Urology-Nephrology



Viagra can be changed to Cialis 5mg daily and coded as BPH.

Which one of the following is recommended initially in the acute treatment of kidney stones? REF
- antispasmodic therapy for stones measuring 10 mm or less.

When to switch to doxycycline in a 32 yo F w/ dysuria ? REF keyword: Chlamydia

Spiking fevers in pregnant UTI are ok up to 72 hrs after start of ABX. REF

Urge incontinence. REF

In elderly patients, detrusor instability is the most common cause of urinary incontinence in both men and women. Incontinence may actually become worse after surgical relief of obstructive prostatic hypertrophy. REF

The tone of the internal sphincter of the bladder is modulated through alpha-adrenergic receptors. Stimulation of these receptors with agents such as pseudoephedrine or imipramine can increase internal sphincter tone and alleviate symptoms. REF


55 yo with constant leakage. What are the 4 type of incontinence and what is the tx for her ? REF

How to rule out pre-renal AKI: Normal spot UNa is usu ~ 40 mEq/dl, in pre-renal AKI it's < 20 mEq/dl.  

UWIM198635 - ACE inhibitors, ARBS, NSAIDS & diuretics increase Lithium by decreasing GFR.

Note - Cr is an organic cation, as are the meds below. Approx 15% of UCr comes from tubular excretion.UWIM198365 - These increase serum Cr by competing with Cr for tubular secretion, but don't decr GFR.
1. cefoxitin
2. cimetidine
3. ketone  bodies
4. flucytosine
5. trimethoprim.

When and how to tx hematuria. REF

Name a treatment for interstitial cystitis. REF

Name the appropriation PE prophylaxis in a fat guy before TURP (REF)
 
Stones - all you need to know:
- Calcium oxalate 60%, Uric acid, cysteine 17% - acidotic - alkalinize w/ fruits, veges & mineral H2O (pH = 7.0-7.5) avoid acids like meat, grain, dairy, legumes.
- Calcium phosphate & struvite - alkalotic - acidify w/ 16 oz cranberry juice daily or betaine 650 mg TID.
- If you don't catch the stone do a 24 hour urine for uric acid, phosphage, calcium, oxalate & magnesium.

In a hyponatremic patient, low Uosm always diagnoses psychogenic polydipsia.

Cardiovascular Topics 08
Question 9 of 10
A 62-year-old male presents for surgical clearance prior to transurethral resection of the prostate. His past history is significant for a pulmonary embolus after a cholecystectomy 15 years ago. His examination is unremarkable except that he is 23 kg (50 lb) overweight. The most appropriate recommendation to the urologist would be to:  (check one)
 A. Cancel the surgery indefinitely 
 B. Place the patient on 650 mg of aspirin daily prior to surgery 
 C. Start the patient on subcutaneous enoxaparin (Lovenox), 40 mg 1–2 hr prior to surgery and once a day after surgery 
 D. Start warfarin (Coumadin) after surgery with a goal INR of 1.5 
 E. Start intravenous heparin according to a weight-based protocol 24 hours after surgery 
Correct.
A patient with a past history of postoperative venous thromboembolism is at risk for similar events with subsequent major operations. The most appropriate treatment of the choices listed would be subcutaneous enoxaparin. Aspirin is ineffective for prophylaxis of venous thromboembolism. Warfarin is effective at an INR of 2.0–3.0. Full anticoagulation with heparin is unnecessary for prophylaxis and can result in a higher rate of postoperative hemorrhage. Ref: Ramzi DW, Leeper KV: DVT and pulmonary embolism: Part II. Treatment and prevention. Am Fam Physician 2004;69(12):2841-2848.

During a comprehensive health evaluation a 65-year-old African-American male reports mild, very tolerable symptoms of benign prostatic hyperplasia, rated as a score of 7 on the American Urological Association Symptom Index. He has never smoked, and his medical history is otherwise unremarkable. Objective findings include an enlarged prostate that is firm and nontender, with no nodules. A urinalysis is normal and his prostate-specific antigen level is 1.8ng/mL.
Based on current evidence, which one of the following treatment options is most appropriate at this time?
  (check one)
 A. Observation, with repeat evaluation in 1 year 
 B. Saw palmetto 
 C. An α-receptor antagonist 
 D. A 5-α-reductase inhibitor 
 E. Urologic referral for transurethral resection of the prostate 
Correct.
Watchful waiting with annual follow-up is appropriate for men with mild benign prostatic hyperplasia (BPH). Prostate-specific antigen (PSA) levels correlate with prostate volume, which may affect the treatment of choice, if indicated (SOR C). PSA levels >2.0 ng/mL for men in their 60s correlate with a prostatic volume >40 mL. This patient’s PSA falls below this level. In men with a prostatic volume >40 mL, 5 -reductase inhibitors should be considered for treatment (SOR A).  -Blockers provide symptomatic relief in men whose disease has progressed to the point that they have moderate to severe BPH symptoms (SOR A). A recent high-quality, randomized, controlled trial found no benefit from saw palmetto with regard to symptom relief or urinary flow after 1 year of therapy. The American Urological Association does not recommend the use of phytotherapy for BPH. Surgical consultation is appropriate when medical therapy fails or the patient develops refractory urinary retention, persistent hematuria, or bladder stones.
Ref: Edwards JL: Diagnosis and management of benign prostatic hyperplasia. Am Fam Physician 2008;77(10):1403-1410, 1413.

118. A 60-year-old female presents with a 1-year history of episodes of urinary incontinence. She 
tells you that she will suddenly feel the need to urinate and can barely make it to the bathroom. 
She occasionally loses urine before reaching the toilet. Her only medication is 
hydrochlorothiazide, which she has been taking for many years for hypertension. On 
examination, her vaginal mucosa is pale and somewhat dry. Minimal prolapse of her vaginal and 
urethral areas is noted. 
Which one of the following would be most appropriate at this point? 
A) Urodynamic testing 
B) Referral for surgical evaluation 
C) Oral estrogen 
D) Oral anticholinergic therapy 
E) Stopping the hydrochlorothiazide 
Item 118 
ANSWER: D 
First-line therapies for urge urinary incontinence include behavioral therapy, such as pelvic muscle 
contractions, and anticholinergic therapy. Oral estrogen is not indicated. Noninvasive treatments should 
be tried initially. Urodynamic testing is indicated preoperatively. Stopping the hydrochlorothiazide would 
not be helpful, as it would not address the issue of detrusor instability. 
Ref: Nygaard I: Clinical practice. Idiopathic urgency urinary incontinence. N Engl J Med 2010;363(12):1156-1162.

164. The best management of localized, well-differentiated prostate cancer in men older than 65 is 
A) radiation implants 
B) external beam radiation therapy 
C) watchful waiting 
D) primary androgen deprivation therapy 
E) robot-assisted prostatectomy 
Item 164 
ANSWER: C 
For men older than 65 years of age with small-volume, low-grade disease and a 10- to 15-year life expectancy, the risk of complications from treatment outweighs any decreased risk of dying from prostate cancer. Radiation, androgen deprivation therapy, and surgical approaches have not been shown to improve disease-free survival (SOR A). 
Ref: Delbanco T, Albertsen PC: Update: A 72-year-old man with localized prostate cancer—14 years later. JAMA 
2009;302(10):1105-1106. 

139. A 77-year-old white male complains of urinary incontinence of more than one year’s duration. 
The incontinence occurs with sudden urgency. No association with coughing or positional 
change has been noted, and there is no history of fever or dysuria. He underwent transurethral 
resection of the prostate (TURP) for benign prostatic hypertrophy a year ago, and he says his 
urinary stream has improved. A rectal examination reveals a smoothly enlarged prostate without 
nodularity, and normal sphincter tone. No residual urine is found with post-void catheterization. 
Which one of the following is the most likely cause of this patient’s incontinence? 
A) Detrusor instability 
B) Urinary tract infection 
C) Overflow 
D) Fecal impaction 
E) Recurrent bladder outlet obstruction

Item 139 
ANSWER: A 
In elderly patients, detrusor instability is the most common cause of urinary incontinence in both men and 
women. Incontinence may actually become worse after surgical relief of obstructive prostatic hypertrophy. 
Infection is unlikely as the cause of persistent incontinence in this patient in the absence of fever or 
symptoms of urinary tract infection. Overflow is unlikely in the absence of residual urine. Impaction is 
a relatively rare cause of urinary incontinence, and associated findings would be present on rectal 
examination. Normalization of the urinary stream and the absence of residual urine reduce the likelihood 
of recurrent obstruction. The prostate would be expected to remain enlarged on rectal examination after 
transurethral resection of the prostate (TURP). 
Ref: Gibbs CF, Johnson TM II, Ouslander JG: Office management of geriatric urinary incontinence. Am J Med 
2007;120(3):211-220. 2) Goldman L, Ausiello D (eds): Cecil Medicine, ed 23. Saunders, 2008, pp 125-128.

24. A 70-year-old white female complains of two episodes of urinary incontinence. On both 
occasions she was unable to reach a bathroom in time to prevent loss of urine. The first episode 
occurred when she was in her car and the second while she was in a shopping mall. She is 
reluctant to go out because of this problem. 
The most likely cause of her problem is 
A) overflow incontinence 
B) stress incontinence 
C) urge incontinence 
D) functional incontinence

Item 24 
ANSWER: C 
At least 10 million Americans suffer from urinary incontinence. In the neurologically intact individual the 
most common subtypes are stress incontinence, which occurs with coughing or lifting; urge incontinence, 
which occurs when patients sense the urge to void but are unable to inhibit leakage long enough to reach 
the toilet; and overflow incontinence, which occurs when the bladder cannot empty normally and becomes 
overdistended. The term functional incontinence is applied to those cases where lower urinary tract 
function is intact but other factors such as immobility and severe cognitive impairment lead to incontinence. 
This patient has mild urge incontinence. The first approach to this problem should be behavioral. In a 
mild case such as this, a cure can be expected, with success rates of 30%–90% in published studies. For 
more severe cases, various pharmacologic agents, including anticholinergics, are useful. Failure of these 
modalities should lead to urodynamic testing and consideration of surgery. 
Ref: Smith PP, McCrery RJ, Appell RA: Current trends in the evaluation and management of female urinary incontinence. 
CMAJ 2006;175(10):1233-1240. 2) Gibbs CF, Johnson TM, Ouslander JG: Office management of geriatric urinary 
incontinence. Am J Med 2007;120(3):211-220.

Mixed Review 61
Which one of the following statements regarding varicoceles is true?  (check one)
 A. Repair of varicoceles usually results in infertility 
 B. The incidence of varicoceles in adult males is <5% 
 C. Most varicoceles are bilateral 
 D. Varicoceles usually begin between 5 and 8 years of age 
 E. A unilateral varicocele on the right side should be referred for further evaluation 
Correct.
Most varicoceles appear in adolescence, occur on the left side, and are asymptomatic. About 10% are bilateral. Surgical repair of large varicoceles can reverse testicular growth arrest, with catch-up growth occurring within 1–2 years. Varicoceles are the most common surgically correctable cause of subfertility in men and the goal of surgery is to maximize chances for fertility. Varicoceles in men are common, with an incidence of approximately 15%. The appearance of a varicocele on the right side only, or in a child less than 10 years of age, is abnormal and may indicate an abdominal or retroperitoneal mass. Ref: Nussinovitch M, Greenbaum E, Amir J, et al: Prevalence of adolescent varicocele. Arch Pediatr Adolesc Med 2001;155(7):855-856. Behrman RE, Kliegman RM, Jenson HB (eds): Nelson Textbook of Pediatrics, ed 17. Saunders, 2004, pp 1819-1820.
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