Uro/Renal Flashcards

Question

Epididymitis definition, sx, dx, tx

Answer 1

Epididymal pain & swelling thought to be secondary to retrograde infection or reflux of urine – bacterial infection MC Etiologies: *males 14-35: chlamydia trachomatis (MC), Neisseria gonorrhea *men >35: E. coli MC S/SXS: gradual onset (hours to days) of unilateral testicular pain & swelling ▪︎groin, flank, or abdominal pain +/- fever/chills, irritative sxs (urgency, frequency, dysuria) PE: ▪︎scrotal swelling/tenderness ▪︎epididymal tenderness & induration ⊕Prehn sign: relief of pain w/ scrotal elevation ⊕cremasteric reflex: stroking of inner thigh causes elevation of ipsilateral testis dx Scrotal U/S – enlarged epididymis, increased testicular blood flow UA: pyuria (↑ WBCs) or bacteriuria NAAT for gonorrhea & chlamydia tx Scrotal elevation, NSAIDs, cool compresses <35yrs: doxycycline (100mg BID x10d) + ceftriaxone (250mg IM x1) >35yrs: FQs (ciprofloxacin, ofloxacin, levofloxacin)

Answer 2

Serous fluid collection within the layers of the tunica vaginalis of the scrotum Etiologies: idiopathic MCC Types: *Communicating: peritoneal/abdominal fluid enters the scrotum via a patent processus vaginalis that failed to close *Noncommunicating: derived from fluid from the mesothelial lining of the tunica vaginalis (no connection to the peritoneum) sx *painless scrotal swelling PE: *translucency (transilluminates) *fluid located anterior/lateral to the testis dx: Testicular U/S tx Usually no tx needed (watchful waiting) *often resolves within the first 12mo of life in infants *often self-limited in adults Refractory: surgical excision

Answer 3

*cystic testicular mass of varicose veins: pampiniform venous plexus & internal spermatic vein MC surgically correctable cause of male infertility Most are left sided (increased left renal vein pressure transmitted to left gonadal vein) sx Asymptomatic varicocele found in 10% of population *may cause testicular atrophy *usually painless but may ⇢ dull ache, heavy sensation PE: ▪︎“bag of worms” feel superior to testicle ▪︎dilation worsens when pt is upright or w/ Valsalva dx: clinical U/S – dilation of pampiniform plexus >2mm tx Observation in most Surgery: *pain, infertility, delayed testicular growth ASSOCIATIONS: *right sided: retroperitoneal/abdominal cancer *sudden onset left sided in older man: RCC

Answer 4

*spermatic cord twists & cuts off testicular blood supply due to congenital malformation Highest Risk: males 10-20yrs, neonates PATHO: insufficient fixation of the lower pole of the testis to the tunica vaginalis (Bell-clapper deformity), leading to increased mobility of the testicle sx ABRUPT ONSET: scrotal, inguinal, or lower abdominal pain ▪︎N/V PE: ▪︎swollen, tender, retracted testicle (high-riding), may have horizontal lie ⊖Prehn sign: no pain relief w/ scrotal elevation ⊖cremasteric reflex: no elevation of testicle after stroking the inner thigh dx Clinical DX: in pts w/ H&P suggestive of torsion, imaging should NOT be performed **immediate surgical exploration Emergency surgical exploration (definitive) ▪︎preferred over U/S if torsion is very likely Testicular Doppler U/S ▪︎decreased or absent testicular blood flow tx *urgent detorsion & orchiopexy (ideally within 6hrs of pain onset) *irreversible damage after 12hrs *orchiectomy if not salvageable

Answer 5

Definition: consistent or recurrent inability to generate or maintain an erection Risk Factors: atherosclerosis (HTN, smoking, hyperlipidemia, diabetes), meds, sickle cell disease, hx of pelvic surgery or perineal trauma, ETOH abuse, hypothyroidism, congenital penile curvature Medications: beta blockers, thiazide diuretics, spironolactone, CCBs, SSRIs, TCAs Types Vascular: MCC! *atherosclerosis, diabetes, CKD, Neurologic: *stroke, seizures, MS, SCI Psychogenic *abrupt onset *normal nocturnal erections *depression, stress Hormonal: *GnRH, LH, testosterone dx Detailed hx & PE *DRE *neuro exam Labs: CBC, chemistry panel, fasting glucose, lipids Hormones: *serum testosterone *prolactin, thyroid studies Nocturnal penile tumescence: *normal erections 🡪 psychogenic cause Duplex U/S *evaluate penile blood flow tx First line: PDE-5 Inhibitors *Sildenafil, Tadalafil, Vardenafil Second line: intracavernosal injection therapy *Prostaglandin E1 (Alprostadil) *Papaverine +/- Phentolamine Testosterone replacement therapy Surgical: *vacuum pump *penile prosthesis *revascularization surgery

Answer 6

Water inside kidney 🡪 distention/dilation of pelvis and calyces by obstruction of free flow of urine from kidney sx *May be palpable abdominal or flank mass dx *Increased BUN/Cr *Electrolyte imbalance *IV urogram, US, CT, MRI tx *Remove obstruction/drain urine *Nephrostomy tube: upper tract *Catheter: lower tract

Answer 7

Tumor of the proximal convoluted renal tubule cells (they are very metabolically active cells so they are the most prone to dysplasia) 95% of primary tumors originating in the kidney *Clear Cell Carcinoma MC Characterized by lack of warning signs, variable presentations, & resistance to chemo/radiation Risk Factors: smoking, HTN, obesity, men, dialysis, cadmium or industrial exposure sx Triad: *hematuria *flank or abdominal pain *palpable abdominal mass *HTN & hypercalcemia Tumors blocks left testicular vein drainage 🡪 left-sided varicocele *malaise, weight loss METS: cannon ball METS to lungs (MC site); bone dx CT (initial) Renal U/S, MRI Erythrocytosis often present tx Stage I-III: radical nephrectomy *immune-mediated therapy (e.g., interleukin-2 & monoclonal antibody molecular targeted treatment) – usually resistant to radiation/chemo Bilateral involvement of solitary kidney: *partial nephrectomy Advanced disease: *molecularly targeted agents *debulking nephrectomy

Answer 8

HTN secondary to renal artery stenosis of 1 or both kidneys *MCC of secondary HTN PATHO: decreased renal blood flow leads to activation of RAAS Etiologies: *atherosclerosis MC in the elderly *fibromuscular dysplasia MC in women <50yrs sx *HA *<20yrs or >50yrs w/ HTN *severe HTN *HTN resistant to 3 or more drugs PE: *abdominal bruit ACEI 🡪 acute kidney injury!!!!! dx *CT angiography *MR angiography *duplex doppler U/S Renal catheter arteriography 🡪 GOLD STANDARD* tx Definitive 🡪 revascularization *angioplasty w/ stent *bypass Medical: ACEI/ARBs *CI if bilateral stenosis *thiazide diuretics *long-acting CCB *mineralocorticoid receptor antagonist

Answer 9

Types: *calcium oxalate (MC), calcium phosphate *uric acid: high protein foods, gout, chemo *struvite: magnesium ammonium phosphate *cystine: congenital defect in reabsorption sx Renal colic: sudden, constant upper lateral back or flank pain over the CVA radiating to the groin or anteriorly; difficult to find a comfortable position N/V, frequency, urgency, hematuria PE: CVA tenderness dx UA: *hematuria *pH <5.0: uric acid, cystine *pH >7.2: struvite Non-contrast CT abdomen/pelvis KUB x-ray: calcium & struvite stones are radiopaque tx <5mm: - 80% chance of spontaneous passage - IV fluids, analgesics, antiemetics - tamsulosin 5-10mm: - 20% chance of spontaneous passage - extracorporeal shock wave lithotripsy - ureteroscopy w/ or w/o stent: immediate relief of obstruction - percutaneous nephrolithotomy: stones >10mm

Answer 10

Osmolality: dissolved particles per unit mass (mOsm/kg) Osmolarity: solutes concentration per unit volume (mOsm/L)

Answer 11

Crystalloids: aqueous solutions w/ varying concentrations of electrolytes *Most commonly used fluids in hospital setting, ⇡ intravascular (ECF) volume Types: isotonic, hypotonic, hypertonic Colloids: solutions that contain larger molecular weight solutes (e.g., albumin, starch) *solutes mostly remain confined to intravascular compartment *NOT routinely used for fluid resuscitation Natural Colloids: albumin, FFP Artificial Colloids: gelatins, dextrans, hydroxyethyl starch (HES)

Answer 12

HYPOVOLEMIA: *secondary to loss of sodium AND water from ECF *results in compromised tissue perfusion Etiology: *GI losses: vomiting, diarrhea, bleeding *Renal losses: diuretics, hypoaldosteronism, osmotic diuresis via glucosuria, salt-wasting nephropathies *Skin losses: sweat, burns *Third-spacing sequestration: intestinal obstruction, crush injury, ascites, pancreatitis/peritonitis Compensatory Mechanisms: *RAAS activation ⇢ Na & H2O reabsorption *ADH release ⇢ H2O reabsorption DEHYDRATION: *H2O loss from ICF ⇢ ECF hypertonicity (⇡ Na) *H2O net shift: ICF ⇢ ECF Etiology: insensible losses, diabetes insipidus S/SXS: secondary to hypernatremia (e.g., HA, confusion, dizziness) Compensatory Mechanisms: *activation of thirst center ⇢ increased intake *ADH release ⇢ H2O reabsorption

Answer 13

hypovolemia = Na and H2O loss dehydration = free water loss

Answer 14

S/SXS related to VOLUME DEPLETION: *lack of energy, easy fatigability, thirst, muscle cramps *postural dizziness, oliguria S/SXS related to FLUID LOSS ETIOLOGY: *V/D, polyuria, severe skin burn *pain caused by underlying third-spacing mechanism S/SXS related to ELECTROLYTE ABNORMALITIES: *hyponatremia ⇢ N/V, lethargy, confusion, seizures *hyperkalemia ⇢ N/V/D, ileus, muscle weakness *acidosis ⇢ tachypnea *alkalosis ⇢ neuromuscular irritability (spasms) Physical Exam: *⇣ interstitial volume ⇢ skin/mucous membrane signs ▪︎ dry skin, ⇣ turgor, tenting, dry mucous membranes *⇣ plasma (intravascular) volume ⇢ SBP & JVP reductions ▪︎ SBPΔ as severity of volume deficit increases ⤷ ~NML ⇢ orthostasis ⇢ posture-independent low SBP ▪︎ ⇣ intensity of Korotkoff sounds & radial pulse ▪︎ ⇣ JVP *Hypovolemic Shock ⇢ tachycardia, cold/clammy extremities, cyanosis, low UO <15mL/h, agitation, confusion

Answer 15

LABS: *low urine volume (oliguria) *BUN/creatinine ratio >20:1 *d/t ⇡ Na reabsorption & resultant ⇣ urea excretion ▪︎ ⇡ BUN (ref. 5-20mg/dL) ⇢ prerenal azotemia ▪︎ creatinine ⇡ only if loss severe enough to ⇣ GFR *hyponatremia (ref. 135-145mEq/L) *hyperkalemia (ref. 3.5-5.0mEq/L) *acid-base disturbances *depends on mechanism of loss ▪︎ vomiting, diuretics (H+ loss) ⇢ metabolic alkalosis ▪︎ diarrhea (HCO3 loss) ⇢ metabolic acidosis *Hct & albumin *depletion of plasma volume ▪︎ ⇡ Hct (i.e., relative polycythemia) ▪︎ ⇡ albumin (ref. 3.5-5g/dL) DX: clinical, confirmed by low urine Na concentration *urine Na <20mEq/L *FENA <1% *urine osmolality concentration >450mOsm/kg ▪︎ specific gravity >1.015 *UA normal in hypovolemia since kidney is not diseased ▪︎ i.e., ⊖protein, ⊖cells/casts

Answer 16

Resuscitation: IV fluid boluses *20mL/kg IV NS or LR Maintenance: *calculate maintenance rate *D5½NS + 20mEq KCl preferred Monitor: I&Os, electrolytes, weight

Answer 17

Isotonic Hypervolemia (salt gain = H2O gain): *intravascular overload of IV fluids w/ electrolytes *postop/trauma stress causing ⇣ Na/H2O excretion *renal insufficiency, cirrhosis, CHF Hypotonic Hypervolemia (salt gain < H2O gain): *replacement of GI losses w/ NaCl-poor solutions *third-spacing, ⇡ ADH w/ surgical stress, SIADH Hypertonic Hypervolemia (salt gain > H2O gain): *excessive Na load w/o adequate H2O intake sx *tachypnea, orthopnea, weight gain *pulmonary edema, crackles, rales *ascites, pleural effusions *⇡ JVD, peripheral edema, oliguria Hypertonic ⇢ symptoms of sodium excess *HA, confusion, dizziness, etc. DX: mainly clinical *serum Na (ref. 135-145mEq/L) Supportive labs/imaging: *CXR, ECHO *NT-proBNP tx *sodium & water restriction *loop diuretics *dialysis may be required if severe

Answer 18

Autosomal dominant polycystic kidney disease (ADPKD) is a relatively common genetic condition resulting from mutation of the PKD1/PKD2 gene Growth of numerous cysts in kidneys made of epithelial cells from renal tubules; can 🡪 kidney failure/ESRD sx *>30yrs, + family hx, abdominal mass Classic presentation 🡪 young pt w/ back/flank pain & HTN 10% have brain aneurysms (worry when they complain of the worse HA of life) Cardiovascular abnormalities: MVP, LVH dx U/S 🡪 many fluid-filled cysts CT: large renal size; multiple thin-walled cysts Anemia UA: *proteinuria, hematuria *pyuria, bacteriuria tx No cure!!! BP control – ACEI/ARB for HTN Treat infections w/ abx Dialysis/transplant w/ renal insufficiency

Answer 19

Adenocarcinoma MC type (95%) *peripheral zone MC area Risk Factors: age, family hx, AA Screening: DRE & PSA level *white male = 50yrs *black male, + FH, or +BRCA mutation = 40yrs sx *difficulty w/ urination *frequency, urgency, urinary retention *decreased urinary stream DRE: *hard, indurated, nodular, enlarged, asymmetrical prostate Back or bone pain 🡪 METS dx PSA (normal <4ng/mL), DRE, transrectal U/S *PSA >10 🡪 transrectal U/S w/ bx *abnormal DRE 🡪 transrectal U/S w/ bx *PSA <4, normal DRE 🡪 annual follow-up *PSA 4-10, normal DRE 🡪 bx recommended If PSA >10 🡪 order bone scan to r/o METS Gleason grading system tx Radical prostatectomy – complication: ED w/ METS: androgen deprivation therapy (leuprolide) Monitor PSA: should be <0.1

Answer 20

Prostate gland inflammation secondary to an ascending infection Acute: *>35yrs: E. coli MC *<35yrs: gonorrhea & chlamydia Chronic: *E. coli MC *proteus sx Irritative voiding sxs: frequency, urgency, dysuria Obstructive sxs: hesitancy, poor or interrupted stream, straining to void, incomplete emptying Acute: exquisitely tender prostate *fever, chills, perineal pain Chronic: nontender (or minimally tender) prostate *usually presents as recurrent UTIs or intermittent dysfunction PE: boggy prostate!!!!! dx UA & urine culture: *acute: pyuria & bacteriuria *chronic: + after massage! AVOID prostatic massage in acute (may cause bacteremia) tx Acute: >35: FQs or TMP-SMX x4-6wks <35: ceftriaxone + doxycycline Chronic: FQs or TMP-SMX x6-12wks *tamsulosin can help w/ chronic pain Refractory (chronic): TURP

Answer 21

PATHO: usually an ascending infection of the lower urinary tract from the urethra Etiologies: *E. coli MC *staph saprophyticus 2nd MC in sexually active sx Irritative sxs: dysuria (burning), frequency, urgency *hematuria, suprapubic pain & tenderness dx UA: pyuria (>10WBCs/hpf), hematuria, leukocytes esterase, nitrites, cloudy urine, bacteriuria Urine culture: definitive *epithelial (squamous cells) = contamination tx - nitrofurantoin or TMP-SMX - FQs second line (“floxacin”) - phenazopyridine (analgesic) *turns urine orange

Answer 22

Infection of the upper GU tract (kidney parenchyma & renal pelvis) PATHO: usually an ascending infection of the lower urinary tract Etiologies: E. coli MC Risk Factors: DM, hx of recurrent UTIs or kidney stones, pregnancy, congenital urinary tract malformations sx Upper tract sxs: fever, chills, back/flank pain; N/V Lower tract sxs: dysuria, urgency, frequency PE: + CVA tenderness Fever, tachycardia dx UA: *pyuria (>10WBCs/hpf) *leukocyte esterase *nitrites *hematuria, cloudy urine *WBC casts – HALLMARK CBC: leukocytosis w/ left shift Urine culture: definitive tx Outpatient: FQs first line (“floxacin”) Inpatient: cephalosporins, FQs, aminoglycosides, penicillins ADMIT: older age, signs of obstruction, comorbid conditions, inability to tolerate PO abx Pregnancy: IV ceftriaxone

Uro/Renal Flashcards

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