Family Medicine Rotation

Family Medicine Rotation: Urology/Renal (PEARLS)

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Balanitis Inflammation of the foreskin and head of the penis

  • Balanitis is most common in uncircumcised men
  • Causes include skin disorders, infection, poor hygiene, uncontrolled diabetes, and harsh soaps
  • Symptoms include pain, redness, and a foul-smelling discharge from under the foreskin

Treatment depends on the cause:

  • Topical antifungal agents: clotrimazole 1% or miconazole 2%, each applied twice daily for one to three weeks
  • For suspected anaerobic infection: metronidazole 0.75% applied twice daily for seven days
  • In extreme cases, the foreskin may need to be removed (circumcision)
Benign prostatic hyperplasia A disease of elderly men (average age is 60 to 65 years); prostate gradually enlarges, creating symptoms of urinary outflow obstruction

  • Enlargement of transitional zone - PSA often elevated > 4
  • The urinary stream may be weak, stop and start (hesitancy), or sensation of incomplete emptying. In some cases, it can lead to infection, bladder stones, and reduced kidney function
  • History, DRE, elevated PostVoid Residual (PVR), urinalysis, cystoscopy, U/S
  • In men with BPH avoid the use of anticholinergic and antihistamines
  • This type of prostate enlargement isn't thought to be a precursor to prostate cancer

Treatments include medications that relax the bladder or shrink the prostate, surgery, and minimally invasive surgery

  • Relax the bladder/urethra:  α-1 blockers - tamsulosin (Flomax) most uroselective provides rapid symptom relief  - smooth muscle relaxation of prostate and bladder neck decreases urethral resistance and obstruction which increases urinary flow can cause dizziness and orthostatic hypotension as well as retrograde ejaculation
  • Decrease prostate size (shrink prostate): 5 alpha-reductase inhibitors (finasteride) and (dutasteride) (androgen inhibitor - inhibits the conversion of testosterone to dihydrotestosterone suppressing prostate growth, and reducing bladder outlet obstruction) has a positive effect on the clinical course of BPH
  • TURP (transurethral resection of the prostate) if refractory to meds - removes excess prostate tissue to relieve obstruction - sexual dysfunction and urinary incontinence
Chlamydia Caused by Chlamydia trachomatis serotypes D-K

  • Often asymptomatic, but may cause discharge from the penis or vagina, painful or more frequent urination, cervicitis, PID, lymphogranuloma venereum, or infertility
  • Evaluation should include a nucleic acid amplification test (NAAT) - sensitivity 80-90% with a specificity of 95-100%
  • If unnoticed or untreated in women, these infections can result in infertility, miscarriage, and an increased risk of a mislocated pregnancy

Treatment:

  • CDC recommended treatment for chlamydia is doxycycline 100 mg PO BID × 7 days
    • Alternative regimens include: Azithromycin 1 g orally in a single dose OR Levofloxacin 500 mg orally once daily for 7 days
  • Persons who receive a diagnosis of chlamydia should be tested for HIV, gonorrhea, and syphilis
  • Treat partners and educate to refrain from sex until the infection is treated
  • During pregnancy, azithromycin 1 g as a single dose or Amoxicillin 500 mg orally three times a day for 7 days is recommended
Cystitis (Lecture) Infection of the bladder and is characterized by dysuria without urethral discharge. E. coli (most common)

  • Dysuria, urgency, frequency, hematuria, new-onset incontinence (in toilet-trained children). Abdominal or suprapubic pain
  • Absence of fever, chills, or flank pain. Change in urine color/odor
  • Urine dipstick: nitriteleukocyte esterase
  • Urinalysis: pyuria, bacteriuria +/− hematuria +/− nitrites
  • Urine culture (gold standard)
    • > 100 k CFU/mL (women)
    • > 1000 CFU/mL men or cath patients
    • → takes 24 h to obtain results

Treat with Nitrofurantoin (not over age 65), Bactrim, Fosfomycin

  • Ciprofloxacin - reserved for complicated cases
  • Postcoital UTI: single-dose TMP-SMX or cephalexin may reduce the frequency of UTI in sexually active women

Lower UTI in pregnancy

  • Nitrofurantoin (Macrobid): 100 mg PO BID × 7 days
  • Cephalexin (Keflex): 500 mg PO BID × 7 days

Interstitial cystitis: Symptoms relieved with voiding. Diagnosis of exclusion.

  • Hunner’s ulcer” on cystoscopy
Epididymitis
Patient will present as → a 25-year-old male with a dull, achy scrotal pain that has been gradually increasing over the last several days. He also reports pain with urination. Physical exam reveals a swollen right testicle with substantial induration. Urinalysis reveals positive leukocyte esterase and 20 WBC/HPF.

Acquired by the retrograde spread of organisms through vas deferens

  • The pathogen is based on the patient's age and risk factors:
    • men < 35 chlamydia and gonorrhea
    • men > 35 E.coli

Epididymitis is characterized by dysuriaunilateral dull aching scrotal pain that can radiate up the ipsilateral flank

  • Swollen epididymis tender; fever/chills
  • + Prehn's sign = relief with elevation is a classic sign

Dx: Urinalysis reveals pyuria and bacteriuria; cultures are positive for suspected organisms

TX:  Supportive care: bed rest, scrotal elevation, analgesics

  • Over 35- E. coli
    • Levofloxacin (Levaquin) 500 mg/day PO for 10 days (21-30 days if associated prostatitis)
    • For patients who are unable to take fluoroquinolones, trimethoprim-sulfamethoxazole (one double-strength tablet twice a day for 10 days) is a good alternative
  • Under 35 – Gonorrhea and chlamydia
    • Doxycycline 100 mg PO BID for 10 days PLUS ceftriaxone 500 mg IM × 1 (or 1 g if the patient weighs 150 kg or greater)
    • Refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms
  • Patients of any age who practice insertive anal intercourse – coverage for N. gonorrhoeae, C. trachomatis, and enteric pathogen infections
    • Ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if patient weighs 150 kg or greater) PLUS a fluoroquinolone (levofloxacin 500 mg orally once daily for 10 days)
Glomerulonephritis Acute glomerulonephritis is an  inflammation of glomeruli causing protein and RBC leakage into the urine, typically caused by an immune response

Two types based on 24-hour urine protein

  • Nephritic syndrome: moderate proteinuria 1-3.5 g/day
    • Classic presentation: edema + HTN + hematuria + RBC Casts/dysmorphic RBCs +  proteinuria 1-3.5 g/day + azotemia
  • Nephrotic syndrome: severe proteinuria > 3.5 g/day
    • Massive edema
    • Fatty casts with “maltese cross” sign
    • Hypoalbuminemia, hyperlipidemia, and lipiduria
    • Oval fat bodies

Nephritic syndrome

Patient will present as → a 26-year-old man who presents with hematuria, periorbital edema, and jaundice. He has a medical history of opioid use disorder with prior hospitalizations for a heroin overdose. He is on methadone but is non-adherent. His blood pressure is 155/102 mmHg. Physical examination is significant for scleral icterus, hepatomegaly, and palpable purpura. Serology shows decreased C3 and C4 levels and elevated anti-hepatitis C antibodies. Urinalysis demonstrates dysmorphic red blood cells and red blood cell casts.  
  • Manifestations: proteinuria, HTN, azotemia, oliguria (<400 ml urine/day), hematuria (RBC casts) hallmark, edema is not as much as nephrotic syndrome
  • Urinalysis: proteinuria < 3.5 grams per day, hematuria, RBC casts
  • Biopsy: hypercellular, immune complex deposition

Several etiologies of acute glomerulonephritis

  1. IgA Nephropathy (Berger disease) - most common cause of acute glomerulonephritis worldwide - often affects young males within days  (24-48 hours) after URI or GI infection - caused by IgA immune complexes which are the first line of defense in respiratory and GI secretions so infections cause an overproduction which then damages the kidneys. Diagnosed by (+) IgA deposits in mesangium and with immunostaining
  2. Postinfectious - Group A strep - 10-14 days after infection - diagnosed with ASO titers and low serum complement - treatment is supportive + antibiotics
  3. Membranoproliferative glomerulonephritis - due to SLE, viral hepatitis
  4. Rapidly progressive glomerulonephritis - crescent formation on biopsy due to fibrin and plasma protein deposition
    1. Goodpasture's syndrome: (+) anti-GBM antibodies, dx linear IgG deposits, treat with high dose steroids, plasmapheresis + cyclophosphamide
    2. Vasculitis - lack of immune deposits (+) ANCA antibodies
      1. Microscopic polyangiitis (+) P-ANCA
        1. Granulomatosis with polyangiitis (Wegener's) (+) C-ANCA

Nephrotic Syndrome

Patient will present as → a 6-year-old boy who is brought to the emergency department by his mother due to swelling around his eyes and legs. The mother reports that the patient recently recovered from an upper respiratory tract infection. Physical exam is significant for periorbital and lower extremity edema. Laboratory testing is significant for hypoalbuminemia and normal complement levels. Urinalysis demonstrates 4+ protein and fatty casts with a “maltese cross” sign.

Nephrotic syndrome is defined as urinary excretion of > 3 g of protein in a 24-hour urine sample due to a glomerular disorder plus edema and hypoalbuminemia

The most common primary causes are:

- Membranous nephropathy: most common in non-diabetic adults associated with malignancies.

  • Caused by immune complex formation in the glomerulus - basement membrane becomes damaged

- Minimal change disease: most common cause in kids. Assume minimal change disease if a child with idiopathic nephrotic syndrome improves after treatment with corticosteroids.

  • The cause and pathogenesis of minimal change disease is unclear and it is currently considered idiopathic.

- Focal segmental glomerulosclerosis (FSGS): obese patients, heroin, and HIV+ black males.

  • Primary, when no underlying cause is found
  • Secondary, when an underlying cause is identified
    • Toxins and drugs such as heroin and pamidronate
    • Familial forms
    • Secondary to nephron loss and hyperfiltration, such as with chronic pyelonephritis and reflux, morbid obesity, diabetes mellitus

The most common secondary causes are:

  1. Lupus: both nephritic and nephrotic
  2. Diabetes: a common cause of nephrotic syndrome and subsequent renal failure
  3. Preeclampsia
Gonorrhea
Patient will present as → a 19-year-old sexually active woman presents to your office with complaints of yellow vaginal discharge and intermittent postcoital vaginal bleeding for 1 week. She otherwise feels well. On examination, there is purulent discharge visible in the endocervical canal. After you collect vaginal fluid for a wet prep and cervical samples for gonorrhea and chlamydia cultures, you note bleeding at the cervical os. On bimanual examination, the patient complains of tenderness on cervical palpation but denies uterine or adnexal tenderness. Wet prep reveals vaginal pH 4; negative whiff; 20 white blood cells (WBCs) per high-power field; and no clue cells, trichomonads, or pseudohyphae.

Caused by N. gonorrhoeae (gram-negative diplococci)

  • Dysuria, urinary frequency, and purulent yellow-green discharge
  • May progress to PID, high rate of coinfection with chlamydia
  • Evaluation should include a nucleic acid amplification test (NAAT) of the first voided urine
  • Clean-catch urine culture to rule out UTI
  • Saline/KOH/Gram stain of vaginal discharge

Treatment:

  • CDC recommends ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
    • For persons weighing ≥ 150 kg (300 lb), 1 g of IM ceftriaxone should be administered.
  • Treatment for coinfection with Chlamydia trachomatis with oral doxycycline (100 mg twice daily for 7 days) should be administered when a chlamydial infection has not been excluded
  • If ceftriaxone is unavailable alternatives include:
    • Gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally as a single dose
    • Cefixime 800 mg orally as a single dose
  • Sexually active patients with symptoms are usually treated presumptively for STDs pending test results
  • Check for other STIs
  • Treat partners and educate to refrain from sex until the infection is treated
  • Make sure to think of gonococcal pharyngitis in anyone with persistent pharyngitis and take samples for culture
Hernias Indirect Inguinal Hernia (Most Common): Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum

  • Often congenital and will present before age one
  • Remember: I ndirect goes through the I nternal I nguinal Ring (an “I” for an “I”)

Direct Inguinal HerniaPassage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum

Nephrolithiasis
Patient will present as → a 31-year-old man with right flank pain radiating into the scrotum, gross hematuria, right-sided hydronephrosis, and normal abdominal x-ray

  • Colicky flank pain radiating to the groin, hematuria, CVA tenderness, and nausea and vomiting
  • CT scan (spiral CT) without contrast of the abdomen and pelvis is the gold standard for diagnosis
  • Urinalysis will often show microscopic hematuria
  • BUN and Cr levels (for evaluation of renal function) and also calcium, uric acid, and phosphate levels

Four types:

  • Calcium oxalate (80%): Most common, excess oxalate, hyperparathyroidism, radiopaque - avoid grapefruit juice (makes calcium oxalate stones worse)
  • Struvite (10%): Associated with chronic UTI with Klebsiella and Proteus species, radiopaque
  • Uric Acid (7%): Form in individuals with persistently acidic urine - Excess meat/alcohol, gout, radiolucent
  • Cystine (1%): Rare genetic, radiolucent (young boy with kidney  stones)

General measures (for all types of stones)

  • Analgesia: IV morphine, parenteral NSAIDs (ketorolac)
  • Vigorous fluid hydration—beneficial in all forms of nephrolithiasis
  • Antibioticsif UTI is present
  • Alpha-blocker therapy (Flomax) for patients with symptomatic ureteral stones >5 mm and ≤10 mm to facilitate ureteral stone passage (usually given to most patients independent of size)
  • Outpatient management is appropriate for most patients. Indications for hospital admission include:
    • Pain not controlled with oral medications
    • Anuria (usually in patients with one kidney)
    • Renal colic plus UTI and/or fever

Stones < 5 mm will have an 80% chance of spontaneous passage

  • Stones > 5 – 10 mm have a 20% chance of passage and may require elective lithotripsy – patients should be considered for early elective intervention
  • Stones > 10 mm are not likely to pass spontaneously. Ureteral stent or percutaneous nephrostomy (gold standard) should be used if renal function is jeopardized. Urgent treatment with extracorporeal shock wave lithotripsy can be used for renal stones of less than 2 cm or for ureteral stones of less than 10 mm

Orchitis
Patient will present as → a 31-year-old male complaining of unilateral scrotal swelling with pain radiating to the ipsilateral groin. Examination reveals a tender swollen testicle, scrotal edema with erythema and shininess of the overlying skin.

Orchitis is an inflammation of the testicles. It can be caused by either bacteria or a virus

  • Commonly caused by ascending bacterial infection from urinary tract
  • Occurs in 25% of postpubertal males with MUMPS
  • Unilateral swollen testicle/tenderness with erythema and shininess of the overlying skin, fever/tachycardia
  • Orchitis is rarely seen without epididymitis unless the patient has mumps

DX: UA reveals pyuria and bacteriuria with a bacterial infection

TX: If mumps is the cause, treat mumps (+ ice/analgesia)

If bacteria is the cause, treat it like epididymitis

  • Age <35 or sexually active postpubertal males (cover for GC/Chlamydia)
    • Ceftriaxone 500 mg IM once PLUS doxycycline 100 mg PO BID for 10 days
    • Azithromycin 2 g PO once PLUS doxycycline 100 mg BID if severe PCN allergy
  • Age >35 (STI not suspected) - Levofloxacin 500 mg/d PO once daily for 10 days (21 days if associated prostatitis)
Prostatitis
Patient will present as → a 63-year-old man with a history of benign prostatic hyperplasia reports 3-days of fever, chills, and pain with urination. He was recently catheterized during admission to the hospital. Physical exam reveals a tender and enlarged prostate on digital rectal exam. Urinalysis reveals pyuria and hematuria.

Ascending infection of gram-negative rods into prostatic ducts

  • Acute: sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency, and dysuria
  • Chronic: variable – asymptomatic ⇒ acute symptomatology
  • All forms present with irritative bladder symptoms (frequency, urgency, dysuria) and some obstruction
  • Physical exam reveals a tender and enlarged prostate on digital rectal exam

DX: Urinalysis will reveal pyuria and hematuria

  • Prostatic fluid = leukocytosis, culture typically positive for E.coli in acute infections
    • chronic usually have enterococcus
  • If you suspect acute prostatitis DO NOT massage the prostate this can lead to sepsis!

TX:

  • Men < 35: Chlamydia and Gonorrhea - ceftriaxone and doxycycline
  • E coli and pseudomonas in men > 35 -  treat with fluoroquinolones or Bactrim for 4-6 weeks to ensure eradication of the infection – culture urine 1 week after the conclusion of therapy
  • Hospitalization in acute - may need parenteral fluoroquinolones
  • If the fever doesn’t resolve in 36 hours, suspect abscess and consult urology
  • Chronic prostatitis is treated with fluoroquinolones or Bactrim x 6-12 weeks
  • NSAIDs = effective for analgesia; alpha 1 blocker may be helpful if lower UTI symptoms are present
  • Chronic, recurrent, resistant prostatitis with/without prostatic calculi may require transurethral resection of the prostate (TURP) for resolution
Pyelonephritis
Patient will present as → a 32-year-old female presents with fever, chills, nausea and flank pain for 24 hours. She developed dysuria and urinary frequency 3 days prior and states that both have worsened. On physical exam, you note suprapubic abdominal pain and CVA tenderness. The urinalysis reveals white blood cell casts.

Irritative voiding + fever + flank Pain + nausea and vomiting + CVA tenderness

Organism: E. coli

  • Urinalysis: Bacteria and WBC casts

Dx:

  • UA shows pyuria, bacteriuria, varying degrees of hematuria, WBC casts
  • CBC shows leukocytosis and left shift
  • Complicated: Ultrasound shows hydronephrosis secondary to obstruction

Tx:

  • Outpatient: FQ (Cipro/Levaquin)/Bactrim for 1-2 weeks (longer if immunocompromised)
  • Inpatient: IV FQ, 3rd/4th gen cephalosporins, extended-spectrum penicillins, gentamicin
  • Failure to respond ⇒ US/imaging
  • F/up urine cultures not mandatory following tx in uncomplicated cases
Testicular cancer
Patient will present as → a 22-year-old male who develops a firm, painless, non-tender testicular mass  with elevated serum β-HCG

  • Presents as a firm, painless, non-tender testicular mass and a feeling of heaviness in the scrotum
  • Seminoma is the most common type (60%)
  • Risk factors include a history of cryptorchidism
  • Diagnostic studies include ultrasound
  • Tumor markers: AFP, βHCG

Treatments include surgery, radiation, and chemotherapy

Urethritis Urethritis is an infection of the urethra with bacteria (or with protozoa, viruses, or fungi) and occurs when organisms that gain access to it acutely or chronically colonize the numerous periurethral glands in the bulbous and pendulous portions of the male urethra and in the entire female urethra

  • Symptoms include pain, burning, or frequent urination, or a discharge from the urethra

DX:  First-void or first-catch urine and sometimes urine culture

  • Positive leukocyte esterase on urine dipstick or having ≥ 10 WBC/HPF on microscopy is suggestive of urethritis
  • Diagnosis by culture is not always necessary. If done, diagnosis by culture requires demonstration of significant bacteriuria in properly collected urine
  • Nucleic acid amplification test allows for the specific identification of N. gonorrhoeae, C. trachomatis, M genitalium

TX: Sexually active patients with symptoms are usually treated presumptively for STDs pending test results

  • A typical regimen is ceftriaxone 500 mg IM x 1 + doxycycline 100 mg PO bid for 7 days
  • Consider replacing doxycycline with azithromycin 1 g PO if compliance in question or pregnancy
  • In the event that results of microbial diagnostic testing are available prior to the patient's receipt of therapy, antimicrobial treatment can be directed towards the identified pathogen(s)
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