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🫀 UROLOGY — COMPLETE DEEP REVIEW

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1. ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY (GU) SYSTEM

Upper Urinary Tract

• Paired retroperitoneal organs located at T12–L3, right kidney slightly lower due to the liver
• Each kidney weighs ~150 g; dimensions approximately 11 × 6 × 3 cm
• Gross structure: Cortex (outer) contains glomeruli and proximal/distal tubules; Medulla (inner) contains loops of Henle and collecting ducts organized into pyramids; Papillae project into minor calyces → major calyces → renal pelvis
• Nephron (~1 million per kidney): the functional unit
  • Glomerulus → Bowman's capsule → Proximal convoluted tubule (PCT) → Loop of Henle → Distal convoluted tubule (DCT) → Collecting duct
• Blood supply: Renal artery (from abdominal aorta at L1–L2) → segmental → interlobar → arcuate → interlobular arteries → afferent arteriole → glomerular capillaries → efferent arteriole → peritubular capillaries / vasa recta
• Renal physiology:
  • GFR: ~125 mL/min (180 L/day filtered; ~1.5 L excreted)
  • Functions: filtration, reabsorption, secretion, concentration/dilution, acid-base regulation, erythropoietin secretion, vitamin D activation (1α-hydroxylation), renin secretion (RAAS), prostaglandin synthesis

• Muscular tubes ~25–30 cm long connecting renal pelvis to urinary bladder
• Three layers: transitional epithelium (urothelium), smooth muscle (inner longitudinal, outer circular), adventitia
• Three natural narrowings (sites of stone impaction):
  1. Ureteropelvic junction (UPJ)
  2. Pelvic brim (crossing of iliac vessels)
  3. Ureterovesical junction (UVJ) — narrowest point
• Peristaltic contractions propel urine (2–6 contractions/min)
• Blood supply: segmental (renal, gonadal, aortic, iliac, vesical arteries)
• Innervation: T10–L2 (sympathetic); pain from ureteral obstruction refers to flank, groin, ipsilateral testicle/labia

Lower Urinary Tract

• Hollow muscular organ in the pelvis behind the pubic symphysis
• Layers: urothelium → lamina propria → detrusor muscle (3 interlacing smooth muscle layers) → adventitia/serosa
• Capacity: ~400–600 mL (first desire to void ~150–200 mL)
• Trigone: triangle at bladder base between two ureteral orifices and internal urethral meatus — smooth, non-distensible
• Micturition physiology:
  • Storage: sympathetic (hypogastric nerve, T10–L2) → relaxes detrusor, contracts internal sphincter; somatic (pudendal nerve, S2–S4) → contracts external sphincter
  • Voiding: parasympathetic (pelvic nerve, S2–S4) → contracts detrusor; somatic relaxation of external sphincter
  • Pontine micturition center coordinates the process

• Male: ~20 cm; 4 segments: prostatic (3 cm), membranous (1–2 cm), bulbar, penile/spongy
• Female: ~4 cm; runs anterior to vagina; much wider → lower infection resistance
• External sphincter: skeletal muscle, voluntary control

Male Genital Organs

• Prostate: walnut-sized gland (20 g normal) encircling the prostatic urethra; three zones: peripheral (70% — site of cancer), central (25%), transition (5% — site of BPH); secretes PSA, citric acid, zinc
• Testes: intra-scrotal, spermatogenesis (seminiferous tubules), testosterone production (Leydig cells), regulated by HPG axis
• Epididymis → Vas deferens → Ejaculatory duct
• Seminal vesicles (fructose-rich secretion, 60% of ejaculate volume)

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2. SYMPTOMATOLOGY OF UROLOGICAL DISEASES

Lower Urinary Tract Symptoms (LUTS)

Pain Patterns

Urinary Changes

• Hematuria (most important urological symptom):
  • Gross vs. microscopic (>3 RBC/HPF)
  • Initial hematuria → urethral/prostatic lesion
  • Terminal hematuria → bladder neck/trigone lesion
  • Total hematuria → kidney, ureter, or generalized bladder lesion
  • Painless gross hematuria = bladder cancer until proven otherwise
• Pyuria: >10 WBC/HPF → infection
• Pneumaturia: gas in urine → vesico-enteric fistula
• Chyluria: milky urine → lymphatic fistula
• Oliguria/Anuria: <400 mL/day / <100 mL/day
• Polyuria: >3 L/day

Other Symptoms

• Urethral discharge: purulent (gonorrhea), mucoid (chlamydia)
• Scrotal swelling: hydrocele, varicocele, epididymo-orchitis, tumor
• Incontinence types: stress (SUI), urgency (UUI), overflow, functional, mixed

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3. LABORATORY, INSTRUMENTAL & RADIOLOGIC EXAMINATION

Laboratory Tests

• Specific gravity (1.003–1.030), pH, protein, glucose, ketones
• Microscopy: RBCs (dysmorphic = glomerular), WBCs, casts (RBC cast = glomerulonephritis), bacteria, crystals

• Midstream clean catch; significant bacteriuria ≥10⁵ CFU/mL (≥10³ if symptomatic)
• Identifies organism and antibiotic sensitivity

• Creatinine clearance, protein excretion, stone-forming minerals (calcium, oxalate, citrate, uric acid)

Instrumental Examination

• Uroflowmetry: Qmax >15 mL/s normal; <10 mL/s suggests obstruction
• Cystometry (CMG): assesses bladder compliance, capacity, detrusor overactivity
• Pressure-flow studies: differentiates obstruction from detrusor underactivity
• Urethral pressure profilometry

• Direct visualization of urethra, bladder; flexible (diagnostic) vs. rigid (operative)
• Indications: hematuria, suspected tumor, stricture, biopsy
• Narrow-band imaging (NBI), photodynamic diagnosis (PDD) enhance flat lesion detection

• Rigid or flexible; for upper tract stone treatment, tumor biopsy, stricture evaluation

Radiologic Examination

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4. CONGENITAL ANOMALIES OF THE GENITOURINARY SYSTEM

Renal Anomalies

• Renal agenesis:
  • Unilateral (1:1000): contralateral compensatory hypertrophy; associated with ipsilateral absent vas/uterine horn; often asymptomatic
  • Bilateral (Potter sequence): oligohydramnios → pulmonary hypoplasia, limb deformities, characteristic facies; lethal
• Supernumerary kidney: extremely rare; extra kidney with separate collecting system

• Renal hypoplasia: small but otherwise normal kidney (<50% normal size); may lead to hypertension and CKD
• Polycystic Kidney Disease (PKD):
  • ADPKD (PKD1/PKD2 mutations): most common hereditary renal disease; bilateral cysts progressive from adulthood → ESRD median 54 years; extrarenal: liver cysts, intracranial aneurysms (5–10%), mitral valve prolapse; Dx: US/CT; Treatment: tolvaptan (V2 receptor antagonist) slows progression
  • ARPKD (PKHD1 mutation): presents in infancy/neonatal period; enlarged echogenic kidneys; congenital hepatic fibrosis; high neonatal mortality
• Medullary sponge kidney: dilated collecting tubules with small medullary cysts; presents with nephrolithiasis and UTIs; benign course
• Multicystic dysplastic kidney (MCDK): non-functioning kidney replaced by cysts; typically unilateral; involutes spontaneously

• Simple renal ectopia: kidney fails to ascend; pelvic kidney most common; risk of obstruction and infection
• Crossed renal ectopia: kidney crosses midline, fuses or not with contralateral kidney
• Horseshoe kidney (1:400):
  • Isthmus (usually parenchymal) connects lower poles at L4–L5 anterior to aorta
  • Caught on inferior mesenteric artery, preventing full ascent
  • Associated with VUR, UPJ obstruction, stone formation, Wilms tumor
  • Diagnosis: US, CT (classic "U" shape on CT); usually incidental
  • Treatment: only if complications arise

• Malrotation: renal pelvis faces anteriorly instead of medially; often accompanies ectopia

Collecting System Anomalies

• Ureteropelvic Junction (UPJ) Obstruction: most common cause of hydronephrosis in children; intrinsic stenosis or crossing vessel; Tx: pyeloplasty (Anderson-Hynes dismembered pyeloplasty — gold standard)
• Ureterovesical Junction (UVJ) Obstruction / Megaureter: primary (aperistaltic segment) or secondary (posterior urethral valves)
• Duplex collecting system (1:125): partial or complete ureteral duplication; Weigert-Meyer rule: upper pole ureter inserts ectopically (more medially/inferiorly) → prone to obstruction; lower pole ureter inserts normally → prone to VUR
• Ureterocele: cystic dilation of intravesical ureter; orthotopic vs. ectopic; may cause obstruction
• Vesicoureteral Reflux (VUR): retrograde urine flow; graded I–V; can cause reflux nephropathy and renal scarring; International Reflux Study: spontaneous resolution common in grades I–III; Tx: antibiotic prophylaxis, endoscopic injection (STING), reimplantation for high-grade persistent reflux
• Posterior Urethral Valves (PUV): most common cause of severe obstructive uropathy in boys; type I (most common — leaflets from verumontanum to lateral walls); presents as neonatal distress, palpable bladder; Dx: VCUG; Tx: endoscopic valve ablation

Bladder Anomalies

• Bladder exstrophy: failure of anterior abdominal wall closure; bladder mucosa exposed; associated with epispadias; complex surgical reconstruction
• Bladder diverticulum: congenital (primary) or acquired; risk of infection, stone, tumor
• Urachal anomalies: persistent urachus → urachal fistula (umbilical urine drainage), cyst, sinus, diverticulum; risk of adenocarcinoma

Urethral Anomalies

• Hypospadias: urethral meatus opens on ventral surface of penis (glandular 50%, coronal, penile, scrotal, perineal); associated with chordee; Tx: urethroplasty (Snodgrass/TIPU procedure); circumcision contraindicated preoperatively
• Epispadias: meatus on dorsal surface; associated with bladder exstrophy; rare in isolation
• Urethral stricture: congenital narrowing; more commonly acquired

Penile/Testicular Anomalies

• Phimosis: inability to retract foreskin; physiologic until age 3–5; pathologic if symptomatic → topical steroids, circumcision
• Cryptorchidism (undescended testis): most common male genital anomaly (3% term, 30% preterm); unilateral > bilateral; risk of infertility, malignancy (4–10× risk), torsion; Tx: orchiopexy by 12–18 months (improves fertility, does not eliminate cancer risk but allows surveillance)
• Varicocele: dilated pampiniform plexus; left > right (90%); "bag of worms"; associated with male infertility; Tx: surgical ligation or embolization if symptomatic or infertility
• Hypospadias (see above)

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5. TRAUMA OF THE GENITOURINARY SYSTEM

Renal Trauma

• Hematuria (gross or micro) + mechanism → CT with IV contrast (multi-phase)
• Note: degree of hematuria does NOT correlate with injury severity (Grade V may have no hematuria if pedicle avulsed)

• Grades I–III: Non-operative management (NOM); bed rest, serial Hgb, repeat imaging if deterioration
• Grade IV: NOM in hemodynamically stable; angioembolization for arterial bleeding
• Grade V: Urgent surgery (nephrectomy or vascular repair); angioembolization may be tried
• Surgical exploration indications: hemodynamic instability, expanding/pulsatile hematoma, suspected vascular injury, ureteropelvic disruption

Ureteral Trauma

• Rare (1% of urinary tract injuries)
• Usually iatrogenic (gynecologic/colorectal surgery) or penetrating trauma
• Blunt: UPJ disruption (deceleration injury)
• Diagnosis: CT urogram, retrograde pyelography; high suspicion as often missed
• Presentation: delayed — urinoma, fever, flank pain, urine leak from wound
• Management:
  • Intraoperative recognition → primary repair over stent (ureteroureterostomy) or ureteroneocystostomy
  • Delayed recognition → percutaneous nephrostomy to divert, then definitive repair

Bladder Trauma

• Contusion: incomplete mucosal tear; no extravasation
• Extraperitoneal rupture (60%): from pelvic fracture; flame-shaped extravasation on cystogram
• Intraperitoneal rupture (30%): blunt force on full bladder; contrast fills peritoneal cavity; requires surgical repair
• Combined (10%)

• Do NOT rely on CT without retrograde filling — bladder must be actively distended

• Extraperitoneal: urethral catheter drainage 10–14 days (most heal spontaneously)
• Intraperitoneal: urgent surgical repair (2-layer closure)

Urethral Trauma

• Mechanism: straddle injury, Foley catheter trauma, penile fracture
• Symptoms: blood at meatus, perineal hematoma (butterfly hematoma)
• Diagnosis: retrograde urethrogram (RUG)
• Treatment: suprapubic catheter → delayed urethroplasty (3–6 months)

• Mechanism: pelvic fracture (associated in 10% of pelvic fractures)
• Classic triad: blood at meatus, inability to void, high-riding/floating prostate on DRE
• NEVER pass urethral catheter blindly if urethral injury suspected → perform RUG first
• Treatment: suprapubic cystostomy as immediate management → delayed primary repair (3 months) via perineal approach
• Complications: stricture, impotence (injury to neurovascular bundles), incontinence

Testicular and Penile Trauma

• Testicular rupture: direct blunt force; US shows disrupted tunica albuginea; Tx: urgent surgical exploration and repair (orchiopexy) or orchidectomy if unviable
• Penile fracture: rupture of tunica albuginea during intercourse; "pop," immediate detumescence, eggplant deformity; Tx: immediate surgical repair
• Penile amputation/degloving: surgical emergency; reimplantation if feasible

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6. NONSPECIFIC INFECTIONS OF THE GENITOURINARY SYSTEM

Urinary Tract Infections (UTI)

• Uncomplicated UTI: normal urinary tract, non-pregnant woman
• Complicated UTI: abnormal tract, catheter, pregnancy, male, immunosuppressed, recurrent, resistant organism
• Significant bacteriuria: ≥10⁵ CFU/mL (symptomatic) or ≥10³ CFU/mL

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Acute Cystitis

• Symptoms: dysuria, frequency, urgency, suprapubic pain, cloudy/smelly urine; NO fever
• Diagnosis: Dipstick (nitrites + leukocyte esterase positive); urine culture
• Treatment:
  • Uncomplicated female: nitrofurantoin 100mg BD × 5 days; or trimethoprim-sulfamethoxazole × 3 days; or fosfomycin 3g single dose
  • Avoid fluoroquinolones for uncomplicated UTI (resistance, side effects)
  • Complicated: 7–14 days based on culture

Acute Pyelonephritis

• Bacterial infection of renal parenchyma and collecting system
• Symptoms: high fever (>38.5°C), chills, flank pain, costovertebral angle (CVA) tenderness, nausea/vomiting ± lower urinary symptoms
• Diagnosis:
  • Urine culture (mandatory), blood cultures if severe
  • CBC: leukocytosis; CRP elevated
  • US/CT if no improvement at 72h (to rule out abscess, obstruction, emphysematous pyelonephritis)
• CT findings: wedge-shaped areas of reduced enhancement (focal pyelonephritis)
• Treatment:
  • Outpatient (mild): oral fluoroquinolone × 7 days (ciprofloxacin 500mg BD) or TMP-SMX × 14 days
  • Inpatient: IV ceftriaxone or piperacillin-tazobactam → oral step-down after 48h afebrile
  • Duration: 14 days total
• Complications: renal abscess, perinephric abscess, sepsis, renal scarring, emphysematous pyelonephritis (gas in renal parenchyma — diabetics — urgent nephrectomy or percutaneous drainage)

Chronic Pyelonephritis / Reflux Nephropathy

• Renal parenchymal scarring from recurrent infections ± VUR
• Imaging: cortical scars overlying dilated clubbed calyces (DMSA scan — gold standard for scarring)
• Can lead to hypertension and CKD

Prostatitis Syndromes (NIH Classification)

Epididymitis and Orchitis

• Acute epididymitis:
  • <35 years: STI (Chlamydia trachomatis, N. gonorrhoeae) → Doxycycline + ceftriaxone

  • 35 years: enteric organisms (E. coli) → fluoroquinolone

  • Symptoms: gradual scrotal pain/swelling, epididymal tenderness; Prehn's sign (pain relief on elevation) may be positive
  • US (color Doppler): increased blood flow (distinguishes from torsion which shows absent flow)
• Orchitis: usually viral (mumps — parotitis precedes by 4–6 days); bacterial by extension from epididymitis; may cause infertility

Fournier's Gangrene

• Necrotizing fasciitis of perineum/scrotum/penis
• Polymicrobial (aerobic + anaerobic synergy); risk factors: diabetes, immunosuppression
• Symptoms: pain out of proportion, crepitus, "dishwater" discharge, rapid spread
• Treatment: EMERGENCY — broad-spectrum antibiotics (imipenem or pip-tazo + metronidazole) + aggressive surgical debridement (often multiple returns to OR); hyperbaric O₂ adjunct; mortality 20–40%

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7. UROLITHIASIS (URINARY STONE DISEASE)

Epidemiology

• Lifetime prevalence ~12% men, ~6% women; recurrence rate ~50% at 10 years
• Peak age: 20–50 years; M:F = 3:1

Stone Composition

Pathophysiology

• Supersaturation of urine → nucleation → crystal aggregation → stone growth
• Promoters: low urine volume, hypercalciuria, hyperoxaluria, hyperuricosuria, low urine pH (uric acid), alkaline urine (struvite, calcium phosphate)
• Inhibitors: citrate (most important — chelates calcium), Tamm-Horsfall protein, pyrophosphate, magnesium

1. Absorptive (most common): increased intestinal Ca absorption → increased urinary Ca
2. Resorptive: hyperparathyroidism → elevated PTH → bone resorption + increased 1,25-OH-D
3. Renal leak: defective tubular Ca reabsorption

Clinical Presentation

• Renal colic: sudden onset, severe, colicky flank pain radiating to groin/ipsilateral genitalia; patient cannot find comfortable position (distinguishes from peritoneal pain)
• N/V, diaphoresis, microscopic hematuria (>85%)
• Stone location symptoms:
  • UPJ: flank pain
  • Mid-ureter: anterior abdominal pain
  • Distal ureter near bladder: irritative LUTS (frequency, urgency)
• Fever + obstruction = urological emergency (infected obstructed kidney → urosepsis)

Diagnosis

Management

• IV access, analgesia: NSAIDs first-line (ketorolac/diclofenac — superior to opioids in RCTs), opioids if NSAIDs contraindicated
• IV fluids if dehydrated; anti-emetics
• Alpha-blockers (tamsulosin): medical expulsive therapy (MET); increases passage rate for distal ureteral stones ≤10 mm (relaxes ureteral smooth muscle)

• Fever + obstruction (infected obstructed system — sepsis risk)
• Solitary kidney with obstruction
• Bilateral obstruction
• Uncontrollable pain or vomiting
• Acute kidney injury

• Increase fluid intake (urine output >2.5 L/day)
• Dietary: reduce sodium, moderate calcium intake (do NOT restrict — paradoxically increases oxalate absorption), limit oxalate-rich foods, moderate protein
• Potassium citrate for hypocitraturia, uric acid, and calcium oxalate stones
• Thiazide diuretics for hypercalciuria (reduces urinary calcium)
• Allopurinol for hyperuricosuria

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8. HYDRONEPHROSIS

Definition

Grading (Society for Fetal Urology — SFU)

Etiology

• Calculus (most common in adults)
• Blood clot
• Papillary necrosis
• Tumor (transitional cell carcinoma)

• UPJ obstruction (most common in children)
• UVJ obstruction / stricture
• Ureterocele
• Posterior urethral valves (bilateral hydronephrosis in boys)

• Malignancy: cervical, colorectal, bladder, prostate cancer
• Retroperitoneal fibrosis (RPF): idiopathic (associated with IgG4 disease) or secondary
• Pregnancy (physiologic, right > left due to dextrorotation of uterus)
• Lymphadenopathy
• Aortic aneurysm

Pathophysiology of Obstruction

• Acute obstruction → ureteral pressure rises → GFR drops → renal blood flow decreases
• Prolonged obstruction → tubular atrophy, interstitial fibrosis, nephron loss
• Unilateral obstruction: contralateral kidney compensates
• Bilateral obstruction: post-renal acute kidney injury (AKI); presents as anuria → urgent decompression required

Clinical Features

• Intermittent or constant flank pain (worse with increased fluid intake — Dietl's crisis in UPJ obstruction)
• Palpable mass (in neonates/children)
• Recurrent UTIs
• Hematuria
• Hypertension
• Renal failure (bilateral)
• Often asymptomatic (incidental finding)

Diagnosis

Management

• Percutaneous nephrostomy (PCN): direct retrograde drainage; preferred when ureteral stenting fails
• Ureteral stenting (double-J/JJ stent): endoscopic; bypasses obstruction

• UPJ obstruction: Dismembered pyeloplasty (Anderson-Hynes) — gold standard; laparoscopic preferred; >90% success
• Ureteral stricture: balloon dilation, endoureterotomy, or open/laparoscopic repair
• Stone: as per urolithiasis management
• Tumor: oncologic management
• Retroperitoneal fibrosis: steroids (idiopathic/IgG4), ureterolysis, tamoxifen; stenting
• Posterior urethral valves: valve ablation

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9. TUMORS OF THE GENITOURINARY SYSTEM

A. RENAL TUMORS

Renal Cell Carcinoma (RCC)

• Classic triad (10% of patients): flank pain + hematuria + palpable mass = advanced disease
• Most: incidental finding on imaging
• Paraneoplastic syndromes (20%):
  • Polycythemia (ectopic EPO)
  • Hypercalcemia (PTHrP)
  • Hypertension (renin)
  • Stauffer syndrome (non-metastatic hepatic dysfunction — reverses after nephrectomy)
  • Cushing syndrome, fever of unknown origin

• T1a: ≤4 cm; T1b: 4–7 cm; T2: >7 cm (all confined to kidney)
• T3: extends to renal vein/IVC/perirenal fat; T3c: IVC above diaphragm
• T4: beyond Gerota's fascia

• CT abdomen with contrast: 3-phase protocol; enhancing mass >20 HU enhancement = suspicious; Bosniak classification for cystic lesions
• MRI: IVC thrombus extent, poor renal function
• CXR/CT chest; bone scan if symptomatic; brain MRI if neurological symptoms
• Biopsy: for metastatic disease (to confirm before systemic therapy); for complex cystic lesions; not routinely needed for solid enhancing mass (go to surgery)

• Localized disease:
  • T1a: partial nephrectomy (nephron-sparing) — standard of care; open/laparoscopic/robotic; renal ablation (RFA, cryoablation) for poor surgical candidates
  • T1b–T2: radical nephrectomy (Gerota's fascia + kidney ± ipsilateral adrenal ± lymphadenectomy) — laparoscopic preferred
  • T3c (IVC thrombus): radical nephrectomy + IVC thrombectomy (may require cardiopulmonary bypass)
• Metastatic (stage IV):
  • Surgery: cytoreductive nephrectomy + resection of solitary metastases (select patients)
  • Systemic therapy: targeted therapy
    • 1st line: sunitinib or pazopanib (VEGFR inhibitors) OR combination ipilimumab + nivolumab (ICI) for intermediate/poor risk
    • 2nd line: cabozantinib, axitinib + pembrolizumab/avelumab
  • RCC is resistant to conventional chemotherapy and radiotherapy

• 5-year survival: T1 ~90%; T2 ~75%; T3 ~60%; T4/metastatic ~12%

Wilms Tumor (Nephroblastoma)

• Most common renal tumor of childhood (peak 3–4 years)
• Embryonal origin (blastemal, stromal, epithelial components)
• Associated: WAGR syndrome (Wilms + Aniridia + GU anomalies + mental Retardation — WT1 deletion 11p13), Beckwith-Wiedemann (WT2 11p15), Denys-Drash (WT1 mutation)
• Presentation: painless abdominal mass; hypertension; hematuria less common
• Never cross midline (unlike neuroblastoma — see below)
• Diagnosis: US, CT abdomen; avoid biopsy (risk of upstaging)
• Treatment: surgical excision (radical nephrectomy) + nephroblastoma protocol (EE-SIOP or COG); chemotherapy (vincristine + actinomycin D ± doxorubicin); radiotherapy for stage III+
• Prognosis: excellent — 5-year survival >85%

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B. UROTHELIAL (TRANSITIONAL CELL) CARCINOMA

Bladder Cancer

• Smoking (most important; 50% of cases; aromatic amines — 2-naphthylamine)
• Occupational exposure: aniline dyes, rubber, leather, paint (aromatic amines)
• Schistosoma haematobium (squamous cell carcinoma — Middle East/Africa)
• Pelvic radiotherapy
• Cyclophosphamide (acrolein metabolite)
• Phenacetin analgesic abuse
• Chronic cystitis

• Urothelial (TCC) 90%
• Squamous cell carcinoma 5% (Schistosoma, chronic irritation)
• Adenocarcinoma 2% (urachal origin, exstrophy)

• Painless gross hematuria (most common; 85%) — until proven otherwise = bladder cancer
• Irritative LUTS (CIS mimics UTI/OAB)
• Advanced: hydronephrosis, pelvic pain, lymphedema

• Urine cytology (sensitivity 90% for high-grade/CIS; poor for low-grade)
• Cystoscopy + biopsy/TURBT (gold standard)
• CT urogram (upper tract evaluation, staging)
• Random bladder biopsies + prostatic urethral biopsy
• Urine markers: NMP22, BTA stat, FISH (UroVysion) — adjuncts

• TURBT (transurethral resection of bladder tumor) — diagnosis + treatment
• Intravesical therapy:
  • Single immediate post-TURBT intravesical chemotherapy (mitomycin C) — reduces recurrence 39%
  • BCG (Bacillus Calmette-Guérin) — most effective agent; immunotherapy for high-risk NMIBC and CIS; induction 6 weeks + maintenance 1–3 years
  • Chemotherapy: mitomycin C, gemcitabine + docetaxel (BCG-unresponsive)
• Risk stratification (EAU):
  • Low risk: TURBT alone + single instillation
  • Intermediate: TURBT + intravesical chemo or BCG
  • High risk / CIS: BCG ± consider cystectomy

• Radical cystectomy (gold standard): male — cystoprostatectomy; female — anterior exenteration (bladder + uterus/ovaries/vaginal wall); pelvic lymphadenectomy
• Urinary diversion: ileal conduit (most common), orthotopic neobladder (continent), Indiana pouch
• Neoadjuvant cisplatin-based chemotherapy (MVAC or gemcitabine/cisplatin) — improves survival by 5–10% at 5 years; MUST be given before cystectomy
• Bladder-sparing trimodality therapy (TMT): maximal TURBT + concurrent chemoradiation — alternative for select patients refusing/unfit for cystectomy
• Metastatic: gemcitabine + cisplatin; pembrolizumab (2nd line); atezolizumab; enfortumab vedotin + pembrolizumab (1st line emerging data)

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C. UPPER TRACT UROTHELIAL CARCINOMA (UTUC)

• Rare (5–10% of urothelial tumors); renal pelvis > ureter
• Lynch syndrome (HNPCC) strongly associated (MLH1, MSH2 mutations)
• Same risk factors as bladder cancer
• Presentation: hematuria, flank pain
• Diagnosis: CT urogram, urine cytology, ureteroscopy + biopsy
• Treatment:
  • Radical nephroureterectomy (RNU) with bladder cuff excision — gold standard
  • Kidney-sparing: ureteroscopic ablation/segmental resection — for low-grade, solitary kidney, bilateral
  • Single postoperative intravesical instillation (chemotherapy)
  • Adjuvant chemotherapy for high-risk

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D. PROSTATE CANCER

• 95% adenocarcinoma; arises from peripheral zone
• Grading: Gleason score (architectural grade 1–5 of two most prevalent patterns; sum = Gleason score 6–10)
• ISUP Grade Groups: Grade 1 (Gleason ≤6), Grade 2 (3+4=7), Grade 3 (4+3=7), Grade 4 (8), Grade 5 (9–10)

• Early: asymptomatic (PSA-detected); localized disease
• Local invasion: obstructive LUTS, hematuria, hematospermia
• Metastatic: bone pain (osteoblastic metastases — axial skeleton, sclerotic on X-ray), pathological fracture, spinal cord compression, constitutional symptoms (weight loss, anemia)

• PSA testing (controversial): individualized decision-making for men 55–69 years after informed discussion; PSA >4 ng/mL prompts biopsy (but threshold varies)
• Digital Rectal Exam (DRE): hard, nodular, asymmetric prostate
• Free:total PSA ratio — higher free PSA = less likely cancer
• PSA density (PSA/prostate volume), PSA velocity

• Multiparametric MRI (mpMRI) — PI-RADS score (1–5); PI-RADS ≥3 → biopsy; reduces unnecessary biopsies and improves detection of clinically significant cancer
• Prostate biopsy: transrectal (TRUS-guided) or transperineal (preferred — lower infection risk); systematic + targeted (MRI-fusion)
• Gleason grade, number of positive cores, % core involvement

• TNM system; key: T3 = extracapsular extension; T4 = invasion of adjacent structures
• Bone scan (if PSA >20, Gleason ≥8, T3/T4 or bone symptoms)
• PSMA PET-CT: superior for nodal/metastatic staging and biochemical recurrence

• Active surveillance (AS): preferred for low-risk/favorable intermediate-risk; PSA every 3–6 months, DRE annually, repeat mpMRI + biopsy; switch to curative treatment if progression
• Radical prostatectomy (RP): open, laparoscopic, or robot-assisted (RARP); nerve-sparing if organ-confined; pelvic lymphadenectomy for intermediate/high risk
• External beam radiotherapy (EBRT): equivalent to surgery for low/intermediate risk
• Brachytherapy (LDR/HDR): seed implants; excellent for low-risk

• Surgery ± adjuvant/salvage RT if positive margins
• EBRT + androgen deprivation therapy (ADT) 6–36 months (adds 10% survival benefit)

• ADT (castration — surgical [bilateral orchidectomy] or medical [LHRH agonists: leuprolide, goserelin; antagonists: degarelix, relugolix])
• Enzalutamide / abiraterone (androgen receptor pathway inhibitors) — added to ADT for metastatic castration-sensitive prostate cancer (mCSPC) and castration-resistant (mCRPC)
• Docetaxel chemotherapy — for high-volume mCSPC (CHAARTED trial) and mCRPC
• Cabazitaxel — 2nd-line chemotherapy for mCRPC
• Radium-223 (Ra-223): alpha-emitting radiopharmaceutical for bone-metastatic CRPC; improves overall survival
• PSMA-targeted therapy (Lu-177-PSMA-617 = Lutetium PSMA): for PSMA-positive mCRPC; VISION trial showed OS benefit
• PARP inhibitors (olaparib, rucaparib): for HRR gene mutations (BRCA1/2)

• RP: urinary incontinence (10–20%), erectile dysfunction (ED) (50–90%); anastomotic stricture
• RT: radiation cystitis/proctitis; late ED; second malignancies
• ADT: hot flushes, osteoporosis, metabolic syndrome, loss of libido, gynecomastia, cognitive effects

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E. BENIGN PROSTATIC HYPERPLASIA (BPH)

• DRE: smooth, rubbery, enlarged prostate; estimate volume
• PSA (exclude cancer; >1.5 correlates with BPH risk)
• Uroflowmetry (Qmax <10 mL/s; voided volume + post-void residual by US)
• Transrectal US (TRUS): prostate volume
• Pressure-flow studies if diagnosis uncertain

• Alpha-blockers (tamsulosin, alfuzosin, silodosin): 1st-line; relax smooth muscle in prostate/bladder neck; effect within days; SE: orthostatic hypotension, retrograde ejaculation
• 5-alpha reductase inhibitors (5-ARIs) (finasteride, dutasteride): shrink prostate 20–30% over 3–6 months; prevent AUR/surgery; best for large prostates (>40 mL); SE: decreased libido, ED, gynecomastia; lower PSA by ~50%
• Combination therapy: alpha-blocker + 5-ARI superior for large glands (MTOPS, CombAT trials)
• PDE-5 inhibitors (tadalafil 5mg daily): approved for LUTS + erectile dysfunction
• Antimuscarinics/Beta-3 agonists (mirabegron): add-on for storage/OAB symptoms after excluding retention

• TURP (Transurethral Resection of Prostate): gold standard; 1–15 cm³ removed per minute; complications: retrograde ejaculation (70%), incontinence (1–3%), TURP syndrome (dilutional hyponatremia from glycine irrigation — now minimized with bipolar/saline), stricture
• Laser techniques: HoLEP (Holmium Laser Enucleation) — preferred for large glands, no size limit; GreenLight laser (PVP); fewer bleeding complications
• Open simple prostatectomy (Millin's/Freyer's): prostate >80–100 mL; Millin's = retropubic; Freyer's = transvesical
• Robotic simple prostatectomy: emerging
• Prostatic urethral lift (UroLift): for men <80 mL without median lobe; preserves ejaculation
• Rezum (steam injection); PAE (prostatic artery embolization): interventional radiology

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F. TESTICULAR TUMORS

• Stage I: confined to testis
• Stage II: retroperitoneal lymph nodes (IIA ≤2 cm, IIB 2–5 cm, IIC >5 cm)
• Stage III: distant metastases or high marker levels

• Testicular US (high sensitivity/specificity; 98%); never perform biopsy transscrotally (risk of lymphatic spread to inguinal nodes instead of retroperitoneal)
• Serum tumor markers: AFP, β-hCG, LDH before surgery (half-lives: AFP ~5–7 days; β-hCG ~1–3 days — post-surgery marker decline confirms staging)
• CT chest/abdomen/pelvis for staging
• PSMA PET or FDG-PET for residual mass post-chemotherapy (seminoma)

• Radical inguinal orchidectomy — diagnosis and treatment for all testicular tumors (via inguinal approach; clamp cord at internal ring before manipulating tumor)
• Consider sperm banking before chemotherapy
• Stage I seminoma: surveillance OR carboplatin ×1 cycle OR RT (paraaortic field) — all equivalent
• Stage I NSGCT: surveillance OR retroperitoneal lymph node dissection (RPLND) OR BEP ×1 cycle
• Stage II–III: BEP chemotherapy (bleomycin, etoposide, cisplatin) × 3–4 cycles — highly effective (>95% cure rate for Stage I; 80% overall cure)
• Residual mass post-chemo: RPLND for NSGCT; FDG-PET for seminoma (if PET negative → observe)
• Salvage chemotherapy: TIP, VeIP, high-dose with stem cell rescue

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G. RENAL PELVIS AND URETERAL TUMORS

• See Upper Tract Urothelial Carcinoma (Section C above)
• Ureteral tumors: hematuria, hydronephrosis, flank pain; CT urogram + ureteroscopy
• Treatment: RNU (gold standard); segmental resection for distal ureter (ureteroneocystostomy) in select cases

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H. URETHRAL TUMORS

• Rare; female > male
• Majority: squamous cell carcinoma (distal urethra, squamous epithelium); proximal urethra: TCC
• Associated with HPV, urethral stricture, recurrent UTI, urethral diverticulum
• Presentation: hematuria, urethral mass, obstructive symptoms, urethral discharge
• Diagnosis: urethroscopy + biopsy, MRI for staging
• Treatment: depends on location/stage; distal lesions → distal urethrectomy; proximal lesions/advanced → urethrectomy + cystectomy + pelvic RT ± chemotherapy; poor prognosis for proximal disease

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10. EMERGENCY UROLOGY

A. Acute Urinary Retention (AUR)

• Definition: Sudden painful inability to void; palpable/percussible bladder
• Causes:
  • Obstructive: BPH (most common in men), urethral stricture, bladder stone, clot retention, prolapsed bladder tumor, prostate cancer, constipation
  • Neurological: spinal cord compression, cauda equina syndrome, multiple sclerosis, diabetic cystopathy
  • Pharmacological: anticholinergics, opioids, alpha-agonists, antihistamines
  • Postoperative: pain, analgesia, fear of voiding
• Precipitants of AUR in BPH: constipation, alcohol, UTI, anticholinergic medication, prolonged immobility, excessive fluid intake
• Management:
  1. Urethral catheterization (Foley 14–16 Fr) — immediate relief; if fails (stricture/false passage) → suprapubic cystostomy (trocar technique)
  2. Drain slowly — controlled decompression (no evidence for gradual drainage vs. immediate)
  3. After catheterization: trial without catheter (TWOC) after 24–48h with alpha-blocker (tamsulosin) — improves TWOC success to ~60%
  4. If TWOC fails → re-catheterization → surgical management (TURP)

B. Testicular Torsion

• Surgical emergency — viability depends on time to detorsion
• Mechanism: twisting of spermatic cord → venous obstruction → arterial ischemia → infarction
• Predisposing: "Bell-clapper" deformity (high investment of tunica vaginalis — allows free rotation); peak ages: neonatal + puberty (2nd peak)
• Presentation: sudden onset severe unilateral testicular pain, swelling, nausea/vomiting; high-riding transverse-lying testis; absent cremasteric reflex (most reliable sign); Prehn's sign NEGATIVE (elevation does not relieve pain)
• Diagnosis: CLINICAL — do not delay surgery for imaging; if US obtained (must not delay): absent/reduced Doppler flow
• Treatment:
  • Immediate surgical exploration (inguinal or scrotal approach)
  • Manual detorsion (toward midline = "opening a book") as temporizing measure
  • Timing: Orchid viability: <6h = ~100%; 6–12h = ~70%; >24h = ~0–20%
  • Orchiopexy (both sides — 3-point fixation with non-absorbable suture) if viable; orchidectomy if necrotic + contralateral orchiopexy
• Differential: epididymo-orchitis (gradual onset, fever, positive Prehn's), torsion of appendix testis ("blue dot sign")

C. Priapism

• Definition: Prolonged penile erection (>4 hours) unrelated to sexual stimulation
• Types:

• Causes (ischemic): SSD (most common worldwide — 33–42%), intracavernosal vasoactive drugs (papaverine, PGE1), antipsychotics (chlorpromazine, risperidone), antidepressants (trazodone), anticoagulants, hematological malignancies, idiopathic
• Stuttering/recurrent priapism: repeated episodes; treat with terbutaline or PDE-5 inhibitors prophylactically (paradoxical benefit)
• Management algorithm (ischemic):
  1. Aspiration of 20–30 mL blood from corpus cavernosum (lateral at 3 or 9 o'clock)
  2. Intracavernous phenylephrine 200 mcg/mL (alpha-1 agonist; preferred — no cardiac beta effects) every 3–5 min; max 1mg total; monitor BP
  3. Irrigation with dilute phenylephrine
  4. Surgical shunts (T-shunt, Al-Ghorab, Winters) if refractory
  5. Penile prosthesis implantation if prolonged ischemia (>48–72h) — prevents corporal fibrosis
• Complications: erectile dysfunction (proportional to duration of priapism), corporal fibrosis, penile deformity

D. Paraphimosis

• Retracted foreskin cannot be reduced over glans → venous engorgement → edema → arterial compromise
• Emergency: can cause glans necrosis
• Treatment:
  1. Manual reduction: compress glans firmly, push back; ice/sugar to reduce edema
  2. Dorsal slit or circumcision if manual reduction fails
  3. Aspiration of glans edema (needle)

D. Renal Colic with Infected Obstructed Kidney

• Most dangerous urological emergency
• Sepsis + obstructive uropathy = pyonephrosis
• Signs: fever + flank pain + septic shock in patient with hydronephrosis
• Treatment: immediate resuscitation + urgent urinary decompression (PCN or ureteral stent) + IV broad-spectrum antibiotics; definitive stone treatment only after infection controlled

E. Urosepsis

• Sepsis originating from urinary tract; Gram-negative bacteremia (E. coli most common)
• Endotoxin (LPS) → cytokine cascade → septic shock
• Management: Sepsis-6 bundle within 1 hour:
  1. Blood cultures × 2
  2. IV broad-spectrum antibiotics (piperacillin-tazobactam ± aminoglycoside; carbapenem for ESBL)
  3. IV fluid resuscitation (30 mL/kg crystalloid)
  4. Lactate measurement
  5. Urine output monitoring (catheterize)
  6. Source control (drain obstruction, remove infected catheter/foreign body)
• ICU if vasopressor-dependent

F. Penile Fracture

• Rupture of tunica albuginea during sexual intercourse (forced bending of erect penis)
• Audible "pop," immediate detumescence, swelling, ecchymosis ("eggplant deformity"), deflection away from injury
• Urethral injury in 20–38%: blood at meatus → RUG before catheterization
• Treatment: immediate surgical repair (ventral subcoronal degloving incision); delays lead to ED, chordee, abscess

G. Urological Trauma Emergencies

• Pelvic fracture + urethral injury: RUG before catheter; suprapubic cystostomy
• Intraperitoneal bladder rupture: urgent surgical repair
• Grade V renal trauma: immediate exploration/nephrectomy
• Scrotal/testicular trauma with rupture: urgent surgical repair

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Summary Table: Key Urological Emergencies

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Causes of Anuria

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1. PRERENAL CAUSES

Hypovolemia (Volume Depletion)

• Severe hemorrhage (trauma, GI bleed, ruptured aortic aneurysm, postpartum hemorrhage)
• Severe dehydration (vomiting, diarrhea, burns, heat stroke)
• Third-space losses (peritonitis, pancreatitis, bowel obstruction, hypoalbuminemia)
• Diuretic overuse

Low Cardiac Output

• Cardiogenic shock (massive MI, acute decompensated heart failure, cardiac tamponade)
• Massive pulmonary embolism
• Severe arrhythmia
• Post-cardiac surgery

Systemic Vasodilation / Distributive Shock

• Septic shock (most common cause of AKI in ICU)
• Anaphylactic shock
• Neurogenic shock
• Adrenal crisis

Renal Artery Hypoperfusion

• Bilateral renal artery stenosis (critical)
• Renal artery thrombosis or embolism (bilateral, or unilateral in solitary kidney)
• Aortic dissection involving renal arteries
• Abdominal compartment syndrome (compresses renal vasculature)

Drugs Reducing GFR

• ACE inhibitors / ARBs — block efferent arteriole dilation → critically reduce GFR in bilateral renal artery stenosis or severe volume depletion
• NSAIDs — inhibit prostaglandin-mediated afferent arteriolar dilation
• Calcineurin inhibitors (cyclosporine, tacrolimus) — afferent arteriolar vasoconstriction
• Contrast nephropathy (in susceptible patients)

Hepatorenal Syndrome (HRS)

• Functional renal failure in severe liver disease/cirrhosis with portal hypertension
• Splanchnic vasodilation → renal vasoconstriction → anuria
• HRS type 1 (rapidly progressive) can produce complete anuria

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2. RENAL (INTRINSIC) CAUSES

Acute Tubular Necrosis (ATN) — Most Common Intrinsic Cause

• Prolonged ischemia (any severe prerenal state → ischemic ATN)
• Nephrotoxins:
  • Drugs: aminoglycosides, amphotericin B, cisplatin, vancomycin, contrast agents, NSAIDs
  • Endogenous: myoglobin (rhabdomyolysis — crush injury, seizures, statin toxicity), hemoglobin (massive hemolysis), uric acid (tumor lysis syndrome)
  • Exogenous toxins: heavy metals (lead, mercury, arsenic), ethylene glycol (→ calcium oxalate crystals), carbon tetrachloride

Rapidly Progressive Glomerulonephritis (RPGN)

• Crescentic GN — can cause anuria within days to weeks
• Types:
  • Type I (Anti-GBM disease / Goodpasture syndrome): anti-GBM antibodies
  • Type II (Immune complex): post-streptococcal GN, lupus nephritis, IgA nephropathy
  • Type III (Pauci-immune / ANCA-associated): Granulomatosis with polyangiitis (GPA), microscopic polyangiitis, eosinophilic GPA
• Presents with hematuria, red cell casts, proteinuria, rapid loss of renal function

Acute Interstitial Nephritis (AIN)

• Drug-induced (most common): NSAIDs, penicillins, cephalosporins, PPIs, sulfonamides, rifampicin, allopurinol
• Infection-related: Leptospirosis, hantavirus, CMV, EBV, legionella
• Autoimmune: SLE, Sjogren's, IgG4-related disease, sarcoidosis
• Classic triad: fever + rash + eosinophilia (present in only ~10%)

Renal Vascular Disease

• Thrombotic microangiopathy (TMA):
  • Hemolytic-uremic syndrome (HUS) — STEC O157:H7 (especially in children); atypical HUS (complement dysregulation)
  • Thrombotic thrombocytopenic purpura (TTP) — ADAMTS13 deficiency
• Bilateral renal vein thrombosis (nephrotic syndrome, hypercoagulable states)
• Malignant hypertension — fibrinoid necrosis of arterioles
• Scleroderma renal crisis — acute vascular thrombosis; can present with abrupt anuria

Acute Cortical Necrosis

• Bilateral cortical infarction; rare but catastrophic
• Causes: obstetric catastrophe (placental abruption, severe PPH), septicemia, HUS
• Hallmark: complete irreversible anuria; calcium deposits in cortex on imaging

Infiltrative / Obstructive Renal Parenchymal Disease

• Bilateral renal lymphoma / leukemic infiltration
• Multiple myeloma (cast nephropathy — light chain tubular obstruction)
• Amyloidosis

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3. POSTRENAL CAUSES

Must be bilateral (or affect a solitary functioning kidney) to cause anuria

Upper Urinary Tract Obstruction (Bilateral)

• Bilateral ureteral obstruction:
  • Pelvic malignancy (cervical, bladder, prostate, rectal cancer) — most common cause of bilateral ureteral obstruction
  • Retroperitoneal fibrosis (RPF) — idiopathic or IgG4-related; bilateral medial ureteral deviation
  • Retroperitoneal lymphadenopathy (lymphoma, metastases)
  • Bilateral ureteral stones (rare but possible)
  • Bilateral ureteropelvic junction (UPJ) obstruction
  • Aortic aneurysm compression
  • Iatrogenic ureteral ligation (gynecological surgery)
• Bilateral renal pelvis obstruction:
  • Bilateral staghorn calculi
  • Blood clots filling both collecting systems

Lower Urinary Tract Obstruction (Single point causing complete bilateral blockage)

• Bladder outlet obstruction:
  • Benign prostatic hyperplasia (BPH) — leading to acute urinary retention and eventual bilateral hydronephrosis
  • Prostate cancer (locally advanced)
  • Bladder neck contracture (post-surgery)
  • Large bladder tumor at the trigone (obstructing both ureteral orifices)
  • Bladder stone impacted at the outlet
  • Neurogenic bladder (detrusor acontractility) — large chronic retention → bilateral reflux/hydronephrosis
• Urethral obstruction:
  • Urethral stricture (post-infectious, post-traumatic, post-instrumentation)
  • Posterior urethral valves (PUV) in male neonates
  • Urethral tumor
  • Phimosis (rarely causing complete obstruction in severe cases)
  • Urethral blood clot

Special Postrenal Situations

• Blocked urinary catheter — most common and easily reversible cause of apparent anuria in catheterized patients (always flush/change catheter first!)
• Bilateral nephrectomy — surgical anuria
• Renal transplant obstruction — ureteral kink, stricture, lymphocele compression

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Summary Classification Table

FENa (Fractional Excretion of Sodium) = (urine Na × plasma Cr) / (plasma Na × urine Cr) × 100

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Approach to the Anuric Patient

1. Rule out blocked catheter — flush or replace immediately
2. Bladder ultrasound — if large bladder → urethral/bladder outlet obstruction → catheterize
3. Renal ultrasound — hydronephrosis present → postrenal; small echogenic kidneys → chronic kidney disease
4. Urine biochemistry (if any urine available): FENa, osmolality, casts
5. Bloods: creatinine, urea, electrolytes (hyperkalemia is the immediate life threat), ABG (metabolic acidosis), CBC, CK (rhabdomyolysis), LDH/haptoglobin (hemolysis), ANCA, ANA, anti-GBM
6. Urgent management of complications: hyperkalemia (ECG → calcium gluconate, insulin/dextrose, salbutamol, resonium, consider dialysis), fluid overload, acidosis
7. Dialysis indications (AEIOU): Acidosis, Electrolytes (refractory hyperkalemia), Intoxication, fluid Overload, Uremia symptoms