Download MBBS Nephrology and Urology Lecture Notes

Nephrology / Urology
1

---

Acute Renal Failure (1)
PRERENAL

--- Content provided by‌ FirstRanker.com ---

RENAL
POSTRENAL
2

---

Acute Renal Failure (2)

--- Content provided by‌ FirstRanker.com ---

PRERENAL
= Shock ( Perfusion)
? Causes
?Hypovolemic (most common)
?Cardiogenic

--- Content provided by‍ FirstRanker.com ---

?Distributive
? Treatment
?Restore circulating volume
?Fluids
?Pressors

--- Content provided by​ FirstRanker.com ---

3

---

Acute Renal Failure (3)
RENAL
= Intrinsic Disease

--- Content provided by‍ FirstRanker.com ---

? Causes
?Vascular
Dissection, Thrombosis, Emboli
?Glomerular
Glomerulonephritis (GN)

--- Content provided by​ FirstRanker.com ---

?Interstitial
Acute Interstitial Nephritis (AIN)
?Tubular (most common)
Acute Tubular Necrosis (ATN)
4

--- Content provided by​ FirstRanker.com ---

---

Acute Renal Failure (4)
Vascular Causes
? Catastrophes along the aorta
?Dissection
?Thrombosis

--- Content provided by⁠ FirstRanker.com ---

? Emboli
? Suspect when more than one
organ along aorta is involved

--- Content provided by‌ FirstRanker.com ---

5

---

Acute Renal Failure (5)
Rapidly Progressive Glomerulonephritis
(Acute Nephritic Syndrome)
? Pathology

--- Content provided by FirstRanker.com ---

?Immune complexes/antibodies
in glomeruli
? Causes
?Autoimmune / Vasculitities
?Post-streptococcal GN

--- Content provided by‍ FirstRanker.com ---

?Wegeners, Goodpastures
Hepatitis B/C
?SLE, PAN, HSP, HUS,
TTP, HELLP
?Malignant Hypertension

--- Content provided by‌ FirstRanker.com ---

6

---

Acute Renal Failure (6)
Rapidly Progressive Glomerulonephritis
(Acute Nephritic Syndrome)
? Clinical Features

--- Content provided by FirstRanker.com ---

?Oliguria, edema, hypertension
? Urine
?Hematuria, pyuria, RBC casts,
mild/moderate proteinuria
? Treatment

--- Content provided by‍ FirstRanker.com ---

?Steroids, immunosuppressive
agents
7

---

Acute Renal Failure (7)
Acute Interstitial Nephritis (AIN)

--- Content provided by‌ FirstRanker.com ---

? Pathology
?Immune mediated
? Causes
?Drugs
?Penicil in, Sulpha

--- Content provided by‍ FirstRanker.com ---

?Diuretics
?NSAIDs
?Infections
8

---

Acute Renal Failure (8)

--- Content provided by‌ FirstRanker.com ---

Acute Interstitial Nephritis (AIN)
? Clinical Features
?Fever, rash, eosinophilia
? Urine
?Pyuria, WBC casts,

--- Content provided by‍ FirstRanker.com ---

eosinophiluria
? Treatment
?Treat underlying infection
?Remove offending agent(s)
9

--- Content provided by‌ FirstRanker.com ---

---

Acute Renal Failure (9)
Acute Tubular Necrosis (ATN)
Leading cause of renal failure
? Ischemic
?Usual y oliguric (<500 mL/day)

--- Content provided by⁠ FirstRanker.com ---

?Leading causes: trauma and sepsis
? Toxic
?Usual y not oliguric
?Causes: Contrast media
Myoglobin(rhabdomyolysis)

--- Content provided by‍ FirstRanker.com ---

Hemoglobin (hemolysis)
Aminoglycosides
Multiple myeloma
Ethylene glycol
10

--- Content provided by‌ FirstRanker.com ---

---

Acute Renal Failure (10)
Rhabdomyolysis (ATN)
? Pathology
?Skeletal muscle injury

--- Content provided by FirstRanker.com ---

?Myoglobin clogs tubules
?Myoglobin causes
positive dip for heme, but
no RBCs seen on micro
? Causes

--- Content provided by‍ FirstRanker.com ---

?Trauma, Crush
?Burns, Electrical injury,
TASER
?Heat stroke, "Found
down"

--- Content provided by⁠ FirstRanker.com ---

?EtOH, other drugs
11

---

Acute Renal Failure (11)
Rhabdomyolysis (ATN)

--- Content provided by‌ FirstRanker.com ---

? Diagnosis
?CK > 5 times normal for
diagnosis (more sensitive
marker than myoglobin
itself)

--- Content provided by FirstRanker.com ---

?Dramatic acute increase in
creatinine (Cr)
? Treatment
?IV hydration
?Treat hyperkalemia and

--- Content provided by⁠ FirstRanker.com ---

hypocalcemia
?Alkalinization of urine with
bicarbonate
12

---

Acute Renal Failure (12)

--- Content provided by‌ FirstRanker.com ---

Contrast Induced Nephropathy (ATN)
? Who is at high risk? ? Mitigating the risk
?Pre-existing renal disease
?Choose a non-contrast
?Recent contrast study

--- Content provided by​ FirstRanker.com ---

study
(within 72 hours)
?Volume expansion
?
?

--- Content provided by‍ FirstRanker.com ---

Hypotension
Low osmolar contrast
agents
?Dehydration
?Bicarbonate infusions

--- Content provided by FirstRanker.com ---

?Diabetes
?Hypertonic saline
?Multiple myeloma
?N-acetylcysteine
?Age > 70

--- Content provided by​ FirstRanker.com ---

?Hypertension
?Hyperuricemia
?Diuretics
13

---

--- Content provided by⁠ FirstRanker.com ---

Acute Renal Failure (13)
POSTRENAL
= Obstruction
? Causes
?Bilateral kidney

--- Content provided by FirstRanker.com ---

crystals in tubules, stones in calyces
?Bilateral ureteric
multiple stones, surgical y cut
retroperitoneal blood, pus or scar,
papillary necrosis

--- Content provided by​ FirstRanker.com ---

?Urethral
prostatic hypertrophy (most common)
neurogenic bladder
phimosis, meatal stenosis

--- Content provided by‍ FirstRanker.com ---

14

---

Acute Renal Failure (14)
MEASURE
PRE-RENAL
RENAL (ATN)

--- Content provided by⁠ FirstRanker.com ---

Fractional


Excretion of Na+
< 1%

--- Content provided by FirstRanker.com ---

> 1%
(FENa)
%

--- Content provided by‍ FirstRanker.com ---

Urine Na+
LOW (< 20)
HIGH (> 40)

--- Content provided by‌ FirstRanker.com ---

mEq/L
BUN / Creatinine

--- Content provided by‌ FirstRanker.com ---

Ratio
HIGH (> 20)
LOW (< 20)

--- Content provided by⁠ FirstRanker.com ---

15

---

Acute Renal Failure (15) ? U/A
FORMED ELEMENT
LOCATION OF
SPECIFIC ENTITIES

--- Content provided by⁠ FirstRanker.com ---

PATHOLOGY
RBC Casts
Glomerular Disease Nephritic
(or dysmorphic RBCs)
Syndrome

--- Content provided by​ FirstRanker.com ---

(Rapidly progressive GN)
WBC Casts
Interstitium
Pyelonephritis
AIN

--- Content provided by FirstRanker.com ---

Eosinophils
Interstitium
Acute Interstitial
Nephritis (AIN)
Granular Casts

--- Content provided by‌ FirstRanker.com ---

Tubule
Acute Tubular
(Cell debris)
Necrosis (ATN)
Hyaline Casts

--- Content provided by​ FirstRanker.com ---

Pre- or post-renal
Pre- or post-renal
(Acellular)
acute renal failure
16

--- Content provided by FirstRanker.com ---

---

Acute Renal Failure (16) ? U/A
RBC Cast
17

---

Acute Renal Failure (17) - Summary
PRERENAL?

--- Content provided by FirstRanker.com ---

Yes
No
Restore circulating
volume
POSTRENAL?

--- Content provided by FirstRanker.com ---

Yes
No
Relieve obstruction
RENAL
Vascular ?

--- Content provided by‍ FirstRanker.com ---

No
Rapidly Progressive GN ?
Acute Interstitial Nephritis (AIN) ?
Acute Tubular Necrosis (ATN)
18

--- Content provided by⁠ FirstRanker.com ---

---

Pink Urine
RBCs ? Hematuria
?Kidney stone
?Cancer
?Nephritic syndrome

--- Content provided by​ FirstRanker.com ---

? Myoglobinuria
NO RBCs = Rhabdomyolysis


VS

--- Content provided by⁠ FirstRanker.com ---

Microscopy
?
Hemoglobinuria
= Intravascular hemolysis
?MAHA (DIC, TTP, HUS)

--- Content provided by‌ FirstRanker.com ---

?Mechanical valve
emergency
19

---

Chronic Renal Failure

--- Content provided by FirstRanker.com ---

The Nephrotic Syndrome = Nephrosis
? Clinical Features

?Massive proteinuria (>3g/24h)
?Hypoalbuminemia

--- Content provided by‌ FirstRanker.com ---

?Edema
?Hyperlipidemia
?Thrombotic diathesis
?DVT/PE
20

--- Content provided by‌ FirstRanker.com ---

---

Chronic Renal Failure
The Nephrotic Syndrome = Nephrosis
? Causes
Primary

--- Content provided by​ FirstRanker.com ---

?Idiopathic entities involving
kidneys alone
?Most commonly focal, segmental
Secondary
?Diabetes mel itus

--- Content provided by‍ FirstRanker.com ---

?Henoch-Schonlein purpura (HSP)
?SLE / Syphilis / Hepatitis B/C
?HIV
?Cancer
?Drugs (gold, mercury. heroin)

--- Content provided by‍ FirstRanker.com ---

21

---

Chronic Renal Failure
Polycystic Kidney Disease

--- Content provided by‌ FirstRanker.com ---

U/S
CT
? Autosomal Dominant
? Flank Pain and Hematuria
? Progressive Renal Failure

--- Content provided by‍ FirstRanker.com ---

? Association with cerebral aneurysms and SAH
22

---

Indications for Emergent Dialysis
? Refractive volume overload
? Refractive hyperkalemia

--- Content provided by⁠ FirstRanker.com ---

? Metabolic acidosis
? Severe Na+ imbalance
? Symptomatic uremia
- Encephalopathy
- Pericarditis

--- Content provided by​ FirstRanker.com ---

- Bleeding
- Nausea/vomiting
? Toxins
23

---

End Stage Renal Disease (1)

--- Content provided by FirstRanker.com ---

Complications
? Cardiac
?Coronary Artery Disease
?Severe Refractory Hypertension
?Uremic Pericarditis

--- Content provided by‍ FirstRanker.com ---

?Tamponade (Beck's triad is rare)
?Pulmonary Edema (furosemide ok if any U/O)
?Uremic Cardiomyopathy (Dx of exclusion)
Consider tamponade in any critically
ill ESRD patient

--- Content provided by​ FirstRanker.com ---

24

---

End Stage Renal Disease (2)
Complications
? Hematologic
?All cel lines are affected

--- Content provided by‌ FirstRanker.com ---

?RBCs ? Anemia
?WBCs ? Infection
?Platelets ? Bleeding
? Neurologic
?Subdural hematoma

--- Content provided by​ FirstRanker.com ---

?Subarachnoid hemorrhage (with polycystic kidneys)
?Uremic encephalopathy
?Dialysis dementia (Dx of exclusion)
Consider subdural hematoma in any
altered ESRD patient

--- Content provided by⁠ FirstRanker.com ---

25

---

End Stage Renal Disease (3)
Complications
? Electrolyte
?Hyperkalemia (K+)

--- Content provided by‍ FirstRanker.com ---

?Bradyasystolic arrest in uremic patients
?Stabilize: Calcium gluconate (for life-threatening
rhythms)
?Shift: HCO3, Insulin/D50, Albuterol (for ECG changes
or levels)

--- Content provided by‍ FirstRanker.com ---

?Eliminate: Binding resin (sodium polystyrene)
?Hypokalemia (K+)
?Ventricular fibril ation in dialysed patients
?PVC's
?Hypocalcemia (Ca2+)

--- Content provided by⁠ FirstRanker.com ---

?Hypomagnesemia (Mg2+)
26

---

End Stage Renal Disease (4)
The Many Faces of Hyperkalemia
The Good

--- Content provided by⁠ FirstRanker.com ---

The Bad
27

---

End Stage Renal Disease (5)
The Many Faces of Hyperkalemia
The Ugly!

--- Content provided by‍ FirstRanker.com ---

28

---

Hemodialysis Complications (1)
? Hypotension (most common)
? Access complications
?Bleeding

--- Content provided by‍ FirstRanker.com ---

?Direct pressure or tourniquet if necessary
?Correct coagulopathy (protamine sulfate, DDAVP)
?Clotting
?"The thril is gone"
?Can inject thrombolytic, surgical removal within 24hr

--- Content provided by⁠ FirstRanker.com ---

?Infection
?Cel ulitis, abscess, "occult" presentation
?S. aureus and gram negatives (Rx with vanco +/-
gentamicin)
?High Output Failure

--- Content provided by‍ FirstRanker.com ---

29

---

Dialysis Access Complications
30

---

Hemodialysis Complications (2)

--- Content provided by​ FirstRanker.com ---

? Altered Mental Status
?Hypotension
?Hypoglycemia
?Hypercalcemia
?Subdural hematoma

--- Content provided by⁠ FirstRanker.com ---

?Dysequilibrium syndrome
?Increased ICP from osmotic shifts during dialysis
?Headache, nausea, confusion
?Diagnosis of exclusion
?Resolves spontaneously. Symptomatic Rx.

--- Content provided by‍ FirstRanker.com ---

? GI Issues
?GI bleeding, constipation and bowel obstruction are
common
31

---

Peritoneal Dialysis

--- Content provided by​ FirstRanker.com ---

? Requires no heparin and occurs slowly (fewer acute
complications)
? Peritoneal infection is the most serious problem
Symptoms: Abdominal discomfort , Fever
Pain during inflow

--- Content provided by‌ FirstRanker.com ---

Diagnosis: Peritoneal fluid analysis
>100 WBCs/mm3, >50% PMNs
S. epidermidis (#1)
S. aureus, Strep. and gram negatives
Treatment: Intraperitoneal antibiotics and lavage

--- Content provided by‌ FirstRanker.com ---

IV antibiotics if systemical y il
32

---

Urinary Tract Infection (1)
? Definition
?Symptoms plus as few as 100 CFUs (colony

--- Content provided by‌ FirstRanker.com ---

forming units) of a single pathogen
? Relapse
?Same organism and serotype
?Less than one month since the initial infection
? Reinfection

--- Content provided by‌ FirstRanker.com ---

?Different organism or serotype
?One to six months after initial infection
33

---

Urinary Tract Infection (2)
UNCOMPLICATED

--- Content provided by‍ FirstRanker.com ---

COMPLICATED

Host
Young, healthy non-
Everyone else

--- Content provided by​ FirstRanker.com ---

pregnant female
Pathogen

Klebsiella Group D Strep
Proteus

--- Content provided by⁠ FirstRanker.com ---

Pseudomonas
E.coli
Enterobacter Staph spp

Work-Up

--- Content provided by‍ FirstRanker.com ---

Culture
Do not culture
+/- Follow-up studies

Treatment

--- Content provided by‌ FirstRanker.com ---

3 days
10 days
Empiric coverage to cover
pseudomonas in high-risk patient

--- Content provided by​ FirstRanker.com ---

34

---

Urinalysis in UTIs
Nitrite test:
Specific but insensitive.

--- Content provided by‌ FirstRanker.com ---

Based on bacterial metabolism of
nitrate to nitrite

Leukocyte esterase:
Specific but insensitive.

--- Content provided by⁠ FirstRanker.com ---

Based on the presence of WBCs
Bacteriuria:
Any bacterium (uncentrifuged)
>15/HPF
(centrifuged)

--- Content provided by⁠ FirstRanker.com ---

Pyuria:
>2-5 WBCs
(centrifuged, female)
>1-2 WBCs
(male)

--- Content provided by⁠ FirstRanker.com ---

35

---

UTI Miscellaneous
? Asymptomatic bacteruria
?Treat only in pregnancy to prevent pyelonephritis
? Sterile pyuria

--- Content provided by⁠ FirstRanker.com ---

?Genitourinary TB (classic sterile pyuria)
?Chlamydia (most common)
? Acute urethral syndrome
?Sterile or low bacterial count with dysuria
?Differential: Chlamydia, GC, HSV, vaginitis

--- Content provided by‌ FirstRanker.com ---

?Treatment: Empiric Rx of STDs
Pyelonephritis incidence is increased in the third trimester
(may precipitate preeclampsia, sepsis and miscarriage)
36

---

--- Content provided by FirstRanker.com ---

Surgical Complications of UTI
? Perinephric abscess
?Complication of UTI, from contiguous spread
?Contrast with renal abscess or carbuncle, which
is from hematogenous spread

--- Content provided by‌ FirstRanker.com ---

? Emphysematous
pyelonephritis
?Occurs in diabetics
?High mortality without
drainage

--- Content provided by‍ FirstRanker.com ---

Consider surgical complications in sick patients with
pyelonephritis ? especially in diabetics
37

---

Fournier's Scrotal Gangrene
? Surgical emergency

--- Content provided by FirstRanker.com ---

? Polymicrobial
? More common in the immunocompromised
?Alcoholic liver disease / cirrhosis
?Diabetes
?IV drug use

--- Content provided by FirstRanker.com ---

? Begins as benign infection (cel ulitis, abscess)
Consider Fournier's in any patient with scrotal, rectal
or genital pain out of proportion to clinical findings
38

---

--- Content provided by FirstRanker.com ---

Fournier's Scrotal Gangrene
39

---

The Many Faces of Fournier's

--- Content provided by FirstRanker.com ---

40

---

The Many Faces of Fournier's
41

--- Content provided by‍ FirstRanker.com ---

---

Necrotizing Soft Tissue Infections
Not Missing the Diagnosis
? Pain Out of Proportion (POOP) or indifference
? Vital sign derangements (esp. tachycardia)
? WBC count

--- Content provided by‌ FirstRanker.com ---

? Low serum Na+
? Blisters
? Odor
? Rapid change
? Skin appearance variable

--- Content provided by‌ FirstRanker.com ---

? Subcutaneous air (crepitus)
42

---

Balanoposthitis
? Balanitis: glans penis
? Posthitis: foreskin

--- Content provided by‌ FirstRanker.com ---

? Rule out diabetes
? Treatment
?Local measures (soap
and water, keep dry)
?Topical bacitracin (peds)

--- Content provided by‍ FirstRanker.com ---

?Topical clotrimazole
(adults)
Balanoposthitis
43

---

Candidal balanitis

--- Content provided by‌ FirstRanker.com ---

44
Logical images Inc.

---

Candidal balanitis
45
Logical images Inc.

--- Content provided by‍ FirstRanker.com ---

---

Phimosis / Paraphimosis
PHIMOSIS
PARAPHIMOSIS

Rarely

--- Content provided by​ FirstRanker.com ---

Emergency
emergent


Unable to

--- Content provided by‍ FirstRanker.com ---

Retracted
Definition retract foreskin
foreskin

--- Content provided by‌ FirstRanker.com ---

Urinary
Complication
Necrosis of glans
retention (Rare)

--- Content provided by‍ FirstRanker.com ---

Dilation of
Compression &
Treatment preputial ostium
dorsal incision
(if retention only)

--- Content provided by⁠ FirstRanker.com ---

46

---

Paraphimosis and Its Treatment

--- Content provided by FirstRanker.com ---

Penile Block
Attempt at Manual
Reduction
47

---

Penile Hair Tourniquet

--- Content provided by⁠ FirstRanker.com ---

? Constricting hair band
? In DDx of persistently crying boy (2-5 y.o)
? Hair may be buried in coronal ridge due to
edema
48

--- Content provided by‌ FirstRanker.com ---

---

Fractured Penis
? During intercourse
? Rupture of tunica albuginea
? Hematoma formation, may involve urethra
? Surgical management

--- Content provided by‍ FirstRanker.com ---

49

---

Priapism (1)
Pathologic erection
? Involves both corpora cavernosa
but not

--- Content provided by​ FirstRanker.com ---

glans or corpus spongiosum
Complications
? Urinary retention
? Impotence
50

--- Content provided by FirstRanker.com ---

Med-Chal enger ? EM

---

Priapism (2)
Two Forms / Causes
? Low-flow priapism (ischemic)
?Sickle cel or other hematologic diseases

--- Content provided by​ FirstRanker.com ---

?Intracavernosal injections
?Drugs (phenothiazines, SSRIs, Viagra et al.,
neuroleptics)
?Spinal cord injuries
? High-flow priapism (arterial injury)

--- Content provided by‌ FirstRanker.com ---

?Trauma (straddle mechanism)
51

---

Priapism (3)
Treatment
? Low flow

--- Content provided by⁠ FirstRanker.com ---

Basic treatment is the same for all causes
?Terbutaline subcutaneously or local y
?Corporal aspiration and irrigation
?Phenylephrine injection into corpora
?Specific hematologic Rx (e.g. transfusion for

--- Content provided by‌ FirstRanker.com ---

sickle cel disease)
?Surgery (placement of shunt)
? High flow
Embolization or surgery
52

--- Content provided by‍ FirstRanker.com ---

---

Penile Lesions ? Syphilis (1)
? Treponema pal idum
? Primary infection
?Painless chancre (arrives 21 days after contact and lasts
4-6 weeks)

--- Content provided by​ FirstRanker.com ---

?Indurated borders
?No constitutional symptoms
?Minimal adenopathy
?Dx: dark field microscopy, RPR, FTA-ABS
?Serology usual y negative first 4-6 weeks

--- Content provided by‌ FirstRanker.com ---

? Treatment
?2.4 mil ion units benzathine penicil in G IM
?Anticipate Jarisch-Herxheimer reaction (slide 56)
53

---

Chancre (primary syphilis)

--- Content provided by​ FirstRanker.com ---

54
Med-Chal enger ? EM

---

Penile Lesions ? Syphilis (2)
? Secondary Syphillis
?6-8 weeks after primary

--- Content provided by FirstRanker.com ---

infection
?Most infectious phase of
syphil is
?Rash on palms, soles,
trunk

--- Content provided by‍ FirstRanker.com ---

?Lesions contain
spirochetes
?In moist areas the
lesions are flat =
condyloma lata

--- Content provided by FirstRanker.com ---

55

---

Secondary Syphilis
56
Med-Chal enger ? EM

---

Penile Lesions ? Syphilis (3)

--- Content provided by‌ FirstRanker.com ---

? Jarisch-Herxheimer reaction
?Antibiotic treatment causes organism death and
the release of endotoxins
?Fever, chil s, headache, myalgia, rash
?Comes on 2-6 hours after the onset of

--- Content provided by​ FirstRanker.com ---

treatment
?Lasts a few hours
?Occurs in 50% of cases of primary syphyllis
(90% of secondary cases)
?Treat with acetaminophen two hours before and

--- Content provided by​ FirstRanker.com ---

after antibiotic treatment
57

---

Penile Lesions - Herpes
? Herpes simplex virus (HSV-1 or HSV-2)
? Primary Infection

--- Content provided by‍ FirstRanker.com ---

? Constitutional symptoms
?Headache, fever, myalgias
? Painful blisters, pustules or ulcers
? Lymphadenopathy
? Complications

--- Content provided by‌ FirstRanker.com ---

?Urinary retention
?Aseptic meningitis (HSV-2)
? Treatment: acyclovir 200 mg 5x/day for 10 days
58

---

Penile Lesions - Herpes

--- Content provided by‍ FirstRanker.com ---

59
Logical images Inc.

---

Penile Lesions - LGV
? Lymphogranuloma venereum (LGV)
? Chlamydia trachomatis

--- Content provided by FirstRanker.com ---

? Urban outbreaks in the U.S.
? Primary infection
? Primary lesion: painless herpes-like ulcer
? Inguinal "buboes" (enlarged nodes), groove
sign

--- Content provided by​ FirstRanker.com ---

? Treatment: doxycycline x 3 weeks
60

---

Lymphogranuloma venereum (LGV)
61

---

LGV

--- Content provided by FirstRanker.com ---

Groove sign
Ulcerated Bubo
62

---

Penile Lesions - Chancroid
? Haemophilus ducreyi

--- Content provided by​ FirstRanker.com ---

? Rare in U.S.
? Primary infection
?Tender papule fol owed by painful ulcer
(multiple lesions may be present and coalesce)
?Painful inguinal adenopathy (buboes)

--- Content provided by​ FirstRanker.com ---

? Culture!
? Treatment: azithromycin or ceftriaxone (single
dose treatment with either agent)
63

---

--- Content provided by⁠ FirstRanker.com ---

Chancroid
64

---

Penile Lesions ? Granuloma Inguinale
? Calymmatobacteruim granulomatis
(Donovaniasis)

--- Content provided by​ FirstRanker.com ---

? Rare in U.S.
? Presentation
?Chronic painless progressive ulcers and
vascular granulomata
?Multilating

--- Content provided by‌ FirstRanker.com ---

?No inguinal adenopathy
? Biopsy! (Donovan bodies)
? Treatment: doxycycline x 3 weeks
65

---

--- Content provided by FirstRanker.com ---

Granuloma Inguinale
66

---

Testicular Torsion (1)
? Peak incidence in puberty
? Bel clapper deformity - bilateral: testis is free

--- Content provided by FirstRanker.com ---

to swing and rotate inside the tunica vaginalis
? Presentation
?Sudden onset of testicular pain
?Testicle is elevated; horizontal lie
?Cremasteric reflex usual y absent

--- Content provided by‌ FirstRanker.com ---

?Prehn's sign usual y absent (relief of pain by
scrotal elevation ? a sign of epididymitis)
Consider torsion in any young male with
abdominal pain
67

--- Content provided by‌ FirstRanker.com ---

---

Testicular Torsion (2)
? Treatment
Manual detorsion
?Detorse medial-to-lateral (like opening a book
when viewed from the feet)

--- Content provided by‍ FirstRanker.com ---

?Relief of pain, normal lie indicates success
?If unsuccessful, try opposite direction
?High salvage rate if detorsed within 6 hours, high
loss rate after 8 hours
Emergency Surgery

--- Content provided by‍ FirstRanker.com ---

?Bilateral y orchidopexy
CALL THE UROLOGIST STAT ? then do the U/S
or nuclear scan!
68

---

--- Content provided by⁠ FirstRanker.com ---

Testicular Appendage Torsion
? Twisting of appendix testis or
other "non-essential" structures
? More common in prepubertal boys
? Blue dot sign: Necrotic

--- Content provided by⁠ FirstRanker.com ---

appendages visualized through
scrotum
? Surgery is not necessary
if diagnosis is unequivocal
(normal color Doppler of testis)

--- Content provided by FirstRanker.com ---

69

---

Epididymitis (1)
? Causes
?Infection (age-related etiology)
?Inflammation (e.g. urine reflux)

--- Content provided by‍ FirstRanker.com ---

? Presentation
?Can mimic torsion but usual y gradual onset of pain
?Cremasteric reflex usual y present (stroking the inner
thigh causes retraction of the scrotum and testicle)
?Prehn's sign usual y present (relief of pain on lifting the

--- Content provided by​ FirstRanker.com ---

testicle) (Ischemic pain of torsion not relieved by lifting)
? Age-related factors
?Young boys: Consider structural abnormality / E. coli
?Sexual y active: Usual y STD-related (Chlamydia/GC)
?Older patients: Think obstruction, prostatism / E.coli 70

--- Content provided by FirstRanker.com ---

---

Epididymitis (2)
? Diagnosis
?Urine frequently
positive for bacteria,

--- Content provided by⁠ FirstRanker.com ---

WBCs, nitrites
?Increased flow on color
Doppler (U/S)
? Treatment
?Antibiotics to cover age-specific causes

--- Content provided by⁠ FirstRanker.com ---

?NSAIDs
?Intermittent ice packs, scrotal support
71

---

Acute Prostatitis
? Causes

--- Content provided by​ FirstRanker.com ---

?Same etiologies as epididymitis
?Similar age-related considerations
? Presentation
?Perineal pain, dyschezia, frequency, dysuria, fever,
chil s, urinary retention

--- Content provided by‍ FirstRanker.com ---

?Boggy, enlarged, tender prostate
? Treatment
?Acute: Prostate massage, Foley contraindicated
Suprapubic drain PRN
IV Antibiotics

--- Content provided by⁠ FirstRanker.com ---

?Chronic: Long term outpatient antibiotics
72

---

Urethritis

--- Content provided by‍ FirstRanker.com ---

? Gonococcal
?White discharge
?Gram negative intracel ular diplococci
?Treatment: ceftriaxone 250mg IM
?Treat for Chlamydia as wel

--- Content provided by⁠ FirstRanker.com ---

? Non-Gonococcal
?Watery or no discharge
?Few findings on smear
?Chlamydia, HSV, Trichomonas,
Ureaplasma,

--- Content provided by​ FirstRanker.com ---

?Treatment: azithromycin (1g x single dose)
doxycycline (100 mg BID x 10 days)
Consider HIV/syphilis and treat partners
73

---

--- Content provided by​ FirstRanker.com ---

Urinary Retention
? Causes
?Mechanical
? Prostatic hyperplasia (most common), meatal stenosis,
urethral stricture

--- Content provided by⁠ FirstRanker.com ---

?Neurologic
? Spinal cord injury, MS, diabetes
? Drugs are a key precipitant/exacerbating factor
? OTC sympathomimetics (e.g. cold remedies)
? TCAs, anticholinergics, antihypertensives

--- Content provided by FirstRanker.com ---

? Opioids
? Treatment
?Coud? catheter if BPH suspected
?DO NOT attempt filiform and fol owers
?Suprapubic drainage if cannot pass

--- Content provided by‌ FirstRanker.com ---

catheter and no urologist available
?Discharge with catheter in place
Coud? catheter
74

---

Non-traumatic Hematuria (1)

--- Content provided by‍ FirstRanker.com ---

? Definition: >5 RBC's/hpf
When during
On Initiation
Bladder/Urethra
urination?

--- Content provided by‌ FirstRanker.com ---

At end
Prostate
Throughout
Renal
Cyclic

--- Content provided by‍ FirstRanker.com ---

Endometriosis
Color?
Brown
Renal
Consistency?

--- Content provided by​ FirstRanker.com ---

Clots
Post-renal
Associated Hx
Recent Infection
Renal

--- Content provided by​ FirstRanker.com ---

Multisystem
(Renovascular, GN,
disease
AIN)
Drugs

--- Content provided by‍ FirstRanker.com ---

75

---

Non-traumatic Hematuria (2)
AGE
Common CAUSES
<20 years

--- Content provided by‍ FirstRanker.com ---

Glomerulonephritis
UTI
20-40 years
Stone
UTI

--- Content provided by FirstRanker.com ---

Carcinoma
>40 years
Carcinoma
Stone
UTI

--- Content provided by⁠ FirstRanker.com ---

>60 years (male)
Prostatism
Carcinoma
76

--- Content provided by​ FirstRanker.com ---

---

Kidney Stones (1)
STONE TYPE
CAUSES
NOTES
(INCIDENCE)

--- Content provided by FirstRanker.com ---

Calcium oxalate
Most related to diet Male predominance
(75%)
IBD (UC and Crohn's)
Warm & dry climates

--- Content provided by‌ FirstRanker.com ---

Hyperparathyroidism
Struvite (Mg-NH4-PO4) Chronic Infection
Staghorn formation
(15%)
(Proteus, pseudomonas)

--- Content provided by‍ FirstRanker.com ---

High pH (>7)
Uric acid
Gout
Radiolucent
(10%)

--- Content provided by⁠ FirstRanker.com ---

Congenital
Low pH (<6)
Cysteine
In-born error
Staghorn formation

--- Content provided by‍ FirstRanker.com ---

(1%)
Renal failure
Indinivir
Indinivir therapy
HIV or post-exposure

--- Content provided by​ FirstRanker.com ---

(protease inhibitor) prophylaxis patients
(<1%)
77

---

Kidney Stones (2)

--- Content provided by‍ FirstRanker.com ---

Common areas of impaction
1
1 Renal calyx
2
2 Ureteropelvic junction (UPJ)

--- Content provided by FirstRanker.com ---

3
3 Pelvic Brim
4
4 Ureterovesical junction (UVJ)

--- Content provided by​ FirstRanker.com ---

UVJ is the most common site of impaction
78

---

Kidney Stones Diagnosis
Hematuria may be absent in 10-20%
Diagnostic Mimics

--- Content provided by⁠ FirstRanker.com ---

? Critical DDx includes: AAA
Testicular torsion
Ectopic pregnancy
Appendicitis
Incarcerated hernia

--- Content provided by‌ FirstRanker.com ---

Biliary colic
Renal colic is the most common misdiagnosis in
cases of abdominal aortic aneurysm
79

---

Kidney Stones Treatment

--- Content provided by FirstRanker.com ---

? NSAIDs
?Avoid in congenital stones, any history of renal failure,
bilateral stones
? Opioid Narcotics
? Hydration

--- Content provided by‌ FirstRanker.com ---

?Fluid boluses increase pain, not helpful
? ECSWL (lithotripsy)
? Percutaneous lithotomy, retrograde lithotomy
? Open Surgery
80

--- Content provided by‌ FirstRanker.com ---

---

Stone Admission Indications
? Concurrent infection
? Concomitant renal insufficiency
? Solitary kidney with complete obstruction
? Uncontrol ed pain or intractable vomiting

--- Content provided by‌ FirstRanker.com ---

? Ruptured renal capsule
Stone Passage
? 5 mm pass 50% of time
? >6 mm pass 10% of the time
? 1 cm stones do not pass)

--- Content provided by FirstRanker.com ---

81

---

Stone Imaging

--- Content provided by‍ FirstRanker.com ---

Plain films-KUB Ultrasound
Non-contrast CT
New Gold Standard
Not sensitive
Not sensitive

--- Content provided by‍ FirstRanker.com ---

Sensitive
Not specific
More specific
Most specific
For - pregnant

--- Content provided by​ FirstRanker.com ---

No info on function
- repeat imaging
(need IVP or CT urogram)
82

---

Staghorn Calculus on Plain Film (KUB)

--- Content provided by FirstRanker.com ---

83

---

--- Content provided by​ FirstRanker.com ---

Renal U/S:
Hydronephrosis
84

---

Renal U/S:
Ruptured Renal Capsule

--- Content provided by⁠ FirstRanker.com ---

85

---

Renal US:
Large Stone in Renal Pelvis
86

--- Content provided by​ FirstRanker.com ---

---

CT:
Hydronephrosis
87

---

--- Content provided by‍ FirstRanker.com ---

CT:
Ruptured Abdominal Aortic Aneurysm
88

---

Renal Transplant Tidbits
? Most common solid organ transplant

--- Content provided by⁠ FirstRanker.com ---

? Transplant location: retroperitoneal in pelvis
? Hepatitis C is very common
? Patients receive azathioprine, cyclosporine
and prednisone
? Cyclosporine is nephrotoxic

--- Content provided by FirstRanker.com ---

Infection and Rejection
Can be subtle clinical y
Any rise in creatinine is cause for alarm
Consult transplant team
89

--- Content provided by‍ FirstRanker.com ---

---

NEPHROLOGY QUESTIONS
90

---

Which of the following is a pre-renal cause
of renal failure?
A. CHF

--- Content provided by‍ FirstRanker.com ---

B. Acute tubular necrosis
C. Renal papil ary necrosis
D. Glomerulonephritis
E. Nephrolithiasis
NEP 1

--- Content provided by FirstRanker.com ---

---

A 25 y/o presents with a 3 week history of
lower extremity edema and fatigue. U/A:
Massive proteinuria. Which of the
following is the most likely diagnosis?
A. Familial hyperlipidemia

--- Content provided by‌ FirstRanker.com ---

B. Hereditary angioedema
C. Thrombotic diathesis
D. Nephrotic syndrome
E. Guil ain Barre syndrome
NEP 2

--- Content provided by‌ FirstRanker.com ---

---

Which is true regarding diabetes
insipidus?
A. The least common drug-related cause is lithium
B. In nephrogenic DI, the kidney responds to
exogenous infusion of ADH

--- Content provided by⁠ FirstRanker.com ---

C. The urine is typical y very dilute
D. Head trauma is not a common cause
E. Results from increased secretion or response to
ADH
NEP 3

--- Content provided by‍ FirstRanker.com ---

---

A 30 y/o dialysis patient presents with a
decreased blood pressure, distended neck
veins, distant heart sounds and equal lung
sounds. A low-grade fever is present.
What is the most likely cause?

--- Content provided by​ FirstRanker.com ---

A. Congestive heart failure
B. Tension pneumothorax
C. Pulmonary embolism
D. Pericardial effusion
E. Dressler's syndrome

--- Content provided by⁠ FirstRanker.com ---

NEP 4

---

A dialysis patient who missed her last
treatment has a bradyasystolic cardiac
arrest. Which of the following would be
most beneficial during her resuscitation?

--- Content provided by‌ FirstRanker.com ---

A. Potassium
B. Magnesium
C. Phosphorus
D. Calcium
E. NaHCO3

--- Content provided by FirstRanker.com ---

NEP 5

---

Which of the following penile lesions is
classically described as painless?
A. Herpes simplex
B. Chancroid

--- Content provided by‌ FirstRanker.com ---

C. Herpes zoster
D. Chancre
E. Inguinal bubo
NEP 6

---

Which of the following is

--- Content provided by​ FirstRanker.com ---

consistent with renal transplants?
A. The least common solid organ
transplanted
B. Hepatitis C is uncommon
C. Cyclosporine is contraindicated

--- Content provided by‌ FirstRanker.com ---

D. Corticosteroids are contraindicated
E. Cyclosporine is nephrotoxic
NEP 7

---

A dialysis patient is brought to the ED with
a sudden, severe headache with vomiting.

--- Content provided by FirstRanker.com ---

What is the likely cause of the patient's
chronic renal failure and subarachnoid
hemorrhage?
A. Acute tubular necrosis
B. Diabetes

--- Content provided by⁠ FirstRanker.com ---

C. Polycystic kidney disease
D. Aminoglycoside toxicity
E. Hypertension
NEP 8

---

A 30 y/o patient is suspected of having

--- Content provided by FirstRanker.com ---

epididymitis. The usual etiology is:
A. Chlamydia trachomatis
B. Urethritis from non-oxyl-9
C. E. coli
D. Klebsiel a

--- Content provided by⁠ FirstRanker.com ---

E. Bacteroides fragilis
NEP 9

---

Which of the following is a true
statement regarding imaging studies
for ureteral stones?

--- Content provided by​ FirstRanker.com ---

A. The IVP demonstrates function and anatomy
B. Contrast reactions and nephrotoxicity are
more likely to occur with non-ionic vs. ionic
contrast
C. Patients who are dehydrated, hyperglycemic,

--- Content provided by​ FirstRanker.com ---

over the age of 70 and with pre-existing
renal disease are good candidates for IVPs
D. Total obstructions induced by ureteral stones
>6mm are poorly visualized on
ultrasonography

--- Content provided by⁠ FirstRanker.com ---

E. Ultrasound is the gold standard in renal stone
imaging
NEP 10

---

Which of the following statements is
true regarding ureteral stones?

--- Content provided by FirstRanker.com ---

A. They are more common in females than males
B. Most uric acid stones are radiopaque
C. Ureteral stones are less common in warmer
climates
D. Few stones > 6 mm wil spontaneously pass

--- Content provided by‌ FirstRanker.com ---

E. The UPJ is the most common location of
obstruction
NEP 11

---

Regarding dialysis-associated
problems, which of the following is true?

--- Content provided by FirstRanker.com ---

A. First-use syndrome is manifested by hypertension
from an anaphylactoid reaction to a new dialyzer
B. Dialysis-related dysequilibrium is treated with
corticosteroids
C. Hypokalemia is the most common cause of dialysis-

--- Content provided by FirstRanker.com ---

related bradyasystolic cardiac arrest
D. Hyperkalemia in dialysis patients can be initial y
treated with IV calcium gluconate.
E. "Dialysis dementia" responds to increasing the
frequency of treatments

--- Content provided by‌ FirstRanker.com ---

NEP 12

---

Which of the following is the most
common cause of painless, gross
hematuria in patients over 40 years of
age?

--- Content provided by​ FirstRanker.com ---

A. Vigorous exercise
B. Kidney / bladder stones
C. GU tumors
D. Bleeding disorders / coagulopathies
E. Foley catheter insertion

--- Content provided by FirstRanker.com ---

NEP 13

---

Which of the following statements is
true regarding acute epididymitis?
A. A positive Prehn's sign is relief of scrotal
pain with rotation of the testes

--- Content provided by FirstRanker.com ---

B. Pain relief on elevation of the testes is
considered suggestive of epididymitis rather
than testicular torsion
C. Epididymitis is most common in young
prepubertal males

--- Content provided by⁠ FirstRanker.com ---

D. The etiologic agent is unrelated to the
patient's age
E. Is always caused by infection
NEP 14

---

A 14 y/o presents with an acute onset of scrotal

--- Content provided by FirstRanker.com ---

pain. He is diagnosed with testicular torsion.
Which of the following is accurate, regarding
this patient's diagnosis?
A. There is an 80-100% salvage rate if detorsed
within 24 hours

--- Content provided by​ FirstRanker.com ---

B. Manual detorsion general y involves rotating
the testes from medial to lateral
C. Peak incidence is 6 years
D. A testicle in torsion usual y lies vertical y
E. Abdominal pain is rare

--- Content provided by​ FirstRanker.com ---

NEP 15

---

Which of the following is true
regarding priapism?
A. This is a pathologic erection involving the
glans and corpora spongiosum

--- Content provided by‍ FirstRanker.com ---

B. SQ epinephrine is used to treat most
reversible causes
C. Exchange transfusions may be necessary for
those caused by sildenafil (Viagra)
D. Most etiologies are veno-occlusive, as

--- Content provided by⁠ FirstRanker.com ---

opposed to arterial
E. The basic treatment varies, dependant on the
cause
NEP 16

---

Which of the following

--- Content provided by​ FirstRanker.com ---

statements, regarding general
urology, is true?
A. Balanitis is an inflammation of the foreskin
B. Posthitis is an inflammation of the glans
penis

--- Content provided by​ FirstRanker.com ---

C. Phimosis is a common cause of urinary
retention
D. Paraphimosis can be a true urologic
emergency
E. The typical age for a penile hair tourniquet is

--- Content provided by​ FirstRanker.com ---

3-7 years
NEP 17

---

Which of the following statements is
true regarding Fournier's gangrene?
A. Penicil in is general y adequate treatment

--- Content provided by FirstRanker.com ---

B. It typical y begins as a benign abscess and
slowly develops into a more serious infection
C. It should be considered in any patient with
scrotal, rectal or genital pain out of proportion
to their clinical findings

--- Content provided by​ FirstRanker.com ---

D. I&D in the ED is usual y adequate therapy
E. Antimicrobials are unnecessary after surgical
debridement
NEP 18

---

Which of the following drugs will not

--- Content provided by​ FirstRanker.com ---

worsen contrast induced nephropathy ?
A. Ibuprofen
B. Furosemide
C. Enalapril
D. N-acetylcysteine

--- Content provided by‌ FirstRanker.com ---

E. Naproxen
NEP 19

---

Which of the following is a cause of
rapidly progressive
glomerulonephritis?

--- Content provided by⁠ FirstRanker.com ---

A. Chronic, control ed hypertension
B. Pyelonephritis
C. Lupus
D. Toxic alcohol overdose
E. Diabetic neuropathy

--- Content provided by‍ FirstRanker.com ---

NEP 20

---

Nephrology Answer Key
1. A
11. D
2. D

--- Content provided by⁠ FirstRanker.com ---

12. D
3. C
13. C
4. D
14. E

--- Content provided by FirstRanker.com ---

5. D
15. B
6. D
16. D
7. E

--- Content provided by⁠ FirstRanker.com ---

17. D
8. C
18. C
9. A
19. D

--- Content provided by‌ FirstRanker.com ---

10. A
20. C

---