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48 Cards in this Set
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This is associated with decubitus ulcers, UTIs, sepsis, renal failure, increased mortality
It is also associated with loss of self-esteem, restriction of social and sexual activities, depression Often a key factor in admitting elderly into skilled nursing facilities |
Urinary Incontinence
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What are the risk factors for urinary incontinence?
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Older Age
Female Gender Increase Body Mass Index Limited Physical Activity |
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What are the transient causes of incontinence? (DIAPPERS)
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Delirium
Infection Atrophic Urethritis or Vaginitis Pharmaceuticals Diuretics, Anticholinergics, Opiods, α-Blockers, α-Agonists, CCBs Psychological Factors Excess Urinary Output Restricted Mobility Stool Impaction |
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What are the four non-transient causes of urinary incontinence?
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Urge Incontinence
Stress Incontinence Overflow Incontinence Mixed Incontinence - Usually a mix of urge and stress |
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Due to uninhibited bladder contractions that cause leakage
Characterized by urinary leakage after the onset of an intense urge to urinate Accounts for approximately 2/3 of all geriatric incontinence cases In men, it is usually secondary to urethral obstruction due to BPH Can also occur when mobility is restricted making it difficult for a person to reach the bathroom in time-”Functional” incontinence |
Urge incontinence
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Usually due to urethral hypermobility caused by failure of normal anatomic support structures of the bladder neck, loss of normal intrinsic pressure within the urethra
Characterized by instantaneous leakage of urine due to increase intra-abdominal pressure: laughing, coughing, lifting heavy objects Second most common cause of incontinence |
Stress Incontinence
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May be idiopathic, secondary to obstruction or secondary to sacral lower motor neuron dysfunction
Associated with bladder overdistention Associated with urinary frequency, nocturia, and frequent leakage of small amounts of urine A postvoid residual volume (>450mL) distinguishes it from urge and stress incontinence |
Overflow Incontinence
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What is involved with the office based evaluation of a patient dealing with incontinence?
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Use a simple screening question to identify issues of incontinence
Thorough history and physical exam Identify transient causes Identify conditions that require referral or evaluation by a urologist or urogynecologist Determine if symptoms are more indicative or urge vs. stress vs. overflow incontinence and start treatment |
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What labs should be performed with incontinence?
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Urinalysis & Urine Culture
UTI, Glycosuria, Cytology Serum Creatinine, Glucose Post-Void Residual Urine Volume Measures the amount of urine left in the bladder after a person has urinated PVR volumes >100mL are abnormal |
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With a full bladder, the patient lies supine on the table and coughs forcefully
Urine leakage makes a presumptive diagnosis of stress incontinence Repeat in the standing position |
Office stress test
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What are four advanced diagnostics for incontinence?
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Cystometrography
Urine Flowmetry Urethral Pressure Profiles Urethral Sphincter Electromygraphy |
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What are the tx options for urge incontinence?
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Behavorial Therapy: Bladder Training, Kegel Exercises, Sacral Nerve Stimulation, Fluid Restriction
Medications Musculotropics - relax bladder muscles, contraindicated in narrow angle glaucoma Oxybutynin (Ditropan) - Preferred due to more specificity for bladder muscle & Tolterodene (Detrol) Tricyclic Antidepressants Imipramine (Tofranil) Surgery - usually after meds are tried |
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What are the treatment options for stress incontinence?
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Behavioral Therapy: Kegel Exercises, Bladder Training, Decrease Caffeine/Alcohol
Weighted Cones, Pelvic Floor Stimulation Pessaries Medications Alpha-adrenergics Pseudoephedrine (Sudafed), Phenylpropanolamine Tri-Cyclic Antidepressents Imipramine (Tofranil) Estrogen - localized tx Surgery - can be a first line tx |
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What are the treatment options for overflow incontinence?
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Intermittent Self-Catheterization
Indwelling Catheterization Suprapubic Catheterization If due to Prostatism then alpha-blockers & 5-Alpha-Reductase Inhibitors may be used Terazosin (Hytrin), Doxazosin (Cardura), Prazosin (Minipress) Finasteride (Proscar) |
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What are other tx options for incontinence?
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Pessaries
Vaginal Cones Electrical Sacral Nerve Stimulation Periurethral Bulking Injections |
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What favors stone creation?
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High ion levels, low urinary volume, low pH and low citrate levels favor stone formation
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Stone blockage is common at three junctions, what are they?
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Ureteropelvic Junction
Crossing of the ureter over the iliac vessels Ureterovesicular Junction- Ureter entering the bladder |
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What are the risk factors for kidney stones?
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Insulin Resistance
Decreased fluid intake Low urine volume Bowel Disease Excess Dietary Meats Excess Dietary Oxalate Excess Dietary Sodium Family History Gout Hyperparathyroidism Renal Tubular Acidosis (Type I) Obesity |
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What are the five major types of kidney stones?
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Five Major Types
Calcium Oxalate (70%) Calcium Phosphate (5-10%) Struvite (15-20%) Uric Acid (10%) Cystine (1%) Majority of stones contain calcium |
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What are the manifestations of kidney stones?
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Sudden Onset Pain -Colicky versus Steady
Unilateral Flank Area Radiation to Ipsalateral Lower Abdomen & Groin Migrates caudally & medially Associated Nausea & Vomiting Hematuria Fever & chills associated with infection |
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Why does bowel disease show up as a risk factor for kidney stones?
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Patients with IBS have an increased acidity of urine and a decreased citrate level.
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What are the diagnostics used with kidney stones?
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Metabolic Evaluation
CBC, Electrolytes, Serum Calcium, Phosphate & Uric Acid Urinalysis Microscopic or Macroscopic Hematuria Urine pH: normal urinary pH 5.9 Uric Acid and Cystine Stones-pH <5.5 Struvite Stones-pH >7.2 Crystals Rule out concurrent infection |
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What imagine diagnostic studies can be used with kidney stones?
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1. KUB radiography
2. Intravenous pyelography 3. Noncontrast helical CT |
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Calcium containing stones are radiopague
Pure Uric Acid stones are radiolucent Cystine stones tend to have ground glass appearance |
Kidneys, Ureter & Bladder (KUB) Radiography
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Provides information on anatomy and functioning of kidney
Contrast material may have nephrotoxic effect |
Intravenous Pyelography
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Most sensitive and specific imaging modality
Identifies both radiopaque & radiolucent stones Identifies associated pathology |
Noncontrast Helical CT
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What is involved with the pain management of kidney stones?
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Adequate Pain Medication
Morphine, Meperidine (Demerol) Avoid Ketorolac (Toradol) |
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When do you need to have a urgent urological consult with kidney stones?
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Urosepsis
Anuria Renal Failure Urinary Obstruction in a patient with one functioning kidney |
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When do you have a hospital admission with urology consult in regards to kidney stones?
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Refractory Pain
Refractory Nausea Extremes of Age Debilitated Condition |
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What is the management of stones less than 5mm?
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Stones <5mm generally pass within one to two weeks
Provide appropriate outpatient pain management Weekly KUB radiographs Patient should strain their urine for stone or stone fragments Alpha Blockers have been shown to enhance stone passage |
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What is the management of stones greater than 5mm?
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Stones >5mm require Urology consult as well as stones that fail to pass within two weeks
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Renal Stones <2cm, Ureteral Stones <1cm are treated how?
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Extracorporeal Shock Wave Lithotripsy - avoid toredol and NSAIDS
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Ureteral Stones are treated how?
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Ureteroscopy
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Renal Stones <2cm are treated how?
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Ureterorenoscopy
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Renal Stones >2cm, Proximal Ureteral Stones >1cm are treated how?
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Percutaneous Nephrolithotomy
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What are five complications of kidney stones?
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Renal Failure
Ureteral Stricture Infection, Sepsis Urine Extravasation Perinephric Abscess |
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What are three ways to prevent kidney stones?
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Increase Fluid Intake
Target 2L of urine production per day Low Salt, Low Meat, Moderate Calcium Intake Sodium restricted to 100mEq/d Protein restricted to 1gm/kg/d Weight Loss if Needed |
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What is involved with the follow up in a patient dealing with kidney stones?
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Baseline Serum Calcium, Phosphate, Uric Acid & Electrolytes
PTH if Calcium is Elevated 24-Hours Urinalysis Check Calcium, Sodium, Oxalate & Citrate Measure Volume Stone Analysis |
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Most common presentation
Urine Calcium >200mg/24h or >4mg/kg/24 Three Categories Absorptive Resorptive Renal |
Hypercalciuric calcium nephrolithiasis
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Due to increased absorption of calcium in the small bowel
Type I: Independent of Calcium Intake Use Cellulose Phosphate (Calcibind) or Thiazide Diuretics for treatment Type II: Diet Dependent Treatment focuses on limiting Calcium intake Type II: Due to a Renal Phosphate Leak Treat with Orthophosphates to inhibit Vitamin D synthesis |
Absorptive hypercalciuric calcium nephrolithiasis
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Secondary to Hyperparathyroidism
Characterized by Increased PTH, Hypercalcemia, Hypophosphatemia & Hypercalciuria Treat the cause of the Hyperparathyroidism |
Resorptive hypercalciuric nephrolithiasis
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Renal tubules are unable to effectively reabsorb filtered calcium which leads to hypercalciuria
Treat with Thiazide Diuretics |
Renal hypercalciuric nephrolithiasis
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Urine Uric Acid >800mg/24h
May be due to dietary excess of uric acid or metabolic defects Increase in uric acid promotes calcium oxalate cyrstals pH >5.5 unlike uric acid stones Treat with purine dietary restrictions or with Allopurinol |
Hyperuricosuric calcium nephrolithiasis
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More that 45mg/24h of urine oxalate
Due to malabsorption or metabolic disorders which increase oxalate production and excretion Treatment is to control the underlying malabsorption syndrome, increase fluids, decrease oxalate intake and take oral calcium supplements |
Hyperoxaluric calcium nephrolithiasis
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Urine Citrate <450mg/24h
Due to a deficiency of citrate in production or excretion Treat with Potassium Citrate Supplements Creates an alkalotic state and increases urinary citrate |
Hypocitraturic calcium nephrolithiasis
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Urinary pH typically <5.5
Pure stones are radiolucent Mixed stones are radiopaque Risk Factors: Gout, Insulin Resistence Treat with Potassium Citrate to increase urinary pH and dissolve the stone Nitrazine pH strips allow the patient to check urine Allopurinol therapy for patients with hyperuricemia |
Uric acid nephrolithiasis
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Urinary pH usually >7.2
Consist of magnesium, ammonium and calcium phosphate More common in women with a history of recurrent urinary tract infections, neurogenic bladder or FBs in the urinary tract Formed by urease producing organisms - pseudomonas, klebsiella - organisms associated with UTI. Treated with Nercutaneous nephrolithotomy Acetohydroxamic acid (Lithostat) Inhibitor of Urease - for pt. that can't tolerate surgery |
Struvite nephrolithiasis
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Autosomal recessive disorder that results in decreased cystine resorption leading to abnormal excretion
Urinary cystine level >250mg/24 is considered diagnostic Pure cystine stones are yellow and radiolucent or faintly opaque (ground-glass appearance) Treat with fluids, Potassium Citrate to alkalinize the urine Cystine binders: Penicillamine & Tiopronin |
Cystine Nephrolithiasis - family predisposition
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