GU & Gyne System

Question 1

List EIGHT intrinsic renal diseases that can result in AKI

Answer 1

1. ATN
2. AIN
3. RTA
4. HIV
5. HSP
6. SLE
7. HUS
8. Goodpasture’s
9. PSGN
10. Wegeners
11. PAN
12. Nephrotic
13. Scleroderma
14. Toxins
15. Multiple myeloma

Question 2

A peritoneal dialysis patient presents complaining of abdominal pain – he has diffuse tenderness on exam. You aspirate peritoneal fluid from his access site. How is the diagnosis of PD-related peritonitis made? What is the treatment?

Answer 2

Diagnosis

• 2+ of:
• Clinical features of peritonitis
• Fluid WBC >100 (after dwell time of 2h) w/ 50% PMN
• Culture positive

Treatment

• Cefazolin 1g IP OD or Vancomycin 30 mg/kg IP and
• Gentamicin 0.6 mg/kg IP OD or Ceftazidime 1 g IP OD

Question 3

What 8 special groups might you consider getting a urine culture in?

Answer 3

1. Young
2. Old
3. Men
4. Immunocompromised
5. On antibiotics
6. Failed treatment UTI
7. Patient seems sick
8. Pregnancy
9. Recurrent pyelonephritis
10. Known anatomic issues (eg. solitary kidney)
11. Serious comorbidities
12. Recent instrumentation (Foley, scope)

Question 4

Define AKI. Describe how AKI can be categorized using the RIFLE system & AKIN system

Answer 4

RIFLE

• Risk: Creat 1.5x , GFR down 25%+, UO <0.5cc/kg
• Injury: Creat 2x, GFR down 50%+, UO <0.5cc/kg
• Failure: Creat 3x or >350, GFR down 75%+, UO <0.3 cc/kg
• Loss: 4 weeks
• ESRD: 3 months

AKIN

• I: creat 1.5-2x baseline, UO <0.5cc/kg
• II: creatinine 2-3x baseline
• III: 3x baseline

Question 5

List 5 U/S findings and 5 CT findings of ovarian torsion

Answer 5

U/S

1. Edema
2. Fluid
3. Enlarged
4. Loss of venous and arterial waveforms
5. Whirlpool

CT

1. Enlarged
2. Thickened tube
3. Fluid
4. Hemorrhage
5. Masses

Question 6

List FIVE causes of non-traumatic hematuria

Answer 6

1. UTI
2. Renal colic
3. AVM
4. GU tumour
5. Vasculitis
6. PSGN
7. Blood thinners
8. HSP
9. Goodpastures
10. SLE

Question 7

A patient with ESRD on HD presents with hypotension. List SIX possible causes

Answer 7

1. Hyperkalemia
2. Sepsis
3. CHF
4. Over-dialysed
5. Dehydration
6. Ischaemia
7. Electrolyte abnormalities
8. Anaphylaxis

Question 8

A woman presents within 72 hours following sexual who wants emergency contraception. What are you going to prescribe What patient population might it be less effective in?

Answer 8

Emergency Contraception

• Copper IUD
• Levonorgestrel (Plan B)
• Take 0.75 mg q12hr x 2 or 1.5 mg x1
• Will feel sick from high doses
• ~89% effective
• LESS EFFECTIVE in obese patients
• Should be taken < 24hrs but can be given up to 72 hrs after intercourse

Question 9

How do you manage a stable abnormal uterine bleed in a patient who is not pregnant?

Answer 9

Does the patient want to get pregnant?

• NSAIDS during menses and TXA

Does the patient not want to get pregnant?

• OCP - containing at least 20 mcg of estradiol
• Assuming no contraindications

Question 10

What is the critical size for the passage of kidney stones?

Answer 10

<5 mm (90% passage rate)

5-10 mm (15% - 40% passage rate)

>10 mm (need a urologist)

Question 11

List 8 causes of low flow priapism

Answer 11

1. Injections: PGE₁
2. Drugs: vasodilators: eg. sildafenil, CCB
3. Pysch drugs: Trazodone, SSRI
4. Anticoagulants
5. Cocaine, Marijuana
6. Testosterone
7. Anemia, Leukemia, Sickle Cell
8. Gout
9. Carbon monoxide
10. Black Widow spider venom
11. Spinal cord injury

Question 12

According to the Public Health Agency of Canada (PHAC), what are the diagnostic criteria for PID?

Answer 12

Minimum

• Sexually active woman
• Pelvic pain
• Adnexal or cervical motion tenderness

Supporting the diagnosis

• Fever
• ESR/CRP elevation
• Documented chlamydia or gonnorhea
• WBC seen on wet mount

Definitive

• Biopsy
• Transvag US
• Laparotomy

Question 13

List 6 causes of an acute painful scrotum

Answer 13

1. Torsion
2. Epididymitis
3. Torsion of appendix teste
4. Neoplasm
5. Trauma
6. Orchitis
7. Hernia
8. Fournier’s

Question 14

What should you assume for a > 20-week pregnant woman with a PV bleed? What should you not do? What should you do?

Answer 14

• Assume it’s a placental previa
• Do not do a speculum exam
• Get an ultrasound
• Give RhoGam if Rh-
• Discuss with Obstetrics

Question 15

In general, what are 6 contraindications to OCP therapy?

Answer 15

1. Pregnant
2. Undiagnosed uterine bleed
3. Thromboembolic disease
   * History of or current DVT/PE
   * History of Factor V Leiden, Protein S/C def, APLS
4. Cerebrovascular disease
5. CAD
6. CV disorders
7. Uncontrolled HTN
8. Estrogen dependent tumors – breast, uterus
9. Impaired liver function
10. Age >35 and smoker
11. DM with evidence of end-organ damage
12. SLE with AP antibodies
13. Migraine with focal neuro symptoms

Question 16

List 3 sites of narrowing in the ureters where stones are most likely to get stuck

Answer 16

1. Pelviureteric junction (PUJ) - at kidney
2. As ureter crosses the common iliac artery bifurcation
3. Vesicoureteric junction (VUJ) - at bladder

Question 17

Define pelvic inflammatory disease (PID). What are 3 etiologic agents? What are 4 risk factors for PID?

Answer 17

PID

• Upper GU infection
• Endometritis
• Salpingitis
• Peritonitis
• Tubo-ovarian abscess

Etiology

• N. gonorrhea
• C. trachomatis
• Mycoplasma

Risk Factors

• Young age
• Multiple sexual partners
• Smoking
• Menses
• IUD (only in 1st 3 weeks after insertion)

Question 18

List 3 absolute and 4 relative indications for hospital admission for urolithiasis

Answer 18

Absolute

1. Intractable Pain
2. Urinary Extravasation
3. Hypercalcemic crisis
4. Septic Stone

Relative

1. Transplant
2. Solitary kidney
3. ++ WBC
4. High grade obstruction
5. Pyschosocial factors

Question 19

List 5 indications for emergency dialysis

Answer 19

AEIOU

• Acidosis
• Electrolyte abnormalities
• Ingestions
• Overload
• Uremia

Question 20

According to PHAC (Canadian Guidelines), what are SIX criteria for hospitalization for PID patients?

Answer 20

1. Failed outpatient treatment
2. Pregnant
3. Hemodynamically unstable/high fever/severe
4. Tuboovarian abscess
5. Unable to tolerate PO
6. Social (HIV/Youth/At-risk group)

Question 21

Provide a 6-item DDX for altered mental status in dialysis patients

Answer 21

DIMES

• Drugs
• Interactions
• Infection
• Sepsis
• Metabolic
• Dialysis dysequilibrium syndrome
• Electrolyte
• Uremic encephalopathy
• Electrolyte derangement
• Structure
• Brain bleed

Dialysis Dysequilibrium Syndrome

• Headache, n/v
• Muscle cramps, malaise
• Seizures
• Due to rapid changes in lytes/fluids post-dialysis

Question 22

List FIVE causes of heme pigment-induced AKI

Answer 22

Muscle Breakdown or Hemolysis

1. Rhabdomyolysis
2. Compartment syndrome
3. Trauma
4. Burns
5. Myosistis
6. Tissue damage
7. Valves
8. Malaria

Question 23

What are the 4 major types of kidney stones?

Answer 23

1. Calcium oxalate – 75%
   * Hyperexcretion of calcium = major contributor
   * Ingesting large quantities of milk, hyperPTH, PUD
   * Also influenced by diet, IBD, radiation enteritis
   * DDx: ethylene glycol poisoning
2. Magnesium-ammonium-phosphate (struvite) – 15%
   * Due to UTIs with urea-splitting organisms – Proteus, Providencia, Klebsiella, Pseudomonas, Staph (KPS)
   * Can form staghorn calculi
3. Uric acid – 10%
   * Occurs with symptomatic gout – uric acid in urine
   * Stones are radiolucent
4. Cysteine – rare
   * Caused by inborn errors of metabolism
   * Forms staghorns

Question 24

What are the FOUR indications for imaging in peds with UTI?

Answer 24

1. Children <2 yo with a first febrile UTI
2. Children with recurrent febrile UTIs
3. Children with FHx of GU disease, poor growth, or HTN
4. Children who do not respond to ABx

Question 25

What are FOUR mechanisms of drug-induced renal failure?

Answer 25

1. **Intravascular volume depletion** * Lasix 2. **Decreased renal perfusion** * ACEi/ARB inhibit efferent renal arteriolar vasoconstriction 3. **Increased catabolism** * Tetracycline 4. **ATN** * Contrast 5. **AIN** * Penicillins 6. **Inhibition of renal PG synthesis** * NSAIDs inhibit PG and cause vasoconstriction of the afferent renal arteriole

Question 26

Provide a DDx for abnormal uterine bleeding (List 10)

Answer 26

**PALMCOINE** * **P**olyps * **A**denomyosis * **L**eiomyomas * **M**alignancy * **C**oagulopathy * **O**vulatory * **I**atrogenic (IUD, OCP) * **N**ot yet classified * **E**ndometrial

Question 27

List 8 risk factors for urolithiasis

Answer 27

1. Hypercalcemia 2. Dehydration 3. Crohn's 4. Hyperuricemia/Gout 5. Family history 6. Sarcoid 7. Recurrent UTI 8. White men

Question 28

List FIVE causes of postrenal AKI

Answer 28

1. BPH 2. Tumour 3. Neurological dysfunction 4. Obstructing stones 5. Clot 6. Trauma 7. Phimosis/stricture 8. Posterior urethral valves

Question 29

List 5 disorders EACH for ulcerative and nonulcerative STIs

Answer 29

**Ulcerative STIs** 1. Syphilis 2. LGV 3. HSV 4. HPV 5. Chancroid **Non-ulcerative STIs** 1. Chlamydia 2. Gonorrhea 3. HIV 4. BV 5. Trichomonas 6. Candida

Question 30

List 10 causes of hematuria

Answer 30

**Kidney** 1. PSGN 2. Pyelonephritis 3. Trauma 4. Anticoagulation 5. Neoplasm 6. Vasculitis (HSP) **Ureter** 1. Trauma 2. Stone 3. Neoplasm **Bladder** 1. Neoplasm 2. Stones 3. Infection 4. Trauma 5. Radiotherapy **Prostate** 1. Infection 2. Radiotherapy **Other** 1. Coagulopathy 2. SLE 3. Sickle Cell Disease

Question 31

List 4 causes of CKD with normal or large kidney size

Answer 31

1. Polycystic kidney disease 2. Amyloidosis 3. Diabetic nephropathy 4. Malignant HTN 5. Multiple myeloma 6. Hydronephrosis

Question 32

A guy comes in with a 5 hr painful erection. Outline your management.

Answer 32

1. Analgesia 2. Exercise may help * Get him to run up and down stairs/do squats etc. * Assuming it's not sickle cell 3. Give a penile block 4. 10 and 2 o'clock insert a 19G and aspirate 5. May need to inject phenylephrine (100-500 mcg)

Question 33

Using urinalysis, UNa, FENa and urine-to-plasma creatinine ratio, **differentiate prerenal azotemia** from **ATN**

Answer 33

**Pre-renal** * UNa \<20 mEq * FeNa \<1% * Urine:Plasma Cr \>40 * Hyaline casts **ATN** * UNa \>40 mEq * FeNa \>2% * Urine:Plasma Cr \<20 * Granular casts FeNa = _Urine Na x Serum Cr_ Serum Na x Urine Cr

Question 34

List EIGHT causes of nephrotic syndrome. What are the THREE characteristics of nephrotic syndrome?

Answer 34

1. Minimal change disease 2. DM 3. SLE 4. HSP 5. Wegeners 6. Amyloid 7. NSAIDS 8. Heroin 9. IE 10. HIV 11. Tumours /malignancy 12. HTN 13. Transplant Rejection **Characteristics:** 1. Hypoalbuminemia 2. Heavy proteinuria (\>3.5g/d) 3. Edema (low oncotic P) 4. Hypertriglyceridemia (often have, not required)

Question 35

List 5 causes of ovarian torsion

Answer 35

1. Tumors 2. Cysts 3. PCOS 4. Ovarian hyperstimulation syndrome (IVF) 5. Complication of pregnancy 6. Normal ovary (rare)

Question 36

Describe the stages of syphilis

Answer 36

**Primary (9-90 days)** * Painless chancre * Pen G 2.4 million units IM x1 **Secondary (5-8 weeks)** * Rash on hands * Malaise, generalized unwell feeling +/- condyloma lata * Pen G 2.4 million units IM x1 if no neuro symptoms **Latent (Years)** * No symptoms * Can be spread to kid * Pen G 2.4 million units IM qWeekly x3 **Tertiary (Years/Decades)** * Heart/Aorta involvement * Pen G 2.4 million units IM qWeekly x3 **Neurosyphilis (any time)** * Altered LOC/Meningitis * Admit * Pen G 4 million units IV q4h **Jarisch Herxheimer Reaction** * When you start treatment and everything gets worse

Question 37

What is the treatment for the following STIs: * Chlamydia * Gonorrhea * Uncomplicated urethral, cervical or rectal * Pharyngeal * Adult conjunctivitis * Disseminated * Syphilis * Primary, secondary, or early latent * Late latent, tertiary * Neuro * HSV * 1st Episode * Recurrent * Chancroid * Lymphogranuloma venereum

Answer 37

* **Chlamydia** * Doxycycline 100 mg PO BID * **Gonorrhea** * Uncomplicated urethral, cervical or rectal * CTX 250 mg IM + Azithro * Pharyngeal * CTX 250 mg IM + Azithro * Adult conjunctivitis * CTX 1 g IM/IV + Azithro * Disseminated * CTX 1 g IM/IV x7d + Azithro once * **Syphilis** * Primary, Secondary or Early latent * Benzathine PCN G 2.4M U IM x1 * Late latent, Tertiary * Benzathine PCN G 2.4M U IM qWeekly x3 * Neuro * Pen G 4M U IV q4h x10d * **HSV (Genital)** * 1st Episode * Valacyclovir 1g BID x7d * Recurrent * Valacyclovir 1g daily x5d * Valacyclovir 500mg BID x3d * **Chancroid** * Azithromycin 1 g PO once * Ceftriaxone 250 mg IM/IV once * Ciprofloxacin 500 mg BID x3d * **LGV (type of Chlamydia)** * Doxy 100 mg BID x21d

Question 38

List prophylaxis options (including dose) for the following: * Gonorrhea * Chlamydia * Trichomoniasis * Hepatitis B * Hepatitis C * HIV * Pregnancy

Answer 38

**Gonorrhea** * Ceftriaxone 250 mg IM/IV of cefixime 800 mg PO **Chlamydia** * Azithro 1g PO or Doxy 100 mg PO BID **Trichomonas** * Metronidazole 500 mg PO **Hepatitis B** * HBIG 0.06 mL/kg up to 14 days after exposure (if unvaccinated or insufficient titers) * Hepatitis B vaccine at 0, 1, 6 months (if unvaccinated or unsure) **Hepatitis C** * Doesn't exist **HIV** * Triple therapy (Truvada + NNRI) **Pregnancy** * Plan B 1.5 mg PO or Copper IUD

Question 39

What are the treatment options for PID as per the Canadian guidelines?

Answer 39

**Inpatient** * Cefoxitine 2g IV q6h + Doxy 100 mg PO BID * Clinda 900 mg IV q8h + Gent 5 mg/kg q24h * Two week course **Outpatient** * CTX 250 mg IM/IV once + Doxy 100 mg BID x14d * Moxi 400 mg PO daily + Flagyl 500 mg BID * Levoflox 500 mg PO daily + Flagyl 500 mg BID * Two week course

Question 40

List FIVE causes of prerenal azotemia

Answer 40

1. Dehydration 2. Hemorrhage 3. Sepsis 4. GI losses 5. Burns 6. CHF

Question 41

Provide treatment options for uncomplicated UTI, uncomplicated pyelonephritis, and complicated UTI

Answer 41

**Uncomplicated UTI** * Nitrofurantoin x5d * Septra x3d * Keflex x7d **Uncomplicated Pyelonephritis** * Ciprofloxacin x10d * Amox-Clav x10d * Septra x10d **Complicated UTI** * Levofloxacin x10d * Amox-Clav x10d * Ciprofloxacin x10d * +/- Gentamycin

Question 42

List THREE causes of vulvovaginitis. For EACH cause, indicate the appearance of the vaginal discharge, appearance on wet mount microscopy, and treatment.

Answer 42

**Bacterial Vaginosis** * White/Clear film * Clue cells * Metronidazole PV/PO (oral preferred if pregnant) **Trichomonas** * Yellow/green * Trichomonads on mount * Metronidazole PO **Candida** * White curds * Fluconazole PO 150 mg x1 or vaginal cream

Question 43

What is the treatment of epididymitis?

Answer 43

**Sexually active? (\<35 yo)** * Ceftriaxone 250 mg IM/IV x1 * Azithomycin 1 g PO x1 **Non sexually active? (\>35 yo)** * Levoflox/Septra x7d **Prepubertal** * Get a urine culture and wait * Only treat if positive

Question 44

List 8 causes of urinary retention

Answer 44

**Penis** 1. Foreign body 2. Phimosis **Urethra** 1. Tumour 2. Stricture 3. Stone **Prostate** 1. BPH 2. Infection 3. Neoplasm **Neurological** 1. Spinal cord injury 2. Diabetes **Drugs** 1. Anticholinergics 2. Beta-blockers 3. Antihistamines 4. Opioids

Question 45

List the type of each of these urine casts

Answer 45

**A = Hyaline Cast** * Dehydration * Exercise * Glomerular proteinuria **B = RBC Cast** * Glomerulonephritis * Vasculitis **C = WBC Cast** * Renal parenchymal inflammation (AIN) * Papillary necrosis * Pyelonephritis **D = Granular Cast** * ATN

Question 46

**Provide THREE DDX for:** * Low FENa (\<1%) and U_Na \< 20 mEq/L * High FENa (\>1%) and U_Na \> 40 mEq/L

Answer 46

**Low FENa (\<1%) and U_Na \< 20 mEq/L** * Dehydration * Third spacing * HUS/TTP * DIC **High FENa (\>1%) and U_Na \> 40 mEq/L** * SIADH * Hypothyroidism * Adrenal Insufficiency * Diurectics * Renal failure

Question 47

With hematuria, how does the microscopic study help you determine the source of the bleeding?

Answer 47

**Renal Blood** * RBC casts * Proteinuria **Non-Glomerular/Lower Urinary Tract** * Clots

Question 48

List 6 causes of red-colored urine without hematuria

Answer 48

1. Rifampin 2. Deferoxamine 3. Beets 4. Rhubarb 5. Nitrofurantoin 6. Iodine

Question 49

List 4 extra-genital presentations of gonorrhea

Answer 49

1. PID 2. Anorectal disease 3. Pharyngitis 4. Conjunctivitis * Ophthalmologic emergency 5. Disseminated gonorrhea

Question 50

Differentiate between testicular torsion, appendix torsion, and epididymitis

Answer 50

**Testicular Torsion** * Bell clapper * Testicle at risk - immediate/sudden pain * Loss of cremaster reflex **Appendix Teste Torsion** * Point tenderness in superior pole * Pain management * Blue dot sign **Epididymitis** * Infection UTI/STI * Usually not profoundly swollen

Question 51

What are the Amsel criteria for BV?

Answer 51

**Diagnosis of BV** 3+ of: 1. Thin, white discharge that coats the vaginal walls 2. Clue cells on microscopy 3. Vaginal fluid pH \> 4.5 (lack of lactobacillus) 4. Fishy odor before/after 10% KOH added (Whiff test)

Question 52

Describe a typical menstrual cycle: length, phase, etc.

Answer 52

1st day of menses = 1st day of cycle Avg cycle = 28-35 days **Ovarian Phases** * **Follicular** * Begins with menses and ends the day before LH surge * Start with low estradiol and progesterone levels which gradually increase * As estrogen levels increase – endometrium thickens * Dominant follicle – releases ovum at the end of follicular phase (LH surge) * **Luteal** (**fixed 14 days in most)** * Begins with LH surge and ends with next menses * Progesterone is produced by corpus luteum * Progesterone matures lining of uterus * If implantation does not occur – CL dies – drops your estrogen/progesterone levels --\> menstruation

Question 53

What are TWO risk factors for contrast-induced nephropathy? If you must do a test that requires contrast, list FOUR ways CIN be prevented?

Answer 53

**Risk Factors** 1. Dehydration 2. Pre-existing AKI 3. Age \>60 4. Use of ionic contrast media 5. DM 6. Multiple myeloma **Prevention (they love to ask this!)** 1. IVF hydration (0.9% NS) before and after study 2. NAC 3. CT without contrast or use another imaging modality (US) 4. Use low osmolal contrast 5. Use lower doses of contrast and limit repeat studies 6. Avoid NSAIDs