Block 34 Week 8 Flashcards
incidence of renal stones?
- 10% incidence
- high reccurence rates
- Majority stones upper tract; can get bladder stones with outflow obstruction
presentation of renal stones?
- acute presentation w renal colic
- loin to groinpain
- haematuria
low urine pH suggests…
Ix of renal stones?
- Look for the GFR, Creatinine & WCC
- Low urine pH suggests uric acid component
imaging for stones?
- Imaging is key – CT KUB gold standard
- X-ray KUB & Ultrasound useful
bladder cancer?
- majority transitional cell carcinoma
- often presents w haematuria
- Referred to 2WW Haematuria clinic for upper tract imaging – CT Urogram or Ultrasound + Flexible Cystoscopy
Tx of BC?
- TURBT (Transurethral Resection of Bladder Tumour
- Chemotherapy – Mitomycin C
- Immunotherapy – BCG
Renal cancer triad?
- classic triad of loin pain, haematuria and mass - not commonly seen tho
Imaging for renal cancer?
- imaging - US, CT w contrast
Tx of renal cancer summary?
- Treatment – Radical Nephrectomy vs. Partial Nephrectomy
- Not usually chemo- or radio-sensitive
- Advanced cases - immunotherapy
Mx of ED?
*Management of risk factors
- Oral therapy (PDE5is)
causes of ED?
- Diabetes
- Atherosclerosis
- Tobacco use
- Obesity
- Pelvic radiotherapy
- Prostate Surgery e.g. TURP
- Blunt injuries to penis
*Multiple Sclerosis - Peyronie’s disease
- Low testosterone
- Antidepressants
- Antihistamines
*Anti-hypertensives - Alpha blockers
- Psychological conditions e.g. depression, anxiety
- Heavy drinking +/- concomitant drug use
Peyorine’s disease - incidence?
- <1% incidence
presentation of Peyronie’s Disease ?
- Present with pain and deformity on erection, a palpable penile plaque, and, in many cases, erectile dysfunction
- Associated with Dupuytren’s contracture and a history of penile trauma
pathophys of Peyronie’s Disease ?
- Minor injury to the tunica albuginea is thought to lead to trapping of fibrin and an excess cytokine reaction that causes disordered healing and focal loss of elasticity
acute phase of Peyronie’s Disease ?
*up to two years
*erectile deformity may worsen
Peyronie’s Disease - when is surgical intervention needed?
- In patients whose deformity prevents intercourse, surgical intervention is needed.
- nesbitt procedure
- Lue procedure
Causes of male factor infertility - endocrine?
Pituitary disease, Hypogonadotropic hypogonadism, Excess of androgens
Causes of male factor infertility - disorders of spermatogenesis
Chromosomal disorders, Cryptorchidism, Testicular torsion, Sertoli cell only, Infection
Causes of male factor infertility - sperm delivery disorders?
Congenital bilateral absence of vas deferens, Ductal obstruction, Erectile dysfunction, Ejaculatory dysfunction
Causes of male factor infertility- penile and sperm causes?
- Penile anatomical disorders
- Sperm function disorders
- Immunological infertility,
- Ultrastructural abnormalities of sperm
Luts?
- Storage symptoms
- Urgency
- Daytime Frequency
- Nocturia
- Voiding symptoms
- Poor flow
- Incomplete emptying sensation
- Hesitancy
BPE vs BOO vs BPH?
BPE – Benign Prostatic Enlargement (clinical)
BOO – Bladder Outflow Obstruction
BPH – Benign Prostatic Hyperplasia (histological)
surgical interventions for BPE/LUTS?
- Transurethral resection of the prostate (TURP)
- Holmium enuculation of the prostate (HoLEP)
- Prostatic artery embolisatio
- Newer techniques – aquablation, steam, microwave, staples, stents
urological emergencies?
- Scrotal Pain
- Acute Urinary Retention
- Renal Colic
- Haematuria
- Urosepsis
- Andrology Emergencies
scrotal pain?
- Testicular torsion - this is a urological emergency
- rare prob in pts over 30 yrs
- only test is exploration
- ideally up to 6 hrs but can be salvagable upto 24 hrs
torsion of hyatid of morgagni?
blue dot sign
Epidymitis?
- chlamydia most causative organisism
- under 35-> refer to GUM clinic
Mx of epididmytis?
- Doxy for chylamdyia
- Ciprofloxacin for Gonorrhoea
acute urinary retention?
- Acute inability to pass urine’
- Can lead to acute renal failure
- Catheterise
Ix of urinary retention?
- Record the volume of urine drained. No urine = consider renal failure
- Urine for culture if suspicion of infection & cover with antibiotics – check local antibiotic policy
- FBC, U&E. Is the creatinine deranged from the patient’s normal baseline?
- don’t check PSA - raised in retention and by catheterization
- rectal examination
- tamsulosin then TWOC
Infected obst kidney?
- UROLOGICAL EMERGENCY
- Resuscitate
- Drain the kidney – nephrostomy or stent
- Antibiotics + urine culture
- Delayed surgical intervention
causes of haematuria?
- cancer - bladder, kidney, ureter, prostate
- stones - kidney, ureter, bladder
- inflammation - interstitial cystitis, cyclophosphamide
- infections
- trauma - kidney, bladder, urethra, pelvic fracture
which type of haematuria has a higher risk of urological cancer?
VH than non visible
Ix for haematuria?
- urine culture
- renal US
- urine cytology
- CT, MRI, renography
LUTS + VH or NHV suggests
bladder cancer
recent onset of bedwetting in an elderly man is often due to
high pressure chronic retention - drain after catheterisation
LUTS - neuro disease?
- neurological disease/ SC/ cauda equina compression - back pain, sciatica, ejaculatory dist, sensory dist in legs, feet, perineum
acute vs chronic loin pain?
- acute loin pain more likely to be due to obstruction e.g. stone
- chronic loin pain suggests disease within kidney or renal pelvis
most common cause of sudden onset severe flank pain?
- commonest cause of sudden onset severe flank pain is the passage of a stone down through the ureter
ureteric stone pain?
- down through the ureter
- ureteic stone pain characteristically starts v suddenly (within minutes), is colicky in nature and radiates to the groin as the stone passes into the lower ureter
- ppt can’t get comfy, often roll around in agony
what suggets that the stone has moved into the intramural part of the ureter?
- if the ppt has pain/ discomfort in the penis and a strong desire to void, suggests that the stone has moved into the intramural part of the ureter
Acute loin pain is less likely to be due to a stone in?
- acute loin pain is less likely to be due to a ureteric stone in women and ppts at the extremes of age
- tends to be disease of men (and women) at 20-60yrs
non stone causes of acute loin pain ?
- clot or tumour colic - loin pain and haematuria
- PUJ obst
- Pyelo
PUJ obst?
- PUJ obstruction - may present acutely w flank pain severe enough to mimic a ureteric stone
- CT demonstrates hydronephrosis with normal ureter below the PUJ and no stone
high fever and stone?
- high fever - >38 but ureteric stone ppts don’t unless there is infection with the obts
- ppts tend to be systemically v unwell
non urological causesof acute loin pain
chronic loin pain -non urological causes?
urological causes of chronic loin pain?
ureteric colic vs peritonitis?
- ppts ureteric colic often move around the bed in agony whilst those w peritonitis lie still
- signs of peritonitis - abd tenderness, guarding
distinguishing urological from non urological loin pain
- examine for abd mass - pulsatile and expansile - leaking AAA
- in women do a preg test
- examine back chest and testicles
stress incontinence?
- involuntary leakage of urine on effort, exertion, sneezing or coughing
urge incontinence?
- involuntary leakage of urine accompanies by or immediately preceded by urgency
MUI?
- comb of SUI and UUI
Prev of incontinence?
- 25% of over 20s have UI, 50% have SUI
what causes stress incont?
- occurs due to bladder neck/ uretheral hypermotility and/or NM defects causing intrinsic sphincter def (sphincter weakness incontinence)
- urine leaks whenever uretheral resistance is exceeded by an inc in abd pressure occuring e.g. exercise or coughing
UUI is caused by?
- may be due to bladder overactivity or less commonly due to pathology that irritates the bladder (infection, tumour, stone)
- symptoms from involun detrustor contractions may be difficult to distinguish from those due to sphincter weakness
- in some ppts detrustor contractions can be provoked by coughing making it diff to distinguish between UUI and SUI
constant leak of urine?
- suggests fistulous communication between the bladder and vagina e.g. due to surgical injury at the time of hysterectomy or C section or rarely presence of an ectopic ureter draining into the vagina - urine leak is usually low in volume but lifelong
abd examination in urological disease
- bc retroperitoneal (kidneys, ureters) or pelvic organs are relatively inaccessible, for the kidneys and bladder to be palpable implies a fairly advanced disease state
characteristics of an enlarged bladder
- arises out of the pelvis
- dull to percussion
- pressure of examining hand may cause a desire to void
Abd distension: causes ?
- foetus - smooth firm mass, dull to percussion
- flatus - hyper-resonant - may be visible peristalsis if intestinal obstruction
- faeces - palpable in the flanks and across the epigastrium, firm, may be sep masses in the line of the colon
- fat
- fluid (ascites) - fluid thrill, shifting dullness
causes of an enlarged kidney?
- mass lies in the paracolic gutter, moves w res, dull to percussion
- can be felt bimanually
- can be ballotted
- renal carcinoma, hydronephrosis, pyelo, perinephric abcess, polcystic disease
charac of an enlarged liver?
- mass descends from under right costal margin
- moves w resp
- dull to percussion
- sharp or rounded edge
causes of hepatomeg?
- infection
- congestion - HF, HV obstruction
- infilitration - amyloid
- space occupying lesions - hepatic cancer, mets, hydatid cyst
- cirrhosis
charac of an enlarged spleen?
- under left costal margin
- firm, smooth, may have palpable notch
causes of splenomegaly?
- infection
- congestion
- infiltration
- space occupying lesions
RCC?
- most common type of kidney tumour
- type of adenocarcinoma that arises from the renal tubules
Classic RCC triad?
haematuria, flank pain, palpable mass
3 types of RCC
- Clear cell(around 80%)
- Papillary(around 15%)
- Chromophobe(around 5%)
Wilms tumour?
- Wilms tumour is a specific type of tumour affecting the kidney in children under 5
Renal cell carcinoma may beasymptomatic, but may present with:
- Haematuria
- Vague loin pain
- Non-specific symptoms of cancer (e.g., weight loss, fatigue, anorexia, night sweats)
- Palpable renal mass on examination
Haematuria
NICE guidelines on recognising cancer advises atwo week waitreferral for those:
- Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
Spread of RCC?
- tends to spread to tissues around the kidney with Gerota’s fascia
- often spreads to the renal vein then to the IVC
spread of RCC to lungs?
- “Cannonball metastases” in the lungs are a classic feature of metastatic renal cell carcinoma.
- Cannonball mets can also occur from choriocarcinoma (cancer in the placenta) and, less commonly, with prostate, bladder and endometrial cancer.
paraneoplastic features of RCC?
- polycythemia - EPO
- Hypercalcaemia - PTHr
- HTN
- Stauffers syndrome
- cushings
HTN from RCC?
due to various factors, including increased renin secretion, polycythaemia and physical compression
Stauffer’s syndrome?
abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis
mx of RCC?
- surgery is first line: partial/ radical nephrectomy
- when surgery can’t be done:
- arterial embolisation
- percutaneous cryotherapy
- radiofreq ablation
When should wilms tumour be considered?
Consider a Wilms tumour in a child under the age of 5 years presenting with a mass in the abdomen. The parents may have noticed the mass
Signs and symptoms of wilms tumour?
- Abdominal pain
- Haematuria
- Lethargy
- Fever
- Hypertension
- Weight loss
diagnosis of wilms tumour?
- initial Ix is US
- CT/ MRI for staging
- biopsy needed for definitive diagnosis
Non muscle invasive bladder cancer Tx- cornerstone?
- transurethral resection of bladder tumour (TURBT) - cornerstone of management - providing diagnosis, staging and initial Tx
BCG in NMIBC?
- intravesical therapy: for high risk NMIBC or carcinoma in situa - BCG immunotherapy
- Maintenance therapy: BCG maintenance therapy may improve outcomes in high-risk patients.
Muscle invasive bladder cancer Tx?
- neoadjuvant chemo - cisplatin based
- radical cystectomy
- bladder sparing approaches - TURBT, radiotherapy, chemotherapy
- adjuvant chemo
tX of met BC?
- first line therapy - platinum based
- immune checkpoint inhibitors like pembrolizumab
RCC - early stage (T1 and T2) Tx?
- Surgery main - partial nephrectomy for t1
- radical nephrectomy in T2
RCC - locally advanced - T3 and T4 tx?
- Radical nephrectomy + lymph node dissection is the standard of care
- Neo-Adjuvant Therapy: Tyrosine kinase inhibitors (TKIs) or immunotherapy can be considered to downsize the tumour before surgery.
Metastatic RCC Tx?
- mainstray of treatment is systemic therapy
- Low risk patients: VEGF inhibitors such as sunitinib, bevacizumab or pazopanib.
- Intermediate and high risk patients: dual immunotherapy with ipilimumab and nivolumab
Features of PC on DRE?
- digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus
- hard, lumpy
when should men be ref for PC?
- Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their prostate feels malignant on digital rectal examination.
- Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their PSA levels are above the age‑specific reference range.
Consider a prostate‑specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in men with:
- any lower urinary tract symptoms, such asnocturia, urinary frequency, hesitancy, urgency or retention or
- erectile dysfunction or
- visiblehaematuria.
PSA?
- protein produced by prostate epithelial cells
- PSA is produced by normal prostate tissue, however levels in the blood tend to increase in malignancy.
asymptomatic PSA testing?
- PSA testing can be discussed with men over 50, and should be offered to those men over 50 who request it
before PSA testing men should not have?
- Active or recent UTI(last 6 weeks)
- Recent ejaculation, anal sex or prostate stimulation
- Engaged vigorous exercise for 48 hours
- Had a urological intervention in the past 6 weeks
Specific clinical triggers to consider a PSA test include:
- Lower urinary tract symptoms(e.g. nocturia, frequency, hesitancy, urgency or retention)
- Visible haematuria
- Unexplained symptomsthat may be explained by advanced prostate cancer (e.g lower back pain, bone pain, weight loss)
- Erectile dysfunction
benefits of PSA testing?
- can detect prostate cancer at early stage -> earlier treatment -> better outcomes
- of PSA testing
- PSA testing can result in false positives -> unecessary biopsies, anx for patients
- PSA can be elevated from other conditions such as BPH
Which ethnicity has the highest risk of PC?
black men
95% of PC are?
- 95% are adenocarcinomas
- majority arise in the peripheral zone of the prostate, with 10-20% arising from the central zone and 10-20% arising from the transitional zone.
signs of symptoms of prostate cancer remote from the prostate gland?
- bone pain - mets?
- weight loss
- fatigue
- urinary symptoms
- neurological symptoms - spread to SC or nerves
Testicular tumours affect?
- It predominantly affects younger men aged 15-35 years and has a higher incidence in Caucasian populations
2 main types of TT?
serminomas (40-60%) and non-seminomatous germ cell tumours (30-50%)
non seminatous germ cell tumours?
embryonal carcinoma, yolk sac tumour, choriocarcinoma, and teratoma.
RF for Test cancer?
- Infertility (increases risk by a factor of 3)
- Cryptorchidism
- Family history
- Klinefelter’s syndrome
- Mumps orchitis
most common presenting feature of TT?
painless lump
other CF of Tc?
- Pain
- lmpotence
- hydrocele
- gynaecomastia
What is elevated in germ cell tumours?
- AFP in 60%
- LDH in 40%
what can be elevated in seminomas?
- Seminomas: hCG may be elevated in around 20%
Referral guidelines for testicular cancer?
- testicular cancer in men if they have a non‑painful enlargement or change in shape or texture of the testis.
- Consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms.
Ix for TT?
US first line
Mx of TT?
- Treatment depends on whether the tumour is a seminoma or a non-seminoma
- Orchidectomy
- Chemotherapy and radiotherapy may be given depending on staging and tumour type
PC - LUTS?
- Nocturia
- Frequency
- Hesitancy
- Urgency
- Dribbling
- Overactive bladder
- Retention
PC - advanced disease?
(e.g haematuria, blood in semen, lower back pain/bone pain secondary to bony metastasis, weight loss, anorexia)
other features of PC
- Visible haematuria
- Abnormal DRE(hard, nodular, enlarged, asymmetrical)
first line Ix for diagnosis of PC?
- Multiparametric MRIis now commonly the first line investigation in the diagnosis of prostate cancer.
- MRI influenced prostate biopsy - guided biopsy offered to patients w a Likert score of above 3
Active surveillance for PC?
- option in low-risk localised prostate cancer.
- It involves regular PSA measurements, digital rectal examinations and multiparametric MRIs.
- It is used as many with low-risk localised disease
radical prostatectomy?
- Radical prostatectomy: is a definitive treatment option for localised prostate cancer. It involves the removal of the entire prostate gland and surrounding tissues
radical radiotherapy?
definitive Tx for localised prostate cancer
adverse effects of radiotherapy to the prostate?
urinary incontinence and erectile dysfunction (though less than radical prostatectomy) as well as bowel symptoms (e.g. faecal incontinence).
SE of radical prostatectomy?
urinary incontinence and ED
androgen deprivation therapy?
- aims to lower androgen levels
- can be given to those with intermediate or high-risk localised disease (normally if receiving radical radiotherapy) or in metastatic disease to slow progression.
adverse effects of androgen deprivation therapy?
include a loss of libido, erectile dysfunction, loss of ejaculation and osteoporosis.
Androgen deprivation therapy - options?
- GnRH agonist: chemical castration - reduced LH/FSH release
- e.g. goserelin
- Bicalutamide (an anti-androgen)
- Bilateral orchidectomy(castration)
localised prostate cancer Mx options?
- Active surveillance
- Radical prostatectomy
- Radical radiotherapy
Low risk PC Mx?
a choice of active surveillance, radical prostatectomy or radical radiotherapy can be offered.
intermediate risk PC Mx?
NICE advises offering radical prostatectomy or radical radiotherapy. They advise considering active surveillance in those declining radical therapy.
High risk PC Mx?
NICE advises offering radical prostatectomy or radical radiotherapy. They do not advise active surveillance in high-risk disease.
locally advanced PC Mx?
Patients are typically managed with prostatectomy and radiotherapy. Docetaxel chemotherapy may beused
metastatic PC Mx?
- Docetaxel chemotherapy and androgen deprivation therapy are often used. Bilateral orchidectomy can be offered as an alternative to androgen deprivation therapies.
prognosis of PC?
- 96% survive one year
- 86% survive 5 yrs after diagnosis
Mx of seminomas and teratomas - surgery?
- orchidectomy
- should be performed in virtually all cases
- both diagnostic and therapeutic
how is orchidectomy performed?
- Orchidectomy must be performed via an inguinal approach. This is to avoid crossing lymph networks - the testicles lymph drain to para-aortic nodes whilst the scrotal skin drains to the inguinal nodes.
stage 1 seminoma Tx?
- Stage I Seminoma (low risk): Standard treatment options include surveillance (active monitoring without immediate treatment) or adjuvant radiotherapy to the retroperitoneal lymph nodes.
high risk seminoma Tx?
Options may include surveillance, adjuvant radiotherapy, or adjuvant chemotherapy.
Advanced seminoma Tx?
Treatment typically involves chemotherapy, such as a combination of bleomycin, etoposide, and cisplatin (BEP regimen).
Stage 1 teratoma Tx?
Treatment usually involves radical inguinal orchiectomy (removal of the affected testicle). Adjuvant treatments such as chemotherapy or radiotherapy may be considered
Advanced teratoma Tx?
Treatment often involves chemotherapy, typically with a regimen such as BEP (bleomycin, etoposide, cisplatin) or EP (etoposide, cisplatin).
renal stones?
- renal stones are also referred to as renal calculi, urolithiasis, nephrolithiasis
- hard stones that form in the renal pelvis
- commonly get stick at the vesico-ureteric junction
2 key comps of renal stones?
- Obstruction leading to acute kidney injury
- Infection with obstructive pyelonephritis
most common type of renal stone?
calcium based - raised calcium and low urine output are key factors
2 types of calcium stones?
- 2 types of calcium stones: calcium oxalate (most common) and calcium phosphate
RF for renal stones?
- dehydration
- hypercalciuria, hyperparathyroidism, hypercalcaemia
- cystinuria
- high dietary oxalate
- renal tubular acidosis
- medullary sponge kidney, polycystic kidney disease
- male sex
- infection
RF for urate stones?
- gout
- ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid
drugs causing renal stones?
- drugs that promote calcium stones: loop diuretics, steroids, acetazolamide, theophylline
which drugs can prevent calcium stones?
- thiazides can prevent calcium stones (increase distal tubular calcium resorption
visibility
uric acid stones?
not visible on XR
Struvite renal stones?
produced by bacteria, therefore, associated with infection
cystine renal stones?
associated with cystinuria, an autosomal recessive disease
staghorn calculus?
- where the stone forms in the shape of therenal pelvis, giving it a similar appearance to the antlers of a deer stag.
- The body sits in therenal pelviswith horns extending into therenal calyces.
- They may be seen on plain x-ray films.
when do staghorn caluli tend to occur?
- Most commonly, this occurs with stones made of struvite.
- In recurrent upper urinary tract infections, the bacteria can hydrolyse the urea in urine to ammonia, creating the solid struvite.
renal colic?
- Unilateral loin to groin painthat can be excruciating (“worse than childbirth”)
- Colicky(fluctuating in severity) as the stone moves and settles
- Patients often move restlessly due to the pain.
Features of renal stones?
- renal colic
- Haematuria
- Nausea or vomiting
- Reduced urine output
- Symptoms of sepsis, if infection is present
Ix of renal stones?
- urine dipstick - usually shows haematuria, helpful to exclude infection
- blood tests - signs of infetion and identify hypercalcaemia
- abd X ray - will show calcium based stones but uric acid stones won’t show up - radiolucent
imaging of renal stones?
- CT KUB - initial Ix for diagnosing stones - within 24 hrs
- US KUB in children and pregnant women
Pain relief for renal stones?
- NSAIDs - IM diclofenac, IV paracetamol
small stones?
- watchful waiting for stones less than 5mm
managing other symptoms w stones?
- antiemetics for nausea and vomiting - cyclizine e..
- ab if infection
which drug can be used to aid w passage of stones?
- tamsulosin - to aid w spontaneous passage of stones
large stones Mx?
- surgical interventions - required in large stones (10mm or larger), stones that do not pass spontaneously or where there is complete obstruction or infection.
surgical interventions for stones - ESWL?
- Extracorporeal shock wave lithotripsy (ESWL) - shock waves directed at stones to break them up
Surgery for stones - Ureteroscopy and laser lithotripsy ?
camera inserted and stone broken up using lasers
other surgical options for stones?
- Percutaneous nephrolithotomy- camera inserted, stones broken up
- open surgery
oxolate
preventing recurrence of calcium stones?
reduce the intake of oxalate-richfoods (e.g., spinach, beetroot, nuts, rhubarb and black tea)
preventing reccurence of uric acid stones?
reduce the intake of purine-rich foods (e.g., kidney, liver, anchovies, sardines and spinach)
reducing recurrence of kidney stones?
- Avoiding excess salt
- Good oral hydration(and adding lemon juice to drinking water)
- Avoiding carbonated drinks
- A balanced diet
- Healthy weight loss
- potassium citrate
- thiazide diuretics
Ix of UTI?
- urine dip
- urine culture
- 24 hr urine collection to measure calcium, oxalate, citrate, uric acid
RF for incontinence?
- advancing age
- previous pregnancy and childbirth
- high body mass index
- hysterectomy
- family history
overactive bladder/ urge incontinence is due to
detrusor overactivity
stress incontinence is due to?
leaking small amounts when coughing or laughing, related to increased intra-abd pressure
overflow incontinence?
due to bladder outlet obstruction, e.g. due to prostate enlargement, overflow after retention
Ix of incontinence?
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
RF for stress incontinence?
- weakening of pelvic floor muscles:
- Age
- Pregnancy & vaginal delivery
- Constipation
- Obesity
- Family history
urge incontinence is characterised by?
- characterised by the urge to pass urine associated with involuntary leakage.
- It occurs secondary to an overactive bladder
- due to detrusor muscle overactivity -> involuntary contractions of the bladder
urge incontinence is mostly?
- mostly idiopathic but can occur secondary to neurological disorders
what causes overflow incont?
- when someone can’t fully empty their bladder with overflow occuring when the bladder becomes v full or secondary to stress/ urge
- can occur secondary to physical obstruction or underactivity of the detrusor muscle:
Overflow incontinence - bladder outlet obst?
- bladder outlet obst e.g. prolapse, fibroids, following pelvic surgery
overflow incont - detrusor underactivity?
- detrusor underactivity: leads to retention and leakage
overflow occurs w?
- This occurs with advancing age, in those with peripheral neuropathy, spinal cord pathologies (e.g. MS) and secondary to medications (e.g. antimuscarinics)
psychological impact of incontinence?
- shame and embarassment -> social withdrawal
- low self esteem
- anxiety
- social isolation - fear or leakage or odor
- reduced QOL - fear of accidents
- financial burden - purchase of absorbent products
physical impacts of incont?
- skin irritation and infection - rash, ulcers
- UTIs
- sleep disturbances due to nocturia
- sexual dysfunction
neurogenic bladder arises from?
- arises from neurological conditions like SC injury, MS, PD, stroke
pathophys of neurogenic bladder?
- damage to nerves disrupts co-ordination between the detrusor muscle, and sphincter muscles
- -> urinary retention, overactive bladder
UMN lesions?
- disruption of voluntary control over bladder function -> detrusor overactivity and increased bladder pressure
- there may also be detrusor-sphincter dyssynergia, where the detrusor muscle contracts while the sphincter remains closed, leading to urinary retention
LMN lesions and bladder?
- These lesions disrupt the reflex arc responsible for bladder emptying and can lead to detrusor areflexia or hyporeflexia, decreased bladder contractility, and urinary retention.
- Overflow urinary incontinence may occur due to bladder overdistension and leakage around the incompetent sphincter.
altered sensation and incontinence?
- decreased awareness of bladder fullness or urgency
- delayed recognition of the need to void/ inability to sense when the bladder is full -> retention/ incontinence
physical impacts of neuropathic bladder disorders?
- incontinence
- retention
- overactivity
- distension
- hydronephrosis
PSYCH impacts of neuropathic bladder disorders?
- stress and anxiety
- depression
- self esteem
- social withdrawal
2 week wait criteria for bladder cancer:
- dysuria w unexplained non visible haematuria age 60 and over
- Haematuria (visible and unexplained) either without urinary tract infection or that persists or recurs after successful treatment of urinary tract infection, age 45 years and over
- Haematuria (non-visible and unexplained) with dysuria or raised white cell count on a blood test, age 60 years and over
- White cell count raised on a blood test with unexplained non-visible haematuria, age 60 years and over
PSA and DRE considered when:
- ED
- haematuria
- LUTS
2 week wait for PC?
- prostate feels malignant
- PSA > reference ranges
LUTs Mx - ? blockers?
- alpha blockers like doxazosin or tamsulosin for moderate to severe LUTS
LUTS - Mx of overactive bladder?
- anticholinergic for overactive bladder
LUTs - ? for enlarged prostate?
- 5-AR inhibitor like finasteride for LUTS with enlarged prostate
LUTS - ? for noctural polyuria?
loop diuretic
Tx urinary retention?
- immediately catheterise for acute retention
- offer alpha blocker
- measure creatinine and image upper urinary tract for chronic retention
referral criteria for urinary incontinence
- persisting bladder or urethral pain
- palpable bladder on bimanual or abdominal examination after voiding
- clinically benign pelvic masses
- associated faecal incontinence
- suspected neurological disease
- symptoms of voiding difficulty
- suspected urogenital fistulae
- previous continence surgery
- previous pelvic cancer surgery
- previous pelvic radiation therapy.
Lifestyle interventions for incontinence?
- caffiene reduction for overactive bladder
- weight loss
first line for stress/ mixed urinary incont?
pelvic floor therspy
first line for urgency/ mixed incont?
- bladder training for urgency/ mixed incontinence
SNRI for stress incont?
duloxetine
surgical options for SI?
- Tension free vaginal tape
- autologous sling procedures
- colposuspension
- intramural urethral bulking
artifical urinary sphincter?
- when the stress incont is caused by neuro disorder or when other surgical interventions fail
- involves a pump inserted into the labia that inflates and deflates a cuff around the urethra allowing women to control continence manually
management of urge incont?
- bladder retraining
- anticholinergics - oxybutinin
- mirabegron
invasive options for overactive bladder?
- botox in bladder wall
- pec sacral nerve stimulation
- augmentation cystoplasty
- urinary diversion
discontinue ? if commencing LAMA
Discontinue SAMA (switch to SABA) if commencing LAMA
reduced ? in PE?
TLCO
Sudden deterioration with ventilation suggests
tension pneumothorax
Summary of leukemias?
- ALL: most common children
- AML: mostly in adults, auer rods
- CLL - smudge cells, most common overall
- CML - Philadelphia chromosome, imatinib
TLS met abn?
- high K
- high P
- low calc
What can be seen in coeliac disease?
howell jolly bodies due to hypospelnism
Transfusion related circ overload?
- HTN
- Raised JVP
- afebrile
- s3 present
TRALI?
- hypotension
- pyrexia
- normal/ unchanged JVP
features of Neph syndrome?
- HTN
- oedema
- hameaturia
- olig
types of nephrotic syndrome?
- focal segmental glomeruloscl
- minimal change
- membranous nephropathy
- diabetic nephropathy
- amyloidosis
types of nephritic syndrome?
- post-strep GN
- IgA nephropathy
- Alport
- membarnoproliferative GN
- rapidly progressive GN
GN =
nephritis
Focal segmental GS?
- Most common NS in african & hispanic
- assoc w sickle cell and HIV
what is seen in focal segmental GS?
effacement of foot podocytes
Minimal change?
- most common Neph S in children
- assoc w recent infection
- rarely assoc w hodgkin lymphoma
what is seen with minimal change?
effacement/ fusion of podocyte foot processes
Primary memb nephropathy?
ab against phospholipase A1
Secondary memb nephropathy?
- infections - hep B and C
- SLE
- meds - NSAIDs, penicillamine, gold
what is seen w memb nephropathy?
- spike and dome appearance
- thickened BM and cap
Mneumonic for mem nephtopathy?
diabetic neph?
- common in ESRD
- usually w other comps like retinopathy
pathophys of diabetic neph?
glycosylation of vascular BM -> hyaline arteriosclerosis -> hyperfiltration at the efferent arteriole
what is seen w diabetic neph?
Kimmelstein wilson nodules: eosinophilic nodule w central acellular region
Amyloidosis?
- most commonly afffects kidneys
- assoc w TB, MM and RA
AA vs AL amyloid?
- AA = chronic inflAAmation
- AL amyloid - multipAL myleoma
staining of amyloid?
- apple green on EM
- congo red stain
Post-strep GN?
- Usually kids
- 2-4 weeks after URTI
Type of hypersensitivity in post-strep GN?
- Type 3
What is positive in post-strep GN?
- anti-strep ab
- O titre
Appearance in post-strep GN?
Granular/ starry sky
rapidly progressive GN (4)?
- goodpastures
- microscopic polyangitis
- diffuse proliferative GN
- granulomastosis w polyangitis
what is seen w RPGN?
Crescents - when we see the crescent we rapidly prepare for Eid
symptoms of goodpastures?
- haematuria
- haemoptysis
Goodpastures?
- type 2 hypersen
- anti-GBM disease
- affects type IV collagen
granulomatosis w polyangitis?
- Wegener’s
- vasculitis
- C-anca - when w C granulomatosis w polyangitis u cry
Symptoms of gran w polyangitis?
- haematuria
- haemoptysis
- nasal involvement - rhinosinusitis
microscopic polyangitis?
- small vessel nectrotising vasculiutis
- Sim to wegeners but no nasal involvement
what is seen in microscopic polyangitis?
p-anca
Diffuse proliferative glomerulonephritis?
- assoc w SLE
- wire loops seen
Dif-LUPUS proliferative GN
alports?
- TIV collagen defect
Symp of alports?
- sensorineural deafness
- GN
- lens dislocation/ retinopathy
What is seen w alports?
basket weaving
Membranoproliferative GN?
- Assoc w hep C and hep B
- most likely to co-occur w neph S
mneumonic for Memb prolif GN?
- Tram-track appearance of GBM
- i get 2 MPG on the tram-track
Primary hyperparathyroid blood results?
- PTH and Ca high
- Phosphate low
Secondary hyperparathyroidism blood results?
- High PTH
- low/ normal Ca
- phosphate High
- Vit D low
causes of 2’ hyperparathyorid?
Parathyroid gland hyperplasia occurs as a result of low calcium, almost always in a setting of chronic renal failure
3’ parathyroidism blood results?
- Ca normal or high
- PTH high
- phos normal/ low
- ALP high
3’ hyperparathyroidism cause?
Occurs as a result of ongoing hyperplasia of the parathyroid glands after correction of underlying renal disorder, hyperplasia of all 4 glands is usually the cause
ACTH interpretation?
pituitary adenoma ACTH results?
cortisol and ACTH suppressed
adrenal adenoma results?
cortisol is not suppressed but ACTH suppressed
neither suppressed?
ectopic ACTH
addisons sick day rules?
double hydro keep fludro the same
met acidosis Tx?
sodium bicarb
CML - we see a ?
inc in granulocytes at diff stages of maturation and thrombocytosis
profile of a megaloblastic anaemia?
- glossitis
- hyperseg neutrophils
= anaemia
Any of the following features in a person aged 0-24 years should prompt a very urgent full blood count (within 48 hours) to investigate for leukaemia:
- Pallor
- Persistent fatigue
- Unexplained fever
- Unexplained persistent infections
- Generalised lymphadenopathy
- Persistent or unexplained bone pain
- Unexplained bruising
- Unexplained bleeding
Anaphylaxis?
acute wheeze, hypotension and no fever, presents acutely → expiratory wheeze
TRALI?
hypotension, not so acute presentation, non-cardiogenic pulmonary oedema → bilateral coarse crackles
CLL transformation?
can transform to high-grade lymphoma (Richter’s transformation) making patients suddenly unwell - NHL
Interpreting FBC?
1.Low Lymphocytes -> the answer should be AML or CML
2. WBC > 100 -> Chronic causes so Consider CML (rule out AML)
3. Presence of bands cell -> confirm CML
Blasts vs bands?
- *blast -> Acute
*bands -> Chronic
Sudden anaemia and low reticulocyte count?
- A sudden anemia and a low reticulocute count indicates parvovirus.
- Acute sequestration and haemolysis causes a high reticulocyte count.
High reticulocytes in?
sequestration crisis
Howell-Jolly cells are characteristic of?
sickle cell
Reed Sternberg cells AKA
- Aka large multinucleate cells with eosinophilic nucleoli
- Aka mirror image nucleoli
most common cause of neutropenic sepsis?
- STaph epidermis
- also the most common cause of peritonitis from dialysis
sickle cell gen Mxc
- analgesia e.g. opiates
- rehydrate
- oxygen
- consider antibiotics if evidence of infection
Exchange transfusion?
- indications include: acute vaso-occlusive crisis (stroke, acute chest syndrome, multiorgan failure, splenic sequestration crisis
- rapidly reduce the percentage of Hb S containing cells
blood transfusion in sickle cell?
- indications include: severe or symptomatic anaemia, pregnancy, pre-operative
- do not rapidly reduce the percentage of Hb S containing cells
Cold haem anaemia mneumonic?
- Cold weather is MMMiserable = cold AIHA -> IgM + caused by Mycoplasma or infectious Mononucleosis (glandular fever)
Warm IAHA?
Warm weather is Great = warm AIHI -> IgG + caused by CLL or SLE
Aplastic crisis?
Aplastic crises in sickle cell disease are associated with a sudden drop in haemoglobin - low reticulocyte coutn seen
What suggests anaphylactic reaction?
The triad ofangioedema, hypotension, and wheezingsuggests an anaphylactic reaction rather than acute haemolysis.
→ acute haemolytic reaction
Fever, abdominal pain, hypotension during a blood transfusion → acute haemolytic reaction
Sideroblastic anaemia iron studies?
- high ferritin
- high iron
- high transferrin saturation
blood staining of sideroblastic A?
- basophilic stippling of red blood cells
? staining of sideroblastic anaemia?
- Prussian blue staining will show ringed sideroblasts
GDP6 def?
sulph- drugs:sulphonamides,sulphasalazine andsulfonylureas can trigger haemolysis
drugs causing haemolysis in GDP6 def?
- anti-malarials: primaquine
- ciprofloxacin
- sulph- group drugs: sulphonamides, sulphasalazine, sulfonylureas
what is CI on VT?
verparmil can cause cardiac arresy
S3 common cause?
S3 is most commonly caused by heart failure which is the result of a dilated, compliant ventricle
Hypertrophic obstructive cardiomyopathy - is classically associated with
S4
J waves?
hypothermis
U WAVES?
Hypokal
Aortic dissection?
- double aortic contour
- widened mediastinum
small vs sq cell carcinomas?
Small cell: ACTH and ADH
Squamous: PTH
chronic diabetic nephropathy?
Chronic diabetic nephropathy will have large/normal sized kidneys on ultrasound whereas most patients with chronic kidney disease have bilateral small kidneys
Magnesium and calc replacement?
Replace magnesium before correcting hypokalaemia. Hypomagnesemia prevents potassium absorption
What shows that the AKI is pre-renal?
The urea to creatinine ratio is high, as it is above 100, indicating that the cause of acute kidney injury is pre-renal - high urea makes it pre-renal e.g. dehydratoon
all ppts w CKD should be started on?
statins
Irradiated blood?
Irradiated blood products are used to avoid transfusion-associated graft versus host disease by destroying T cells
blister cells and haemolyisis ->
GDP6 deficiency
CML presentation
- anaemia: lethargy
- weight loss and sweating are common
- splenomegalymay be marked → abdo discomfort
- an increase in granulocytes at different stages of maturation +/- thrombocytosis
Richter’s transformation
/
Ritcher’s transformation occurs when leukaemia cells enter the lymph node and change into a high-grade, fast-growing non-Hodgkin’s lymphoma.Patients often become unwell very suddenly.
Ritcher’s transformation is indicated by one of the following symptoms:?
- lymph node swelling
- fever without infection
- weight loss
- night sweats
- nausea
- abdominal pain
HHS?
- Higher sugar loss and higher fluid loss, extreme dehyration
- Head change - neuro: confusion
- No abd pain and No ketones
- Slower onset and stable potassium
HHS mX?
- treat hydration first: 0.9% normal saline
- Stabilise sugar w insulin
Thyrotoxic strom Mx?
treated with beta blockers, propylthiouracil and hydrocortisone. Iv propanolol first line
What can reduce levothyroxine abs?
Iron / calcium carbonate tablets can reduce the absorption of levothyroxine - should be given 4 hours apart
HHS diagnosis?
The diagnostic criteria for HHS include hypovolaemia, hyperglycaemia (blood sugar > 30mmol/L) and a serum osmolality > 320mosmol/kg.
sulfonylureas stimulate insulin release ->
weight gain
De Quervain’s thyroiditis?
In De Quervain’s thyroiditis there is globally reduced uptake of iodine-131 during thyroid scintigraphy
-> aplastic anaemia
normocytic anaemia, leukopenia and thrombocytopenia = aplastic anaemia.
Most common type of NHL
- Diffuse large B cell most common
burtkitt lymphoma?
- Burkitt lymphoma typically affects young or immunosuppressed patients.
follicular lymphoma?
- Follicular lymphoma is a fairly common subtype of NHL (16% of cases) however it is low grade and usually very slow growing with symptoms developing over months to years.
what indicates mM?
A raised ESR and osteoporosis represents multiple myeloma unless proven otherwise
rescue therapy for diabetes
- basal insulin
- sulfonylrurea - glicazide
- for v symptomatic ppts
DVLA rules?
- All patients with diabetes who are treated with insulin must notify the DVLA. For the DVLA to license an insulin-treated individual with a Group 1 licence, they must meet all the following criteria:
- Adequate hypoglycaemia awareness
- No more than 1 episode of severe hypoglycaemia while awake in the preceding 12 months AND the most recent episode occurred more than 3 months ago
- Practises appropriate glucose monitoring
- Not regarded as a likely risk to the public while driving
- Meets the visual standards for acuity and visual field
- Under regular review
Features of an addisonian crisis:
- Hyponatraemia
- Hyperkalaemia
- Hypoglycaemia
insulin in HHS ->
Giving insulin in hyperosmolar hyperglycaemic state may provoke sudden and dramatic fluid shift between compartments, which may result in central pontine myelinolysis
Most common type of thyroid cancer?
papillary
Papillary TC?
- young females
- mets to cervical LNs
thyroglobulin is a TM for?
papillary and follicular thyroid cancer
follicular thyroid cancer?
generally women >50 years old. Metastasis to lung and bones.
Medullary thyroid cancer?
- parafollicular cells which produce calcitonin so this can be used as a tumour marker
- MEN2
anaplastic TC?
Elderly patient. Very poor prognosis
Lymphoma TC?
might present with dysphagia or stridor
Erratic blood glucose control, bloating and vomiting think
GASTROPARAESIS
post mI?
Leads V1 and V2 showing tall R waves is characteristic of a posterior MI
treating hyper vs hyponatreamua too fac?
- Treating hypernatreamia too fast -> cerebral odema
- treating hypo too fast -> Central pontine myelinolys
COC increases risk of?
- increased risk of breast and cervical cancer
COCP is protective against?
- ovarian
- endometrial cancer
alc units?
volume (ml) * ABV / 1,000
thionamides in preg?
pTU in T1, switch to carbimazole in T2 and T3 - pTU has higher risk of hepatitis
ACRO TESTS?
- IGF-1
- OGTT: confirm diagnosis
primary hyperaldosteronism ->
hypernatreamia and hypokalamia
Rupture of the papillary muscle due to a myocardial infarction →
Rupture of the papillary muscle due to a myocardial infarction → acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema
-> ? RHEUMATIC FEVER
Recent sore throat, rash, arthritis, murmur → ?rheumatic fever
what can be done to reduce risk of sudden cardiac death HOCM?
An implantable cardioverter-defibrillator can be inserted to reduce the risk of sudden cardiac death in HOCM
After starting an ACE inhibitor, significant renal impairment may occur if the patient has?
undiagnosed bilateral renal artery stenosis
s3?
- gallop rhythm
- HF and severe AS
Loud p2?
pulm hTN
soft S1?
caused by a prolonged PR, severe mitral stenosis or mitral regurgitation
s4?
- his is an extra sound causes by atrial contraction against a stiff ventricle.
- It is associated with hypertrophic obstructive cardiomyopathy and hypertension
Ix for bladder cancer?
cytoscopy is Ix of choice
pioglitazone side effects?
PIO-glitazone risks:
- Pee: Bladder cancer
- Ischaemic (not quite but helps me): Heart failure
- Osteo: Fractures
High vs low pressure retention?
- Chronic urinary retention is classed as high pressure urinary retention if renal function is impaired or if there is hydronephrosis
- Low pressure chronic urinary retention presents with a painless distended bladder, but no associated hydronephrosis or renal impairment.
