URINARY TRACT INFECTIONS

URINARY TRACT INFECTIONS
DEFINITIONS

Bacteruria = bacteria in urine (not necc UTI)

Urethritis = inflammation of the urethra

UTI = inflammatory response of urothelium to bug in urine (includes upper and lower)

Cystitis = lower urinary tract inflammation of bladder resulting in frequency, urgency,
dysuria, suprapubic pain (infectious and non-infectious causes)

Pyelonephritis = upper urinary tract inflammation of renal parenchyma and collecting
system producing fever, anorexia, back and flank pain

Uncomplicated UTI = structurally and functionally normal urinary tract

Complicated UTI = structurally or functionally abnormal urinary tract (Ex: underlying neurologic
condition, sturctural abnormality, metabolic disorder)

Recurrent infection = same bug + > 10 days after stopping treatment

Relapsing infection = same bug + < 10 days after stopping treatment

Reinfection = different bug + > 10 days after stopping treatment

Superinfectio = different bug + < 10 days after stopping treatment
EPIDEMIOLOGY

Febrile infant without source: overall 5% UTI rate

UTI more common in neonatal boys but girls becomes more common in infancy and later

Incidence of structural abnormalities

Infant male: 97%

Infant female: 50%

Asymptomatic bacteruria also very common 1-4%

Bacteruria rates gradually increase in women such that 5-10% at 70 and 10-20% at 80 yo have
bacteruria on routine checks

Bacteruria in men is less uncommon unless catheterized or scoped: rates do increase in elderly 3%
at 70yo, 10% at 80yo
PATHOPHYSIOLOGY

Urine is normally sterile until external sphincter in men and bladder neck in women

Complete bladder emptying with urination is a major defense to prevent bacteruria

Any factor that prevents complete emptying (stricture, cath, fb, etc) and/or promotes stasis of urine
increases infection rate

Men normally have staph, strep in distal urethra without problems

Women are more prone to UTI b/c of short urethra and fecal bug contamination in area

Retrograde entry is by far the MCC of UTI

Name risk factors for developing a UTI

Catheter: 1% of outpatient caths get uti; 15% of pregnant or debilitated patients

Cystosope

Foreign body

Ureteric or urethral strictures

Obstruction from renal calculi

Abnormal posterior urethral valves

Vesicoureteral reflux


Prostatic hypertrophy obstructing urine

Diabetes b/c of increase glucose in urine (may be initial dx clue of recurrent uti)

Pregnancy b/c of incomplete bladder emptying from uterine pressure
What bugs cause UTIs?
BUG
NOTES
K
Klebsiella
Occurs more often in institutionalized
E
E.coli
Ecoli cause > 80% of UTIs
E
Enterococcus
Occurs more often in institutionalized
P
Proteus
Pseudomonas
Occurs more often in institutionalized
S
Staphylococcus
saprophyticus
Coag -ve gram positive
Causes 11% (2nd MCC of UTIs)
Normal skin flora in perineum
Serratia



Adhesions = fimbriae that allow the bugs to attach to receptors on the uroepithelial cells and not be
flushed out with urination
Resistence to antibiotics common due to plasmid transfer (exchange of DNA between bugs)
Is the distinction between lower and upper tract infections important?

Lower: generally only involves the superficial mucosa of the bladder and high
urinary concentrations of antibiotics are easily obtained and resolves quicker

Upper: involvement of medullary tissue is a “deeper” infection and also b/c of
kidney involvement it is more difficult to obtain high urine concentrations of abx
CLINICAL FEATURES

Infants: lethargy, vomiting, poor feeding, fever, irritability, diarrhea, FTT

Children: abdominal pain, dysuria, frequency, fever

Check urine in kids with very low threshold!!

Fever is a poor indicator of severity of infection

Lower: dysuria, frequency, urgency, hypogastric pain

Upper: fever, anorexia, nausea, vomiting, back/flank pain

Lower vs upper tract is actually not very accurate clinical distinction: one study showed that 3050% of women with only lower tract symptoms have involvement of kidneys
URINE COLLECTION

Catheter (or suprapubic aspiration)

Neonates

Infants

Young children

Elderly, debilitated especially women

Bag specimen

Only useful if -ve

+ve needs to be followed by cath

Do NOT send for culture (95% false +ve rate)

Midstream

Appropriate in older children and adults

Best samples are from men

Skin prep important to decrease contamination

Debatable how good this is!!
One study collected midstream urines on women with document
proven sterile urine by cath specimen
50% of women grew bacterial colonies which ranges in numbers
from 10^3 to 10^5

Evaluating contamination

Bacteria present with moderate to high numbers of epithelial cells =
contamination

Bacteria presnet with no or few epithelial cells = clean

Note that leukocytes are picked up from perineum thus leuks can be
contamination related
URINALYSIS

Leukocyte esterase

Enzyme found in wbc.s

Nitrite

Produced by nitrate reductase which is an enzyme found in gram -ve bacteria

Microscopy

Looking for wbc.s, bacteria, epithelial cells

There are chamber counting methods but most are done by direct counting

Direct counting affected by centrifugation, specimen handling, operator, etc

NO specific level of pyuria is diagnostic of UTI

Urine culture is the gold standard, not R/M

See peds summary for specificity
Wbc > 5/hpf
Wbc > 10/hpf

Bacteria
Not 100% sensitive
Not 100% specific
See peds summary
Bacteria by a catheter or suprapubic aspiration is much more
specific than bacteria by midstream or bag specimen



Gram Stain

Helps differentiate leukocytes from epithelial cells and bacteria

Gram stains more likely positive in coliforms vs staph
Combinations

Sensitivity/specificity varies with studies depending on what culture is defined as
being positive (ranges from 10^2-10^6 CFU/ml)
Urine Culture

Definitive dx of UTI

What is a positive culture?
10^5 CFU/ml is the traditional cutoff
10^5: 95% chance of infection
10^4: 50% chance of infection
10^5 number came from studies with upper tract infection!
Study: 40% of symptomatic women with culture counts of bugs <
10^5 will yield bacteruria by suprapubic aspiration
This is a consistent number in the literature where 30 - 50% of
women with cystitis symptoms have -ve culture by the 10^5
CFU/ml criteria
Thus some suggest that women with lower tract symptoms who
grow a known UTI bug from a clean specimen with > 10^2
CFU/ml is a specific indicator of UTI

Q: what are the Indications for urine culture (Box 94-1)

Q: who are at high risk for bacteremia, complicated UTIs, resistent organisms
(Box 94-2)
SUSPICIOS HISTORY FOR NON-DIAGNOSTIC R/M (IND FOR CULTURE)
Increased risk of complicated UTI and bacteremia
Young: neonates, infants, children < 12yo
Elderly
Immunocompromised
Longer duration (symptoms >5 days)
Signs of an upper tract infection
Signs of systemic toxicity (fever, tachycardia, sepsis)
Significant comorbitidies (DM, sickel, cancer, debiliating dz, alcoholism)
Urinary obstruction or reflux for any cause (including stone)
Pregnant women
Increased risk of unusual or resistant organims
Recent catheterization or instrumentation
Males
Partially treated and treatment failures
Patient taking antibiotics for other reason
Recurrent renal infections
Recently hospitalized
IMAGING

Majority do not require imaging

Ultrasound

R/o renal or perirenal abscess and obstructions that need to be drained: indicated
in septic patients and those with fever > 72 hours of antimicrobial therapy

Pediatrics to r/o structural renal anomalies
All boys with first time UTI
All girls under 4 yo with first time UTI

VCUG

Best test to look for reflux

Less radiation than IVP

Pediatric imaging

Rationale? detect renal and ureteral abnormalities to prevent recurrent UTIs, renal
scarring, renal failure, hypertension

Which tests? ultrasound and VCUG

When? within weeks as outpatient unless septic in ICU

CT

IV contrast CT abdomen is very good at looking for pyelonephritis, abscess,
hydronephrosis, hydroureter, masses, alternative dx

Generally not done as initial tests
SPECIAL POPULATIONS

Pregnancy

10% incidence

Higher prematurity and fetal mobidity, preterm labor, anemia

Pyelonephritis rates are much higher (20%)





Compressive and hormonal precipitants to infection
MUST treat asymptomatic bacteruria as complications are common
Must pick safe antibiotics in pregnancy: cephalosprins, penicillins, nitrofurantoin,
septra if used before third trimester

Lower threshold for admission and iv abx

Close follow up needed
Diabetes and Sickle cell

Increased risk of pyelonephritis, papillary necrosis, and perinephric abscesses

Admit, iv abx
Indwelling Catheters

Do not treat asymptomatic bacteruria (promotes resistance)

Remove catheter if possible for asymptomatic bacteruria

Treatment includes antibiotics and replacing the catheter

Note that chronic indwelling catheters are “special” catheters that have lower
infection rates

Lower threshold for iv therapy and admission b/c higher risk of bacteremia,
unusual bugs and treatment failures
DDX OF DYSURIA

Lower and upper UTI

Urethritis from STDS

Vulvovaginitis

Prostatis

Chemical irritants

Allergic inflammation

Trauma
DIAGNOSIS
HISTORY
PHYSICAL
LABORATORY
UTI
(upper and lower)
Feels internal
Sudden onset
Frequency, urgency,
small volume voids
Suprapubic
tenderness
Flank tenderness
Fever
Pyuria
Hematuria
Bacteruria
Positive urine culture
URETHRITIS
FROM STDS
Feels internal
Gradual onset
STD risk factors
Frequency, urgency
less common
Vaginal discharge
Vaginal or cervical
discharge
Vulvar lesions
Pyuria
No hematuria
No bacteruria
Urine Culture -ve
Abnormal cervical smear
STD culture +ve
VULVOVAGINITI
S
Feels external
Gradual onset
Vaginal discharge
Vaginal odor
Vaginal discharge
No pyuria
No hematuria
No bacteruria
Urine Culture -ve
Abnormal cervical smear
Vaginal smear +/- positive
TRAUMA,
IRRITATION,
Feels external
None of above
No pyruia
DIAGNOSIS
HISTORY
IRRITATION,
ALLERGY
Gradual onset
Trauma to area
Creams or other
irritants/allergens to
area
PHYSICAL
LABORATORY
No hematuria
No bacteruria
Culture -ve
APPROACH TO DDX OF DYSURIA

UTI is the MCC of dysuria but must think of urethritis and vaginitis

Chlamydia may be present in up to 20% of women with dysuria

STD risks, vaginal discharge, or wbc.s on urine without bacteria: should do pelvic and cervical
cultures and or urine for chlamydia

Vaginitis dysuria is often described as “external”; vaginitis will not cause frequency/dysuria

If unsure of UTI vs STD, do urine C/S and cervical cultures
TREATMENT

General







Duration





Ecoli is the MC bug and resistance varies
Resistance is increasing
Ampicillin resistance is 30-45%
Septra resistance is 15-30%
Cranberry juice: one study showed that 300 ml of cranberry juice per day
decreased the bacteriuria with pyuria in elderly women
Controversial
Shorter duration with lower tract, longer with upper tract
Some studies have looked at single dose therapy; slightly lower cure rates
Longer duration has no benefit for lower tract unless high risk or complicated
Three days po therapy is indicated for uncomplicated lower UTI
CMAJ study this year showed equal efficacy with less s/e

Lower tract low risk: 3 days

Lower tract higher risk: 7 days

Upper tract; 10-14 days
Antibiotic choices

PO: septra, nitrofurantoin, keflex, ciprofloxacin, ofloxacin, amoxicillin

IV: ceftriazone, ampicillin + gentamycin, ciprofloxacin, levofloxacin, etc

Choice depends on low risk vs high risk and local resistance patterns,

Hooton et al JAMA 1995: septra po X 3/7 was the most cost effective

Amoxil: resistance is too high to use

Ampicllin: resistance is too high to use

Fluroquinolones should generally be reserved for complicated UTIs, recurrent, or
resistant UTIs

Nitrofurantoin
Excellent urine concentration
Cheap and effective
Low serum levels thus low side-effects
Consistent bacterial resistance

-
Doesn’t cover proteus and klebsiella as well as septra
MacroBID is the macrocrystalline form which has less GI s/e
MacroBID: 100 mg po bid X 3/7 - 7/7 (take with food to decrease
GI side effects)
-
Excellent urine concentration
Cheap and effective
Covers klebsiella and proteus better than nitrofurantoin
Has more GI side-effects than macrobid
Trimethoprim: inhibits dihyrdofolate reductase thus decreases the
production of folate (folate antagonist)
Sulfamethoxazole: competes with PABA (para-aminobenzoic
acid) which decreases the bacterias ability to produce folate
Complications: steven’s - johnson syndrome, toxic epidermal
necrolysis, fulminant hepatic failure, aseptic meningitis, aplastic
anemia
Don’t use in pregnancy (cleft palate, etc)
Adults: septra DS one tab bid X 3/7 - 7/7 or regular septra two
tabs bid
Children: 0.5 ml/kg bid
Septra


Ciprofloxacin
Gentamycin
-
Lower tract: 250 mg po bid X 3/7 - 7/7
Upper tract: 500 mg po bid X 7/7-10/7
Covers all uti bugs except only 75% coverage of enterococcus
Note association with tendon rupture
Can cause Cdiff, rashes, photosensitivity
Do NOT use in kids (bones), pregnancy, or lactating women
VERY concentrated in urine
Ceftriaxone + gentamycin iv if septic
Ceftriaxone covers most bug but gentamycin is very concentrated
in the urine
Also adds ENTEROCOCCUS coverage which ceftriaxone does
not cover
ANTIBIOTIC SELECTION IN LOWER TRACT UTIs

Low Risk

No high risk features

Duration = 3 days

Antibiotics
Septra DS one tab bid X 3/7
MacroBID 100 mg po bid X 3/7 with food
Ciprofloxacin 250 mg po bid X 3/7

Higher Risk

Longer duration (>5 days)








Significant comorbid illness (DM, sickle, cancer, debiliating dz,
alcoholism)
Urinary tract abnormalities
Recent catheterization or instrumentation, or hospitalization
Taking antibiotics for another reason
Recurrent infection
Males
Antibiotics
Septra DS one tab bid X 7/7
MacroBID 100 mg po bid X 7/7 with food
Ciprofloxacin 500 mg po bid X 7/7
NB: go to ciprofloxacin for structural abnormalities or
significant comorbidities
Pregnancy (UTI or asymptomatic Bacturuiria)

Duration = 7 days

Antibiotics
MacroBID 100 mg po bid X 7/7
Amoxil 250 mg po tid X 7/7
Keflex 500 mg po qid X 7/7
UPPER TRACT INFECTION

PO therpay

No indications for iv

Duration = 10 - 14 days

Antibiotics
Septra DS one tab bid X 10/7
Ciprofloxacin 500 mg po bid X 10/7

IV therapy

IV therapy until stable and afebrile X 24hrs

Urosepsis

Vomiting

Immunosuppressed

< 3months or elderly

Pregnant

Urinary structural abnormality or stone dz

Antibiotics
Ceftriaxone 1gm q 24hr (add gentamycin if septic)
Ciprofloxacin 400 mg iv q 12hr
Ampicillin 1gm q6hr + Gentamicin 1mg/kg q8hr

Admission > HPTP

Significant dehydration or ongoing vomiting

Immunosuppressed

< 3 months or elderly

Pregnant

Structural abnormality or stone dz

Social factors
PEDIATRIC UTIs
EPIDEMIOLOGY

3% of girls before 11yo

1% of boys before 11yo

Neonates: more common in boys

Infancts and children: more common in girls
PATHOPHYSIOLOGY

Ecoli is still the MC bug

Proteus is more common in older boys

Klebsiella is more common in neonates

Neonates: blood borne source thus high frequency of sepsis

Infants and children: urethral source
CLINICAL FEATURES

Neonates

Poor feeding

Vomiting

Irritability

Lethargy

Hypothermia

Fever

Failure to thrive

Sepsis

Infants

Poor feeding

Vomiting/diarrhea (esp vomiting w/o diarrhea)

Fever

Strong - smelling urine

Younger Children

Abdominal pain

Vomiting

Strong - smelling urine

Fever

Enuresis

Frequency, dysuria, urgency

Older Children

Fever

Enuresis

Frequency, dysuria, urgency

CVA tenderness
HOW TO COLLECT THE URINE

Age

< 3 months: cath and no questions

> 3 years: clean catch hopefully

Inbetween: cath, bag, suprapubic tap

Indications for cath urine

Age under 3 months

Urosepsis

Known structural urinary abnormaltiy

Prior history of UTIs

Recurrent or relapsing infections

Positive bag specimen

3 months - 3 years: who to cath?

Strong suspicion: go for cath because you will need it anyways

Low suspicion: start with bag, stop if R/M is -ve (dip isn’t good enough in kids)

Parental preference: discuss options of waiting, needing cath anyway

Complicated history: abnormal anatomy, recurrent/relapse infection

What is a positive microscopy?

wbc > 5/hpf by cath

wbc > 10/hpf by bag

What is a positive culture?

Bag cultures are useless

Cath cultures > 10^???
INDICATIONS FOR ULTRASOUND AND VCUG

See pediatric UTI practice parameter
MANAGEMENT

Age < 3 months

Admit all

IV ampicillin and gentamycin

Alternative is cefotaxime

Do not need to do LP: recent study showing that majority of csf where -ve and
when they were +ve it was the same bug and did not change managment

Age 3 - 6 months

Management is controversial

Some use admission and iv abx for all

Some use outpatient iv therapy for all

Some use outpatient po therpay for all

Increasing use of outpatient management

Follow up and social factors must be tight for outpatient therapy

Outpatient therapy = suprax (cefixime)

Indications for iv therapy
Signs of toxicity
Vomiting
High risk for complications: structural urinary abnormalities
Immunocompromised states

Age > 6 months - 12 years

Indications for iv therapy
Urosepsis/toxicity
Vomiting
Immunosuppressed
Urinary structural abnormality or stone dz

Antibiotics for oral therapy
6mo - 2yrs: Suprax (cefixime) 8 mg/kg od (NOT BID)
> 2 yrs: Septra 1ml/kg bid X 7-10 days
UTI, PROSTATITIS, URETHRITIS IN MEN
GENERAL

UTI uncommon in abscence of instrumentation

Lack of circumcision, anal sex, BPH are other risk factors

Pneumaturia with gas forming organisms or vesicoenteric fisutlas is described

Prostatitis should be on ddx: examine the prostate!

Men should have a urine culture done b/c it is uncommon

Similar treatment: septra, cipro, macrobid

PEARLS of UTI in men

Obstruction must be rule out as a cause

Obstruction must be dealt with if there is a UTI (very high risk of sepsis): ? Does
this mean urgent TURP for BPH with obstruction then UTI

Have a lower threshold for urology referral in men to r/o obstruction

Urethral catheterization is only indicated with urinary retension: the risk of
causing an infection should deter catheterization simply for specimen collection

Retention + UTI: abx for UTI and catheter to overcome retention
PYELONEPHRITIS

As above

May present with gross hematuria

High risk for gram -ve sepsis

Urine culture should be done

R/O obstruction if there is no clear precipitant (catheter): ultrasound, IVP

Obstruction: BPH, prostatic ca, renal calculi, ureteral strictures, urethral strictures, other tumors

Oral therapy: septra, cipro

IV therapy: ceftriazone, cipro
URETHRITIS

Gonococcal (GU)

Non-gonococcal (NGU): chlamydia, myocplasma, ureoplasma

If you have GC you have chlamydia 50% of the time and vica versa so just treat for both!

Gonococcal urethritis: almost all are symptomatic and majority will have discharge

Chlamydial urethritis: 25% will have NO signs or symptoms

Must consider on ddx of dysuria in men (probably more common than uti in right age group)

Swab urethral discharge or pass swab 2 cm into urethra and swirl





Gram stain of discharge can be diagnostic
First day void for chlamydia and gonorrhea can be done
Urine for Chlamydia: 15 ml of FIRST VOID into sterile container and take to lab
Consider ureoplasma, HSV, trichomonas, candida if symptoms persist despite treatment
Associations

Gonorrhea: dermatitis, arthritis

Chlamydia: reiter’s syndrome

Proper collection of urethral samples

Label specimens as urethral discharge (not just penis)

Use the blue Genprobe kit

Insert 2-4 cm and rotate

When to do a charcoal swab? Persistent symptoms and/or treatment failure
should have a charcoal swab sent for GC culture

Mycoplasma/ureaplasma: submit a mycoplasma DUO transport media swab
Treatment

Azithromycin 1 mg po X 1 (chlamydia) + cefixime 400 mg po X 1 (GC)

Doxycycline 100 mg po bid X 7/7 + ciprofloxacin 500 mg po X 1

PROSTATITIS

Bugs are KEEPS

Majority are Ecoli (80%)

Remainder are proteus, enterococcus, klebsiella, pseudomonas (20%)

Acute Bacterial Prostatitis

Fever, chills, low back pain, perineal pain, pelvic pain, hypogastric pain, buttocks

Dysuria, frequency, urgency, urinary retention

Must be on DDX of any elderly male with dysuria

Malaise, arthralgias, myalgias

Exam: tender, swollen gland that is firm and warm

May have spontaneous urethral exudate

Do not massage as this increases bacteremia

Cystitis occurs with prostatitis in majority thus urine culture will reveal bug;
prostatic massage in the acute prostate is not warranted to express discharge

Duration of treatment = 30 days

Oral Rx: Septra DS one tab bid X 30 days or ciprofloxacin 500 mg po bid X 30 d

IV Rx: Ampicillin 2 gm iv q6hr + Gentamycin 7 mg/kg q 24hr

Consult urology if associated urinary retention

Septra is concentrated in prostatic secretions

Chronic Bacterial Prostatitis

Frequency, dysuria, urgency +/- pelvic or abdo pain with a flare of chronic prost

Fevers and chills are uncommon

Examination of the prostate is usually unremarkable (non-tender)

Relapsing UTI by same organism is the HALLMARK of chronic prostatitis




Prostadynia



Dx: prostatic massage produces secretions in first 10 ml urine with > 10 wbc/hpf
Septra has good prostatic penetration and is actually concentrated in secretions
Septra DS one tab bid X 4-12 weeks or cipro 500 bid X 30 days
Prostate pain without evidence of infection
No wbc.s in urine
Prostate nontender
RENAL CALCULI
INTRODUCTION

95% have underlying specific pathophysiology and are not simply idiopathic

All types of stones have a common pathogeneisis based on excessive supersaturation

3:1 male to female (except infection stones which are MC in female)

Prevelence: 7% of men, 3% of women

Majority (75%) occur b/w 20-50 yo; PEARL first onset “renal colic” in > 50yo is
uncommon thus look for something else: AAA, cancer, renal infarct, etc

Calcium stones are the MC stones in males, females, and children

Recurrence is 50%; recurrence peak at 1-2yrs and 8-10yrs

Risk factors for renal calculi

Male, fhx, older

Primary hyperparatyroidism

Mil-alkali syndrome

Sarcoidosis

Crohn’s

Laxative abues

Recurrent UTI

RTA type I
TYPES OF STONES

Calcium oxalate stones (75%)

Struvite = Magnesium-ammonium-phosphate stones(15%)

Uric acid stones (10%)

Cystine stones (1%)
CALCIUM OXALATE STONES

Idiopathic Hypercalcuria

MC (70% of all nephrolithiasis) in adults AND children

Patients have hypercalcuria but NOT hypercalcemia (b/c of hormones)

Treatment
fluids (double or triple to be effective; keep urine white)
thiazides are the most useful Rx (increases resorption of
calcium; contraindicated in hyperparathyroidism)
sodium cellulose phosphate
orthophosphates
allopurinol
low calcium diet

Primary Hyperparathyroidism

MOST frequent single primary systemic disorder assoc w/ nephrolithiasis

must R/O by serum calcium level (> 10mg/dL X or 12.6mmol/L X 3)

55% have nephrolithiasis

treatment: removal of adenoma or subtotal parathyroidectomy for
hyperplasia

Idiopathic Calcium Lithiasis

All labs normal; often have low urine volume

Treatment: high fluid intake, low calcium diet, low oxalate diet, thiazides

Excess oxalic acid: Small bowel disease: crohns, ulcerative colitis, radiation enteritis,
jejunoileal bypass
STRUVITE STONES

Infection Stones

Only stone more common in females

80% of all staghorn calculi are struvite

Urease-induced b/c splitting of urea by urease is the source of MGNH4PO4H20

E. coli is NOT urease producing (KEPS)

MCC are Proteus, Pseudomonas, Klebsiella, Staph aureus

Infection can also produce soft, mucoid, radiolucent concretions called matrix
concretions which may mineralize to form a staghorn calculus (big stone)

Evaluation: blood and urine biochemistry, urine C/S, radiological evaluat

Therapy: surgical removal is mainstay + medical Rx for infection
URIC ACID STONES

ONLY radiolucent stone (note -ve CT in suspected renal colic; could be radiolucent
stone)

Uric acid from diet (purines) and endogenous

Predispositions (i) hyperuricosuria, (ii) acid urine (iii) decr urine volume

Etiology: hyperurecemia, idopathic (MCC), diet

Think of in people with GOUT!

Treatment

fluid intake of 2L/d

low purine diet (meat, fish, poultry)

alkalinization

allopurinol (xanthine oxidase inhibitor, use if stones recurr or if 24hr uric
acid excretion > 600mg./d)
CYSTINE STONES

Cystinuria








autosomal recessive affecting aa transporters in kidney and GIT
excessive excretion of COLA (cysteine, ornithine, lysine, arginine)
usu presents in 2nd or 3rd decade but may present earlier
stones are radiopaque
urinary sediment shows hexagonal benzene crystals
screen by cyanide-nitroprusside test (positive is a purple-red color)
NOT as common as calcium stones in children
treatment

hydration usu effective alone


alkalinization w/ bicarb and acetaozolamide
D-penecillamine (many s/es: sensitiviey, blood cell
disorders, VitB6 inhibition, etc, etc) .... works by increasing
solubility in urine
PATHOPHYSIOLOGY

Ureteric obstruction, shifting of blood flow to opposite kidney, decreased GFR to effected
kidney, peristalsis decreases

Irreversible damage from complete obstruction does not occur until 1-2 weeks

Irreversible damage can occur from incomplete obstruction but this is less common

Passage determined by size

< 5mm 90% spontaneously pass

5 - 8mm
15% spontaneously pass

> 8 mm
5% spontaneously pass

Five common locations of obstruction

Renal calyx

Ureteropelvic junction = UPJ (1cm pelvis narrows to 2-3 mm ureter)

Pelvic brim (ureter crosses under the iliac vessels)

Ureterovesicular junction = UVJ (most common location for impaction
because the ureter enters the muscular coat of the bladder and is narrow)

Vesicular orifice
CLINICAL FEATURES

Onset at night or early morning is classic

Abrupt onset that reaches maximal intensity very quickly

Flank and back pain that radiates to lower quadrant, inguinal region, testicle or labia

May be constant or colicky (renal colic actually a misnomer as most have constant pain)

Constant pain related to obstruction, hydronephrosis, capsular tension

Unilateral, colicky pain related to ureteral spasm

Frequency, urgency, dysuria occurs as the stone nears the bladder

May be misdiagnosed as a UTI (note blood > wbcs, no bacteria, unilateral severe pain)

Classically can’t sit still (peritonitis doesn’t want to move)

Fever suggests alternative dx or renal colic + UTI

Abdominal tenderness is minimal or absent
EVALUATION

Urine pH > 7.6 suggest urease splitting organisms present in urine. TRA is dx

Urine proteinuria from blood leaking in

Urine for crystals may show calcium oxalate, uric acid, etc

R&M

Hematuria sensitivity is 85%

Degree of hematuria does not correlate with severity of obstruction

Wbc.s can be present from blood

Significant wbc.s should raise concern for infection (? What level)

Bacteruria should suggest infection

Culture should be done for possible infection

Other lab tests

CBC, urea, creatinine in all

Recurrent stones
Serum uric acid elevated in 50% of uric acid stone formers
Serum calcium for PTH, sarcoidosis,
Serum phosphorus will be up with PTH
24hr urine for calcium, phosphorus, uric acid if above do
not demonstrate the cause of recurrent stones
IMAGING

KUB

50% sensitive and 70% specific

NOT adequate for dx

Only used as part of IVP

Phlebolith: very round, may have lucent center

Stones: irregularly shaped, no lucent center

Calcified lymph nodes may also cause false +ves

Sacrum makes stone identification very difficult

IVP

Sensitivity 95%

Advantages: shows amount of hydro

Contraindications: renal failure (Cr > 130), contrast allergy, multiple
myeloma, pregnancy, dehydration

Delayed nephrogram > 5 min after injection is most sensitive indicator

Columnization: the ureter should not be seen in its entirety on a single film
b/c it is a dynamic structure with normal peritalsis; with obstruction,
peristalsis decreases and the volume in the ureter increases resulting in a
column of dye

Definitive dx = column of dye ending at a calculus

The hyperosmolar nature of the contrast may actually assist the stone
passage

Ultrasound

Good for hydronephrosis

Not good for identifying stones

Test of choice in pregnancy

CT KUB

Most sensitive test: 98%; 100 % specific (Chen J Emerg Med 1999;17:
p299)

Able to detect 1 mm stones and better documentation of size thus predicts
course and which ones will pass

Very good for alternative diagnoses: found in 10 - 35% in various series

Can be done more rapidly: decreased time in ED has been shown

Doesn’t cost much more ($600 vs $400)

Who requires ED imaging?

Controversial

First presentations

Uncertain dx

New onset > 50 yo (uncommon)


Who requires r/o AAA

Syncope

Age > 50 yo

Vasculopaths

Hypotension, tachycardia

Abdominal mass

No previous renal colic
Which imaging test is better?

Worster Ann Emerg Med Sept 2002

Fours studies met their inclusion criteria

Liklihood ratio was better for CT than IVP (significant)

NO RCT, generally small trials
DIFFERENTIAL DIAGNOSIS OF PRESUMED RENAL COLIC

AAA: mc misdx (EVER person > 40yo must r/o AAA); can have hematuria

Ischemic gut

Pyelonephritis

Renal carcinoma

Renal vein thrombosis

Papillary necrosis

Renal TB

Renal infarct (will require infused scan!):

Renal artery thrombosis (vasculopaths)

Renal artery embolism (Afib, endocarditis, akinesis)

Renal artery dissection (Ao dissection)

Renal vein thrombosis (Hypercoag states, nephrotic syndromes)

Renal artery aneurysm rupture

Ovarian torsion

Endometriosis

Ovarian vein thrombosis

Bowel obstruction

Biliary colic

Appendicitis (can have hematuria)
PAIN MANAGEMENT IN RENAL COLIC

NSAIDS

NSAIDs are very effective in renal colic

NSAIDs have been shown to be equally effective to opiods

How do NSAIDS work in renal colic?
Analgesic from PGE1 inhibition
Decreases ureteral spasm
Decrease renal capsular pressure secondary to decreased
GFR by vasoconstriction of afferent vessel

Every renal colic should get NSAID unless contraindicated
Renal failure
GI hemmorhage
Peptic ulcer dz
Asthma precipitated by NSAIDs

Which NSAID?
Ibuprofen 600 - 800 mg po

Indocid 100 mg pr
Toradol 10 - 30 mg iv (RR of GI bleed is 27 compared to
other NSAIDS)
Opiods

Use in combination with NSAID

Studies show combination > opiod alone

Use alone if NSAID contraindicated

Miscellaneous

Fluid boluses: increase hydronephrosis, increase pain and decrease the
passage of the stone (DOG study that showed stones pass through
ureters better if there is dehydration vs overhydration)

Buscopan has been used as an antispasmotic
INDICATIONS FOR ADMISSION

Absolute

Persistent pain

Persitent vomiting

Obstruction + infection

Urine extravasation

Hypercalcemic crisis

Solitary kidney or transplant with obstruction

Relative

High-grade obstruction

Prior renal disease

Size of obstructing stone > 6mm (definately if > 8mm)

Prolonged symptoms
UROLOGIC MANAGEMENT

Which stones require intervention?

8/5 rule

> 8mm in kidney requires intervention

> 5mm in ureter urequires intervention

ESWL = Lithotripsy

Very useful for proximal stones

85% success rate with stones in kidney

Upper ureteral stones can be pushed more proximally with the
ureteroscope then blasted with the lithotripser

Kidney stones < 2 cm

Ureteral stones < 1 cm

Scope removal

Ureteroscopy or ureterorenoscopy

Renal stones < 2 cm

Percutaneous Nephrolithotomy

Tract from the collecting system to the skin

Used for stones to large for lithotripsy

Renal stones > 2 cm

Ureteral stones > 1 cm

Open stone surgical removal

Rarely used

Indicated if structural abnormality that needs to be fixed or as last resort

Stone + UTI = nephrostomy + stent + iv abx

Acute renal failure = surgical mx

High-Grade Obstruction

No universal definition

Generally means signficant hydronephrosis

Does not need admission

Urologic follow up: watch for 1-2 weeks

No irreversible damage for 2-3 weeks
DISCHARGE

Discharge with percocet Rx

RTED pain, fever, vomiting

F/U with GP for calcium etc testing if recurrent stone dz

F/U with urology if not passed in 4 weeks

Increase fluids, low calcium, low oxalate (nuts, chocolate, rhubarb, beets, dark veggies)

Thiazide diuretics for hypercalcuria

Allopurinal for uric acid

Who needs to strain the urine?

Uncertain diagnosis

Recurrent stones: take to GP for testing

Some say all b/c urology referral indicated if not passed in 4 weeks
VESICULAR STONES

Can form in the bladder but usually are formed in kidney

MC in elderly men with indwelling catheters or UTIs with urease-splitting organisms

Other risks: bladder neck obstruction from BPH, neurogenic bladder, vesical diverticular,
irradiation, shistosomiasis

Presentation = dysuria and hematuria

sudden interruption of a vesical stone is very suggestive (intermittent blockage by stone)

Physical examination is normal
THE ACUTE SCROTUM
INTRODUCTION

Medical emergency

Pain, mass, swelling, aching

Review anatomy: normal testis lies in vertical axis with a slight forward tilt

Epididymis is above the superior pole in the posterolateral position
PHYSICAL EXAMINATION

Testicular size, mass, tenderness, discoloration

Epididymis: size, tenderness

Cremasteric reflex: stroke or pinch of inner thigh should cause elevation of testicle > 0.5 cm
DIFFERENTIAL DIAGNOSIS

Testicular torsion

Appendix testes torsion

Orchitis

Testicular tumor

Testicular trauma

Epididymitis

Varicocele

Hydrocele

Spermatocele

Hernia: cannot get “above” mass
TESTICULAR TORSION

Introduction

1:4000 people

50% will lose the testicle

Two peaks of incidence: < 1 year and puberty

Can occur at any age

Very common in undescended testicles: inguinal mass + empty hemiscrotum

Pathophysiology

Bell-Clapper deformity: the tunica vaginalis completely covers the testicle and
attaches higher up on the spermatic cord thus the testis “dangles” in the scrotum
and is moblile (normally only partly covers testicle - posterosuperior)

Obstruction of venous return then vein thrombosis

Increased pressure of spermatic cord then arterial compromise

Testicular infarction necrosis, edema, swelling

Salvage rate 80-100% if pain duration < 6hrs

Pain > 24hrs has very low salvage rate



Clinical Features

Sudden onset of scrotal and testicular pain is classic

Prior history of pain in 40% that spontaneously resolved

Associated with nausea and vomiting

Common after exertion or during sleep

Absence of urinary symptoms is the general rule

Swollen, tender, firm hemiscrotum

Reactive hydroceles are common

Absence of cremasteric reflex (presense of reflex is 98% sensitive)

High-riding transverse lie testes (not reliable)

Prehn’s sign: elevation of the testicle relieves the pain of epididymitis (this sign is
UNRELIABLE)

PEDS: may have predominant abdo pain
Every abdo pain needs
Diagnosis
their NADS examined

Urinalysis: wbc.s suggests epididymitis

Color flow Doppler: sensitivity 85-90%,
specificity 100%

Radioisotope scanning: 85-90% sensitive, 95% specific
Management

Manual detorsion = OPEN THE BOOK

This is only a temporizing maneuver until the OR

Use analgesia +/- PSA to detort the testicle

Open book will not always be the right direction; stop if it seems to get worse

Do not do cord blocks

Immediate urology referral and OR
TORSION OF APPENDAGES

Several vestigial appendages exist in the normal scrotum

There are testicular appendages and epididymal appendages

Most commonly seen in 3-13yo

Symptoms usually less severe than the testicular torsion

History of previous episodes is uncommon

No vomiting, fever, dysuria, or penile discharge
Blue dot sign of the torsed, echymotic appendage


Reactive hydroceles are very common and may obscure the torsed appendage

Urinalysis without pyruria or bacteruria

Color flow doppler shows a normal testis

Mx: rest, analgesia, ice, scrotal elevation

Resolution expected in 7-10days

Surgical excision is reserved for refractory cases
EPIDIDYMITIS

Introduction

MC misdiagnosis with testicular torsion

Usually occurs in adult men

Average age is 25yo

Rare in prepubertal kids

Pathophysiology

Retrograde ascent of urethral and bladder pathogens

Inflammation begins in the vas deferens and descends down to the epididymis

Early presenation may show inguinal pain with inflammation of the groin

Inflammation and edema of the epididymis

The testis may or may not become inflammed (orchitis)

Bacteria in men > 35yo = Ecoli, Pseudomonas (KEEPS)

Bacteria in men < 35yo = Chlamydia, Gonorrhea, Syphillus

Underlying urologic pathology common in older men

Majority of STD epididymitis will NOT have urethral discharge complaint

Syphillus: may be more common than recognized; usually only diagnosed when
syphillus is evident elsewhere

Other: TB, amiodarone induced

PEDS
Adolescents: GC, chlamydia
Prepubesent: KEEPS

Clinical features

Gradual onset over hours to days

Reaches maximal intensity over hours, not
suddenly
KID COULD

Febrile, low grade (38)
PRESENT WITH

UTI symptoms commonly preceed
FEVER ONLY

Very sensitive/tender scrotum

General edema, eythema are NOT present in early
epididymitis

Cremasteric reflex present

Epididymis swollen, tender after 4hours

Spermatic cord may be edematous as well

Prehen’s sign = relief with elevation of the testicle on that side

Diagnosis

Urinalysis with wbc.s and bacteria only in 50%!

Bacteria will not be seen on microscopy if GC or chlamydia is the cause

Culture of urethral discharge if present

Pyuria, fever, bacteruria dysuria COULD STILL BE A TORSION

Color flow doppler or nuc med scan indicated in majority

Studies will show normal or increased testicular flow

Managment

Presumed STD bugs: younger, risk factors
Azithromycin 1 gm po X 1 + Cefixime 400 mg po X 1 ???????
Doxycycline 100 mg po bid X 10 days (takes longer to eradicate
from the epididymis than simple STD urethritis)
Rosen: Ceftriaxone 250 mg im X 1 then doxycycline X 14 d
MUST treat sexual partners


Presumed coliform bugs: older, no STD risks
Septra DS one tab po bid X 14 days
Ciprofloxacin 500 mg po bid X 14 days is an alternativE
PEDS (not suspecting STDs): Septra X 10 days if well;
ceftriaxone or cefotaxime and HPTP or admission if sick
Other
Rest, Ice, Analgesics
Urology referral especially older patients: many have BPH etc
Counsel re complications: infertility, abscess, chronic
ORCHITIS

Introduction

Acute infection or inflammation of the testis

Rare without a preceeding epididymitis b/c testes is resistant to infection

Less common than epididymitis or prostatitis

Bacterial Pyogenic Orchitis

Testicular spread from epididymitis

Klebsiella, Ecoli, Pseudomonas, staph, strep

Viral Orchitis

MUMPS is the MCC = paramyxo virus
Uncommon in prepubertal boys
More common in pubertal boys (30%)

Other: EVV, coxsachie, arbovirus, enterovirus, etc

Clinical features

Pyogenic: fever, marked pain, swelling of testicle, reactive hydrocele, very tender
testicle, pyruia, leukocytosis

Viral: testicular pain and swelling 5 days after onset of viral illness; seen 5 days
after the onset of parotitis with the MUMPS; resolves in 5 days

Urinalysis and urine culture should be obtained

Doppler Flow Ultrasound if torsion is possible

Managment

Bacterial: Septra or cipro

Viral: supportive, NSAID, ice
TESTICULAR TUMORS

MC cancer of young men

Average age is 32yo

Epididymitis is the MC misdiagnosis

Increased incidence of tumors in undescended testis = cryptorchidism (both sides!!)

Seminomas are the most common cause (embryonal cells, teratomas)

Metastasis by lymphatic system

Presents with scrotal swelling that isn’t classic for torsion or epididymitis

Majority are not painful but may be described as “heaviness”

Acute hemorrage into the tumor may produce sudden pain

PEARL = positive beta HCG with certain testicular tumors

Color Flow Doppler is the initial test of choice

CXR for ? Mets

Abdo CT for ? Mets


Mx: admit, consult urology and oncology
Prognosis is good with oorchiectomy and radiateion therapy
VARICOCELE

Collection of venous varicosities of the spermatic veins in the scrotum

15% of adolescent males

Uncommon < 10 yo

Left sided in 90% and can be bilateral

Right sided: suspect IVC syndrome, IVC thrombosis

Sudden onset left sided: renal cell carcinoma with obstruction of left renal vein

Tender, swollen

Swelling increases in upright position

May have “bag of worm” appearance

Ultrasound if any diagnostic concern

Surgical correction if symptomatic or bilateral
IDIOPATHIC SCROTAL EDEMA

Common in kids

mOst are unilateral

No allergen is identified in most

Painless scrotal swelling, may be pruritic

Minimal tenderness

Swelling may extend into groin

No masses or systemic symptoms

Resolves in days without treatment
HYDROCELE

Fluid in the tunica vaginalis

Communicating = connection with peritoneum

Most are right sided

Painless swelling

Transillumination

Dopplar shows normal flow
INGUINAL HERNIA

Indirect = processus vaginalis does not obliterate and thus connection b/w scrotum and peritoneum

Right sided more common

Can lead to bowel obstruction

Swelling, pain, erythema, bowel obstruction, ischemic gut all possible

Ultrasound if diagnostic concern

Sedation and attempted reduction

Surgery consult if can’t reduce or ischemia suspected
ACUTE URINARY RETENTION
INTRODUCTION

AUR = sudden inability to pass urine

Common in elderly men

30% of men in the 70-80 range will experience

Women: atonic, decompensated bladder from years of infrequent voiding

Young: spinal cord diseases (MS, syringomyelia, etc)

Psychogenic is rare and a dx of exclusion

Drug induced is common: antihistamines, anticholinergics, alpha agonists especially

Men: BPH is the MCC
ETIOLOGY (think anatomically)

Penis: phimosis, paraphimosis, stenosis, FB

Urethra: tumor, stone, stenosis, stricture, etc

Prostate: BPH, cancer

Nerves: SC, syingomyelia, cauda equina

Drugs: antihistamines, anticholinergics, alpha agonists, antispasmotics, opiates

Psychogenic
CLINICAL FEATURES

Obstructive symptoms

Hesitancy, straining

Decreased size, caliber, force of urine stream, dribbling

Interruption of urine stream and sensation of incomplete emptying

Previous retention

Irritative symptoms: Frequency, Urgency, Dysuria, Nocturia

Prior hx of retention, urologic procedures, strictures, prostatectomy

May have symtoms of UTI

BPH or prostatic mass on exam inmen

Palpable bladder

Renal failure if severe

Relative increase in BUN to Creatinine

Urinalysis for UTI, also do culture

IVP, ultrasound, CT not indicated in ED unless toxic or ddx unsure
MANAGEMENT

Urethral catheterization: 16-18 Fr catheter

18 Fr. Coude’ tip catheter: upward deflection in the distal 3 cm which allows it to pass over an
elarged median lobe of the prostate and be directed toward the roof of the urethra

Consult urology

Suprapubic catheter placement: comercial kits or central lines

Hematuria is common after decompression

Hypotension can occur after decompression (vesicovascular reflex: decreased sympathetic tone)

Gradual emptying is recommended but unproven thus some recommend rapid emptying

Discharge with indwelling catheter and urologic follow up

Those with retention and UTI need admission, iv antibiotics, urgent drainage
HEMATURIA
INTRODUCTION

Asymptomatic hematuria occurs in 10% of men and 20% of women

Gross hematuria is much more significant: 5Xs the rate of significant disease

Every patient with microscopic hematuria should be told to get repeat urine by GP
PATHOPHYSIOLOGY

Lower tract: 60%, upper tract 40%

Urologic cancer: 5% of microsocopic hematuria and 20% of gross hematuria if > 50yo

Anticoagulation does not usually cause hematuria unless over anticoagulated

Men > 60 yo: MCC is BPH

“Worm-like” clots are highly suggestive of tumors
ETIOLOGY

Prerenal




Renal




Post Renal





Factitious




Coagulopathy
Collagen vasc dz
Sickle cell dz
Glomerular (dysmorphic rbc.s, rbc casts, proteinuria > 2+)
IgA nephropathy
Glomeruloneprhitis
Lupus neprhtis
Vasculitis
Non-Glomerular (normal round rbcs, no rbc casts or proteinuria)
Renal cell ca
Pyelonephritis
PCDD
Interstitial neprhitis
Papillary necrosis
Ureter: stone
Bladder: Cysitis (infectious or inflammatory) or cancer
Prostate: prostatitis, BPH
Epididmis: epididymitis
Urethra: urethritis, FB, factitious
Vaginal bleeding
Rectal bleeding
Automanipulation
Pigmentation (+ve dipstick but -ve microscopy)
Myoglobinuria
Hemoglobinuria
Porphyria
Foods: beets, berries, rhubarb
Drugs: pyridium, qinine, rifampin
CLINICAL FEATURES

History

Bleeding disorder

Large thick clots with bladder origin

Small stringy clots with kidney origin

What part of the urine stream: initial is urethra; total is bladder or upper; terminal
is bladder neck or prostatic urethra

Pain: stone, infection, necrosis, glomerulonephritis

Trauma

UTI symptoms

Sickle cell dz

Cancer risks: older, smoker, weight loss, certain chemotherapeutics, occupational
exposures to dyes and rubbers, pelvic irradiation

Hematuria + erythematous skin rash + fever = IgA nephropathy

Fhx deafness and renal dz = Alport nephritis

Rash, arthritis, hematuria = LUPUS

Hemopytis, hematiura, anemia = goodpastures

ENT + Lung + kidney = Wegener’s granulomatosis

Preceeding strep pharyngitis, impetigo = post strep GN

Sickle cellers and diabetics get papillary necrosis

Renal colic should be obvious

Diagnostic strategies

Dipstick is only positive if there has been lysis of rbcs or myoglobinuria

Most urines with rbc.s will be positive on the dipstick but not all

RBC casts suggest glomerular source

Microscopic hematuria = > 3 rbc.s/hpf

Exercise-Induced Hematuria

Strenuous exercise

Transient glomerular and post glomerular hematuria

Can be from bladder microtrauma

Needs cystoscopy if doesn’t resolve in 48hr
DISPOSITION

Hematuria without identifiable cause needs investigation

Cystoscopy is the first test

Ultrasound and CT are subsequent tests
BLADDER CANCER
B: ETIOLOGY
1. Chemical carcinogens from industrial exposure
- textile workers, dye workers, tire and rubber workers, leather, bootblacks,
painters, truck drivers, petroleum, hair dressers, chemical workers
2. Cigarette smoking
- most important factor related to bladder CA
- 40% of cases have direct relation
- risk is 2X
-  conc of tryptophan metabolites in urine, and other carcinogens (nitrosamines)
3. Schistosoma hematobium: middle east and Asia
4.Chronic inflam of infection: stones, infection, catheter
5. Drugs: cyclophosphamide
C: PATHOLOGY
- 90% are Transitional Cell Carcinoma (TCC)
- 5% are Squamous Cell Carcinoma (SCC) – usu related to chronic inflam (catheter,stone diver)
- 2% are Adenocarcinomas
DIAGNOSIS
1. Symptoms
- hematuria – 85% diagnosed by investigation for hematuria
*** painless, total, gross hematuria is classical presentation***
This is bladder CA until proven otherwise.
- bladder irritability – frequency, urgency, dysuria
2. Diagnostic procedures
- cystoscopy and transurethral resection (must be done)
- urinary cytology (random, fresh specimen is best)
- tumor must be in contact with urinary stream
- tumor must be shed into the urine
- the shed cells must be distinguished from normal urothelium
3. Radiology
- IVP = excretory urethrogram
- CT – limited use except for detecting mets
-US – mets, hydronephros
F: TREATMENT
SUPERFICIAL = resection + intravesicular chemo or cystectomy
INVASIVE CANCER = radical cystectomy with urinary diversion, chemo for mets
MISCELLANEOUS UROLOGY TOPICS
BENIGN PROSTATIC HYPERTROPHY

Rx: alpha antagoinists to reduce prostate smooth muscle tone (terazocin) or 5 alpha-reductase
inhibitors to redusce side (finasteride)

Surgery: recurrent UTIS, refractory urinary retension, gross hematuria, renal failure
PROSTATIC CANCER

Non-curative therapy: > 72yo or < 15 years life expectancy

Hormaonal therapy: orchiectomy, estrogens, LHRH analogs, antiandrogens

Palliateive radiotherapy

Curative theapy: < 72yo and > 15 year life expectancy

Radical prostatectomy

Radiation therapy

Radiation beads

Palliative Radiotherapy

Painful bone mets

Epidural spinal cord compression

Pathological fractures

Life-threatening hematuria

Chemotherapy

Generally for palliation
RENAL TUMORS

Benign




Malignant


Cysts: simple vs PCKD
Benign paillomas
Angiomyolipoma
Renal cell carcinoma
MC malignant kidney tumor in adults
2nd MC of renal mass (cysts are more common)
Flank pain, hematuria, mass
Majority actually present with hematuria and no mas
Paraneoplastic syndromes are common: hormone related
symptoms also common: polycythemia (erythropoeitin),
hypertension (renin), hyperthyroid (TSH), hypercalcemia,
cushings
30% have mets at time of dx
Tx= nephrectomy
Wilm’s tumor
MC tumor in kids
TORSION
EPIDIDYMITIS
TUMOR
HYDROCELE
TORSION
EPIDIDYMITIS
TUMOR
HYDROCELE
AGE
< 1yo
Pubesent
Any
20-30yo
Any
Hx
Sudden onset
Maximal intensity at
onset
Unilateral
Prior episode
No dysuria etc
Gradual onset
Intensity builds over
hours
Unilateral or bilateral
No prior episodes
Urinary sx
Gradual onset
Minimal pain
Gradual onset
Minimal apin
No urinary
symptoms
PE
Sever tenderness
No transillumination
No fever
Severe tenderness
No transillumination
Fever
Minimal tendernss
No fever
No
transillumination
Transillumination
URINE
Urine normal
Wbcs, bacteria
Normal
+ve Bhcg in some
Normal
U/S
Decreased flow
Normal or increased
Mass
Normal flow