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Family Medicine EOR > Urology/Renal > Flashcards

Urology/Renal Flashcards

1
Q

What is balanitis?

A

inflammation of the foreskin and head of penis

  • blanitis is most common in uncircumcised men
  • causes include skin disorders, infection, poor hygiene, uncontrolled diabetes, and harsh soaps
  • symptoms include pain, redness, and a foul-smelling discharge from under the foreskin
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2
Q

What is the tx of balanitis?

A

depends on the cause

  • topical antifungal agents: clotrimazole 1% or miconazole 2%, each applied twice daily for one to three weeks
  • for suspected anaerobic infection: metronidazole 0.75% applied twice daily for seven days
  • in extreme cases, the foreskin may need to be removed (circumcision)
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3
Q

What is benign prostatic hyperplasia?

A

a disease elderly men (average age is 60 to 65 years); prostate gradually enlarges, creating symptoms of urinary outflow obstruction

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4
Q

What are the characteristics of benign prostatic hyperplasia?

A
  • enlargement of transitional zone - PSA often elevated >4
  • the urinary stream may be weak, stop and start (hesitancy) or sensation of incomplete emptying
  • in some cases, it can lead to infection, bladder stones, and reduced kidney function
  • history, DRE, elevated PostVoid Residual (PVR), urinalysis, cystoscopy, U/S
  • in men with BPH avoid the use of anticholinergic and antihistamines
  • this type of prostate enlargement isn’t thought to be a precursor to prostate cancer
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5
Q

What is the tx of benign prostatic hyperplasia?

A

treatments include medications that relax the bladder or shrink the prostate, surgery, and minimally invasive surgery

  • relax the bladder/urethra: alpha-1 blockers - tamsulosin (climax) most uroselective providers rapid symptoms relief - smooth muscle relaxation of prostate and bladder neck decreases urethral resistance and obstruction which increases urinary flow can cause dizziness and orthostatic hypotension as well as retrograde ejaculation
  • decrease prostate size (shrink prostate): 5 alpha-reductase inhibitors (finasteride) and dutasteride) (androgen inhibitor - inhibits the conversion of testosterone to dihydrotestosterone surpassing prostate growth, and reducing bladder outlet obstruction) has a positive effect on the clinical course of BPH
  • TURP (transurethral resection of the prostate) if refractory to meds - removes excess prostate tissue to relieve obstruction - sexual dysfunction and urinary incontinence
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6
Q

What is Chlamydia?

A

caused by chlamydia trachomatis serotypes D-K

  • often asymptomatic, but may cause discharge from the penis or vagina, painful or more frequent urination, cervicitis, PID, lymphogranuloma venereum, or infertility
  • evaluation should include a nucleic acid amplification test (NAAT) - sensitivity 80-90% with a specificity of 95-100%
  • if unnoticed or untreated in women, these infections can result in infertility, miscarriage, and an increased risk of a dislocated pregnancy
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7
Q

What is the tx for Chlamydia?

A
  • treat with azithromycin 1 g PO x 1 or doxycycline BID x 7 days
    • ceftriazone 250 mg IM x 1 to cover for gonorrhea
  • sexually active patients with symptoms are usually treated presumptively for STDs pending test results
  • check for other STIs
  • treat partners and educate to refrain from sex until the infection is treated
  • in pregnancy azithromycin 1 gm x 1 dose or amoxicillin TID x 7 days
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8
Q

What is cystitis?

A

infection of the bladder and is characterized by dysuria without urethral discharge E. coli (most common)

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9
Q

What are the characteristics of cystitis?

A
  • dysuria, urgency, frequency, hematuria, new-onset incontinence (in toilet-trained children), abdominal or suprapubic pain
  • absence of fever, chills, or flank pain, change in urine color/odor
  • urine dipstick: nitrate, leukocyte esterase
  • urinalysis: pyuria, bacteriuria +/- hematuria, +/- nitrites
  • urine culture (gold standard)
  • > 100 k CFU/mL (women)
  • > 1000 CFU/mL men or Cath patients
  • takes 24 h to obtain results
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10
Q

What is the tx for cystitis?

A

treat with nitrofurantoin (not over age 65), Bactrim, fosfomycin

  • ciprofloxacin - reserved for complicated cases
  • postcoital UTI: single-dose TMP-SMX or cephalexin may reduce the frequency of UTI in sexually active women
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11
Q

What is the the tx for lower UTI in pregnancy?

A
  • nitrofurantoin (Macrobid): 100 mg PO BID x 7 days

- cephalexin (Keflex): 500 mg PO BID x 7 days

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12
Q

What are the characteristics of interstitial cystitis?

A

symptoms relieved with voiding

  • diagnosis of exclusion
  • Hunner’s ulcer on cystoscopy
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13
Q

What is epididymitis?

A

acquired by the retrograde speed of organisms through vas deferens

  • the pathogen is baed on patient’s age and risk factors:
  • men < 35 chlamydia and gonorrhea
  • men > 35 E. coli
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14
Q

What is epididymitis characterized by?

A

dysuria, unilateral dull aching scrotal pain that can radiate up the ipsilateral flank

  • swollen epididymis tender; fever, chills
    • Prehn’s sign = relief with
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15
Q

How is epididymitis dx?

A

urinalysis reveals pyuria and bacteriuria; cultures are positive for suspected organisms

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16
Q

What is the tx for epididymitis?

A

supportive care: bed rest, scrotal elevation, analgesics

  • over 35 - E. coli
  • levofloxacin (Levaquin) 500 mg/day PO for 10 days (21 days if associated prostatitis
  • oflaxacin 300 mg PO BID for 10 days
  • Under 35 - gonorrhea and chlamydia
  • doxycycline 100 mg PO BID PLUS cetriaxone 250 mg IM x 1
  • refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms
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17
Q

What is glomerulonephritis?

A

acte glomerulonephritis is an inflammation of glomeruli causing protein and RBC leakage into the urine, typically caused by an immune response

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18
Q

What are the two types of glomerulonephritis?

A

based on 24-hour urine protein

  • Nephritic syndrome: moderate proteinuria 1-3.5 g/day
  • classic presentation: edema + HTN + hermaturia + RBC casts/dysmorphic RBCs + proteinuria 1-3.5 g/day + azotemia
  • Nephrotic syndrome: severe proteinuria > 3.5 g/day
  • massive edema
  • fatty casts with “Maltese cross” sign
  • hypoalbuminemia, hyperlipidemia, and lipiduria
  • oval fat bodies
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19
Q

What are the manifestations of nephritic syndrome?

A

proteinuria, HTN, azotemia, oliguria (<400 ml urine/day), hematuria (RBC casts) hallmark, edema is not as much as nephrotic syndrome

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20
Q

What is the urinalysis of nephritic syndrome?

A

proteinuria < 3.5 grams per day, hematuria, RBC casts

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21
Q

What does the biopsy of nephritic syndrome show?

A

hypercellular, immune complex deposition

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22
Q

What are the etiologies of acute glomerulonephritis?

A
  • IgA nephropathy (Berger disease)
  • Postinfections
  • Membranoproliferative glomerulonephritis
  • rapidly progressive glomerulonephritis
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23
Q

What is IgA nephropathy (Berger disease)?

A

most common cause of acute glomerulonephritis worldwide

  • often affects young males within days (24-48 hours) after URI or GI infection
  • caused by IgA immune complexes which are the first line defense in respiration and GI secretions so infections causes an overproduction which then damages the kidneys
  • diagnosed by (+) IgA deposits in mesangium and with immunostaining
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24
Q

What is post infectious glomerulonephritis?

A

Group A strep

  • 10-14 days after infection
  • diagnosed with ASO titers and low serum complement
  • treatment is supportive + antibiotics
25
Q

What is membrnoproliferative glomerulonephritis?

A

due to SLE, viral hepatitis

26
Q

What is rapidly progressive glomerulonephritis?

A

crescent formation on biopsy due to fibrin and plasma protein deposition

  • Goodpasture’s syndrome: (+) anti-GBM antibodies, dx liner IgG deposits, treat with high dose steroids, plasmapheresis + cyclophosphamide
  • vasculitis - lack of immune deposits (+) ANCA antibodies
  • microscopic polyangitis (+) P-ANCA
  • granulomatosis with polyangitis (Wegener’s) (+) C-ANCA
27
Q

What is nephrotic syndrome?

A

defined as urinary excretion of > 3 g of protein in a 24-hour urine sample due to a glomerular disorder plus edema and hypoalbuminemia

28
Q

What are the primary causes of nephrotic syndrome?

A
  • membranous nephropathy
  • minimal change disease
  • focal segmental glomerulsclerosis
29
Q

What is membranous nephropathy?

A

most common in non-diabetic adults associated with malignancies
-caused by immune complex formation in the glomerulus - basement membrane becomes damaged

30
Q

What is minimal change disease?

A

most common cause in kids

  • assume minimal change disease if a child with idiopathic nephrotic syndrome improves after treatment with corticosteroids
  • the cause and pathogenesis of minimal change disease is unclear and it is currently considered idiopathic
31
Q

What is focal segmental glomerulosclerosis?

A

obese patients, heroin, and HIV+ black males

  • primary, when no underlying cause is found
  • secondary, when an underlying cause is identified
  • toxins and drugs such as heroin and pamidronate
  • familial forms
  • secondary to nephron loss and hyper filtration, such as with chronic pyelonephritis and reflux, morbid obesity, diabetes mellitus
32
Q

What are the most common secondary causes of nephrotic syndrome?

A
  • lupus: both nephritic and nephrotic
  • diabetes: a common cause of nephrotic syndrome and subsequent renal failure
  • preeclampsia
33
Q

What is gonorrhea?

A

caused by N. gonorrhoeae (gram-negative diplococci)

  • dysuria, urinary frequency, and purulent yellow-green discharge
  • may progress to PID, high rate of confection with chlamydia
  • evaluation should include a nucleic acid amplification test (NAAT) of first voided urine
  • clean-catch urine culture to rule out UTI
  • saline/KOH/Gram stain of vaginal discharge
34
Q

What is the tx of gonorrhea?

A
  • CDC recommends dual therapy with a single dose of 250 mg IM ceftriaxone (to treat gonorrhea) + 1 g or oral azithromycin (to treat chlamydia)
  • always empirically treat chlamydia with azithromycin or doxycycline
  • if ceftriaxone is unavailable - cefixime 400 mg PO single dose + azithromycin (to treat chlamydia)
  • sexually active patients with symptoms are usually treated presumptively for STDs pending test results
  • check for other STIs
  • treat partners and educate to refrain from sex until the infection is treated
  • make sure to think of gonococcal pharyngitis in anyone with persistent pharyngitis and take samples for culture
35
Q

What is an indirect inguinal hernia?

A

most common

  • passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum
  • often congenital and will present before age one
  • remember: Indirect goes through the Internal inguinal ring (an “I” for an “I”)
36
Q

What is a direct inguinal hernia?

A

passage of intestine through the external inguinal ring at hesselbach triangle, rarely enters the scrotum

37
Q

What are the characteristics of nephrolithiasis?

A
  • colicky flank pain radiating to the groin, hematuria, CVA tenderness, and nausea and vomiting
  • CT scan (spiral CT) without contrast of the abdomen and pelvis is the gold standard for diagnosis
  • urinalysis will often show microscopic hematuria
  • BUN and Cr levels (for evaluation of renal function) and also calcium, uric acid, and phosphate levels
38
Q

What are the four types of nephrolithiasis?

A
  • calcium oxalate (80%): most common, excess oxalate, hyperparathyroidism, radiopaque - avoid grapefruit juice (makes calcium oxalate stones worse)
  • struvite (10%): associated with chronic UTI with Klebsiella and Proteus species, radiopaque
  • Uric Acid (7%): form in individuals with persistently acidic urine - excess meat/alcohol, gout, radiolucent
  • Cystine (1%): rare genetic, radiolucent (young boy with kidney stones)
39
Q

What are the general measures for nephrolithiasis?

A
  • analgesia: IV morphine, parenteral NSAIDs (ketorolac)
  • vigorous fluid hydration - beneficial in all forms of nephrolithiasis
  • antibiotics - if UTI is present
  • alpha-blocker therapy (Flomax) for patients with symptomatic urethras stones > 5 mm and <10 mm to facilitate ureteral stone passage (usually given to most patients independent of size)
  • outpatient management is appropriate for most patients, indication for hospital admission include:
  • pain not controlled with oral medications
  • Anura (usually in patients with one kidney)
  • renal colic plus UTI and/or fever
40
Q

What is the percentage of passing a stone spontaneously?

A

Stones <5 mm will have an 80% chance of spontaneous passage

  • stones >5-10 mm have a 20% chance of passage and may require elective lithotripsy - patients should be considered for early elective intervention
  • stones > 10 mm are not likely to pass spontaneously, ureteral stent or percutaneous nephrostomy (gold standard) should be used if renal function is jeopardized, urgent treatment with extracorporeal shock wave lithotripsy can be used for renal stones less than 2 cm or for ureteral stones less than 10 mm
41
Q

What is orchitis?

A

An inflammation of the testicles

-it can be caused by either bacteria or a virus

42
Q

What are the characteristics of orchitis?

A
  • commonly caused by ascending bacterial infection from urinary tract
  • occurs in 25% of postpubertal males with MUMPS
  • unilateral swollen testicle/tenderness with erythema and shininess of the overlying skin, fever/tachycardia
  • orchitis is rarely seen without epididymitis unless the patient has mumps
43
Q

How is orchitis dx?

A

UA reveals pyuria and bacteriuria with a bacterial infection

44
Q

What is the tx for orchitis?

A
  • if mumps if the cause, treat mumps (+ice/analgesia)
  • if bacteria is the cause, treat like epididymitis
  • cetriaxone 250 mg IM + doxy 100 mg BID x 10 days if <35
  • Cipro 500 mg BID 10-14 days if >35
45
Q

What is prostatitis?

A

Ascending infection of gram-negative rods into prostatic ducts

46
Q

What are the characteristics of prostatitis?

A
  • acute: sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency, and dysuria
  • Chronic: variable - asymptomatic = acute symptomatology
  • all forms presents with irritative bladder symptoms (frequency, urgency, dysuria) and some obstruction
  • physical exam reveals a tender and enlarged prostate on digital rectal exam
47
Q

How is prostatitis dx?

A

Urinalysis will reveal pyuria and hematuria

  • prostatic fluid = leukocytosis, culture typically positive for E. Coli in acute infections
  • chronic usually have enterococcus
  • if you suspect acute prostatitis DO NOT massage the prostate this can lead to sepsis
48
Q

What is the tx for prostatitis?

A
  • men < 35: chlamydia and gonorrhea - cefritaxone and azithromycin (or doxycycline)
  • E. Coli and pseudomonas in men > 35 - treat with fluroquinolones or Bactrim for six weeks to ensure eradication of the infection - culture urine 1 week after the conclusion of therapy
  • hospitalization in acute - may need parenteral fluoroquinolones
  • if the fever doesn’t resolve in 36 hours, suspect abscess and consult urology
  • chronic prostatitis is treated with fluoroquinolones or Bactrim x 6-12 weeks
  • NSAIDs = effective for analgesia; alpha 1 blocker may be helpful if lower UTI symptoms are present
  • chronic, recurrent, resistant prostatitis with/without prostatic calculi may require transurethral resection of the prostate (TURP) for resolution
49
Q

What is pyelonephritis?

A

Irritative voiding + fever + flank pain + nausea and vomiting + CVA tenderness

  • organism: E. Coli
  • urinalysis: bacteria and WBC casts
50
Q

How is pyelonephritis dx?

A
  • UA shoes pyuria, bacteriuria, varying degrees of hematuria, WBC casts
  • CBC shows leukocytosis and left shift
  • complicated: ultrasound shows hydroephrosis secondary to obstruction
51
Q

What is the tx for pyelonephritis?

A
  • outpatient: FQ (cipro/levaquin)/Bactrim for 1-2 weeks (longer if immune compromised
  • inpatient: IV FQ 3rd/4th cephalosporins, extended-spectrum penicillins, gentamicin
  • failure to respond = US/imaging
  • f/up urine cultures not mandatory following tx in uncomplicated cases
52
Q

What are the characteristics of testicular cancer?

A
  • presents as a firm, painless, non-tender testicular mass and a feeling of heaviness in the scrotum
  • seminoma is the most common type (60%)
  • risk factors include a history of cryptorchidism
  • diagnostic studies include ultrasound
  • tumor markers: AFP, Beta-HCG
53
Q

What is the tx of testicular cancer?

A

Surgery, radiation, and chemotherapy

54
Q

What is urethritis?

A

Is an infection of the urethra with bacteria (or with Protozoa, viruses, or fungi) and occurs when organisms that gain access to it acutely or chronically colonize the numerous periurethral glands in the bulbous and pendulous portions of the male urethra and in the entire female urethra

55
Q

What are the symptoms of urethritis?

A

Painful, burning or frequent urination or a discharge from the urethra

56
Q

What are the characteristics of urethritis?

A

First-void or first-catch urine and sometimes urine culture

  • positive leukocyte esterase on urine dipstick or having >10 WBC/HPF on microscopy is suggestive of urethritis
  • diagnosis by culture is not always necessary, if done, diagnosis by culture requires demonstration of significant bacteriuria is properly collected urine
  • nucleic acid amplification test allows for the specific identification of N. Gonorrhoeae, C. Trachomatis, m genitalium
57
Q

What is the tx for urethritis caused by N. Gonorrhoeae?

A

Gram-negative diplococci

  • ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infection PLUS azithromycin (1 gram in a single oral dose) for possible additional activity against N. Gonorrhoeae and for the treatment of potential chlamyida coinfection
  • doxycycline (100 mg orally twice daily for seven days) is an alternative option for second agent to administer with ceftriaxone
58
Q

What is the tx urethritis caused by C. Trachomatis?

A
  • azithromycin (1 gram single-dose therapy) with observed therapy
  • doxycycline (100 mg orally twice daily for seven days) is an alternative option for a second agent to administer with ceftriaxone
    • ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infection

Family Medicine EOR (14 decks)

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