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1. Birhanu Yadecha (MSc in Adult Health Nursing) 1 Nursing Care of Patient with GUS March 31, 2023

2. Chapter Content Anatomy and physiology overview (3hrs) Assessment Investigations Genito Urinary system disorders 1.Fluid and electrolyte imbalance (2.5hr) 2. Acid base disturbances (2hr ) 3. Disorders of urinary system a. Infections of the urinary tract (UTI )(2hr) Pyelonephritis and Ureteritis Cystitis’s Urethritis 2 March 31, 2023 b. Glomerular diseases: 2hrs o Glomerulonephritis o Nephrotic syndrome C. Urolithiasis 1/2hr D renal failure( 2hr) Acute and Chronic Renal failure

3. E. Other disorders (2hr): BPH Prostate cancer Epididymitis Testicular Cancer Hydrocele Varicocele Priapism testicular torsion Sexually transmitted infections (5hrs) 3 March 31, 2023

4. Objectives At the end of this session the students will be able to:- Describe anatomy and physiology of Genito -urinary system Assess patients with Genito -urinary system disorders Manage patient with fluid and electrolyte imbalances Manage patient with Acid base imbalances Manage patient with upper and lower Uninary tract infections Manage patient with acute and chronic kidney disease Manage patient with STIs 4 March 31, 2023

5. Anatomy and physiology overview The urinary system is composed of Paired kidney Paired ureter Urinary bladder urethra 5 March 31, 2023

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7. Kidney brownish-red structures located retroperitoneally from the 12th thoracic vertebra to the 3rd lumbar vertebra in the adult The upper portions of both kidneys rest on the lower surface of the diaphragm An adult kidney: weighs 120 to 170 g , 12 cm long , 6 cm wide, and 2.5 cm thick. Protected by ribs, muscle, fascia, fat Classification: parenchyma and pelvis Parenchyma: cortex and medulla Cortex: glomeruli , proximal and distal tubules, and cortical collecting ducts and their adjacent peritubular capillaries. 7 March 31, 2023

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10. The hilum , or pelvis , is the concave portion of the kidney through which the renal artery enters and the renal vein exits Nephron: functional unit of kidney 1 million in each kidney Renal corpuscle and tubules Glomeruli, Bowman’s capsule, proximal tubule, loop of Henle, distal tubule, and collecting ducts 10 March 31, 2023

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13. Cortex Outer Contain renal corpuscles Distal and proximal CT medulla Middle Loop of henle Collecting tubules Renal pyramid 13 March 31, 2023

14. The glomerulus is composed of three filtering layers: the capillary endothelium, the basement membrane, and the epithelium 14 March 31, 2023

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16. Kidneys cont’d A fferent arteriole:- branches to form the glomerulus, which is the capillary bed responsible for glomerular filtration. Blood leaves the glomerulus through the efferent arteriole and flows back to the inferior vena cava . Each kidney is capable of providing adequate renal function if the opposite kidney is damaged or becomes nonfunctional 16 March 31, 2023

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19. Proximal convoluted tubule (PCT) Reabsorbs most of the useful substances of the filtrate: Sodium (65%) Water (65%) Bicarbonate (90%) Chloride (50%) Glucose (nearly 100%), etc. The primary site for secretion (elimination) of drugs, waste and hydrogen ions 19 March 31, 2023

20. Distal Convoluted Tubule (DCT) Aldosterone S odium is reabsorbed and potassium is secreted. Water and chloride follow the sodium. Collecting Duct ADH - the duct become porous to water The last segment to save water for the body Peritubular Capillaries Transport reabsorbed materials from the PCT and DCT into kidney veins  general circulation Help complete the conservation process (reabsorption) that takes place in the kidney 20 March 31, 2023

21. Descending Limb of the Loop of Henle Freely permeable to water and relatively impermeable to solutes (salt particles) “Saves water and passes the salt” Ascending Limb of the Loop of Henle Impermeable to water and actively transports (reabsorbs) salt ( NaCl ) to the interstitial fluid “Saves salt and passes the water.” 21 March 31, 2023

22. . Ureters Each kidney has a single ureter-connects renal pelvis with urinary bladder ½ inch diameter 12 to 18 inches in length Urethra Tube for eliminating urine from the body Men- 6 to 10 inches Women- 1 to 1.5 inches Urinary bladder Muscular sac Men- in front of rectum Women- in front of the vagina Temporary urine storage site Enables voiding 22 March 31, 2023

23. Functions of the Kidney Urine formation Excretion of waste products ((ammonia, uric acid, urea, creatine , creatinine, and amino acids) Regulation of electrolytes Regulation of acid–base balance Control of water balance Control of blood pressure Renal clearance Regulation of red blood cell production Synthesis of vitamin D to active form Secretion of prostaglandins 23 March 31, 2023

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25. Urine formation 25 March 31, 2023

26. Urine formation cont′d Urine is formed in the nephrons through a complex three-step process: G lomerular filtration T ubular reabsorption and Tubular secretion The various substances normally filtered by the glomerulus, reabsorbed by the tubules, and excreted in the urine include sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid. 26 March 31, 2023

27. Urine formation cont′d Within the tubule, some of these substances are selectively reabsorbed into the blood Some substances, such as glucose, are completely reabsorbed in the tubule and normally do not appear in the urine Amino acids and glucose are usually filtered at the level of the glomerulus and reabsorbed so that neither is excreted in the urine . 27 March 31, 2023

28. Urine formation cont′d Glucose , however, appears in the urine (glycosuria) if the amount of glucose in the blood and glomerular filtrate exceeds the amount that the tubules are able to reabsorb Normally, glucose is completely reabsorbed when the blood glucose level is less than 200 mg/ dL (11 mmol /L ). In diabetes, when the blood glucose level exceeds the kidneys’ reabsorption capacity, glucose appears in the urine. Glycosuria is also common in pregnancy . 28 March 31, 2023

29. Urine formation cont′d Protein molecules are also generally not found in the urine However , low-molecular-weight proteins ( globulins and albumin ) may periodically be excreted in small amounts . Transient proteinuria in amounts less than 150 mg/ dL is considered normal and does not require further evaluation. Persistent proteinuria usually signifies damage to the glomeruli. 29 March 31, 2023

30. Glomerulus Is composed of three filtering layers : C apillary endothelium B asement membrane and E pithelium G lomerular membrane normally allows filtration of fluid and small molecules but limits passage of larger molecules, such as blood cells and albumin . Kidney function begins to decrease at a rate of approximately 1% each year beginning at approximately age 30 . 30 March 31, 2023

31. Glomerular filtration As blood flows into the glomerulus from an afferent arteriole , filtration occurs. F iltered fluid, also known as filtrate or ultrafiltrate , then enters the renal tubules . Filtrate normally consists of water, electrolytes, and other small molecules, because water and small molecules are allowed to pass, whereas larger molecules stay in the bloodstream Under normal conditions, about 20% of the blood passing through the glomeruli is filtered into the nephron 31 March 31, 2023

32. Glomerular filtration The normal blood flow through the kidneys is about 120 mL/min Efficient filtration depends on adequate blood flow maintaining a consistent pressure through the glomerulus. Many factors can alter this blood flow and pressure hypotension, decreased oncotic pressure in the blood, and increased pressure in the renal tubules from an obstruction 32 March 31, 2023

33. Tubular reabsorption & tubular secretion In tubular reabsorption S ubstance moves from the filtrate back into the peritubular capillaries . In tubular secretion S ubstance moves from the peritubular capillaries into tubular filtrate. Of the 180 L of filtrate that the kidneys produce each day, 99% is reabsorbed into the bloodstream The normal adult GFR is about 100 to 120 mL/min . 33 March 31, 2023

34. Cont. Although most reabsorption occurs in the proximal tubule it, occurs along the entire tubule . Filtrate becomes concentrated under the influence of antidiuretic hormone (ADH) and becomes urine Creatinine clearance is an excellent measure of renal function: A s renal function declines, creatinine clearance decreases The average person voids 1,200 to 1,500 mL of urine in 24 hours 34 March 31, 2023

35. Urination( Micturation ) Urination (micturition) is a spinal cord reflex over which voluntary control may be exerted . Stimulus: stretching of detrusor muscle Sensory impulses travel to the sacral spinal cord , motor impulses return along parasympathetic nerves to the detrusor muscle , causing contraction . At the same time, the internal urethral sphincter relaxes If the external urethral sphincter is voluntarily relaxed, urine flows into the urethra 35 March 31, 2023

36. Characteristics of Urine Amount 1000ml-2000ml Color: straw or amber Dilute and concentarted Specific Gravity: 1.010 to 1.025 pH: range is 4.6 to 8.0, with an average of 6.0 . Vegetarian: alkali urine PH Protein diet: acidic PH 36 March 31, 2023

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38. Constituents 95% water urea, creatinine , and uric acid 38 March 31, 2023

39. 39 Aging and the Urinary System March 31, 2023

40. Reproductive structure The male reproductive system is mostly located outside of the body. These external organs include the penis, scrotum and testicles. Internal organs include the vas deferens, prostate and urethra. The male reproductive system is responsible for sexual function, as well as urination. March 31, 2023 40

41. Anatomy and physiology overview 41 Male Genital organ Anatomy March 31, 2023

42. Female reproductive organs A female's internal reproductive organs are the vagina, uterus, fallopian tubes, and ovaries. The vagina is a muscular, hollow tube that extends from the vaginal opening to the uterus . accessory glands, and external genital organs. March 31, 2023 42

43. Female genital organ anatomy 43 March 31, 2023

44. Assessment Health history • The patient’s chief concern or reason for seeking health care , the onset of the problem, and its effect on the patient’s quality of life The location, character, and duration of pain, if present, and its relationship to voiding; factors that precipitate pain, and those that relieve it • History of UTI, including past treatment or hospitalization for urinary tract infection • Fever or chills • Previous renal or urinary diagnostic tests or use of indwelling urinary catheters 44 March 31, 2023

45. Symptoms Dysuria Hesitancy , straining , Urgency Frequency Incontinence Hematuria or color change Nocturia Hematuria Stone in urine Swelling of lid and leg Flank pain Costo -vertebral angle pain 45 March 31, 2023

46. Female patients: number and type (vaginal or cesarean) of deliveries ; use of forceps; vaginal infection, discharge, or irritation ; contraceptive practices Presence or history of genital lesions or sexually transmitted diseases Habits: use of tobacco, alcohol, or recreational drugs • Any prescription and over-the-counter medications 46 March 31, 2023

47. Unexplained Anemia Pain Change in voiding pattern Past medical: Urinary tract infections Renal stones Use of indwelling catheters Diabetes Hypertension 47 March 31, 2023

48. Heart attacks Angina Gout Lupus erythematosus Sickle-cell disease Beta hemolytic streptococci Systemic infections Cancer Glomerulonephritis Polycystic kidney disease • Do you have any history of falls, motor vehicle accidents, or other trauma ? • Do you have any history of renal diagnostic tests ? 48 March 31, 2023

49. Family History of Urinary Disorders Current Medications, Over-the-Counter Medications , or Herb Use Diet and Fluid Intake 49 March 31, 2023

50. PHYSICAL EXAMINATION General Survey • Height • Weight • Posture • Gait • Apparent State of Health 50 Possible abnormal findings Hyperlipidemia • Obesity • Ambulation difficulty • Lethargy • Weakness March 31, 2023

51. Vital Signs • Blood pressure • Pulse • Respiratory rate • Pulse oximetry 51 Hypertension • Orthostatic hypotension • Tachycardia • Bradycardia • Irregular heart rates March 31, 2023

52. Cognitive Function and Neurological Status • Confusion • Lethargy • Insomnia • Diminished deep tendon reflexes • Hyperesthesia • Paresthesias • Peripheral neuropathy • Decreased mentation • Headaches 52 March 31, 2023

53. Skin, Hair, and Nail Assessment • Skin pallor, color, yellow gray cast • Excoriations • Changes in turgor • Bruising • Changes in skin texture • Dry skin • Distal portion of nail beds white • Capillary refill less than 3 seconds • Impetigo—a streptococcal infection of the skin 53 March 31, 2023

54. Eyes • Conjunctival pallor • Corneal calcification • Retinal arteriosclerotic changes • Blurred vision Ears, Nose, and Throat • Deafness • Strep throat 54 March 31, 2023

55. Cardiovascular • Hypertension • Friction rub • Cardiac enlargement of the left ventricle • Dysrhythmias • Angina or chest pain • Pericardial effusion • Heart failure • Pulmonary edema • Distended neck veins • Edema 55 March 31, 2023

56. Respiratory • Shortness of breath • Tachypnea • Rales • Acid–base disturbances • Kussmaul’s respirations 56 Hematological • Anemia • Bruising • Bleeding tendencies • Infections March 31, 2023

57. Gastrointestinal • Weight loss • Anorexia • Vomiting • Loss of appetite • Constipation • Diarrhea • Malnutrition • Metallic taste in the mouth • Foul urine odor to breath • Ascites • Gastritis • Gastrointestinal bleeding 57 Musculoskeletal • Osteoporosis • Bone and joint problems • Muscle weakness • Gait disturbances • Fractures Endocrine System • Hyperlipidemia • Hyperglycemia • Anemia • Hypertension March 31, 2023

58. 58 Genitourinary March 31, 2023

59. PHYSICAL EXAMINATION Examination of Abdomen: palpation of kidney Suprapubic: palpation and percussion of bladder Genitalia Rectum: digital rectal examination for BPH lower back: CVA tenderness lower extremities . For edema 59 March 31, 2023

60. Diagnostic tests Urinalysis Urine Culture Urine Concentration Test or Specific Gravity Residual Urine Quantitative Test for Protein Creatinine Clearance Urine Cytology Urine Bladder Cancer Markers (Bladder Tumor Antigen) BTA, 60 Renal function test X ray Ultasonography CT scan and MRI Endoscopic studies Renal angiography March 31, 2023

61. Blood Chemistry Studies Kidney Function Tests Serum Creatinine Reference values: 0.6–1.5 mg/ dL Blood Urea Nitrogen (BUN) Reference value: 8–20 mg/ dL Uric Acid Reference value: 2–7 mg/ dL BUN-to- Creatinine Ratio Reference value: About 10:1 61 March 31, 2023

62. Urinalysis result Color : Pale yellow to amber Odor : Aromatic PH : 4.6-8.0 Specific Gravity :1.010-1.025 Protien : 0–18 mg/ dL 0–150 mg/24 hr Glucose : none Ketone : none Blirubin : none Nitrate : Negative Leukocyte Esterase: Negative RBC : 0-4/ hpf WBC: 0-5/ hpf Casts : None to occasional, hyaline casts 62 March 31, 2023

63. FLUID AND ELECTROLYTE BALANCE AND DISTURBNCES 63 March 31, 2023

64. AMOUNT AND COMPOSITION OF BODY FLUIDS Total volume 60% of BW ICF 2/3 of Volume ECF Intravascular 3L Interstitial 11-12L Transcellular 1L 64 March 31, 2023

65. Body fluid normally shifts between the two major compartments or spaces in an effort to maintain an equilibrium between the spaces. 65 March 31, 2023

66. Electrolytes Electrolytes in body fluids are active chemicals Cations : which carry positive charges, and anions: which carry negative charges). 66 March 31, 2023

67. E CF Cations Sodium ( Na+) 142 Potassium ( K+) 5 Calcium (Ca++) 5 Magnesium (Mg++) 2 Total cations 154 Anions Chloride (Cl−) 103 Bicarbonate ( HCO3− ) 26 Phosphate ( HPO4−) 2 Sulfate ( SO4− ) 1 Organic acids 5 Proteinate 17 Total anions 154 67 March 31, 2023

68. ICF Cations Potassium (K+) 150 Magnesium (Mg++) 40 Sodium (Na+) 10 Total cations 200 Anion Phosphates and sulfates 150 Bicarbonate ( HCO3− ) 10 Proteinate 40 Total anions 200 68 March 31, 2023

69. REGULATION OF BODY FLUID COMPARTMENTS Osmosis Movement of water Osmotic pressure Oncotic pressure Osmotic diuresis Diffusion Movement of molecule Random movement of molecule 69 March 31, 2023

70. Filtration Movement of water and solutes occurs from an area of high hydrostatic pressure to an area of low hydrostatic pressure . Sodium–Potassium Pump Movement of sodium and potassium against gradient 70 March 31, 2023

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72. HOMEOSTATIC MECHANISMS Kidney Functions Heart and Blood Vessel Functions Lung Functions Pituitary Functions: release ADH Adrenal Functions: Aldostrone Parathyroid Functions: ca++ BARORECEPTORS RENIN–ANGIOTENSIN–ALDOSTERONE SYSTEM ADH AND THIRST OSMORECEPTORS RELEASE OF ATRIAL NATRIURETIC PEPTIDE 72 March 31, 2023

73. Fluid Volume Disturbances FLUID VOLUME DEFICIT (HYPOVOLEMIA ) Loss > gain Dehydration: loss of water and excess sodium Causes: fluid loss (vomiting, Diarrhea, sweating, GI suctioning Risk factors: diabetes insipidus , adrenal insufficiency , osmotic diuresis , hemorrhage, and Third-space fluid shifts 73 March 31, 2023

74. Clinical Manifestations FVD can develop rapidly and can be mild, moderate, or severe , acute weight loss; decreased skin turgor; oliguria; concentrated urine; postural hypotension; a weak, rapid heart rate ; flattened neck veins; increased temperature; decreased central venous pressure; cool, clammy skin related to peripheral vasoconstriction; thirst; anorexia; nausea; lassitude; muscle weakness; and cramps. 74 March 31, 2023

75. Assessment and diagnostic findings BUN: creatinine >20:1 Electrolyte profile: Major anions and cations Specific gravity 75 March 31, 2023

76. Medical Management Mild FVD: oral fluid For severe FVD: isotonic solution(ringer lactate or Normal saline) Assessment of intake and output Weight assessment vital signs, central venous pressure, level of consciousness, breath sounds , and skin color Assess renal function if pt is oliguric 76 March 31, 2023

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78. Nursing Management fluid intake and output at least every 8 hours, and sometimes hourly Daily body weights Vital signs are closely monitored Skin and tongue turgor Mental function Preventing FVD Correcting FVD 78 March 31, 2023

79. FLUID VOLUME EXCESS (HYPERVOLEMIA) isotonic expansion of the ECF Causes: Na+ and water retention Pp Fluid overload i mpaired homeostatic mechanism heart failure, renal failure , and cirrhosis of the liver excessive amounts of table salt 79 March 31, 2023

80. Clinical Manifestations edema, distended neck veins, and crackles tachycardia; increased blood pressure, pulse pressure, and central venous pressure; increased weight; increased urine output; and shortness of breath and wheezing 80 BP, PP, CVP, Weight, urine output March 31, 2023

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82. Assessment and Diagnostic Findings BUN and hematocrit levels: decrease Urine Na+ level increases Pulmonary congestion 82 March 31, 2023

83. Medical Management Salt and water restrictions PHARMACOLOGIC THERAPY: diuretics Hemodialysis 83 March 31, 2023

84. Nursing Management measures intake and output weighed daily breath sounds degree of edema PREVENTING FVE: teach patient about salt restriction DETECTING AND CONTROLLING FVE: promoting rest, restricting sodium intake, monitoring parenteral fluid therapy, and administering appropriate medications TEACHING PATIENTS ABOUT EDEMA 84 March 31, 2023

85. Electrolyte Imbalances 85 March 31, 2023

86. SIGNIFICANCE OF SODIUM Sodium is the most abundant electrolyte in the ECF ranges from 135 to 145 mEq /L primary determinant of ECF osmolality primary regulator of ECF volume A loss or gain of sodium is usually accompanied by a loss or gain of water muscle contraction and the transmission of nerve impulses. 86 March 31, 2023

87. Sodium imbalances Excess(hypernatremia): Serum sodium >145 mEq /L Deficit( Hyponatremia ): Serum sodium <135 mEq /L 87 March 31, 2023

88. Sodium Imbalance: Causes Hyponatremia GI loss(diarrhea and vomiting) Diuretics( Thiazide ) Excess water intake( psychogenic polydipsia, infusion of electrolyte free fluid Endocrine(adrenal insufficiency, hypothyroidism) Chronic disease(CLD, CHF) SIADH(head trauma, stroke, oat cell lung cancer hypernatremia Insensible loss(fever, hyperventilation, burns) Renal water loss(diabetes insipidus ) vomiting and diarrhea Cushing's syndrome hypertonic tube feedings without adequate water supplements salt water near-drowning victims. 88 March 31, 2023

89. 89 Hyponatremia Hypernatremia System Central nervous system Anxiety, headaches, muscle twitching and weakness, seizures Fever, agitation, restlessness, seizures Cardiovascular Hypotension; tachycardia; with severe deficit, vasomotor collapse, thready pulse Hypertension, tachycardia, pitting edema, excessive weight gain GI Nausea, vomiting, abdominal cramps Rough, dry tongue; intense thirst Genitourinary Oliguria or anuria Oliguria Respiratory Cyanosis with severe deficiency Dyspnea , respiratory arrest, and death (from dramatic increase in osmotic pressure) Cutaneous Cold, clammy skin; decreased skin turgor Flushed skin; dry, sticky mucous membranes March 31, 2023

90. Diagnostic tests The serum sodium level is less than 135 mEq /L in patients with hyponatremia and greater than 145 mEq /L in those with hypernatremia . 90 March 31, 2023

91. Management Hponatremia oral sodium supplement restricted water intake demeclocycline or lithium infusion of 3% or 5% sodium chloride solution 91 hypernatremia Oral water Hypotonic saline (0.3% sodium chloride) or Isotonic non saline (5% dextrose in water) Desmopressin acetate for diabetes insipidus March 31, 2023

92. Nursing diagnosis Anxiety Deficient fluid volume Disturbed thought processes Fatigue Fear Ineffective tissue perfusion: Cardiopulmonary Risk for injury 92 March 31, 2023

93. Nursing interventions For patients with hyponatremia Watch for and report an extremely low serum sodium level. Monitor urine specific gravity and other laboratory results. Record fluid intake and output accurately, and weigh the patient daily. During administration of isosmolar or hyperosmolar sodium chloride solution, watch closely for signs and symptoms of hypervolemia ( dyspnea , crackles, engorged neck or hand veins), and report them immediately. Conserve the patient's energy through rest, planning, and setting of priorities; avoid unnecessary fatigue. 93 March 31, 2023

94. For patients with hypernatremia Monitor serum sodium levels. Notify the physician of a rapid decrease in levels because rapid correction of hypernatremia may lead to cerebral edema. An increase in the serum sodium level should also be reported because it may signal the need for additional treatment. 94 March 31, 2023

95. During fluid replacement therapy, observe the patient for signs and symptoms of cerebral edema, particularly headache, lethargy, nausea, vomiting, widening pulse pressure, decreased pulse rate, and seizures. Accurately record fluid intake and output , checking for body fluid loss. Weigh the patient daily. Assist with oral hygiene. Frequently lubricate the patient's lips with a water-based lubricant. Provide mouthwash or gargle if the patient is alert. 95 March 31, 2023

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97. SIGNIFICANCE OF POTASSIUM Potassium is the major intracellular electrolyte; in fact, 98% of the body’s potassium is inside the cells. The remaining 2% is in the ECF , and it is this 2% that is important in neuromuscular function . influences both skeletal and cardiac muscle activity 80% of the potassium is excreted daily by kidney 20% bowel and sweat 97 March 31, 2023

98. Potassium imbalances excess (hyperkalemia) : Serum potassium >5.0 mEq /L Deficit ( hypokalemia ): Serum potassium < 3.5mEq/L Pseudohyperkalemia , 98 March 31, 2023

99. Causes Hyperkalemia Exceation problem: oliguric renal failure, use of potassium-conserving diuretics metabolic acidosis, Addison’s disease, Potasium release from cells(crush injury, burns, stored bank blood transfusions,) rapid IV administration of potassium Hypokalemia excessive GI losses chronic renal disease, such as tubular potassium wasting potassium-wasting diuretics, steroids, and certain sodium-containing antibiotics alkalosis or insulin effect prolonged potassium-free I.V. therapy hyperglycemia, causing osmotic diuresis and glycosuria Cushing's syndrome, 99 March 31, 2023

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102. Diagnostic tests Potassium Level 102 March 31, 2023

103. Treatment: hypokalemia administration of 40 to 80 mEq /day of potassium Dietary intake of potassium: raisins, bananas, apricots, and oranges When oral administration of potassium is not feasible, the IV route is indicated. The IV route is mandatory for patients with severe hypokalemia ( eg , a serum level of 2 mEq /L). 103 March 31, 2023

104. ADMINISTERING I.V. POTASSIUM SAFELY I.V. infusion concentrations generally shouldn't exceed 60 mEq /L . The infusion rate shouldn't exceed 20 mEq / hour , unless indicated Use volumetric devices whenever concentrations of more than 40 mEq /L are infused. Never administer potassium by I.V. push or bolus; doing so may cause cardiac arrest. Monitor cardiac rhythm during rapid I.V. administration of potassium to avoid cardiac toxicity Monitor the I.V. site for signs and symptoms of infiltration, phlebitis, and tissue necrosis. 104 March 31, 2023

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106. Management: hyperkalemia Restriction of potassium cation exchange resins ( eg,Kayexalate): oral or enema SE : hypomagnesemia and hypocalcemia Emergency management(severe hyperkalemia): IV calcium gluconate Monitor BP, ECG Bradycardia: stop infusion IV administration of sodium bicarbonate IV administration of regular insulin and a hypertonic dextrose solution 106 March 31, 2023

107. SIGNIFICANCE OF CALCIUM More than 99% of the body’s calcium is located in the skeletal system; it is a major component of bones and teeth . plays a major role in transmitting nerve impulses and helps to regulate muscle contraction and relaxation, including cardiac muscle plays a role in blood coagulation It exists in plasma in three forms: ionized, bound , and complexed 107 March 31, 2023

108. absorbed from foods in the presence of normal gastric acidity and vitamin D excreted primarily in the feces , the remainder in urine serum calcium level is controlled by PTH and calcitonin 108 March 31, 2023

109. CALCIUM DEFICIT (HYPOCALCEMIA) A total body calcium deficit(osteoporosis) Hypoparathyroidism (may follow thyroid surgery or radical neck dissection), malabsorption , pancreatitis, alkalosis , vitamin D deficiency, massive subcutaneous infection , generalized peritonitis, massive transfusion of citrated blood, chronic diarrhea, decreased parathyroid hormone , and diuretic phase of renal failure 109 March 31, 2023

110. Clinical manifestations Numbness, tingling of fingers, toes positive Trousseau’s sign and Chvostek’s sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, ↓ prothrombin, ECG : prolonged QT interval and lengthened ST. 110 March 31, 2023

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112. Management IV administration of calcium calcium gluconate , calcium chloride, and calcium gluceptate SE: hypotension Vitamin D therapy: enhance ca++ absorption Increasing the dietary in take of calcium to at least 1,000 to 1,500 mg/day: milk products; green, leafy vegetables; canned salmon; sardines; fresh oysters). 112 March 31, 2023

113. Calcium excess ( hypercalcemia ) Serum calcium >10.5 mg/ dL Hyperparathyroidism , malignant neoplastic disease, prolonged immobilization, overuse of calcium supplements, vitamin D excess, oliguric phase of renal failure, acidosis, corticosteroid therapy, thiazide diuretic use, increased parathyroid hormone, and digoxin toxicity 113 March 31, 2023

114. Clinical manifestations Muscular weakness, constipation, anorexia, nausea and vomiting, polyuria and polydipsia, hypoactive deep tendon reflexes , lethargy, deep bone pain, pathologic fractures, flank pain, and calcium stones . ECG: shortened QT interval, bradycardia, heart blocks. 114 March 31, 2023

115. Treatment administering fluids to dilute serum calcium and promote its excretion by the kidneys IV administration of 0.9% sodium chloride+ Furosemide (Lasix) Dilute Inhibit ca++ absorption Calcitonin : useful for patients with heart disease or renal failure who cannot tolerate large sodium loads. 115 March 31, 2023

116. Acid- Base disturbances 116 March 31, 2023

117. Acid–Base Disturbances pH is an indicator of ( H+) concentration. Homeostatic mechanisms keep pH within a normal range (7.35–7.45). These mechanisms consist of buffer systems , the kidneys , and the lungs . 117 March 31, 2023

118. The Buffer system prevent major changes in the pH by R emoving or Releasing H + A ct quickly to prevent excessive changes in H+ conc. major extracellular buffer system is the bicarbonate-carbonic acid buffer system Normally: HCO3-:H2CO3= 20:1 CO 2 + H2O H2CO3 HCO3- + H+ 118 March 31, 2023

119. Buffer Cont. If this ratio is altered, the pH will change. Carbon dioxide (CO2) is a potential acid (CO2 + H2O = H2CO3 ). Less important buffer: inorganic phosphates and the plasma proteins . Intracellular buffers: proteins , organic and inorganic phosphates, and, in red blood cells, hemoglobin. 119 March 31, 2023

120. Kidneys Regenerate or reabsorb bicarbonate ion there by regulate PH 120 March 31, 2023

121. Lungs control the CO2 and thus the carbonic acid content of the ECF Do so by adjusting ventilation 121 March 31, 2023

122. ACUTE AND CHRONIC METABOLIC ACIDOSIS (BASE BICARBONATE DEFICIT) characterized by: a low pH and a low plasma bicarbonate concentration. Causes: gain of hydrogen or loss of bicarbonate Classified as high anion gap or low -anion gap Anion gap = Na+ − (Cl− + HCO3 −)= 8-12mEq or 12-16mEq 122 March 31, 2023

123. Continued……. Normal anion gap acidosis--- is due to loss of bicarbonate: diarrhea, fistulas, diuretics, excessive chloride, parenteral nutrient without HCO3- A reduced or negative anion gap is primarily caused by hypoproteinemia : rare case High anion gap acidosis: excessive accumulation of fixed acid: 30mEq/L Ketoacidosis, Lactic acidosis uremia, methanol or ethylene glycol toxicity, and ketoacidosis with starvation 123 March 31, 2023

124. Clinical manifestations headache , confusion, drowsiness, increased respiratory rate and depth, nausea , and vomiting. Peripheral vasodilation and decreased cardiac output occur when the pH falls below 7. decreased blood pressure, cold and clammy skin, dysrhythmias, and shock 124 March 31, 2023

125. Assessment and Diagnostic Findings ABG: Bicarbonate <22mEq/L, PH<7.35 Hyperkalemia Hyperventilation Anion gap calculation 125 March 31, 2023

126. Medical management Detect and treat underlying causes Bicarbonate adminstration if PH<7.1 or HCO3- is < 10 intravenous administration of 50 to 100 meq of NaHCO3, over 30 to 45 min, during the initial 1 to 2 h of therapy. Monitor for serum potassium level 126 March 31, 2023

127. ACUTE AND CHRONIC METABOLIC ALKALOSIS (BASE BICARBONATE EXCESS) C haracterized by: a high pH and a high plasma bicarbonate concentration . It can be produced by a gain of bicarbonate or a loss of H + Cause: vomiting or gastric suction with loss of hydrogen and chloride ions, pyloric stenosis , loss of potassium(diuretic treatment), alkali ingestion 127 March 31, 2023

128. Clinical Manifestations symptoms related to decreased calcium ionization , such as tingling of the fingers and toes , dizziness, and hypertonic muscles Respiratory depression PH>7.6 and Hypokalemia: ventricular disturbance 128 March 31, 2023

129. Assessment and Diagnostic Findings ABG: PH>7.45, HCO3->26mEq/L PaCo2 rises Hypokalemia 129 March 31, 2023

130. Medical Management Treat underlying causes Restore fluid (NS) KCL Carbonic anhydrase inhibitor: Acetazolamide(inhibit HCO3- reabsorption) Monitor input - output 130 March 31, 2023

131. ACUTE AND CHRONIC RESPIRATORY ACIDOSIS (CARBONIC ACID EXCESS) Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg . Causes: retention of CO2 acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, Overdose of sedatives, sleep apnea syndrome, administration of oxygen to a patient with chronic hypercapnia (excessive CO2 in the blood ), severe pneumonia, and acute respiratory distress syndrome. Respiratory muscular dystrophy, myasthenia gravis, and Guillain-Barré syndrome. 131 March 31, 2023

132. Clinical Manifestations Sudden hypercapnia (elevated PaCO2) can cause increased PR, BP and RR mental cloudiness, and feeling of fullness in the head Increase in ICP, resulting in papilledema and dilated conjunctival blood vessels. Hyperkalemia Chronic respiratory acidosis occurs with pulmonary diseases such as chronic emphysema and bronchitis, obstructive sleep apnea , and obesity. if the PaCO 2 rises rapidly, cerebral vasodilation will increase intracranial pressure; cyanosis and tachypnea will develop. 132 March 31, 2023

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134. Assessment and Diagnostic Findings ABG: PH<7.35, PaCO2>42mmHg X ray ECG to determine underlying Causes Screening for drug overdose 134 March 31, 2023

135. Medical Management Treat underlying causes Antibiotics Bronchodilators Thrombolytics Remove secretion Hydration Mechanical ventilation Put patient on semi fowler’s position 135 March 31, 2023

136. ACUTE AND CHRONIC RESPIRATORY ALKALOSIS (CARBONIC ACID DEFICIT) Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg . Causes: hyperventilation anxiety, hypoxemia, the early phase of salicylate intoxication, gram-negative bacteremia, and inappropriate ventilator settings 136 March 31, 2023

137. Clinical Manifestations lightheadedness due to vasoconstriction and decreased cerebral blood flow, inability to concentrate, Numbness and tingling from decreased calcium ionization, tinnitus , and at times loss of consciousness. Cardiac effects of respiratory alkalosis tachycardia and ventricular and atrial dysrhythmias 137 March 31, 2023

138. Assessment and Diagnostic Findings ABG: PH>7.45, PaCO2 <42mmHg Hypokalemia Hypocalcemia 138 March 31, 2023

139. Medical Management Treatment of underlying causes If the cause is anxiety, the patient is instructed to breathe more slowly to allow CO2 to accumulate or To breathe into a closed system (such as a paper bag ). A sedative may be required to relieve hyperventilation in very anxious patients . 139 March 31, 2023

140. Disease of the kidney 140 March 31, 2023

141. Urinary Tract infection Learning Objective: At the end of this unit the student will be able to 1. Define urinary tract infections. 2. List the etiologies of urinary tract infections. 3. Describe the epidemiology of urinary tract infections. 4. Explain the pathogenesis of urinary tract infections. 5. Describe the clinical features of urinary tract infections. 6. List the common complications urinary tract infections. 7. Describe the most commonly used tests for the diagnosis of urinary tract infections. 8. Make an accurate diagnosis of urinary tract infections. 9. Treat urinary tract infections with appropriate antibiotics. 10. Design appropriate methods of prevention and control of urinary tract infections. 141 March 31, 2023

142. Definitions UTI : is an acute infection of the urinary tract, and is subdivided into two general anatomic categories : • Lower urinary tract infection: which includes urethritis and cystitis and • Upper urinary tract infection: includes ureteritis , acute pyelonephritis, and intrarenal and perinephric abscesses ). Lab definition : growth of more than 10 5 organisms per milliliter : asymptomatic bacteruria ( 102 to 104/mL): in symptomatic patients 142 March 31, 2023

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146. Etiology Etiologic agents for community acquired cases • Commonest causes are E. coli (80%) , S. saprophyticus (10 %), Klebsiella pneumoniae (5%) and other (5%) • In acute uretheral syndrome (Sexually transmitted organisms: N. gonorrhea , Chlamydia trachomitis , Trichomonas , Candida, and herpes simplex virus may cause lower UTI) • In elderly Enterococcus fecalis may be a cause for UTI. • Bacteremia is often due to S. aureus . 146 March 31, 2023

147. Continued… Hospital acquired/ catheter associated UTI • E. coli (30%) • Enterococci (15%) • Pseudomonas (10%) S. aureus , yeasts, and other Enterobacteriacea 147 March 31, 2023

148. Routs of inoculation Urethral inoculation Hematogenous spread 148 March 31, 2023

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152. Clinical presentation A strong, persistent urge to urinate A burning sensation when urinating Passing frequent, small amounts of urine Urine that appears cloudy Urine that appears red, bright pink or cola-colored — a sign of blood in the urine Strong-smelling urine Pelvic pain, in women — especially in the center of the pelvis and around the area of the pubic bone 152 March 31, 2023

153. Types of urinary tract infection Upper back and side (flank) pain High fever Shaking and chills Nausea Vomiting 153 Bladder (cystitis) Pelvic pressure Lower abdomen discomfort Frequent, painful urination Blood in urine Kidneys (acute pyelonephritis) Urethra (urethritis) Burning with urination Discharge March 31, 2023

154. Acute Pyelonephritis: • Symptoms of acute pyelonephritis generally develop rapidly over a few hours or a day and include a fever, shaking chills, nausea, vomiting, and diarrhea. • Symptoms of cystitis may or may not be present. • Physical examination: fever, tachycardia, and generalized muscle tenderness, marked tenderness on deep pressure in one or both costovertebral angles or on deep abdominal palpation ( Costvertebral angle tenderness ). • In some patients, signs and symptoms of gram-negative sepsis predominate. 154 March 31, 2023

155. Urethritis: • Approximately 30% of women with acute dysuria, frequency, and pyuria have midstream urine cultures that show either no growth or insignificant bacterial growth . Clinically, these women cannot always be readily distinguished from those with cystitis . In this situation, a distinction should be made between women infected with sexually transmitted pathogens, such as C. trachomatis, N. gonorrhoeae , or herpes simplex virus, and those with low-count E. coli or staphylococcal infection of the urethra and bladder. • Chlamydial or gonococcal infection should be suspected in women with a gradual onset of illness, no hematuria , no suprapubic pain , and more than 7 days of symptoms . 155 March 31, 2023

156. Continued • The additional history of a recent sex-partner change, especially if the patient's partner has recently had chlamydial or gonococcal urethritis, should heighten the suspicion of a STI, as should the finding of mucopurulent cervicitis . • Gross hematuria , suprapubic pain , an abrupt onset of illness, a duration of illness of < 3 days, and a history of UTIs favor the diagnosis of E. coli UTI. 156 March 31, 2023

157. Catheter-Associated UTIs: • Bacteriuria develops in at least 10 to 15% of hospitalized patients with indwelling urethral catheters . The risk of infection is about 3 to 5% per day of catheterization. • Clinically, most catheter-associated infections cause minimal symptoms and no fever and often resolve after withdrawal of the catheter. • Gram-negative bacteremia, which follows catheter-associated bacteriuria in 1 to 2% of cases, is the most significant recognized complication of catheter-induced UTIs. • The catheterized urinary tract has repeatedly been demonstrated to be the most common source of gram-negative bacteremia in hospitalized patients, generally accounting for about 30% of cases. 157 March 31, 2023

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168. Investigation Urinalysis Culture of the urine Blood Radiologic urologic evaluation 168 March 31, 2023

169. 169 Complications March 31, 2023

170. Prevention Drink plenty of liquids, especially water Wipe from front to back Empty bladder soon after intercourse Avoid potentially irritating feminine products 170 March 31, 2023

171. Management Acute Uncomplicated lower UTI in women Ciprofloxacin, 500mg P.O., BID, for 3 days• OR Norfloxacin 400 PO BID for 3 days Alternatives Nitrofurantoin 50mg P.O., QID for 7 days OR Cefpodoxime proxetil 100mg P.O, BID for 3 days Cotrimoxazole160/800mg P.O, BID for 3 days 171 March 31, 2023

172. Continued….. Acute uncomplicated pyelonephritis in women : Ciprofloxacin , 500mg P.O., BID, oral for 7-10 days Alternatives Cotrimoxazole 160/800mg P.O, BID for 14 OR Cefpodoxime proxetil , 200mg P.O., BID for 10 days 172 March 31, 2023

173. Continued…. Severe acute uncomplicated pyelonephritis First line Ciprofloxacin , 400mg, I.V , BID till patient improves and continue oral Ciprofloxacin 500mg, PO, BID to complete 10-14 days course Alternatives Ceftriaxone , 2gm, I.V, daily or 1gm, I.V, BID till patient improves and continue oral Ciprofloxacin 500mg, PO, BID to complete 10-14 days course. 173 March 31, 2023

174. Continued…. Complicated UTIs and UTI in men First line and alternatives – similar to uncomplicated UTIs but needs prolonged duration 174 Factors which suggest complicated UTI: The presence of an indwelling catheter or the use of intermitten bladder catheterization, obstructive uropathy of any aetiology , stones, vesicoureteric reflux or other functional abnormalities, peri -and postoperative UTI, CKD and transplantation, diabetes mellitus and immunodeficiency states. March 31, 2023

175. Inflammatory Disorders 175 March 31, 2023

176. Acute Glomerulo - Nephritis 176 March 31, 2023

177. ACUTE GLOMERULONEPHRITIS Glomerulonephritis is an inflammation of the glomerular cap- illaries . A primarily a disease of children older than 2 years of age, but it can occur at nearly any age . Glomerulonephritis occurs on its own or as part of another disease, such as lupus or diabetes. 177 March 31, 2023

178. Causes Infections Post-streptococcal glomerulonephritis . Bacterial endocarditis. Viral infections . Immune diseases Lupus Goodpasture syndrome IGA nephropathy Vasculitis Polyarteritis . Granulomatosis with polyangiitis . 178 March 31, 2023

179. Conditions likely to cause scarring of the glomeruli Hypertension diabetic nephropathy Focal segmental glomerulosclerosis . Infrequently, chronic glomerulonephritis runs in families. One inherited form, Alport syndrome , also might impair hearing or vision. 179 March 31, 2023

180. glomerulonephritis is associated with certain cancers, such as multiple myeloma , lung cancer and chronic lymphocytic leukemia . 180 March 31, 2023

181. Pathophysiology Precipitating factors a group A beta-hemolytic streptococcal infection of the throat precedes the onset of glomerulonephritis by 2 to 3 weeks It may also follow impetigo (infection of the skin) and acute viral infections (URT infections , mumps, VZV, EBV, HBV, and HIV infection ). In some patients, antigens outside the body ( eg , medications, foreign serum) In other patients, the kidney tissue itself serves as the inciting antigen. 181 March 31, 2023

182. Clinical Manifestations hematuria :microscopic or gross The urine may appear cola-colored because of RBCs and protein plugs or casts. Glomerulonephritis may be so mild, severe renal failure with oliguria. Proteinuria (primarily albumin ), BUN serum creatinine levels may rise Some degree of edema and hypertension is noted in 75% of patients . headache, malaise, and flank pain, CVA tenderness 182 March 31, 2023

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184. Elderly patients may experience circulatory overload with dyspnea , engorged neck veins, cardiomegaly, and pulmonary edema. Atypical symptoms include confusion, somnolence , and seizures, which are often confused with the symptoms of a primary neurologic disorder. 184 March 31, 2023

185. Diagnostic Findings the kidneys become large, swollen, and congested antistreptolysin O or anti- DNase B titers elevated serum IgA Proteinuria Hemturia 185 March 31, 2023

186. Possible Complications Acute kidney failure Chronic kidney disease High blood pressure.   Nephrotic syndrome Hypertensive encephalopathy , heart failure, and pulmonary edema . optic neuropathy 186 March 31, 2023

187. Medical Management Non pharmacology Input and output monitoring chart and daily weight measurements - Salt restriction - Determine 24-hour fluid requirement Giving maintenance fluid orally 187 March 31, 2023

188. Pharmacologic First-line Amoxacillin 30-50mg/kg/24 hours, divided into 2-3 days for 7-10 days Control BP with furosemide (4-6mg/kg in two divided doses, intravenously) If furosemide is not enough to control the blood pressure, add nifedipine 0.25-0.5mg/kg/dose Q6hours If hyperkalemia give calcium gluconate 10%, 0.5ml/kg IV over 10 minutes, OR Glucose 0.5-1.0gm/kg and insulin 0.1-0.2units/kg as a bolus If the above treatment fail refer for dialysis 188 March 31, 2023

189. Nephrotic syndrome: Learning objectives: at the end of this lesson the student will be able to: 1. Define nephrotic syndrome. 2. List the etiologies of nephrotic syndrome. 3. Describe the clinical features of nephrotic syndrome. 4. Identity complications of nephrotic syndrome.. 5. Understand the diagnostic approach of nephrotic syndrome. 6. Understand the principle of management of nephrotic syndrome. 189 March 31, 2023

190. Definition The nephrotic syndrome is a clinical complex characterized by: • Significant proteinuria of >3.5 g/1.73m2/per 24 h (for practical purpose >3.0 to 3.5 g per 24 h) is the most important clinical feature or 3+ or 4+ dipstick, or 40mg/ hr • Hypoalbuminemia <2.5mg/dl • Edema • hypercholesterolemia (> 200mg/dl) and lipiduria • Hypercoagulability 190 March 31, 2023

191. Etiology 1 . Multisystem diseases account for 50 –70 % of adult nephrotic syndrome. a. Diabetes mellitus b. Collagen vascular diseases c. Amyloidosis 2. Neoplasms: - leukemias , lymphomas and solid tumors 3. Infections: - viral, bacterial, protozoan and helimenthic 4. Primary glomerulopathies ( Idiopathic ): - account for 30 –50 % of adult nephrotic syndrome 191 March 31, 2023

192. Clinical picture Proteinuria and hypoalbuminemia : Edema Hyperlipidemia : Hypercoagulability Other complications: Protein malnutrition Iron-resistant microcytic hypochromic anemia due to transferrin loss Hypocalcemia 192 March 31, 2023

193. Diagnosis 1 . Confirming significant proteinuria • Quantify 24 hours urine protein • Comparing with urinary creatinine level on a single void urine • Measurement of urinary protein by a dipstick (+3 or +4 diagnostic if the first two are not available) 2. Renal biopsy ( if available ): to identify the underlying histopathologic abnormality 193 March 31, 2023

194. Treatment The treatment of nephrotic syndrome involves:- 1. Specific treatment of the underlying morphologic entity Steroids , and cytotoxic drugs 2 . Measures to control proteinuria: - a. Dietary protein restriction: the potential value of dietary protein restriction for reducing proteinuria must be balanced against the risk of contributing to malnutrition . b. Angiotensin-converting enzyme (ACE) inhibitors : decrease proteinuria by decreasing glomerular filtration pressure c. Controlling hypertension: keeping BP below 130/80 reduces proteinuria. 194 March 31, 2023

195. 3. Treatment of complications of nephrotic syndrome. a. Edema: should be managed cautiously by : Moderate salt restriction, usually 1 to 2 g/day Loop diuretics can be given in higher doses: It is unwise to remove > 1.0 kg of edema per day as more aggressive diuresis may precipitate intravascular volume depletion and prerenal azotemia. b. Thromboembolism : Anticoagulation is indicated for patients with deep venous thrombosis, arterial thrombosis, and pulmonary embolism. Heparin may not be effective because of urinary loss of anti- thrombin III. c. Hyperlipidemia : may need lipid lowering agents Simvastatin( po ) d. Vitamin D deficiency: Vit -- D supplementation. 195 March 31, 2023

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198. Acute Renal Failure Learning objectives: at the end of this lesson the student will be able to : 1. Define acute renal failure. 2. List the etiologies of acute renal failure. 3. Describe the pathophysiology of acute renal failure. 4. Identify the clinical manifestation of acute renal failure. 5. Identify complications of acute renal failure. 6. Understand the diagnostic approach of acute renal failure. 7. Understand the principles of management of acute renal failure. 8. Understand the course and prognosis of acute renal failure. 9. Refer patients with acute renal failure to hospitals with better facilities 198 March 31, 2023

199. Definition Acute renal failure is a syndrome characterized by: • Rapid decline in glomerular filtration rate (hours to days ) • Retention of nitrogenous wastes due to failure of excretion • Disturbance in extracellular fluid volume and • Disturbance electrolyte and acid base homeostasis. Based on the amount of urine output acute renal failure may be classified as • Anuric : - if urine volume is less than 100 ml/day • Oliguric : - if urine volume is less than 400 ml/day • Non- oliguric : - if urine volume is greater than or equal 400 ml/day 199 March 31, 2023

200. Etiologic classification of acute renal failure Prerenal ARF Hypovolemia Low cardiac output Altered renal systemic vascular resistance ratio Intrinsic Renal ARF Renovascular obstruction Disease of glomeruli or renal microvasculature Acute tubular necrosis Interstitial nephritis 200 March 31, 2023

201. Continued …… Post renal ARF (OBSTRUCTION ) Ureteric Bladder neck Urethra 201 March 31, 2023

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203. Diagnosis of ARF: Careful history is essential • Exposure to nephrotoxins and drugs • Anuria may indicate post-renal causes • Skin rashes may indicate allergic nephritis • Evidences of volume depletion: diarrhea, bleeding • Pelvic and per-rectal examination: look for evidence of abortion • Ischemia or trauma to the legs or arms may indicate rhabdomyolysis • Recent surgical or radiologic procedures • Past and present use of medications • Family history of renal diseases 203 March 31, 2023

204. Complications of ARF Intravascular overload Electrolyte disturbance Hyperkalemia Hyponitremia Hyperphosphatemia Hypocalcemia Hypercalcemia 204 Metabolic acidosis Hyperuricemia Bleeding tendency Seizure Chronic Renal failure March 31, 2023

205. Diagnostic work up Urinalysis: Microscopic evaluation of urinary sediment. • Presence of few formed elements or hyaline casts is suggestive of prerenal or postrenal azotemia. • Many RBCs may suggest calculi , trauma , infection or tumor • Eosinophilia : occurs in 95 % of patients with acute allergic nephritis • Brownish pigmented cellular casts and many renal epithelia cells are seen in patients with acute tubular necrosis (ATN ) • Pigmented casts without erythrocytes in the sediment from urine but with positive dipstick for occult blood indicates hemoglobinuria or myoglobinuria • Dipstick test: trace or no proteinuria with pre-renal and post-renal ARF; mild to moderate proteinuria with ATN and moderate to severe proteinuria with glomerular diseases. • RBCs and RBC casts in glomerular diseases • Crystals RBCs and WBCs in post-renal ARF. 205 March 31, 2023

206. BUN: 12-20mg/dl Creatine Level: 0.2–0.8 mg/mL . Radiography/imaging • Ultrasonography: helps to see the presence of two kidneys, for evaluating kidney size and shape, and for detecting hydronephrosis or hydroureter . It also helps to see renal calculi, and renal vein thrombosis. Retrograde pyelography: is done when obstructive uropathy is suspected 206 March 31, 2023

207. Management of Acute renal failure: Preliminary measures Exclusion of reversible causes Correction of prerenal factors Maintenance of urine output: Specific Therapies : To date, there are no specific therapies for established intrinsic renal ARF due to ischemia or nephrotoxicity. • Management of these disorders should focus on elimination of the causative hemodynamic abnormality or toxin, avoidance of additional insults, and prevention and treatment of complications. • Specific treatment of other causes of intrinsic renal ARF depends on the underlying pathology . 207 March 31, 2023

208. Fluid and electrolyte management Hypervolemia: salt restriction and diuretics Metabolic acidosis: sodium bicarbonate Hyperkalemia: Restrict dietary K+ intake , Give calcium gluconate 10 ml of 10% solution over 5 minutes Hyperphosphatemia : oral aluminum hydroxide or calcium carbonate Anemia: 208 March 31, 2023

209. Chronic kidney disease With chronic kidney disease, the kidneys don’t usually fail all at once. Instead , kidney disease often progresses slowly over a period of years. This is good news because if CKD is caught early, medicines and lifestyle changes may help slow its progress 209 March 31, 2023

210. Risk factors for CKD hypertension , diabetes mellitus, autoimmune disease, older age, African ancestry, a family history of renal disease, a previous episode of acute renal failure, the presence of proteinuria, abnormal urinary sediment, or structural abnormalities of the urinary tract. 210 March 31, 2023

211. Glomerular Filtration Rate (GFR) Glomerular filtration rate (GFR) is the best measure of kidney function . A math formula using the person’s age, race, gender and their serum creatinine is used to calculate a GFR 211 March 31, 2023

212. Below shows the five stages of CKD and GFR for each stage: Stage 1 with normal or high GFR (GFR > 90 mL/min) Stage 2 Mild CKD (GFR = 60-89 mL/min) Stage 3A Moderate CKD (GFR = 45-59 mL/min) Stage 3B Moderate CKD (GFR = 30-44 mL/min) Stage 4 Severe CKD (GFR = 15-29 mL/min) Stage 5 End Stage CKD (GFR <15 mL/min) 212 March 31, 2023

213. CHRONIC RENAL FAILURE end result of a gradually progressive loss of renal function occasionally results from a rapidly progressive disease of sudden onset that gradually destroys the nephrons and eventually causes irreversible renal damage Few symptoms develop until after more than 75% of glomerular filtration is lost. 213 March 31, 2023

214. Causes chronic glomerular disease, such as glomerulonephritis chronic infections, such as chronic pyelonephritis or tuberculosis congenital anomalies, such as polycystic kidney disease vascular diseases, such as renal nephrosclerosis or hypertension obstructive processes, such as calculi or benign prostatic hypertrophy collagen diseases, such as systemic lupus erythematosus nephrotoxic agents, such as long-term aminoglycoside therapy endocrine diseases, such as diabetic nephropathy disorders that impair circulation, such as sickle cell disease. 214 March 31, 2023

215. Clinical findings Renal Early fluid and electrolyte imbalances Hyponatremias dry mouth, fatigue, and nausea hypotension, loss of skin turgor, and listlessness that may progress to somnolence and confusion Later , Urine output decreases, and the urine is very dilute, with casts and crystals present Accumulation of potassium Sodium retention causes fluid overload 215 March 31, 2023

216. Cardiovascular. hypertension and an irregular pulse are noted. Life-threatening cardiac arrhythmias can occur . With pericardial involvement, you may auscultate a pericardial friction rub . Uremic toxins cause the pericardial sac to become inflamed and irritated. Heart sounds may be distant if pericardial effusion is present . Bibasilar crackles may be auscultated, and peripheral edema may be palpated if heart failure occurs. 216 March 31, 2023

217. Respiratory reduced pulmonary macrophage activity with increased susceptibility to infection . If pneumonia is present, lung sounds may be decreased over areas of consolidation. Bibasilar crackles indicate pulmonary edema . With pleural involvement, the patient may complain of pleuritic pain, and you may auscultate a pleural friction rub. Crackles may indicate pleural effusion. Kussmaul's respirations occur with metabolic acidosis. 217 March 31, 2023

218. GI. With inflammation and ulceration of GI mucosa, inspection of the mouth may reveal gum ulceration and bleeding and, possibly, parotitis . The patient may complain of h iccups, a metallic taste in the mouth, anorexia, nausea, and vomiting caused by esophageal, stomach, or bowel involvement. You may note a uremic fetor (ammonia smell) to the breath. Abdominal palpation and percussion may elicit pain 218 March 31, 2023

219. Skin Inspection of the skin typically reveals a pallid, yellowish bronze color. The skin is dry and scaly with purpura, ecchymoses , petechiae , uremic frost (most often in critically ill or terminal patients), and thin , brittle fingernails with characteristic lines. The hair is dry and brittle and may change color and fall out easily. The patient usually complains of severe itching. 219 March 31, 2023

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221. Neurologic. alterations in level of consciousness that may progress from mild behavior changes, shortened memory and attention span , apathy, drowsiness, and irritability to confusion, coma, and seizures. Headache and blurred vision indicate uremia. The patient may complain of hiccups, muscle cramps, fasciculations , and twitching, which are caused by muscle irritability. He may also complain of restless leg syndrome. One of the first signs of peripheral neuropathy, restless leg syndrome causes pain, burning, and itching in the legs and feet that may be relieved by voluntarily shaking, moving, or rocking them. This condition eventually progresses to paresthesia, motor nerve dysfunction (usually bilateral footdrop ) and, unless dialysis is initiated, flaccid paralysis. 221 March 31, 2023

222. Endocrine Children with chronic renal failure exhibit growth retardation, even with elevated growth hormone levels. Adults may have a history of infertility, decreased libido, amenorrhea in females, and impotence in men. 222 March 31, 2023 Hematologic Inspection may reveal purpura , GI bleeding and hemorrhage from body orifices, easy bruising, ecchymoses , and petechiae caused by thrombocytopenia and platelet defects.

223. Musculoskeletal The patient may have a history of pathologic fractures and complain of bone and muscle pain caused by calcium-phosphorus imbalance and consequent parathyroid hormone imbalances. You may note gait abnormalities or, possibly, an inability to ambulate. Children may have impaired bone growth and bowed legs from rickets. 223 March 31, 2023

224. Diagnosis Increased: blood urea nitrogen, serum creatinine, sodium, and potassium levels decreased arterial pH and bicarbonate levels low hematocrit and hemoglobin levels; decreased red blood cell (RBC) survival time; mild thrombocytopenia; platelet defects; and metabolic acidosis Hyperglycemia and hypertriglyceridemia 224 March 31, 2023

225. Urine specific gravity becomes fixed at 1.010; urinalysis may show proteinuria, glycosuria, RBCs, leukocytes, and casts and crystals X-ray studies, reduced kidney size Renal biopsy EEG metabolic encephalopathy 225 March 31, 2023

226. Treatment A low protein diet A high-calorie diet prevents ketoacidosis restrict sodium, phosphorus, and potassium vital signs, weight changes, and urine volume loop diuretics such as furosemide antihypertensives 226 March 31, 2023 Cardiac glycosides Antiemetics cimetidine, omeprazole, or ranitidine iron and folate supplements An antipruritic, such as trimeprazine or diphenhydramine

227. DIALYSIS Dialysis is a procedure for cleaning and filtering the blood. It substitutes for kidney function During dialysis, the client’s blood is filtered by diffusion and osmosis . Substances such as water, urea , creatinine , and dangerously high levels of potassium move from the blood through the semipermeable membrane to the dialysate, the solution used during dialysis that has a composition similar to normal human plasma. Dialysis is performed by hemodialysis and peritoneal dialysis. Either technique can be performed at home or in a dialysis center . 227 March 31, 2023

228. Hemodialysis requires transporting blood from the client through a dialyzer, a semipermeable membrane filter in a machine. The dialyzer contains many tiny hollow fibers. Blood moves through the hollow fibers. Water and wastes from the blood move into the dialysate fluid that flows around the fibers, but protein and RBCs do not . The filtered blood is returned to the client. The entire cycle takes 4 to 6 hours and is performed three times a week . 228 March 31, 2023

229. Vascular Access Arteriovenous Fistula is a surgical anastomosis ( connection) of an artery and vein lying in close proximity An arteriovenous graft is a type of vascular access method that uses a tube of synthetic material (e.g., Gore-Tex or polytetrafluoroethylene ) to connect a vein and artery in the upper or lower arm 229 March 31, 2023

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231. Dialysis Absolute indications for dialysis include: Symptoms or signs of the uremic syndrome Refractory hypervolemia Sever hyperkalemia Metabolic acidosis. 231 March 31, 2023

232. Obstruction of urinary system 232 March 31, 2023

233. Benign Prostatic Hyperplasia is enlargement, or hyper-trophy, of the prostate gland. The prostate gland enlarges, extending upward into the bladder and obstructing the out-flow of urine is common in men older than 40 years Clinical Manifestations • The prostate is large, rubbery, and nontender . • Hesitancy in starting urination, increased frequency of urination , nocturia , urgency, abdominal straining . 233 March 31, 2023

234. Decrease in volume and force of urinary stream, interrup-tion of urinary stream, dribbling • Sensation of incomplete emptying of the bladder, acute urinary retention (more than 60 mL), and recurrent UTIs. • Fatigue, anorexia, nausea and vomiting, and pelvic discom -fort are also reported, and ultimately azotemia and renal failure result with chronic urinary retention and large residual volumes. Rt : catheterization , prostatectomy 234 March 31, 2023

235. CANCER OF THE PROSTATE Prostate cancer is the most common cancer in men Risk factors for prostate cancer increasing age : after the age of 50 years, and more than 70% of cases occur in men over 65 years Familial predisposition A diet high in red meat and fat increases the risk for prostate cancer March 31, 2023 235

236. Clinical Manifestations Early asymptomatic Large tumor : difficulty and frequency of urination, urinary retention, and decreased size and force of the urinary stream, Other symptoms may include blood in the urine or semen and painful ejaculation Physical examination stony hard prostate on DRE March 31, 2023 236

237. Dx : through biopsy and cytology PSA: may indicate prostate mass Rx: surgical, chemotherapy and radiation March 31, 2023 237

238. Nephrolithiasis Renal stones (calculi) consist mainly of crystal aggregates. Stones form in the collecting ducts and may be deposited anywhere from renal pelvis to urethra. 238 March 31, 2023

239. Types of stones Calcium Oxalate: (39.4%) Calcium Oxalate/phosphate:(13.8%), Phosphate : ( 15.4%), Calcium Phosphate : (13.2%), uric acid (8%), cysteine (2.8%), mixed stones (6.4%). 239 March 31, 2023

240. Location Nephrolithiasis refers to a kidney stone , the size of which may range from microscopic to several centimeters . Ureterolithiasis is a stone in the ureter. Ureteral stones usually are small; some may be no larger than a grain of sand. 240 March 31, 2023

241. Pathophysiology and Etiology The reason urinary calculi form is not fully understood. Predisposing factors include the following : Calciuria Dehydration UTI with urea-splitting organisms such as P. mirabilis , Obstructive disorders Metabolic disorders, such as gout Osteoporosis, in which bone is demineralized Prolonged immobility Cystinuria dietary oxalate/ hyperoxaluria 241 March 31, 2023

242. Effects due to stone Calculi traumatize the walls of the urinary tract pain as violent contractions of the ureter Total or partial obstruction Increase in pressure above obstruction Pressure causes pain The retained urine distend the renal pelvis hydronephrosis 242 March 31, 2023

243. Signs and Symptoms Symptoms of a kidney or ureteral stone vary with size, location, and cause. Small stones may pass unnoticed; Pain: Stones in the kidney cause loin pain. Stones in the ureter cause renal (ureteric) colic . This classically radiates from the loin to the groin and is associated with nausea and vomiting 243 March 31, 2023

244. Bladder or urethral stones may cause pain on micturition, strangury or interruption of urine flow Infection may be acute, chronic, or recurrent may present with cystitis (frequency, dysuria), pyelonephritis (fever, rigors, loin pain, nausea, vomiting), or pyonephrosis ( infected hydronephrosis ). Other : haematuria ; proteinuria; sterile pyuria ; calculus anuria. 244 March 31, 2023

245. Tests Urinalysis shows evidence of gross or microscopic hematuria In addition, the urinalysis may show a pH conducive to stone formation, increased specific gravity, mineral crystals , and casts. Leukocytes in the urine and an elevated white blood cell count indicate an infectious process. Radiography identifies most translucent kidney stones. If visualization is inconclusive, an IVP shows dye-filling defects caused by a stone. The dye stops at a certain point in the ureter and demonstrates enlargement above the obstruction. Kidney ultrasonography also detects obstructive changes . Depending on how long the stone has been present, some blood chemistry values, such as serum creatinine , BUN , and serum uric acid, may be elevated. Analysis of the stone content is useful in preventing recurrence. 245 March 31, 2023

246. Medical Management Small calculi are passed naturally with no specific interventions. If the stone is 5 mm or less in diameter and moving, the pain is tolerable, and if there is no obstruction, the client is managed medically with vigorous hydration, analgesics (including opioids and NSAIDs), antimicrobial therapy, and drugs that dissolve calculi or eventually alter conditions that promote their formation. For larger stones, extracorporeal shock wave lithotripsy (ESWL ), a procedure that uses 800 to 2400 shock waves aimed from outside the body toward soft tissue to dense stones, may be used. The stones are shattered into smaller particles that are passed from the urinary tract . Renal Colic: IV fluid , analgesia( dicofenac or Morphine) metoclopramide 10mg IV and antibiotics Procedures: retrograde stent insertion, nephrostomy, and antegrade pyelography Open surgery is rarely needed 246 March 31, 2023

247. Prevention Drink plenty of fluid, especially in summer or tropics (keep urine output >3L/24h). drink enough at night to cause voiding 2–3 times per night Calcium stones: calcium intake (dairy products); avoid vitamin D supplements . Oxalate stones: oxalate intake (less tea, chocolate, nuts, strawberries, rhubarb, spinach, beans, beetroot ) Triple phosphate stones: antibiotics urinary alkalinization (to maintain pH >6); allopurinol (100–300mg/24h PO ). Cystine stones: vigorous hydration 247 March 31, 2023

248. March 31, 2023 248

249. Orchitis Orchitis is inflammation of the testis (testicular congestion). The S/S of orchitis usually have an abrupt onset, including Testicular swelling on one or both sides Pain – mild to severe; Tenderness in one or both testicles N/V, Fever Discharge from penis Prostate enlargement and tenderness March 31, 2023 249

250. Causes - A number of bacterial & viral organisms can lead to orchitis . Bacterial orchitis –Often the cause of the infection is an STD, particularly gonorrhea or Chlamydia. Viral orchitis - Most cases are the result of mumps. Physical trauma – particularly in individuals with hazardous occupation Thermal – (radiation) decrease testicular secretion & can cause atrophy of the testis. March 31, 2023 250

251. Risk factors Not being immunized against mumps; Being older than 45; Recurring UTI Surgery that involves the genitals or urinary tract, b/s of the risk of infection Malformations in the urinary tract present at birth (congenital) High-risk sexual behaviors that can lead to STDs March 31, 2023 251 Complications testicle to shrink (atrophy). Scrotal abscess Rarely it can impair fertility

252. Treatment Symptomatic Rx for viral orchitis : analgesics, bed rest, elevating the scrotum and applying cold packs. Antibiotic for bacterial orchitis Protection of STIs & Sexual partner management if the cause is an STI Immunization against mumps March 31, 2023 252

253. EPIDIDYMITIS Epididymitis is an infection of the epididymis that usually descends from an infected prostate or urinary tract . It may also develop as a complication of gonorrhea. In men younger than age 35, the major cause of epididymitis is Chlamydia trachomatis c/f; unilateral pain and soreness in the inguinal canal pain and swelling in the scrotum and the groin . Fever and chills Pyuria and bacteria in urine Rx: antibiotics , epididymectomy (recurrent) Complications: infertility March 31, 2023 253

254. March 31, 2023 254

255. TESTICULAR CANCER Testicular cancer is the most common cancer in men 15 to 35 years of age . Classification: germinal, non germinal and secondary March 31, 2023 255

256. March 31, 2023 256 Classification: Germinal Non Germinal Secondary 90% of cases Seminomas Non seminomas 4% of cases Leydig cell tumor Sertoli cell Most common lymphoma Poor prognosis Clinical Manifestations Initially pain less swelling of testicles Local extension: backache from lymph node involvement Metastasis weight loss, weakness

257. March 31, 2023 257 Diagnosis Tumor marker: HCG and AFP(alpha fetoprotein) Imaging Biopsy Management Surgery Chemo and radiation therapy

258. March 31, 2023 258 HYDROCELE A hydrocele is a collection of fluid, generally in the tunica vaginalis of the testis, although it may also collect within the spermatic cord . The tunica vaginalis becomes widely distended with fluid . Hydrocele can be differentiated from a hernia by transillumination ; a hydrocele transmits light, whereas a hernia does not. Hydrocele may be acute or chronic. Acute hydrocele may occur in association with acute infectious diseases of the epididymis or as a result of local injury or systemic infectious diseases, such as mumps . The cause of chronic hydrocele is unknown . Mild hydrocele do not require treatment Large hydrocele: surgery

259. March 31, 2023 259

260. March 31, 2023 260 VARICOCELE A varicocele is an abnormal dilation of the veins of the pampiniform venous plexus in the scrotum (the network of veins from the testis and the epididymis that constitute part of the spermatic cord). usually occur in the veins on the upper portion of the left testicle in adults . In some men, a varicocele has been associated with infertility . Few, if any, subjective symptoms may be produced by the enlarged spermatic vein, and no treatment is required unless fertility is a concern. Symptomatic varicocele (pain, tenderness, and discomfort in the inguinal region) is corrected surgically by ligating the external spermatic vein at the inguinal area. An ice pack

261. March 31, 2023 261

262. Testicular torsion Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum. The reduced blood flow causes sudden and often severe pain and swelling . Surgical untwisting March 31, 2023 262

263. Phimosis It is a condition in which the foreskin is constricted so that it can not be retracted over the glans penis. Cause – congenitally or inflammation Treatment - instruction to clean the preputial area. - Circumcision is the only management March 31, 2023 263

264. Paraphimosis It is a condition in which the foreskin is retracted behind the glans penis & because of narrowing and subsequent edema can not be reduced back to its position. Treatment – manual reduction but circumcision is the best management. March 31, 2023 264

265. Phimosis is a tight prepuce that cannot be retracted over the glans Paraphimosis is a tight prepuce that, once retracted, cannot be returned. 265 March 31, 2023

266. Priapism Priapism is a prolonged erection of the penis. The persistent erection continues hours beyond or isn't caused by sexual stimulation. Priapism is usually painful . Priapism most commonly affects men in their 30s and older . March 31, 2023 266

267. Causes Blood disorders Prescription medications Alcohol and drug use Injury Other factors March 31, 2023 267

268. Symptoms Ischemic and non ischemic Ischemic priapism , also called low-flow priapism, is the result of blood not being able to leave the penis . Erection lasting more than four hours or unrelated to sexual interest or stimulation Rigid penile shaft, but the tip of penis (glans) is soft Progressive penile pain March 31, 2023 268

269. Nonischemic priapism, also known as high-flow priapism, occurs when penile blood flow isn't regulated appropriately . Erection lasting more than four hours or unrelated to sexual interest or stimulation Erect but not fully rigid penile shaft March 31, 2023 269

270. March 31, 2023 270 Prevention to prevent future episodes Treatment for an underlying condition, such as sickle cell anemia, that might have caused priapism Use of oral or injectable phenylephrine. Veno -dilator Aspiration of blood with needle

271. March 31, 2023 271 Sexually transmitted infections

272. March 31, 2023 272 The STIs are preventable diseases and curable (except viral STIs which includes HIV, HPV, HBV and herpes simplex) The Mode of transmission Sexual intercourse (Most common) Mother to child Blood transfusion Other contacts with blood or blood products

273. March 31, 2023 273 Service provider generally use one of the following three diagnostic approaches in the management of STIs Etiologic approach :- By identifying the causative agent using lab diagnosis. Clinical approach :- Using clinical experience to identify symptoms which are typical for specific STI. Syndromic approach :- identification of clinical syndromes .

274. March 31, 2023 274 Examination of patient with STIs History taking P/E with or without laboratory support During examination Create good relationship with the patient Build trust Provide privacy and confidentiality to prevent stigmatization

275. March 31, 2023 275 urethral discharges Vaginal discharges genital ulcer, lower abdominal pain, scrotal swelling inguinal bubo neonatal conjunctivitis Common syndromes in STIs

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277. March 31, 2023 277 Aetiology N. gonorrhe Commonest causes of urethral discharge & dysuria C. Trachomatis T. Vaginalis Rare causes of urethritis Ureaplasma urealyticum Urethritis caused by N. gonorrhoea has usually an acute onset with profuse and purulent discharge while that of C. trachomitis will be of subacute onset with scanty mucopurulent discharge . However, mixed infections by both organisms can occur in 20% of pts

278. Treatment Ciprofloxacin, 500mg PO stat OR Spectinomycin , 1gm IM as single dose PLUS Doxycycline, 100 mg PO bid for 7 days OR Tetracycline, 500mg PO QID for 7days OR Erythromycine , 500 mg po qid for 7 days Persistent/ Recurent Urethral Discharge Metronidazole, 2gm PO as a single dose March 31, 2023 278

279. March 31, 2023 279 Genital Ulcer Primary syphilis , genital herpes , chancroid , LGV , and granuloma inguinale are common ulcerative lesions of the genitalia in men and women. Aetiology Common causes of genital ulcer are Treponema palidum – syphilis Herpes simplex virus – herpes genitalia (genital herpes) Haemophilus ducreyi-chancroid Chylamidia trachomatis serotypes L 1 , L 2 and L 3 – LGV Chlymmatobacterium granulomatis – GI

280. March 31, 2023 280 Clinical Features Syphilis (Hard chancre ) A disease characterized by a primary lesion, a later secondary eruption on the skin and mucus membranes, then a long period of latency, and finally late lesion, of skin, bones, viscera, CNS and CVS Etioiopy – Treponema pallidum , a spirochete Three stages are described in the clinical presentation of syphilis. Genital ulcer occurs in the primary stage of the disease. It starts as a small papular lesion that rapidly ulcerates to produce a non –tender, indurated lesion with a clean base and a raised edge known as hard chancre .

281. March 31, 2023 281 Stages of syphilis Primary Secondary Tertiary hard chancre Lymphadenopathy Rash after 4-6weeks Symmetrical Do not itch Contagious destructive, non-infectious lesions of the skin, bones , viscera, and mucosal surfaces CVS and CNS complication

282. March 31, 2023 282 Secondary Syphilis Rash

283. March 31, 2023 283 Secondary Syphilis – Condylomata Lata

284. March 31, 2023 284 Herpes genitalia (Genital herpes) Latency and frequent recurrence occur The lesions are painful initially presenting erythematous macules , which then progress to vesicles, pustules, ulcers and finally crusts. Prolonged and severe disease with extensive tissue involvement and higher rate of dissemination occur in patients with HIV infection. First episode primary genital herpes is x-zed by fever, head ache, malaise and myalgias . Pain, itching, dysuria , vaginal and urethral discharge, and tender inguinal lymph adenopathy are the predominant local symptoms. Complication Genital herpes – Recurrence Aseptic meningitis and encephalitis

285. March 31, 2023 285

286. March 31, 2023 286 Chancroid /soft chancre/ It is a bacterial infection characterized by single or multiple painful necrotizing ulcers at the site of infection . The lesions are painful progressing from a small papule to pustule and then ulcer with soft margins described as soft chancre. Inguinal adenopathy that becomes necrotic and fluctuant (buboes) follow the ulcer. It is endemic and the commonest cause of genital ulcer in many developing countries. Most frequently diagnosed in men , especially those who frequently prostitutes. Complication Penile auto amputation

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288. March 31, 2023 288 LGV ( lymphgranuloma venerium ) The diseaese starts as a small painless papule that develops to an ulcer. After a week or so painful regional lymphadenopathy develops with symptoms of fever, chills, head ache, malaise, anorexia and wt loss. Elephantiasis of genitalia, scrotum and vulva occur in either sex. Complication Genital edema Salphingitis Infertility PID

289. March 31, 2023 289 Granuloma Inguinale It is a chronically progressive ulcerative disease with out systemic symptoms. The pt usually presents with a non- suppurative genital lesion , which develop from a small firm papule to a painless ulcer with a beefy red appearance and non – purulent base. Complication Genital pseudo elephantiasis Adhesion Urethral, vaginal or rectal stenosis .

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291. Treatment for non vesicular genital ulcer Benzathine penicillin G, 2-4 million units IM single dose OR Doxycycline, 100 mg P.O. BID for 14 days PLUS Ciprofloxacin 500 mg po bid for 3 days Treatment for vesicular, multiple or recurrent genital ulcer Acyclovir , 200 mg P.O 5 times daily for 10 days OR 400 mg P.O. TID for 10 days March 31, 2023 291

292. March 31, 2023 292 Vaginal Discharge Causes of vaginal discharge Neisseria gonorrhoea Chylamydia trachomatis Trichomonas vaginalis Gardnerella vaginalis Candida albicans

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294. March 31, 2023 294 The first three are sexually acquired and the last two are endogenous infections. The first two cause cervicitis while the last three cause vaginitis . The presence of vaginal discharge may represent either cervical or vaginal pathology. There fore, the initial evaluation of a pt that has vaginal discharge includes risk assessment and clinical examination with a speculum to determine the site of infection

295. March 31, 2023 295 Vaginitis Bacterial vaginosis , vaginal thrush and trichomoniasis are the usual causes of vaginitis . Bacterial vaginosis and trichomoniasis are more frequent among sexually active women while vaginal thrush occurs when there is impairment of local or systemic defence mechanisms. Risk assessment is usually negative and cervix looks healthy and discharge is not coming from the cervical opening in isolated vaginitis

296. March 31, 2023 296 Cervicitis The presence of purulent or mucopurulent exudation from the cervical os frequently indicates gonococcal or chlamydial infection. The risk factors include age less than 25 yrs, single status, multiple sexual partners, a change of sexual partner recently and history of STI previously either in the pt or in the partner. On speculum examination the presence of redness, contact bleeding, spotting and endocervical discharge suggests the diagnosis of cervicitis

297. March 31, 2023 297 Complications PID PROM(pregnancy) PTL (preterm labour)

298. March 31, 2023 298 Recommended treatment for V. discharge Risk assessment positive Ciprofloxacin 500 mg PO stat Or Spectinomycin 2g IM stat Plus Doxycycline 100mg PO BID for 7 days Plus Metronidazole 500 mg PO BID for 10 days   Risk assessment negative Metronidazole 500 mg PO BID for 7 days Plus Clotrimazole vaginal tab 200mg at bed time for 3 days

299. March 31, 2023 299 Lower abdominal pain due to PID PID refers to an acute clinical syndrome that results from ascending infection from the cervix and/or vagina . The upper structures of the female genital organs are affected. The term PID includes Endometritis , Parametritis , Salphingitis , Oophoritis , Pelvic peritonitis, Tuboovarian abscess and Inflammation around the liver, spleen, or appendix.

300. March 31, 2023 300 The common pathogens associated with PID, which are transmitted through sexual route, include N. gonorrhoea, C. trachomatis , M. Homonis and bacteroides . Other organism like streptococcus species E.coli and H. influenza may some times cause PID but their transmission is not via the sexual route. PID and STI share many of the same risk factors and in most instances PID is caused by STIs.

301. March 31, 2023 301 Clinical Features vaginal discharge Bilateral lower abdominal pain or pelvic pain is the most common clinical complaints Lower abdominal tenderness together with cervical excitation tenderness are indicative of PID. Other causes of lower abdominal pain like appendicitis, ectopic pregnancy, and cholecystitis should be ruled out by proper examination .

302. March 31, 2023 302 Recommended Rx for PID Outpatient Ciprofloxacin 500 mg PO stat Or Spectinomicin 2g IM stat Plus Doxycycline 100mg PO BID for 14 days Plus Metronidazole 500mg PO BID for 14 days Remove IUD and do counselling for contraception Admit if there is no improvement with in 72 hrs

303. March 31, 2023 303 Inpatient Ceftriaxone 250mg IV/IM daily Or Spectinomicin 2g IM BID Plus Doxycycline 100mg PO BID for 14 days Plus Metronidazole 500mg PO BID for 14 days or CAF 500mg QID Inpatient regimen is given for at least 48 hrs and the pt clinically improves After discharge from hospital the pt has to continue with the oral Rx.    

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305. March 31, 2023 305 Scrotal swelling The cause of scrotal swelling can vary depending on the age of the pt. Among pts who are younger than 35 years, the swelling is likely to be caused by N. gonorrhoea and c. trachomatis . However scrotal swelling among patients older than 35 yrs is commonly caused by gram-negative organisms and rarely TBc .

306. Scrotal swelling…. Other infectious causes of scrotal swelling could be brucellosis, mumps, onchocerciasis or infection with w. bancrofti . It is important to exclude other causes of scrotal swelling like testicular torsion, trauma and incarcerated inguinal hernia as they may require urgent referral for proper surgical evaluation and Rx. Complications Epididymitis Infertility Impotence Prostatitis March 31, 2023 306

307. March 31, 2023 307 Recommended Rx of scrotal swelling The Rx of scrotal swelling suspected to be of STI origin is similar to that of a urethral discharge . Ciprofloxacin 500mg PO stat Or Spectinomycin 2gm IM stat Plus Doxycycline 100mg PO BID for 7days Or TTC 500mg PO BID for 7 days

308. March 31, 2023 308 Inguinal bubo It is swelling of inguinal lymph nodes as a result of STI, it should be remembered that infections on the lower extremities or in the perineum could produce swelling of the inguinal lymph nodes The common sexually transmitted pathogens that cause inguinal swelling include T. pallidum , C. trachomatis , (serotype L 1 , L 2 , L 3 ), H. ducreyi and C. granulomatis . However, unlike other causes of inguinal bubo, syphilis doesn’t cause necrosis and abscess collection in the lymph nodes. In conditions where the clinical examination doesn’t reveal fluctuant bubo, syphilis should be considered and be treated accordingly. Surgical incisions are contraindicated and the pus should only be aspirated using a hypodermic needle.