8) urinary, trauma + substance abuse Flashcards
Male urinary incontinence
- commonest type of incontinence in men? 1
- other type of incontinence that can occur if large prostate? 1
nb female is in GOSH notes
commonest = URGE (see gynae notes for symptoms etc)
nb men a lot less likely to get stress as better pelvic floors / no babuies stretching them…
can get OVERFLOW incontinence due to large prostate (BPH or Ca) - ie in retension but then a bit comes through
nb elderly men can also get functional incontinence - ie they just forget / can’t get to loo in time (eg dementia, difficulty mobilising) - pads best mx for this!
nb urinary incontinence prevelence: Up to 50% of women and up to 25% of men older than 65 years are affected.
MALE URINARY INCONTINENCE
- what examinations to consider? 2
- bedside tests to consider? 2
- abdo exam (looking for bladder distension)
- DRE
- MSU (could be a symptom of a UTI)
- bladder scan (too see if overflow secondary to retension)
nb if doing PSA as suspision of Ca - either take blood test before to DRE or take blood 1 week after DRE (as DRE will increase PSA!)
urge incontinence management:
- 1st line? 1
- 2nd line? 1
URGE INCONTINENCE
1st line) bladder retraining for at least 6 WEEKS!
2nd line) OXYBUTININ (is an anticholinergic so can increase falls risk in elderly!)
BENIGN PROSTATIC HYPERTROPHY (BPH)
- voiding / obstructive symptoms? 5
- storage / irritative symptoms?
- main complications? 3
VOIDING / OBSTRUCTIVE - hesitancy - weak or intermittent urinary flow - straining - terminal dribbling - incomplete emptying ^think of these in chronological order!
STORAGE / IRRITATIVE - urgency - frequency - urgency incontinence - nocturia (don't forget these ones, get from chronic stretching of bladder and muscles/nerves etc!)
COMPLICATIONS
- UTI
- urinary retention
- obstructive uropathy
Benign prostatic hypertrophy
- 1st line med? 1 (class and named example)
- 2nd line med? 1 (class and named example)
also mechanism of action AND side effects for both
- surgical management option?
1) ALPHA BLOCKER
= Tamsulosin, doxazosin
- decrease smooth muscle tone
- SE: dizzy, postural hypotension, dry mouth (block adrenaline etc so makes sense)
2) 5a-REDUCTASE INHIBITORS
= finasteride (takes 6 months to be effective)
- blocks conversion to testosterone to active form -> reduction in size of prostate
- SE: reduced libido, erectile dysfunction + ejaculation probs, gynaceomastia
SURGERY = transurethral resection of prostate (TURP)
nb can also use desmopressin if persistent and refractory nocturia
NEPHROTIC SYNDROME
- pathophysiology?
- biggest cause in children? 1
- other primary causes? 2
- secondary causes?
injury to the podocyte meaning that large proteins can be excreted by the kidneys (when can’t normally!)
kids = minimal change disease
PRIMARY (90%)
- minimal change disease
- membranous nephropathy/ glomerulonephritis
- focal segment glomerulosclerosis (FSGS)
SECONDARY
- diabetic nephropathy
- hep B or C
- SLE
- amyloidosis (incl from RA and myeloma)
- paraneoplastic
- drug-related (NSAIDs, anti-TNF
nb many of these can present as nephritic of nephrotic syndrome
NEPHROTIC SYNDROME
- main triad of features? 3
- describe urine (ie appearance + amount)
- other symptoms? 3
- Obs change? 1 (nb not commonly seen in minimal change disease)
- later signs / features? 2
1) OEDEMA
2) PROTEINURIA
3) HYPOALBUMINAEMIA
nb oedema norm starts periorbitally then peripheral
urine
- oligouric
- frothy (high protein)
- abdo pain
- anorexia
- diarrhoea
- norm or high BP (norm in MCD)
later
- pleural effusion
- ascites
nb may also have symptoms of underlying disease: eg malar rash in SLE
NEPHROTIC SYNDROME
- main 4 complications (+ how each presents)
also describe pathophysiology of each, briefly!
VTE (40%)
- renal vein trhombosis (flank pain + haematuria) and DVT/PE
- dt loss of antithrombin protein
INFECTION (20%)
- eg cellulitis, strep infections, spontaneous bacterial peritonitis
- dt loss of serum IgG + complements etc
HYPOCALCAEMIA
- presents as parasthesia, muscle spasms, tetany
- dt loss of vit D and binding protein
AKI (poss -> CKD)
- self explanatory
NEPHROTIC SYNDROME
- bedside tests? 2
- blood test need for diagnosis
^and what all of these show
- what investigation to find underlying cause? 1 (and who should NOT have this 1st line)
other possible findings on blood tests:
- urea + Cr?
- cholesterol?
- sodium?
- calcium?
- vit D?
- clotting?
- inflamm markers?
1) urine dip (protein+++)
2) protein:Cr ratio (PCR) VERY high
- nb can do 24hr protein urine instead
3) albumin blood test (low)
RENAL BIOPSY
- on ALL (except kids, unless don’t respond to treatment)
- urea + Cr = norm or raised
- cholesterol = raised
- sodium = low
- calcium = low
- vit D = low
- clotting = prolonged clotting time
- inflamm markers = ESR + CRP may be raised
nb can also do other tests to find cause based on clinica suspision (eg HbA1c if think DM, bez-jones proteins if think myeloma, ANA and Anti-DsDNA for SLE etc)
MANAGEMENT of NEPHROTIC SYNDROME
- management for children? 1
- mx to reduce oedema? 1
- mx to reduce proteinuria? 1
- mx to reduce infection risk? 2
- mx to reduce thrombotic risk? 1
- mx to reduce cholesterol? 1
STEROIDS for kids (90% will go away - although can remit - use cyclophosphamide is refractory)
reduce oedema
= furosemid (+ fluid restrict, daily weights)
reduce protein loss
= ACEi/ARBs
infeciton risk
= flu vaccine
= pneumococcal vaccine
(and treat any infections promptly)
thrombotic risk
= LMWH prophylactic dose
cholesterol
= statin
ALSO FIND OUT AND TREAT UNDERLYING CAUSE!
NB MAJORITY RELAPSE
BLADDER CANCER
- which type are majority in developed country?
- main risk factor? 1
- age and gender at greatest risk?
- other risk factors? 4
TRANSITIONAL CELL (>90%)
= SMOKING
- increased age
- male (5:2)
- aromatic amines (rubber)
- radiotherapy
- chronic cystitis
- schistosomiasis
nb schistomiasis common in developing world and causes squamous cell cancer!
nb can also rarely get adenocarcinoma
BLADDER CANCER
- most common symptom? 1
- additional symptoms? 3
- finding on exam in advanced disease? 1
PAINLESS VISIBLE HAEMATURIA
irritiative voiding symptoms - dysuria - urinary frquency - urgency (ie can mimic a UTI)
palpable suprapubic mass (if advanced)
nb can rarely present in urinary retension (either due to direct pressure of tumour or clot retension)
BLADDER CANCER
- bedside tests? 2
- which two groups of people (based on age and symptom) get a 2WW? 2
- what’s the 1st and 2nd line investigations (once referred to renal)? 2
- urine dip (blood++ and no other findings - ie no WBCs or nitrites)
- MSU - negative for bacteria
2WW
- over 45 AND unexplained visible haematuria
- over 60 AND unexplained non-visible haematuria AND either dysuria or raised WCC on blood test
1) cystoscopy + biopsy
2) CT or MR urogram (for staging)
haematuria - main DDx for bladder Ca? 3
- haemorrhagic cystitis
- UTI
- renal cancer
or could be trauma eg from catheter or if on anticoagulants etc
Management of bladder cancer
- non-invasive (Tis/Ta/T1)? 1 for all (3 to consider)
- muscle invasive (T2-3)? 1 is 1st line (2 to consider)
- metastatic? 1
NON-INVASIVE (Tis/Ta/T1)
1) TURBT (trans-urethral resection of bladder tumour
consider:
- post-op chemo (if intermediate risk)
- intravesical immunotherapy (BCG) (if high risk)
- radical cystectomy (if high risk)
MUSCLE INVASIVE (T2-3) 1st) radical cystectomy (with urinary stoma or continent urinary diversion)
consider
- neoadjuvant chemo before surgery (cisplatin)
- radiotherapy (if not fit for surgery)
METASTATIC
- palliative chemo (cisplatin + gemcitabine)
nb can have pallitive radiotherapy as well
HYDRONEPHROSIS
- causes of UNI-lateral? 4 (incl acronym)
- causes of BI-lateral? 5 (incl acronym)
UNILATERAL = PACT
- Pelvic-ureteric obstruction (congenital or acquired)
- Aberrant renal vessels
- Calculi
- Tumours of renal pelvis
BILATERAL = SUPER
- Stenosis of urethra
- Urethral valve
- Prostatic enlargement
- Extensive bladder tumour
- Retro-peritoneal fibrosis
“have a PACT with the body to only mess up one of the kidneys, oh SUPER (sarcastic) they’ve failed on their pact!”
also makes sense - higher up the urin ary tract - more likely to cause unilateral!
nb Women with gynecological malignancies may present with hydronephrosis. Cervical, uterine, and ovarian cancers should therefore always be considered in nonpregnant women with new-onset hydronephrosis!
HYDRONEPHROSIS
- how normally present?
- main finding on exam?
- main two complications?
depends on cause
- isolated hydronephrosis often asymptomatic
- LUTS if prostate
- flank pain if secondary to stones
enlarged kidneys (one or both)
COMPLICATIONS
- chronic kidney disease (esp if bilateral)
- super-imposed infection (often bad!!)
HYDRONEPHROSIS
- main investigation to diagnose? 1
- 2nd line investigaiton to find cause? 1
- other bedisde tests to do? 2
- blood to always do? 1
1st) USS KUB - to diagnose
2nd) CT KUB - to find cause
- urine dip
- MSU
(to exclude infection)
U+Es
- if renal function impaired, more likely to be bilateral pathology!
Management of HYDRONEPHROSIS
- options for acute upper tract obstruction? 2
- what can be given to reduce pain associated with these? 1
- immediate options for lower tract obstruction? 2
- definitive management?
UPPER tract (ACUTE)
- nephrostomy tube
- ureteric stent
= a-blocker (tamsulosin) to reduce stent-related pain
LOWER tract (ACUTE)
- urethral catheter
- suprapubic catheter
TREAT UNDERLYING CAUSE
- get stone out
- TURP if prostate causing
- pyeloplasty
- debulking if large gynae tumour
CAUSES of URINARY TRACT OBSTRUCTION
- luminal? 3
- mural? 4
- extra-mural? 4
nb this is just another way of classifying
LUMINAL
- stones
- blood clots
- intra-luminal tumour
MURAL
- congenital
- acquired stricture
- neuromuscular dysfunction
- schistosomiasis
EXTRA-MURAL
- abdo/pelvic tumour
- retroperitoneal fibrosis
- iatrogenic (post-op)
- prostatic enlargement (BPH, Ca)
RENAL CANCER
- type of cancer most commonly seen in adults? 1
- name and type of cancer seen in children? 1
Clear cell carcinoma = adults (80%)
wilms tumour (nephroblastoma) = children (see paeds notes)
nb Transitional cell/urothelial carcinoma of the renal pelvis is the second most common renal malignancy and accounts for ∼ 8% of renal cancers in adults.
RENAL CANCER
- age and gender most at risk?
- lifestyle risk factors? 2
- renal risk factors? 2
- other medical risk factors? 4
- hereditary cancer syndromes that increase risk? 4
nb exclude wilms tumour from this - see paeds notes
- male
- age >40
- smoking
- obesity
- polycystic kidney disease as a result of end-stage kidney failure (nb not hereditary PKD)
- renal pelvic stones
- HTN
- immunosuppression
- chronic hep C infection
- sickle cell disease (get renal medullary carcinoma, diff to clear cell)
CANCER SYNDROMES
- Von Hippel-Lindau syndrome
- Hereditary papillary renal cell carcinoma (HPRCC)
- Tuberous sclerosis
Hereditary - leiomyomatosis and renal cancer syndrome (HLRCC, Reed’s syndrome)
^all of these are autosomal dominant (also affect at a younger age than sporadic cancers)
KIDNEY CANCER:
- classic triad of symptoms?
- additional systemic symptoms? 4
- what paraneoplastic syndromes can be seen? 6
- symptoms if local involvement of IVC? 3
- symptoms if local spread to left testicular vein? 1
1) HAEMATURIA (non-visible and intermittent initially)
2) loin pain (only get if tumour >10cm)
3) loin/abdo mass
^haematuria is commonest
- weight loss
- fatigue
- night sweats
- fever (may present as fever of unknown origin!!)
PARANEOPLASTIC SYNDROMES
- HTN (^renin)
- HYPERCALCAEMIA (PTHrP parathyroid hormone-related protein from tumour - or bone mets!)
- POLYCYTHAEMIA (epo) or leukemoid reaction
- CUSHING’S syndrome (^ACTH)
- STAUFFER’S syndrome (non-metastatic derangement in LFTs and clotting - pathology unknown)
- LIMBIC ENCEPHALITIS (memory loss, psychosis, depression)
IVC (budd-chiari syndrome)
- lower limb oedema
- ascites
- hepatic dysfunction
LEFT TESTICULAR VEINS
- a rapidly developing VARICOCELE in men (doesn’t empty when pt lies down)
- a rare but classic symptom of RCC in the left kidney (nb doesn’t happen on R as R testicular vein drains directly in IVC)
nb also lumg symptoms if mets to lung and same with bone!
nb also often anaemic!
nb probs don’t need to know all of these - I just found it interesting…
RENAL CANCER
- gold standard investigation? 1
- what to consider to rule out bladder Ca? 1
- what two imaging to do to look for mets? 2 (classic sign on one of these?)
1st) CONTRAST CT
- if poor renal function, flush with lots of saline (but need contrast!)
consider cytoscopy to rule out bladder Ca
nb can do USS as first line but will end up needing CT
looking for mets:
- CXR (canonball mets = classic!)
- skeletal survey or bione scan
RENAL CANCER
- 1st line management?
- additional management option? 1
- what therpaies DON’T work? 2
1) RADICAL NEPHRECTOMY
biologics in addition (or instead if mets!)
RCC tend to be radio and chemo-resistant!
URINARY STONES
- risk factors for calcium oxalate stones? 3
- risk factors for uric acid stones? 4
- risk factor for struvite stones? 1
- risk factor for calcium phosphate stone? 1
- main risk factor for cystine stones? 1
- main risk factors for xanthine stones? 1
- which of these types is (by far) the commonest? 1
- which causes staghorn calculi? 1
- other risk factors for all? (one lifestyle, one FHx, one med condition)
nb see other flashcards for meds risk factors
aka urolithiasis/nephrolithiasis
CALCIUM OXALATE (75%)
= HIGH calcium (incl high PTH)
= HIGH oxalate (nuts, peanuts + other foods)
= LOW citric acid (ie citrus fruits)
(- also high uric acid!)
(nb can also get if drink antifreeze, and also in IBD dt malabsorption)
(vit C supplements -> oxalate - so increase risk)
URIC ACID (aka urate) (10%) anything that increases uric acid!
= gout
= ileostomy/colostomy (loss of bicarb + fluid -> acidic urine -> precipitation of uric acid
= extensive tissue breakdown (eg cancer)
= kids with inborn errors of metabolism
STRUVITE (10%)
= chronic/repeated UTIs from urease producing bacteria (Proteus mirabilis, S. saprophyticus, Klebsiella)
- causes STAGHORN CALCULI
CALCIUM PHOSPHATE (<5%) = renal tubular acidosis (type 1 + 3) (also in high PTH)
CYSTINE (<5%)
= cystinuria (inherited recessive)
XANTHINE (<5%)
= Xanthinuria (hereditary)
RISK FACTORS FOR ALL
- dehydration
- FHx kidney stones
- polycystic kidney disease or medullary sponge kidney
(also urinary stasis is risk factor for bladder stones!)
Medications and urinary stones
- diuretic which increases risk? 1
- other meds that increase risk? 3
- diuretic which reduces risk?
INCREASE RISK = loop diuretics - steroids - acetazolamide (glaucoma med) - theophylline
DECREASE RISK
= thiazides (they increase distal tubular calcium resorption)
nb these are generally risks for calcium oxalate stones
nb see amboss for crystal appearance, urine pH and radiopacity of each
CLINICAL PRESENTATION of urinary tract stones:
- classic renal colic pain?
- systemic symptoms? 2
- possible findings if bladder stones? 3
- what sign on examination for hydronephrosis? 1
- what sign indicates concurrent infection? 1
Severe unilateral and colicky flank pain (renal colic)
- loin to groin
- Paroxysmal or progressively worsening
- Area around kidneys may be tender on percussion (costovertebral angle tenderness)
nb can get visible haematuria (but is often non-visible)
- nausea + vomiting
- diaphoresis
- if FEVER or RIGOR - think infection added on! = bad!
bladder stones - Dysuria - frequency - urgency (may get complete urinary retention!!)
if palpable kidney - think hydronephrosis!
nb Renal colic is a misnomer as the pain does usually not wax and wane like in intestinal colic - but people do writh around - like in other colic!
nb can also get reduced bowel sounds - dt partial illeus dt pain
URINARY STONES
- bedside tests? 2
- important bloods? 2 (why?)
- diagnostic test? 1
- three places in urinary tract where most comon to find a stone? 3
- dipstick (blood!! - leuco or nitrite mean added infection!)
- MSU (check for infection)
- FBC (high WCC means infection)
- U+Es (if kidney function off = bad/bilateral!)
NON-CONTRAST CT KUB for diagnosis (ultrasound should not be used!)
Commonest places
PUJ, pelvic brim and VUJ
also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis
nb can also do calcium and urate to look for causes!
nb CRP and ESR are norm psotive too
MANAGEMENT of URINARY STONES
- best analgesic mx for all? 1
- when do you manage expectantly? 1 (med can give to help pass? 1)
- when do you do schock-wave lithotripsy? 1
- when do you do ureteroscopy? 1
- when do you do a percutaneous nephrolithotomy? 1
- when would you do a nephrostomy tube / stent? 3
IM or PR diclofenac = best analgesic (not in pregnancy, severe heart disease or renal impariment though!)
manage expectantly
= <0.5cm (will pass on it’s own within 4 wks)
(nb manage actively if single kidney, prev transplant, any structural kidney abnormality)
- TAMSULOSIN can help pass!
external shock-wave lithotripsy
= stone 0.5-2cm (aggregate)
ureteroscopy
= stone 0.5-2cm (aggregate) in PREGNANCY
Percutaneous nephrolithotomy
- >2cm stone burden or staghorn calculi
neophrostomy tube / stent (ie urgent decompression)
- hydronephrosis
- complete blockage form one kidney (or AKI)
- concurrent pyelonephritis
nb Percutaneous nephrolithotomy
- In this procedure, access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed.
prevention of urinary stones:
- dietary advice for calcium stones? 3
- med for calcium stones? 1
- med options for oxalate stones? 2
- med options for uric acid stones? 2
Prevention of renal stones
Calcium stones - high fluid intake - low animal protein - low salt diet = thiazide diuretics
(a low calcium diet has not been shown to be superior to a normocalcaemic diet)
Oxalate stones
- cholestyramine
- pyridoxine
Uric acid stones
- allopurinol
- urinary alkalinization e.g. oral bicarbonate
POLYCYSTIC KIDNEY DISEASE
- inheritance pattern?
- main presenting symptom?
- other common way to present?
- change to obs that often seen?
- who to screen for in?
- investigation to diagnose/screen? 1
- prognosis?
dominant (nb can rarely get recessive form)
abdo pain (60%) dt increased formation of stones, haemorrhage into cyst
LARGE PALPABLE KIDNEYS ON EXAM!
recurrent UTIs
get HYPERTENSION
screen everyone with positive family history
- there is a diagnostic criteria used (ie no. of cysts and age)
abdo USS for diagnosis and screening
prognosis depends on type - end-stage renal failure by 50 or slower one that is by 70years
