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Urology Part I
Clinical Medicine: Urology including in-depth Urinalysis
| Question | Answer |
|---|---|
| T/F: Using a urinary catheter is a more sterile collection for UA | True, but only to an extent: bacteria can begin to grow on the catheter within hours |
| 3 Steps of Urinalysis | 1) Visualization 2) Dipstick 3) Microscopy |
| Red urine in UA | Food: beets, blackberries, rhubarb; Medical: blood (from UTI, stones, cancer [bladder or renal]), hemolysis |
| Orange urine in UA | Food: carrots; Drugs: rifampin, phenazopyridine |
| Green urine in UA | Food: Asparagus; Medical: UTI from pseudomonas |
| Brown or cola urine in UA | Food: fava beans; Medical: bilirubin, Gilbert syndrome, hepatobiliary disease |
| T/F: A heavier specific gravity of the UA means you are more hydrated | FALSE: It means you are less hydrated because there is less water and a higher concentration of solutes in the urine and solutes are heavier than water. |
| Is urine usually more acidic or basic? | Acidic. Helps break up stones that are formed at higher pHs (calcium oxalate/calcium phosphate) |
| What else should you test for if urine positive for protein? | Glucose |
| Categorizations of protein UA | Normal <10 mg/dL Trace proteinurea-approximately 10-30 mg/dL 1+ ~ 30mg/dL 2+ ~100 mg/dL 3+~300 mg/dL 4+1000 mg/dL |
| 6 things that can cause transient protein classification | 1) CHF 2) fever 3) strenuous exercise 4) seizure disorders (since it is like working out) 5) stress 6) orthostatic proteinuria |
| Reference range for glucose in UA and why? | Negative, if glucose was found (as in DM), it is because glucose serum levels are too high and proximal tubules become overwhelmed and cannot reabsorb excess so it spills into urine. This can be normal in pregnancy. |
| Reference range for ketones in UA and why? | Negative, seen in DM, diabetic ketoacidosis, severe exercise or starving/fasting. Carbs are lacking or not processed correctly -> fat metabolism |
| Reference range for blood in UA and why? | Negative! Positive can come from gross hematuria, hemoglobinuria, myoglobinuria, false positives. Can be from UTI or a stone. |
| Reference range for bilirubin in UA and why? | Negative. If positive: suspect obstructive hepatobiliary conditions (stone in bile duct, pseudocyst in pancreas, carcinoma, hepatitis -> RUQ problems!) Would be conjugated and unconjugated. |
| Reference range for nitrite in UA and why? | None. If positive: suspect UTI (90% specificity). E.Coli, Klebsiella, proteus most common and convert nitrates to nitrite. Doesn't rule out UTI if negative (others don't convert nitrate->nitrite or urine passes through too quickly) |
| Reference range for urobilinogen in UA and why? | Small amounts. Mostly reabsorbed by portal circulation but a small amount is excreted into urine. More than small amount? Obstructive biliary disease and severe cholestasis. Increased levels? Extreme hemolysis, liver parenchymal disease, constipation. |
| Reference range for leukocyte esterase (pyuria/WBCs) in UA and why? | Negative. Positive when WBCs are lysed. Increased WBC called pyuria and is suggestive of infection. |
| What would make us get a microscopy and what are we looking for? | Blood in urine, persistent protein, suspect stones/crystals. Looking at RBC, WBC, epithelial cells, crystals, casts, organisms. |
| Reference range for RBCs (specifically) in UA and why? | <2/hpf (high powered field). If higher, and patients smoke, need to rule out malignancy, specifically bladder cancer. |
| Reference range for WBCs (specifically) in UA and why? | 2-5 cell/hpf. If elevated: infx, inflammation, or contamination. |
| Reference range for epithelial cells in UA and why? | <15-20 cell/hpf. High numbers indicate contamination or simply not a good catch/sample. |
| Reference range for casts in UA and why? What are casts? RBCs, WBCs, Waxy? | 0-5 hyaline casts/lpf. Hyaline normal in small numbers; made of w/ organic matrix made from Tamm-Horsfall mucoprotein. Acidic urine and low flow rate promote formation. Others abnormal: RBC: glomerulonephritis, WBC: pylelonephritis, Waxy: renal failure. |
| What are crystals and why/how do they form? | solid forms of particular dissolved substance. shape, color, and urine pH all play a role in IDing crystals. (Acidic: calcium oxalate, uric acid, cysteine; Alkaline: triple phosphate [associated w/ proteus infx]) |
| T/F: Most common bacterial infection seen in women is UTI | True; 1/2 of all women will experience UTI in their life. |
| Most common UTI location? | Bladder (cystitis) |
| Most common route for UTI | ascending infection from urethra; can spread through blood or lymph but that is rare |
| 3 mechanisms bladder protects itself from UTIs | 1) efficient emptying keeps colony counts low 2) glycosaminoglycan or mucin coating decreasing bacteria adherence 3) urine acidic pH and high osmolality |
| T/F: longer urethra in men means less risk of UTI | True, women are at higher risk because their urethra is shorter. |
| Risk factors for women UTI and the 2 categories we divide them in | premenopausal: sexual activity, spermicides, new partner w/in last year. postmenopausal: decreased estrogen, ^ bladder urinary stasis, incontinence from cystocele |
| Risk factors for men UTI | higher incidence in uncircumsized vs circumcised, men w/ prostatis or no prostate (prostate secretes zinc which has antibacterial properties) |
| Mechanical risk factors for UTIs | 1) enlarged prostate 2) urethral strictures 3) kidney stones 4) defective bladder constriction; ALL lead to post void residual 5) catheter related infections |
| T/F: 40% of nosocromial UTIs are related to catheters | False, it is more like 80%; DOES represent 40% of all nosocromial infections. Understand the distinction. |
| Methods of bacterial virulence | 1) fibriae help attach and travel up urinary tract 2) hemolysin is a toxin that damages membranes 3) protease secretes urease 4) endotoxin triggers inflammatory reaction (enterobacteriase, psuedomonas) |
| Sx of UTI | IRRITATIVE VOIDING SX: increased frequency, dysuria, urgency, hematuria, fever (almost soley w/ pyelo), N/V (pyelo), tachycardia or sick-looking (pyelo) |
| 3 PEs for UTI (these can help differentiate one from another as well) | 1) Suprapubic tenderness (cystitis), 2) CVA tenderness (pyelo), 3) tender prostate on DRE (prostatitis) |
| Urine Cx: Indications, Definitions and ABX Use | I: if you suspect pyelo or recurrent Sx for 2-4 weeks. D: Colony Forming Units (CFU) >10 to the 5th power. A: Don't EVER hold Abx until Cx returns. Tx! |
| 3 most common UTI pathogens; Most common in pregnant women? | 1) E. Coli 2) Staphylococcus saprophyticus (SS) (MOST COMMON IN PREGNANT WOMEN), Proteus |
| What makes a UTI "complicated"? | Hx of childhood UTIs, immunocompromised, pregnant, male, underlying metabolic disorder, urologic abnormalities (stones, stents, catheters etc) |
| Acute Uncomplicated Cystitis: Most common pathogen, Dx, Tx (Tx in preg as well), if relapse, Test of Cure | P: 70-85% E. coli. Dx: Sx and dipstick (no Cx) Tx: Septra (TMP/SMX) 3-7 days. Nitrofurantoin for pregnant women. Cipro is second line if they have resistance. If relapse, get Cx and Tx 7-14 days, TOC: retest in 7 days to ensure it is gone |
| Acute Complicated Cystitis: | E. coli still predominant, but not by as much. Cx. Tx: 7-14 days and have follow up Cx. Can lead to urosepsis. |
| T/F: recurrent cystitis is defined as 5+ UTIs documented w/ urine Cx per year | False, just 3+ per year. |
| Don't Tx ASx bacteriurea unless Pt is in one of these groups: | 1) pregnant 2) renal transplant 3) about to have urinary tract procedure |
| Extra test in males? | Yes, need to do DRE to rule out prostatis. |
| Indwelling catheter: Infxs and Tx | 40% of all nosocromial infections; only treat if pt is Sx (fever/dysuria). Tx: Fluoroquinolones for 10-14 days for moderate infx, 14-21 days for severe infx. If candiduria, Tx: fluconazole. |
| Uncomplicated Pyelonephritis: Suspect when, Dx, | Suspect:cystitis looking w/ flank pain, severe illness, gram neg bacteremia; Dx: dipstick showing pyuria, microscopy w/WBC casts, urine Cx >10 to the fifth power; Tx: 14 days of Septra or Cipro or if they have other illnesses: Ceftriaxone (rocephin) |
| Dx Tests for Pyelonephritis | Ultrasound: sensitive, inexpensive and safe: TOC. IV Pyelogram is next. |
| T/F: STDs don't increase the risk for HIV transmission. | False, they sho nuff do. 2 Ways: 1) desquamation of skin cells produces an inflammatory response 2) portal of entry on mucous membrane surface |
| A few examples of ulcerative STDs | Syphilis, genital herpes, etc. |
| A few examples of drip/discharge STDs | Gonorrhea, chlamydia, nongonococcal urethritis, trichomonas, candidiasis |
| Example of non-ulcerative, non-drip STDs | Genital HPV (16 and 18) -> Cervical cancer |
| Syphilis: Epidemiology, Pathogen | widely distributed in 1940s, all time low in 2000s mostly due to education, rates still high in urban areas everywhere and rural in South and poor/underserved, and MSM. Pathogen: T. pallidum. |
| Syphilis: Testing/Dx | VDRL: screening tool (no Dx). RPR: initial Dx confirmation, doesn't always show. FTA-ABS: Dx confirmation, more specific, and best test after 3-4 weeks. |
| Primary Syphilis: Manifestations | 3 week incubation. Painless chancre resolving in 1-5 week; HIGHLY INFECTIOUS |
| Secondary Syphilis: Manifestations | hematogenous dissemination of spirochetes usually 2-8 weeks after chancre appears. Whole body rash esp. palms/soles, mucous patches, condylomata lata (warts, HIGHLY INFECTIOUS), B-Sx. Sx resolve in 2-10 weeks; avoid sexual contact |
| Syphilis: Tx | Penicillin G 2.4 million units IM in a single dose (for Primary and Secondary) |
| Genital Herpes Simplex: Manifestations, Dx | Direct contact (may be asymptomaic shedding even if they don't have lesions). Vesicles -> PAINFUL ulcerations -> crusting. Dx: Viral Cx, serology (western blot), PCR |
| Genital Herpes Simplex: Epidemiology and Complications | One of the most 3 common STDs. 25% of US population by age 35 (mostly HSV-2). Transmission usually from subclinical infx. Underdiagnosed. Comps: neonatal transmission, enhanced HIV transmission, psychosocial issues |
| Genital Herpes Simplex: Tx | Acyclovir for 7-10 days (one of the other -clovirs will work as well |
| Epidemiology of Gonorrhea | associated w/ increased susceptibility to HIV. Resistance is increasing to Cipro! |
| Gonorrhea: Manifestations | Urethritis in male, incubation 1-14 days Sx: dysuria and urethral discharge, Dx: gram stain urethral smear +>98%. Urogenital infection in females: endocervical canal primary site and urethra, Sx: Majority ASYMPTOMATIC, Dx: gram stain smear + 50-70% |
| Rider's Syndrome | I cannot see, I cannot pee, I cannot bend my knee. Disseminated gonorrhea associated w/ skin lesions. Urethritis in a male under 35 with knee pain? Gonorrhea until proven otherwise. |
| Gonorrhea Tx: | Ceftriaxone 250 IM in a single dose (w/lidocaine), or Doxy 100mg orally for 7 days. ALWAYS follow Tx w/ that of Chlamydia (Azithromycin 1 gram orally in single dose slurry) ***G treat for C, but don't have to treat for G if C.*** |
| T/F: 50% of cervical cancers have HPV DNA detected in them | False, 99% of cervical cancers have HPV DNA detected w/in tumor. Routine pap smear screening ensures early detection and Tx |
| Other manifestations from HPV | perianal warts, penile warts, cervical warts, even possible warts on the tongue |
| Two categories of Tx for genital warts | 1) patient-applied 2) provider-administered |
| Most frequent cause of urethritis is heterosexual men | Nongonococcal urethritis (NGU); 45& of cases of Gonorrhea also have NGU (recall G treat for C, but don't have to treat C if G) |
| Pathogens of Nongonoccal urethritis (NGU) | Chlamydia trachomatis, ureaplasma urealyticum, mycoplasma genitalium |
| Chlamydia: General, Epidemiology, Risk Factors | obligatyory intracellular bacteria (acts like virus but is bacteria), on the rise in the US, RF: adolescence, new/multiple sex partners, presence of another STD, oral contraceptive user, lack of barrier protection |
| Chlamydia: Transmission, Sx and Dx | sexual or vertical (mother to baby), >50% asymptomatic. Sx and Dx: visible abnormal urethral discharge, positive leukocyte esterase test, Hx of urethral discharge, positive urine screening test for chlamydia |
| T/F: cotton swabs or wooden shafts are typically used and preferred for discharge sampling of NGU | False: metal shaft recommended |
| T/F: First-catch or dirty catch of urine is required for urine testing in NGU | True. |
| Example of Nucleic acid amplification test (NAATs) | Gen-Probe (can test for chlamydia [99% specificity] and gonorrhea) |
| Direct fluorescent antibody (DFA) | Detects intact bacteria with a fluorescent antibody. Useful for a variety of specimen sites |
| Enzyme immunoassay (EIA | Detects bacterial antigens with an enzyme-labeled antibody. |
| Nucleic acid hybridization (NA probe) | Detects specific DNA or RNA sequences of C. trachomatis and N. gonorrhoeae |
| Uncomplicated NGU: Tx and Management | 1) Azithromycin 1 gram orally (in a slurry), single dose. 2) Doxycycline 100 mg orally bid for 7 days. 3) Partners should be evaluated, tested and treated. 4) Abstain from sexual intercourse 7 days after COMPLETION of Abx |
| T/F: Chlamydia is a reportable disease in all states, including NC | True, report must be filed w/in 7 days of laboratory confirmed case. |
| T/F: If NGU is persisting, dig a little deeper for causes | True, duh. Wet prep from urethra should be examined for T. Vaginalis |
| T/F: Latex catheters are preferred over silicone | False, silicone has a 2% urethritis rate compared to latex 22% |
| Encrustation | mineral salts in urine form on outside, inside and balloon of catheter leading to urethritis and stricture -> bacteria (proteus) adhere to catheter -> UTI |
| Physiology of normal micturation: PNS | innervates detrusor muscle and causes contraction. Cholinergic effect for EMPTYING BLADDER! |
| Physiology of normal micturation: SNS | bladder and internal urethral sphincter. Primariliy beta-adrenergic -> relaxation -> filling of bladder. |
| Normal bladder capacity | 300- 600 cc |
| First sensation of filling | 50-75 cc |
| First urge to void | 150-300 cc |
| Definition of Incontinence | Involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem |
| T/F: Incontinence is a normal part of aging | FALSE, it is not a normal part of aging and is under-diagnosed and under-treated. 80% of incontinence can be cured or improved. |
| Incontinence: Epidemiology, Cost to Society, Morbidity | Women>men, prevalence ^ w/age, SIGNIFICANTLY higher rates in nursing home residences; $16-20 billion annually; M: secondary infx possible, UTI/urosepsis from catheters/urinary retention, falls/fractures slipping on urine, nocturia, psych eff, deyhydration |
| A few age related changes of note | Increased bladder contractions (detrusor hyperactivity) in both genders, excretion of more volume, men: prostatic hypertrophy, women: decreased estrogen |
| DIAPPERS pneumonic | D elirium I nfection A trophic urethritis/vaginitis P harmaceuticals P sychiatric causes E xcessive urinary output R estricted mobility S tool impaction |
| Inability to store urine | URGE OR STRESS INCONTINENCE; detrusor contracts too often, bladder doesn't fill to capaity, frequent incontinence w/ small volume, Sx: ^ frequency, ^ urgency, nocturia, dysuria, pain w/urination |
| Inability to empty urine | OVERFLOW INCONTINENCE; bladder unable to contract sufficiently, blockage of outflow (BPH), bladder fills beyond normal capacity and overflows, continual/frequent leak of urine, Sx: difficulty starting stream, weak caliber of stream, incomplete voiding |
| Urge incontinence | problem w/ storing urine; most common in elderly, strong immediate urge to void followed by involuntary loss of urine. Detrusory hyperreflexia: stroke/dementia/spinal cord injury asso. w/ ^ contractions. Irritation of bladder, overactive bladder syndrome |
| Stress incontinence | problem w/ storing urine; women>men, ^ intra-abdominal pressure, weakness of pelvic floor |
| Overflow incontinence | problem w/ emptying urine; most commonly results from neurogenic bladder (DM, chronic alcoholism, disc disease). Can also be from muscle relaxants, BBs and outlet obstructions (BPH, tumor, stricture, spinal cord lesion, pelvic surgery, A-agonists |
| Mixed incontinence | combo of stress, urge, or outflow and functional incontinence. The stress and urge combo is very common in elderly women. |
| Some incontinence Physical Exam findings | diastasis recti (affecting intrabodominal pressure), DTR, lower sensation/strength, inflammation/infection of pelvis, cystocele (opening of bladder), rectocele (oepning of rectum to bladder), rectal impaction |
| Incontinence: Tx | Correct any causes (DIAPPERS), least invasive step-wise approach, habit/toilet training/PT ('Kegals"), "Double voiding technique", tobacco cessation, anti-muscarinic, anti-cholenergics, alpha blockers in OAB Sx w/ BPH. |
| Incontinence Referal/consultation criteria (9) | 1 Uncertain diagnosis 2 Uncertain treatment plan 3 Failure to respond to therapy 4 Severe Prolapse 5 Consultation regarding surgery 6 Hematuria 7 Neurologic Symptoms 8 Recurrent urinary tract infections 9 Abnormal PVR |
| Nephrolithiasis: Hx and PE | severe flank pain radiating toward groin (depending on side inflammed kidney), nausea +/- vomiting, renal colic, hematuria |
| Nephrolithiasis: Epidemiology | 10% in industrialized nations, Male:Female 3-4:1, Whites>blacks, 10% need hospitalization, 5% surgery for large stones, so most are outpatient. More in the south due to concentrated urine due to loss of sweat. |
| Stone Composition | Most calcium stones (75-80%). or too little citrate. Struvite (15-20%), chronic UTI and a raise of pH, Tx: acidification of urine; Oxalate stones (5%), Uric Acid Stones (10%), Cystine Stones (1%) |
| Calcium stones: Patho, Types, Tx | Hypercalciuria (primary hyperparathyroidism, intestinal hyperabsorption, idiopathic) Tx: thiazide diuretics (takes Ca out of distal tubule so it doesn't accumulate in urine); Hypocitraturia: Tx: potassium citrate; Hyperoxaluria (increase Ca intake) |
| Uric Acid Stones: Patho, Tx | Hyperuricosuria: Gout (uric rich foods), low urinary pH, malignancy; Tx: allopurinol for hyperuricemia, potassium citrate to raise urinary pH |
| Stuvite Stones: Patho | Recurrent UTI w/ urea-splitting organisms and increase pH (often proteus, ureaplasma) |
| Cystine Stones: Patho, Tx | often presents in childhood, autosomal recessive disorder, stones very resistant to shockwave therapy (surgical removal needed) |
| T/F: Hypercitraturia is one of the most common metabolic defects that predisposes to stone formation | False: HYPOcitraturia, often caused by high protein diets like Paleo/Atkins |
| Nephrolithiasis: Manifestations | flank pain radiating to groin, severe pain lasting 20-60 min (renal colic), hematuria on urinalysis, N/V, Dysuria/urgency (less common). Pts will bound around room unable to get comfortable as opposed to staying absolutely still. |
| Nephrolithiasis: Dx | Non-contrast helical CT scan is gold standard w/ specificity nearly 100%. Ultrasound TOC in pregnancy but can miss some smaller stones and some ureteral stones. KUB XRay good for Ca stones but CT still best, IVP another possibility |
| Nephrolithiasis: DD (5) | 1) Bleeding w/in kidney 2) ectopic pregnancy 3) aortic aneurysm 4) acute intestinal obstruction 5) malignancy |
| T/F: Stones >5mm will rarely pass on their own | True, almost all will need lithotripsy or surgical removal |
| Nephrolithiasis: Tx | increase fluid intake w/ min goal of 2 liters of urine output/day (where normal would be 1.5 liters/day). Pain control: NSAIDs, opioids while waiting for stones to pass. Hospitalization for severe pain |
| Work up of first episode of stones | Confirm Dx, strain for stone (analyze once passed), minimal labs: urinalysis |
| Prevention after first episode of stones | increase urine output to 2L/day (water is best), don't restrict Ca, thiazide diuretics allow more Na/Ca reabsorption, decrease meat intake (protein intake decreases urinary pH and increases uric acid |
| Work up of recurrent episodes of stones | (relapse rate 50% in first 10 years) Similar to initial work up except you want to get lab data, iPTH and vitamin D, 24 hour urine collection for chemistry (hypocytriuria) |
| When to refer stones to Urology | stone>10mm, failure to pass symptomatic stone, bilateral obstructing stones, anuria, intractable pain, urosepsis/acute renal failure |
| Red urine | Foods – Beets, blackberries, rhubarb Drugs – Propofol, chlorpromazine, thioridazine, Ex-lax Medical conditions –Blood due to Urinary tract infections (UTIs), nephrolithiasis, hemoglobinuria (rhabdomyolysis), porphyrias (urine color, port wine) |
| Orange urine | Foods – Carrot, vitamin C Drugs – Rifampin, phenazopyridine |
| Green urine | Food – Asparagus Drugs – Vitamin B, methylene blue, propofol, amitriptyline |
| Blue urine | Drugs – Methylene blue, indomethacin, amitriptyline, triamterene, cimetidine (intravenous), promethazine (intravenous) Medical condition – Blue diaper syndrome (also known as tryptophan malabsorption) |
| Purple urine | Medical condition – Bacteriuria in patients with urinary catheters (purple urine bag syndrome) |
| Brown urine | Food – Fava beans Drugs – Levodopa, metronidazole, nitrofurantoin, primaquine, chloroquine, methocarbamol, senna Medical conditions – bilirubin b/c of:Gilbert syndrome, tyrosinemia, hepatobiliary disease |
| Black urine | Medical conditions – Alkaptonuria, malignant melanoma |
| White urine | Drug – Propofol Medical conditions – Chyluria, pyuria, phosphate crystals |
| Cloudy/turbid urine | infection, casts, renal failure, blood |
| Specific gravity of urine...low or high? | Low: Dilute urine-excess fluid, severe kidney dz, diuretics High: Dehydration or substances in urine (sugar, protein—need to confirm on UA) |
| pH fluctuations on U/A | Low (acid)- high protein diet, ketones (diabetes/starvation), systemic acidosis (resp or metab). High (basic) Vegetarian, systemic alkalosis (severe vomiting, hyperventilation, ^ alkali ingestion), UTI, Stagnant urine (overgrowth), Renal tubular acidosis |
| Causes of protein in U/A | Kidney damage, cancer, hypertension, diabetes, SLE, heart failure, pregnancy |
| Causes of glucose in U/A | Diabetes, adrenal gland or liver dysfunction, may be normal during pregnancy |
| Causes of ketones in U/A | Diabetes and starvation |
| Causes of blood in U/A | UTI, cancer (kidney or bladder), renal calculi, anticoagulant excess, malignant hypertension, menstrual blood, sickle cell disease or trait, hemorrhagic cystitis |
| Causes of bilirubin in U/A | Positive: Think obstructive hepatobiliary conditions & liver disease such as hepatitis |
| Causes of Nitrite in U/A | >90% specificity for UTI (E. coli, pseudomonas, Klebsiella, proteus, enterobactor), False neg (low sensitivity <50%) when bacteria don’t convert-Staph, Strep, haemophilus, urine not in bladder long enough, level of ascorbic acid is high. . |
| Causes of Urobilinogen in U/A | Low levels obstructive biliary disease & sever cholestasis High: excessive hemolysis, liver parenchymal disease, constipation & intestinal bacterial overgrowth |
| Causes of leukocyte esterase in U/A | Positive results imply UTI. Results from breakdown of WBC in urine release leukocyte esterase enzyme. Can have sterile pyuria from analgesic nephropathy or bacteria that don’t grow in normal culture (chlamydia, mycobacterium tuberculosis, ureaoplasma) |
Created by:
crward88
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