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Urology Part I

Clinical Medicine: Urology including in-depth Urinalysis

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