Elisco 12-14-07 Hematuria

Front 1

Accurate H/P necessary: What are the high points?

Back 1

Pain, voiding symptoms, smokers and prior history of stones or tumors.

Front 2

Causes of microscopic hematuria include:

Back 2

stones, coagulopathies, infections, tumor, trauma and tuberculosis

Front 3

#2 cancer in smokers?

Back 3

bladder

Front 4

SHITTT means what

Back 4

stones, hemoglobinopathies, infectionss, tumor, trauma, and TB

Front 5

Once a diagnosis of hematuria is made a step wise evaluation is necessary:

Step 1. Check urine _______, if positive for infection; treat.
Step 2. If urine C/S is negative obtain an upper tract evaluation._____ ______ __________ of kidneys depending on the patient.
Step 3. If renal US or CT scan is positive, such as a stone, tumor or hydronephrosis, the refer to a urologist.
Step 4. If upper tract evaluation is negative, then the patient requires c___________.
Step 5. If cystoscopy is positive, such as a bladder tumor, stone, stricture or BPH would manage accordingly.
Step 6. If cystoscopy is negative then obtain urine c________.
Step 7. If cytologies are negative, patient may have idiopathic hematuria and would reevaluate in how long?.

Back 5

Once a diagnosis of hematuria is made a step wise evaluation is necessary:

Step 1. Check urine culture, if positive for infection; treat.
Step 2. If urine C/S is negative obtain an upper tract evaluation. CT scan or US of kidneys depending on the patient.
Step 3. If renal US or CT scan is positive, such as a stone, tumor or hydronephrosis, the refer to a urologist.
Step 4. If upper tract evaluation is negative, then the patient requires cystoscopy.
Step 5. If cystoscopy is positive, such as a bladder tumor, stone, stricture or BPH would manage accordingly.
Step 6. If cystoscopy is negative then obtain urine cytologies.
Step 7. If cytologies are negative, patient may have idiopathic hematuria and would reevaluate in six months.

Front 6

Most common cause of microscopic hematuria in men is waht?

Back 6

BPH

Front 7

H/P high points for gross hematuria

Back 7

H/P very important: Length of time, pain, trauma, GU surgery, anticoagulants, chemotherapy, indwelling foley catheter, terminal or initial hematuria, and presence of clots.

Front 8

Management of Gross Hematuria:

Step 1. Place large 22-24F 3 way f_____ catheter and start continuous irrigation.
Step 2. Stabilize patient hemodynamically and obtain appropriate labs, T/C if necessary.
Step 3. Once patient is stable, obtain upper tract evaluation _______ with contrast if possible.
Step 4. If CT scan is positive, such as a stone or tumor, urologic evaluation is necessary.
Step 5. If CT scan is negative, and bleeding continues, immediate c__________ should be done. This will be both diagnostic and therapeutic.
Step 6. If bleeding due to c_____________, support patient and correct problem.

Back 8

Management of Gross Hematuria:

Step 1. Place large 22-24F 3 way foley catheter and start continuous irrigation.
Step 2. Stabilize patient hemodynamically and obtain appropriate labs, T/C if necessary.
Step 3. Once patient is stable, obtain upper tract evaluation CT scan with contrast if possible.
Step 4. If CT scan is positive, such as a stone or tumor, urologic evaluation is necessary.
Step 5. If CT scan is negative, and bleeding continues, immediate cystoscopy should be done. This will be both diagnostic and therapeutic.
Step 6. If bleeding due to coagulopathy, support patient and correct problem.

Front 9

Best imaging for renal mass?

Back 9

MRI

Front 10

Urologic Diagnosis and Management of Stones:

95% of patients with stones have h___________.

The most common type of stone is ______ ______, 70%.

80% of stones are radio-_______.

U___ acid and c______ stones comprise the other 20%.

Back 10

Urologic Diagnosis and Management of Stones:

95% of patients with stones have hematuria.

The most common type of stone is calcium oxalate, 70%.

80% of stones are radio-opaque.

Uric acid and cystine stones comprise the other 20%.

Front 11

Any patient with flank and hematuria that is suspected of having a stone should have a _____ ______ ________

CT scan is excellent for both upper and lower tract stones.

___ no longer the “gold standard”

Back 11

Any patient with flank and hematuria that is suspected of having a stone should have a non-contrast CT scan.

CT scan is excellent for both upper and lower tract stones.

IVP no longer the “gold standard”

Front 12

Detailed H/P including family members that are stone formers. What are the high points to ask about?

Back 12

Diet (Tea, pepper, ..)

Medications (Tums, calcium supplements)

Surgeries (gastric bypass - question why is later)

Front 13

Why do gastric bypass pts form kidney stones?

Back 13

extra strong bones from high weight releases calcium as weight is lost

Front 14

Labs to order for stone formers

Back 14

24 hr. urine: Calcium, oxalate, uric acid, magnesium and citrate.

Serum uric acid, calcium and parathyroid levels.

Serum electrolytes including; BUN and Creatinine.

Front 15

Medical Management of Stone Formers:

Certain recommendations for all stone formers include:

Back 15

Increase fluid intake, want >2 lts of
urine/day.

Place dietary limits on oxalates and
sodium.

Front 16

Medical Management of Stone Formers :

What diuretics can you use?

Back 16

Thiazide; very good in the treatment of certain hypercalciuric states.

This diuretic has been shown to correct the renal leak of calcium by augmenting calcium reabsorption in the distal tubule.

HCTZ 25mg to 50mg daily

Front 17

Medical Management of Stone Formers:

A_________; used in the treatment of hyperuricosuric calcium oxalate nephrolithiasis resulting from uric acid overproduction.

This drug directly reduces the production of uric acid and therefore lowers uric acid in the urine.

Dosage 300mg/day.

Back 17

Medical Management of Stone Formers:

Allopurinol; used in the treatment of hyperuricosuric calcium oxalate nephrolithiasis resulting from uric acid overproduction.

This drug directly reduces the production of uric acid and therefore lowers uric acid in the urine.

Dosage 300mg/day.

Front 18

Medical Management of Stone Formers:

Patients with primary hyperparathyroidism need to be evaluated by an endocrinologist and most likely will need a _____________

Back 18

Medical Management of Stone Formers:

Patients with primary hyperparathyroidism need to be evaluated by an endocrinologist and most likely will need a parathyroidectomy

Front 19

Urologic Management of Stones:

Based on size and location of the stone.

Patients may have significant amount of pain and require ________ for control.

Any evidence of hydronephrosis, infection or a procedure is being planned, ____________ should be given.

With the new technologies in fiber optics, advances in ESWL and lasers, ___ stones can be broken up or removed.

Back 19

Urologic Management of Stones:

Based on size and location of the stone.

Patients may have significant amount of pain and require narcotics for control.

Any evidence of hydronephrosis, infection or a procedure is being planned, antibiotics should be given.

With the new technologies in fiber optics, advances in ESWL and lasers, all stones can be broken up or removed.

Front 20

Urologic Management of Stones

Renal pelvic and proximal ureteral stones are best managed with the “___________” method.

Stent followed by _____.

Mid and distal ureteral stones best managed by ureteroscopy and removal.

ESWL can be used but is limited by the pelvic bones.

Back 20

Urologic Management of Stones

Renal pelvic and proximal ureteral stones are best managed with the “push bang” method.

Stent followed by ESWL.

Mid and distal ureteral stones best managed by ureteroscopy and removal.

ESWL can be used but is limited by the pelvic bones.

Front 21

Urologic Diagnosis of Bladder Calculi:

The causes of bladder calculi differ from that of upper tract stones.

Most common cause is BPH (with secondary stasis of urine), other causes include tumor and foreign bodies.

Staples, sutures, catheters and stents.

Back 21

Urologic Diagnosis of Bladder Calculi:

The causes of bladder calculi differ from that of upper tract stones.

Most common cause is BPH (with secondary stasis of urine), other causes include tumor and foreign bodies.

Staples, sutures, catheters and stents.

Front 22

Urologic Management of Bladder Calculi:

Stones are managed nicely via cystoscopy followed by _______ ________ lithotripsy or laser lithotripsy.

Must also remove the source of the stone

Back 22

Urologic Management of Bladder Calculi:

Stones are managed nicely via cystoscopy followed by electro-hydrolic lithotripsy or laser lithotripsy.

Must also remove the source of the stone