Blackboard EMQs Renal and Urology Flashcards

1
Q

A 30 year old man presents with a swelling within the left scrotum, which aches when he stands. On examination, the swelling is not tender & feels like a ‘bag of worms’.

What is the most likely diagnosis?
A. Epididymal cyst
B. Inguinal hernia
C. Hydrocele
D. Teratoma
E. Torsion of the testis
F. Testicular gumma
G. Varicocele
H. Seminoma
I. Acute epididymitis
J. Mumps orchitis
K. Chronic epididymitis
L. Scrotal haemotoma
A

G. Varicocele

A bag of worms is pathognomic. A varicocele is where the internal spermatic veins and pampiniform plexus that drain the testis are abnormally dilated. The cause is due to a combination of factors including increased hydrostatic pressure in the left renal vein, or incompetent/congenitally absent valves. It occurs in 15% of adolescent boys and adult men and is 90% left sided, and can be bilateral. Ultrasound can be helpful if the diagnosis is in doubt. Small varicoceles can be brought out by Valsalva, and may require some experience to diagnose. Surgical correction can reverse the impeded testicular growth in adolescents and also improve sperm parameters (40% of men who come to a male fertility clinic have a varicocele) if this is a problem. However, many can be simply reassured or observed with serial examinations. Note that a varicocele does not transilluminate unlike a hydrocele.

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2
Q

A 25 year old presents with pyrexia, headache & painful swelling of his face & testes.

What is the most likely diagnosis?
A. Epididymal cyst
B. Inguinal hernia
C. Hydrocele
D. Teratoma
E. Torsion of the testis
F. Testicular gumma
G. Varicocele
H. Seminoma
I. Acute epididymitis
J. Mumps orchitis
K. Chronic epididymitis
L. Scrotal haemotoma
A

J. Mumps orchitis

The tender face swelling indicates mumps parotitis. Epidydimo-orchitis is the most common extra-salivary complication of mumps in males and presents as pain and swelling in one or both testicles. Mumps can also cause an aseptic meningitis, oophoritis in women and uncommonly, mastitis, encephalitis and SN deafness. Constitutional symptoms of fever, malaise, headache, myalgia and anorexia are commonly seen. Those unvaccinated and international travellers are at increased risk. The mumps vaccine is incoporated as part of MMR. Mumps is caused by an RNA paramyxovirus and spread by respiratory droplets. If the diagnosis needs to be confirmed, then serological or saliva testing is possible looking for IgM. Treatment is supportive with symptom relief mainly with analgesia and antipyretics.

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3
Q

A 64 year old man presents with a swelling of his left testis, which is gradually increasing in size. On examination, the swelling is hard, non-tender & does not transilluminate.

What is the most likely diagnosis?
A. Epididymal cyst
B. Inguinal hernia
C. Hydrocele
D. Teratoma
E. Torsion of the testis
F. Testicular gumma
G. Varicocele
H. Seminoma
I. Acute epididymitis
J. Mumps orchitis
K. Chronic epididymitis
L. Scrotal haemotoma
A

H. Seminoma

Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30 and this is why the better option for this question would be a seminoma. In reality, you cannot tell from the age. Radical orchidectomy and histology is the initial treatment in most cases.

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4
Q

A 45 year old man presents with a painless swelling in his scrotum. His left testis cannot be felt. The swelling transilluminates.

What is the most likely diagnosis?
A. Epididymal cyst
B. Inguinal hernia
C. Hydrocele
D. Teratoma
E. Torsion of the testis
F. Testicular gumma
G. Varicocele
H. Seminoma
I. Acute epididymitis
J. Mumps orchitis
K. Chronic epididymitis
L. Scrotal haemotoma
A

C. Hydrocele

A hydrocele is a collection of serous fluid between the layers of the tunica vaginalis. Patients mainly present with a painless swollen scrotum (which can be on one or both sides) which feels like a water-filled balloon. Surgery is only performed if the hydrocele is problematic. As a result of the fluid, most hydroceles can be transilluminated. On examination, the hydrocele cannot be differentiated from the testicle. The mass can also increase in size with increased intra-abdominal pressure (such as coughing, crying or raising the arms) which causes peritoneal fluid to move into the scrotal sac. This causes the mass to vary in size during the day (smaller after lying down).

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5
Q

A 20 year old man presents with an acute onset of vomiting & pain in the lower abdomen after playing football. His abdomen is soft but he has a very tender, swollen right testis, which lies high within the scrotum.

What is the most likely diagnosis?
A. Epididymal cyst
B. Inguinal hernia
C. Hydrocele
D. Teratoma
E. Torsion of the testis
F. Testicular gumma
G. Varicocele
H. Seminoma
I. Acute epididymitis
J. Mumps orchitis
K. Chronic epididymitis
L. Scrotal haemotoma
A

E. Torsion of the testis

This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. Apyrexial would point away from epididymo-orchitis but a high index of suspicion is necessary and if there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is also fixed to the posterior wall.

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6
Q

A 40 year old man presents with a painless swelling in his scrotum which is fluctuant & transilluminable. Both testes are easily palpable.

What is the most likely diagnosis?
A. Epididymal cyst
B. Inguinal hernia
C. Hydrocele
D. Teratoma
E. Torsion of the testis
F. Testicular gumma
G. Varicocele
H. Seminoma
I. Acute epididymitis
J. Mumps orchitis
K. Chronic epididymitis
L. Scrotal haemotoma
A

A. Epididymal cyst

The painless cystic swelling found here on examination, which is also clearly differentiated from the testicle and transilluminates is sufficient to diagnose an epididymal cyst. These are harmless and treatment should only be considered if problematic.

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7
Q

A 26 year old man presents with a painless lump in his left testis of 6 weeks duration. On examination, he has no inguinal lymphadenopathy. He has an elevated serum alpha-fetoprotein.

What is the most likely diagnosis?
A. Testicular tumour
B. Acute tubular necrosis
C. Carcinoma of the prostate
D. Chronic kidney disease
E. Testicular torsion
F. Acute pyelonephritis
G.  Acute epididymo-orchitis
H. Hydrocele
I. Inflamed hydatid de morgani
J. Carcinoma of the kidney
K. Ureteric colic
A

A. Testicular tumour

Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30 and this is why the better option for this question would be a seminoma. In reality, you cannot tell from the age. Radical orchidectomy and histology is the initial treatment in most cases.

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8
Q

A 6 year old boy presents with painless haematuria & scrotal oedema of 2 days duration. His urine demonstrates granular casts.

What is the most likely diagnosis?
A. Testicular tumour
B. Acute tubular necrosis
C. Carcinoma of the prostate
D. Chronic kidney disease
E. Testicular torsion
F. Acute pyelonephritis
G.  Acute epididymo-orchitis
H. Hydrocele
I. Inflamed hydatid de morgani
J. Carcinoma of the kidney
K. Ureteric colic
A

B. Acute tubular necrosis

Acute tubular necrosis is due to injury to the tubular epithelial cells in the kidney which causes these cells to die or detach from the basement membrane. The injury can be ischaemic or nephrotoxic. The condition is oftenasymptomatic and detected on lab tests. Patients tend to have a history of hypertension, fluid depletion (resulting in poor renal perfusion) or exposure to nephrotoxic drugs (like radiocontrast agents, NSAIDs, amphotericin B and aminoglycosides – 10-20% of those on aminoglycosides develop ATN). Those with underlying kidney disease, DM or hypovolaemia are more likely to develop ATN. On urinalysis, the centrifuged urine may show pigmented, muddy brown granular casts which suggests ATN and this is the diagnostic point in this question. The patient may also present with oliguria/anuria and hypotension and compensatory tachycardia due to fluid depletion. The haematuria may suggest an underlying cause and the patient’s oedema may be evidence of circulatory collapse. There is no specific treatment apart from supportive care.

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9
Q

A 70 year old man presents with poor stream & nocturia and bone pain in his thighs. On examination he has a palpable bladder & enlarged prostate gland. His blood pressure is 170/95.

What is the most likely diagnosis?
A. Testicular tumour
B. Acute tubular necrosis
C. Carcinoma of the prostate
D. Chronic kidney disease
E. Testicular torsion
F. Acute pyelonephritis
G.  Acute epididymo-orchitis
H. Hydrocele
I. Inflamed hydatid de morgani
J. Carcinoma of the kidney
K. Ureteric colic
A

C. Carcinoma of the prostate

This patient clearly has symptoms of lower urinary tract outfow obstruction which could have been present for some time. His prostate is enlarged too, and he has an obstructed bladder. This could have cause either chronic or acute kidney disease. Prostate cancer often metastasizes to bone and bone metastases might be causing his bone pain. His hypertension is most likley incidental since hypertension is so common in the population. Prostate cancer is uncommon in men under 50. Management of this condition is either expectant or definitive depending on life expectancy. Key investigations are PSA and DRE and diagnosis is confirmed on a trans-rectal ultrasound-guided needle biopsy. A PSA normally ranges from 0-4 microgams/L however this varies with age and race. Prostate cancer is graded on the Gleason score (2-10), which is the sum total of two scales from 1 to 5 which is based on how differentiated the tumour’s predominant cell lines are. It is 95% of the time an adenocarcinoma as it is a malignant growth orginating from the glandular cells of the prostate.This patient will also have a bone scan with plain XRs to correlate any positive findings – which may show lytic or blastic lesions causing this patient’s pain in the thighs.

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10
Q

A 70 year old man presents with poor stream & nocturia for the last year. He also described poor apetite, itching and some nausea. On examination he had excorations over his skin, a palpable bladder & smoothly enlarged prostate gland. His blood pressure is 170/95.

What is the most likely diagnosis?
A. Testicular tumour
B. Acute tubular necrosis
C. Carcinoma of the prostate
D. Chronic kidney disease
E. Testicular torsion
F. Acute pyelonephritis
G.  Acute epididymo-orchitis
H. Hydrocele
I. Inflamed hydatid de morgani
J. Carcinoma of the kidney
K. Ureteric colic
A

D. Chronic kidney disease

This patient has symptoms of lower urinary tract outfow obstruction which have been present for some time and evidence of BPH with chronic urinary retention. His itch, nausea and poor apetite could be caused by chronic uraemia (near end stage chronic kidney disease). His hypertension is most likley incidental since hypertension is so common in the population, but could be from salt and water retention as a result of his chronic kidney disease. The most common causes of CKD are DM and hypertension. Hence, glycaemic control and optimisation of BP are key in slowing the progression of disease. CKD is a risk factor for cardiovascular disease.

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11
Q

A 12 year old boy presents to casualty with red, painful, swollen scrotum. His mid-stream urine is normal.

What is the most likely diagnosis?
A. Testicular tumour
B. Acute tubular necrosis
C. Carcinoma of the prostate
D. Chronic kidney disease
E. Testicular torsion
F. Acute pyelonephritis
G.  Acute epididymo-orchitis
H. Hydrocele
I. Inflamed hydatid de morgani
J. Carcinoma of the kidney
K. Ureteric colic
A

E. Testicular torsion

This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. Normal MSU rules against an infection (epididymo-orchitis). If there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is also fixed to the posterior wall.

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12
Q

A 75 year old man presents with increased micturation & backache. On examination, he has a palpable bladder & an enlarged prostate. His serum acid phosphatase & alkaline phosphatase are both elevated.

What is the most likely diagnosis?
A. Testicular tumour
B. Acute tubular necrosis
C. Carcinoma of the prostate
D. Chronic kidney disease
E. Testicular torsion
F. Acute pyelonephritis
G.  Acute epididymo-orchitis
H. Hydrocele
I. Inflamed hydatid de morgani
J. Carcinoma of the kidney
K. Ureteric colic
A

C. Carcinoma of the prostate

Prostate cancer often metastasizes to bone and bone metastases might be causing his back pain. The palpable bladder is due to urinary outflow obstruction. Prostate cancer is uncommon in men under 50. Management of this condition is either expectant or definitive depending on life expectancy. Key investigations are PSA and DRE and diagnosis is confirmed on a trans-rectal ultrasound-guided needle biopsy. A PSA normally ranges from 0-4 microgams/L however this varies with age and race. Prostate cancer is graded on the Gleason score (2-10), which is the sum total of two scales from 1 to 5 which is based on how differentiated the tumour’s predominant cell lines are. It is 95% of the time an adenocarcinoma as it is a malignant growth orginating from the glandular cells of the prostate. The raised enzyme profile is also suggestive here.

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13
Q

A 25 year old man presents with a 6 month history of painless enlargement of the left hemi-scrotum. The swelling is fluctuant, translucent, confined to the scrotum, & the testis cannot be felt separately.

What is the most likely diagnosis?
A. Tuberculosis of testicle
B. Varicocele
C. Undescended testicle
D. Squamous cell carcinoma
E. Hernia
F. Hydrocele
G. Testicular torsion
H. Cardiac failure
I. Testicular malignancy
J. Epididymal cyst
K. Epididymo-orchitis
A

F. Hydrocele

A hydrocele is a collection of serous fluid between the layers of the tunica vaginalis. Patients mainly present with a painless swollen scrotum (which can be on one or both sides) which feels like a water-filled balloon. Surgery is only performed if the hydrocele is problematic. As a result of the fluid, most hydroceles can be transilluminated. On examination, the hydrocele cannot be differentiated from the testicle. The mass can also increase in size with increased intra-abdominal pressure (such as coughing, crying or raising the arms) which causes peritoneal fluid to move into the scrotal sac. This causes the mass to vary in size during the day (smaller after lying down).

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14
Q

A 17 year old man presents with a 6 hour history of sudden onset of severe left scrotal pains. The scrotum is red & swollen, the testis & epididymis are very tender.

What is the most likely diagnosis?
A. Tuberculosis of testicle
B. Varicocele
C. Undescended testicle
D. Squamous cell carcinoma
E. Hernia
F. Hydrocele
G. Testicular torsion
H. Cardiac failure
I. Testicular malignancy
J. Epididymal cyst
K. Epididymo-orchitis
A

G. Testicular torsion

This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. The main differential is epididymo-orchitis but a high index of suspicion is necessary and if there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is also fixed to the posterior wall.

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15
Q

A 30 year old man presents with an intermittent swelling in the right scrotum. Examination demonstrates a soft, compressible lump in the scrotum, the upper limit of which cannot be palpated.

What is the most likely diagnosis?
A. Tuberculosis of testicle
B. Varicocele
C. Undescended testicle
D. Squamous cell carcinoma
E. Hernia
F. Hydrocele
G. Testicular torsion
H. Cardiac failure
I. Testicular malignancy
J. Epididymal cyst
K. Epididymo-orchitis
A

E. Hernia

This is an inguinal hernia. It is where the abdominal contents along with its layers of peritoneum and fascia protrude through the inguinal canal. Remember that on examination, a direct hernia cannot be controlled by pressure at the midpoint of the inguinal ligament whereas an indirect hernia can be controlled by occlusive pressure in this manner. Remember also, your anatomy of the region. The hernial sac of a direct hernia lies medial to the inferior epigastric artery whereas the hernial sac of an indirect hernia lies lateral to the artery. The hernia itself can be either reducible or irreducible and may additionally be obstructed, strangulated or incarcerated.

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16
Q

A 23 year old man has a dull ache in the left scrotum. He has noticed a firm, 2cm, non-tender lump at the front of the testicle. He has palpable supraclavicular lymph nodes.

What is the most likely diagnosis?
A. Tuberculosis of testicle
B. Varicocele
C. Undescended testicle
D. Squamous cell carcinoma
E. Hernia
F. Hydrocele
G. Testicular torsion
H. Cardiac failure
I. Testicular malignancy
J. Epididymal cyst
K. Epididymo-orchitis
A

I. Testicular malignancy

Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. The supraclavicular lymph nodes here are an extratesticular manifestation – others include bone pain from metastasis, swelling of the lower extremities due to venous occlusion and gynaecomastia. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30 and this is why the better option for this question would be a seminoma. In reality, you cannot tell from the age. Radical orchidectomy and histology is the initial treatment in most cases.

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17
Q

A 70 year old man presents with mild dysuria, urinary hesitancy & terminal dribbling. He also has bilateral testicular pain, swelling & tenderness of both testes & epididymis. His temperature is 37.5 degrees Celsius.

What is the most likely diagnosis?
A. Tuberculosis of testicle
B. Varicocele
C. Undescended testicle
D. Squamous cell carcinoma
E. Hernia
F. Hydrocele
G. Testicular torsion
H. Cardiac failure
I. Testicular malignancy
J. Epididymal cyst
K. Epididymo-orchitis
A

K. Epididymo-orchitis

Generally speaking, younger males are more likely to have an STI whereas older men are more likely to have an infection with enteric organisms such as ESBL. He is mildly febrile with tenderness on-top of urinary symptoms which points towards epididymo-orchitis. A urethral swab should be sent for Gram stain and culture of secretions. A urine dipstick is also necessary combined with urine MC+S. Treatment involves bed rest, scrotal elevation, analgesia and antibiotics if indicated.

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18
Q

A 25 year old patient presents with 1 year history of painful scrotal swelling. On examination there is a hard smooth swelling of the right testis. It did not transilluminate. There was no cough impulse.

What is the most likely diagnosis?
A. Teratoma
B. Metastasis
C. Torsion of testis
D. Strangulated indirect inguinal hernia
E. Varicocele
F. Retractile testis
G. Mumps orchitis
H. Hydrocele
I. Cryptoorchidism
J. Trauma
K. Epididimo-orchitis
A

A. Teratoma

Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30. Radical orchidectomy and histology is the initial treatment in most cases.

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19
Q

An 18 year old patient brought to the A&E department by his father because of sudden onset of severe painful swelling of the scrotum. There was no history of trauma. On examination – distressed young man who had difficulty in walking with exquisite tenderness of the scrotum. He was apyrexial.

What is the most likely diagnosis?
A. Teratoma
B. Metastasis
C. Torsion of testis
D. Strangulated indirect inguinal hernia
E. Varicocele
F. Retractile testis
G. Mumps orchitis
H. Hydrocele
I. Cryptoorchidism
J. Trauma
K. Epididimo-orchitis
A

C. Torsion of testis

This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. Apyrexial points away from epididymo-orchitis but a high index of suspicion is necessary and if there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is fixed to the posterior wall.

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20
Q

A 70 year old patient with 1 year history of swelling of the scrotum which has become painful in the last 4 days. On examination the patient is afebrile with a firm tender swelling in the left side of the scrotum extending to the inguinal region. There is no cough impulse.

What is the most likely diagnosis?
A. Teratoma
B. Metastasis
C. Torsion of testis
D. Strangulated indirect inguinal hernia
E. Varicocele
F. Retractile testis
G. Mumps orchitis
H. Hydrocele
I. Cryptoorchidism
J. Trauma
K. Epididimo-orchitis
A

D. Strangulated indirect inguinal hernia

This swelling has become recently painful indicating that this hernia has strangulated. Urgent surgical intervention is necessary. Inguinal hernias lie superomedial to the PT whereas femoral hernias like inferolateral to the PT.

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21
Q

A 24 year old political refugee presents with a tender swollen right testicle of 3 days duration. Examination reveals tender mandibular swelling. Temperature 38 degrees Celsius. Swollen tender testicle which does not transilluminate

What is the most likely diagnosis?
A. Teratoma
B. Metastasis
C. Torsion of testis
D. Strangulated indirect inguinal hernia
E. Varicocele
F. Retractile testis
G. Mumps orchitis
H. Hydrocele
I. Cryptoorchidism
J. Trauma
K. Epididimo-orchitis
A

G. Mumps orchitis

The tender mandibular swelling indicates mumps parotitis. Epidydimo-orchitis is the most common extra-salivary complication of mumps in males and presents as pain and swelling in one or both testicles. Those unvaccinated and international travellers are at increased risk. The mumps vaccine is incoporated as part of MMR. Mumps is caused by an RNA paramyxovirus and spread by respiratory droplets. If the diagnosis needs to be confirmed, then serological or saliva testing is possible looking for IgM. Treatment is supportive with symptom relief mainly with analgesia and antipyretics.

22
Q

A 52 year old company director presents with fever. He has recently returned from a conference in SE Asia. Examination – Temp 37.5 degrees Celsius. Few tender inguinal lymph node. Tenderness of spermatic cord & testis.

What is the most likely diagnosis?
A. Teratoma
B. Metastasis
C. Torsion of testis
D. Strangulated indirect inguinal hernia
E. Varicocele
F. Retractile testis
G. Mumps orchitis
H. Hydrocele
I. Cryptoorchidism
J. Trauma
K. Epididimo-orchitis
A

K. Epididimo-orchitis

Generally speaking, younger males are more likely to have an STI whereas older men are more likely to have an infection with enteric organisms such as ESBL. This patient is however likely to have an STI due to his foreign exploits. Risk factors include unprotected sexual intercourse. He is febrile with tenderness and has reactive lymphadenopathy which points towards epididymo-orchitis. A urethral swab should be sent for Gram stain and culture of secretions. A urine dipstick is also necessary combined with urine MC+S. Treatment involves bed rest, scrotal elevation, analgesia and antibiotics if indicated. As this is likely to be sexually transmitted, a combination of ceftriaxone and doxycycline is indicated to cover for Chlamydia trachomatis and Neisseria gonorrhoeae.

23
Q

A fit 28 year old man comes for an insurance medical & is found to have microscopic haematuria & on abdominal examination is found to have 2 large masses about 20cms by 12cms in each flank.

What is the most appropriate next step?
A. Biopsy of prostate 
B. Prostate specific antigen blood test
C. X-ray lumbar spine
D. 24 hour urine monitoring
E. CT scan
F. ASO titre blood test
G. Cytoscopy
H. Abdominal ultrasound
I. MSU: microscopy and cultures
J. Retrograde pyelogram
A

H. Abdominal ultrasound

This sounds like autosomal dominant poly-cystic kidney disease. There may be a family history of PKD or end-stage renal failure or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and SAH). Patients may have haematuria, palpable kidneys and symptoms of a UTI. Hypertension and flank pain are also commonly seen. Hepatosplenomegaly may also be found. A renal ultrasound is the first test to order when the diagnosis is suspected. If the ultrasound is equivocal, a CT scan can be done of the abdomen and pelvis.

24
Q

A 25 year old woman comes back from holiday complaining of a 2 day history of frequency & dysuria. On dipsticking the urine you find red cells, leukocytes & protein.

What is the most appropriate next step?
A. Biopsy of prostate 
B. Prostate specific antigen blood test
C. X-ray lumbar spine
D. 24 hour urine monitoring
E. CT scan
F. ASO titre blood test
G. Cytoscopy
H. Abdominal ultrasound
I. MSU: microscopy and cultures
J. Retrograde pyelogram
A

I. MSU: microscopy and cultures

This young woman has presented with a UTI (dysuria, frequency, haematuria). Sexual activity the strongest risk factor for UTIs in women and she’s just come back from ‘holiday’. It is diagnosed with a urine dipstick (already done), and microscopic analysis for bacteria, WBC and RBC and urine culture and antibiotic sensitivities. Antibiotic selection should be based on local guidelines or known sensitivities. Uncomplicated UTIs with no known antibiotic resistance can be treated with co-trimoxazole or nitrofurantoin. If there is resistance, a quinolone can be considered such as ciprofloxacin.

25
Q

A 75 year old man who presents with frank haematuria. He tells you that 3 years ago he had a similar episode & was diagnosed as having ‘warts in the bladder’. After treatment, he moved & was lost to follow-up but had been symptom free since then.

What is the most appropriate next step?
A. Biopsy of prostate 
B. Prostate specific antigen blood test
C. X-ray lumbar spine
D. 24 hour urine monitoring
E. CT scan
F. ASO titre blood test
G. Cytoscopy
H. Abdominal ultrasound
I. MSU: microscopy and cultures
J. Retrograde pyelogram
A

G. Cytoscopy

“Warts in the bladder” is the way of some sneaky urologist avoiding telling this man he had cancer. He was treated, and like all cancer patients, was followed up. Unfortunately, this sounds like a recurrence. Gross haematuria is the primary symptom of bladder cancer. Cystoscopy and urinary cytology are key in diagnosis. Low grade tumours are papillary and easy to see on cystoscopy whereas high grade tumours and carcinoma in situ are often difficult to visualise. Resection provides diagnosis and primary treatment in one step.

26
Q

A 45 year old man wakes in the night with severe pain in his right flank radiating round to the front & into his groin. He can’t get comfortable, but on examination his abdomen is soft with no masses. His urine shows a trace of blood but no other abnormality.

What is the most appropriate next step?
A. Biopsy of prostate 
B. Prostate specific antigen blood test
C. X-ray lumbar spine
D. 24 hour urine monitoring
E. CT scan
F. ASO titre blood test
G. Cytoscopy
H. Abdominal ultrasound
I. MSU: microscopy and cultures
J. Retrograde pyelogram
A

E. CT scan

This patient has renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases. Up to 85% of stones are visible on a plain KUB although urate stones are radiolucent. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones. Stones are analysed after they are extracted or when they are expelled to check their composition. It is worth noting that in all females of child bearing age, a urine pregnancy test is necessary to exclude an ectopic pregnancy.

27
Q

A 75 year old man presents with acute pain in his ribs and back. He also has urinary frequency and a poor flow with a hard prostate on digital examination.

What is the most likely diagnosis?
A. Acute prostatitis
B. Gram negative septicaemia
C. Hydronephrosis
D. Localised prostate cancer
E. Advanced prostate cancer
F. Bladder calculus
G. Bacterial cystitis
H. Benign prostatic enlargement
A

E. Advanced prostate cancer

This patient has advanced age and the hard prostate combined with symptoms of bony metastases indicate advanced prostate cancer. The normal size of the prostate is about the size of a walnut. Management may be expectant or definitive depending on life expectancy. PSA is a serum proteinase which is a tumour marker for prostate cancer. A bone scan will also need to be done given this patient’s back and rib pain. A biopsy will be necessary and prostate cancer is graded on the Gleason score (sum of two scores from 1-5 giving a score from 2-10). An MRSI is an emerging test. Most prostate cancers are adenocarcinomas.

28
Q

A 60 year old man has suprapubic pain on standing and difficulty emptying his bladder with blood at the end of the stream.

What is the most likely diagnosis?
A. Acute prostatitis
B. Gram negative septicaemia
C. Hydronephrosis
D. Localised prostate cancer
E. Advanced prostate cancer
F. Bladder calculus
G. Bacterial cystitis
H. Benign prostatic enlargement
A

F. Bladder calculus

There is pain on standing and difficulty urinating because the calculus falls and blocks the bladder outflow. Blood comes at the end of the stream from urine that has passed the damaged area of urothelium. Patients tend to present with suprapubic pain, haematuria and obstructive symptoms. Examination may reveal suprapubic tenderness. The first test to order is urinalysis. A non-contrast CT abdomen is also indicated to look for the stone.

29
Q

A 65 year old man presents with a large painless bladder and overflow incontinence at night and a raised creatinine level.

What is the most likely diagnosis?
A. Acute prostatitis
B. Gram negative septicaemia
C. Hydronephrosis
D. Localised prostate cancer
E. Advanced prostate cancer
F. Bladder calculus
G. Bacterial cystitis
H. Benign prostatic enlargement
A

C. Hydronephrosis

This patient has BPH which has caused hydronephrosis. This is an example of bilateral obstructive uropathy. Acute presentations are often painful whereas chronic presentations are more insidious in onset. Blockage of urinary flow by the enlarged prostate has led to urinary retention and overflow incontinence. Initial treatment aims to relieve the pressure on the kidneys. This involves catheterisation as the first line treatment. The patient should be started on alpha blockers at the time of catheterisation.

30
Q

A 30 year old man complains of pain in the rectum, groin and urinary frequency with dysuria.

What is the most likely diagnosis?
A. Acute prostatitis
B. Gram negative septicaemia
C. Hydronephrosis
D. Localised prostate cancer
E. Advanced prostate cancer
F. Bladder calculus
G. Bacterial cystitis
H. Benign prostatic enlargement
A

A. Acute prostitis

Acute prostatitis is the most frequently made urological diagnosis in men under 50. It is commonly caused by E. coli and can cause lower abdominal, perineal, rectal and ejaculatory pain. It is associated with the presence of a UTI and BPH. As a result there may be dysuria and frequency. The prostate gland may feel warm and boggy to touch and DRE will reveal an intensely tender gland.This patient does not appear septic and first line treatment is with an oral quinolone such as ciprofloxacin for 10 days with an NSAID for pain relief. A prolonged course of antibiotics is needed if chronic prostatitis follows the acute occurence.

31
Q

A 28 year old builder has an intermittent lump in the left groin for 6 weeks. It is painless. On examination it is above the inguinal ligament, can be induced by coughing, is reducible & is non-tender.

What is the most likely diagnosis?
A. Strangulated femoral hernia
B. Haemotoma
C. Lipoma
D. Folliculitis
E. False aneurysm
F. Lymphoma
G. Sebaceous cyst
H. Reactive lymph node
I. Inguinal hernia
J. Abscess
A

I. Inguinal hernia

Builders are involved in heavy lifting which increases intra-abdominal pressure, predisposing to the development of a hernia. The lump is painless and reducible with a cough impulse so this is not strangulated. Inguinal hernias lie superomedial to the pubic tubercle whereas femoral hernias lie inferolateral to the PT. The male: female ratio for inguinal hernias is 7:1.

32
Q

40 year old woman with fever, weight loss & malaise for 2 months. She has had 2 courses of antibiotics from her GP for presumed chest infections. On examination there is a rubbery 2cm diameter lump in the right groin & 1.5cm diameter lump in the left groin. They are not tender.

What is the most likely diagnosis?
A. Strangulated femoral hernia
B. Haemotoma
C. Lipoma
D. Folliculitis
E. False aneurysm
F. Lymphoma
G. Sebaceous cyst
H. Reactive lymph node
I. Inguinal hernia
J. Abscess
A

F. Lymphoma

Constitutional ‘B’ symptoms are present: fever, weight loss, malaise, night sweats. Rubbery, non-tender LNs further point towards malignancy.The main differential is between Hodgkin’s and non-Hodgkin’s lymphoma.

33
Q

66 year old woman with right leg ulcer dressed by district nurse for 2 months. On examination there is a tender warm lump in the right groin.

What is the most likely diagnosis?
A. Strangulated femoral hernia
B. Haemotoma
C. Lipoma
D. Folliculitis
E. False aneurysm
F. Lymphoma
G. Sebaceous cyst
H. Reactive lymph node
I. Inguinal hernia
J. Abscess
A

H. Reactive lymph node

The leg ulcer indicates that there is local inflammation. Reactive lymphadenopathy is common when there is infection or inflammation.

34
Q

72 year old woman with 2 day history of painful lump in left groin. On examination there is an exquisitely tender 3cm mass in groin.

What is the most likely diagnosis?
A. Strangulated femoral hernia
B. Haemotoma
C. Lipoma
D. Folliculitis
E. False aneurysm
F. Lymphoma
G. Sebaceous cyst
H. Reactive lymph node
I. Inguinal hernia
J. Abscess
A

A. Strangulated femoral hernia

Femoral hernias protrude through the femoral ring into the femoral canal, inferior and posterior to the inguinal ligament. They lie inferolateral to the PT. They are much more common in women than men and as they are typically small, they are easily missed on examination, particularly in fat patients. Femoral hernias have a high rate of strangulation and subsequent complications. This very tender mass indicates this hernia has strangulated and urgent surgical intervention is necessary.

35
Q

62 year old man with enlarging pulsatile mass in left groin. 3 days previously he had had a coronary angiogram.

What is the most likely diagnosis?
A. Strangulated femoral hernia
B. Haemotoma
C. Lipoma
D. Folliculitis
E. False aneurysm
F. Lymphoma
G. Sebaceous cyst
H. Reactive lymph node
I. Inguinal hernia
J. Abscess
A

E. False aneurysm

This is a false or pseudoaneurysm as it does not involve all layers of the arterial wall. This has resulted from arterial trauma during the angiogram. Most cases of false aneuryms are as a result of iatrogenic trauma. A haematoma has formed between the breached layers and the remaining intact artery, causing the lump, which is pulsatile as blood rushes through the artery.

36
Q

A 22 year old woman presents to her GP with a 1 week history of increased frequency of micturation and dysuria. Abdominal examination reveals mild supra-pubic tenderness. You perform a dipstick that reveals haematuria and a positive nitrite and leucocyte esterase.

What is the most likely diagnosis?
A. Ureteric colic
B. Acute pyelonephritis
C. Renal calculi
D. UTI
E. Trauma
F. Bladder carcinoma
G. Renal cell carcinoma
H. Prostatic varices
I. Urine tract obstruction
A

D. UTI

E coli causes most uncomplicated cases and Staph saprophyticus is implicated in 5-20%. Sexual intercourse is the single biggest risk factor in women, although other risks include spermicide use, post-menopause, FH and presence of a foreign body like an indwelling catheter. Symptoms include frequency, dysuria, back pain, haematuria with upper tract involvement suggested by urgency, suprapubic pain, fever and/or tenderness over the costovertebral angle. The first test is a dipstick analysis, although if negative with a suggestive history, it is still likely to be a UTI. Dipstick will show positive nitrite and leucocyte esterase. MSU should be sent for MC+S in some cases such as atypical symptoms or unexpected urinalysis findings.

37
Q

A 70 year old male life long smoker complains of painless haematuria to his GP.

What is the most likely diagnosis?
A. Ureteric colic
B. Acute pyelonephritis
C. Renal calculi
D. UTI
E. Trauma
F. Bladder carcinoma
G. Renal cell carcinoma
H. Prostatic varices
I. Urine tract obstruction
A

F. Bladder carcinoma

Gross haematuria is the primary symptom of bladder cancer. Risk factors include smoking, exposure to carcinogens such as the aromatic amines used in rubber and dye industries, age >55, pelvic radiation and Schistosomiasis resulting in SCC (related to chronic inflammation – so other risks also include UTI, stones etc). Bladder cancer is the most common cancer in Egypt, for the latter reason. Cystoscopy and urinary cytology are key in diagnosis. Low grade tumours are papillary and easy to see on cystoscopy whereas high grade tumours and carcinoma in situ are often difficult to visualise. Resection provides diagnosis and primary treatment in one step.

38
Q

A 36 year old man comes to A&E with severe right sided loin pain radiating to his right testicle. It is of sudden onset and he is unable to find a comfortable position in which to lie.

What is the most likely diagnosis?
A. Ureteric colic
B. Acute pyelonephritis
C. Renal calculi
D. UTI
E. Trauma
F. Bladder carcinoma
G. Renal cell carcinoma
H. Prostatic varices
I. Urine tract obstruction
A

A. Ureteric colic

This patient has renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases. Up to 85% of stones are visible on a plain KUB although urate stones are radiolucent. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones. Stones are analysed after they are extracted or when they are expelled to check their composition. It is worth noting that in all females of child bearing age, a urine pregnancy test is necessary to exclude an ectopic pregnancy.

39
Q

A 75 year old retired banker complains of an episode of haematuria. He tells you that he saw blood at the start of voiding and then the urine became clearer as he continued to void. He also tells you that he is hypertensive. A digital rectal examination reveals a smooth enlarged prostate gland.

What is the most likely diagnosis?
A. Ureteric colic
B. Acute pyelonephritis
C. Renal calculi
D. UTI
E. Trauma
F. Bladder carcinoma
G. Renal cell carcinoma
H. Prostatic varices
I. Urine tract obstruction
A

H. Prostatic varices

The examination findings and haematuria at the beginning of the stream, combined with this patient’s history of hypertension suggests prostatic varices as a cause of the bleeding. A varix is an abnormally dilated vein which is prone to rupture and haemorrhage.

40
Q

An 81 year old male complains of haematuria. He has been an inpatient for 3 weeks following admission for a left hip replacement due to osteoarthritis. His cathether was removed two days ago as he is becoming increasingly mobile.

What is the most likely diagnosis?
A. Ureteric colic
B. Acute pyelonephritis
C. Renal calculi
D. UTI
E. Trauma
F. Bladder carcinoma
G. Renal cell carcinoma
H. Prostatic varices
I. Urine tract obstruction
A

E. Trauma

This patient has had a catheter removed two days ago, which accounts for his gross haematuria (instrumentation of the urinary tract causing damage). The diagnosis is clinical based on the presence of the catheter.

41
Q

A 56 year old smoker complains of seeing bright red blood when he passes water. He mentions no pain but did have a UTI 5 years ago.

What is the most likely diagnosis?
A. Pseudo-haematuria
B. Bladder cancer
C. Nephrotic syndrome
D. Post infectious glomerulonephritis
E. Henoch-Schonlein purpura
F. Ureteric colic
G. Waldenstrom's macroglobinaemia
H. Goodpasture's disease
I. UTI
A

B. Bladder cancer

Gross (classically painless) haematuria is the primary symptom of bladder cancer. Risk factors include smoking, exposure to carcinogens such as the aromatic amines used in rubber and dye industries, age >55, pelvic radiation and Schistosomiasis resulting in SCC (related to chronic inflammation – so other risks also include UTI, stones etc). Bladder cancer is the most common cancer in Egypt, for the latter reason. Cystoscopy and urinary cytology are key in diagnosis. Low grade tumours are papillary and easy to see on cystoscopy whereas high grade tumours and carcinoma in situ are often difficult to visualise. Resection provides diagnosis and primary treatment in one step.

42
Q

A 19 year old girl presents with increasing frequency of passing urine, dysuria and foul smelling urine.

What is the most likely diagnosis?
A. Pseudo-haematuria
B. Bladder cancer
C. Nephrotic syndrome
D. Post infectious glomerulonephritis
E. Henoch-Schonlein purpura
F. Ureteric colic
G. Waldenstrom's macroglobinaemia
H. Goodpasture's disease
I. UTI
A

I. UTI

This young woman has presented with a UTI (dysuria, frequency, and foul smelling urine). Sexual activity the strongest risk factor for UTIs in women. It is diagnosed with a urine dipstick and microscopic analysis for bacteria, WBC and RBC and urine culture with antibiotic sensitivities. Antibiotic selection should be based on local guidelines or known sensitivities. Uncomplicated UTIs with no known antibiotic resistance can be treated with co-trimoxazole or nitrofurantoin. If there is resistance, a quinolone can be considered such as ciprofloxacin.

43
Q

A 5 year old boy has haematuria and a non-blanching rash over his upper thighs.

What is the most likely diagnosis?
A. Pseudo-haematuria
B. Bladder cancer
C. Nephrotic syndrome
D. Post infectious glomerulonephritis
E. Henoch-Schonlein purpura
F. Ureteric colic
G. Waldenstrom's macroglobinaemia
H. Goodpasture's disease
I. UTI
A

E. Henoch-Schonlein purpura

Henoch-Schonlein purpura is the most common vasculitis in childhood and in all cases there is a rash of palpable purpura which are typically non-blanching. If there is no rash, then it is not HSP. They are normally 2-10mm in diameter and are due to the extravasation of blood into the skin. They can occur anywhere on the body but are usually concentrated on the lower extremities. Half of all patients have abdominal pain and arthralgias are commonly present (found in about 80%) and often associated with oedema. The joints most often affected are the knees and ankles. About half will show signs of renal disease such as proteinuria or haematuria. Risk factors for this condition include being male, age 3-15 and history of prior UTI. Complications can occur and the most common cause of death is renal failure. Serum IgA levels may also be elevated.

44
Q

A 40 year old builder has a 4 hour history of haematuria and extreme abdominal pain, that he describes as “coming in waves” between his right flank and right testicle.

What is the most likely diagnosis?
A. Pseudo-haematuria
B. Bladder cancer
C. Nephrotic syndrome
D. Post infectious glomerulonephritis
E. Henoch-Schonlein purpura
F. Ureteric colic
G. Waldenstrom's macroglobinaemia
H. Goodpasture's disease
I. UTI
A

F. Ureteric colic

This patient has renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases and macroscopic haematuria may also be present although this is rare. Dehydration is a strong risk factor for renal stone formation and this man’s job may make him susceptible to inadequate fluid intake. A low urine output can lead to higher levels of urinary solutes, therefore leading to stone formation. Up to 85% of stones are visible on a plain KUB although urate stones are radiolucent. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard otherwise. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones. Stones are analysed after they are extracted or when they are expelled to check their composition. It is worth noting that in all females of child bearing age, a urine pregnancy test is necessary to exclude an ectopic pregnancy.

45
Q

An 11 year old girl has periorbital oedema. Her urine tests positive for microscopic haematuria and proteinuria. Anti-streptolysin O titre (ASOT) is positive.

What is the most likely diagnosis?
A. Pseudo-haematuria
B. Bladder cancer
C. Nephrotic syndrome
D. Post infectious glomerulonephritis
E. Henoch-Schonlein purpura
F. Ureteric colic
G. Waldenstrom's macroglobinaemia
H. Goodpasture's disease
I. UTI
A

D. Post infectious glomerulonephritis

This is post-infectious glomerulonephritis caused by group A beta-haemolytic streptococcus with renal endothelial cell damage. Serological markers would expect to show antibodies to streptococcus and low complement and treatment here is with antibiotics. The high ASOT (antistreptolysin O antibody titres) indicates post-streptococcal GN. There may also be positive anti-Dnase and antihyaluronidase in post-streptococcal GN.

46
Q

A 60 year old obese woman presents to A&E with a history suggesting biliary colic. Her medical history includes hypertension (treated with an ACE inhibitor) and dyslipidaemia. She smokes regularly and drinks alcohol socially. Abdominal ultrasound demonstrates gallstones as well as a 6cm left-sided renal mass. On further questioning, there has been haematuria.

What is the most likely diagnosis?
A. Polycystic kidney disease
B. Benign renal cyst
C. Ureteric cancer
D. Renal cell carcinoma 
E. Renal artery stenosis 
F. Bladder cancer
G. Hyperkalaemia 
H. HIV 
I. Chronic kidney disease
J. UTI 
K. Pyelonephritis 
L. Rhabdomyolysis
M. Renal tuberculosis
A

D. Renal cell carcinoma

Renal cancer arising from the parenchyma/cortex is known as renal cell carcinoma. Clear cell renal cell carcinoma accounts for most primary renal cancers. They are often asymptomatic and diagnosed incidentally like on imaging when localised malignant looking renal masses are seen. Surgery for early local disease (which is diagnosed in more than half) can be curative in up to 90%. Renal masses are usually only symptomatic in late disease. The classic triad is of haematuria, flank pain and an abdominal mass – this is only seen in 10%. Uncommonly, a patient may present with symptoms of metastatic disease such as bone pain or respiratory symptoms. Symptoms, if present, also include abdominal pain, oedema/ascites from IVC disruption and scrotal varicocele in males. Risk factors include: smoking, male gender, living in developed countries, obesity, hypertension, FH, high parity and ionising radiation.

47
Q

A 24 year old lady has repeatedly had urinary tract infections and is frustrated because she must have antibiotics every 2-3 months. She tells you her mother died when she was young from a “bleed in the brain”.

What is the most likely diagnosis?
A. Polycystic kidney disease
B. Benign renal cyst
C. Ureteric cancer
D. Renal cell carcinoma 
E. Renal artery stenosis 
F. Bladder cancer
G. Hyperkalaemia 
H. HIV 
I. Chronic kidney disease
J. UTI 
K. Pyelonephritis 
L. Rhabdomyolysis
M. Renal tuberculosis
A

A. Polycystic kidney disease

This sounds like autosomal dominant polycystic kidney disease. There may like in this case be a FH, of PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and subsequent SAH – the bleed in the brain). Patients may have haematuria (which can be gross), palpable kidneys and symptoms of a UTI which is common in those with the condition. Hypertension and flank pain are also commonly seen. Hepatosplenomegaly may also be found. A renal ultrasound is the first test to order when the diagnosis is suspected. If the ultrasound is equivocal, a CT scan can be done of the abdomen and pelvis.

48
Q

A 30 year old lady presents to A&E feeling very feverish, complaining of dysuria and haematuria with severe flank pain.

What is the most likely diagnosis?
A. Polycystic kidney disease
B. Benign renal cyst
C. Ureteric cancer
D. Renal cell carcinoma 
E. Renal artery stenosis 
F. Bladder cancer
G. Hyperkalaemia 
H. HIV 
I. Chronic kidney disease
J. UTI 
K. Pyelonephritis 
L. Rhabdomyolysis
M. Renal tuberculosis
A

K. Pyelonephritis

UTIs involving the renal parenchyma typically presents with fever. Acute onset fever with urinary symptoms and flank pain point to acute pyelonephritis. Urinalysis is highly sensitive but not very specific. Pregnancy is a risk factor for complicated disease as the enlarging uterus compresses the ureters and hormonal changes increase the likelihood of obstructive uropathy. In uncomplicated pyelonephritis, the most common cause is E. coli and gram stain will typically reveal gram negative rods, either E. coli, Proteus or Klebsiella. Gram positive cocci that could be implicated include enterococci and staphylococci. Older patients can often also present non-specifically. Treatment should start before culture results are received to prevent the patient from deteriorating, with empirical antibiotics.

49
Q

A rough looking homeless man presents to A&E with dysuria, haematuria and frequency. Examination reveals a scrotal mass. Chest x-ray is abnormal.

What is the most likely diagnosis?
A. Polycystic kidney disease
B. Benign renal cyst
C. Ureteric cancer
D. Renal cell carcinoma 
E. Renal artery stenosis 
F. Bladder cancer
G. Hyperkalaemia 
H. HIV 
I. Chronic kidney disease
J. UTI 
K. Pyelonephritis 
L. Rhabdomyolysis
M. Renal tuberculosis
A

M. Renal tuberculosis

GU TB common presents with symptoms of dysuria, haematuria and urinary frequency. Some 20-30% of patients may also be asymptomatic, and sometimes extensive renal destruction may have occurred by the time it is diagnosed. Genital TB in men may present as a scrotal mass and in women there may be pelvic pain. Diagnosis relies on culturing TB from morning urine samples (3 samples are recommended) or biopsy of the lesion. CXR in these patients is abnormal in most cases. Up to 90% are TST positive on Mantoux testing. Extrapulmonary TB can also include pericardial, abdominal, disseminated, skeletal, CNS and pleural TB. Homelessness here is an epidemiological risk factor. Other risks include birth in high TB countries (Asia, Latin America and Africa in particular) and exposure to TB.

50
Q

A 50 year old man is brought into hospital by his wife. She tells you he has become increasingly confused for the last 3 days and is always scratching himself. ABG shows a metabolic acidosis. She remembers he was recently started on a new tablet by his GP.

What is the most likely diagnosis?
A. Polycystic kidney disease
B. Benign renal cyst
C. Ureteric cancer
D. Renal cell carcinoma 
E. Renal artery stenosis 
F. Bladder cancer
G. Hyperkalaemia 
H. HIV 
I. Chronic kidney disease
J. UTI 
K. Pyelonephritis 
L. Rhabdomyolysis
M. Renal tuberculosis
A

E. Renal artery stenosis

Renal artery stenosis is basically narrowing of the renal artery. It occurs typically due to atherosclerosis or fibromuscular dysplasia. The presentation tends to be with accelerated or difficult to control hypertension. Acute kidney injury can be seen after starting an ACE inhibitor or an angiotensin II receptor antagonist which this patient has been prescribed. The afferent arteriole is stenosed in RAS and angiotensin II is needed to maintain GFR by constricting the efferent arteriole. ACE inhibitors prevent conversion of angiotensin I to angiotensin II, which is needed to maintain renal perfusion pressure in those with RAS. The result is this patient has acute renal failure and has developed uraemia. The metabolic acidosis is also as a result of renal failure.

There may not be any clinical consequences of RAS – just because someone’s renal arteries are narrowed does not mean they are suffering worsening kidney function, although this may be the case, especially after blockade of the renin-angiotensin system. A definitive diagnosis is made on imaging, where there is some controversy on what is most appropriate to use. USS is safe and non-invasive but the sensitivity and specificity is low. CT/MR angiography has the risk of contrast nephropathy and nephrogenic systemic fibrosis. Conventional angiography (the best test available) has the risk of bleeding and emboli as well as contrast related risks already mentioned.