Step 3 Genitourinary

• It is a disease characterized by the deposition of lgA in the renal glomerulus.
• It has an unclear etiology.
• The common presentation is gross hematuria following an acute upper respiratory infection. Flank pain can also occur, and this is possibly caused by stretching of the renal capsule.
• Dysmorphic red blood cells in the urine are very suggestive of a glomerular process.
• Majority of the patients have a benign cause with very slow progression of the renal disease.
• Male patients with hypertension and 24-hour urinary proteins more than 1 g are likely to progress rapidly. There is no definitive therapy for lgA nephropathy. ACE inhibitors and fish oil treatment have been tried.

Acute poststreptococcal glomerulonephritis follows a streptococcal throat infection with a gap of more than 10 days between throat infection and onset of renal disease

• Transurethral resection of the prostate (TURP) is frequently associated with the use of 20-30 liters of isosmotic flushing solutions that lack sodium but contain glycine, sorbitol, or mannitol.
• Up to three liters of this fluid may enter the circulation by either direct entrance into the large prostatic veins or by leaking into the retroperitoneal space through the opened prostatic capsule.
• As a result, the plasma sodium concentration may fall below 100 mEq/L, causing nausea, confusion, disorientation, twitching, seizures, and hypotension.
• Hyponatremia can be confirmed by establishing the presence of an osmolal gap that can exceed 30-60 mosmol/kg.

• Hepatorenal syndrome is a common cause of acute renal failure in patients with cirrhosis but should be considered a diagnosis of exclusion.
• A fluid bolus is needed to confirm that the renal failure is not secondary to intravascular volume depletion.
• A combination of midodrine and octreotide along with albumin is the treatment of choice after the diagnosis is confirmed.

• Patients with cirrhosis develop decreased peripheral vascular resistance secondary to splanchnic vasodilation, which can cause the decreased renal perfusion of hepatorenal syndrome.
• Similarly, volume depletion due to over-diuresis can cause renal dysfunction of a pre-renal etiology.
• BUN/Cr ratio of 20:1 is compatible with either scenario.

• Scleroderma (systemic sclerosis) is characterized by the abnormal deposition of collagen in multiple organ systems.
• Thickening of the vessel wall and narrowing of the vascular lumen in the renal arterioles result in ischemia, which activates the renin-angiotensin system. This results in hypertension, which is often as severe as malignant hypertension

• ACE inhibitors are the agents of choice in the treatment of scleroderma renal crisis since these reverse the angiotensin-induced vasoconstriction. Goal should be to reduce blood pressure to baseline over 72 hours.
• ACE inhibitor of choice in these patients is captopril, given that it has a relatively short time to onset and is the agent with which there is the most clinical experience for scleroderma renal crisis.
• Since ACE inhibitors result in efferent arteriole vasodilation, there may be a mild drop in GFR and subsequent worsening of creatinine,, as is commonly seen in scleroderma renal crisis.
• While ACE inhibitors are generally avoided in most patients with acute renal failure, scleroderma renal crisis is an exception to this general rule as long as renal function is closely monitored.

• It is as an undesired, painful erection that begins as a nonischemic state and progresses to veno-occlusion, acidosis, anoxia and finally, ischemia.
• Etiologies are numerous and include thromboembolism (e.g., sickle cell anemia), neurogenic dysfunction, neoplasia, trauma, and medication (with psychotropics most commonly responsible).
• Trazodone is very notorious for causing priapism due to alpha-adrenergic blockade or serotonergic receptor stimulation.

• An erection that lasts longer than 3 hours is considered an emergency, and requires urologic consultation because permanent damage to the corpora and impotence can ensue.
• When conservative treatment (e.g., ice pack application) or medication (to decrease arterial inflow and increase venous outflow) is administered within the first several hours, the erection usually resolves with no lasting damage.
• First-line medical treatment is injection of an alpha adrenergic agonist such as phenylephrine or epinephrine every five minutes until detumescence is achieved.

• Studies have shown the superior sensitivity and specificity of non-contrast helical CT scan over other diagnostic modalities in the diagnosis of nephrolithiasis.
• The standard procedure is to obtain 8 mm slices using the CT scan, however decreasing the size to 3-5 mm slices will further increase sensitivity and specificity.
• USG of the kidneys, ureters and bladder (KUB) is the procedure of choice for cases wherein IVP or CT scan cannot be obtained or is contraindicated (i.e. pregnant patients); however, it may miss small stones, and sometimes miss even ureteral stones.

• Drainage of the obstructed portion of the urinary tract via percutaneous nephrostomy or retrograde ureteral stent placement will facilitate prompt stabilization of the patient and rapid relief of symptoms.
• Either method of drainage is acceptable, depending on the expertise of available clinical staff.
• However, percutaneous nephrostomy is generally preferred in patients who are clinically unstable or have very large stones.

• It is seen in patients with heavy, long-term use of aspirin, phenacetin, acetaminophen or other nonsteroidal antiinflammatory drugs.
• Chronic necrosis of the renal papilla with calcification is typically seen.
• Acute papillary necrosis can also occur and lead to acute renal colic.
• Urine examination reveals hematuria, proteinuria, and pyuria.
• The urine culture is usually sterile.
• Discontinuation of the analgesic causes stabilization or even improvement in renal function.

This combination of impotence, muscular atrophy, and buttock claudication is often referred to as Leriche Syndrome.

• It is frequently associated with peripheral vascular disease, which may be either occult or associated with buttock claudication and atrophy of the thigh musculature (leriche syndrome).
• An ankle brachial index is appropriate in these patients to screen for peripheral vascular disease.
• Evaluation of the coronary arteries may also be necessary as there is a high association of peripheral vascular disease with coronary artery disease, which in turn is associated with adverse events during sexual activity.

The absence of nocturnal erections makes a vascular or neurogenic cause of erectile dysfunction likely, since nocturnal erections are typically maintained in patients with psychosocial or hormonal causes of sexual dysfunction.

• It manifests as nonspecific systemic symptoms, arthralgias, palpable purpura, lymphadenopathy, hepatosplenomegaly and peripheral neuropathy.
• Most forms of generalized vasculitis cryoglobulinemia commonly involves the kidneys.
• Initial manifestations of renal disease usually include asymptomatic hematuria, proteinuria and mild elevation of serum creatinine levels.
• The presence of hepatitis C infection is the most important clue.
• Once cryoglobulinemia is suspected, circulating cryoglobulins should be measured to establish the diagnosis .

• Anti-viral therapy is the mainstay of treatment for patients with mixed cryoglobulinemia associated with hepatitis C infection.
• In patients without renal dysfunction, alpha interferon and ribavirin are employed, while in patients with impaired renal function, only alpha-interferon is typically used.

• It can present with florid nephrotic range proteinuria.
• This often results from nonsteroidal antiinflammatory medications which cause a reversible decline in renal blood flow and glomerular filtration rate due to the inhibition of vasodilatory prostaglandin production.
• NSAIDs can also produce acute interstitial nephritis, wherein a kidney biopsy would show minimal changes and a typical interstitial inflammatory pattern.

• Urinary tract infections in men usually represent prostatitis as opposed to cystitis, particularly if there are symptoms of urinary obstruction.
• Prostatic massage and Foley catheter should be avoided due to the risk of bacteremia.

• The use of certain antibiotics is limited in prostatitis since not all antibiotics penetrate the prostate.
• Either a fluoroquinolone or trimethoprim-sulfamethoxazole would be good choices for empiric treatment.

• Thry are often secondary to maternal birth trauma or instrumentation of the urethral tract.
• The condition may present first with postvoid dribbling, followed by dysuria and dyspareunia (three Ds).
• Pain is especially common if the diverticulum becomes infected and distended with pus.
• Hematuria, recurrent urinary tract infections, and stress urinary incontinence are also associated with urethral diverticula.

• Urethroscopy may be used to diagnose a urethral diverticulum but is invasive and may have difficulty in visualizing the contents of the diverticulum such as calculus or neoplasm.
• Transvaginal ultrasound and MR are both noninvasive imaging modalities that are sensitive for the detection of urethral diverticula in the appropriate context.
• Sensitivity of MCUG in diagnosing Urethral diverticulum is lower than other imaging modalities as the diverticulum may not fill if the diverticular neck is narrow.

The increased serum creatinine level after the initiation of ACE inhibitor therapy is highly suggestive of renal artery stenosis (typically bilateral or unilateral stenosis of a solitary kidney or a transplant).

• These factors are severe hypertension, male sex, early age of diagnosis, and early development of renal dysfunction.
• ACE inhibitors are considered as the drugs of choice for controlling hypertension and preventing progression of renal failure in these patients.

• Patients with adult polycystic kidney disease are predisposed to the following extra-renal manifestations:
• 1. Hepatic, pancreatic, splenic, and pulmonary cysts
• 2. Cerebral aneurysms
• 3. Aortic aneurysm
• 4. Colonic diverticula
• 5. Mitral valve prolapse
• 6. Inguinal and abdominal hernias

• The most common extrarenal manifestation of ADPKD is hepatic cysts (70-80 %).
• A higher incidence of colonic diverticula is seen in ESRD patients who are on dialysis.
• Hypertension is not an extrarenal manifestation of ADPKD.
• Although berry aneurysms are common (present in approximately 10-15% of patients), cyst formation in the brain is rare.

• Ultrasonography is the most cost-effective screening procedure for asymptomatic family members of a patient with ADPKD.
• The presence of at least three to five cysts in each kidney is required to make a diagnosis of ADPKD.

• Smoking is a risk factor for renal cell cancer. Patients present with flank pain, a palpable mass, and non-glomerular hematuria; paraneoplastic syndromes (polycythemia) are common.
• Systemic symptoms such as fever (usually intermittent) is frequently accompanied by night sweats, anorexia, weight loss, and fatigue.
• Initial evaluation includes renal imaging (ultrasound, CT and/or MRI) and urine dipstick/microscopic examination.

• One of the side effects associated with Viagra is its effect on blue-green color vision.
• Studies have shown that 3% of the patients taking recommended doses can experience blue haze.
• For these reasons, the US Federal Aviation Authority (FAA) has recommended all pilots to wait for a period of at least six hours after taking Viagra before flying a plane.

Patients presumptively diagnosed with prostatitis should first be evaluated with a urinalysis and urine culture.

• It is a common noninfectious inflammatory disorder characterized by a history of pain in the lower abdomen or genitals and more than 20 leukocytes/hpf in prostatic secretions.
• Cultures of these secretions are negative.

• Symptomatic relief of nonbacterial prostatitis may be achieved with the use of Sitz baths and anti-inflammatory medications.
• Transurethral microwave thermotherapy may also improve symptoms, and psychotherapy is recommended for patients experiencing sexual dysfunction.

• It may arise as either a complication of acute prostatitis or without any evidence of initial infection.
• This more subtle condition is common in men who have dysuria and increased urinary frequency without the signs of acute prostatitis, and in men with recurrent UTIs.
• Symptoms tend to be milder and prostate examination may even be normal, but cultures of urine or prostatic secretions are usually positive.

• The presence of proteinuria affects prognosis and treatment in patients with chronic kidney disease, and is considered significant beginning at levels of 500-1000 mg.
• Inhibition of the renin-angiotensin system with ACE inhibitors or angiotensin receptor blockers (ARBs) is most beneficial for patients with proteinuria; benefit of ACE inhibitors or ARBs is less significant if there is no proteinuria.

• The first step in the management of all patients with hematuria is to obtain a urinalysis.
• Urinalysis confirms the presence of hematuria, and differentiates extraglomerular hematuria from glomerular hematuria.
• Red cell casts, dysmorphic red cells, and associated proteinuria are features of glomerular bleeding.
• Centrifugation of urine allows distinction between hematuria, hemoglobinuria, and myoglobinuria.

• Diabetics have a high risk of erectile dysfunction, and the risk progressively increases with age and the duration of the diabetes.
• Vascular complications and neuropathy are the main causes of increased prevalence of erectile dysfunction in these patients, although psychological causes should not be overlooked.
• Phosphodiesterase inhibitors (e.g., sildenafil) are the first-line drugs in the treatment of these patients.
• When it is used with an alpha-blocker, it is important to give the drugs separately with at least a 4-hour interval to reduce the risk of hypotension.

• 1. Gross hematuria with no evidence of glomerular disease or infection
• 2. Microscopic hematuria with no evidence of glomerular disease or infection but increased risk for malignancy
• 3. Recurrent urinary tract infections
• 4. Obstructive symptoms with suspicion for stricture, stone
• 5. Irritative symptoms without urinary infection
• 6. Abnormal bladder imaging or urine cytology

• Gross hematuria warrants evaluation of both the upper and lower urinary tracts.
• Computed tomography urogram is recommended for the upper tract; ultrasound is an alternate test, especially for patients with chronic kidney disease.
• Cystoscopy is recommended for evaluation of the lower tract, with urine cytology as an alternate test for low-risk patients.

• Hematuria frequently occurs with extremely strenuous exercise, and can occur in both contact and non-contact sports.
• The diagnosis should be considered one of exclusion even with the appropriate history, and follow up urinalysis is needed in 1 week to ensure that the hematuria has resolved.

• Physicians are ethically obligated to report colleagues who subject patients to potentially harmful treatments.
• State medical boards are authorized to conduct investigations of possible misconduct and institute disciplinary actions if indicated.

Before considering peritoneal dialysis as a treatment option in patients with adult polycystic kidney disease, it is important to rule out diverticulosis.

• For renal transplantation purposes, the best donor is a sibling with no HLA mismatches.
• Blood relatives with up to three HLA mismatches, or non-relatives with a median of four HLA mismatches are also adequate candidates, even though the average possibility of survival (after 10 years) of the renal graft is 20% lower than that obtained from relatives with absolute compatibility.
• Cadaveric donors must have no mismatches in order to be better alternatives than a living donor.

• Candidates who are younger than 14 years of age or older than 65 years are considered suboptimal or marginal kidney donors.
• Furthermore, it is not ethical to allow organ donation by children because they are not capable of giving the appropriate consent required.
• Only in some special situations in which HLA compatibility is critical can the possibility of organ donation by a child be discussed.

• It should be suspected in patients with severe hypertension, resistance to multiple medications, worsening from a previously stable baseline, or young age of onset.
• Renovascular hypertension is the most common secondary cause of hypertension and should be suspected in patients with renal atrophy, recurrent flash pulmonary edema, abdominal bruit, atherosclerotic disease elsewhere in the body, or renal failure.

• Surgical management is the only chance of cure for patients with renal cell carcinoma.
• If the renal mass is confined within the renal capsule (stage 1), partial nephrectomy can be offered.
• If the process extends through the renal capsule but not beyond Gerota's fascia (stage II), radical nephrectomy is the best treatment option.
• Radical nephrectomy can also be employed in patients with invasion of major veins, abdominal lymph nodes and adrenal glands, (stage III) although it is technically more difficult.

• The immediate (DVT, Hospital Acquired Infections ) and long-term complications of donor nephrectomy are low.
• Patients have an increased risk of gestational complications (fetal loss, preeclampsia, gestational diabetes, and gestational hypertension) after donor nephrectomy compared to pregnancies before the procedure.
• It is generally recommended that women complete their planned childbearing prior to kidney donation.
• The risk of end-stage renal disease and overall mortality following kidney donation are the same as in the general population.

• Schistosoma haematobium is the typical causative agent of urinary schistosomiasis.
• Patient usually have microhematuria and anemia.
• The most common method of diagnosing schistosomiasis is demonstration of parasite eggs in the stool or urine.
• It is preferable to collect urine samples for examination between 10 am and 2 pm, when the egg excretion is maximal.

• Retrograde ejaculation occurs in 70% of patients after TURP.
• The bladder neck fails to close after the procedure, and enables the sperm to flow backward to the bladder.