Urology_Nephrology Flashcards
(56 cards)
Initial lab test for nephrolithiasis
UA<div>CBC</div><div>Lytes</div><div>BUN/Creat</div><div>Ca</div><div>Po4</div><div>Uric acid</div><div>Preg test</div>
Stone imaging
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IVP features of stone
Direct stone visualization<div>Unilateral ureteral dilation</div><div>Delayed nephrogram appearance</div><div>Lack of normal peristalsis</div><div>Perirenal contrast extravasation</div>
<p>Indications for Admission of urinary stone</p>
<ul> <li>Septic stone (stone + fever/UTI)</li> <li>Solitary kidney and complete obstruction</li> <li>Severe pain requiring parenteral analgesics</li> <li>Intractable nausea/vomiting</li> <li>Large stone:–>6 mm stones pass 10% of the time, 1 cm stones will not pass</li> <li>Concomitant acute renal insufficiency</li> <li>Ruptured renal capsule with urine extravasation</li> <li>Special populations: pregnant, pediatric, renal transplant patients</li> </ul>
<p>Renal Colic Treatment</p>
<ul> <li>Medical expulsive therapy: Alpha-1 receptor antagonist (tamsulosin)</li> <li>Extracorporeal shock wave lithotripsy (ESWL)</li> <li>Ureteroscopy +/- stent placement</li> <li>Percutaneous nephrolithotomy</li> <li>Open stone surgery</li> </ul>
Risk factors for nephrolithiasis
Chronic dehyfration<div>Diet</div><div>Obesity</div><div>FHx</div><div>Medications</div><div><br></br></div>
Sites of stone impaction
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Causes of urinary retention
Mechanical:<div> BPH</div><div> Meatal stenosis</div><div> Urethral stricture</div><div> Malignant tumers to prostate/bladder</div><div> Bladder stones</div><div><br></br></div><div>Neurogenic:</div><div> Stroke</div><div> SC injuries</div><div> MS</div><div> DM (advanced)</div><div><br></br></div><div>Drugs:</div><div> OTC sympathomimetics (cold remidies)</div><div> TCA</div><div> Anticholinergics (oxybutynin)</div><div> Antihypertensives</div><div> Opioids</div><div><br></br></div><div>Infection</div><div> acute prostatitis</div><div> Urethral herpes</div><div> Peri-urethral abscess</div><div> TB</div><div> Cystitis</div>
Important things to do in urinary retention
Bedside U/S (bladder vol, R/U AAA)<div>Neurological exam (sph tone & sensation, LE strength, DTRs)</div><div>Labs: (U/A & culture, creat)</div>
Risk factors for urologic malignancies
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<p>Acute Kidney Injury: Renal</p>
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<p>Acute Kidney Injury: Urinalysis</p>
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<p>What are indications for emergent hemodialysis? List 5.</p>
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ESRD electrolytes dist
HyperK<div>HypoK<br></br><div>HypoCa</div></div><div>HypoMg</div>
Renal Transplant Complications
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Urinalysis in UTI Criteria for Rx
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False negative nitrite test
Vit C ingestion (cranberry juice)<div>Insuff time between last void and collection</div><div>Delay occur between collection and testing the sample</div>
DDx of pyuris
GU TB (sterile pyuria)<div>Epididymitis</div><div>Prostatitis</div><div>Infected stone</div>
What are the features of complicated UTI
All patients are regarded as complicated UTI except young, healthy nonpregnant woman<div><br></br></div><div>Fever, chills, rigors</div><div>Significant fatigue, malaise</div><div>Flank pain</div><div>CVAT</div><div>Pelvic/perineal pain in men</div>
Indications of admission in UTI
Septic patient<div>Uncontrolled pain</div><div>Unable to tolerate oral intake</div><div>Functional decline</div><div>Associated urinary obstruction</div>
Surgical complications of UTI
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Rx of UTI in Peds
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Risk factors of Prostatitis
Cystitis<div>Urethritis (STI)</div><div>Epididymitis</div><div>Instrumentation (TURP, cystoscopy, catheterization)</div>
Rx of Prostatitis
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Fournier’s Gangrene: Management
Genital Ulcers – History
- Sexual partners (male, female or both)
- Type of intercourse (oral, vaginal, anal)
- Barrier contraception use
- Painful vs. painless lesion
- Constitutional symptoms
- Rash
- Urinary symptoms
- Urethral discharge
Duration of pain
Similar prior episodes
Genitourinary trauma
Recent urologic surgery
Medication use (intracavernosal injections of papaverine/ prostaglandin E1, antihypertensives, neuroleptics, or oral agents for erectile dysfunction)
Substance abuse (esp. cocaine)
Medical history (eg, sickle cell disease)
History of malignancy (eg, prostate cancer, bladder cancer)
blood gas analysis of the first corporal aspirate
Result:
Red sample, consistent with arterial sample = high-flow priapism.
Dark, acidic sample = low-flow priapsim
-Position the patient supine/ allowing exposure of the dorsal penis
-Prep the skin with iodine/chlorhexidine
-Prep analgesic (lidocaine/xylocaine 1-2% +/- bupivacaine 0.5-1%)
-Landmark insertion sites (10 and 2 o’clock positioning for two point landmark OR mid-pubic arch for one point landmark at penis base)
-Insert needle at landmark site/s, aspirate, direct towards each dorsal penile nerve, and inject 5-7cc anaesthetic bilaterally
Hold manual pressure on glans OR wrap glans penis in compression gauze, for at least five minutes
Consider topical ice, osmotic agents (sugar)
Manual Reduction
Lubricate glans
Hold foreskin with both hands/ fingers of the hand
Use thumbs to push glans penis through paraphimosis
Perform penile block/ conscious sedation
Insert 21 gauge needle in several locations through foreskin
Milk to remove fluid from the edematous foreskin
Attempt manual reduction
Dorsal slit
Perform penile block/ conscious sedation
Indicated if refractory to all other reduction methods
Identify the dorsal midline of the foreskin
Clamp with a hemostat for 30-60 sec
Cut a dorsal slit of foreskin to allow foreskin reduction
Oversew the edges with absorbable suture
Urologist consultation - commits patient to circumcision
-Urinary frequency
-Hematuria
-Abdominal pain
-Back pain
-Nausea and/or vomiting
-New daytime incontinence
-Unexplained fever
-Uncircumcised males
-Younger age
-Fever >39°C or fever duration >24-48 h
-Previous UTI
-Sexual activity
-Urinary tract pathology
-Recent urologic instrumentation
-Neurogenic bladder
-Klebsiella spp.
-Proteus spp.
-Enterobacter spp.
-Enterococcus spp.
-S. aureus (neonates)
-Group B streptococci (neonates)
-S. saprophyticus (adolescents)
-Chlamydia trachomatis (adolescents)
Midstream urine sample for urinalysis and culture
Non-toilet trained children:
Urethral catheterization
Suprapubic aspiration
Clean-catch urine
Pediatric urine collection bag (PUC)
For urinalysis only; don’t culture (high rates of contamination)
Useful to screen/rule out for UTI (unlikely if completely normal urinalysis). Unable to rule in UTI
--Note: 7-10 day course is recommended for febrile UTI
--Note: oral antibiotics can be chosen for initial treatment (even if febrile) if the child is not seriously ill and likely to receive and tolerate every dose
Amoxicillin: 50 mg/kg/day (divided in three doses)
Amoxicillin/clavulanate: (7:1 formulation) 40 mg/kg/day (divided in three doses)
TMP-SMX: 8 mg/kg/day of the trimethoprim component, divided in two doses
Cefixime: 8 mg/kg/day (given as a single dose)
Cefprozil: 30 mg/kg/day (divided in two doses)
Cephalexin: 50 mg/kg/day (divided in four doses)"
What follow-up investigations are warranted, if any? In which situations is follow-up indicated?"
-Children <2 years should be investigated after their first febrile UTI with a renal/bladder ultrasound to identify any significant renal abnormalities
-Voiding cystourethrogram (VCUG) is not required for children with a first UTI unless the renal/bladder ultrasound reveals findings suggestive of vesicoureteral reflux, renal anomalies or obstructive uropathy
What factors will determine your disposition for this patient? What follow-up should be arranged, if any?
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-Creatinine level (acute renal failure defined as >20% increase from baseline in renal transplant patients)
-Sub- or supra-therapeutic immunosuppressant levels
-Other abnormal lab or imaging findings
-Urine output
-Ability to tolerate oral rehydration
Critical to discuss disposition with the on-call transplant team (admission vs. discharge with close outpatient monitoring and follow-up)
Indications for hospital admission with a kidney stone
Absolute
Obstructing stone with signs of infection
Intractable nausea & vomiting
Severe pain requiring parenteral analgesics
Urinary extravasation
Hypercalcemic crisis
Pregnant woman
Relative
Significant comorbidities complicating outpatient management
High grade obstruction
Leukocytosis
Size of stone
Solitary kidney/intrinsic renal disease
Psychosocial disease
