Urology Flashcards
(111 cards)
1
Q
evaluation and tx of urinary retention
A
- Placement of foley catheter and UA
- Imaging indicated only if infection or stones suspected
- Patients d/c home with foley in place, urology follow up (leave in w/ BPH, post surgery)
- NO ABX UNLESS HIGH RISK
- consider alpha adrenergic blockers (tamsulosin) after urologist consult (postural hypotension)
2
Q
how do you get a clean UA sample w/ a woman on her period?
A
quick in and out cath to prevent tampon/blood contamination
3
Q
__% of females and ___% of males will experience kidney stones
A
5% F
12% M
3:1 M:F
4
Q
contraindications for IVPs
A
- allergy (0.1%) affected,
- DM
- RI creatinine over 1.8
- dehydration
- multiple myeloma
- patients on glucophage (fatal metabolic acidosis)
5
Q
tx of intestital nephritis/renal ARF
A
- Discontinue the offending drug
- Self limited if recognized early, may require brief dialysis
- Corticosteroids
6
Q
how do you dx pyelonephritis
A
- CVA tenderness
- UA: dip will show protein, LE, nitrites
- Micro: WBC’s bacteria, WBC casts,
- Urine Cx +
- CBC: leukocytosis with left shift
7
Q
medical tx for kidney stones
A
Calcium oxalate stones: Hypercalciuria: thiazide diuretic + potassium citrate
Uric acid stones:
- Increase urine pH to 6.5-7.0
- Potassium Citrate
- Allopurinol
8
Q
presentation of acute cystisis
A
- Dysuria
- Frequency
- Urgency
- Suprapubic pain
- Hematuria- Amount of blood in urine is NOT proportional to the size of the stone
- Low grade fever
9
Q
sudden and severe drop in blood pressure (shock) or interruption of blood flow to kidneys from severe injury or illness
A
pre-renal ARF
10
Q
PE findings of ARF
A
- Look for evidence of either hypovolemia (tachycardia, orthostatic VS, decreased skin turgor)
- Hypervolemia (S3, JVD, edema, rales)
- Percuss the bladder ( percussable with 150 ml, palpable with 500 ml urine)
- U/S can tell you how much urine is in bladder
11
Q
what causes staghorn calculi
A
struvite stones
12
Q
what type of kidney stones do not cause pain?
A
intra-renal stones (actually in the kidney or bladder)
13
Q
urinalysis and urine culture findings w/ renal colic and their associated ddx
A
- hematuria- does not correlate w/ % of obstruction- inflammation (ie. appendicitis)
- pyuria– inflammation or bacteriuria infection
- crystals– may correspond to stone type
- pH over 7.6– proteus infection or Renal tubular acidosis (RTA)
14
Q
what are the 3 mechanism of ARF
A
- preprenal (50%) – perfusional/shock
- intrarenal–glomerular, tubular, interstitial
- postrenal– obstructive
*Usually rule out pre and post renal before considering the many intrinsic causes
15
Q
dx of prerenal AFR
A
- Urine spec grav over 1.030- (concentrated)
- Serum Bun/Creatinine over 20
- Urine osmolality over500 (H)
- FENA less than 1
16
Q
PE findings of kidney stones
A
- Vitals: tachy, HTN, tachypnea, diaphoresis (if hypotensive be concerned)
- fever– stone that is secondarily infected
- flank tenderness, CVA tenderness
- Abdominal tenderness but without peritoneal signs. Pain should not be exacerbated with exam. (NO POINT TENDERNESS)
- BS hypoactive
- IMPORTANT TO ASCULATE FOR BRUITS
17
Q
describe when each procedure is indicated:
- ESWL (extracorporeal shock wave therapy)
- Percutaneous Nephrolithotomy
- renal stents
- ureteroscopy
A
- ESWL (extracorporeal shock wave therapy)- for renal stones less than 2cm
- Percutaneous Nephrolithotomy- renal stones over 2cm or proximal ureteral stones less than 1cm
- renal stents
- ureteroscopy- distal ureteral stones
18
Q
tx of glomerulonephritis/ renal ARF
A
- high dose corticosteroids,
- possible exchange transfusions until chemotherapy.
19
Q
tx of chronic renal failure
A
- Good management of underlying condition (ie. good control blood sugars)
- Dialysis
- Transplantation
20
Q
struvite stones/staghorn calculi requires what type of environment?
A
pH greater than 7.2 and ammonia (caused by UTIs) Proteus is the most common organism
21
Q
what does IVP evaluate?
A
- evaluates renal function
- it visualizes the entire urinary tract
- assesses the function of the kidney
- degree of obstruction
22
Q
a stone must be how big to show up on a KUB image
A
2mm
23
Q
when is flomax less helpful in kidney stones?
A
- smaller stones
- ppl with hypotension
24
Q
clinical presentation of kidney stones
A
- severe renal colic on affected side
- pt constantly moving trying to find a position of comfort
- visceral pains (caused by distention of the ureter)
- N/V
*not typically shocky– if hypotensive think about other things
25
does cranberry juice help with UTIs?
- Cranberry Juice contains 3 proanthocyanidin chemical compounds which prevent the adherence of E. coli to the uroepithelial cells.
- 200-750 ml of juice or daily cranberry tablets may reduce infection by up to 20%
*but very sugary!!
26
struvite stones/staghorn calculi is most commonly seen with what?
FB in urinary tract and neurogenic bladder
*proteus is the most common organism
27
most common microscopic finding w/ pyelonepthritis
WBC casts
28
what is the tx for UTIs
1. 7 day course of nitrofuratoin 100mg BID in women (7 day course in children and men too)
2. 3 day oral coures of TMP/SMZ (have increasing resistance patterns)
3. Fosomysin (monurol) 3g oral ($$)
4. increase fluids
5. Urinary tract analgesic (phenazopyridine)
6. longer course (7-10 days) in preg, DM, elderly recurrences
29
what is acute renal failure
Sudden decrease in Renal function resulting in an inability to maintain fluid and electrolyte balance and excrete nitrogenous wastes
- Failure is defined as a 2-3 fold increase in serum creatinine +/- a decrease in urine out put of less than 5 cc/kg/hr for 24 hours
* serum creatinine is most useful marker
30
what group of people are at greatest risk for kidney stones
- 70% between 20-50y/o
| - Caucasians (rare in AA and NA)
31
dx of intestital nephritis/renal ARF
Diagnosis: fever, azotemia, rash, arthralgias
Urine micro: pyuria, esp. eosinophiluria**, WBC casts, hematuria
renal biopsy*
32
what do these casts typically suggest?
- WBC casts
- Muddy brown casts
- Red cell casts
WBC casts= pyelonephritis or interstitial nephritis/renal ARF
Muddy brown casts= Acute tubular necrosis
Red cell casts= glomerulonephritis
33
Calcium Oxalate stone are associated w/ what?
1. hypercalcemia from primary hyperparathyroidism
2. hypercalciuria
3. malignancy
4. sarcoid
5. hyperoxaluric states (a lot of sweet tea) from:
- Crohns
- Jejunal ileal bypass
- small bowel disease
34
what meds can cause urinary retention?
1. anti-cholinergic medications (w/ BPH and strong anti-emetic),
2. antihistamines
3. ephedrine and amphetamines
35
____ may cause hydronephrosis due to compression, and hematuria (ureteral irritation)
rupturing AAA
36
dx of glomerulonephritis/ renal ARF
Dependent edema and hypertension
UA shows red cell casts
37
pros of helical CT for kidney stones
1. Fast, no contrast
2. IDs the stone anywhere along the GU tract
3. accurately sizes the stone
4. Hounsfield typing may differentiate type of stone, less than 400 consistent with uric acid
5. May give information about other intra-abdominal structures (AAA, mass)
38
SE of of phenazopyridine
Urinary tract analgesic-- stains tears (no contacts) and urine
39
why are NSAIDs beneficial for renal colic
- non-sedating
- no ureteral spasm
- no effects on hemodynamics
*keterolac (Toradol) or diclofenac most widely used
40
prior to all radiation tests (ie. CT) think about what type of study for females?
serum pregnancy test
41
common causes of urinary retention
1. usually secondary to obstruction (ie. prostate BPH or post-op)
2. women: MS**, UTI (spasm), prolapse of bladder/rectum/or uterus
3. medications
42
risk factors for renal artery embolus
* embolic diseases
1. Afib
2. PVD
3. IVDU
43
ARF renal causes
- ATN (acute tubular necrosis) (85%)-- from ischemia or toxin
- Interstitial Nephritis (10-15%)
- Glomerulonephritis (5%)
44
acute inpatient tx of pyelonephritis
- Child, pregnant pt, acutely ill
- IV abx usually ampicillin and Gentamycin to start
- Consider follow up C&S
45
____ as indicated for renal colic, a good idea before contrast studies
SPT
46
with prerenal AFR, all shock syndromes implicated including:
1. septic
2. cardiogenic
3. hemorrhagic
4. hypovolemic
*if you can fix the shock, you fix the kidneys if caught in time
47
Uric acid is associated w/ what
1. super saturation of urine w/ uric acid
| 2. 20% of gout patients develop these
48
procedures for stone removal
1. ESWL (extracorporeal shock wave therapy)
2. Percutaneous Nephrolithotomy
3. renal stents
4. ureteroscopy
49
gold standard of cystisis/UTI
urine culture
* not in ED though due to length of time getting results-> does not guide ED management
- useful in cases of tx failure, preg, or diabetic, and complicated UTI
50
how is a diagnose of kidney stones made w/ US
Diagnosis of stones is made through visualizing obstruction specifically hydronephrosis*
51
clinical presentation of renal artery embolus
1. pain
2. hematuria
3. vomiting
4. appear more sick than kidney stones
*difficult to distinguish from a stone
52
disadvantages of helical CT
1. Less information about the degree of obstruction as compared with IVP
2. May not be readily available
3. Radiation exposure similar to IVP
53
Pros and cons of KUBs
Pros:
- helpful in pts w/ documented stones presenting to ED
- may be useful after CT
- radio-opaque stones will show up
Cons:
- uric acid stones won't show up
- limited by gas patterns, fecoliths, pleboliths, small stones
- must be 2cmm to be visible on fims
- no info on fxn of kidney
54
presentation of ARF
1. Azotemia= nitrogenous waste accumulation (increase BUN/Cr)
2. Uremia= symptomatic azotemia- nausea, vomiting, lethargy, AMS
55
causes of non-infectious dysuria
1. trauma- rough or frequent intercourse
2. decreased estrogen in postmenopasual women-- leads to atrophic vaginitis
3. scented soaps or lotions
56
DDX for kidney stones
1. AAA--> listen for bruit
2. Renal Artery thrombosis/embolism
3. Testicular torsion
4. Ectopic pregnancy
5. Appendicitis
6. Cholecystitis
57
what organisms more commonly cause cystisis?
(KEEP)
| Klebsiella, Enterobacteria, E. coli, proteaus
58
sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumor, or injury
-nursing home female patients, and males with large prostates
postrenal ARF
59
positive urine cultures is defined as what?
over 105 colony forming units/hpf
60
with ED evaluation of ARF, first r/o life threatening complications:
- Hyperkalemia (check Chem7 and EKG)
- Pulmonary edema (SOB, cough, pericardial effusion)
- Pericardial effusion
61
when can you see WBC and RBC in the urine w/ AAA or an inflammatory process (appendicitis, cholesysitis)?
when it presses against ureter
62
sx of pyelonephritis
1. fever
2. flank pain
3. myalgia
4. anorexia
5. N/V
6. urinary sx
63
what are the top 2 etiologies of chronic renal failure
1. DM- normal sized kidneys
| 2. HTN- small kidneys
64
presentation of urinary retention
1. Straining to void
2. Decrease in force of urine stream
3. Interruption of urination
4. Sensation of incomplete emptying
5. Irritative sx: frequency, dysuria, urgency, nocturia
*can lose bladder tone
65
when do you order blood labs for renal colic?
- CBC only if concerned about infection (immunocompromised)
| - Chem 7 (electrolytes, BUN, creatinine) order prior to a contrast study
66
standard for renal stone imaging in ED
helical CT
67
If an AAA is misdiagnosed, it is most likely called ___
renal colic
68
general guidelines for pts with kidney stones
1. Increase fluids to ~ 3 L/day for u/o of 2 L/day ( want Dilute urine)
2. Normal calcium intake (don’t take tums or Ca2+ supplement– real food Ca2+ sources)
3. Decrease sodium intake
4. Decrease oxalate (chocolate, nuts, black tea, dark roughage) and avoid excess vitamin C supplements
5. Decrease protein
69
describe what an ESWL procedure is
- stone removal procedure
- Done under fluoroscopy (US pulsations to break up stones)
- Stones are crushed and passed in 2 weeks
- Indicated for renal stones less than 2cm***
70
what are imagings 4 fxns?
1) Confirms diagnosis
2) R/O other serious disorders
3) defines site of stone
4) Detects or R/O serious complications such as obstruction
71
common drug offenders that cause ATN/renal ARF
1. aminoglycosides,
2. amphotericin,
3. contrast dye, 4. cyclosporines
*Loop diuretics may help in fluid overload, may require dialysis
72
important history questions to ask when assessing for possible kidney stones
1. Previous episodes of renal colic
2. Recurrent or Chronic UTI’s
3. Family history for hereditary disorders causing stones.
4. Immunocompromise
5. Solitary functioning kidney, or transplant (don’t miss this)
6. Bone pain, fractures (hyperparathyroidism), gout, PUD
7. Diet, antacid use
73
outpatient tx of pyelonephritis
Oral fluoroquinolone (Ciprofloxin 500 mg bid) for 14 days +/- 400 mg IV loading dose or 1gm IV Ceftriaxone q 24 hours until oral medication can be tolerated.
74
describe what a percutaneous nephrolithotomy is
-Percutaneous stent is placed through the back under anesthesia to drain obstruction and remove renal stones over 2cm or proximal ureteral stones less than 1cm
75
Pros and cons of ultrasound for kidney stones
Pros:
- study of choice in preg. pts
- best at showing stones in renal calyx and UVJ
Cons:
- operator and anatomy dependent (due to overlying structures)
- poor for showing ureteral stones
- can't size calculi (indirectly looks at obstruction)
76
describe an ureteroscopy
- Indicated for distal ureteral stones
- Outpatient procedure, usually requires sedation
- May require placement of a stent
77
gold standard test for urolithiasis and its complications?
IVP (intravenous pyelogram)
*rarely used in ED though
78
criteria for admissions/consultation w/ kidney stones
1. Intractable vomiting
2. Uncontrolled pain
3. Single kidney or transplanted kidney with obstruction
4. Concomitant UTI with obstruction
5. ? High grade obstruction or stones greater than 8 mm
6. Bilateral stones
7. Social issues
79
IVP disadvantages
1. May not directly visualize stone and may not accurately size the stone
2. Time consuming (over 1hr)
3. Contrast and radiation exposure
80
complications of a percutaneous nephrolithotomy procedure
- bleeding
| - injury to collecting system and infection
81
__% of ICU admissions have ARF
| ___% of hospitalized patients develop ARF
30%
25%
82
what imaging is helpful w/ dx of AFR
1. Renal Ultrasound- May show obstruction upper or lower tract, small kidneys, hydronephrosis
* CT not used as contrast may cause more injury
83
what meds are most commonly used in the ED for renal colic?
Analgesia: nacrotics/NSAIDS, anti-emetics (zofran), and toradol/diclofenac
84
when do complicated UTI most commonly occur?
1. pyelonephritis
2. catheter, stent or tube in GU system
3. Males (r/o other STDs or autoimmune)
4. obstructive stone
5. preg.
6. DM severe
7. anatomic abnl
8. CA or immune suppression
9. hospital UTI
10. tx failure
85
ddx/cautions of cystisis
1. non-infectious dysuria
2. kidney stone
3. sterile pyuria
4. unclean specimen
86
what people with kidney stones need imaging?
1. first time stones should be imaged
2. Frequent stone formers who are not infected and symptomatically improved, do not require a study
3. History of IVDU requires a study
87
important things to consider with renal stents
- may become obstructed
- KUB is helpful in verifying placement
- check for UTI
88
types of kidney stones
1. Calcium oxalate (80%)
2. Struvite (2-20%)-- fill renal calyx
3. Uric acid (6%)-- easily passed
4. Cystine (1%)-- only occurs in pts w/ cystinuria
others: dihydroxyadenine, xanthine, silicate, triamterene, silicate
89
complications/contraindications for an ESWL procedure
Complications:
- hematoma formation
- ureteral obstruction from stone fragments
Contraindications:
-for women of childbearing years, ? Impact on the ovary
90
what are triple phosphate stones
struvite stones/staghorn calculi
*composed of phosphate, ammonium, and magnesium
91
what stones are likely to pass?
1. less than 4mm= 75% will pass
2. 4-5mm= 50% will pass
3. 6mm= 10% will pass
4. greater than 10mm usually require urologic interventions
*intercourse helps pass distal renal stones in UVJ
92
____% will have a recurrence within 5 years, ___ within 1 year
50%
1/3
93
outpatient follow up for kidney stones
1. stone analysis
2. complete urinalysis +/- 24 hr urine
3. blood chemistry
94
complications of an urteroscopy procedure
ureteral stricture
95
dx of ARF
1. microscopic UA
2. BUN, creatinine, urine sodium and FENA equation
3. CBC, chem7, CXR, EKG
4. renal U/S
96
out patient care for kidney stones
1. set home w/ NSAID, narcotic, and anti-nausea meds
2. flomax or calcium channel blocker in select pts
3. adequate hydration to produce CLEAR URINE
4. offer strainer until stone passes
5. RTC precautions: uncontrollable pain, vomiting, fever, abdominal pian (worry about secondary infection)
97
Areas of stone impaction
1. Renal calyx (tougher to get impacted unless renal stagehorn)
2. Ureteropelvic junction (where ureter comes into calyx)
3. UVJ-smallest diameter in the urinary tract--Most common site of impaction
98
how does kidney stone location correlate with pain
1. Stones in the kidney = flank pain
2. Stones in proximal to mid ureter = flank pain, anterior abdomen to lower quadrant
3. Stones at the UVJ (ureteral vesical junction)= labia, scrotum, groin region
4. UVJ and bladder stones may cause urgency, and dysuria as well as pain, or urinary retention
99
direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduce blood supply
intrarenal ARF
100
causes of glomerulonephritis/ renal ARF
-Immune deposition causes, vaculitis, anti glomerular basement membrane disease (goodpasture syndrome)
**often caused by strep. pneumococcal complication
101
dx of ATN
1. BUN ration less than 20:1, FENA less than 1%
| 2. Microscopic: renal tubular epithelial cells, muddy brown casts*
102
tx recommendations for uric acid stones
- diet changes
- allopurinol
- increased water intake to prevent further stones
103
tests to assess renal artery embolus
1. IVP (study of choice)
2. angiogram
3. non-contrast CT-does not give info on renal fxn or blood flow
4. elevated CPK
5. arteriogram= definitive study
104
what patients do you need to be very cautious with when determining btwn renal colic and AAA
pts over 50y/o w/
1. flank pain
2. H/O tobaccos
3. HTN
4. PVD
105
what organism most commonly causes pyelonephritis
E coli 75% of time
106
ED role in renal colic
1. relieve pain
2. exclude life threatening diagnoses (AAA)
3. provide appropriate disposition, f/u and instructions for returning
4. hydration??- if needed
*not every pt needs a definitive dx
107
what type of stones are not seen on xray?
1. Calcium oxalate-- radio-opaque
| 2. Uric Acid-- radiolucent
108
how do you dx cystisis
UA: dipstick LE+, nitrates +(from clean catch midstreamm)
Microscopic pyuria, bacteria, over 5 WBCs/hpf, over 5 RBCs/hpf
109
causes of intestital nephritis/renal ARF
1. Drugs: PCN, Ceph, sulfa, NSAID’s rifampin
2. Infections: Strep, RMSF, CMV, Histoplasmosis,
3. Immunologic: SLE, Sjogren’s, Sarcoid
*Immune mediated response
110
indication for urine culture w/ FU
1. frequent UTIs
2. no improvement in 48 hrs
3. pyelonephritis
111
dx of renal AFR
1. Spec grav less than 1.010-(Normal or dilute)
2. Serum Bun/Creat less than 10
3. Urine osmolality less than 300
4. FENA over 1
