PANCE Genitourinary Pearls | NCCPA Content Blueprint

PANCE Genitourinary Pearls | NCCPA Content Blueprint

NCCPA CONTENT BLUEPRINT HIGH YIELD GENITOURINARY PEARLSThe NCCPA™ PANCE and PANRE Genitourinary Content Blueprint

  1. 9 types of GU tract conditions
  2. 6 types of infectious and inflammatory conditions
  3. 5 types of GU neoplastic diseases
  4. 7 types of renal diseases
  5. 2 types of fluid and electrolyte disorders
  6. Acid Base Disorders

Total: 30 conditions

GU Blueprint Course

 GU Tract Conditions (PEARLS)

The NCCPA™ PANCE and PANRE Genitourinary Content Blueprint includes 9 GU tract conditions
Benign prostatic hyperplasia In men with BPH, avoid use of anticholinergic and antihistamines

PSA is often ↑ in BPH - correlate with risk of symptom progression

  • PSA is considered normal < 4
  • PSA > 4 think BPH, prostate CA and prostatitis

Treat with 5-α reductase inhibitors - finasteride and dutasteride (androgen inhibitor - inhibits conversion of testosterone to dihydrotestosterone suppressing prostate growth, and reducing bladder outlet obstruction) has positive effect on clinical course of BPH

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

Congenital abnormalities Vesicoureteral reflux (VUR) is retrograde passage of urine from the bladder back into the ureter and collecting system - diagnosed with VCUG

Hypospadias and Epispadias urethra opens onto the underside/topside of the penile shaft

Cryptorchidism (ReelDx) If testicles non-palpable at 6 mo well-child exam, refer to urology/surgery for evaluation and possible orchiopexy, ↑ Risk in premature infants 30%, if not repaired risks infertility
Erectile dysfunction Phosphodiesterase 5 inhibitors: Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), do not use with nitrates may cause hypotension
Hydrocele/varicocele (ReelDx) (+) transillumination - hydrocele

Bag of worms in scrotum - varicocele (made worse when patient is upright and improves when patient is supine)

Incontinence Stress incontinence - results from activity such as laughing or coughing

Urge incontinence - results from an overactive detrusor muscle

Nephrolithiasis/urolithiasis (ReelDx) Extracorporeal shock wave lithotripsy is indicated in patients with stones greater than 6 mm in size or intractable pain.There are four major types of stones:

  • Calcium oxalate: 75% to 85% – stones are radiopaque
    • most common type of stone avoid GRAPEFRUIT JUICE (makes calcium oxalate stones worse)
  • Uric Acid: 5% to 8% – stones are radiolucent.
    • Form in individuals with persistently acidic urine.
  • Cystine: < 1% – stones are radiolucent (in young boy with kidney  stones)
  • Struvite: 10% to 15% – stones are radiopaque – (only in chronic UTI need chronic abx as tx)
Paraphimosis/phimosis Paraphimosis - Inability to return foreskin to normal position causes tourniquet effect, is a medical emergency

Phimosis - Inability to retract the foreskin, usually resolves by age 5, betamethasone topically, if no improvement circumcision

Testicular torsion Asymmetric high riding testicle “bell clapper deformity”, Negative prehn's sign (lifting of testicle will not relieve pain)

GU Infectious and Inflammatory Conditions (PEARLS)

The NCCPA™ PANCE and PANRE Genitourinary Content Blueprint includes 6 infectious and inflammatory conditions
Cystitis Cystitis is an infection of the bladder and is characterized by dysuria without urethral discharge, E. coli (M/C)

  • Lower UTI in pregnancy - Nitrofurantoin (Macrobid): 100 mg PO BID × 7 days 0r Cephalexin (Keflex): 500 mg PO BID × 7 days
  • Postcoital UTI: single-dose TMP-SMX or cephalexin may reduce frequency of UTI in sexually active women.
Epididymitis + Prehn's sign = relief with elevation of the scrotum is a classic sign
Orchitis > 25 % are associated with MUMPS, swollen testicle with erythema and shininess of the overlying skin, age <35 or sexually active postpubertal males (cover for GC/Chlamydia)
Prostatitis Etiology is based on patient's age and risk factors

  • Chlamydia and Gonorrhea in men < 35 - ceftriaxone and azithromycin (or Doxycycline)
  • E coli in men > 35 -  treat with fluoroquinolones or bactrim x 1 month
  • Chronic prostatitis  is treated with fluoroquinolones or bactrim x 6-12 weeks

If you suspect acute prostatitis do not massage the prostate this can lead to sepsis!

Pyelonephritis Fever + flank Pain + nausea and vomiting + CVA tenderness + white blood cell casts in urine, 7 days of cipro or levaquin
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

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

 Neoplastic Diseases of the Genitourinary System (PEARLS)

The NCCPA™ PANCE and PANRE Genitourinary Content Blueprint includes 5 GU neoplastic diseases
Bladder cancer Painless hematuria in a smoker, transitional cell carcinoma is the most common type
Prostate cancer PSA is considered normal < 4

PSA > 4 think BPH, prostate CA and prostatitis

What is the recommended age to start annual prostate screening?

White male average risk: 50 years old - Black male, + FMHX or + BRCA mutations: 40 years old

Renal cell carcinoma Classic triad of flank pain + hematuria + painless abdominal/renal mass

  • Renal clear cell carcinoma is the most common type (80%)
  • Transitional cell is the second most common type (20%)
  • Surgery with radical nephrectomy usually is curative
Testicular cancer Firm, painless, nontender testicular mass, seminoma is the most common type (60%), Risk factors include history of cryptorchidism
Wilms tumor (ReelDx) Child with painless, unilateral abdominal mass with no other signs of symptoms, also known as nephroblastoma

Renal Diseases (PEARLS)

The NCCPA™ PANCE and PANRE Genitourinary Content Blueprint includes 7 types renal diseases
Acute renal failure (ReelDx)
  1. Acute tubular necrosis (ATN) is a medical condition involving the death of tubular epithelial cells that form the renal tubules of the kidneys, prerenal is the most common cause -  FENa (Fractional Excretion of Sodium is going to be GREATER than 2%) + MUDDY, PIGMENTED, GRANULAR CASTS, Renal tubular epithelial cells, + High Urine Osmolality
  2. Interstitial nephritis - form of nephritis affecting the interstitium of the kidneys surrounding the tubules -  Eosinophils, WBC casts and hematuria
  3. Glomerulonephritis: Hematuria and red cell casts
Chronic kidney disease CKD is progression of ongoing loss of kidney function (GFR) defined as less than 60 mL/min/1.73 m² or presence of kidney damage (proteinuria, glomerulonephritis or structural damage from polycystic kidney disease) for > 3 months

Measurement of GFR is the gold standard - The Cockcroft - Gault formula (requires age, body weight and serum creatinine) or Modification of Diet in Renal Disease equation

Management includes Blood pressure control < 130/80, ACE or ARB, A1c 6.5-7.5%

Patients with chronic renal failure typically present with hypocalcemia, hyperphosphatemia, and metabolic acidosis

Glomerulonephritis (Nephritic Syndrome) Immune-mediated glomerular inflammation results in glomerular damage which results in urinary protein and RBC loss

  • 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
      2. Granulomatosis with polyangiitis (Wegener's) (+) C-ANCA
Hydronephrosis Often the result of obstruction or infection, treat underlying cause
Nephrotic syndrome (ReelDx) Glomerular damage results in increased urinary protein loss

  • Manifestations: Proteinuria, hypoalbuminemia, edema, hyperlipidemia, edema is predominant feature, transudative pleural effusion
  • Urinalysis: proteinuria > 3.5 grams per day, fatty casts, oval fat bodies
  • Biopsy: hypo-cellular minimal change disease loss of podocytes on microscopy
Polycystic kidney disease Associated with cerebral aneurysms, autosomal dominant genetic disorder, no cure, treat with BP control
Renal vascular disease Renal arteriography = GOLD STANDARD for diagnosis, renal artery bruit, patient placed on ACE who develops renal failure think renal artery stenosis

 Fluid and Electrolyte Disorders (PEARLS)

The NCCPA™ PANCE and PANRE Genitourinary Content Blueprint requires includes 2 fluid and electrolyte disorders
Hypervolemia - disorders of water excess (hyponatremia)

Increased free water = decreased serum sodium = hyponatremia

Plasma sodium concentration of less than 135 mEq/L (Hyponatremia), serum Na should be corrected slowly—by ≤ 10 mEq/L over 24 h to avoid osmotic demyelination syndrome

Peripheral and presacral edema, pulmonary edema, JVD, hypertension, decreased hematocrit, decreased serum protein, decreased BUN:CR

Hypovolemia disorders of water deficiency (hypernatremia)

Decreased free water = increased serum sodium = hypernatremia

Poor skin turgor, dry mucous membranes, flat neck veins, hypotension, increased BUN/CR ratio > 20:1 **decrease of flow to kidneys means more bound urea in the blood which means ↑ BUN

plasma sodium will be greater than 145 mEq/L

Diabetes insipidus - Low urine sodium and polyuria usually indicate DI

  • Neurogenic (central) is caused by deficient secretion of vasopressin (ADH - anti-piss-hormone) from the posterior pituitary
  • Nephrogenic DI is caused by kidneys that are unresponsive to normal vasopressin levels - usually inherited X-linked or from lithium or renal disease
  • Urine osmolality of less than 250 despite hypernatremia, indicated Diabetes Insipidus
Hyperkalemia Peaked T waves
Hypokalemia Flattening of T waves, U wave
Hypocalcemia Long QT interval
Hypercalcemia Short QT interval
Hypomagnesemia Tall T wave
Hypermagnesemia  Prolonged PR, Widened QRS

 Acid/Base Disorders (PEARLS)

Three Step Approach to Acid Base Disorders

  • Look at your PH (7.35-7.45 is normal)
    • < 7.35 = acidosis
    • > 7.45 = alkalosis
  • Next look at your PCO2 is it normal low or high (35-45 normal)
    • ↑ CO2 and ↓PH = respiratory acidosis
    • ↓ CO2 and ↑ PH = respiratory alkalosis
    • If you don't see a change in the CO2 in relation to the PH then take a look at the HCO3
  • Finally look at the HCO3 is it normal low or high (20-26 normal)
    • ↓ HCO3 and ↓PH = metabolic acidosis
    • ↑ HCO3 and ↑ PH =metabolic alkalosis

Table comparing types of acid base disorders:

Type Example Cause
Respiratory Acidosis  PH 7.30, high PCO2 60, Normal Bicarb 22 Breathing to slow (holding onto CO2 is acidic), opiates, barbiturates
Respiratory Alkalosis PH 7.52, low PCO2 25, Normal Bicarb 22 Breathing too fast (blowing of CO2), Pulmonary embolism, Fever, Hyperthyroid
Metabolic Acidosis PH 7.30, Normal PCO2 40, Low Bicarb 16
  • Need to calculate anion gap: Anion Gap = Na – (Cl + HCO3-) = 10-16
  • High anion gap (>16) = lactic acidosis (think metformin), diabetic ketoacidosis, aspirin overdose
    • MUDPILES:
      • Methanol
      • Uremia
      • Diabetic Ketoacidosis
      • Paraldehyde
      • Infection
      • Lactic Acidosis
      • Ethylene Glycol
      • Salicylates
  • Low anion gap < 16 = think diarrhea, renal tubular acidosis
Metabolic Alkalosis PH 7.52, Normal PCO2 40, High Bicarb Bulimia, overdose of antacids

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