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Clin Med III > Nephrology, Male GU > Flashcards

Nephrology, Male GU Flashcards

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1
Q

Kidney functions (7)

A
  • Acid-base regulation
  • Water balance
  • Electrolyte balance
  • Toxin excretion
  • BP
  • EPO production
  • Vit D & renin secretion
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2
Q

Risk factors for AKI

A
  • HTN
  • CHF (low-flow)
  • DM
  • MM
  • Chronic infection
  • Myeloproliferative disorder
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3
Q

What is RIFLE criteria?

A

Assess AKI based on SCr elevation & urine output

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4
Q

What does RIFLE stand for?

A

Risk
Injury
Failure
2 outcomes - Loss of renal fx (>4wks), ESRD (>3 mo)

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5
Q

Pre-renal causes of AKI

A
  • Hypovolemia
  • Decreased CO
  • NSAIDs
  • ACEI/ARBs
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6
Q

Intrinsic causes of AKI

A
  • Ischemia
  • Toxins
  • Vascular (renal a./v. obstruction)
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7
Q

Most common post-renal causes of AKI

A
  • BPH
  • Malignancy
  • Neurogenic bladder
  • Pregnancy
  • Med crystals (acyclovir, methotrexate, idinavir)
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8
Q

Labs for pre-renal AKI

A
  • BUN:Cr >20:1
  • FeNa <1%, FeUrea<35% or FeUA <9%
  • Hemoconcentration
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9
Q

What would you see in pre-renal AKI urine?

A

Hyaline casts & high specific gravity

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10
Q

Tx for pre-renal AKI

A
  • IVF
  • Diuretics, nitrates, dobutamine if decr. CO
  • Dose-adjust/hold meds cleared by kidney
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11
Q

Intrinsic renal diseases (6)

A
  • Acute interstitial nephritis
  • Acute tubular necrosis
  • Post-streptococcal glomerulonephritis
  • IgA nephropathy
  • Henoch-Schonlein Purpura
  • Nephrotic syndrome
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12
Q

Labs for acute tubular necrosis

A
  • Elevated BUN/Cr
  • HyperK+, hyperPO4, hyperuricemia
  • FeNa >2%
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13
Q

What would you see in acute tubular necrosis urine?

A

Pigmented granular casts (muddy-brown casts)

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14
Q

Tx for acute tubular necrosis

A
  • Aggressive volume replacement
  • Consider high dose loop diuretic if oliguria
  • Protein restriction
  • Dialysis
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15
Q

Etiology of post-streptococcal glomerulonephritis

A

Strep-A containing immune complex deposition in glomerulus

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16
Q

Presentation of PSGN

A
  • AKI 7-12 days s/p sore throat/impetigo
  • HTN
  • Oliguria
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17
Q

Tx for PSGN

A
  • Antibiotics (usually PCN)

- Anti-HTN meds, salt restriction, diuretics

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18
Q

IgA nephropathy urine

A

Red or coca-cola

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19
Q

Dx IgA nephropathy

A

Renal biopsy

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20
Q

Tx for IgA nephropathy

A
  • ACEI/ARB
  • Steroid
  • Renal transplant if needed
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21
Q

Who is commonly affected by HSP?

A

Children ~6 y/o

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22
Q

Classic presentation of HSP

A
  • Rash esp. LE, butt
  • Abd pain, vomiting
  • Arthralgias
  • Edema
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23
Q

Tx HSP

A

Supportive (immunosuppressants and/or plasmapharesis)

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24
Q

Etiology of HSP

A

IgA complex deposition

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25
Classic presentation of nephrotic syndrome (4)
- Heavy proteinuria (>3.5g/24hr) - Hypoalbuminuria (<3g/24hr) - Peripheral edema - Lipiduria (foamy urine)
26
How do cells in minimal change dz look?
Diffuse effacement (flat) of epithelial cell foot processes
27
Tx for minimal change dz
Prednisone
28
Presentation of postrenal AKI
Anuria!
29
Tx for postrenal AKI
- Tx underlying cause | - Catheterization (Foley, suprapubic)
30
2 components of polycystic kidney disease
Multisystem & Cyst formation
31
What's so bad about polycystic kidney dz?
- 50% need transplant/dialysis by age 60 | - Intracranial aneurysm
32
Si/Sx of polycystic kidney dz
- Pain - Bleeding - HTN - Nodular hepatomegaly
33
Dx polycystic kidney dz
U/S
34
Tx for polycystic kidney dz
- ACEI/ARBs - NO NSAIDs (bleeding) - Surgical cyst decompression - Nephrectomy - Transfusions prn
35
Indications for dialysis
- Acidosis (hyperK+, hyperPO4, hypoCa2+) - OD - Volume overload - Uremia
36
Acute vs. chronic kidney disease
``` Acute = rapid & reversible Chronic = progressive & irreversible ```
37
Normal GFR
≥90
38
GFR of ___ indicates kidney dysfunction
<60
39
GFR of ___ indicates ESRD
<15
40
Approach to pt with new renal dysfunction
- Consider etiologies (pre-renal, renal, post-renal) - GFR/SCr - Urine dipstick (protein, RBC) - US or CT w/out contrast - Urinalysis (casts) - Consider MM via serum/urine protein electrophoresis
41
GFR of _____ for _____ indicates CKD
<60mL/min for >3 months
42
3 risk factors for CKD
- Diabetes - HTN - African ancestry
43
Sx's of CKD
- Asx until Stage 3 or 4 | - Anemia, fatigue
44
ESRD sx's
- Encephalopathy - Muscle twitches/cramps - LE edema - Pruritus - Uremic syndrome (sx's associated w/ azotemia)
45
Labs for CKD
- 24hr urine - Elevated BUN, SCr - HyperK+, hyperphosphatemia, hypocalcemia - Proteinuria on UA - RBC/WBC casts
46
Complications of CKD
- Anemia (decr. EPO) - Metabolic acidosis (decr. HCO3 reabsorption) - Poor Vit D, Ca2+, phosphorus metabolism - Fractures - Volume overload - Hyperkalemia - Uremia - CV issues (HTN, athero, CHF)
47
Tx for CKD
- Tx underlying disorder - Dialysis (ARF or ESRD) - Eventual transplant for ESRD (kidney-pancreas for T1DM)
48
When would you refer CKD pt to nephrologist?
- GFR <30 - Rapidly progressing - Poorly controlled HTN on 4 agents - Rare/genetic causes of CKD (polycystic) - Suspected RAS
49
Staging of CKD
``` Stage 0: GFR>90 Stage 1: Kidney damage w/ normal GFR Stage 2: GFR 60-89 Stage 3: GFR 30-59 Stage 4: GFR 15-29 Stage 5: GFR <15 ```
50
Microalbuminuria
30-300mg/L of albumin in urine
51
Macroalbuminuria
>300mg/L of albumin in urine
52
Leading cause of ESRD
DM
53
First sign of diabetic nephropathy
Microalbuminuria
54
Tx for diabetic nephropathy
ACEI/ARB +/- diuretic (for HTN)
55
What is the BP goal for diabetic nephropathy?
<130/80
56
What is the BP goal for hypertensive nephropathy
<140/90
57
First line for hypertensive nephropathy
ACEI/ARB - may cause AKI (d/c if doesn't improve), hyperkalemia (reduce K+ retaining drugs if >6mmol/L)
58
___% pts will have recurrent urinary calculi (kidney stones)
50%
59
Types of kidney stones
- Ca2+ (most common) - Struvite - Uric acid - Cystine
60
Risk factors for Ca2+ stone
- Dehydration - Increased oxalate absorption (short bowel syndrome) - Grapefruit, tomato, apple juice - Sodas w/ phosphoric acid - High salt & protein intake - Loop diuretics (esp. thiazides) - TONS of antacids - Long-term steroids - Vit D/C - Hyperparathyroidism - Malignancy
61
Risk factors for uric acid stones
- Gout - Hyperuricosuria - Chronic diarrhea - HTN, DM, obesity
62
Risk factors for struvite stones
UTI's - esp. Proteus
63
Presentation of nephrolithiasis
- Waxing/waning, colicky pain - Constant writhing - N/V, diaphoresis - Tachycardia, hypotn - Dysuria, frequency, urgency, hematuria (distal stones) - CVA tenderness
64
Top imaging choices for nephrolithiasis
Non-contrast CT UNLESS pregnant/child (US instead)
65
CT findings consistent with nephrolithiasis
- Ureteral, collecting system dilatation - Perinephric, periureteric stranding (inflammation) - Nephromegaly - "Rim sign" around stone
66
Pros/cons of US for kidney stones
(+) Pregnant, child, signs of obstruction (hydroureter, loss of ureteric jet) (-) Poor visualization unless at UPJ or UVJ, can't measure size of stone
67
Besides CT & US, what are 2 other imaging options for kidney stone dx
- IV pyelography (measure SCr first b/c uses contrast) | - KUB
68
Pros/cons for IV peylography
(+) Size, location, radiodensity, degree of obstruction | -) Not for RF, poor visualization of non-GU stuff (can't r/o other d/o
69
KUB's not really the best option for nephrolithiasis. Name 3 reasons.
- Only sees radiolucent stones - Stones can be covered by stool, gas, bones - Non-urologic radiopacities may be mistaken as stones (calcified LNs, gallstones, stool, phleboliths)
70
Management of nephrolithiasis
- IVF, NSAIDs (bridge w/ narcotics?), metoclopramide (anti-emetic), tamsulosin?, abx? - Can alkalnize w/ K+ citrate if uric acid stone - If able to tolerate PO, stay home → strain urine, bring back for analysis
71
What's so great about NSAIDs for kidney stones?
- Analgesic - Antispasmodic - Antiemetic
72
Indications for referral of kidney stones to urology
>5mm >1 stone Hydronephrosis Pregnant
73
3 options for >5mm kidney stone mgmt
- Extracorporeal shock wave lithotripsy (proximal stones) - Ureteroscopy (mid-distal stones) - Percutaneous nephrolithotomy (>2cm, complex stones)
74
Criteria for extracorporeal shock wave lithotripsy
- Radiopaque <2cm renal or <1cm ureteral - Not morbidly obese - No hard/cystine stones - C/I pregnancy, tightly impacted stones, untreatable bleeding d/o
75
Complications of extracorporeal shock wave lithotripsy
- Perinephric hematoma | - Requires spontaneous passage of fragments, which can obstruct
76
Struvite = _____
Staghorn
77
Most common bacteria that causes struvite stones
Proteus
78
Tx for struvite stones
Percutaneous nephrolithiotomy +/- ESWL Medication not enough
79
When would you want to send someone w/ kidney stones for metabolic evaluation?
Recurrent stones (usually uric acid, cystine) or strong FHx
80
What kind of cells are involved in bladder cancer?
Transitional cells
81
Risk factors for bladder cancer
- Smoking - Occupational exposures - Chronic urinary inflammation (SCI, indwelling catheter) - Previous pelvic radiation
82
Si/Sx of bladder cancer
- Painless hematuria +/- LUTS | - Advanced = LE edema, bony/pelvic/flank pain, palpable mass
83
Gold standard for dx bladder cancer
Cytoscopy w/ bx (also therapeutic)
84
Typical metastatic destinations of bladder cancer
- Bone - Brain - Lung
85
Tx for non-muscle invasive bladder cancer
- Endoscopic transurethral resection of bladder tumor or radical cystectomy - Intravesicle instillation (catheter) of BCG vaccine or chemo
86
Tx for muscle-invasive bladder cancer
Neoadjuvant chemo followed by radical cystectomy w/ regional LN dissection +/-radiation
87
Risk factors for RCC
- Smoking - Obesity - HTN - Renal transplant/dialysis w/ cystic renal dz
88
Si/Sx for RCC
- "Classic" triad: Hematuria, flank pain, flank mass | - Paraneoplastic syndromes (hyperCa2+, non-met liver dysfunction, HTN, erythrocytosis)
89
Diagnostic imaging of choice for RCC
CT w/ contrast (alternative = US)
90
Which is more common, cystitis or pyelonephritis?
Cystitis
91
Risk factors for cystitis in men
Insertive intercourse, uncircumcised
92
Most common bacterial cause of cystitis
E. coli (also Klebsiella, Proteus)
93
Risk factors for cystitis
- Recent sex - Spermicide - Diaphragms - Indwelling catheters - Diabetes, obesity - Short urethra syndrome
94
What kind of urine sample do you want for cystitis assessment?
Midstream, unspun
95
Tx for cystitis
Bactrim, cipro or Macrobid | +/- Pyridium (phenazopyridine) bladder analgesic (orange urine ADR)
96
Most common bacterial causes of pyelonephritis
E. coli (also Klebsiella, Proteus) | Pseudomonas in healthcare exposures
97
In addition to LUTS similar to cystitis, what else might pyelonephritis sx's include?
Fever, chills, N/V
98
Indications for hospitalization in pyelonephritis
- Sepsis - Persistent fever - Unable to tolerate PO - Urinary tract obstruction
99
Tx for pyelonephritis
- Outpatient → Cipro or levo - Inpatient → Augmentin, Bactrim, cefpodoxime +/- Pyridium, Motrin, Tylenol, Zofran, IVF
100
Sx's of cystitis in pregnant pt
Usually asx - cystitis found incidentally on routine UA
101
Tx for cystitis in pregnancy
Macrobid, Augmentin, cefpodoxime, or fosfomycin
102
Tx for pyelonephritis in pregnancy
- Beta lactams - PCN derivatives - Cefazolin - Ceftriaxone +/- admission
103
Tx for asx bacteriuria
Don't treat in elderly | Bactrim, Macrobid, cipro (same as cystitis)
104
Most common causes of RAS
- Atherosclerosis (most common) | - Fibromuscular dysplasia
105
Angiogram of atherosclerosis vs. fibromuscular dysplasia
- Atherosclerosis = narrowing of contrast at renal artery | - FMD = "string of beads"
106
Risk factors for RAS
- CKD - DM - Tobacco - HTN
107
When should you consider revascularization in RAS
>70% angiographic stenosis OR 50-70% angiographic stenosis associated with resting mean pressure gradient >10mmHg, systolic hyperemic pressure gradient >20mmHg or renal fractional flow reserve <0.8
108
2 components of RVHTN
HTN d/t RAAS + RAS
109
Si/Sx's that may indicate RAS
- Severe/refractory/sudden-onset HTN (e.g. <160/100) - Flash pulmonary edema - Atherosclerosis - Retinopathy - Abdominal bruits
110
Lab findings associated w/ RAS
- Hypokalemia (hyperaldosteronism) - Azotemia s/p ACEI/ARB +/- incr. Cr, proteinuria
111
Gold standard for RAS dx
Renal artery angiography
112
Alternatives to renal artery angiography for RAS dx
- MRA (C/I if CrCl <30) - CTA (C/I if CrCl <60) → preferred for FMD - Duplex US (operator dependent)
113
1st line tx for RAS
Medications → anti-HTN (ACEI/ARB) + statins + antiplatelet
114
When would you prefer CCB over ACEI/ARB in RAS tx
- Bilateral RAS - Single kidney w/ RAS - Can't monitor SCr, electrolytes
115
2nd line tx for RAS
Percutaneous renal angioplasty +/- stenting → preferred for FMD (w/ stent), refractory, intolerance to meds, bilateral RAS or single kidney
116
What is the last line tx for RAS? Indications?
Renovascular bypass → pts w/ unsuccessful PTRAS or extensive atherosclerosis in aorta
117
What is Wilm's tumor?
2nd most common abdominal tumor in children
118
Common metastatic locations for Wilm's tumor
- IVC - Lungs - Liver
119
Is Wilm's tumor curable?
Yes! 90% cure rate w/ resection +/- chemo/radiation
120
Risk factors for cryptorchidism
- Low birth weight | - Premature baby
121
What is cryptorchidism?
Undescended testis mostly d/t gubernaculum defect
122
Most intra-abdominal testes are found ______ in cryptorchidism
Within a few cm of internal inguinal ring
123
Cryptorchidsm hx increases future risk of ____ and ____ and ____
Testicular cancer Infertility (esp. if bilateral) and indirect hernia
124
Refer infants w/out spontaneous testicular descent by _____
6 months (corrected for gestational age)
125
Surgery needed for cryptorchidsm by ____
age 1
126
Pediatric hydroceles are.....
Normal - resolve by age 1
127
Noncommunicating vs communicating hydrocele
- Noncommunicating d/t trauma, inflammation | - Communicating d/t patent processus vaginalis
128
How do you differentiate hydrocele from other penile d/o's?
Transillumination!
129
Tx for hydrocele
Mostly observation | Surgical closure of patent processus vaginalis if communicating hydrocele
130
Varicocele is more common on the....
left side
131
Grading of varicoceles
Grade I → palpable only w/ Valsalva Grade II → palpable at rest but invisible Grade III → easily visible
132
What differentiates varicocele from other penile d/o's?
Bag of worms
133
Tx for varicocele
Nothing or embolization
134
Tx for hypospadias
Nothing or surgery (make sure not to circumcise - need that skin for repair) +/- testosterone pretx
135
Risk factor for hypospadias
Low birth weight
136
Is phimosis normal?
In newborns, yes - usually resolves by adolescence Pathological if difficulty urinating or abdnormal sex
137
Causes of phimosis
- Tip of foreskin too narrow to pass over glans - Inner surface of foreskin fused w/ glans - Frenulum too short to allow for complete foreskin retraction
138
Tx for phimosis
Manual stretching, change masturbation, preputioplasty, circumcision
139
Paraphimosis is....
Urological emergency!! | Ischemia can turn to gangrene or autoamputation
140
Higher incidence of paraphimosis in ____
uncircumcised men (but can happen in circumcised w/ external objects)
141
Tx for paraphimosis
- Gental retraction | - If severe, dorsal split procedure w/ eventual circumcision
142
Testicular torsion is ......
A urological emergency!
143
Irreversible damage after _____ in testicular torsion
12 hrs of ischemia
144
What kind of irreversible damage can occur d/t testicular torsion?
Infertility, even in contralateral testis
145
Manifestation of testicular torsion
- Severe testicular pain - Negative cremasteric reflex - "Bell clapper" sign (high-rising horizontal testis)
146
What kind of imaging can be used to confirm testicular torsion?
US w/ Doppler flow
147
Managment of testicular torsion
Manual/surgical detorsion (most torsions are medially rotated) → bilateral gubernacular fixation after
148
Most prostate cancers are located in ______
Peripheral zone
149
Most common bacterial causes of acute bacterial prostatitis
GNR - most common E. coli & Psuedomonas
150
Risk factors for acute bacterial prostatitis
- UTIs - Prostate bx - Catheter - Structural abnormalities
151
Presentation of acute bacterial prostatitis
- Fever - Dysuria - Perineal, suprapubic, or back pain - Extremely tender, warm, edematous prostate on DRE +/- Urinary retention
152
Labs for acute bacterial prostatitis
``` Leukocytosis w/ left shift UA - pyuria, bacteriuria, hematuria UCx Elevated inflammatory markers (CRP, ESR) Elevated PSA ```
153
Imaging for acute bacterial prostatitis
Usually none unless doesn't improve in 48hrs w/ abx → CT, MRI
154
Indications for admission for acute bacterial prostatitis
- Sepsis - Cant tolerate PO - Concern for adherence - Multiple comorbidities
155
Tx for acute bacterial prostatitis
Bactrim, cipro, levo, gentamycin
156
Si/Sx of chronic bacterial prostatitis
Asx or subtle - LUTS - Low grade fever - Dull pelvic, perineal, testicular pain - Prostate usually not tender
157
Labs for chronic bacterial prostatitis
- UA frequently normal → UCx | - Expressed prostate secretions = WBC, bacteria
158
Imaging for chronic bacterial prostatitis
Usually none - if super chronic, may see prostate calculi on x-ray
159
Tx for chrnoic pbacterial prostatitis
Bactrim (if resistant, quinolones or cephalexin)
160
Inflammatory prostatitis
Prostate pain w/out bacteria; dx of exclusion
161
Labs for inflammatory prostatitis
- UA/UCx normal - Expressed prostate secretions → leukocytosis, incr. macrophages - Prostate bx → inflammatory tissue
162
Tx for inflammatory prostatitis
Tamsulosin or cipro | +/- dutasteride (5-alpha reductase inhibitor) → only in older men b/c affects sperm
163
Classification of epididymitis
Sexually transmitted vs. non-sexual transmitted
164
Most common causes of sexually transmitted epididymitis
Gonorrhea & Chlaymdia
165
Most common causes of non-sexually transmitted epididymitis
E. coli
166
Presentation of epididymitis
- Unilateral pain/swelling - Urethral discharge - Dysuria - Fever - Normal cremasteric reflex
167
Imaging for epididymitis
Scrotal US
168
Tx for epididymitis
- Bed rest, scrotal elevation, ice - Sexually transmitted → azithro, ceftriaxone, doxy - Non-sexually transmitted/low-risk → levo
169
Orchitis is most often associated with _____
Mumps
170
Bacterial causes of orchitis
N. gonorrhea in age 14-35 | E. coli in age <14, >35
171
Presentation
- Associated parotitis 4-7 days prior - Unilateral swollen red testis - Fever, malaise, myalgia
172
Imaging for orchitis
Scortal US to differentiate from epididymitis
173
Tx for orchitis
Supportive - scrotal elevation, NSAIDs, ice
174
Urethritis is most common in ______
Young, sexually active men
175
Causes of urethritis
Gonococcal vs. non-gonococcal (mostly chlamydia)
176
Presentation of urethritis
- Dysuria, pruritus, burning at urethral meatus - Discharge (purulent = gonorrhea, watery = chlamydia) - Non-gonococcal commonly asx - Inguinal LAD
177
Labs for urethritis
- First catch UA → leukocytes | - Gram stain of urethral dischrage (PMN = chlamydia, G- diplococci = gonorrhea)
178
Tx for urethritis
Azithro + doxy + ceftriaxone
179
Classification of testicular ca
- Germ cell tumors → NSGCT vs. seminoma | - Sex cord-stromal tumors
180
Risk factor for testicular ca
Cryptorchidism hx
181
Testicular ca is slightly more common on ________
Right side
182
Presentation of testicular malignancy
- Asx - Painless nodule/enlargement of testis - Gynecomastia if GCT - Supraclavicular LNs
183
Order of operations for dx testicular cancer
Scrotal US → cryopreservation of sperm → CT → serum tumor markers → radical inguinal orchioectomy + retroperitoneal LN dissection to determine histology, staging, tx
184
Scrotal US finding for malignancy
Cystic or fluid-filled mass Hypoechoic w/out cystic area = seminoma Non-homogenous w/ cystic area/calcifications = NSGCT
185
Serum tumor markers for testicular ca
- AFP, HCG elevated in NSGCT | - LDH in any GCT
186
Why do you need to do retroperitoneal LN dissection for testicular ca?
Only reliable method for finding micromets, important for staging, decr. relapse risk
187
Risk factors for prostate Ca
- African ancestry - High dietary fat - FHx
188
Presentation of prostate ca
Most are asx - Abnormaly prostate (nodules, asymmetry, indurated) - LUTS (might be d/t BPH) - Boney pain - LE edema - Urinary retention
189
Screening for prostate ca
DRE + PSA (but PSA not specific)
190
Diagnosis of prostate ca
Abnormal DRE + High PSA + transrectal US-guided bx → can repeat bx 1-2x if negative but PSA high
191
Imaging for staging prostate ca
MRI > TRUS
192
Gleason staging
Prognosis of prostate cancer
193
Main tx for metastatic prostate ca
Palliative androgen deprivation tx (ADT)
194
ED is associated with ___
CAD → ED w/o obvious cause should be screened for CVD
195
peyronie's dz
Penile deformity/curvature d/t subtle trauma/fibrosis
196
Diagnostic studies for Peyronie's dz
- Nocturnal penile tumescence testing (normal = psychogenic/hormonal; impaired = vascular or neurogenic) - Duplex doppler or angio (venous leak or artery obstruction)
197
Tx for Peyronie's dz
PDE-5 inhibitors (sildenafil, vardenafil, tadalfafil, avanafil)
198
C/I for PDE5 inhibitors
Nitrates | Relative C/I w/ alpha-adrenergic antagonists (-zosin)
199
If medical tx didn't work for Peyronie's and your pt doesn't want to resort to surgery yet, what options are there?
- Vacuum-assisted erection device | - Penile self-injection/intraurethral prostaglandin-E1
200
Surgical options for Peyronie's
- Penile prosthesis | - Penile revascularization (super strict criteria)
201
Criteria for priapism
prolonged erection >4 hrs unresolved by ejaculation
202
Priapism is....
Urological emergency
203
Tx for priapism
Nerve block w/ lidocaine → phenylephrine injection → aspirate blood +/- saline irrigation → surgery

Clin Med III (4 decks)

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