Venous Drugs
145
What Hx questions are asked when assessing ED?
Dec libido- androgen deficiency
Anejaculation- androgen deficiency, DM, surgery, radiation
Premature ejaculation
Anorgasmia
146
What meds can cause ED?
Anti-HTN: BB TZD Spironolactone Clonidine
Antidepressant
Opioid
Doxazosin/Terazosin
147
Rapid onset of ED suggests ?
Nonsustainable erection suggests ?
Complete loss of nocturnal erections suggests ?
Psychogenic
Trauma
Anxiety
Venous leak
Vascular/Neuro Dz
148
What labs are ordered for ED work up
What special test is used to determine organic from psychogenic ED?
Lipids Glucose TSH
T/Prolactin
Nocturnal tumescence
PDE-5 inhibitor trial
Direct injection
Imaging
149
PTs w/ psychogenic ED may benefit from ? Tx
MOA of PDE-5 inhibitor
Sex therapy/counseling
Allows cGMP to be unopposed, enhances blood flow
150
What are the adverse effects of using PDE-5 inhibitors
PDE-5s need to be used w/ caution or are c/i when used w/ ?
HOTN
Priapism
Caution- A-blockers
C/i- nitro/nitrates
151
What are the relative c/i to using PDE-5 inhibitors?
What food needs to be avoided?
Coronary ischemia not on nitrates
HF
HOTN/multiple anti-HTN meds
CYP450-3A4 inhibs (Eryth Cime Ket Itra)
Grapefruit juice
152
Directions for using Sildenafil
What education piece is applicable for all PDE-5 inhibitors?
1hr before on empty stomach, lasts 4hrs
Fatty meal= delayed absorption
Stimulation still needed for erections
153
What PDE-5 inhibitor is similar to Sildenafil but lasts x 24hrs?
What are the benefits of using Tadalafil?
Vardenafil
Onset 30-60min
Lasts 36hrs
FDA approval BPH w/ ED
154
Which PDE-5 inhibitor may be taken w/ the shortest plan of intercourse
What is the method of administration for Alprostadil
Avanafil- 15min prior
Prostaglandin E2 via syringe/suppository
155
How are PTs w/ documented androgen insufficiency and ED managed?
What must be done prior to Rx this med?
Androderm- injection/patch of Testosterone
R/o prostate Ca
156
What erection assistance is given to PTs w/ venous d/o who fail injection therapy?
What is the last resort of Tx ED
Vacuum
Inflatable penile implant
157
When is vascular reconstruction a Tx consideration for ED?
What can cause retrograde ejaculation?
Trauma induced arterial occlusions
Congenital venous occlusions
Bladder neck disruption
158
How is primary premature ejaculation Tx?
What causes secondary premature ejaculation?
Behavior mod/sex health
Anesthetic/systemic meds
ED
159
# Define Oligozoospermia
Define Azoospermia
<15mil sperm in ejaculate
Complete absence of sperm
160
How long does spermatogenesis take?
What medications can affect spermatogenesis?
What meds affect sperm motility?
74 days
Cimetidine Finasteride Tesosterone
SSRI/Spironolactone
Sulfasalazine
Nitrofuantoin
161
What med causes retrograde ejaculation
What medication lowers FSH
Tamsulosin
Phenytoin
162
What affect does varicoceles have on sperm
What issues can dec overall spermatogenesis?
Abnormal motility/morphology
Obesity
CV/Thyroid/Liver dz
163
DM can have ? effect on sperm
What is the initial study done for infertility work up?
Dec genesis
Retro/ane ejaculation
SA after 3d abstinence
Two samples, two occasions separated by 60 days
164
What are the normal values of SA results?
What is the next step if low ejaculate volume is noted?
Volume: 1.5-5mL
Concentration: +15M
Motility: >45%
Morphology: >3%
Post-ejac UA
165
# Define Oligozoospermia
What is the next step if this is found?
Abnormal sperm concentration
Repeat SA
Abnormal- get T/Prl, LH, FSH
Normal- repeat again
166
What is the sequence of SA testing needed for confirmation
What endocrine evaluations are done during infertility?
1st result- confirm w/ 2nd
Same= done
Different- do 3rd test
Need 2 like results
T FSH LH Prl Estradiol
167
When is genetic testing warranted for infertility?
Why would a transrectal US be ordered for infertility?
__% of infertility cases will remain a mystery after work ups
<10mill or azoospermia
Low volume w/o evidence of retrograde ejaculation
25%
168
Prostate growth is only stable between ? ages?
What is a common PE finding of acute bacterial prostatitis
What therapeutic Tx step is avoided in these PTs
30-45y/o
Exquisite tenderness during DRE
Prostatic massage, may cause septicemia
169
What are the MC microbes causing prostatitis
How does this condition present?
E coli
Pseudomonas
Sudden perineal, sacral and suprapubic pain w/ fever
170
When Tx acute bacterial prostatitis, when do PTs need to be re-evaluated?
What is the next step for them?
24-48hrs of ABX w/ no improvement
Pelvic CT/transrectal US
171
What meds are used for Tx of acute bacterial prostatitis
What two meds are added for Tx any STIs
FQN- Cipro w/ f/u at 14days
Trimeth/Sufameth, dec efficacy
Fosfomycin- Tx multi-drug resistant Ecoli
Ceftriax and Doxy
172
PTs w/ bacterial prostatits that have abnormal VS or systemic Sxs are admitted and Tx w/ ?
What is the only microbe associated w/ chronic bacterial prostatitis
Piper-Tazo
Cefotaxime w/ aminoglycoside
Enterococcus
173
How does chronic prostatitis present
What follow on test is usually ordered to assess urinary retention?
Low back/perieneal pain
Boggy prostate
Post void residual volume
174
PTs w/ chronic prostatitis and systemic Sxs are admitted for Tx w/?
How are they Tx outpatient?
What meds can be added for pain relief
Ampicillin and Gentamycin
3rd gen Cephalosporin
FQN
Any x 4-6wks:
PO Trimeth/Sulfameth
FQN
Beta lactam ABX
NSAIDs
Alpha blockers -osin
175
What is the MC and prominent S/Sxs of non-bacterial prostatitis
What will be seen on lab results
Pain during/after ejaculation
Inc leukocytes
Neg cultures of expressed prostate secretions and urine
176
After excluding all other Dxs but prior to giving non-bacterial prostatitis Dx, what must be r/o?
How are non-bacterial prostatitis PTs Tx
Bladder Ca
-osins
PDE-5 inhibs
Therapy/psych/counseling
177
What process promotes prostate cell proliferation?
? is the MC benign tumor in men and is ? related
5 alpha reductase converts testosterone into DHT
BPH, age
178
What are the two primary factors associated w/ development of BPH?
This hyperplastic process is an over growth of ? cells located in ? area
DHT, Age
Stroma, Epithelium
Transition
179
What is the most important tool used in BPH evaluation
What ortho issue must be r/o in PTs during a BPH work up?
AUA questionnaire: 7 questions scaled 0-5pts
Cauda equina
180
How does a prostate feel during DRE if BPH is present
Serum PSA is only obtained if ?
Why is a serum BUN/Cr needed?
Smooth Firm Elastic enlargement
PTs life expectancy is >10yrs
R/o postrenal azotemia
181
If PTs BPH AUA score is 8 or more, what additional studies are considered?
CT/US are only needed if ?
Urodynamic
PVR
Urinary tract dz
BPH complications: SUCH Stones UTI CKDZ Hematuria
182
How are BPH PTs Tx based on AUA scores
When is surgery an absolute indication?
0-7: monitor
8-35: medical/surgical therapy
Failed catheter removal
Bladder diverticula
BPH sequelae: recurrent UTI hematuria stones CKDz
183
What meds are used for BPH
Alpha blockers:
Praz/Doxa/Terazosin
Alpha-1a blockers:
Tamsul/Alfuzosin (fewer s/e)
5-RA inhibitors:
Finasteride x 6mon minimum, also reduces PSA x 50%
Dutasteride
PDE-5 inhib:
Tadalafil- Tx BPH and ED
184
What phytotherapy can be used for BPH although not proven to provide benefit?
P africanum
E purpurea
H rooperi
Palmetto berry
Pollen extract
Trembling poplar
185
What 'minimally' invasive procedures may be done for BPH Txs
What conventional procedure is done?
```
TULIP
TUNA
Implants
Microwave hyperthermia
Electrovaporization
```
TURP
186
What surgical procedure is performed when prostate is too large to remove endoscopically?
? is the MC non-cutaneous cancer in US men?
TUIP
Open simple prostatectomy
Prostate cancer
187
? is the 2nd leading cause of Ca related deaths
What are the RFs?
Prostate
Age AfAm FamHx
High fat intake
188
PSA levels above ? suggest but are not Dx inclusive of prostate Ca
If PT has elevated BUN/Cr means ?
If PT has elevated AlkPhos means ?
>4ng/mL
Urine retention/obstruction
Skeletal metastases
189
What is the preferred method for prostate ca imaging/biopsy?
When are PTs referred for this procedure?
TRUS biopsy from apex, mid and base
Abnormal DRE/elevated PSA
190
When PTs PSA is >20ng, they may be referred for ? imaging test?
Current screening recommendations include ?
Radionuclide bone scan
DRE PSA and TRUS
191
PSA screenings is a Grade C and only recommended for ? age groups?
Do not screen PTs over ? age
55-69
>70y/o, Grade D
192
When/why would prostate screening be initiated at 50?
When would it be initiated at 45y/o?
50y/o w/ average risk
Black men
FDR Dx <60y/o
BRCA 1 mutation
193
Most prostate Cas are ? type
that start ?
Define Gleason score
Adenocarcinomas
Peripheral zone
2-10
Correlates to volume, stage and prognosis
194
What is removed during a radical prostatectomy
Who are the ideal candidates for this surgery?
Seminal vesicles
Ampullae of Vas Deferens
Prostate
T1 and T2
195
# Define Brachytherapy
Most prostate Ca are ? depenent and can be Tx w/ ?
Implantation of radioactive source into prostate (palladium iodine iridium)
Hormone dependent
Androgen suppression w/ hormone therapy
196
What is the acronym used for prostate Ca prognosis
What can be used/done for prostate cancer prevention
CAPRA- CAncer of the Prostate Risk Assessment
```
Antioxidant- Lycopene
Cruciferous veggies
Vit D
Omega 3s
Polyphenols (green tea)
```
197
# Define Balantitis
Define Balanoposthitis
Inflammation of glans
Inflammation of gland and/or foreskin d/t CAlbicans
198
Balanoposthitis may be the sole presenting sign of ? Dx
How is this Tx
DM
Nystatin
Clotrim/Fluconazole
Recurrent- circumcision refer
199
When is an PO Cephalosporin added to Tx of balanoposthitis
What are the two types of phimosis
Cephalexin
Physiologic- born that way
Pathologic- infection/scar
200
How is a phimosis temporarily Tx
What is the definitive Tx
What can be done to avoid the need for surgical Tx
Dilate preputial ostium
Dorsal slit, Circumcision
Topical steroids HC 1% w/ daily retractions
201
# Define Paraphimosis
After reduction, all PTs need to have /
Retracted foreskin trapped behind glans
Uro refer for circumcision
202
What breaks during a penile fracture
What may need to be done to preserve urethral integrity
Tear of penil tunica albuginea
Retrograde urethrography
203
# Define Epispadias
Define Hypospadias
Meatus opens on dorsal side
Meatus opens on ventral side
204
Facts of Epispadias
Facts of Hypospadias
```
More common
Associated w/ feminization
No circumcisions
Repaired prior to 18mon, usually 6mon
Great prognosis
```
Common incontinence due to improper development of sphincter
Dorsal curvature
Poor prognosis
205
# Define Chordee
This may be associated w/ ?
Abnormal ventral curvature of penis d/t short urethra/fibrous tissue on corpus spongiosum
Hypospadias
206
# Define Peyronie Dz
This condition is associated w/ ? other PE finding
How is it Tx
Acquired malformation of tunica albuginea
Dupuytren contracture
Collagen clostridial injection- only FDA approved
CCBs
Interferon injection
207
# Define Priapism
Since this is not an arousal problem, what can cause it?
Erection >4hrs, ischemic injury to corpora cavernosa
Pelvic tumor/infection
Sickle
Leukemia
Penile/spine trauma
208
What are the two types of priapisms
Both types require ?
Non-ischemic: high flow from injury sparing erectile function, Tx may not be required
Ischemic: low flow, Tx w/ needle aspiration or phenylephrine
Urology referral
209
When are penile cancers more likely to show their rare existence?
What are the RFs?
Almost all are ? type
6th decade
HPV
Uncircumcised
Phimosis
Squamous cell*- glands
Bowen Dz- red plaque on shaft
E of Q- red ulceration/Bowen on glans
210
How are penile Cas Tx
How are urethral strictures Tx
Biopsy required
Internal urethrotomy
Open surgical repiar
211
What is the MC referral to urology for the scrotum for?
Why are these concerning?
Mass
Masses arising from tests are usually malignant
Arising from epididymis/spermatic cord usually benign
212
How do malignancies of the testes present on PE?
Where do hydroceles collect fluid
How are these differentiated and more commonly seen
Painless, firm and solid that don't transilluminate
Parietal/visceral of tunica vaginalis
1st year of life
Transillumination
213
Where do epididymal cysts grow?
Difference between epididymal cyst and spermatocele
Caput of epididymis
EC: <2cm
Sp: >2cm on head of epididymis
214
# Define Varicocele
When are these concerning?
Dilated pampiniform plexus of spermatic veins, MC on L
Unilateral R side
Dilated when PT supine
Sudden onset/rapid growth
215
Why are R sided varicoceles concerning?
How are they managed?
Retroperitoneal malignancy
CT scans
216
# Define Indirect Hernia
Define Direct Hernia
Congenital patent vaginalis, through inguinal ring
Protrude through abdominal viscera through posterior wall of inguinal canal
217
When are torsions most common?
This happens due to inadequate fixation to ? structure
How can this occur w/out activity?
Neonates
Post-puberty
Tunica vaginalis
Cremaster contraction during REM
218
What is the most sensitive PE test for torsion?
What is the test of choice
How is the Open Book procedure done?
Absent cremaster reflex
Doppler US
R- counter clockwise
L- clockwise
219
? is the MC cause of scrotal pain
What causes this?
How does this present and how is it differentiated
Epididymitis and Epididymo-orchitis
MC- infectious: G/C, urethritis
Non-STI: UTI, prostatitis, Gram-Neg rods
Post strain w/ fever
Pos Phrehn sign
220
How are Epididymitis and Epididymo-orchitis Tx
"Blue dot" on testes indicates ? issue
STI: Ceftriax and Doxy/Azith
Non-STI: Cipro/Levo
Bed rest, elevation for both
Torsion of appendix testis, slower/more gradual onset
221
# Define Fourniers Gangrene
What population is this seen in
Necrotizing fasciitis of perineum and scrotal skin
DM
222
Post void residual volume less than ? is considered adequate and normal
What is the DIAPPERS acronym stand for
<50mL
```
Delirium
Infection
Atrophic
Pharm
Psych
Excessive output
Restricted mobility
Stool impact
```
223
What are the 4 established causes of urinary incontinence
What are the RFs
Destrusor over activity- urge
Urethral incompetence- stress
Obstruction
Detrusor over activity- over flow
F: FamHx Obesity* Age Multiparity
M: DM Age Prostate Neuro
224
What is the MC cause of established geriatric incontinence
What is the corner stone to detrusor over activity Tx
Urge incontinence, detrusor over activity
Bladder training on schedule
225
PCKDz may be associated w/ ? cardiac valve issues?
RCC prognosis
MVP
Aortic abnormalities/aneurysms
T1: <7cm, encapsulated w/ 90% 5yr survival rate
226
How is detrusor over activity Tx
If behavior therapies don't work what meds are used?
What med can be given specifically for the overactive bladder Sxs?
Kegels
Tolterodine, Oxybutynin
Miragegron- B3 agonist
227
What is an alternate Tx for detrusor over activity if PO meds are avoided?
Men w/ BPH and detrusor over activity and post-voiding residual volume of 150mL or less can benefit from ? combo
Botox A injections
Antimuscarinic + A-blocker
228
Instantaneous urine leakage in response to stress indicates?
This can be seen in men that have had ?
Urethral incompetence- 2nd MC cause in older females
Radical prostectomy
229
How is the cough stress test conducted?
How is stress incontinence Tx
Cough w/ full bladder
Instant leak- stress incontinent
Delay/persistent leak- uninhibited bladder contraction
Weight loss
Kegel/Pessarie/cones
Sling surgery- last, best
230
How is urethral obstruction incontinence Tx
What is the least common cause of incontinence
Surgical decompression
Catheter
A-blockers
Finasteride if BPH present, 6mon wait time
Detrusor underactivity due to sacral motor dysfunction
231
What lab result shows urinary incontinence due to detrusor under activity?
How is this form Tx
Reatined urine volume >450mL
Bladder training
232
? is the 2nd MC urologic Ca
What type of Ca are these
Bladder at 73y.o
Epithelial (Uro, Squamous, Adeno)
233
What are the biggest RFs for bladder Ca
How is a Dx confirmed
Smoking
Industrial dye/solvents
Schistosomiasis
Cystoscopy and Biopsy
234
How is bladder Ca staged
```
Ta
T1
T2
T3a
T3b
T4- prostate invasion
Ta/1= superficial
T2+= invasive
```
235
What is the initial Tx for all bladder tumors
What is the prognosis
Transurethral resection
Ta-T1= good, 81%
T2/3- 50-75% 5yr after radical -ectomy
236
? is the MC neoplasm in men 15-35y/o
How is this MC Dx
Testicular ca
Orchiectomy
237
Most testicular Ca are ? tumors
They are slightly more common on ? side
What is the primary RF
Germ cell
R
Cryptochordism
238
What lab results may be increased in testicular Ca work ups
What sequence of images are ordered during work up?
How are these Tx
LDH AFP hCG
US
Orchiectomy
CT/PET
Radical orchiectomy
239
Secondary tumors/metastasis are rare in testicular Ca except for ?
What is the 5yr prognosis?
Lymphoma
Stage 1-3: almost 100%
