Renal And Urologic Semiology

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o Scrotal transillumination

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scrotal lesions that transilluminate include hydrocele, spermatocele and varicocele.

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o Testicular torsion

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acute, unilateral scrotal pain usually occurring in adolescent due to sudden twisting of spermatic cord producing testicular ischemia. The involved testicle is tender, edematous and indurated; elevation of testicle does not relieve pain.

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o Testicular mass or nodule

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non-tender, solid testicular mass is assumed to be cancer until proven otherwise. Testicular cancer is the most common solid cancer in men 15-35 years of age.

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o Varicocele

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common condition due to dilatation of pampiniform plexus of spermatic veins, recognized as scrotal enlargement that feels like “bag of worms”. In addition, varicoceles disappear with recumbence, and the examining finger cannot find the superior margin of lesion. Usually asymptomatic and more often left-sided, it can be a cause of infertility. Rarely may signal left renal cell carcinoma if cancer invades left renal vein and impedes left testicular venous drainage.

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o Genital wart

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reflecting papilloma virus (HPV) infection, this is a sexually transmitted disease and a risk factor for penile carcinoma (and for cervical cancer in sex partners).

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o Herpes simplex lesion

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usually occurs in the form of multiple painful vesicles due to HSV-2 infection; primary infection occurs about 6 days after exposure and is very painful with associated dysuria, fever, inguinal adenopathy and headache (occasionally with frank viral meningitis). Recurrent disease has milder symptoms. Asymptomatic patients may shed virus and transmit disease with sexual contact. The attack rate is 70% in sero-negative exposed subjects.

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o Paraphimosis

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inability to replace a retracted foreskin; typically a very painful condition, this can be a medical emergency as increasing penile edema will result in penile ischemia and necrosis if not reduced.

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o Penile cancer

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squamous cell carcinoma in most, begins as a painless papule that progresses. HPV DNA is found in 30-50% of lesions.

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o Phimosis

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inability to retract foreskin, this is a strong risk factor squamous cell carcinoma of the penis.

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o Syphilitic chancre

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painless lesion occurring ~21 days after exposure reflecting site of spirochete entry. Begins as a solitary papule that ulcerates, it is indurated and without exudate. It will heal in 4-8 weeks without treatment.

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o Direct inguinal

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usually due to congenital weakness in abdominal wall musculature, the hernia proceeds directly through abdominal wall. The hernia sac will touch the side of the examining finger in the inguinal canal.

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o Indirect inguinal

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usually acquired and more common in elderly and obese man, the hernia proceeds indirectly into scrotal sac via the inguinal canal. The hernia sac will touch the tip of the examining finger in the inguinal canal.

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o Femoral

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more common in women, this hernia occurs through the femoral canal and is inferior to the inguinal ligament (latter feature differentiates this from above inguinal hernias).

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• Differential diagnosis of palpable kidneys

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normal kidneys are not palpable (except in extremely thin individuals); palpable kidneys are found in adult polycystic kidney disease, renal cell carcinoma, angiomyolipoma (tuberous sclerosis) and the rare entity, xanthogranulomatous pyelonephritis.

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• Costo-vertebral angle tenderness

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due to swelling of renal capsule and elicited by percussion with medial aspect of fist, this is most commonly due to pyelonephritis, but can also be caused by hydronephrosis.

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• Uremic frost

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white powdery dusting of the skin most common in patients with severe renal failure with BUN > 200 mg/dL (reflects crystallized urea from sweat).

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varicocele: dilation of penpinoform plexus of veins. L goes straight to IVC; R goes into the left renal vein. Feels like a bag of worms. Increased blood flow warms the scrotum and can inhibit sperm formation. + Transluminate

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Hydrocele: fluid in scrotum. + Transluminate

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Spermatocele: sperm stuck in cord. + Transluminate

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Serminoma = will not transluminate, nontender, usu in men 20-30, curable early in life, but fatal later on

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Testicular torsion = acute onset of pain, N/V, need dx quickly

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Syphilitic chancre = painless, indurated borders, primary entrance of spirochete

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Genital warts due to HPV (condyloma acuminata) = risk for penile and cervical cancer

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HSV = painful vesicles - diagnostic

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Phimosis = inability to pull back foreskin --> risk for cancer from chronic irritation and lack of hygiene

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paraphimosis = ischemia and necrosis, MEDICAL EMERGENCY; inability to put foreskin back over glands penis

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penile cancer = risks include phimosis, HPV, lack of circumcision and other risk factors for penile cancer

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femoral hernia on left = more common in women

inguinal hernia on right = more common in men

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indirect inguinal hernia = down the inguinal canal + transabdominal

finger in the canal + valsalva maneuver = finger goes straight through

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direct inguinal hernai = goes straight through abdominal wall

finger in canal + valsalva = touches side of finger

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renal cell carcinoma = palpable

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adult polycystic kidneys - palpable

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xanthogranulomatous pyelonephritis = recurrent infections

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angiomyolipomas in tuberous sclerosis

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Costovertebral angle tenderness = indicates pyelonephritis or hydronephrosis from swelling of the kidney

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striated nephrogram in acute pyelonephritis

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bilateral hydronephrosis

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distended bladder

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splenomegaly vs left kidney - spleen is palpable and moves with respiration; kidneys are retroperioteanl and do not move with respiration

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impetigo = honey colored scale, caused by S. aureus or GAS --> risk factor for post-infectous glomerulonephritis

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Henoch-Schonlein purpura = look for RBC cast in urine or hematuria - sign of acute glomerulonephritis

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uremic frost = BUN >200-300

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oxalate crystals = +AGAP think ethylene glycol ingestion

presents with acidosis and renal failure

rhomboid cyrstals

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struvite cyrstals (triple phosphate = look like coffin lids present in alkaline urine

think about ureas organisms such as proteus

can develop stag horn calciculi very quickly

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White cell cast (coarse granular cast) = inflammatory state of kidney tubules (acute pyelonephritis)

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RBC cast = acute glomerulonephritis

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malignant HTN with grade 4 retinopathy (papilledema)

- causes

- popultion

- symptom

- pathophysiology

- biopsy results

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Causes: eclampsia, scleroderma renal crisis

pop: more common in men and AA

sx: visual impairment common

pathophys: overwhelming auto regulation, endothelial damage, natriuresis and volume depletion with activation of RAAS) - diuretics not indicated unless there is evidence of gross heart failure (puts are already intravascularly volume depleted)

biopsy: kidney biopsy likely to show onion-skin glomerular lesion; arterioles would show damage with necrosis.

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CVA tenderness

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associated with renal pathology - esp those producing kidney inflammation or edema; tenderness produced by swelling inside capsule; pyelonephritis, hydronephrosis, renal stone, renal infarction

NOT:

- acute cystitis (should not have upper tract findings.

- cancer of testes or kidney - usu painless

- SI palpation = lower than CVA

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what kind of cancer is penile cancer, what is detected in most cancers, what are 5 risk factors?

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- squamous cell carcinoma

- HPV

- 1. multiple sex partners, 2. hx of genital warts, 3. lack of circumcision, 4. phimosis, 5. HIV infection

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impetigo - pathophys, exam results, pop, complication

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pathophys: infection cause by staph aureus or strep progenies (GAS).

exam: reveals flaccid vesicles and bull that rupture to produce honey colored crush

pop: children in economically disadvantaged in warm climates.

complication: if GAS could produced post-strep glomerulonephritis

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HSP = henoch-schonlein purpura

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IgA vasculitis, in children - usu presents with rash, and risk of GI bleeding

rash = palpable purpura

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testicular cancer = pop, presentation, metastasis locations and symptoms,

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pop: 15-35

presentation: painless testicular nodule or unilateral enlargment, some have dull ache in lower abdomen, scrotum or perianal area

dx: early, may present with mets, check:

- supraclavicular lymph node

- pulmonary sx

- bone or back pain

biopsy: testes and lymph node to prove met disease

order of met = limbo-aortic nodes, supraclavicular, iliac, inguinal

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ethylene glycol ingestion

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metabolic acidosis with high anion gap

oxalate crystals

tx; fomepizole and dialysis

methanol is metabolized to formic acid

morphine produces respiratory acidosis

RTA = produces normal AGAP metabolic acidosis

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syphilis progression

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primary: chancre representing spirochete entry site = oral, anal, hand, genital; painless, 21d incubation, begins as a papule that ulcerates usu solitary w/o exudate & w/indurated edges

secondary: skin manifestations usu on palms and soles, healing chancre, constitutional findings may present liver, kidney and CNS

tertiary: neurologic (argyll-robertson pupil); cardiovascular (aortic aneurysm)

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uric acid crystals seen in hyperuricemia or gout

- urea splititng organisms associated with alkaline urine

- oxalate crystals = usu w/ ethylene glycol

- glomerulonephritis = hematuria, pyuria and RBC cast

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von Recklinghausen's disease risk associated with

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internal malignancies (nerve sheath tumors; gastrointestinal stroma); pheochromocytoma

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dermatomyositis risk associated with

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internal malignancy

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tuberous sclerosis associated with

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increased risk for cancer

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SLE associated with risk for

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renal disease (glomerulonephritis) and brain diseases (cerebritis, stroke)

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Anti-cholinergic drug side effect

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doxepin = anticholinergic drug that can produced BPH leading to distended urinary bladder

- prostate cancer usu does not present with acute urinary retention and + hard prostatic nodule

- bilateral renal stones does not cause bladder distention but does cause bilateral hydronephrosis

- bladder stone is very rare and a firm suprapubic mass would be palpated

- UTI doesn't present with urinary obstruction unless it is untreated gonococcal urethritis but would produce abnormal genital exam

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Lindsay's nails

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associated with renal failure and associated metabolic acidosis and hyperkalemia.

hyperkalemia initially causes peaked T waves followed by QRS complex widening and sine wave pattern prior to death

tx: IV Ca and lower K+ later with insulin/glucose, albuterol and dialysis

- hyponatremia occurs with renal failure and contribute to altered sensorium and seizures but would not produce the ECG finding

- anemia and bacteremia produce hypotenion and tachycardia, but not ECG finding

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Left upper Quadrant mass

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- enlarged spleen

- enlarged liver across midline

- renal mass

spleen should move (descend with inspiration), renal masses should not change position with respiratory cycle

- renal masses usu include renal cancer, xanthogranulomatous pyelonephritis (due to recurrent UTIs) and AD-PCKD; angiomyolipoma may also be palpable

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endocarditis

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palpable purport suggests cutaneous vasculitis

DDx: disseminated infections and non-infectious disorders (vasculitis, CT diseases, drug reactions, malignancy)

- red cell casts strongly indicate glomerulonephritis + fever, aortic inusfficency murmor - leads to infectious endocarditis as number 1 diagnosis - blood culture best choice

- microscopy of skin scrapings = mycosis or body lice suspected

- punch biopsy = confirm vasculitis but not give a specific diagnosis

- renal function tests = non- specific, UA already est renal involvement

- ASO tighter useful for GAS (PSGN or rheumatic fever)

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BPH

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older men, presenting with frequent urination, weak stream, incomplete bladder emptying, nocturne, intermittency and hesitancy.

anticholinergic drugs exacerbate the problem

DRE reveals diffusely enlarged gland that is rubbery in consistency and non-tender

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adenocarcinoma of prostate

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older men, usu asymptomatic but may present with mets (back pain from spine involvement)

DRE reveals hard nodule

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acute prostatitis

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acute illness in young-middle aged men

fever, mailaise, dysruia, pelvic and/or penile pain + obstructive complaints (dribbling frequency)

DRE reveals tender edematous gland

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indirect hernia traverses inguinal ring and touches tip of examining finger - more common in adults and children

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direct hernia projects directly through abdominal wall defect - rare in children more seen in elderly, obese males with weak abdominal walls

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tumor lysis syndrome

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chemotherapy for aggressive lymphoma - spillage of intracellular contents (K+, PO4, uric acid)

- acute renal failure and hyperkalemia are dreaded consequences

- ATN is renal pathology w/UA revealing muddy brown casts

- renal failure leads:

-- to intravascular volume overload due to inability to excrete fluid

-- high AGAP metabolic acidosis (due to high hippurate, sulfate, PO4) = uremia

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scrotal varicocele

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dilation of pampiniform plexus of spermatic veins

PE: disappearance with recumbency, inability to place finger above lesion and bag of worms palpation - will transilluminate; frequently asx but may produce dull aching scrotal pain.

- causes testicular atrophy and infertility

- more common on the left side due to venous drainage (goes into renal vein vs IVC)

- if involves left renal vein may signify renal cancer

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nutcracker syndrome

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left renal vein compression by superior mesentery artery and aorta - may present with varicocele and hematuria

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oliguria tx

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place foley catheter to ensure there is no urinary retention

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tx phimosis vs paraphimosis

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topical steroid cream vs surgical intervention

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AD- PCKD

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sx: falnk pain, hematuria, renal stones in 30s-40s

usu HTN

cysts in other organs (liver, pancreas)

intracranial aneurysms risk

renal failure by 60 yo

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reasons for palpable kidneys

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renal carcinoma

polycystic kidneys

xanthogranulomatous pyelonephritis

angiomyolipoma