GU & Gyne System Flashcards
This deck covers Chapters 87-90 in Rosens, compromising all of urology and gynecology.
List EIGHT intrinsic renal diseases that can result in AKI
- ATN
- AIN
- RTA
- HIV
- HSP
- SLE
- HUS
- Goodpasture’s
- PSGN
- Wegeners
- PAN
- Nephrotic
- Scleroderma
- Toxins
- Multiple myeloma
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?
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
What 8 special groups might you consider getting a urine culture in?
- Young
- Old
- Men
- Immunocompromised
- On antibiotics
- Failed treatment UTI
- Patient seems sick
- Pregnancy
- Recurrent pyelonephritis
- Known anatomic issues (eg. solitary kidney)
- Serious comorbidities
- Recent instrumentation (Foley, scope)
Define AKI. Describe how AKI can be categorized using the RIFLE system & AKIN system
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
List 5 U/S findings and 5 CT findings of ovarian torsion
U/S
- Edema
- Fluid
- Enlarged
- Loss of venous and arterial waveforms
- Whirlpool
CT
- Enlarged
- Thickened tube
- Fluid
- Hemorrhage
- Masses
List FIVE causes of non-traumatic hematuria
- UTI
- Renal colic
- AVM
- GU tumour
- Vasculitis
- PSGN
- Blood thinners
- HSP
- Goodpastures
- SLE
A patient with ESRD on HD presents with hypotension. List SIX possible causes
- Hyperkalemia
- Sepsis
- CHF
- Over-dialysed
- Dehydration
- Ischaemia
- Electrolyte abnormalities
- Anaphylaxis
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?
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
How do you manage a stable abnormal uterine bleed in a patient who is not pregnant?
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
What is the critical size for the passage of kidney stones?
<5 mm (90% passage rate)
5-10 mm (15% - 40% passage rate)
>10 mm (need a urologist)
List 8 causes of low flow priapism
- Injections: PGE1
- Drugs: vasodilators: eg. sildafenil, CCB
- Pysch drugs: Trazodone, SSRI
- Anticoagulants
- Cocaine, Marijuana
- Testosterone
- Anemia, Leukemia, Sickle Cell
- Gout
- Carbon monoxide
- Black Widow spider venom
- Spinal cord injury
According to the Public Health Agency of Canada (PHAC), what are the diagnostic criteria for PID?
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
List 6 causes of an acute painful scrotum
- Torsion
- Epididymitis
- Torsion of appendix teste
- Neoplasm
- Trauma
- Orchitis
- Hernia
- Fournier’s
What should you assume for a > 20-week pregnant woman with a PV bleed? What should you not do? What should you do?
- Assume it’s a placental previa
- Do not do a speculum exam
- Get an ultrasound
- Give RhoGam if Rh-
- Discuss with Obstetrics
In general, what are 6 contraindications to OCP therapy?
- Pregnant
- Undiagnosed uterine bleed
- Thromboembolic disease
* History of or current DVT/PE
* History of Factor V Leiden, Protein S/C def, APLS - Cerebrovascular disease
- CAD
- CV disorders
- Uncontrolled HTN
- Estrogen dependent tumors – breast, uterus
- Impaired liver function
- Age >35 and smoker
- DM with evidence of end-organ damage
- SLE with AP antibodies
- Migraine with focal neuro symptoms
List 3 sites of narrowing in the ureters where stones are most likely to get stuck
- Pelviureteric junction (PUJ) - at kidney
- As ureter crosses the common iliac artery bifurcation
- Vesicoureteric junction (VUJ) - at bladder
Define pelvic inflammatory disease (PID). What are 3 etiologic agents? What are 4 risk factors for PID?
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)
List 3 absolute and 4 relative indications for hospital admission for urolithiasis
Absolute
- Intractable Pain
- Urinary Extravasation
- Hypercalcemic crisis
- Septic Stone
Relative
- Transplant
- Solitary kidney
- ++ WBC
- High grade obstruction
- Pyschosocial factors
List 5 indications for emergency dialysis
AEIOU
- Acidosis
- Electrolyte abnormalities
- Ingestions
- Overload
- Uremia
According to PHAC (Canadian Guidelines), what are SIX criteria for hospitalization for PID patients?
- Failed outpatient treatment
- Pregnant
- Hemodynamically unstable/high fever/severe
- Tuboovarian abscess
- Unable to tolerate PO
- Social (HIV/Youth/At-risk group)
Provide a 6-item DDX for altered mental status in dialysis patients
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
List FIVE causes of heme pigment-induced AKI
Muscle Breakdown or Hemolysis
- Rhabdomyolysis
- Compartment syndrome
- Trauma
- Burns
- Myosistis
- Tissue damage
- Valves
- Malaria
What are the 4 major types of kidney stones?
-
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 -
Magnesium-ammonium-phosphate (struvite) – 15%
* Due to UTIs with urea-splitting organisms – Proteus, Providencia, Klebsiella, Pseudomonas, Staph (KPS)
* Can form staghorn calculi -
Uric acid – 10%
* Occurs with symptomatic gout – uric acid in urine
* Stones are radiolucent -
Cysteine – rare
* Caused by inborn errors of metabolism
* Forms staghorns
What are the FOUR indications for imaging in peds with UTI?
- Children <2 yo with a first febrile UTI
- Children with recurrent febrile UTIs
- Children with FHx of GU disease, poor growth, or HTN
- Children who do not respond to ABx
What are FOUR mechanisms of drug-induced renal failure?
-
Intravascular volume depletion
* Lasix -
Decreased renal perfusion
* ACEi/ARB inhibit efferent renal arteriolar vasoconstriction -
Increased catabolism
* Tetracycline -
ATN
* Contrast -
AIN
* Penicillins -
Inhibition of renal PG synthesis
* NSAIDs inhibit PG and cause vasoconstriction of the afferent renal arteriole
Provide a DDx for abnormal uterine bleeding (List 10)
PALMCOINE
- Polyps
- Adenomyosis
- Leiomyomas
- Malignancy
- Coagulopathy
- Ovulatory
- Iatrogenic (IUD, OCP)
- Not yet classified
- Endometrial
List 8 risk factors for urolithiasis
- Hypercalcemia
- Dehydration
- Crohn’s
- Hyperuricemia/Gout
- Family history
- Sarcoid
- Recurrent UTI
- White men
List FIVE causes of postrenal AKI
- BPH
- Tumour
- Neurological dysfunction
- Obstructing stones
- Clot
- Trauma
- Phimosis/stricture
- Posterior urethral valves
List 5 disorders EACH for ulcerative and nonulcerative STIs
Ulcerative STIs
- Syphilis
- LGV
- HSV
- HPV
- Chancroid
Non-ulcerative STIs
- Chlamydia
- Gonorrhea
- HIV
- BV
- Trichomonas
- Candida
List 10 causes of hematuria
Kidney
- PSGN
- Pyelonephritis
- Trauma
- Anticoagulation
- Neoplasm
- Vasculitis (HSP)
Ureter
- Trauma
- Stone
- Neoplasm
Bladder
- Neoplasm
- Stones
- Infection
- Trauma
- Radiotherapy
Prostate
- Infection
- Radiotherapy
Other
- Coagulopathy
- SLE
- Sickle Cell Disease
List 4 causes of CKD with normal or large kidney size
- Polycystic kidney disease
- Amyloidosis
- Diabetic nephropathy
- Malignant HTN
- Multiple myeloma
- Hydronephrosis
A guy comes in with a 5 hr painful erection. Outline your management.
- Analgesia
- Exercise may help
* Get him to run up and down stairs/do squats etc.
* Assuming it’s not sickle cell - Give a penile block
- 10 and 2 o’clock insert a 19G and aspirate
- May need to inject phenylephrine (100-500 mcg)
Using urinalysis, UNa, FENa and urine-to-plasma creatinine ratio, differentiate prerenal azotemia from ATN
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
List EIGHT causes of nephrotic syndrome. What are the THREE characteristics of nephrotic syndrome?
- Minimal change disease
- DM
- SLE
- HSP
- Wegeners
- Amyloid
- NSAIDS
- Heroin
- IE
- HIV
- Tumours /malignancy
- HTN
- Transplant Rejection
Characteristics:
- Hypoalbuminemia
- Heavy proteinuria (>3.5g/d)
- Edema (low oncotic P)
- Hypertriglyceridemia (often have, not required)
List 5 causes of ovarian torsion
- Tumors
- Cysts
- PCOS
- Ovarian hyperstimulation syndrome (IVF)
- Complication of pregnancy
- Normal ovary (rare)
Describe the stages of syphilis
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
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
-
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
- Uncomplicated urethral, cervical or rectal
-
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
- Primary, Secondary or Early latent
-
HSV (Genital)
- 1st Episode
- Valacyclovir 1g BID x7d
- Recurrent
- Valacyclovir 1g daily x5d
- Valacyclovir 500mg BID x3d
- 1st Episode
-
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
List prophylaxis options (including dose) for the following:
- Gonorrhea
- Chlamydia
- Trichomoniasis
- Hepatitis B
- Hepatitis C
- HIV
- Pregnancy
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
What are the treatment options for PID as per the Canadian guidelines?
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
List FIVE causes of prerenal azotemia
- Dehydration
- Hemorrhage
- Sepsis
- GI losses
- Burns
- CHF
Provide treatment options for uncomplicated UTI, uncomplicated pyelonephritis, and complicated UTI
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
List THREE causes of vulvovaginitis. For EACH cause, indicate the appearance of the vaginal discharge, appearance on wet mount microscopy, and treatment.
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
What is the treatment of epididymitis?
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
List 8 causes of urinary retention
Penis
- Foreign body
- Phimosis
Urethra
- Tumour
- Stricture
- Stone
Prostate
- BPH
- Infection
- Neoplasm
Neurological
- Spinal cord injury
- Diabetes
Drugs
- Anticholinergics
- Beta-blockers
- Antihistamines
- Opioids
List the type of each of these urine casts

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
Provide THREE DDX for:
- Low FENa (<1%) and UNa < 20 mEq/L
- High FENa (>1%) and UNa > 40 mEq/L
Low FENa (<1%) and UNa < 20 mEq/L
- Dehydration
- Third spacing
- HUS/TTP
- DIC
High FENa (>1%) and UNa > 40 mEq/L
- SIADH
- Hypothyroidism
- Adrenal Insufficiency
- Diurectics
- Renal failure
With hematuria, how does the microscopic study help you determine the source of the bleeding?
Renal Blood
- RBC casts
- Proteinuria
Non-Glomerular/Lower Urinary Tract
- Clots
List 6 causes of red-colored urine without hematuria
- Rifampin
- Deferoxamine
- Beets
- Rhubarb
- Nitrofurantoin
- Iodine
List 4 extra-genital presentations of gonorrhea
- PID
- Anorectal disease
- Pharyngitis
- Conjunctivitis
* Ophthalmologic emergency - Disseminated gonorrhea
Differentiate between testicular torsion, appendix torsion, and epididymitis
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
What are the Amsel criteria for BV?
Diagnosis of BV
3+ of:
- Thin, white discharge that coats the vaginal walls
- Clue cells on microscopy
- Vaginal fluid pH > 4.5 (lack of lactobacillus)
- Fishy odor before/after 10% KOH added (Whiff test)
Describe a typical menstrual cycle: length, phase, etc.
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
What are TWO risk factors for contrast-induced nephropathy? If you must do a test that requires contrast, list FOUR ways CIN be prevented?
Risk Factors
- Dehydration
- Pre-existing AKI
- Age >60
- Use of ionic contrast media
- DM
- Multiple myeloma
Prevention (they love to ask this!)
- IVF hydration (0.9% NS) before and after study
- NAC
- CT without contrast or use another imaging modality (US)
- Use low osmolal contrast
- Use lower doses of contrast and limit repeat studies
- Avoid NSAIDs