Torsion is the most common cause of acute scrotal swelling and pain
-Underlying cause is a high attachment of tunica vaginalis that occurs in 12% of males
-Symptoms may include nausea and vomiting and even fever (in addition to testicular symptoms)
-Examination may demonstrate a horizontal and elevated testis
-The cremasteric reflex is usually absent, but its presence does not rule out testicular torsion.
-Elevation of the scrotum does not relieve the pain
-Doppler can confirm diagnosis although it is often not needed
-If surgery is done after 6 hours of onset the chances of testicular atrophy are extremely high
-During surgery the opposite (normal) testis is also fixed because the high attachment anomaly is often bilateral
Differential diagnosis:
1) Acute epididymitis and/or orchitis
-Onset is more gradual with fever and dysuria.
-Elevation of the scrotum may reduce discomfort
-Cremasteric reflex may or may not be present
-Teatment is with rest, analgesia, and antibiotics if there is concern about a bacterial infection
2) Torsion of the appendix testis
-Localized tenderness over the upper portion of the testis
-Blue dot sign
-Cremasteric reflex is present
-Treatment is analgesia
Showing posts with label Nephro/Urology. Show all posts
Showing posts with label Nephro/Urology. Show all posts
Hemolytic-uremic syndrome
Hemolytic-uremic syndrome (HUS), is essentially a vasculopathy characterized by hemolytic anemia, acute renal failure and thrombocytopenia. It is caused by a variety of agents but most commonly by E. coli O157:H7, which is a gram negative bacteria acquired via contaminated food or drinks.
Pathophysiology:
-Shiga toxin-producing E. coli (STEC) or enterohemorrhagic E. coli (EHEC) produce a toxin called verotoxin or shiga-like toxin.
-Toxin enters the bloodstream and causes damage to the body's vascular endothelium.
-Endothelial damage leads to platelet activation that causes thrombocytopenia. The renal glomerular endothelial cells express a receptor for the toxin.
Clinical features:
-HUS is characterized by the triad of hemolytic anemia, thrombocytopenia, and acute renal failure.
-Preceding bloody diarrhea may or may not be present.
(HUS must be distinguished from Thrombotic thrombocytopenic purpura (TTP) which in addition to the triad above has fever and neurological signs. TTP is caused by an acquired defect in the protein ADAMTS13.)
Treatment:
-Supportive treatment for low platelets (transfusion if bleeding)
-Supportive treatment of renal failure (electrolyte balance, dialysis as needed)
-Plasmapheresis is often used in early cases to get rid of the circulating toxin
-With supportive care majority of the patients have good renal outcomes
Pathophysiology:
-Shiga toxin-producing E. coli (STEC) or enterohemorrhagic E. coli (EHEC) produce a toxin called verotoxin or shiga-like toxin.
-Toxin enters the bloodstream and causes damage to the body's vascular endothelium.
-Endothelial damage leads to platelet activation that causes thrombocytopenia. The renal glomerular endothelial cells express a receptor for the toxin.
Clinical features:
-HUS is characterized by the triad of hemolytic anemia, thrombocytopenia, and acute renal failure.
-Preceding bloody diarrhea may or may not be present.
(HUS must be distinguished from Thrombotic thrombocytopenic purpura (TTP) which in addition to the triad above has fever and neurological signs. TTP is caused by an acquired defect in the protein ADAMTS13.)
Treatment:
-Supportive treatment for low platelets (transfusion if bleeding)
-Supportive treatment of renal failure (electrolyte balance, dialysis as needed)
-Plasmapheresis is often used in early cases to get rid of the circulating toxin
-With supportive care majority of the patients have good renal outcomes
Systemic Lupus Erythematosus (SLE) Nephritis Classes and Prognosis
Class I has no histologic changes and
has the best prognosis.
Class II has proliferation in the
mesangium and has good prognosis.
Class III has focal proliferation. It
has variable prognosis.
Class IV has diffuse proliferation and
bad prognosis.
Class V has membranous changes and
relatively better progrnosis.
Class VI has scarred glomeruli and end
stage disease.
This letter M has five red circles. (Membranous)
Hematuria(Blood in urine) causes and differential diagnosis
Causes of visible blood urine/gross hematuria/macroscopic hematuria:
1) Trauma
Kidney injury is usually secondary to a blunt injury to the flank or abdomen. Penetrating injuries from gunshots and stab wounds are less common causes. Rarely deceleration injuries in motor vehicle accidents, and laceration by fractured lower ribs present with gross hematuria.
Ureteral trauma is rare and most commonly iatrogenic(during a surgery/endoscopic procedures).
Bladder trauma can be commonly seen in motor vehicle accidents with pelvic fractures.
Urethral injury is seen almost exclusively in males, and presents as blood at the tip of the urethra (It is important not to catheterize patients with suspected urethral injury before they have been evaluated by urology.)
2) Nephrolithiasis
Usually causes microscopic hematuria but gross hematuria can been seen. Family history of kidney stones is present in many but not all patients.
3) Hematologic
Sickle cell anemia, Bleeding disorders and patients on warfarin/heparin can present with gross hematuria. Renal vein thrombosis, which can happen in a setting of hyper-coagulable state such as renal cell carcinoma or nephrotic syndrome, generally presents with pain and gross hematuria.
4) Structural causes
Benign prostatic hyperplasia (BPH) increases chances of urethral bleed and gross hematuria. Kidney lesions such as polycystic kidney, medullary sponge kidney, and medullary cystic disease may be associated with gross hematuria. Vascular malformations and arterial-venous fistulas are rare causes of hematuria.
5) Infectious
Lower urinary tract infections and pyelonephritis are common causes of macroscopic hematuria.Urinary TB may present with hematuria.
6) Medical renal disease
Hints to a medical renal disease include: Proteinuria, Hypertension, Renal failure, Dysmorphic RBCs and casts in urine.(e.g. SLE, Glomerulonephritis etc)
Benign familial hematuria is a genetic disease resulting in thinning of the basement membranes. Alport syndrome is an inherited disorder which has hematuria in addition to proteinuria, deafness, and high BP leading to renal failure.
7) Oncologic
Renal cell carcinoma, transitional cell carcinoma and kidney metastasis can present with hematuria. Prostate cancer can present with intermittent gross hematuria. Therapy for certain other cancers for e.g. Cyclophosphamide for leukemia can cause hemorrhagic cystitis and hematuria. Radiotherapy can cause damage to bladder mucosa and hematuria.
8) Miscellaneous
Menstrual bleeding, pseudohematuria (due to certain medications or food - rifampicin, pyridium, beets, rhubarb etc) should be distinguished from real hematuria.
1) Trauma
Kidney injury is usually secondary to a blunt injury to the flank or abdomen. Penetrating injuries from gunshots and stab wounds are less common causes. Rarely deceleration injuries in motor vehicle accidents, and laceration by fractured lower ribs present with gross hematuria.
Ureteral trauma is rare and most commonly iatrogenic(during a surgery/endoscopic procedures).
Bladder trauma can be commonly seen in motor vehicle accidents with pelvic fractures.
Urethral injury is seen almost exclusively in males, and presents as blood at the tip of the urethra (It is important not to catheterize patients with suspected urethral injury before they have been evaluated by urology.)
2) Nephrolithiasis
Usually causes microscopic hematuria but gross hematuria can been seen. Family history of kidney stones is present in many but not all patients.
3) Hematologic
Sickle cell anemia, Bleeding disorders and patients on warfarin/heparin can present with gross hematuria. Renal vein thrombosis, which can happen in a setting of hyper-coagulable state such as renal cell carcinoma or nephrotic syndrome, generally presents with pain and gross hematuria.
4) Structural causes
Benign prostatic hyperplasia (BPH) increases chances of urethral bleed and gross hematuria. Kidney lesions such as polycystic kidney, medullary sponge kidney, and medullary cystic disease may be associated with gross hematuria. Vascular malformations and arterial-venous fistulas are rare causes of hematuria.
5) Infectious
Lower urinary tract infections and pyelonephritis are common causes of macroscopic hematuria.Urinary TB may present with hematuria.
6) Medical renal disease
Hints to a medical renal disease include: Proteinuria, Hypertension, Renal failure, Dysmorphic RBCs and casts in urine.(e.g. SLE, Glomerulonephritis etc)
Benign familial hematuria is a genetic disease resulting in thinning of the basement membranes. Alport syndrome is an inherited disorder which has hematuria in addition to proteinuria, deafness, and high BP leading to renal failure.
7) Oncologic
Renal cell carcinoma, transitional cell carcinoma and kidney metastasis can present with hematuria. Prostate cancer can present with intermittent gross hematuria. Therapy for certain other cancers for e.g. Cyclophosphamide for leukemia can cause hemorrhagic cystitis and hematuria. Radiotherapy can cause damage to bladder mucosa and hematuria.
8) Miscellaneous
Menstrual bleeding, pseudohematuria (due to certain medications or food - rifampicin, pyridium, beets, rhubarb etc) should be distinguished from real hematuria.
Erectile Dysfunction and its treatment with PDE5 inhibitors(sildenafil, tadalafil, vardenafil)
ED affects close to 20 million men in the US. It is often associated with cardiovascular risk factors like diabetes, hypertension and smoking.
International index of erectile dysfunction can assist in diagnosis.
Treatment includes ruling out treatable organic causes and sildenafil citrate. Sildenafil (Viagra) is an oral phosphodiesterase-5 inhibitor and works by increasing blood flow to the spongiform tissue of the penis.
PDE5 inhibitors(sildenafil, tadalafil, vardenafil) are relatively safe drugs. Contraindications to their use include cardiovascular disease(severe), heart attack within 3 months, stroke within 6 months, heart failure within 6 months(moderate or severe), unstable angina or coital angina, poorly controlled arrhythmias, poorly controlled blood pressure, and hereditary degenerative retinal disorders. Vardenafil can also cause QT-interval prolongation. Caution is recommended when using other vasodilator drugs because the resulting hypotension may be severe.
International index of erectile dysfunction can assist in diagnosis.
Treatment includes ruling out treatable organic causes and sildenafil citrate. Sildenafil (Viagra) is an oral phosphodiesterase-5 inhibitor and works by increasing blood flow to the spongiform tissue of the penis.
PDE5 inhibitors(sildenafil, tadalafil, vardenafil) are relatively safe drugs. Contraindications to their use include cardiovascular disease(severe), heart attack within 3 months, stroke within 6 months, heart failure within 6 months(moderate or severe), unstable angina or coital angina, poorly controlled arrhythmias, poorly controlled blood pressure, and hereditary degenerative retinal disorders. Vardenafil can also cause QT-interval prolongation. Caution is recommended when using other vasodilator drugs because the resulting hypotension may be severe.
Cystinuria
Cystinuria – is due to failure of renal tubules to absorb amino acid Cysteine. Cyanide test which detects Sulfhydryl Groups will detect presence of Cystine in the urine.
Renal Tubular Acidosis
Tamsulosin
Tamsulosin (Flomax) is a drug used in the management of Benign prostatic hyperplasia. It is a highly selective Alpha-1a blocker and hence does not effect blood pressure. (Recall that Postural Hypotension is a side effect of non selective Alpha blockers e.g. prazosin).
Transurethral Prostate Resection and seizures!
Dont forget hyponatremia if a patient has seizures or is disoriented after TURP. The most common complication of TURP = retrograde ejaculation.
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