Upper UTIs
To kidneys
pyelonephritis: renal abscess, perirenal abscess
Lower UTIs
urethritis, cystitis, (prostatitis)
Classifications of UTIs
community acquired
nosocomial (from catheter)
upper v lower
complicated v non-complicated
UTI in elderly
40-50% asymptomatic bacteruria
group w/highest prevalence of UTIs
reproductive age females
Renal abscess
pus pocket in kidneys
perirenal abscess
abscess in fascia and fat
Mechanisms of UTI
Ascending infection
hematogenous
fistula
Pregnancy effect on UTIs
4-10% incidence
20-40% untreated get pyelonephritis
What bacteria causes 80% of first UTIs?
E. coli (1, 4, 6, 18, 75)
What are the two differential diagnoses for UTIs?
dysuria (infectious, non-infect)
acute intra-abdominal diseases (appendicitis, cholecystitis, etc.)
What organism causes UTI in 10-15% young females?
staph. saprophyticus
Factors that predispose UTI
Age pregnancy diabetes MS spinal cord injuries immun compromised malignancy
Organisms that cause complicated and uncomplicated UTIs
uncomplicated: E. coli
complicated: s. saprophyticus, resistant: pseudomonas, proteus
UTI is one of top ten concurrent illness with…?
Diabetes!
UTI general symptoms
suprapubic pain/heaviness
hematuria
pain near/in epigastrium - radiate inferiorly
How many colonies of pathogen accounts for acute urethral syndrome (urethritis)? and what is it during pregnancy?
<100,000
pregnancy: 10,000
definition of hemorrhagic cystitis
bladder inflammation w/dysuria, hematuria, or hemorrhage
interstitial cystitis (aka bladder pain syndrome)
pain w/full bladder (urinary urgency, pain relieved by emptying)
Dx of exclusion (unknown cause)
most common symptoms of interstitial cystitis*
bladder pain, nocturia, frequency, urgency, suprapubic pain
Hunner’s lesions (ulcers)
In interstitial cystitis
thinning of bladder wall and pinpoint bleeding
causes pain if come in contact w/other bladder surfaces
Pyelonephritis
infection of renal parenchyma and pelvis
women 5X men
Presentation of pyelonephritis
fever >102F, chills (may be absent in 1/3 elderly) flank pain N/V CVAT- UNI-lateral pyuria leukocytosis
How to Dx Pyelonephritis
CBC: leukocytosis urine culture: 90% positive!! Urinalysis: pyuria, nitrates, hematuria Gram Stain: before empiric Tx Blood cultures: only if Dx uncertain
Normal urine culture results
<10,000 organisms/ml
Abnormal urine culture results
> 100,000 organisms/ml - WOMEN
>10,000 organisms/ ml - PREG, MEN
Pyelonephritis Tx
fluoroquinolone (Cipro)
amoxicillin
azotemia
elevated BUN
get w/late renal obstruction
Red Flags for urolithiasis
flank pain fever elevated WBC gravel (small stones) immunocompromised children recurrent/nonresolving infection
Tx for urolithiasis
Penicillins - can have resistance quickly (E. coli)
Sulfonamides - G6PD deficiency (hemolysis)
macrobid (nitroflurantoin)
cipro - least resistance for e. coli
Tx for interstitial cystitis
elmiron (PO)
DMSO - through catheter into bladder to coat lining
Moderate to Severe kidney infection tx
IV ceftrioxone or gentamycin
Dx for UTI
urinalysis
urine dip stick
culture: predispositions
What does cranberry juice do for UTIs?
Acidify urine
Why does prostate involvement in UTIs cause lower back pain?
prostate drains to sacral lymph node and up spine
What urine is best for urinalysis?
First voided urine
mid-stream (vulva/plans penis cleansed beforehand)
When is microscopic urinalysis done and what does it look at?
if urinalysis/dipstick abnormal
cellular elements, cats, crystals, RBC, WBC, yeast, malignancy
Basic urinalysis/dip stick
gross exam
chemical: pH, glu, bili, protein, ketones, blood, nitrate
milky urine
pyruia, lipiduria, chyluria (lymph fluid)
cloudy urine
bacteria, yeast, calculi, fecal, sperm, prostate fluid
How can myoglobinuria (from muscle trauma) change urine
red or bown-black
Rhabdomyolysis
muscle breakdown –> kidney damage –> black urine
Pseudomonas infection change urine to…?
blue, green, blue-green (also chlorophyll: cancer, wound healing, weight control, liver detox)
specific gravity
density of specimen, correlates w/urine osmolality
normal: 1.001-1.035
urine osmolality
particles/weight of fluid
fixed specific gravity at 1.01
isosthenuria (intrinsic renal insufficiency)
normal urine pH
5.0 - 6.0
relative hydration v relative dehydration in specific gravity
value of less than 1.010 –> relative hydration
value greater than 1.020 –> relative dehydration
causes of low specific gravity
DI, pyleno/glomerulo, diuretics, adrenal insufficiency
causes of high specific gravity
dehydration, glycosuria, impaired renal function, SIADH
Relationship between urinary pH and serum pH*
urinary pH reflects the pH in the serum
Risk of alkaline pH
staghorn calculi
pseudomonas, proteus infection
How to further evaluate persistent positive proteinuria on dipstick?
24hr urine collect
Postural Proteinuria
prolonged standing –> proteinuria
(during day but not night)
“orthostatic” proteinuria
order of severity of different proteinurias
microalbuminuria –> albuminuria –> proteinuria –> heavy proteinuria
microalbumin helps detect..?
early DM (–> renal mortality)
Glycosuria in..?
DM
Fanconi’s syndrome
liver/pancreatic disease
How to determine site of bleeding
blood beginning of stream: urethral
diffuse: bladder or above (total, all throughout)
blood end of stream: prostate, base of bladder
Dipstick in detecting UTI
85-95% effective as culture
>10 WBC/hpf –> inflam.
How do nitrites get in urine?
bacteria produce reductase to reduce urinary nitrate to nitrite
E. coli, klebsiella, enterobacter, proteus, staph., pseudomonas
significance of conjugated bilirubin and urobilinogen in urine
usually undetectable levels in urine
liver dysfunction, biliary obstruction
hemolysis (urobilinogen)
What part of urine is examined in microscopic exam?
centrifuged sediment
very helpful as confirmatory and detecting new info
casts (urine)
tube shaped proteins
helps localize disease to specific location in GU
What amount of RBC is abnormal in urine
> 3 RBC/HFP
Most common cause of WBC in urine*
UTI
ATN = acute tubular necrosis
kidney disorder: damage to tubule cells of kidneys –> acute kidney failure
significance of a lot of squamous epithelial cells in urine sediment
contamination
Painless gross hematuria is…?*
CANCER UNTIL PROVEN OTHERWISE
(85% bladder, 40%renal cell)
usually uroepithelial tumor
Is hematuria screened?
No, bc common and asymptomatic in many
Types of hematuria diseases
maple syrup urine disease: autosomal recessive, branched chain AAs
iced tea urine: dehydration or acute kidney injury
coca-cola urine: choluria, bile in urine
clots in urine USUALLY indicate…?
lower urinary tract source
True or false: Amount of blood loss does not correlate to color change
true
1st step w/gross hematuria specimen*
centrifugation
after centrifugation, SEDIMENT is red. what does it mean?
hematuria
after centrifugation, supernatant is red. what does it mean?
need to dipstick for other causes
Red supernatant, heme negative dipstick
porphyria, phenazopyridine, beeturia
Red supernatant, heme positive dipstick
myoglobinuria (clear plasma), hemoglobinuria (red plasma)
microscopic hematuria is found…?
incidentally
Source of microscopic hematuria*
most commonly RENAL
Source of gross hematuria*
most commonly UROEPITHELIAL
causes of hematuria
prerenal: systemic
renal: glomerular, non-glomerular
postrenal: ureters, bladder, urethra, prostate
Prerenal hematuria: systemic examples
coagulopathy
anticoagulation
collagen vascular disease
sickle cell
Red cell casts and what can be Dx*
cylindrical structure (microscopy) Dx: glomerulonephritis or vasculitis --> kidney biopsy
Isomorphic RBC in urine sediment marks what type of bleeding?
non-glomerular
Dysmorphic RBC in urine sediment marks what type of disease?
glomerular diseases
What to rule out w/postrenal causes?*
malignancy of bladder and ureter!
Differential Dx of hematuria
TICS
What is a big risk factor for malignancy from hematuria findings?*
tobacco use (2x)
most common urologic cancer
transitional cell carcinoma (bladder cancer)
what Phenazopyridine (Pyridium) do to urine?
make it dark orange to red
when is cytology used?
in conjunction w/other tests for cancer (only in sepcific situations)
What can CT urography show?
stones very well (more than U/S)
blood
cancers
when to use cystoscopy
gross hematuria:
- no evidence of glomerular disease or infection
- OR with clots
conditions that causes ulceration of penis*
HPV
Syphilis
chancre
chancroid
categories of prostate disease
benign neoplastic (BPH)
infectious (prostatitis)
malignant (prostate ca)
Leading cancer diagnosed in males?
prostate cancer (men die with not of)
crenated cell*
RBC with spikey appearance
when in hypertonic urine
ghost cell*
RBC that lost hemoglobin bc in hypotonic cell and absorbed water –> swollen
waxy cast
deteriorated from granular cast
smooth
Frequency of BPH (benign prostatic hyperplasia)
50% males at 50yo
Functions of prostate
muscle seals off bladder during ejaculation, propels
30% semen
gland: secrete alkaline fluid, protects sperm in acidic vagina
prostate specific antigen (PSA) function
produced by prostate that dissolves cervical mucous cap
evaluated for prostate function
Growth of prostate accessory organs are dependent on what?
androgens (have androgen receptors)
What hormone regulates prostate?
5-alpha reductase metabolize testosterone to DHT –> regulates prostate
3 zones of prostate
central
transitional
peripheral: post lat
which zone of prostate is where 70% of cancer
peripheral zone
which zone of prostate is responsible for BPH
Transitional
When does growth phase begin again for prostate?
40-50yo
Symptoms of BPH (LUTS)*
bladder outlet obstruction
hypertrophy of detrusor muscle
decreased capacity of bladder
most common urologic emergency
Acute Urinary Retention
Bladder volume in Acute Urinary Retention*
≥300 cc of urine
Absolute contraindication for catheterization in urologic emergencies?*
urethral injury (blood) at meatus or hematuria
Most common pathogen in UTI for men/women*
E. coli
Renal colic
type of pain w/kidney stones on affected side
comes in waves
stone stuck in urinary tract
what size stone usually passes through?
<10mm
Significance of UTI in males?*
ALWAYS complicated!
What is urosepsis caused by?
UTI traveling up –> systemic infection
emergency
Tx of testicular torsion
surgical detorsion
4-6 hrs: 100% viability
12hrs: 20%
24hrs: 0%!!!
most common age for testicular torsion?
12-18 yo
differential Dx for testicular torision
twisting of vestigial appendage along testicle (younger pts) - blue dot sign (necrosis/infarct)
use doppler U/S to differentiate
pain resolves 5-10 days
penile fracture
rupture of one of tunica albuginea
“eggplant deformity”
during tumescence
priapism
prolonged erection not w/sex stimulus
doppler U/S
ISCHEMIC V NON-ISCHEMIC
Ischemic v Non-ischemic priapism
ischemic: blood doesn’t drain from penis properly –> can permanent ED, emergency surgery, painful
non-ischemic: Connection forming b/t an artery and corpus cavernosum, painless, not emergency
azoospermia*
no sperm in semen
What can kill sperm?
high temp
PRE-TESTICULAR cause of infertility
gonadotropic hypogonadism
pituitary disease
endocrine: androgen excess, glucocorticoid, thyroidisms
hyperprolactinemia: inhibit GNRH
examples of gonadotropic hypogonadism in pre-testicular infertility
isolated gonadotropin (Kalman’s)
isolate LH or FSH
congenital
examples of pituitary disease in pre-testicular infertility
pituitary insufficiency
hemochromatosis: iron deposits
exogenous hormones: excess estrogen
TESTICULAR causes of infertility
GENETICS: primary failure
varicocele: 40% primary and secondary
Most common attributable cause of primary and secondary infertility in males- 40%*
varicocele
Which side is more common for varicocele?
left (80-90%)
POST-TESTICULAR cause of infertility
disorders of sperm transport
disorders of sperm motility/function: congenital, maturation
Globozoospermia*
maturation defect
No acrosin-no penetration of zona pellucida
Sperm DNA fragmentation
greater than 30% index –> reduce fertility
“Normal” (morphology and motility) sperm may have DNA fragmentation!*
biggest concern for sperm DNA fragmentation
age! >46yo
biggest cause of azoospermia*
40% obstructive
what happens in andropause by age 80?**
testosterone levels around pre-pubertal levels
Psychological symptoms of andropause?
anxiety
depression
sexual symptoms of andropause?*
impotence: loss of erection
Physiologically, what does low testosterone do?
increase cholesterol (precursor)
function of draping
separate surgically clean areas away from non-surgically clean areas to prevent further contamination
International prostate symptom score
1-7 mild
20-35 severe
Tx of BPH
mild: watch
mild-moderate: alpha blocker (hytrin)
severe: alpha blocker, 5 alpha reductase inhibitor (effective on 30% patients)
severe: surgery (TURP)
turp
trans urethral resection of prostate
gold standard for BPH
Effect of chronic bacterial prostatitis
recurrent UTIs, uncommon (acute least common)
Types of prostatitis
acute/chronic bacterial prostatitis
chronic prostatitis
asymptomatic inflammatory prostatitis
rectal exam result in acute bacterial prostatitis
exquisitely tender, swollen, firm and hot prostate
prostate cancer symptoms
may be asymptomatic or mimic BPH
Gleeson grading system
quantify cancer aggressiveness
Prostate cancer treatment in young patients
radical prostatectomy
lab result in BPH
PSA slightly elevated
Conditions for ulcerations of penis*
chancre: primary syphilis, painless, palpate edge
chancroid: painful, soft edge, inguinal adenopathy
syphilis
HSV: ulcerating painful lesions
Erythroplasia of Queyrat
fixed drug eruption
Phimosis v. Paraphimosis*
Phi: foreskin cannot be fully retracted
Para: UROLOGIC EMERGENCY; foreskin cant go back over glans!
Paraphimosis*
Inability to return the retracted foreskin to its natural position covering the glans. –> EDEMA AND CONGESTION OF GLANS* –> PENILE NECROSIS
Meatal Stenosis, in child?
narrowing of the opening of theurethra
sx: Urine flow reduced and hesitant. Urine stream goes upward instead of downward
Hypospadius*
urethral meatus more proximal unknown cause (hormonal defic. or compression in utero?)
Peyronie’s Disease*
by fibrous scarring or plaques within the tunica albuginea
cause: micro/macrotrauma (break penis)
“saxophone penis”
Reactive Arthritis*
REITER’S SYNDROME
Another name for Erythroplasia of Queyrat*
Bowman’s disease of glans penis
Chordee (assoc w/hypospadius)
deficiency of ventral skin compared to dorsal skin
illusion of curvature OF GLANS when the penis is erect
Chordee (assoc w/hypospadius)*
deficiency of ventral skin compared to dorsal skin
illusion of curvature OF GLANS when the penis is erect
risk assoc w/hypospadius*
9% cryptorchidism (cancer risk)
9% inguinal hernia (w/hydrocele)
RISK FACTORS FOR PEYRONIE’S DISEASE**
HTN DM gout beta-blockers possible vit E deficiency NOT hygiene
Peyronie’s disease –> associated disorders?
Dupuytren’s contractures
ledderhose disease
autoimmune conditions
Dupuytren’s contractures
progressive thickening and shorting of the palmar fascia leading to debilitating digital contractures
Ledderhose disease
plantar fibromatosischaracterized by thickening of the foot’s deep connective tissue
Indications for surgical Tx of peyronie’s disease
disease for 1 year
Dx for 6 months
severity in sexual dysfunction
Phimosis
foreskin cannot be fully retracted (urine breaks down skin)
congenital or acquired
Risk of acquired phimosis*
repeated catheterization; forceful foreskin retraction*** infections poor hygiene lichen sclerosis DM
common symptoms of phimosis
Unable to retract prepuce
Narrowing or diversion of the urinary stream
Ballooning of prepuce with urination
Tx of phimosis
elective circumcision - procedure of choice
children: wait until 5 yo (may resolve)
Risk of paraphimosis*
Iatrogenic: Health care provider leaves foreskin retracted after penile examination, cleaning, cystoscopy, or catheter insertion.
Balanoposthitis*
Inflammation of glans (balanitis) and foreskin (posthitis)
causes: STD
Fournier’s Gangrene*
Bacterial infection of the skin on genitals and perineum from wound infection
Penile cancer can start from what?*
condyloma accuminata, HPV 16 50%
Penile cancer
get bad very quickly, need to be caught early!
Buschke-Löwenstein tumor
HPV 6 and 11 - verrucous carcinoma of the penis
Erythroplasia of Queyrat
In situ form of squamous cell carcinoma on glans penis
multiple red plaques
who is most commonly affected by Erythroplasia of Queyra
older uncircumcised men
psoriasis on penis
thick, scaly plaques
Reiter’s disease
reactive arthritis
infection Autoimmune response (chlamydia)
Sx: arthritis, conjunctivitis, and urethritis (can’t see, can’t pee, can’t climb a tree)
20-40% (men): painless penile lesions (balanitis circinata) distinctive winding erosions
cremaster reflex
stroke inside of thighs, testicle rises
testicular pain differentials
Epididymitis/Epididymo-Orchitis
Orchitis
Testicular Torsion
Torsion of Testicular appendix
torsion testicle
abrupt severe pain
no cremaster reflex affected side
high riding testing, transverse lie
prehn’s sign
prehn’s sign
lack of pain relief with testicle elevation
in testicular torsion
How to Dx testicular torsion
U/S
dont wanna miss!! Timing critical!
How to Dx testicular torsion*
U/S
SURGICAL EMERGENCY
Testicular torsion causes
testes “swinging freely” - anatomical defect
“bell clapper deformity”: no normal posterior anchoring
intravaginal v extravaginal testicular torsion
Intravaginal: testicle rotates on the spermatic cord within the tunica vaginalis
Extravaginal: torsion OUTSIDE the tunica vaginalis (scrotal ligament)
bell clapper deformity
testis lies HORIZONTALLY
tunica vaginalis extends up over spermatic cord –> testis suspended in tunica vaginalis by spermatic cord.
Testicle salvage rate after 24hrs
0-10%
Appendiceal Torsion
affect upper pole
92% remnant of mullerian duct
“blue dot sign”
blue dot sign
Appendiceal Torsion - necrosis of appendage
Tx for epididymitis*
<35yo: doxycycline 14 days
>50yo: cipro (WITH CAUTION)
Mumps virus can cause…?*
orchitis (70% unilaterally) -
most common cause of orchitis
Orchitis usually accompanied by…?
epididymitis
bacterial orchitis Tx*
<35yo: Ceftriaxone AND either doxycycline or azithromycin
>50yo: Fluoroquinolone
VIRAL ORCHITIS tX
Bedrest
supportive care
Orchitis Sx
pain
swollen testes
hematuria
testicular cancers are..?*
painless scrotal mass
most common side of varicocele
left side
Hydrocele etiology*
Failure of patent processus vaginalis to close & failure of peritoneal fluid to be re-absorbed
common in newborn boys
transilluminating mass on exam
hydrocele
hydrocele can be associated with..?
indirect hernia
Non-communicating forms of hydrocele may result from…?*
trauma, infection, or neoplasm
hydrocele Tx
may resolve on its own
surgical resection
communicating v noncommunicating hydrocele
communicating: free flow of abdominal fluid to sac
non: doesnt
spermatocele
Usually asymptomatic, small mass of the epididymis
benign (epididymis dilation)
epididymal cyst >2cm
Where you feel inguinal hernias during exam
direct: side of finger
indirect: tip
complications of hernias*
incarceration: not easily reduced
strangulation –> need herniorrhaphy (emergency)
complications of cryptorchidism*
infertility
malignancy
Klinefelter’s (XXY) put you at risk for…? (testicular disorder)
testicular cancer
hypogonadism
most common sign of testicular cancer*
hard, painless lump
most common type of testicular cancer*
germ cell tumors
before metastasis of testicular cancer…
nearly 100% cure!
Cystoscopy
rigid v flexible
can resect bladder tumor, prostate (TURP)
Malecot & Pezzer catheters
Surgical placement
ionic v nonionic IV contrast material
ionic: higher osmolality, more side effects
non-ionic: lower, less
IV contrast in high risk patients
dont use them! use other!
IV contrast risks
acute renal impairment
Iv contrast and DM pts
can cause Fatal metabolic acidosis (lactic acidosis)
IV contrast risks
acute renal impairment
nephrotoxic
Iv contrast and DM pts
can cause Fatal metabolic acidosis (lactic acidosis)
hold metformin if using contrast
idiosyncratic rxn to IV contrast
iodine anaphylactoid response
How many views in an abdominal series X-ray
3 views:
CXR
abdominal “flat plate” (kidney, ureter, bladder)
upright abdominal film
abdominal flat plate
KUB: kidney, ureter, bladder
“scout film”
CT
“Multiple plain films”
Computer reconstruction of 2D view, CUTS
spiral CT (sCT ) or helical CT
Thin collimation of 1-mm image reconstruction and multiple detectors
CT
“Multiple plain films”
Computer reconstruction of 2D view
cross section
When to use CT scan in urology
renal: mass, cyst (U/S 1st), trauma, calculi
BEST IMAGING FOR RENAL CALCULI*
Spiral/Helical CT
MRI urology
Very useful for soft tissue GU diagnosis
gadolinium contrast - safer than iodinated
Transrectal Ultrasound (TRUS)
good for prostate
Radionuclide Imaging
IV administration of radionuclide tagged cells
identify where the cells have traveled/concentrated
good for physiologic studies (blood flow, kidney function, excretion)
GU angiograph
Radio-opaque contrast injected IV and then imaged using x-ray based imaging modality such as fluoroscopy (real-time moving x-ray images)
Voiding Cystourethrogram
- Water-soluble contrast material delivered to bladder
- “spot film” taken while pts void
(used in voiding difficulties, vesicoenteric fistula)
static cystograms**
films taken prior to voiding
Intravenous Pyelograms (IVP)
3 films: w/contrast
scout film
nephrogram phase (after 2-3min)
excretion films (after 15-20min)
Retrograde Pyelography (RGP)
Demonstrates ureter and renal collecting system (pelvis & calyces).
FILL CONTRAST INTO URETER w/cystoscope(NOT IV)