Renal Approach to hematuria, dysuria, and nocturia

Question 1

upper DDx of Hematuria

Answer 1

Renal malignancy
Renal cysts
Urinary stones
Glomerulonephritis
UTI 
-pyelonephritis
-Cystitis

Question 2

lower DDx of hematuria

Answer 2

Bladder cancer
Bladder stone
Hemorrhagic cystitis (cyclosphamide)
BPH
Prostate cancer
Urethritis
Urethral trauma (urinary cather)

Question 3

what is an uncomplicated UTI

Answer 3

acute cystitis or pyelonephritis in a non pregnant outpatient woman without any anatomic abnormalities or urinary instrumentation

Question 4

what are complicated UTI and some examples

Answer 4

UTIs that are associated with factors increasing colonization and decreasing efficacy of therapy

• Pregnancy
• Urinary retention or obstruction
• renal failure
• renal transplant
• Males
• Anatomic abnormalities
• Urinary catheter or urinary instrumentation
• immunocomprimised

Some references include all pyelonephritis cases

Question 5

what is definition of recurrent UTI

Answer 5

> 2 infections in six months or >3 infections in one year

Question 6

what is the definition pf asymptomatic bacteriuria

Answer 6

Bacteriuria present on urine culture but no clinical UTI symptoms present in patient

Question 7

what is definition of Catheter-associated UTI (CA-UTI)

Answer 7

UTI associated with placement of urinary catheter or within 48 hours of removal

Question 8

what are the major risk factors for UTIs

Answer 8

Female sex
Hx of UTI
Sexual activity
Condom/diaphragm/spermicide use
Vaginal infection
Indwelling urinary catheters
DM
Obesity 
Immunosuppression
Urinary tract abnormalities

Question 9

what is the pathogenesis of UTIs

Answer 9

Uropathogenic bacteria colonizing the GI tract, perineium, or vagina inoculate the urethra and ascend into the bladder

Question 10

Common UTI pathogens

Answer 10

Gram Negative:

• E Coli
• Klebsiella pneumonia
• Proteus mirabillis
• pseudomonas aeruginosa

Gram Positive:

• Enterococcus species
• Staphylococcus saprophyticus
• Group B streptococcus

Question 11

Classic presentation of cystitis

Answer 11

Dysuria
Urinary frequency
Urinary urgency

suprapubic abdominal pain
gross or microscopic hematuria

Question 12

Classic presentation of Pyelonephritis

Answer 12

Fever/chills/rigors
Flank pain
CVA tenderness on exam
Fatigue
Nausea/vomitting and anorexia

Question 13

what is a common presentation of UTI in older adults

Answer 13

Altered mental status

Question 14

what are some complications of UTIs

Answer 14

Sepsis and septic shock
AKI
Perinephric abscess
Emphysematous pyelonephritis
Papillary necrosis

Question 15

what are the diagnostic tools of UTIs

Answer 15

Urine dipstick

• Leukocyte esterase
• Nitrates
• Blood
• color is cloudy

Urinalysis with urine microscopy

• Hematuria
• pyuria
• WBC cast
• Bacteria present

Urine culture with sensitivities

Question 16

what is seen on Urine culture with sensitivities to know a true UTI

Answer 16

True UTI have > 10,000 CFU (colony forming units/ml)

Question 17

what is the treatment of Uncomplicated cystitis?

Answer 17

Nitrofurantoin
Trimethoprim-sulfamethoxazole DS
Fosfomycin

second line antibiotics

• Fluoroquinolones
• B-lactams

Question 18

what is the treatment of acute pyelonephritis or complicated UTI?

what is the treatment of asymptomatic bacteriuria?

Answer 18

if no hospitalization is required oral antibiotics
if hospitalization is required treat with IV antibiotics

no treatment is needed of asymptomatic bacteruria unless patient is pregnant

Question 19

how soon should Urinary catheters be removed?

Answer 19

AS SOON AS POSSIBLE

Question 20

what is prostatitis and what are the risk factors

Answer 20

infection of the prostate gland
-more common in young and middle aged men

risk factors:

• functional or anatomical anomalies
• Urinary tract instrumentation
• UTIs
• Diabetes
• Smoking
• HIV

Question 21

what are the typical bacteria in Prostatitis

Answer 21

Gram negative bacilli:

• E.Coli
• Klebsiella pneumonia
• proteus mirabilis
• pseudomonas aeruginosa

Gram positive cocci

• entercococcus species
• normal skin flora

Question 22

Classic presentation of acute bacterial prostitis

Answer 22

Patients typically appear acutely ill
-fever chills, malaise, N/V, and even signs of sepsis

Irritate voiding symptoms

Obstructive symptoms

suprapubic or perineal pain

Question 23

classic presentation of chronic bacterial prostatitis

Answer 23

Patients typically present with more subtle signs and symptoms compared to acute prostatitis

symptoms of recurrent UTIs

Obstructive symptoms

suprapubic or perineal pain

pain with ejaculation or blood in semen

Question 24

what is the diagnosis of acute or chronic prostatitis

Answer 24

Acute:

• digital rectal exam
• urinalysis and urine culture

Chronic prostatitis

• digital rectal exam
• urinalysis and urine culture
• diagnostic standard is prostatic massage (4 glass test or 2 glass test

Question 25

What is the treatment of prostatitis and for how long?

Answer 25

Fluoroquinolones Trimethoprim-Sulfamethoxazole duration of antibiotics is 4-6 weeks

Question 26

what are the risk factors of BPH

Answer 26

``` age metabolic syndrome Obesity genetic susceptibility excessive coffee or caffeine intake ```

Question 27

Pathogenesis of BPH

Answer 27

results from increased total number of stromal and glandular epithelial cells within the prostate

Question 28

pathogenesis of Lower urinary tract symptoms

Answer 28

Bladder outlet obstruction (BOO) from BPH | and detrusor muscle overactivity secondary to BOO

Question 29

Clinical presentation of BPH and LUTs

Answer 29

Storage symptoms: -urinary frequency, urgency, nocturia, and urinary incontinence Voiding symptoms -slow urinary stream, straining to void, urinary intermittency (starting/stopping micturition), splitting of voiding stream, terminal dribbling

Question 30

Diagnosis of BPH

Answer 30

``` Digital rectal exam Urinalysis BMP Prostate specific antigen -often elevated in BPH ``` Post void residual U/S

Question 31

Pharmacologic Treatment of BPH

Answer 31

A1-blockers - tamsulosin, alfuzosin, doxazosin - improvement in 1-2 weeks 5a-reductase inhibitors - finasteride, dutasteride - improvement in 6-12 months Anticholinergic agents - oxybutynin, tolterodine, fesoterodine, darifenacin - decrease detrusor muscle contraction Phosphodiesterase 5-inhibitors - used mainly in erectile dysfunction and LUTs - tadalafil

Question 32

what is a surgical treatment for BPH

Answer 32

Transurethral resection of prostate (TURP) simple prostatectomy - open - laparascopic - robotic-assisted

Question 33

what is the DDx of Nocturia

Answer 33

``` Urinary incontinence Diuretics BPH UTIs Primary polydipsia Polyuria\-Diabetes insipidus ```

Question 34

what is the likelihood of getting a symptomatic stone recurrence at 1, 5, and 10 years

Answer 34

15% at 1 year 35% to 40% at 5 years 50% at 10 years

Question 35

what is the percentage of kidney stones that are calcium?

Answer 35

80%

Question 36

what are the classical symptoms of Nephrolithisis

Answer 36

Intermittent, severe flank pain that radiates to groin Hematuria -gross of microscopic Gravel passage or visualized stone passage nausea/vomitting

Question 37

What are complications of Nephrolithiasis

Answer 37

Hydronephrosis can lead to AKI or CKD recurrent urinary infections if stones become infected

Question 38

what are the diagnosis of nephrolithiasis

Answer 38

Non-contrast CT abdomen and pelvis -renal stone protocol CT can do: - Kidney Ureter bladder x ray - renal and bladder U/S - Urinalysis with microscopy - strain urine - Metabolic evaluation after stone

Question 39

what stones are radioopaque and what are radiolucent?

Answer 39

radiopaque: calcium oxalate/phosphate and struvite (can see) Radiolucent: uric acid and cystine: (cant see)

Question 40

``` stone shapes: Cystine crystals? Uric acid crystals? Struvite? Calcium oxalate monohydrate? Calcium oxalate dihydrate? ```

Answer 40

Cystine crystals = hexagonal crystal Uric acid crystals = Rhombic plates or rosette shaped crystals Struvite (MAP) = coffin lid crystal Calcium oxalate monohydrate = dumbell-shaped crystals Calcium oxalate dihydrate = envelope shaped crystal

Question 41

Medical therapy for Nephrolithiasis

Answer 41

``` Fluids Pain control Anti nausea medication Expulsive therapy (dilates ureter) -alpha blocker -calcium channel blocker (nifedipine) ```

Question 42

Surgical therapy for Nephrolithiasis

Answer 42

- Extracorporeal sock wave lithotripsy - ureteroscopy with basket stone extraction - percutaneous nephrolithotomy (PUL) or open nephrolithotomy