Term
| What are the 5 major causes of non-glomerular hematuria? |
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Definition
1) Cancer - UNTIL PROVEN OTHERWISE
2) Trauma
3) Stones
4) Infection
5) Iatrogenic |
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Term
| What is a typical workup for hematuria? |
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Definition
1) UA
- Upper vs. Lower
2) CT scan (contrast or none)
3) Cystoscopy
4) Retrograde urethrogam and cystogram
**90% of workup will be negative!** |
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Term
| What are common causes/treatments of blunt renal trauma? |
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Definition
1) MVA, fall, contact sports
2) Treatment
- Observation (until urine clear)
- Surgery for grade V (thrombosis of main artery, multiple lacerations or avulsion of main renal artery/vein) |
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Term
| What are the common causes/treatments of blunt bladder trauma? |
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Definition
1) MVA, Deceleration with GROSS hematuria
**Get retrograde urethrogram first.
2) Producing Contusions, Extraperitoneal ruptures (Drain bladder) and Intraperitoneal ruptures (Surgery) |
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Term
| Why might you see gross blood at meatus? What do you do? |
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Definition
Rupture of Membranous urethra, often from pelvic fracture.
Operative realignment. |
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Term
| What situation might cause a butterfly hematoma and how would you treat? |
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Definition
Straddle trauma to bulbar urethra
Treat with extended drainage and look out for stricture disease long term. |
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Term
| Why might you see gross blood in urine following sex |
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Definition
| Penile urethra injury from fractured penis. |
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Term
What do each of the following theories say about stone formation?
1) Matrix
2) Inhibitor
3) Crystalloid |
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Definition
Probably a combination
1) Organic matrix of compounds present in all stones are causally related to stone formation.
2) Deficiency in urine of crystallization inhibitors.
3) Supersaturation with respect to stone-forming constituents. |
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Term
| What metabolic defects are associated with Calcium Oxalate Monohydrate or Dihydrate crystals? |
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Definition
MOST common crystals (85%) with male dominance in stone belt (texas to virginia)
1) Alkaline urine pH
2) Hypercalciuria
- Increased gut absorption (increased 1,25, vit D or dietary excess)
- Increased bone reabsorption
- Increased renal excretion. (renal leak)
3) Hyperoxaluria
- >40 mg/24 h (not pH dependent)
- increased production or intestinal absorption
4) Hyperuricosuria
- may act as nucleus for calcium salt precipitation |
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Term
| What might cause enteric hyperoxaluria and why is it a worry? How do you treat? |
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Definition
Calcium Oxalate crystals!
1) Malabsorption (Crohn's or Intestinal bypass)
- Fatty acid soaps bind calcium in gut and prevent it from complexing with oxalate, which is then "Free" to be absorbed.
2) Treat with calcium or magnesium supplements (paradoxical)
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Term
| How do you diagnose/treat Calcium Oxalate crystals? |
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Definition
1) Diagnose with stone analysis and 24h UA (calcium oxalate crystals NOT diagnostic)
2) Treatment
- Decrease urinary calcium/sodium/oxalate/uric acid
- Inhibitors
- Fluids, treat underlying condition |
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Term
What are the risk factors for Calcium phosphate crystals?
How do you diagnose/treat? |
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Definition
1) Risk
- Hypercalciuria (Vitamin D intoxication, Hyperparathyroidism, Sarcoid)
- Alkaline urine (Acidification defect like Type 1 RTA or milk-alkali syndrome)
2) Like calcium oxalate, stones are not diagnostic, but you need 24 UA with hypercalciuria and other causative risk factors.
3) Treat by decreasing calcium excretion and giving fluids/education |
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Term
A patient presents with gout, psoriasis, obesity and persistently acid, concentrated urine (pH= 5)
How to you confirm diagnosis/treat? |
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Definition
Sounds like Uric Acid Calculi, so perform stone analysis and 24h urine study for hyperuricosuria.
Alkalinize urine to pH 6.5-7 and give fluids/education |
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Term
What are the risk factors for Struvite crystals?
How do you diagnose/treat? |
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Definition
1) UTI with urea-splitting organism like Proteus present in alkaline urine due to superaturation with magnesium-ammonium phosphate.
2) Stone analysis for struvite crystals to confirm UTI with urea splitting organism and treat with Antibiotics or Percutaneous lithotripsy. |
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Term
What are the risk factors for Cystine crystals?
How do you diagnose/treat? |
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Definition
1) Cystinuria- AR defect in dibasic amino acid transport in renal tubule and gastric mucose
- COLA (cystine, ornithine, lysine, arginine)
2) Stone analysis for Hexagonal crystal and Cyanide-Nitroprusside test (qualitative) with 24h urine analysis (quantitative) as well.
3) Treat with high fluid intake and patient education.
Drugs include Potassium citrate (alkali therapy), d-Penicillamine (toxic) and Tiopronin (better tolerated) |
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Term
Why might you prescribe each of the following drugs (e.g. which stones)?
1) Citrate
2) Thiazide diuretic
3) Sodium cellulose phosphate
4) Allopurinol
5) Antibiotics
6) D-penicillamine
7) Thiola |
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Definition
1) Alkalinize for calcium phosphate stones
2) Decrease urinary calcium for calcium stones
3) Binds calcium in gut for absorptive hypercalciuria
4) Decreases urinary uric acid for uric acid and calcium stones.
5) Struvite stones in UTI
6) Cystine stones (toxic to kidney and induces lupus)
7) Cystine stones (better tolerated than d-Penicillamine) |
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Term
| What is the proper protocol for acute management of stones? |
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Definition
Treatment
1) 90% will pass spontaneously
2) Increase fluid intake, strain urine to catch stone for analysis
3) Start steroid, alpha blocker and antibiotic
4) Surgery IF infection, obstruction >4 weeks, Intractable pain/nausea or LARGE size.
Surgery
- If in lower or middle third or ureter use Ureteroscope with basket or ESWL
- If large calculus and/pr in the pelvis or upper third of ureter, use percutaneous removal and Ureteroscope. |
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