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phase 2a clinical > genito-urinary > Flashcards

genito-urinary Flashcards

1
Q

BPE definition

A

benign prostatic enlargement

clinical diagnosis

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2
Q

BPH definition

A

benign prostatic hyperplasia

histological diagnosis

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3
Q

BOO definition

A

bladder outflow obstruction

urodynamic diagnosis

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4
Q

LUTS definition

A

constellation of symptoms

neither gender nor disease specific

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5
Q

hydronephrosis definition

A

dilation of renal pelvis of the kidney

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6
Q

obstructive uropathy definition

A

functional or anatomical obstruction of urine flow at any level of the urinary tract

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7
Q

supravesical obstruction definition

A

above the level of the bladder

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8
Q

infravesical obstruction definition

A

below the level of the bladder

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9
Q

LUTS: storage symptoms

A

urgency
nocturia
frequency
overflow incontinence

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10
Q

LUTS: voiding symptoms

A 
poor intermittent stream
hesitancy
incomplete emptying
post micturition 
straining
haematuria 
dysuria
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11
Q

PSA

A

PSA is a glycoprotein that is expressed by normal and neoplastic prostate tissue
In the semen
small amounts in bloodstream normally

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12
Q

PSA is raised in…

A 
BPH
prostate cancer
perineal trauma
BMI <25
taller men
recent ejaculation
black africans
prostatitis 
UTI
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13
Q

flow rates and residual volume

A

how much urine being passed, how long for and flow rate

max flow rate is more useful if >150ml is voided

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14
Q

frequency volume chart

A

measure volume voided and time, over a minimum of 3 days
polyuric= >40ml/kg/24 hours
noturic >30% voided at night

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15
Q

acute urine retention

A

sudden onset of painful inability to pass urine usually with over 500ml in the bladder
bladder usually tender

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16
Q

acute urine retention: causes

A 
prostatic obstruction
urethral strictures
anticholinergics
alcohol
constipation
infection
spinal compression- cauda equina syndrome
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17
Q

acute urine retention: investigations

A

normal renal biochemistry
renal ultrasound
PSA tests

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18
Q

acute urine retention: treatment

A

catheter

alpha-1 blocker: relaxes smooth muscle in bladder neck to aid voiding

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19
Q

chronic urine retention

A

more insidious and may be painless- over catheterise if there is pain
more difficult to define
incomplete bladder emptying

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20
Q

chronic urine retention: causes

A

prostatic enlargement due to BPH/prostate cancer
pelvic malignancy
diabetes

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21
Q

chronic urine retention: presentation

A

overflow incontinence
loss of appetite
constipation
distended abdomen

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22
Q

urinary tract obstruction

A

common and should be considered if they have a renal impairment
damage can be permanent
partial, complete, unilateral or bilateral

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23
Q

urinary tract obstruction: luminal causes

A

stones
blood clot
sloughed papilla
tumour

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24
Q

urinary tract obstruction: mural causes

A

congenital or acquired stricture
neuromuscular dysfunction
schistomiasis

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25
urinary tract obstruction: extra mural causes
``` abdominal or pelvic mass retroperitoneal fibrosis BPH prostate cancer pregnancy inflammation ```
26
acute upper urinary tract obstruction: presentation
loin pain radiating to groin
27
chronic upper urinary tract obstruction: presentation
flank pain renal failure infection polyuria
28
acute lower urinary tract obstruction: presentation
acute urinary retention with severe suprapubic pain | distended, palpable bladder- dull to percussion
29
chronic lower urinary tract obstruction: presentation
urine frequency, hesitancy, poor stream, terminal dribbling | UTI/urinary retention/large prostate possible
30
urinary tract obstruction: investigations
bloods mid stream urinary sample- culture and sensitivity ultrasound
31
upper urinary tract obstruction: treatment
nephrostomy- artificial opening between kidney and skin, urinary diversion from upper tract alpha 1 antagonist 5 alpha reductase inhibitor
32
lower urinary tract obstruction: suprapubic catheter
less risk of urethral damage required general anaesthetic for insertion small risk of bowel injury during insertion less likely to be colonised by bacteria than urethral
33
lower urinary tract obstruction: surgery
transurethral resection of prostate <14% impotent 1% incontinent 10% ED
34
indications for surgery with LUTS
RUSHES ``` Retention UTIs Stones Haematuria Elevated creatinine due to bladder outflow obstruction Symptoms deterioration ```
35
BPE: benign prostatic enlargement
increase in size of prostate without presence of malignancy
36
BPE: epidemiology
common 24% men 40-64 y/o 40% >60
37
BPE: risk factors
increased age | testosterone
38
BPE: pathophysiology
increase in epithelial stromal cell numbers in periurethral area of the prostate benign nodular musculofibrous and glandular layers of the prostate transitional zone enlarges- partially blocking the urethra
39
BPE: presentation
LUTS abdominal pain acute urinary retention
40
BPE: LUTS
``` nocturia frequency urgency post-micturition dribbling poor steam haematuria bladder stones ```
41
BPE: differential diagnosis
``` bladder tumour bladder stones trauma prostate cancer chronic prostatitis UTI ```
42
BPE: investigations
``` digital rectal exam serum electrolytes transrectal ultrasound biopsy mid-stream urine sample ```
43
BPE: lifestyle treatments
avoid caffeine and alcohol relax when voiding void twice in a row to aid emptying
44
BPE: alpha 1 antagonists
oral tamsulosin relax smooth muscle in the bladder neck and prostate increases urinary flow rate and improve obstructive symptoms SE= drowsiness, ejaculatory failure and dizziness- avoid in postural hypertension
45
BPE: 5 alpha reductase inhibitors
oral finasteride block conversion of testosterone to dihydrotestosterone (responsible for prostate growth) SE= impotence and decreased libido
46
BPE: surgical treatment
for those with large prostate or fail to respond to medical therapy TURP or TUIP
47
BPE: transurethral resection of prostate
gold standard option, especially for larger prostates
48
BPE: transurethral incision of prostate
less destructive than TURP and less risk to sexual function | better option for smaller prostates
49
BPE: complications if untreated
bladder calculi UTI haematuria acute retention
50
AKI definition
an abrupt sustained rise in serum urea and creatine due to a rapid decline in GFR leasing to a failure to maintain fluid, electrolyte and acid-base homeostasis
51
AKI classification: RIFLE classifications
old system to define AKI | an increase in serum creatinine or decrease in urine output
52
AKI classification: RIFLE stands for..
``` Risk Injury Failure Loss End stage renal disease ```
53
AKI KDIGO classification: criteria for diagnosing
used currently rise in creatinine 26 micromol/L in 48 hours ride in creatinine >1.5x baseline urine output <0.5ml/kg/hr for over 6 hours
54
AKI epidemiology
common in elderly | 25% of patients with sepsis and 50% of those with septic shock
55
AKI: associated with..
``` diarrhoea haematuria haemoptysis hypotension urine retention ```
56
AKI aetiology: pre renal
``` 40-70% renal hyperfusion hypovolaemia hypotension low CO ```
57
AKI aetiology: intrinsic
10-50% renal parenchyma damage acute tubular necrosis
58
AKI aetiology: intrinsic, vascular
renal artery/vein thrombosis cholesterol emboli vasculitis malignant hypertension
59
AKI aetiology: intrinsic, glomerular
glomerulonephritis autoimmune drugs infection
60
AKI aetiology: intrinsic, interstitial
drugs | infiltration- lymphoma, infection, tumour lysis syndrome
61
AKI aetiology: post renal
10-25% | urinary tract obstruction at ureter, bladder or prostate
62
AKI aetiology: post renal, luminal
stones clots sloughed papillae
63
AKI aetiology: post renal, mural
malignancy BPH strictures
64
AKI risk factors
``` age >75 heart failure chronic liver disease sepsis poor fluid intake past history of AKI diabetes prostate cancer nephrotoxic drugs ```
65
AKI presentation
``` depends on cause and severity palpable bladder/kidneys small urine volume irregular heartbeat from hyperkalaemia uraemia symptoms (fatigue, weakness, confusion, seizures) Thirst oedema ```
66
AKI differential diagnosis
``` abdominal aortic aneurysm alcohol toxicity alcoholic/diabetic ketoacidosis chronic renal failure dehydration heart failure ```
67
AKI investigations: dipstick
can suggest infection (leukocytes and nitrates) and glomerular disease (blood and protein)
68
AKI investigations: blood count
anaemia and high ESR suggests myeloma or vasculitis as cause
69
AKI investigations: ultrasound
``` renal size (small= CKD) obstruction and hydronephrosis cysts and masses ```
70
AKI investigations: CT-KUB
kidneys, ureters and bladder looks for obstructing masses or calculi retroperitoneal fibrosis
71
AKI treatment: pre renal underlying cause
correct volume depletion | treat sepsis
72
AKI treatment: intrinsic cause
refer early to nephrology if concern over tubulointerstitial glomerular pathology
73
AKI treatment: post renal underlying cause
catheterise and consider CT-KUB | obstruction and hydronephrosis- cystoscopy or nephrostomy insertion
74
AKI treatment: nephrotoxic drugs to stop
NSAIDs ACE inhibitor gentamicin amphotericin
75
AKI treatment: indications for dialysis
``` symptomatic uraemia including pericarditis or tamponade hyperkalaemia pulmonary oedema severe acids high potassium ```
76
AKI treatment: complications of renal replacement therapy
cardiovascular disease infection amyloid accumulates in long term malignancy is common
77
stress incontinence
caused by sphincter weakness urine leaks with increased intra-abdominal pressure rises more common in females
78
stress incontinence: causes
neurogenic or congenital | different for males and females
79
male stress incontinence: causes
post-prostatectomy
80
male stress incontinence: treatment
artificial sphincter | male sling
81
female stress incontinence: causes
secondary to birth trauma | degradation of pelvic floor and urethral sphincter
82
female stress incontinence: treatment
pelvic floor exercises duloxetine surgery= sling or artificial sphincter
83
urge incontinence
strong desire to void and unable to hold urine
84
urge incontinence: causes
detrusor overactivity- rise in detrusor pressure on filling (more common in women) can be bladder hypersensitivity from UTI, bladder stones or tumours
85
urge incontinence treatment: bladder exercises
gradually increase the interval between voids
86
urge incontinence treatment: behavioural therapy
controlling caffeine and alcohol | frequency volume charts
87
urge incontinence treatment: anticholinergic agents
oxybutynin act against cholinergic system (parasymp) decreases detrusor excitability
88
urge incontinence treatment: botox of bladder
stop release of Ach from pre-synaptic terminal- paralyses bladder huge side effect= urinary retention
89
urge incontinence treatment: bladder augmentation
detrusor myecotmy | cystoplasty= adding bowel to bladder to increase surface area
90
voiding problems: obstructive
BPE, urethral stricture, prolapse/mass if BPE give alpha blockers, maybe 5 alpha reductase inhibitors if that fails then TURP
91
voiding problems: non-obstructive
detrusor underactivity | long term catheterisation to empty
92
neuropathic bladder dysfunction: spastic spinal cord injury
reflexes work but not controlled by brain | supra-conal lesion
93
neuropathic bladder dysfunction: spastic spinal cord injury losses
loss of co-ordination and completion of voiding
94
neuropathic bladder dysfunction: spastic spinal cord injury features
reflex bladder contractions detrusor sphincter dyssynergia (loss of complete voiding) poorly sustained bladder contraction unsafe- bladders at risk
95
neuropathic bladder dysfunction: flaccid spinal cord injury
conus lesion | decentralised bladder
96
neuropathic bladder dysfunction: flaccid spinal cord injury losses
reflex contraction guarding reflex receptive relaxation
97
neuropathic bladder dysfunction: flaccid spinal cord injury features
areflexic bladder stress incontinence risk of poor compliance unsafe- kidneys at risk
98
neuropathic bladder dysfunction treatment
alpha adrenergic blockers sphincterotomy cystoplasty permanent catheterisation
99
neuropathic bladder dysfunction treatment: prevent autonomic dysreflexia
commonly causes by over-distension or bladder occurs in lesions above T6 overstimulation of symp nervous system below lesion (due to noxious stimulus)
100
neuropathic bladder dysfunction treatment: maintain bladder safety
an unsafe bladder is one that puts kidneys at risk | risks= raised bladder pressure, vesico-ureteric reflux, chronic infection
101
neuropathic bladder dysfunction treatment: symptom control
harness reflexes to empty bladder into incontinence device | suppress reflexes converting bladder to flaccid type, then empty regularly
102
bladder problems in MS
``` caused by neurogenic detrusor overactivity overactive bladder syndrome urinary urgency frequency incomplete bladder emptying ```
103
prostate tumours
most common male malignancy | majority are adenocarcinomas in peripheral zone and slow growing
104
prostate tumours: epidemiology
6th most common in world incidence increases with age by 80 y/o, 80% have malignant foci but most seem to lie dormant
105
prostate tumours: aetiology
hormonal factors- increased testosterone
106
prostate tumours: risk factors
family history (3 or more affected relatives) genetic (BRCA2 confers a 5/7x higher risk) increasing age being black- higher testosterone
107
prostate tumours: pathophysiology
androgen receptors on prostate are responsible for growth local spread= seminal vesicles, bladder and rectum spread via lymph haematogenous spread= bone or brain, liver and lung
108
prostate tumours: presentation
``` LUTS if local disease suggestions of metastasis: weight loss bone pain anaemia ```
109
prostate tumours: differential diagnosis
BPH prostatitis bladder tumours
110
prostate tumours: investigations
hard and irregular prostate on digital exam raised PSA trans-rectal ultrasound urine biomarkers
111
prostate tumours: treating disease confined to prostate
radical prostatectomy if <70 y/o radiotherapy and hormone therapy brachytherapy surveillance if >70 y/o and low risk
112
metastatic prostate tumours: endocrine therapy
prostate cancer is hormone sensitive binding androgen receptor stimulates tumour growth choice of androgen deprivation or receptor blockers (bicalutamide)
113
metastatic prostate tumours: androgen deprivation
orchidectomy- removal of testes | LHRH agonists- stimulate and inhibit pituitary gonadotrophin (testosterone)
114
prostate tumours: symptom treatment
analgesia treat hypercalcaemia radiotherapy for bone metastases/spinal cord compression
115
renal cell carcinoma
aka hypernephroma | arises from proximal convoluted tubular epithelium
116
renal cell carcinoma: epidemiology
most common renal tumour in adults more common in males more common in >50 y/o 25% have metastases on presentation
117
renal cell carcinoma: risk factors and aetiology
``` smoking obesity hypertension renal failure and haemodialysis von hippel lindau syndrome ```
118
renal cell carcinoma: von hippel lindau syndrome
autosomal dominant on chromosome 3 short arm | loss of both copies of tumour suppressor gene
119
renal cell carcinoma: pathophysiology
malignant cancer of proximal convoluted tubular epithelium | spread may be direct (renal vein), via lymph or haematogenous (bone, liver, lung)
120
renal cell carcinoma: presentation
``` asymptomatic and discovered incidentally haematuria anorexia hypertension in 30% (renin secretion by tumour) fever in around 20% ```
121
renal cell carcinoma: differential diagnosis
transitional cell carcinoma wilms' tumour renal oncocytoma
122
renal cell carcinoma: investigations
``` ultrasound CT abdo MRI BP bloods renal biopsy bone scan ```
123
renal cell carcinoma: CT imaging
more sensitive than ultrasound in detecting small renal mass shows involvement of the renal vein or IVC using contrast demonstrates kidney function
124
renal cell carcinoma: blood test
FBC- detect polycythaemia and anaemia- EPO decrease ESR can be raised liver biochemistry may be abnormal
125
renal cell carcinoma: treating localised
nephrectomy- remove kidneys (unless bilateral then partial nephrectomy)
126
renal cell carcinoma: ablative techniques of treatment
such as cryoablation and radiotherapy are used in patients with significant comorbidities who wouldn't tolerate surgery can harm kidney function
127
renal cell carcinoma: treating metastatic or locally advanced
interleukin-2 and interferon alpha: cause remission in 20% if no response: -biological angiogenesis targeted therapy (sunitinib, sorafenib) -temisorlimus: improves survival more than interferon
128
Wilms' tumour: pathology
childhood tumour of primitive renal tubules and mesenchymal cells
129
Wilms' tumour: epidemiology
seen w/i first 3 years of life | chief abdo malignancy in children
130
Wilms' tumour: presentation
abdominal mass | less common= haematuria
131
Wilms' tumour: investigations
diagnosis is established by ultrasound, CT and MRI
132
Wilms' tumour: treatment
combination of nephrectomy, radiotherapy and chemo
133
bladder cancer
transitional cell carcinoma calyces, renal pelvis, ureter, bladder and urethra are all lined by transitional epithelium so all susceptible but bladder is most common
134
bladder cancer: epidemiology
50% of TCC 4th most common cancer in men, 8th in women mainly occurs >40 y/o, peaks >80 y/o
135
bladder cancer: risk factors
``` smoking chronic inflammation of urinary tract increased age male family history paraplegia exposure to drugs- phenacetin occupational exposure- benzidine ```
136
bladder cancer: pathophysiology
>90% TCCm 5% squamous cell carcinoma, <1% adenocarcimona tumour spread: local= to pelvic structures lymphatic= iliac and para-aortic nodes haematogenous= liver and lungs
137
bladder cancer: presentation
painless haematuria is most common symptom recurrent UTIs voiding irritability
138
bladder cancer: differential diagnosis
haemorrhagic cystitis renal cancer UTI urethral trauma
139
bladder cancer: investigations
``` cystoscopy with biopsy urine microscopy CT urogram urinary tumour markers MRI ```
140
non muscle invasive bladder cancer: treatment
surgical resection | possible chemo to reduce recurrence- mitomycin, doxorubicin and cisplatin
141
localised muscle invasive bladder cancer: treatment
radical cystectomy- bladder removal post-op chemo- methotrexate, vinblastine, adriamycin and cisplatin (M-VAC) radical radiotherapy if not fit for surgery
142
metastatic bladder cancer: treatment
palliative chemo and radiotherapy
143
testicular tumours: epidemiology
most common cancer in males 15-44 y/o 10% occur in undescended testes 96% from germ cells
144
testicular tumours: germ cell origin
seminomas: 25-40 y/o and >60y/o teratomas: infancy
145
testicular tumours: non-germ cell origin
leydig cell tumours sertoli cell tumours sarcomas
146
testicular tumours: risk factors
undescended testes infant hernia infertility family history
147
testicular tumours: presentation
``` painless lump in testicle testicular pain abdo pain cough and dyspnoea abdo mass ```
148
testicular tumours: differential diagnosis
testicular torsion lymphoma hydrocele epididymal cyst
149
testicular tumours: investigations
ultrasound biopsy CXR and CT for staging serum tumour markers
150
testicular tumours: serum tumour markers
alpha-fetoprotein and/or beta subunit of human chorionic gonadotropin: - raised in teratomas - B-hCG in minority with seminomas - AFP not elevated in pure seminomas
151
testicular tumours: treatment
radical orchidectomy via inguinal approach seminomas with mets below diaphragm treated with radiotherapy only widespread tumours and teratomas= treated with chemo sperm storage offered
152
kidney physiology: GFR
volume of fluid filtered from glomeruli into bowman's space per unit time normally 120ml/min each kidney receives 20% of CO
153
kidney physiology: proximal convoluted tubule
sugars, amino acid and bicarb are reabsorbed here absorbs 70% of Na+ and the water that follows most vulnerable to damage
154
kidney physiology: faconi syndrome
``` rare damage resulting in: -glycosuria -acidosis -phosphate wasting resulting in osteomalacia -aminoaciduria ```
155
kidney physiology: loop of henle
reabsorbs 25% of sodium and water that follows sodium, potassium, chloride transporters are more active in ascending loop loop diuretics work here
156
kidney physiology: Distal convoluted tubule
5% sodium reabsorbed here and water follows | thiazide diuretics work here
157
kidney physiology: BP control
juxtaglomerular apparatus is solute sensing organ | high conc. of solutes then GFR low so releases renin
158
kidney physiology: collecting tubule and salts
most salt has been reabsorbed tightly regulated by aldosterone secreted potassium and hydrogen into urine water absorbed via aquaporin 2 channels (controlled by ADH)
159
kidney physiology: aldosterone and Na+ reabsorption
hyperaldosteronism- lots of Na+ reabsorption, negative lumen, so K+ and H+ rush in and results in hyperkalaemic alkalosis
160
kidney physiology: potassium control
potassium freely filtered and mostly reabsorbed in proximal tubule/loop of henle governed by distal delivery of sodium and aldosterone
161
kidney physiology: K+ modifying renal meds and hypokalaemia
loop diuretics | thiazide diuretics
162
kidney physiology: K+ modifying renal meds and hyperkalaemia
spironolactone (aldosterone antagonist) ACE inhibitors angiotensin receptor blockers
163
kidney physiology: diuretics
not nephrotoxic but cause hypovolaemia, which in itself is nephrotoxic thiazide and loop are powerful together and result in profound diuresis
164
kidney physiology: water
water conc. detected through osmoreception in hypothalamus | too conc. then ADH released and cause an increase in aquaporin in collecting duct- more water absorbed
165
kidney physiology: erythropoietin
renal cortex= oxygen sensor- blood flow and oxygen requirement (GFR) are matched EPO is hormone that produced haemoglobin and is produced in response to tissue hypoxia
166
kidney physiology: vitamin D
vitamin D hydroxylation occurs here | 25-hydroxy vitamin D to 1,25-dihydroxy vitamin D (calcitriol) (active vitamin D)
167
chronic kidney disease
longstanding, usually progressive impairment in renal function, for more than 3 months GFR <60ml/min/1.73m2
168
chronic kidney disease: epidemiology
6-11% can be defined as having CKD | more common in females
169
chronic kidney disease: classification
proteinuria, haematuria or evidence of abnormal anatomy or systemic disease
170
chronic kidney disease: aetiology
``` diabetes M (type 2>1) hypertension atherosclerotic renal vascular disease polycystic kidney disease amyloidosis family history idiopathic=20% cases ```
171
chronic kidney disease: risk factors
``` diabetes M hypertension old age females>males proteinuria AKI smoking african/asian chronic NSAIDs usage ```
172
chronic kidney disease pathophysiology
nephrons are failed and scarred so burden of filtration falls to fewer nephrons these experience increased flow (hyperfiltration) as blood flow is unchanged so undergo glomerular hypertrophy it's a vicious cycle and accelerates remnant nephron failure
173
chronic kidney disease: presentation
``` early stages are asymptomatic symptoms common when serum urea conc. exceeds 40mmol/L: -malaise -anorexia -insomnia -polyuria -itching -nausea/vomiting -oedema ```
174
chronic kidney disease investigations: anaemia
normochromic normocytic | due to reduced erythropoietin produced by kidneys
175
chronic kidney disease investigations: bone disease
bone pain renal osteodystrophy- osteoporosis, osteomalacia renal phosphate retention and impaired 1,25-dihydroxy vitamin D production
176
chronic kidney disease investigations: neurological
occurs in all patients with sever CKD autonomic dysfunction presents as postural hypotension and disturbed GI motility in advance uraemia there is depressed cerebral function, twitching and seizures
177
chronic kidney disease investigations: CVD
MI, cardiac failure and stroke | due to increased frequency of hypertension, hyperlipidaemia and vascular calcification
178
chronic kidney disease complications: skin disease
pruritus due to nitrogenous waste products of urea | brown discolouration of nails
179
chronic kidney disease: differential diagnosis
AKI | differentiation depends on history, duration of symptoms and measurements of serum creatinine
180
chronic kidney disease investigations: urinalysis
haematuria- indicates glomerulonephritis proteinuria- suggestive of glomerular disease or infection mid stream sample sent for microscopy
181
chronic kidney disease investigations: serum biochemistry
urea, electrolytes, bicard and reatine low eGFR raised alkaline phosphatase raise PTH if CKD stage 3+
182
chronic kidney disease investigations: bloods
``` raised phosphate low Ca2+ Hb low raised viscosity fragmented red cells indicate intravascular haemolysis ```
183
chronic kidney disease investigations:urine microscopy
white cells- bacterial UTI eosinophilia- allergic tubulointerstitial nephritis granular casts- active renal disease red cells- glomerulonephritis
184
chronic kidney disease investigations: imaging
ultrasound to check renal size and to check for obstructions | CT to detect stones, retroperitoneal fibrosis and other causes of obstruction
185
chronic kidney disease treatment: aims
aimed at underlying cause slow the deterioration of kidney function reduce CVS risk treat complications
186
chronic kidney disease treatment: treat reversible causes
``` relieve obstruction stop nephrotoxic drugs stop smoking become healthy weight tight glucose control in diabetes ```
187
chronic kidney disease treatment: control BP
target= <130/80 ACE inhibitors- ramipril diuretic- oral bendroflumethiazide, prevents hyperkalaemia and reduce BP
188
chronic kidney disease treatment: limit bone disease
check PTH and treat if raised restrict diet give phosphate binders to decrease gut absorption and avoidance of phosphate food vitamin D and calcium supplements
189
chronic kidney disease treatment: limit CVD complications
lower cholesterol with statins | give aspirin
190
chronic kidney disease treatment: controlling symptoms
anaemia- iron/folate/folic acid acidosis- treat with sodium carbonate oedema- furosemide
191
chronic kidney disease treatment: RRT
``` renal replacement therapy: haemofiltration haemodialysis peritoneal dialysis replacement ```
192
chronic kidney disease treatment: indications for dialysis
``` symptomatic uraemia-pericarditis or tamponade hyperkalaemia not controlled pulmonary oedema severe acids high potassium metabolic acidosis ```
193
chronic kidney disease treatment: haemofiltration
most commonly used blood pump draws blood out ultrafiltrate is removed from patient and combined with simultaneous infusion of replacement solution then returns via a catheter in the jugular, subclavian or femoral vein
194
chronic kidney disease treatment: haemodialysis
blood passed over semi-permeable membrane against dialysis fluid flowing opposite direction the meeting of blood w/ less conc. solution allows diffusion of small solutes down the gradient Blood taken from artery and returned into vein at AV fistula
195
chronic kidney disease treatment: haemodialysis complications
``` can't clear large solutes time consuming hypotension nausea chest pain fevers infected catheter ```
196
chronic kidney disease treatment: peritoneal dialysis
mainly for CKD, rare in AKI uses their peritoneum as a membrane that fluid and solutes are exchanged with blood done at home at night
197
chronic kidney disease treatment: peritoneal dialysis complications
infection abdo wall herniation intestinal perforation loss of membrane function over time
198
chronic kidney disease treatment: complications of RRT
CVD due to hypertension and calcium/phosphate dysregulation infection amyloid accumulates in long term dialysis- carpal tunnel, arthralgia and fractures
199
chronic kidney disease: kidney transplant
donors deceased or alive (best results) more cost effective than dialysis doubles life expectancy
200
acute glomerulonephritis: causes
``` bacterial infection hep b/c schistomiasis malaria infective endocarditis systemic sclerosis ```
201
acute glomerulonephritis causes: post streptococcal infection
e.g strep pyogenes occurs in a child 1-3 weeks post infection bacterial antigen trapped in glomerulus, leading to an act diffuse proliferative glomerulonephritis
202
acute glomerulonephritis treatment: post streptococcal infection
antibiotics | supportive
203
acute glomerulonephritis causes: SLE
rash, arthralgia, kidney failure, neuro symptoms, pericarditis nucleus antibody positive and double strand DNA positive low complement C3 and 4
204
acute glomerulonephritis treatment: SLE
immunosuppression steroids cyclophosphamide rituximab
205
acute glomerulonephritis causes: ANCA associated vasculitis
multisystem small vessel vasculitis- attacks small vessels in kidney and eye
206
acute glomerulonephritis treatment: ANCA associated vasculitis
immunosuppression steroids cyclophosphamide rituximab
207
acute glomerulonephritis causes: goodpasture's disease
acute glomerulonephritis and pulmonary alveolar haemorrhage | presence of circulating antibodies directed against intrinsic antigen to basement membrane (of glomeruli and lung)
208
acute glomerulonephritis treatment: goodpasture's disease
remove antibody via plasma exchange immunosuppression steroids
209
acute glomerulonephritis causes: IgA nephropathy
more common cause of glomerulonephritis in the developed world IgA deposition in mesangium (structural support to glomerulus) and kidney gets attacked
210
acute glomerulonephritis treatment: IgA nephropathy
BP control | ACE inhibitors/angiotensin receptor blockers
211
acute glomerulonephritis: presentation
``` haematuria proteinuria hypertension oliguria deteriorative kidney function decrease in GFR uraemia ```
212
acute glomerulonephritis: uraemia symptoms
anorexia pruritus- rash lethargy and nausea
213
acute glomerulonephritis: investigations
``` take history to determine cause measure eGFR, proteinuria, serum urea and electrolytes- determines current status culture- swab from throat/infected skin urine dipstick renal biopsy ```
214
nephrotic syndrome
caused by structural and functional abnormalities of podocytes leaking huge amounts of protein- kidney function remains the same
215
nephrotic syndrome: triad
oedema hypoalbuminaemia proteinuria- >3.5g/24hours
216
nephrotic syndrome: hyperlipidaemia
often present liver goes into overdrive due to albumin and other protein loss increases risk of blood clots and produces raised cholesterol
217
nephrotic syndrome: epidemiology
rare diabetes is most common secondary cause 10-25% of nephrotic syndrome in adults, most common cause in children
218
nephrotic syndrome primary causes: minimal change disease
seen in children and adults | most common cause of nephrotic syndrome in children
219
nephrotic syndrome primary causes: membrane neuropathy
``` adults idiopathic or secondary: -drugs, penicillamine or NSAIDs -autoimmune, SLE, thyroiditis -infection, hep b/c -neoplasia, lung, colon, stomach ```
220
nephrotic syndrome primary causes: deposition of IgG and C3
along outer aspect of glomerular basement membrane treated with immunosuppression
221
nephrotic syndrome primary causes: focal segmental glomerulosclerosis
scarring is focal and only some glomeruli involved CD80 in podocytes increase permeability of glomeruli treat with corticosteroids and immunosuppressants
222
nephrotic syndrome: secondary causes
``` diabetes mellitus amyloid infections SLE,RA drugs malignancy ```
223
nephrotic syndrome: pathophysiology
injury to podocyte appears to be the main cause podocytes wrap around glomerular capillaries and maintain filtration barrier- preventing large molecular weight proteins from entering urine
224
nephrotic syndrome: presentation
``` normal-mild increase in BP proteinuria normal-mild decrease in GFR hypoalbuminarmia pitting oedema frothy urine ```
225
nephrotic syndrome differential diagnosis: congestive heart failure
where there is oedema and raised jugular venous pressure
226
nephrotic syndromedifferential diagnosis: cirrhosis
where there is signs of hypoalbuminaemia and oedema | signs of chronic liver failure
227
nephrotic syndrome: investigations
establish cause- usually with biopsy urine dipstick serum albumin is low
228
nephrotic syndrome complications: susceptibility to infection
due to low serum IgG, decreased complement activity and reduced T cell function all due to loss of immunoglobulins in urine and the treatment
229
nephrotic syndrome complications: thromboembolism
hypercoagulable state due to increase clotting factors (liver gone into overdrive)
230
nephrotic syndrome complications: hyperlipidaemia
increased cholesterol and triglycerides due to hepatic lipoprotein synthesis (liver in overdrive)
231
nephrotic syndrome treatment: reduce oedema
loop diuretics- IV furosemide thiazide diuretics- IV bendroflumethiazide increased fluid salt restriction
232
nephrotic syndrome treatment: reduce proteinuria
ace inhibitor- ramipril angiotensin receptor blockers- candesartan eat high protein diet
233
nephrotic syndrome treatment: reduce risk of complications
prophylactic anticoagulation w/ warfarin reduce cholesterol w/ statins- simvastatin treat infections/vaccinate
234
minimal change disease
disease of kidney that can cause nephrotic syndrome
235
minimal change disease: epidemiology
most common cause of nephrotic syndrome in children more common in boys <5y/o accounts for 20% of adult nephrotic syndrome
236
minimal change disease: risk factors/aetiology
``` idiopathic atopy is present in 30% Hep C/HIV and TB are rare causes associated with hodgkin's lymphoma Drugs ```
237
minimal change disease: drug aetiology
NSAIDs lithium antibiotics- rifampicin, ampicillin bisphosphonates
238
minimal change disease: pathophysiology
electron microscopy shows fusion of foot processes on podocytes- consistent with disrupted podocyte actin cytoskeleton
239
minimal change disease: presentation
proteinuria oedema- around face fatigue frothy urine
240
minimal change disease: biopsy
normal under light microscopy | check under electron microscopy
241
minimal change disease: treatment
high dose of corticosteroids- prednisolone (reverses proteinuria in 95% cases, but majority relapse) frequent relapse is treated with cyclophosphamide or ciclosporin
242
asymptomatic urinary abnormalities
incidental finding of dipstick haematuria, and possible proteinuria kidney function and BP normal
243
asymptomatic urinary abnormalities: causes
thin membrane disease | IgA nephropathy
244
asymptomatic urinary abnormalities: thin membrane disease
more likely to leak blood into the urine
245
erectile function
neurovascular phenomenon under hormonal control
246
cavernosal sinusoids during flaccidity
penile smooth muscle is contracted | helicine arteries are constricted, sinusoids are empty and emissary veins open
247
cavernosal sinusoids during erection
penile smooth muscle relaxes helicine arteries dilate, filling sinusoidal spaces they then compress subtunical venous plexus against the tunica albuginea reduced venous outflow
248
nerve supply of erections
erection- parasymp, s2-4 ejaculation- symp, T11-L2 Point and Shoot Cavernous nerve carries these fibres posterolateral to prostate- risk of damage during prostatectomy
249
flaccid penile state and vascular supply
sympathetic tone- arterioles constricted
250
erect penile state and vascular supply
parasymp stimulation- arteriolar dilation, trabecular smooth muscle relaxation
251
testosterone and erectile function
required for normal function
252
primary acquired low testosterone
pituitary | hypothalamus
253
secondary acquired low testosterone
testes injury drugs
254
smooth muscle mediated erection control
arteriolar dilation | trabecular relaxation
255
nitrous oxide release and erection control
acetylcholine effect on endothelium parasymp nerve endings causes intracellular cyclic GMP rise
256
erectile dysfunction
persistent inability to attain or maintain an erection sufficient to permit satisfactory sexual performance
257
erectile dysfunction: epidemiology
1/50 at age 40 | 1/4 at 65
258
erectile dysfunction: aetiology
``` psychogenic organic: -vasculogenic -neurogenic -hormonal -anatomical -drug induced ```
259
erectile dysfunction: risk factors
``` lack of exercise obesity smoking hypercholesterolaemia metabolic syndrome diabetes x3 risk ```
260
specific conditions that cause erectile dysfunction
``` diabetes mellitus MI, hypertension liver disease renal failure trauma prostatectomy ```
261
erectile dysfunction investigations: lab tests
fasting glucose lipid profile morning testosterone- if low, perform prolactin, FSH, LH
262
erectile dysfunction investigations: special tests
nocturnal penile tumescence and rigidity intracavernosal injection test arteriography
263
erectile dysfunction treatment
identify and treat reversible causes lifestyle and risk factor modification patient and partner involvement in education and counselling
264
erectile dysfunction treatment: testosterone replacement
primary testicular failure/HPG failure | contraindicated if history of prostate cancer
265
erectile dysfunction: first line treatment
phosphodiesterase (PDE5) inhibitors
266
erectile dysfunction: second line treatment
intracavernous injections intraurethral alprostadil vacuum devices
267
erectile dysfunction and viagra
effective 30-60 mins after administration reduced efficiency after fatty meal check nitrates
268
erectile dysfunction and viagra: efficacy
in diabetes, 66.6% improved | 63% successful intercourse
269
erectile dysfunction and viagra: common adverse events
``` headache flushing dyspepsia nasal congestion dizziness visual disturbances myalgia ```
270
erectile dysfunction treatment: vacuum constriction devices
passive engorgement efficiency 90% those with motivated and understanding partner do best
271
erectile dysfunction treatment: intracavernosal injections
alprostadil 5-40micrograms training required efficacy 70%
272
erectile dysfunction treatment: intracavernosal injections, complications
penile pain 11% priapism 1% fibrosis 2%
273
erectile dysfunction treatment: prolonged erection
aka priapism >4 hours long risk of permanent ischaemic damage to corpora aspirate corpora with 19 gauge needle
274
erectile dysfunction treatment: intraurethral alprostadil
MUSE pellet 125-1000 micrograms | efficiency 30-66%
275
erectile dysfunction treatment: intraurethral alprostadil side effects
pain 29-41% dizziness 2-14% urethral bleeding 5%
276
erectile dysfunction: third line therapy, penile prosthesis
malleable prosthesis, semi rigid inflatable, 2 or 3 piece satisfaction rates 70-87%
277
diagnosing scrotal masses
a lump is cancer until proven otherwise can you get above it? is it separate from the testis? cystic or solid?
278
what is the scrotal mass? Cannot get above
inguinoscrotal hernia or proximally extending hydrocele
279
what is the scrotal mass? separate and cystic
epididymal cyst
280
what is the scrotal mass? separate and solid
epididymitis or varicocele
281
what is the scrotal mass? testicular and cystic
hydrocele
282
what is the scrotal mass? testicular and solid
tumour or haematocele
283
epididymal cyst
smooth, extra-testicular, spherical cyst in the head of the epididymis
284
epididymal cyst: epidemiology
usually develop around the age of 40 not uncommon rare in children
285
epididymal cyst: pathophysiology
contain clear and milky (spermatocele) fluid | lie above and behind the testes
286
epididymal cyst: presentation
- normal present having noticed a lump - often multiple and may be bilateral - small cysts may remain undetected and asymptomatic - when large, often painful - well defined and transluminate since fluid filled
287
epididymal cyst: differential diagnosis
spermatocele hydrocele varicocele
288
epididymal cyst: investigation and treatment
scrotal ultrasound | usually no treatment needed but if painful then surgical excision
289
hydrocele
abnormal collection of fluid within tunica vaginalis
290
hydrocele: epidemiology
clinically apparent scrotal hydrocele are evident in 6% of term males beyond the newborn period most paediatric cases are congenital
291
primary hydrocele: aetiology
more common and larger usually in younger men associated with patent processus vaginalis, typically resolved in first year of life
292
secondary hydrocele: aetiology
rarer and presents in older boys and men | secondary to- trauma, infection, TB, testicular torsion
293
hydrocele: pathophysiology
overproduction of fluid in the tunica vaginalis= simple hydrocele processus vaginalis fails to close, allowing peritoneal fluid to communicate freely with scrotal portion= communicating hydrocele
294
hydrocele: presentation
scrotal enlargement with non-tender, smooth, cystic swelling pain is not a feature unless it is infected testes may be difficult to palpate in large cases
295
hydrocele: differential diagnosis
must differentiate from testicular torsion and strangulated hernia
296
hydrocele: investigations
ultrasound | serum alpha-fetoprotein and human chorionic gonadotrophin to help exclude malignant teratomas
297
hydrocele: treatment
resolve spontaneously | therapeutic aspiration or surgical removal
298
varicocele
abnormal dilation of testicular veins in the pampiniform venomous plexus- caused by venous reflux
299
varicocele: epidemiology
left side more commonly effected unusual in under 10 years increases after puberty
300
varicocele: aetiology
angle at which the left testicular vein enters the left renal vein increased reflux from compression of renal vein lack of effective valves between testicular and renal veins
301
varicocele: presentation
often visible as distended scrotal blood vessels- feel like bag of worms dull ache or scrotal heaviness scrotum hangs lower than the normal side
302
varicocele: differential diagnosis
secondary to other pathological processes blocking testicular vein- kidney tumours
303
varicocele: investigations
venography | colour doppler ultrasound
304
varicocele: treatment
surgery if pain, infertility or atrophy
305
testicular torsion
twisting of the spermatic cord resulting in occlusion of the testicular blood vessels- can lead to ischaemia and infarct (germ cells are most susceptible cell line)
306
testicular torsion: epidemiology
common urological emergency typically occurs in neonates or post pubertal boys can occur in men of all ages left side more common than right
307
testicular torsion: aetiology
underlying congenital malformation- testis not fixed to scrotum, allowing free movement trauma
308
testicular torsion: risk factors
genetic factors
309
testicular torsion: presentation
- any boy with abdo pain should be checked - sudden onset pain in one testis - pain comes on during activity - pain in abdo, nausea and vomiting - inflammation - testis may lie high or transverse
310
testicular torsion: differential diagnosis
``` epididymo-orchitis tumour trauma acute hydrocele idiopathic scrotal oedema ```
311
testicular torsion: investigations
doppler ultrasound urinalysis- excludes infection do not delay surgical exploration
312
testicular torsion: treatment
surgery- expose and untwist testis (6 hour window to save testis) orchidectomy and bilateral fixation
313
renal cystic disease
solitary or multiple renal cysts are common, especially in advancing age often asymptomatic occasionally cause pain or haematuria if large
314
types of renal cysts
``` simple cysts hydronephrosis medullary sponge cysts acquired cystic disease polycystic- when a lot of them it can be bad ```
315
simple renal cysts
most common form | benign
316
hydronephrosis
when ureter is blocked and kidney dilates and gets bigger
317
medullary sponge cyst
dilation of collecting ducts
318
inherited renal cysts
caused by mutation | dominant or recessive
319
development of congenital renal cysts
mutation leads to predisposition for cyst formation increased abnormal cell hyperproliferation -> loss of planar polarity -> cyst initiation -> fluid secretion by epithelial cells -> cyst
320
acquired renal cysts
``` develop over time no mutation bilateral or unilateral isolated to kidneys associated with CKD ```
321
causes of renal cysts
simple- develop over time acquired- CKD genetic causes drugs such as lithium
322
autosomal dominant polycystic kidney disease
multiple cysts develop gradually and progressively, throughout the kidney- eventually resulting in renal enlargement and kidney tissue destruction
323
autosomal dominant polycystic kidney disease: epidemiology
most common inherited kidney disease high penetrance presents in adulthood (20-30 y/o) more common in males
324
autosomal dominant polycystic kidney disease: aetiology
mutations on PKD1 gene on chromosome 16 (85%) | mutations in PKD2 gene on chromosome 4 (15%)
325
autosomal dominant polycystic kidney disease: risk factors
family history or ADPKD, ESFR or hypertension
326
autosomal dominant polycystic kidney disease: pathophysiology
PKD1 encodes polycystin 1- cell to cell and/or cell to matrix interactions, regulating tubular and vascular development PKD2 encodes polycystin 2- functions as a calcium ion channel Disruption of polycystin pathways result in reduced cytoplasmic calcium, causing defective ciliary signalling and disoriented cell division- cyst formation
327
autosomal dominant polycystic kidney disease: presentation
``` loin pain and/or haematuria from- haemorrhage into cyst, cyst infection or UT stone discomfort as kidney size increases excessive water and salt loss nocturia renal colic due to blood clots hypertension renal stones renal failure ```
328
autosomal dominant polycystic kidney disease: extra-renal presentations
``` subarachnoid haemorrhage associated with berry aneurysm polycystic liver disease pancreatitis male infertility ovarian cysts diverticular disease ```
329
autosomal dominant polycystic kidney disease: differentials
acquired and simple cysts of the kidneys autosomal recessive PKD medullary sponge kidney tuberous sclerosis
330
autosomal dominant polycystic kidney disease: investigations
``` personal history family history BP may be raised genetic testing for PKD1 and PKD2 ultrasound ```
331
autosomal dominant polycystic kidney disease: ultrasound
at risk individuals in is diagnostic if: - 15 to 39 y/o 3+ cysts - 40 to 59 y/o 2+ cysts (each kidney) - 60+ y/o 4+ cysts, each kidney exclude if over 40 y/o and less than 2 cysts
332
autosomal dominant polycystic kidney disease: treatment
no treatment shown to slow the disease progression BP control with ramipril treat stones and give analgesia laparoscopic removal of cysts to help pain renal replacement therapy
333
autosomal recessive polycystic kidney disease: epidemiology
rarer than ADPKD | disease of infancy
334
autosomal recessive polycystic kidney disease: aetiology
PKHD1 mutation on long arm of chromosome 6
335
autosomal recessive polycystic kidney disease: risk factors
family history
336
autosomal recessive polycystic kidney disease: presentation
variable multiple renal cysts and congenital hepatic fibrosis enlarged polycystic kidneys 30% develop kidney failure
337
autosomal recessive polycystic kidney disease: differentials
ADKPD multicystic dysplasia hydronephrosis renal vein thrombosis
338
autosomal recessive polycystic kidney disease: diagnosis
diagnosed antenatally or neonatally ultrasound MRI or CT to monitor liver disease genetic testing
339
autosomal recessive polycystic kidney disease: treatment
``` no current treatment genetic counselling laparoscopic removal of cysts to help pain BP control treat stones renal replacement therapy ```
340
renal stones
consist of crystal aggregates, they form in the collecting ducts and may be deposited anywhere from the renal pelvis to the urethra
341
renal stones: epidemiology
``` 10-15% lifetime risk peak age 20-40 y/o more common in males unusual in children 50% recurrence risk ```
342
renal stones: risk factors and aetiology
``` chemical composition of urine anatomical abnormalities dehydration infection hypercalcaemia hyperoxaluria hypercalciuria primary renal disease diuretics gout ```
343
renal stones: pathophysiology
stones form because solute conc. exceed saturation calcium oxalate= 60-65% calcium phosphate= 10%
344
calcium renal stones: hypercalciuria causes
hyperparathyroidism excessive dietary intake of calcium idiopathic hypercalciuria- increased gut absorption
345
calcium renal stones: hyperoxaluria causes
high dietary intake of oxalate rich food- spinach, rhubarb and tea low dietary calcium increased intestinal resorption due to GI disease
346
uric acid renal stones: causes
associated with hyperuricaemia with/without gout dehydration patients with ileostomies are at particular risk from dehydration and bicarb loss
347
infection induced renal stones: causes
mixed infective stones are composed of magnesium ammonium phosphate as well as calcium
348
cystine renal stones: causes
cystinuria- autosomal recessive condition affective cysteine in epithelial cells of renal tubules
349
renal stones: presentation
``` most asymptomatic loin pain dysuria haematuria Renal colic ```
350
renal stones: RENAL COLIC
rapid onset pain results from upper urinary tract obstruction excruciative utereric spasms pain is from loin to groin associated with nausea and vomiting worse with fluid loading radiates to groin and ipsilateral testis/labia
351
renal stones: history taking SOCRATES
``` Site Onset Character Radiation Associated features Timing Exacerbating/relieving factors Severity ```
352
renal stones: differential diagnosis
vascular accident- AAA bowel pathology ectopic pregnancy/ovarian cyst testicular torsion
353
renal stones: urine
dipstick- positive for blood, looks for RBCs, protein and glucose mid stream specimen- microbiology culture
354
renal stones: bloods
serum urea, electrolyte, creatinine and calcium | FBC
355
renal stones: KUB Xray
first line investigation | 80% sensitive
356
renal stones: non-contrast CT- KUB
gold standard rapid 99% sensitive no contrast so no renal damage/allergy
357
renal stones: ultrasound
shows kidney stones and renal pelvis dilation | sensitive for hydronephrosis
358
renal stones: antibiotics
IV cefuroxime or IV gentamicin | prevent pyonephorisis- can lose renal function in 24 hours
359
renal stones: treatment
antiemetics analgesia observe for sepsis 90% stones under 5mm in lower ureter pass
360
renal stones: medical expulsive therapy
stones over 5mm with pain | oral nifedipine or alpha blocker (tamsulosin) promote expulsion
361
renal stones: if still not passing after previous treatment...
extracorporeal shockwave lithotripsy- ultrasound fragments stones keyhole surgery to remove stones that are large
362
renal stones: prevention of recurrence
``` over hydration normal-low calcium intake low salt intake normal dairy intake reduce BMI reduce animal proteins active lifestyle ```
363
uric acid renal stones
can be caused by long term allopurinol use only form in acidic urine deacidification of urine with oral sodium bicarbonate
364
cysteine renal stones: prevention of recurrence
over hydration urine alkalisation cysteine binders- captopril
365
chlamydia trachomatis
gram negative most common STI more common in women, 15-25 y/o
366
neisseria gonorrhoea
gram negative diplococcus | more common in men
367
CT and GC sites of occurrence in adults
``` urethra endocervical canal rectum pharynx conjunctiva ```
368
CT and GC sites of occurrence in neonates
conjunctiva | atypical pneumonia
369
CT and GC in males
primary site is urethra | dysuria and urethral discharge
370
incubation of gonorrhoea in males
2-5 days
371
incubation of chlamydia in males
7-21 days
372
asymptomatic gonorrhoea in males %
10%
373
asymptomatic chlamydia in males %
at least 50%
374
transmission of gonorrhoea, female to male %
60-80%
375
transmission of chlamydia, female to male %
70%
376
complications of chlamydia in males
epididymo-orchitis | reactive arthritis
377
CT and GC in females
primary site of infection is cervix | non-specific symptoms of dysuria, menstrual irregularity and discharge
378
female asymptomatic chlamydia %
>70%
379
female asymptomatic gonorrhoea %
50%
380
female gonorrhoea incubation
up to 10 days
381
female chlamydia incubation
ill defined
382
gonorrhoea transmission male to female %
50-90%
383
chlamydia transmission male to female %
70%
384
CT + GC female complications: pelvic inflammatory disease
- infection spreads up fallopian tube, leading to inflammation and scarring - tubular factor infertility - ectopic pregnancy - chronic pelvic pain
385
CT + GC female complications: neonatal transmission
ophthalmia neonatorum- conjunctivitis | atypical pneumonia
386
chlamydia diagnosis
often diagnosed in established relationships since there is long symptomatic carriage Nucleic Acid Amplification Tests
387
chlamydia diagnosis: samples
males- first void urine | females- self collected vaginal swabs or endocervical swabs
388
gonorrhoea diagnosis
``` associated with recent partner change culture on selective medium to confirm NAAT antibiotic sensitivity testing near patient test ```
389
gonorrhoea diagnosis: near patient test
microscopy of gram stained smears male= sample from urethra female=sample from endocervix
390
chlamydia treatment
partner management test for other STIs oral azithromycin stat, one dose or oral doxycycline for 7 days- more effective
391
gonorrhoea treatment
partner notification test for other STIs continuous surveillance of antibiotic sensitivity single dose treatment is preferred IM ceftriaxone with azithromycin stat
392
syphilis
treponema pallidum subspecies pallidum early infection- w/i 2 years (primary, secondary and early latent) late- >2 years (late latent, CNS, CVS , gummatous)
393
primary syphilis
primary chancre- 95% genital skin, nipples, mouth incubation= 9-90 days dusky macule=papule, indurated clean based non-tender ulcer
394
secondary syphilis
onset 6-8 weeks after infection 70% present with skin rash 30% mucous membrane lesions 50-60% lymphadenopathy
395
transmission of early syphilis
40-60% of contactable partners of index cases are infected
396
vertical transmission of syphilis
primary and secondary >90% 50% foetal loss or stillbirth 50% congenital syphilis
397
prognosis for untreated syphilis
65% no clinical sequelae 15% late benign gummatous 2-40 yr after exposure 10% neurosyphilis 2-30 yr after exposure 10% CVS 20-30 yr after
398
syphilis diagnosis
early moist lesions- can identify motile spirochetes on wet mount using dark ground microscopy rash ulcer
399
syphilis diagnosis: ulcer
any genital ulcer is syphilis until proved otherwise | serology usually positive if ulcer present for 2+ weeks
400
serological tests of syphilis
- screening EIA | - confirmatory tests for samples which screen positive (Treponema Pallidum Particle Agglutination test)
401
syphilis treatment
penicillin by injection | partner notification
402
Primary prevention of STIs
reducing risk of acquiring STI campaigns vaccination- Hep B/ HPV
403
Anti-retroviral primary prevention of STIs
PEP | PrEP
404
Secondary prevention of STIs
diagnosing cases easy access to STI tests and treatment targeted screening
405
tertiary prevention of STIs
reducing morbidity/mortality anti-retrovirals for HIV prophylactic antibiotics for PCP
406
partner notification
aims to control infection by identifying key individuals and sexual networks warn unsuspecting and attempt to break the chain of infection
407
partner notification: why trace them?
breaks chain of transmission prevent re-infection of index patient prevent complications of untreated infections
408
partner notification: how are they traced?
patient referral | provider referral via text or letter
409
Urinary tract infection
inflammatory response of the urothelium to bacterial invasion associated with bacteriuria and pyuria >105 organisms/ml of fresh mid-stream urine
410
classification of UTIs: location
lower vs upper
411
classification of UTIs: clinical risk
uncomplicated vs complicated
412
classification of UTIs: timing
single/isolated vs unresolved | acute vs chronic
413
bacterial features of UTI
uropathogenic strains of E.coli (UPEC) causes 80% of uncomplicated UTIs
414
bacterial features of UTI: UPEC attachment molecules
fimbriae/pilli afimbrial attachments acid polysaccharide coat that resits phagocytosis
415
bacterial features of UTI: bacteria adhere to...
urothelium vaginal epithelium vaginal mucus
416
bacterial features of UTI: avoidance of host defences
capsule resist phagocytosis | e.coli release cytokine that are directly toxic
417
bacterial features of UTI: proteus spp. secrete urease
increases risk of stone formation
418
UTI: host defence mechanisms
antegrade slushing of urine tamm-horsfall protein- antimicrobial properties low urine pH and high osmolarity urinary IgA
419
upper UTI
pyelonephritis
420
lower UTI
cystitis (bladder) prostatitis epididymo-orchitis urethritis
421
complicated UTI
infection in those with abnormal urinary tract treatment failure is more likely complications more likely
422
uncomplicated UTI
UTI in healthy, non-pregnant women with normal urinary tract
423
UTI: epidemiology
more common in women | affects 1/3 of women in lifetime
424
UTI: risk factors
``` female sexual intercourse pregnancy menopause low host defence catheter obstruction ```
425
UTI: pathogenesis
infection via ascending transurethral route | women = more susceptible due to shorter urethra and proximity to anus
426
pyelonephritis
infection of renal parenchyma and soft tissues of renal pelvis
427
pyelonephritis: aetiology, KEEPS
``` Klebsiella spp. E.coli = majority Enterococcus spp. Proteus spp. Staphylococcus spp. coagulase neg ```
428
pyelonephritis: epidemiology
predominantly in females <35 y/o associated with significant sepsis and systemic upset main cause= UPEC
429
pyelonephritis: risk factors
``` structural renal abnormalities calculi catheterisation pregnancy diabetes immunocompromised ```
430
pyelonephritis: pathophysiology
mainly due to E.coli from own patient's bowel flora | ascend transurethral route
431
pyelonephritis: presentation
``` triad: loin pain, fever, pyuria headache rigors bacteriuria malaise, nausea, vomiting ```
432
pyelonephritis: differentials
diverticulitis AAA kidney stones cystitis/prostatitis
433
pyelonephritis: treatment
rest analgesia antibiotics- oral ciprofloxacillin surgery to drain abscesses or relieve calculi
434
pyelonephritis: urine dipstick
detects nitrites (bacteria breakdown nitrates-> nitrites) detects leukocyte elastase foul smelling urine
435
pyelonephritis: midstream urine microscopy
culture and sensitivity | gold standard
436
pyelonephritis: bloods
FBC- elevated white cell count | CRP and ESR may be raised
437
pyelonephritis: urgent ultrasound
detect calculi, obstruction, abnormal anatomy and incomplete bladder emptying
438
cystitis
urinary infection of bladder
439
cystitis: epidemiology
much more common in women can occur in children most common cause is e.coli
440
cystitis: risk factors
urinary obstruction resulting in urinary stasis previous damage to bladder epithelium bladder stones
441
cystitis: presentation
``` dysuria frequency urgency suprapubic pain haematuria offensive smelling/cloudy urine ```
442
cystitis: investigation
gold standard= microscopy and sensitivity of sterile mid-stream urine
443
cystitis: first line antibiotic treatment
trimethoprim or cefalexin
444
cystitis: second line antibiotic treatment
ciprofloxacin or co-amoxiclav
445
prostatitis
infection and inflammation of prostate gland
446
prostatitis: epidemiology
common in men of all ages | most common UTI in men <50
447
prostatitis: acute aetiology
streptococcus faecalis e.coli chlamydia
448
prostatitis: chronic aetiology
bacterial- streptococcus, faecalis, e.coli, chlamydia | non-bacterial- elevated prostatic pressure, pelvic floor myalgia
449
prostatitis: risk factors
STI UTI indwelling catheter increasing age
450
prostatitis: acute presentation
systemically unwell fever, rigor, malaise pain on ejaculation LUTS
451
prostatitis: chronic presentation
same as acute for >3 months
452
prostatitis: differentials
cystitis BPH calculi bladder neoplasia
453
prostatitis: diagnosis
tender and/or hard prostate on DRE urine dipstick blood cultures STI screening
454
prostatitis: acute treatment
IV gentamicin + IV co-amoxiclav or IV tazocin abscess drainage if necessary
455
prostatitis: chronic treatment
4-6 week course of quinolone e.g. ciprofloxacin | maybe alpha blocker- tamsulosin
456
prostatitis: complication
urinary retention
457
urethritis
urethral inflammation due to infectious or non-infectious causes primarily sexually acquired
458
urethritis: epidemiology
most commonly diagnosed condition and treated in men @ GUM clinics
459
urethritis: gonococcal cause
neisseria gonorrhoea
460
urethritis: non-gonococcal causes
chlamydia trachomatis= most common | mycoplasma genitalium
461
urethritis: non infective causes
trauma urethral stricture irritation calculi
462
urethritis: risk factors
sexually active | unprotected sex
463
urethritis: presentation
``` 90-95% asymptomatic with gonorrhoea dysuria urethral pain penile discomfort skin lesions ```
464
urethritis: differentials
``` candida balantis epididymitis cystitis prostatitis malignancy ```
465
urethritis: investigations
NAAT microscopy of gram stained smears of genital secretion blood cultures urine dipstick to exclude UTI
466
urethritis: NAAT
nucleic acid amplification test female- self collected vaginal swab male- first void volume
467
urethritis: chlamydia treatment
oral azithromycin stat test for other STIs erythromycin for 14 days if pregnant partner notification
468
urethritis: gonorrhoea treatment
IM ceftriaxone with azithromycin | partner notification
469
epididymo-orchitis
acute is a clinical syndrome of pain, swelling and inflammation of epididymis that can extend to testis
470
epididymo-orchitis: epidemiology
most common in males 15-30 and >60
471
epididymo-orchitis: aetiology
mumps trauma predominantly catheter related in elderly
472
epididymo-orchitis: under 35 aetiology
CT and GN
473
epididymo-orchitis: over 35 aetiology
UTI, KEEPS
474
epididymo-orchitis: risk factors
previous infection indwelling catheter structural/functional abnormality of urinary tract anal intercourse
475
epididymo-orchitis: presentation
subacute onset of unilateral scrotal pain and swelling | may be urethritis or discharge in STI
476
epididymo-orchitis: differential diagnosis
testicular torsion- must be ruled out first as emergency | hydrocele, trauma, abscess
477
epididymo-orchitis: investigations
NAAT dipstick ultrasound STI screening
478
epididymo-orchitis: chlamydia treatment
oral doxycycline 7 days
479
epididymo-orchitis: gonorrhoea treatment
IM ceftriaxone and oral azithromycin
480
epididymo-orchitis: UTI treatment
oral ciprofloxacin
481
epididymo-orchitis: general treatment
antibiotics should be for 2-4 weeks NSAID analgesia scrotal support- underwear abstain from sex

phase 2a clinical (8 decks)

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