Clinical Pearls for Urology

What is vesicoureteral reflux?

retrograde passage of urine from the bladder into the upper urinary tract

Who is most likely to have vesiculoureteral reflux?

caucasian >> AA

female > males

When are people diagnosed with vesiculoureteral reflux?

-prenatal on ultrasonography (hydronephrosis)

-postnatal after having a febrile UTI

If someone is <2 months and has vesiculoureteral reflux what med do you give?

Cephalexin, Ampicillin or Amoxicillin

If someone is >2 months and has vesiculoureteral reflux what med do you give?

Bactrim (TMP-SMZ)

urethral prolapse presentation

-painless bleeding

-can become painful or cause urinary symptoms

-beefy red donut shaped protrusion

Conservative treatment for urethral prolapse

-observation

-topical estrogen

-anti-inflammatory creams

-sitz baths

If a reduction is done on a urethral prolapse, what needs to be done after?

cystoscopy to rule out ureterocele

What is Epispadias?

Dorsal location of the urethra (rare)

What is often associated with epispadias?

bladder exstrophy

What is the most common cause of urethral stricture in developed countries?

iatrogenic

What is the most common cause of urethral stricture in developing countries?

trauma

Presentation of urethral stricture

Obstructive voiding symptoms

◦Decreased force of stream

◦Incomplete bladder emptying

◦Terminal dribbling

◦Intermittency of stream

Urinary retention

Urinary tract infections

What diagnostic test is most useful for diagnosing an anterior urethral stricture?

Retrograde Urethrogram (RUG)

What diagnostic test is most useful for diagnosing a posterior urethral stricture?

Voiding Cystourethrogram (VCUG)

What is the most common initial treatment for urethral stricture?

urethral dilation and endoscopic urethrotomy

-note: high rate of recurrence

What is hypospadias?

congenital anomaly resulting in abnormal ventral placement of the urethral opening

What is an environmental cause for hypospadias?

prenatal exposure to estrogenic compounds --> leads to disruption of androgenic stimulation

Describe forme fruste in hypospadias

2 urethral openings at penis tip

Describe a standard case of hypospadias

ventral or dorsal placement of urethral opening

What is Xanthogranulomatous pyelonephritis?

chronic urinary obstruction with chronic infection leading to suppurative destruction of renal tissue

What types of cells are characteristic of Xanthogranulomatous pyelonephritis?

foamy lipid-laden histiocytes (xanthoma cells)

Common cause of Xanthogranulomatous pyelonephritis

E. coli

presentation of Xanthogranulomatous pyelonephritis

-usually unilateral mass

-fever

-chills

-flank pain/mass

-bacteriuria

-Hx of urolithiasis

What would you see on urinalysis of Xanthogranulomatous pyelonephritis

WBCs and protein

treatment for Xanthogranulomatous pyelonephritis

partial or total nephrectomy

What does a renal abscess result from?

severe infection that leads to liquefaction of renal tissue which is then sequestered, forming an abscess

common cause of renal abscess (pathogen)

E. coli

presentation of renal abscess

-fever

-chills

-flank mass/pain

-abdominal pain

-dysuria

What is the characteristic finding of a renal abscess on imaging?

"ring" sign that forms from the inflammatory wall around fluid collection causing a rim around mass

treatment for renal abscess

Ampicillin or vancomycin + amino glycoside

-can do surgical drainage

What is Pyonephrosis?

bacterial infection of a hydronephrotic, obstructed kidney

-leads to suppurative destruction of the renal parenchyma and potential loss of renal function

-puss in the kidney that is hydronephrotic

Presentation of pyonephrosis

-VERY ILL

-fever

-chills

-flank pain

-Hx or calculi or surgery is common

-lower urinary tract symptoms often absent

-sepsis can happen QUICKLY

What would you see on a renal US if someone has pyonephrosis?

dilated pyelocalyceal system with fluid debris levels

-calculi possible

what is acute pyelonephritis?

infectious inflammatory disease involving the kidney parenchyma and renal pelvis

risk factors for acute pyelonephritis

-women

-sexual intercourse "Honeymoon cystitis"

-menopause: decreased bladder tone

-pregnancy

most common cause of acute pyelonephritis

E. coli

common cause of acute pyelonephritis in sexually active women

staph saprophyticus

presentation of acute pyelonephritis

-fever

-tachycardia

-back/flank pain

- positive CVA tenderness

-nausea/vomiting

What is the definitive diagnosis for acute pyelonephritis?

urine culture

inpatient treatment for acute pyelonephritis

-IV ampicillin

-IV ceftriaxone

-IV ciprofloxacin

outpatient treatment for acute pyelonephritis

-Ciprofloxacin

-Levofloxacin

-Bactrim

How does someone get chronic pyelonephritis?

repeated or inadequate treatment for renal infections, which leads to scarring, atrophy of kidney, and renal insufficiency

Presentation of chronic pyelonephritis

-most asymptomatic and found on imaging incidentally

-Hx of frequent UTIs or pyelonephritis

-chronic flank pain

-renal failure

-HTN, anemia

How is the diagnosis made for chronic pyelonephritis?

radiologic or pathologic exam

Goal for treatment of chronic pyelonephritis?

prevent further damage

What is emphysematous pyelonephritis?

necrotizing infection characterized by the presence of gas within the renal parenchyma or perinephric tissue

Patients with what underlying condition usually present with emphysematous pyelonephritis?

diabetes melitus

Common pathogen in emphysematous pyelonephritis

E. coli

Presentation of emphysematous pyelonephritis

-fever

-chills

-flank pain

-abdominal pain

-n/v

How is the diagnosis made for emphysematous pyelonephritis?

imaging --> see gas in renal parenchyma

Treatment for emphysematous pyelonephritis

-control blood sugar

-relieve obstruction

-kidney removal

How is Recurrent cystitis defined?

2 or more culture positive UTIs in 6 months or 3 or more culture positive UTIs in 1 year

RF for recurrent cystitis

-sexual intercourse

-use of spermicides

-incomplete bladder emptying

-maternal FHx of UTI

-post-menopausal

Treatment for recurrent cystitis

lifestyle modifications

-avoid use of spermicides

-urinate after intercourse

-wipe front to back

-increase water intake

Supplements

-D-mannose

-cranberry

Methanamine hippurate

What is interstitial cystitis?

chronic bladder pain w/o a known etiology and with negative urine cultures

presentation of interstitial cystitis

-pain (exacerbated by filling of bladder)

-pressure

-discomfort or spasms of bladder

-urinary frequency/urgency

What is the goal of treatment in interstitial cystitis?

relieve symptoms

What meds can be given to those with interstitial cystitis?

Amitriptyline and NSAIDs

What is the diagnostic tool of choice for asymptomatic bacteriuria?

clean-catch voided urine

What is acute cystitis/UTI?

confined to the bladder/lower urinary tract

What is the common pathogen that causes acute cystitis/UTI?

E. coli

symptoms of acute cystitis/UTI

-dysuria

-urinary frequency/urgency

-suprapubic pain/pressure

-occasionally hematuria

How do you treat acute cystitis/UTI?

-Nitrofurantoin

-Bactrim

-Fosfomycin

-Fluoroquinolones

What is Complicated cystitis/UTI?

infection that is no longer just in the bladder

Presentation of Complicated cystitis/UTI?

active UTI with:

-fever

-flank pain

-CVA tenderness

-pelvic or perineal pain in men

-n/v

Important things needed to diagnose Complicated cystitis/UTI

-good H&P

-urinalysis and urine culture

What is the DOC for Complicated cystitis/UTI?

fluoroquinolones

Primary HSV presentation

-can be severe

-multiple painful genital vesicles/ulcers

-dysuria and sometimes urinary retention

-fever

-tender inguinal LAD

-headache

non primary HSV presentation

-fever, lesions and less systemic symptoms

What is the preferred diagnostic tests for HSV in active lesions?

-viral culture

-PCR

What meds treat HSV and how soon should you start them?

-Meds: Acyclovir, Valcyclovir, and Famciclovir

-start within 72 hours of lesion presentation

What types of HPV cause genital warts?

types 6 and 11

What types of HPV cause penile cancers?

types 16 and 18

What is the most common presentation of HPV?

genital warts

diagnosis for HPV

mostly clinical

-can get biopsy if unsure

Patient applied treatment for HPV

-Imiquimod 5% cream

-Podophyllotoxin 0.5% solution or gel

-Sinecatechins 15% ointment

Clinician applied treatment for HPV

-cryotherapy

-trichloroacetic acid

-surgical removal

What is the causative agent for syphilis?

Treponema pallidum

What is the epidemiology for syphilis?

-men in western US

-MSM

-AA

-ages 20-34 y/o

presentation of early syphilis

-painless chancres

-regional lymphadenopathy

-heals spontaneously w/in 3-6 weeks

presentation of secondary syphilis

-rash (diffuse, symmetric macular or papular rash with lesions that are copper, red, or reddish-brown)

-systemic signs (fever, HA, malaise, sore throat)

-adenopathy

-neuro (HA, meningitis)

-MSK (osteitis and synovitis)

Presentation of late syphilis

-up to 20 years after infection

-cardiovascular

-gummatous (granulomatous, modular lesions occurring on skin and bones)

What test is more specific for syphilis diagnosis?

Treponemal test

What test is highly specific for neurosyphilis?

CSF-VDRL

How do you treat syphilis?

Penicillin G

What is the most common cause of urethritis in men?

Chlamydia

What is the causative agent for chlamydia?

Chlamydia trachomatis

RF for chlamydia

-young age (<25)

-race (highest in AA)

-incarcerated populations

-military recruits

-new or multiple sexual partners

-Hx of previous chlamydial infections

-unprotected sexual intercourse

presentation of chlamydia

-most are completely asymptomatic

-urethritis is MC clinical manifestation in males and cervicitis is MC in females

-could have epididymitis

-could have proctitis

Progression of cervicitis due to what has a high rate of infertility?

due to chlamydia

What is the classic triad for reactive arthritis?

Conjunctivitis/uveitis

Urethritis

Arthritis

"Chlamydia Upsets All"

What is the test of choice to diagnose chlamydia?

Nucleic Acid Amplification Test (NAAT)

Treatment for Chlamydia?

doxycycline or azithromycin

What is the causative agent for Gonorrhea?

Neisseria gonorrhoeae

Presentation of gonorrhea

-urethritis (MC)

-epididymitis

-extragenital infection

-conjunctivitis (if spread to eyes)

-sore throat

What is the classic triad for disseminated infection of gonorrhea?

Tenosynovitis

Polyarthralgias

Dermatitis

"Ten Polyamorous Dermatologists got gonorrhea"

How do you diagnose Gonorrhea?

NAAT is test of choice

If you get a microscopy of gonorrhea, what will you see?

-polymorphonuclear leukocytes with intracellular gram negative diplococci

Treatment for Gonorrhea

Ceftriazone + Doxycycline (to treat for chlamydia)