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Renal/GU ITE ReviewAcute Renal FailurePrerenal azotemia-60%Patients are oliguric, kidney retains resorptive function and ability to conserve sodiumUrine is concentrated (SG >1.020), osmolality >500, FENa <1%, low urine Na <20 mEq/L; UA normal or occasional hyaline castBUN/Cr >20Causes: Hypovolemia (V/D, blood loss, diuretics, skin losses), decreased effective blood volume (sepsis, anaphylaxis, third spacing, hypoalbuminemic states, decreased cardiac output)Treatment: correct hypoperfusionPostrenal azotemia-15%Obstruction of urine flow at any point from renal collecting system to urethra (ureteral obstruction must be bilateral)Anuria with complete obstruction to polyuria with partial obstructionUA normalCauses: ureter (crystals, stones, blood clots, malignancy, retroperitoneal fibrosis), bladder (BPH-MCC, prostate malignancy, bladder carcinoma, blood clots, neurogenic bladder-drugs, DM, spinal cord injury), urethra (stricture, phimosis, meatal stenosis)Treatment: foley catheterRenal azotemia-25%Pathology of kidney or renal tubule; tubules lose ability to concentrate and reabsorb sodiumUrine is dilute (SG 1.010), osmolality <300, FENa >2%, high urine Na >40 mEq/LBUN/Cr <20Acute tubular necrosis (ATN)-90%Renal tubular casts, muddy brown granular castsCauses: ischemia (prolonged hypoperfusion, hemorrhage), nephrotoxins (aminoglycosides, ethylene glycol, heavy metals, contrast dye), pigments (hemoglobin, myoglobin)Acute interstitial nephritis (AIN)Eosinophilia, granular and white cell castsCauses: drugs (PCN, cephalosporins, sulfa, NSAIDs, diuretics, allopurinol), infection (bacterial, protozoan, fungal), immune (lupus, leukemia, lymphoma, sarcoidosis)GlomerulonephritisRBCs, RBC casts, proteinuriaHypertension, edema, CHF 2° volume overloadCauses: postinfectious (strep-abx do not decrease incidence), noninfectiousVascularVasoconstrictive disease (malignant htn, TTP), vasculitisThrombosis (renal artery/vein)Treatment: remove offending agent, treat any underlying causeComplicationsHyperkalemia: most immediate life-threatening complication; GET AN EKG!!!Calcium onset <3 min; gluconate less toxic than chloride if extravasation but may not be effective in low flow states; chloride contains more calcium than gluconateAlbuterol, glucose/insulin, bicarb, Kayexalate, dialysisHypocalcemia, hypomagnesemia, anion gap metabolic acidosis, volume overloadIndications for dialysis (AEIOU)A=acidosisE=electrolyte abnormalities (resistant hyperK)I=ingestion of toxic dialyzable substance (lithium, methanol, ethylene glycol)O=overload of fluidU=uremia (pericarditis, encephalopathy, bleeding)Myoglobinuric Renal FailureTrauma (crush, burn, seizure, prolonged exercise), intoxication (alcohol, PCP)→rhabdo→myoglobinemia→toxic effect on renal tubules→ATN→renal failureUrine is reddish-brown, +blood on dipstick, no RBCs on microscopic, renal tubular casts, brown granular casts, myoglobinuria (not reliable)Serum myoglobin (not reliable), serum CK (most sensitive), hypocalcemia, hyperkalemiaTreatment: avoid nephrotoxins, aggressive hydration, mannitol, Lasix, alkalinize urine with sodium bicarbOther types of renal failureNephrotic syndrome: high urine protein excretion, peripheral edema, metabolic abnormalities (hypoalbuminemia, hypercholesterolemia)Minimal change disease: kids; may be preceded by URI or immunization; responds to steroidsFocal segmental glomerulosclerosis (FSGS): African-Americans, sickle cell, IVDU, htn, DM; higher frequency of renal failure; tx-steroids, immunosuppressantsMembranous nephropathy: Caucasians 30-50%; HBV, HCV, syphilis, malaria, SLE, gold, penicillamine; 24% assoc w neoplasm; proteinuria, occasional microhematuria, hypercoagulopathy (renal vein thrombosis); spontaneous remission 25%Membranoproliferative glomerulonephritis (MPGN): can present with nephrotic or nephritic features; assoc w infection, autoimmune dz, HCV, cryoglobulins, low C3; 50% mortality rate or progression to ESRD w/in 5 yrs of bxDiabetic nephropathy: leading cause of ESRD in US; onset 5-10 yrs after onset of type I DM; tx=TGCP, ACEIOthers: malignancy (lymphoma, myeloma), infection (HIV, HBV, HCV, syphilis, leprosy, malaria), SLE, amyloidosis, sickle cell, preeclampsiaDialysis related problemsVascular access hemorrhageMinor bleeding from puncture: nonocclusive pressure; reassess for thrillSignificant bleeding from aneurysm or pseudoaneurysm: direct pressure, vascular consultVascular access thrombosisMost common problem; loss of thrill; unable to access during sessionVascular surgery consult; don’t irrigate b/c can cause clot embolizationVascular access infectionOften Staph; more common in artificial than native graftsSigns of infection (redness, warmth, induration) may be absent; may only have feverTx= blood cultures, antibiotics (Vanco); may not require removal of devicePeritoneal dialysisPeritonitis: cloudy dialysate effluent, abdominal pain, fever; fluid WBC > 100 with > 50% PMNs or positive Gram stainDisequilibrium syndromeRapid solute shifts during hemodialysis; most often during first sessionHeadache, nausea, malaise, disorientation, confusion, seizure, coma, deathTx= supportive; r/o other causes of ?MSCardiac arrest: beware of hyperkalemia and acute pericardial tamponadeUrinary tract infectionsCystitis: dysuria, urgency, frequency, hematuria, suprapubic discomfort, significant bacteriuriaCauses: SEEK PPStaph saprophyticus (2nd), E. coli (1st), Enterobacter, Klebsiella, Proteus, PseudomonasUncomplicated UTI: most UTIs; nonpregnant, healthy women with no neurologic or structural dysfunctionTreatment: 3-6 days (Bactrim, quinolone, nitrofurantoin)Complicated UTI: associated with any neurologic, structural, or comorbid condition that increases risk for acquiring infection and reduces efficacy of standard tx regimens. Factors that predisposeStructural (calculi, catheters, stents, prostatic infection, urinary diversion procedures)Metabolic or hormonal (diabetes, pregnancy)Vesicoureteral reflux, immunocompromise, recent urinary tract instrumentationMale gender, extremes of age, unusual pathogens, recent antibiotic use or failed treatment for UTI, symptoms longer than 7 daysTreatment: 7-10 daysPyelonephritis: fever, flank pain, vomiting, malaise, CVA tenderness, significant bacteriuriaConsider hospitalization: Severe illness/sepsis; extremes of age; uncertain diagnosis; h/o stones, obstruction, instrumentation; underlying anatomic urinary tract abnormality; comorbidities; failed outpatient; persistent vomiting; immunocompromised; poor access to followupCulture all except uncomplicated cystitisNephrolithiasisComposition 80% contain calcium (2/3 calcium oxalate, 1/3 calcium phosphate); associated with dehydration, hyperoxaluria, hypercalciuria (hyperthyroidism, hyperparathyroidism, neoplasm, sarcoidosis, multiple myeloma, distal RTA), PUD (ingest large amts of calcium)15% struvite (magnesium-ammonium-phosphate); caused by chronic UTI from urea-splitting organisms (Proteus)6-10% uric acid; gout, myeloproliferative disease, leukemia, high protein diet1-3% cysteine; familial PresentationUnilateral colicky pain in flank, back, lower quadrantRadiation to groin, labia, testiclesDysuria, frequency, hematuriaNausea, vomitingSevere discomfort, diaphoresis, restlessnessBeware of AAA, iliac aneurysms, renal vein thrombosisDiagnosisOnly 80% have hematuria90% seen on KUB; can be used to follow progression/passageCT is test of choiceIVP can show delayed nephrogram, hydronephrosis, hydroureter, extravasationUltrasound in pregnant patients and kidsImage: first episode, unclear diagnosis, coexistent UTI, elderlyMost common sites of stone impactionUreteropelvic junctionPelvic brim (where ureter crosses iliac vessels)Ureterovesical junction (most narrow point in ureter)Likelihood of spontaneous passage: <5mm pass 90%, 5-8 mm pass 15%, >8mm pass 5%Coexistent UTI is a urologic emergency!!Admit: High-grade obstruction, intractable pain or vomiting, associated UTI, solitary or transplanted kidney, unclear diagnosis, extravasation of dye, renal failure, stone > 5mm (relative)NSAIDs and narcotics act synergisticallyBladder calculi: elderly men; complication of other urologic disease, assoc w urinary stasis, infection of residual bladder urine with urea-splitting organisms. Pain on voiding, hematuria, sudden interruption of urinary streamHematuriaTrauma: bladder injury, ureter injury, retroperitoneal injuryAnemia, thrombocytopenia, renal insufficiency: HUSFlank pain: nephrolithiasisUrine + for heme and – for RBCs: rhabdomyolysisDysuria, frequency: UTIHearing loss: Alport syndromeHemoptysis: Goodpasture syndromeImmigrant: SchistosomiasisNephrotic syndrome, flank pain: renal vein thrombosisProteinuria, RBC casts: glomerulonephritisRecent URI: glomerulonephritis, IgA nephropathyGross hematuria: imaging is recommended for age >40Acute urinary retentionCausesBPH-most common; hesitancy, diminished stream quality, dribbling, nocturia, sensation of incomplete bladder emptying often precede retentionObstructive: prostate carcinoma, prostatitis, urethral stricture, posterior urethral valves, phimosis, paraphimosis, balanitis, meatal stenosis, calculi, blood clots, circumcision, urethral foreign body, constricting penile ring, clogged FoleyNeurogenic: spinal cord injury, herniated lumbosacral disk (cauda equina), CNS tumors, stroke, diabetes, MS, encephalitis, tabes dorsalis, syringomyelia, herpes simplex, herpes zoster, alcohol withdrawal, postop Pharmacologic: anticholinergics, antihistamines, antidepressants, antispasmodics, narcotics, sympathomimetics, antipsychotics, antiparkinsonianPass a Foley, coude, suprapubic catheterBeware of postobstructive diuresis, especially if chronic urinary retentionMale GU disordersOrchitisUsually direct extension of epididymitis; viral orchitis is caused by mumpsTesticular pain and swelling; with mumps, symptoms evolve several days after onset of parotitis.Acute bacterial prostatitisFrequency, urgency, dysuria, obstructive voiding symptoms, perineal discomfort, fever, myalgias, malaise, low back or rectal painUsually gram negatives (80% E. coli)Tender, swollen prostate is warm and firmDo not massage the prostate because it can precipitate bacteremiaTreatment with quinolone or Bactrim for 30 daysIf urinary drainage needed, suprapubic catheter (not foley)Penile ulcersHSV, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereumBehcet’s syndrome: Vasculitis with chronic oral ulcerations, relapsing iridocyclitis, genital ulcers; may also have polyarthritis and erythema nodosum; tx=steroidsFournier’s gangreneNecrotizing infection of subq tissue of perineumBacteroides fragilis, E. coliAcute onset, toxic; painful, erythematous edematous scrotum, +/- crepitus/gangreneRisk: diabetes, chronic steroids, alcoholic, local traumaAbx, urology consult, debridement, hyperbaric oxygenBalanoposthitisInflammation of glans penis (balanitis) and the foreskin (posthitis)If recurrent, think diabetesRetraction of foreskin reveals foul, purulent material; glans is red, swollen, tender to palpationTopical antifungal, circumcision, good hygiene, consider anti-strep abx, r/o diabetesPhimosisInability to retract foreskin behind glans; usually secondary to chronic infection of foreskin; usually uncircumcised menTx= dorsal slit if difficulty voiding; circumcisionParaphimosisInability to pull retracted foreskin back over glansInfection, trauma, hair tourniquet, sexual activityDistal venous congestion can lead to arterial compromise, necrosis, gangreneTx= manual reduction, ice, dorsal slit, circumcisionPenile fractureTear of tunica albuginea (usually during erection)Retrograde urethrogram to r/o urethral injuryPriapismLow-flow: decreased venous outflow→venous stasis, ischemia of corpus cavernosae but spares glans and corpus spongiosum→rigid, painful penile shaft and soft glans Causes: sickle cell, leukemia, intracavernosal injections for ED, trazodone, marijuana, idiopathicHigh-flow: rare; not a true emergency; increased arterial blood flow to corpus cavernosae→increased venous blood flow→partially rigid, painless penile shaft and hard glans Causes: groin/straddle injury (arterial-cavernosal shunt), high spinal cord injury/lesionTerbutaline sub q, analgesia, pseudoephedrine injection, corporeal aspiration, shunt surgeryTesticular torsionBimodal peaks: first few days of life and ages 12-18Predisposition: bell-clapper deformityIncreased mobility; testicle lacks normal attachment at vaginalisTransverse lie of testesAcute onset severe unilateral testicular pain or lower abdominal pain; +/- recent history of strenuous physical activity or h/o of testicular pain with resolutionExam done with patient standing: swollen, firm, high-riding testicle with transverse lie; contralateral testicle also transverse lie b/c bell-clapper deformity; +/- reactive hydrocele; loss of cremasteric reflex most reliable sign; no urinary sx; Immediate urology consult!! Then attempt manual detorsion (opening a book), Doppler ultrasoundSalvage rate 100% at 6 hrs but approaches 0% at 24 hoursTorsion of appendices epididymis and testisUnilateral pain, more gradual in onset, not as severe, localized to involved appendix early; late, generalized scrotal swelling and tendernessBlue dot sign: visualization of necrotic appendix testis through scrotal wall on superior aspect of testicle on transilluminationSelf-resolving, benign processes. Rest, scrotal elevation, analgesiaEpididymitisGradual onset unilateral pain and swelling; associated fever and dysuriaExam: tenderness and swelling of epididymis (located posteriorly); elevation of testicle relieves pain (Prehn’s sign)Etiology: Age <35-Chlamydia, gonorrhea; age >35- gram negatives (E. coli, Pseudomonas)Tx= <35 years- ceftriaxone IM and doxy x 10 days; >35 years- quinolone 10-14 days3-11% pts on amiodarone develp epididymitisHydrocele: fluid collection in tunica vaginalis; transilluminates, not firm or hardVaricocele: “bag of worms,” 85-95% on leftTesticular tumor: painless, unilateral scrotal mass palpated discretely from the testis; firm and hard ................
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