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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
Q

urinary tract obstruction: extra mural causes

A 
abdominal or pelvic mass
retroperitoneal fibrosis
BPH
prostate cancer
pregnancy
inflammation
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26
Q

acute upper urinary tract obstruction: presentation

A

loin pain radiating to groin

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27
Q

chronic upper urinary tract obstruction: presentation

A

flank pain
renal failure
infection
polyuria

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28
Q

acute lower urinary tract obstruction: presentation

A

acute urinary retention with severe suprapubic pain

distended, palpable bladder- dull to percussion

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29
Q

chronic lower urinary tract obstruction: presentation

A

urine frequency, hesitancy, poor stream, terminal dribbling

UTI/urinary retention/large prostate possible

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30
Q

urinary tract obstruction: investigations

A

bloods
mid stream urinary sample- culture and sensitivity
ultrasound

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31
Q

upper urinary tract obstruction: treatment

A

nephrostomy- artificial opening between kidney and skin, urinary diversion from upper tract
alpha 1 antagonist
5 alpha reductase inhibitor

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32
Q

lower urinary tract obstruction: suprapubic catheter

A

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

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33
Q

lower urinary tract obstruction: surgery

A

transurethral resection of prostate
<14% impotent
1% incontinent
10% ED

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34
Q

indications for surgery with LUTS

A

RUSHES

Retention
UTIs
Stones
Haematuria
Elevated creatinine due to bladder outflow obstruction
Symptoms deterioration
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35
Q

BPE: benign prostatic enlargement

A

increase in size of prostate without presence of malignancy

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36
Q

BPE: epidemiology

A

common
24% men 40-64 y/o
40% >60

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37
Q

BPE: risk factors

A

increased age

testosterone

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38
Q

BPE: pathophysiology

A

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

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39
Q

BPE: presentation

A

LUTS
abdominal pain
acute urinary retention

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40
Q

BPE: LUTS

A 
nocturia
frequency
urgency
post-micturition dribbling
poor steam
haematuria
bladder stones
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41
Q

BPE: differential diagnosis

A 
bladder tumour
bladder stones
trauma
prostate cancer
chronic prostatitis 
UTI
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42
Q

BPE: investigations

A 
digital rectal exam
serum electrolytes
transrectal ultrasound
biopsy
mid-stream urine sample
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43
Q

BPE: lifestyle treatments

A

avoid caffeine and alcohol
relax when voiding
void twice in a row to aid emptying

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44
Q

BPE: alpha 1 antagonists

A

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

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45
Q

BPE: 5 alpha reductase inhibitors

A

oral finasteride
block conversion of testosterone to dihydrotestosterone (responsible for prostate growth)
SE= impotence and decreased libido

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46
Q

BPE: surgical treatment

A

for those with large prostate or fail to respond to medical therapy
TURP or TUIP

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47
Q

BPE: transurethral resection of prostate

A

gold standard option, especially for larger prostates

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48
Q

BPE: transurethral incision of prostate

A

less destructive than TURP and less risk to sexual function

better option for smaller prostates

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49
Q

BPE: complications if untreated

A

bladder calculi
UTI
haematuria
acute retention

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50
Q

AKI definition

A

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

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51
Q

AKI classification: RIFLE classifications

A

old system to define AKI

an increase in serum creatinine or decrease in urine output

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52
Q

AKI classification: RIFLE stands for..

A 
Risk
Injury
Failure
Loss
End stage renal disease
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53
Q

AKI KDIGO classification: criteria for diagnosing

A

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

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54
Q

AKI epidemiology

A

common in elderly

25% of patients with sepsis and 50% of those with septic shock

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55
Q

AKI: associated with..

A 
diarrhoea
haematuria
haemoptysis
hypotension
urine retention
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56
Q

AKI aetiology: pre renal

A 
40-70%
renal hyperfusion
hypovolaemia
hypotension
low CO
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57
Q

AKI aetiology: intrinsic

A

10-50%
renal parenchyma damage
acute tubular necrosis

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58
Q

AKI aetiology: intrinsic, vascular

A

renal artery/vein thrombosis
cholesterol emboli
vasculitis
malignant hypertension

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59
Q

AKI aetiology: intrinsic, glomerular

A

glomerulonephritis
autoimmune
drugs
infection

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60
Q

AKI aetiology: intrinsic, interstitial

A

drugs

infiltration- lymphoma, infection, tumour lysis syndrome

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61
Q

AKI aetiology: post renal

A

10-25%

urinary tract obstruction at ureter, bladder or prostate

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62
Q

AKI aetiology: post renal, luminal

A

stones
clots
sloughed papillae

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63
Q

AKI aetiology: post renal, mural

A

malignancy
BPH
strictures

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64
Q

AKI risk factors

A 
age >75
heart failure
chronic liver disease
sepsis
poor fluid intake
past history of AKI
diabetes
prostate cancer
nephrotoxic drugs
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65
Q

AKI presentation

A 
depends on cause and severity
palpable bladder/kidneys
small urine volume
irregular heartbeat from hyperkalaemia
uraemia symptoms (fatigue, weakness, confusion, seizures)
Thirst
oedema
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66
Q

AKI differential diagnosis

A 
abdominal aortic aneurysm
alcohol toxicity
alcoholic/diabetic ketoacidosis
chronic renal failure
dehydration 
heart failure
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67
Q

AKI investigations: dipstick

A

can suggest infection (leukocytes and nitrates) and glomerular disease (blood and protein)

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68
Q

AKI investigations: blood count

A

anaemia and high ESR suggests myeloma or vasculitis as cause

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69
Q

AKI investigations: ultrasound

A 
renal size (small= CKD)
obstruction and hydronephrosis
cysts and masses
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70
Q

AKI investigations: CT-KUB

A

kidneys, ureters and bladder
looks for obstructing masses or calculi
retroperitoneal fibrosis

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71
Q

AKI treatment: pre renal underlying cause

A

correct volume depletion

treat sepsis

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72
Q

AKI treatment: intrinsic cause

A

refer early to nephrology if concern over tubulointerstitial glomerular pathology

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73
Q

AKI treatment: post renal underlying cause

A

catheterise and consider CT-KUB

obstruction and hydronephrosis- cystoscopy or nephrostomy insertion

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74
Q

AKI treatment: nephrotoxic drugs to stop

A

NSAIDs
ACE inhibitor
gentamicin
amphotericin

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75
Q

AKI treatment: indications for dialysis

A 
symptomatic uraemia including pericarditis or tamponade
hyperkalaemia
pulmonary oedema
severe acids
high potassium
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76
Q

AKI treatment: complications of renal replacement therapy

A

cardiovascular disease
infection
amyloid accumulates in long term
malignancy is common

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77
Q

stress incontinence

A

caused by sphincter weakness
urine leaks with increased intra-abdominal pressure rises
more common in females

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78
Q

stress incontinence: causes

A

neurogenic or congenital

different for males and females

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79
Q

male stress incontinence: causes

A

post-prostatectomy

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80
Q

male stress incontinence: treatment

A

artificial sphincter

male sling

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81
Q

female stress incontinence: causes

A

secondary to birth trauma

degradation of pelvic floor and urethral sphincter

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82
Q

female stress incontinence: treatment

A

pelvic floor exercises
duloxetine
surgery= sling or artificial sphincter

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83
Q

urge incontinence

A

strong desire to void and unable to hold urine

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84
Q

urge incontinence: causes

A

detrusor overactivity- rise in detrusor pressure on filling (more common in women)
can be bladder hypersensitivity from UTI, bladder stones or tumours

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85
Q

urge incontinence treatment: bladder exercises

A

gradually increase the interval between voids

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86
Q

urge incontinence treatment: behavioural therapy

A

controlling caffeine and alcohol

frequency volume charts

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87
Q

urge incontinence treatment: anticholinergic agents

A

oxybutynin
act against cholinergic system (parasymp)
decreases detrusor excitability

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88
Q

urge incontinence treatment: botox of bladder

A

stop release of Ach from pre-synaptic terminal- paralyses bladder
huge side effect= urinary retention

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89
Q

urge incontinence treatment: bladder augmentation

A

detrusor myecotmy

cystoplasty= adding bowel to bladder to increase surface area

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90
Q

voiding problems: obstructive

A

BPE, urethral stricture, prolapse/mass
if BPE give alpha blockers, maybe 5 alpha reductase inhibitors
if that fails then TURP

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91
Q

voiding problems: non-obstructive

A

detrusor underactivity

long term catheterisation to empty

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92
Q

neuropathic bladder dysfunction: spastic spinal cord injury

A

reflexes work but not controlled by brain

supra-conal lesion

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93
Q

neuropathic bladder dysfunction: spastic spinal cord injury losses

A

loss of co-ordination and completion of voiding

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94
Q

neuropathic bladder dysfunction: spastic spinal cord injury features

A

reflex bladder contractions
detrusor sphincter dyssynergia (loss of complete voiding)
poorly sustained bladder contraction
unsafe- bladders at risk

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95
Q

neuropathic bladder dysfunction: flaccid spinal cord injury

A

conus lesion

decentralised bladder

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96
Q

neuropathic bladder dysfunction: flaccid spinal cord injury losses

A

reflex contraction
guarding reflex
receptive relaxation

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97
Q

neuropathic bladder dysfunction: flaccid spinal cord injury features

A

areflexic bladder
stress incontinence
risk of poor compliance
unsafe- kidneys at risk

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98
Q

neuropathic bladder dysfunction treatment

A

alpha adrenergic blockers
sphincterotomy
cystoplasty
permanent catheterisation

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99
Q

neuropathic bladder dysfunction treatment: prevent autonomic dysreflexia

A

commonly causes by over-distension or bladder
occurs in lesions above T6
overstimulation of symp nervous system below lesion (due to noxious stimulus)

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100
Q

neuropathic bladder dysfunction treatment: maintain bladder safety

A

an unsafe bladder is one that puts kidneys at risk

risks= raised bladder pressure, vesico-ureteric reflux, chronic infection

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101
Q

neuropathic bladder dysfunction treatment: symptom control

A

harness reflexes to empty bladder into incontinence device

suppress reflexes converting bladder to flaccid type, then empty regularly

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102
Q

bladder problems in MS

A 
caused by neurogenic detrusor overactivity
overactive bladder syndrome
urinary urgency
frequency
incomplete bladder emptying
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103
Q

prostate tumours

A

most common male malignancy

majority are adenocarcinomas in peripheral zone and slow growing

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104
Q

prostate tumours: epidemiology

A

6th most common in world
incidence increases with age
by 80 y/o, 80% have malignant foci but most seem to lie dormant

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105
Q

prostate tumours: aetiology

A

hormonal factors- increased testosterone

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106
Q

prostate tumours: risk factors

A

family history (3 or more affected relatives)
genetic (BRCA2 confers a 5/7x higher risk)
increasing age
being black- higher testosterone

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107
Q

prostate tumours: pathophysiology

A

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

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108
Q

prostate tumours: presentation

A 
LUTS if local disease
suggestions of metastasis: 
weight loss
bone pain
anaemia
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109
Q

prostate tumours: differential diagnosis

A

BPH
prostatitis
bladder tumours

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110
Q

prostate tumours: investigations

A

hard and irregular prostate on digital exam
raised PSA
trans-rectal ultrasound
urine biomarkers

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111
Q

prostate tumours: treating disease confined to prostate

A

radical prostatectomy if <70 y/o
radiotherapy and hormone therapy
brachytherapy
surveillance if >70 y/o and low risk

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112
Q

metastatic prostate tumours: endocrine therapy

A

prostate cancer is hormone sensitive
binding androgen receptor stimulates tumour growth
choice of androgen deprivation or receptor blockers (bicalutamide)

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113
Q

metastatic prostate tumours: androgen deprivation

A

orchidectomy- removal of testes

LHRH agonists- stimulate and inhibit pituitary gonadotrophin (testosterone)

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114
Q

prostate tumours: symptom treatment

A

analgesia
treat hypercalcaemia
radiotherapy for bone metastases/spinal cord compression

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115
Q

renal cell carcinoma

A

aka hypernephroma

arises from proximal convoluted tubular epithelium

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116
Q

renal cell carcinoma: epidemiology

A

most common renal tumour in adults
more common in males
more common in >50 y/o
25% have metastases on presentation

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117
Q

renal cell carcinoma: risk factors and aetiology

A 
smoking
obesity 
hypertension
renal failure and haemodialysis 
von hippel lindau syndrome
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118
Q

renal cell carcinoma: von hippel lindau syndrome

A

autosomal dominant on chromosome 3 short arm

loss of both copies of tumour suppressor gene

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119
Q

renal cell carcinoma: pathophysiology

A

malignant cancer of proximal convoluted tubular epithelium

spread may be direct (renal vein), via lymph or haematogenous (bone, liver, lung)

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120
Q

renal cell carcinoma: presentation

A 
asymptomatic and discovered incidentally
haematuria
anorexia
hypertension in 30% (renin secretion by tumour)
fever in around 20%
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121
Q

renal cell carcinoma: differential diagnosis

A

transitional cell carcinoma
wilms’ tumour
renal oncocytoma

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122
Q

renal cell carcinoma: investigations

A 
ultrasound
CT abdo
MRI
BP
bloods
renal biopsy
bone scan
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123
Q

renal cell carcinoma: CT imaging

A

more sensitive than ultrasound in detecting small renal mass
shows involvement of the renal vein or IVC
using contrast demonstrates kidney function

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124
Q

renal cell carcinoma: blood test

A

FBC- detect polycythaemia and anaemia- EPO decrease
ESR can be raised
liver biochemistry may be abnormal

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125
Q

renal cell carcinoma: treating localised

A

nephrectomy- remove kidneys (unless bilateral then partial nephrectomy)

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126
Q

renal cell carcinoma: ablative techniques of treatment

A

such as cryoablation and radiotherapy are used in patients with significant comorbidities who wouldn’t tolerate surgery
can harm kidney function

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127
Q

renal cell carcinoma: treating metastatic or locally advanced

A

interleukin-2 and interferon alpha: cause remission in 20%
if no response:
-biological angiogenesis targeted therapy (sunitinib, sorafenib)
-temisorlimus: improves survival more than interferon

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128
Q

Wilms’ tumour: pathology

A

childhood tumour of primitive renal tubules and mesenchymal cells

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129
Q

Wilms’ tumour: epidemiology

A

seen w/i first 3 years of life

chief abdo malignancy in children

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130
Q

Wilms’ tumour: presentation

A

abdominal mass

less common= haematuria

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131
Q

Wilms’ tumour: investigations

A

diagnosis is established by ultrasound, CT and MRI

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132
Q

Wilms’ tumour: treatment

A

combination of nephrectomy, radiotherapy and chemo

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133
Q

bladder cancer

A

transitional cell carcinoma
calyces, renal pelvis, ureter, bladder and urethra are all lined by transitional epithelium so all susceptible
but bladder is most common

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134
Q

bladder cancer: epidemiology

A

50% of TCC
4th most common cancer in men, 8th in women
mainly occurs >40 y/o, peaks >80 y/o

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135
Q

bladder cancer: risk factors

A 
smoking
chronic inflammation of urinary tract
increased age
male
family history 
paraplegia
exposure to drugs- phenacetin
occupational exposure- benzidine
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136
Q

bladder cancer: pathophysiology

A

> 90% TCCm 5% squamous cell carcinoma, <1% adenocarcimona

tumour spread:
local= to pelvic structures
lymphatic= iliac and para-aortic nodes
haematogenous= liver and lungs

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137
Q

bladder cancer: presentation

A

painless haematuria is most common symptom
recurrent UTIs
voiding irritability

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138
Q

bladder cancer: differential diagnosis

A

haemorrhagic cystitis
renal cancer
UTI
urethral trauma

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139
Q

bladder cancer: investigations

A 
cystoscopy with biopsy
urine microscopy
CT urogram
urinary tumour markers
MRI
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140
Q

non muscle invasive bladder cancer: treatment

A

surgical resection

possible chemo to reduce recurrence- mitomycin, doxorubicin and cisplatin

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141
Q

localised muscle invasive bladder cancer: treatment

A

radical cystectomy- bladder removal
post-op chemo- methotrexate, vinblastine, adriamycin and cisplatin (M-VAC)
radical radiotherapy if not fit for surgery

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142
Q

metastatic bladder cancer: treatment

A

palliative chemo and radiotherapy

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143
Q

testicular tumours: epidemiology

A

most common cancer in males 15-44 y/o
10% occur in undescended testes
96% from germ cells

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144
Q

testicular tumours: germ cell origin

A

seminomas: 25-40 y/o and >60y/o
teratomas: infancy

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145
Q

testicular tumours: non-germ cell origin

A

leydig cell tumours
sertoli cell tumours
sarcomas

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146
Q

testicular tumours: risk factors

A

undescended testes
infant hernia
infertility
family history

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147
Q

testicular tumours: presentation

A 
painless lump in testicle
testicular pain 
abdo pain
cough and dyspnoea 
abdo mass
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148
Q

testicular tumours: differential diagnosis

A

testicular torsion
lymphoma
hydrocele
epididymal cyst

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149
Q

testicular tumours: investigations

A

ultrasound
biopsy
CXR and CT for staging
serum tumour markers

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150
Q

testicular tumours: serum tumour markers

A

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
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151
Q

testicular tumours: treatment

A

radical orchidectomy via inguinal approach
seminomas with mets below diaphragm treated with radiotherapy only
widespread tumours and teratomas= treated with chemo
sperm storage offered

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152
Q

kidney physiology: GFR

A

volume of fluid filtered from glomeruli into bowman’s space per unit time
normally 120ml/min
each kidney receives 20% of CO

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153
Q

kidney physiology: proximal convoluted tubule

A

sugars, amino acid and bicarb are reabsorbed here
absorbs 70% of Na+ and the water that follows
most vulnerable to damage

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154
Q

kidney physiology: faconi syndrome

A 
rare
damage resulting in:
-glycosuria
-acidosis
-phosphate wasting resulting in osteomalacia
-aminoaciduria
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155
Q

kidney physiology: loop of henle

A

reabsorbs 25% of sodium and water that follows
sodium, potassium, chloride transporters are more active in ascending loop
loop diuretics work here

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156
Q

kidney physiology: Distal convoluted tubule

A

5% sodium reabsorbed here and water follows

thiazide diuretics work here

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157
Q

kidney physiology: BP control

A

juxtaglomerular apparatus is solute sensing organ

high conc. of solutes then GFR low so releases renin

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158
Q

kidney physiology: collecting tubule and salts

A

most salt has been reabsorbed
tightly regulated by aldosterone
secreted potassium and hydrogen into urine
water absorbed via aquaporin 2 channels (controlled by ADH)

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159
Q

kidney physiology: aldosterone and Na+ reabsorption

A

hyperaldosteronism- lots of Na+ reabsorption, negative lumen, so K+ and H+ rush in and results in hyperkalaemic alkalosis

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160
Q

kidney physiology: potassium control

A

potassium freely filtered and mostly reabsorbed in proximal tubule/loop of henle
governed by distal delivery of sodium and aldosterone

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161
Q

kidney physiology: K+ modifying renal meds and hypokalaemia

A

loop diuretics

thiazide diuretics

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162
Q

kidney physiology: K+ modifying renal meds and hyperkalaemia

A

spironolactone (aldosterone antagonist)
ACE inhibitors
angiotensin receptor blockers

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163
Q

kidney physiology: diuretics

A

not nephrotoxic but cause hypovolaemia, which in itself is nephrotoxic
thiazide and loop are powerful together and result in profound diuresis

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164
Q

kidney physiology: water

A

water conc. detected through osmoreception in hypothalamus

too conc. then ADH released and cause an increase in aquaporin in collecting duct- more water absorbed

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165
Q

kidney physiology: erythropoietin

A

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

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166
Q

kidney physiology: vitamin D

A

vitamin D hydroxylation occurs here

25-hydroxy vitamin D to 1,25-dihydroxy vitamin D (calcitriol) (active vitamin D)

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167
Q

chronic kidney disease

A

longstanding, usually progressive impairment in renal function, for more than 3 months
GFR <60ml/min/1.73m2

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168
Q

chronic kidney disease: epidemiology

A

6-11% can be defined as having CKD

more common in females

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169
Q

chronic kidney disease: classification

A

proteinuria, haematuria or evidence of abnormal anatomy or systemic disease

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170
Q

chronic kidney disease: aetiology

A 
diabetes M (type 2>1)
hypertension
atherosclerotic renal vascular disease
polycystic kidney disease
amyloidosis
family history
idiopathic=20% cases
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171
Q

chronic kidney disease: risk factors

A 
diabetes M
hypertension
old age 
females>males
proteinuria
AKI
smoking
african/asian
chronic NSAIDs usage
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172
Q

chronic kidney disease pathophysiology

A

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

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173
Q

chronic kidney disease: presentation

A 
early stages are asymptomatic
symptoms common when serum urea conc. exceeds 40mmol/L:
-malaise
-anorexia
-insomnia
-polyuria
-itching
-nausea/vomiting
-oedema
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174
Q

chronic kidney disease investigations: anaemia

A

normochromic normocytic

due to reduced erythropoietin produced by kidneys

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175
Q

chronic kidney disease investigations: bone disease

A

bone pain
renal osteodystrophy- osteoporosis, osteomalacia
renal phosphate retention and impaired 1,25-dihydroxy vitamin D production

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176
Q

chronic kidney disease investigations: neurological

A

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

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177
Q

chronic kidney disease investigations: CVD

A

MI, cardiac failure and stroke

due to increased frequency of hypertension, hyperlipidaemia and vascular calcification

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178
Q

chronic kidney disease complications: skin disease

A

pruritus due to nitrogenous waste products of urea

brown discolouration of nails

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179
Q

chronic kidney disease: differential diagnosis

A

AKI

differentiation depends on history, duration of symptoms and measurements of serum creatinine

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180
Q

chronic kidney disease investigations: urinalysis

A

haematuria- indicates glomerulonephritis
proteinuria- suggestive of glomerular disease or infection
mid stream sample sent for microscopy

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181
Q

chronic kidney disease investigations: serum biochemistry

A

urea, electrolytes, bicard and reatine
low eGFR
raised alkaline phosphatase
raise PTH if CKD stage 3+

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182
Q

chronic kidney disease investigations: bloods

A 
raised phosphate
low Ca2+
Hb low
raised viscosity
fragmented red cells indicate intravascular haemolysis
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183
Q

chronic kidney disease investigations:urine microscopy

A

white cells- bacterial UTI
eosinophilia- allergic tubulointerstitial nephritis
granular casts- active renal disease
red cells- glomerulonephritis

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184
Q

chronic kidney disease investigations: imaging

A

ultrasound to check renal size and to check for obstructions

CT to detect stones, retroperitoneal fibrosis and other causes of obstruction

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185
Q

chronic kidney disease treatment: aims

A

aimed at underlying cause
slow the deterioration of kidney function
reduce CVS risk
treat complications

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186
Q

chronic kidney disease treatment: treat reversible causes

A 
relieve obstruction
stop nephrotoxic drugs
stop smoking
become healthy weight
tight glucose control in diabetes
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187
Q

chronic kidney disease treatment: control BP

A

target= <130/80
ACE inhibitors- ramipril
diuretic- oral bendroflumethiazide, prevents hyperkalaemia and reduce BP

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188
Q

chronic kidney disease treatment: limit bone disease

A

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

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189
Q

chronic kidney disease treatment: limit CVD complications

A

lower cholesterol with statins

give aspirin

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190
Q

chronic kidney disease treatment: controlling symptoms

A

anaemia- iron/folate/folic acid
acidosis- treat with sodium carbonate
oedema- furosemide

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191
Q

chronic kidney disease treatment: RRT

A 
renal replacement therapy:
haemofiltration
haemodialysis
peritoneal dialysis
replacement
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192
Q

chronic kidney disease treatment: indications for dialysis

A 
symptomatic uraemia-pericarditis or tamponade
hyperkalaemia not controlled
pulmonary oedema
severe acids
high potassium
metabolic acidosis
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193
Q

chronic kidney disease treatment: haemofiltration

A

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
Q

chronic kidney disease treatment: haemodialysis

A

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
Q

chronic kidney disease treatment: haemodialysis complications

A 
can't clear large solutes
time consuming
hypotension
nausea
chest pain
fevers
infected catheter
196
Q

chronic kidney disease treatment: peritoneal dialysis

A

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
Q

chronic kidney disease treatment: peritoneal dialysis complications

A

infection
abdo wall herniation
intestinal perforation
loss of membrane function over time

198
Q

chronic kidney disease treatment: complications of RRT

A

CVD due to hypertension and calcium/phosphate dysregulation
infection
amyloid accumulates in long term dialysis- carpal tunnel, arthralgia and fractures

199
Q

chronic kidney disease: kidney transplant

A

donors deceased or alive (best results)
more cost effective than dialysis
doubles life expectancy

200
Q

acute glomerulonephritis: causes

A 
bacterial infection
hep b/c
schistomiasis
malaria
infective endocarditis
systemic sclerosis
201
Q

acute glomerulonephritis causes: post streptococcal infection

A

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
Q

acute glomerulonephritis treatment: post streptococcal infection

A

antibiotics

supportive

203
Q

acute glomerulonephritis causes: SLE

A

rash, arthralgia, kidney failure, neuro symptoms, pericarditis
nucleus antibody positive and double strand DNA positive
low complement C3 and 4

204
Q

acute glomerulonephritis treatment: SLE

A

immunosuppression
steroids
cyclophosphamide
rituximab

205
Q

acute glomerulonephritis causes: ANCA associated vasculitis

A

multisystem small vessel vasculitis- attacks small vessels in kidney and eye

206
Q

acute glomerulonephritis treatment: ANCA associated vasculitis

A

immunosuppression
steroids
cyclophosphamide
rituximab

207
Q

acute glomerulonephritis causes: goodpasture’s disease

A

acute glomerulonephritis and pulmonary alveolar haemorrhage

presence of circulating antibodies directed against intrinsic antigen to basement membrane (of glomeruli and lung)

208
Q

acute glomerulonephritis treatment: goodpasture’s disease

A

remove antibody via plasma exchange
immunosuppression
steroids

209
Q

acute glomerulonephritis causes: IgA nephropathy

A

more common cause of glomerulonephritis in the developed world
IgA deposition in mesangium (structural support to glomerulus) and kidney gets attacked

210
Q

acute glomerulonephritis treatment: IgA nephropathy

A

BP control

ACE inhibitors/angiotensin receptor blockers

211
Q

acute glomerulonephritis: presentation

A 
haematuria
proteinuria
hypertension
oliguria 
deteriorative kidney function
decrease in GFR
uraemia
212
Q

acute glomerulonephritis: uraemia symptoms

A

anorexia
pruritus- rash
lethargy and nausea

213
Q

acute glomerulonephritis: investigations

A 
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
Q

nephrotic syndrome

A

caused by structural and functional abnormalities of podocytes
leaking huge amounts of protein- kidney function remains the same

215
Q

nephrotic syndrome: triad

A

oedema
hypoalbuminaemia
proteinuria- >3.5g/24hours

216
Q

nephrotic syndrome: hyperlipidaemia

A

often present
liver goes into overdrive due to albumin and other protein loss
increases risk of blood clots and produces raised cholesterol

217
Q

nephrotic syndrome: epidemiology

A

rare
diabetes is most common secondary cause
10-25% of nephrotic syndrome in adults, most common cause in children

218
Q

nephrotic syndrome primary causes: minimal change disease

A

seen in children and adults

most common cause of nephrotic syndrome in children

219
Q

nephrotic syndrome primary causes: membrane neuropathy

A 
adults
idiopathic or secondary:
-drugs, penicillamine or NSAIDs
-autoimmune, SLE, thyroiditis
-infection, hep b/c
-neoplasia, lung, colon, stomach
220
Q

nephrotic syndrome primary causes: deposition of IgG and C3

A

along outer aspect of glomerular basement membrane

treated with immunosuppression

221
Q

nephrotic syndrome primary causes: focal segmental glomerulosclerosis

A

scarring is focal and only some glomeruli involved
CD80 in podocytes increase permeability of glomeruli
treat with corticosteroids and immunosuppressants

222
Q

nephrotic syndrome: secondary causes

A 
diabetes mellitus
amyloid
infections
SLE,RA
drugs
malignancy
223
Q

nephrotic syndrome: pathophysiology

A

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
Q

nephrotic syndrome: presentation

A 
normal-mild increase in BP
proteinuria
normal-mild decrease in GFR
hypoalbuminarmia
pitting oedema
frothy urine
225
Q

nephrotic syndrome differential diagnosis: congestive heart failure

A

where there is oedema and raised jugular venous pressure

226
Q

nephrotic syndromedifferential diagnosis: cirrhosis

A

where there is signs of hypoalbuminaemia and oedema

signs of chronic liver failure

227
Q

nephrotic syndrome: investigations

A

establish cause- usually with biopsy
urine dipstick
serum albumin is low

228
Q

nephrotic syndrome complications: susceptibility to infection

A

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
Q

nephrotic syndrome complications: thromboembolism

A

hypercoagulable state due to increase clotting factors (liver gone into overdrive)

230
Q

nephrotic syndrome complications: hyperlipidaemia

A

increased cholesterol and triglycerides due to hepatic lipoprotein synthesis (liver in overdrive)

231
Q

nephrotic syndrome treatment: reduce oedema

A

loop diuretics- IV furosemide
thiazide diuretics- IV bendroflumethiazide
increased fluid
salt restriction

232
Q

nephrotic syndrome treatment: reduce proteinuria

A

ace inhibitor- ramipril
angiotensin receptor blockers- candesartan
eat high protein diet

233
Q

nephrotic syndrome treatment: reduce risk of complications

A

prophylactic anticoagulation w/ warfarin
reduce cholesterol w/ statins- simvastatin
treat infections/vaccinate

234
Q

minimal change disease

A

disease of kidney that can cause nephrotic syndrome

235
Q

minimal change disease: epidemiology

A

most common cause of nephrotic syndrome in children
more common in boys <5y/o
accounts for 20% of adult nephrotic syndrome

236
Q

minimal change disease: risk factors/aetiology

A 
idiopathic
atopy is present in 30%
Hep C/HIV and TB are rare causes
associated with hodgkin's lymphoma
Drugs
237
Q

minimal change disease: drug aetiology

A

NSAIDs
lithium
antibiotics- rifampicin, ampicillin
bisphosphonates

238
Q

minimal change disease: pathophysiology

A

electron microscopy shows fusion of foot processes on podocytes- consistent with disrupted podocyte actin cytoskeleton

239
Q

minimal change disease: presentation

A

proteinuria
oedema- around face
fatigue
frothy urine

240
Q

minimal change disease: biopsy

A

normal under light microscopy

check under electron microscopy

241
Q

minimal change disease: treatment

A

high dose of corticosteroids- prednisolone (reverses proteinuria in 95% cases, but majority relapse)
frequent relapse is treated with cyclophosphamide or ciclosporin

242
Q

asymptomatic urinary abnormalities

A

incidental finding of dipstick haematuria, and possible proteinuria
kidney function and BP normal

243
Q

asymptomatic urinary abnormalities: causes

A

thin membrane disease

IgA nephropathy

244
Q

asymptomatic urinary abnormalities: thin membrane disease

A

more likely to leak blood into the urine

245
Q

erectile function

A

neurovascular phenomenon under hormonal control

246
Q

cavernosal sinusoids during flaccidity

A

penile smooth muscle is contracted

helicine arteries are constricted, sinusoids are empty and emissary veins open

247
Q

cavernosal sinusoids during erection

A

penile smooth muscle relaxes
helicine arteries dilate, filling sinusoidal spaces
they then compress subtunical venous plexus against the tunica albuginea
reduced venous outflow

248
Q

nerve supply of erections

A

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
Q

flaccid penile state and vascular supply

A

sympathetic tone- arterioles constricted

250
Q

erect penile state and vascular supply

A

parasymp stimulation- arteriolar dilation, trabecular smooth muscle relaxation

251
Q

testosterone and erectile function

A

required for normal function

252
Q

primary acquired low testosterone

A

pituitary

hypothalamus

253
Q

secondary acquired low testosterone

A

testes
injury
drugs

254
Q

smooth muscle mediated erection control

A

arteriolar dilation

trabecular relaxation

255
Q

nitrous oxide release and erection control

A

acetylcholine effect on endothelium
parasymp nerve endings
causes intracellular cyclic GMP rise

256
Q

erectile dysfunction

A

persistent inability to attain or maintain an erection sufficient to permit satisfactory sexual performance

257
Q

erectile dysfunction: epidemiology

A

1/50 at age 40

1/4 at 65

258
Q

erectile dysfunction: aetiology

A 
psychogenic
organic:
-vasculogenic
-neurogenic
-hormonal
-anatomical
-drug induced
259
Q

erectile dysfunction: risk factors

A 
lack of exercise
obesity
smoking
hypercholesterolaemia
metabolic syndrome
diabetes x3 risk
260
Q

specific conditions that cause erectile dysfunction

A 
diabetes mellitus
MI, hypertension
liver disease
renal failure
trauma
prostatectomy
261
Q

erectile dysfunction investigations: lab tests

A

fasting glucose
lipid profile
morning testosterone- if low, perform prolactin, FSH, LH

262
Q

erectile dysfunction investigations: special tests

A

nocturnal penile tumescence and rigidity
intracavernosal injection test
arteriography

263
Q

erectile dysfunction treatment

A

identify and treat reversible causes
lifestyle and risk factor modification
patient and partner involvement in education and counselling

264
Q

erectile dysfunction treatment: testosterone replacement

A

primary testicular failure/HPG failure

contraindicated if history of prostate cancer

265
Q

erectile dysfunction: first line treatment

A

phosphodiesterase (PDE5) inhibitors

266
Q

erectile dysfunction: second line treatment

A

intracavernous injections
intraurethral alprostadil
vacuum devices

267
Q

erectile dysfunction and viagra

A

effective 30-60 mins after administration
reduced efficiency after fatty meal
check nitrates

268
Q

erectile dysfunction and viagra: efficacy

A

in diabetes, 66.6% improved

63% successful intercourse

269
Q

erectile dysfunction and viagra: common adverse events

A 
headache
flushing
dyspepsia
nasal congestion
dizziness
visual disturbances
myalgia
270
Q

erectile dysfunction treatment: vacuum constriction devices

A

passive engorgement
efficiency 90%
those with motivated and understanding partner do best

271
Q

erectile dysfunction treatment: intracavernosal injections

A

alprostadil 5-40micrograms
training required
efficacy 70%

272
Q

erectile dysfunction treatment: intracavernosal injections, complications

A

penile pain 11%
priapism 1%
fibrosis 2%

273
Q

erectile dysfunction treatment: prolonged erection

A

aka priapism
>4 hours long
risk of permanent ischaemic damage to corpora
aspirate corpora with 19 gauge needle

274
Q

erectile dysfunction treatment: intraurethral alprostadil

A

MUSE pellet 125-1000 micrograms

efficiency 30-66%

275
Q

erectile dysfunction treatment: intraurethral alprostadil side effects

A

pain 29-41%
dizziness 2-14%
urethral bleeding 5%

276
Q

erectile dysfunction: third line therapy, penile prosthesis

A

malleable prosthesis, semi rigid
inflatable, 2 or 3 piece
satisfaction rates 70-87%

277
Q

diagnosing scrotal masses

A

a lump is cancer until proven otherwise
can you get above it?
is it separate from the testis?
cystic or solid?

278
Q

what is the scrotal mass? Cannot get above

A

inguinoscrotal hernia or proximally extending hydrocele

279
Q

what is the scrotal mass? separate and cystic

A

epididymal cyst

280
Q

what is the scrotal mass? separate and solid

A

epididymitis or varicocele

281
Q

what is the scrotal mass? testicular and cystic

A

hydrocele

282
Q

what is the scrotal mass? testicular and solid

A

tumour or haematocele

283
Q

epididymal cyst

A

smooth, extra-testicular, spherical cyst in the head of the epididymis

284
Q

epididymal cyst: epidemiology

A

usually develop around the age of 40
not uncommon
rare in children

285
Q

epididymal cyst: pathophysiology

A

contain clear and milky (spermatocele) fluid

lie above and behind the testes

286
Q

epididymal cyst: presentation

A
  • 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
Q

epididymal cyst: differential diagnosis

A

spermatocele
hydrocele
varicocele

288
Q

epididymal cyst: investigation and treatment

A

scrotal ultrasound

usually no treatment needed but if painful then surgical excision

289
Q

hydrocele

A

abnormal collection of fluid within tunica vaginalis

290
Q

hydrocele: epidemiology

A

clinically apparent scrotal hydrocele are evident in 6% of term males beyond the newborn period
most paediatric cases are congenital

291
Q

primary hydrocele: aetiology

A

more common and larger
usually in younger men
associated with patent processus vaginalis, typically resolved in first year of life

292
Q

secondary hydrocele: aetiology

A

rarer and presents in older boys and men

secondary to- trauma, infection, TB, testicular torsion

293
Q

hydrocele: pathophysiology

A

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
Q

hydrocele: presentation

A

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
Q

hydrocele: differential diagnosis

A

must differentiate from testicular torsion and strangulated hernia

296
Q

hydrocele: investigations

A

ultrasound

serum alpha-fetoprotein and human chorionic gonadotrophin to help exclude malignant teratomas

297
Q

hydrocele: treatment

A

resolve spontaneously

therapeutic aspiration or surgical removal

298
Q

varicocele

A

abnormal dilation of testicular veins in the pampiniform venomous plexus- caused by venous reflux

299
Q

varicocele: epidemiology

A

left side more commonly effected
unusual in under 10 years
increases after puberty

300
Q

varicocele: aetiology

A

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
Q

varicocele: presentation

A

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
Q

varicocele: differential diagnosis

A

secondary to other pathological processes blocking testicular vein- kidney tumours

303
Q

varicocele: investigations

A

venography

colour doppler ultrasound

304
Q

varicocele: treatment

A

surgery if pain, infertility or atrophy

305
Q

testicular torsion

A

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
Q

testicular torsion: epidemiology

A

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
Q

testicular torsion: aetiology

A

underlying congenital malformation- testis not fixed to scrotum, allowing free movement
trauma

308
Q

testicular torsion: risk factors

A

genetic factors

309
Q

testicular torsion: presentation

A
  • 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
Q

testicular torsion: differential diagnosis

A 
epididymo-orchitis
tumour
trauma
acute hydrocele
idiopathic scrotal oedema
311
Q

testicular torsion: investigations

A

doppler ultrasound
urinalysis- excludes infection
do not delay surgical exploration

312
Q

testicular torsion: treatment

A

surgery- expose and untwist testis (6 hour window to save testis)
orchidectomy and bilateral fixation

313
Q

renal cystic disease

A

solitary or multiple renal cysts are common, especially in advancing age
often asymptomatic
occasionally cause pain or haematuria if large

314
Q

types of renal cysts

A 
simple cysts
hydronephrosis
medullary sponge cysts
acquired cystic disease
polycystic- when a lot of them it can be bad
315
Q

simple renal cysts

A

most common form

benign

316
Q

hydronephrosis

A

when ureter is blocked and kidney dilates and gets bigger

317
Q

medullary sponge cyst

A

dilation of collecting ducts

318
Q

inherited renal cysts

A

caused by mutation

dominant or recessive

319
Q

development of congenital renal cysts

A

mutation leads to predisposition for cyst formation
increased abnormal cell hyperproliferation -> loss of planar polarity -> cyst initiation -> fluid secretion by epithelial cells -> cyst

320
Q

acquired renal cysts

A 
develop over time
no mutation
bilateral or unilateral
isolated to kidneys
associated with CKD
321
Q

causes of renal cysts

A

simple- develop over time
acquired- CKD
genetic causes
drugs such as lithium

322
Q

autosomal dominant polycystic kidney disease

A

multiple cysts develop gradually and progressively, throughout the kidney- eventually resulting in renal enlargement and kidney tissue destruction

323
Q

autosomal dominant polycystic kidney disease: epidemiology

A

most common inherited kidney disease
high penetrance
presents in adulthood (20-30 y/o)
more common in males

324
Q

autosomal dominant polycystic kidney disease: aetiology

A

mutations on PKD1 gene on chromosome 16 (85%)

mutations in PKD2 gene on chromosome 4 (15%)

325
Q

autosomal dominant polycystic kidney disease: risk factors

A

family history or ADPKD, ESFR or hypertension

326
Q

autosomal dominant polycystic kidney disease: pathophysiology

A

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
Q

autosomal dominant polycystic kidney disease: presentation

A 
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
Q

autosomal dominant polycystic kidney disease: extra-renal presentations

A 
subarachnoid haemorrhage associated with berry aneurysm
polycystic liver disease
pancreatitis
male infertility
ovarian cysts
diverticular disease
329
Q

autosomal dominant polycystic kidney disease: differentials

A

acquired and simple cysts of the kidneys
autosomal recessive PKD
medullary sponge kidney
tuberous sclerosis

330
Q

autosomal dominant polycystic kidney disease: investigations

A 
personal history
family history 
BP may be raised
genetic testing for PKD1 and PKD2
ultrasound
331
Q

autosomal dominant polycystic kidney disease: ultrasound

A

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
Q

autosomal dominant polycystic kidney disease: treatment

A

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
Q

autosomal recessive polycystic kidney disease: epidemiology

A

rarer than ADPKD

disease of infancy

334
Q

autosomal recessive polycystic kidney disease: aetiology

A

PKHD1 mutation on long arm of chromosome 6

335
Q

autosomal recessive polycystic kidney disease: risk factors

A

family history

336
Q

autosomal recessive polycystic kidney disease: presentation

A

variable
multiple renal cysts and congenital hepatic fibrosis
enlarged polycystic kidneys
30% develop kidney failure

337
Q

autosomal recessive polycystic kidney disease: differentials

A

ADKPD
multicystic dysplasia
hydronephrosis
renal vein thrombosis

338
Q

autosomal recessive polycystic kidney disease: diagnosis

A

diagnosed antenatally or neonatally
ultrasound
MRI or CT to monitor liver disease
genetic testing

339
Q

autosomal recessive polycystic kidney disease: treatment

A 
no current treatment
genetic counselling
laparoscopic removal of cysts to help pain
BP control
treat stones
renal replacement therapy
340
Q

renal stones

A

consist of crystal aggregates, they form in the collecting ducts and may be deposited anywhere from the renal pelvis to the urethra

341
Q

renal stones: epidemiology

A 
10-15% lifetime risk
peak age 20-40 y/o
more common in males
unusual in children
50% recurrence risk
342
Q

renal stones: risk factors and aetiology

A 
chemical composition of urine
anatomical abnormalities
dehydration
infection
hypercalcaemia
hyperoxaluria
hypercalciuria
primary renal disease
diuretics
gout
343
Q

renal stones: pathophysiology

A

stones form because solute conc. exceed saturation
calcium oxalate= 60-65%
calcium phosphate= 10%

344
Q

calcium renal stones: hypercalciuria causes

A

hyperparathyroidism
excessive dietary intake of calcium
idiopathic hypercalciuria- increased gut absorption

345
Q

calcium renal stones: hyperoxaluria causes

A

high dietary intake of oxalate rich food- spinach, rhubarb and tea
low dietary calcium
increased intestinal resorption due to GI disease

346
Q

uric acid renal stones: causes

A

associated with hyperuricaemia with/without gout
dehydration
patients with ileostomies are at particular risk from dehydration and bicarb loss

347
Q

infection induced renal stones: causes

A

mixed infective stones are composed of magnesium ammonium phosphate as well as calcium

348
Q

cystine renal stones: causes

A

cystinuria- autosomal recessive condition affective cysteine in epithelial cells of renal tubules

349
Q

renal stones: presentation

A 
most asymptomatic
loin pain
dysuria
haematuria
Renal colic
350
Q

renal stones: RENAL COLIC

A

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
Q

renal stones: history taking SOCRATES

A 
Site
Onset
Character
Radiation
Associated features
Timing
Exacerbating/relieving factors
Severity
352
Q

renal stones: differential diagnosis

A

vascular accident- AAA
bowel pathology
ectopic pregnancy/ovarian cyst
testicular torsion

353
Q

renal stones: urine

A

dipstick- positive for blood, looks for RBCs, protein and glucose
mid stream specimen- microbiology culture

354
Q

renal stones: bloods

A

serum urea, electrolyte, creatinine and calcium

FBC

355
Q

renal stones: KUB Xray

A

first line investigation

80% sensitive

356
Q

renal stones: non-contrast CT- KUB

A

gold standard
rapid
99% sensitive
no contrast so no renal damage/allergy

357
Q

renal stones: ultrasound

A

shows kidney stones and renal pelvis dilation

sensitive for hydronephrosis

358
Q

renal stones: antibiotics

A

IV cefuroxime or IV gentamicin

prevent pyonephorisis- can lose renal function in 24 hours

359
Q

renal stones: treatment

A

antiemetics
analgesia
observe for sepsis
90% stones under 5mm in lower ureter pass

360
Q

renal stones: medical expulsive therapy

A

stones over 5mm with pain

oral nifedipine or alpha blocker (tamsulosin) promote expulsion

361
Q

renal stones: if still not passing after previous treatment…

A

extracorporeal shockwave lithotripsy- ultrasound fragments stones
keyhole surgery to remove stones that are large

362
Q

renal stones: prevention of recurrence

A 
over hydration
normal-low calcium intake
low salt intake
normal dairy intake
reduce BMI
reduce animal proteins
active lifestyle
363
Q

uric acid renal stones

A

can be caused by long term allopurinol use
only form in acidic urine
deacidification of urine with oral sodium bicarbonate

364
Q

cysteine renal stones: prevention of recurrence

A

over hydration
urine alkalisation
cysteine binders- captopril

365
Q

chlamydia trachomatis

A

gram negative
most common STI
more common in women, 15-25 y/o

366
Q

neisseria gonorrhoea

A

gram negative diplococcus

more common in men

367
Q

CT and GC sites of occurrence in adults

A 
urethra
endocervical canal
rectum
pharynx
conjunctiva
368
Q

CT and GC sites of occurrence in neonates

A

conjunctiva

atypical pneumonia

369
Q

CT and GC in males

A

primary site is urethra

dysuria and urethral discharge

370
Q

incubation of gonorrhoea in males

A

2-5 days

371
Q

incubation of chlamydia in males

A

7-21 days

372
Q

asymptomatic gonorrhoea in males %

A

10%

373
Q

asymptomatic chlamydia in males %

A

at least 50%

374
Q

transmission of gonorrhoea, female to male %

A

60-80%

375
Q

transmission of chlamydia, female to male %

A

70%

376
Q

complications of chlamydia in males

A

epididymo-orchitis

reactive arthritis

377
Q

CT and GC in females

A

primary site of infection is cervix

non-specific symptoms of dysuria, menstrual irregularity and discharge

378
Q

female asymptomatic chlamydia %

A

> 70%

379
Q

female asymptomatic gonorrhoea %

A

50%

380
Q

female gonorrhoea incubation

A

up to 10 days

381
Q

female chlamydia incubation

A

ill defined

382
Q

gonorrhoea transmission male to female %

A

50-90%

383
Q

chlamydia transmission male to female %

A

70%

384
Q

CT + GC female complications: pelvic inflammatory disease

A
  • infection spreads up fallopian tube, leading to inflammation and scarring
  • tubular factor infertility
  • ectopic pregnancy
  • chronic pelvic pain
385
Q

CT + GC female complications: neonatal transmission

A

ophthalmia neonatorum- conjunctivitis

atypical pneumonia

386
Q

chlamydia diagnosis

A

often diagnosed in established relationships since there is long symptomatic carriage
Nucleic Acid Amplification Tests

387
Q

chlamydia diagnosis: samples

A

males- first void urine

females- self collected vaginal swabs or endocervical swabs

388
Q

gonorrhoea diagnosis

A 
associated with recent partner change
culture on selective medium to confirm
NAAT
antibiotic sensitivity testing
near patient test
389
Q

gonorrhoea diagnosis: near patient test

A

microscopy of gram stained smears
male= sample from urethra
female=sample from endocervix

390
Q

chlamydia treatment

A

partner management
test for other STIs
oral azithromycin stat, one dose
or oral doxycycline for 7 days- more effective

391
Q

gonorrhoea treatment

A

partner notification
test for other STIs
continuous surveillance of antibiotic sensitivity
single dose treatment is preferred IM ceftriaxone with azithromycin stat

392
Q

syphilis

A

treponema pallidum subspecies pallidum
early infection- w/i 2 years (primary, secondary and early latent)
late- >2 years (late latent, CNS, CVS , gummatous)

393
Q

primary syphilis

A

primary chancre- 95% genital skin, nipples, mouth
incubation= 9-90 days
dusky macule=papule, indurated clean based non-tender ulcer

394
Q

secondary syphilis

A

onset 6-8 weeks after infection
70% present with skin rash
30% mucous membrane lesions
50-60% lymphadenopathy

395
Q

transmission of early syphilis

A

40-60% of contactable partners of index cases are infected

396
Q

vertical transmission of syphilis

A

primary and secondary >90%
50% foetal loss or stillbirth
50% congenital syphilis

397
Q

prognosis for untreated syphilis

A

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
Q

syphilis diagnosis

A

early moist lesions- can identify motile spirochetes on wet mount using dark ground microscopy
rash
ulcer

399
Q

syphilis diagnosis: ulcer

A

any genital ulcer is syphilis until proved otherwise

serology usually positive if ulcer present for 2+ weeks

400
Q

serological tests of syphilis

A
  • screening EIA

- confirmatory tests for samples which screen positive (Treponema Pallidum Particle Agglutination test)

401
Q

syphilis treatment

A

penicillin by injection

partner notification

402
Q

Primary prevention of STIs

A

reducing risk of acquiring
STI campaigns
vaccination- Hep B/ HPV

403
Q

Anti-retroviral primary prevention of STIs

A

PEP

PrEP

404
Q

Secondary prevention of STIs

A

diagnosing cases
easy access to STI tests and treatment
targeted screening

405
Q

tertiary prevention of STIs

A

reducing morbidity/mortality
anti-retrovirals for HIV
prophylactic antibiotics for PCP

406
Q

partner notification

A

aims to control infection by identifying key individuals and sexual networks
warn unsuspecting and attempt to break the chain of infection

407
Q

partner notification: why trace them?

A

breaks chain of transmission
prevent re-infection of index patient
prevent complications of untreated infections

408
Q

partner notification: how are they traced?

A

patient referral

provider referral via text or letter

409
Q

Urinary tract infection

A

inflammatory response of the urothelium to bacterial invasion
associated with bacteriuria and pyuria
>105 organisms/ml of fresh mid-stream urine

410
Q

classification of UTIs: location

A

lower vs upper

411
Q

classification of UTIs: clinical risk

A

uncomplicated vs complicated

412
Q

classification of UTIs: timing

A

single/isolated vs unresolved

acute vs chronic

413
Q

bacterial features of UTI

A

uropathogenic strains of E.coli (UPEC) causes 80% of uncomplicated UTIs

414
Q

bacterial features of UTI: UPEC attachment molecules

A

fimbriae/pilli
afimbrial attachments
acid polysaccharide coat that resits phagocytosis

415
Q

bacterial features of UTI: bacteria adhere to…

A

urothelium
vaginal epithelium
vaginal mucus

416
Q

bacterial features of UTI: avoidance of host defences

A

capsule resist phagocytosis

e.coli release cytokine that are directly toxic

417
Q

bacterial features of UTI: proteus spp. secrete urease

A

increases risk of stone formation

418
Q

UTI: host defence mechanisms

A

antegrade slushing of urine
tamm-horsfall protein- antimicrobial properties
low urine pH and high osmolarity
urinary IgA

419
Q

upper UTI

A

pyelonephritis

420
Q

lower UTI

A

cystitis (bladder)
prostatitis
epididymo-orchitis
urethritis

421
Q

complicated UTI

A

infection in those with abnormal urinary tract
treatment failure is more likely
complications more likely

422
Q

uncomplicated UTI

A

UTI in healthy, non-pregnant women with normal urinary tract

423
Q

UTI: epidemiology

A

more common in women

affects 1/3 of women in lifetime

424
Q

UTI: risk factors

A 
female
sexual intercourse
pregnancy
menopause
low host defence
catheter
obstruction
425
Q

UTI: pathogenesis

A

infection via ascending transurethral route

women = more susceptible due to shorter urethra and proximity to anus

426
Q

pyelonephritis

A

infection of renal parenchyma and soft tissues of renal pelvis

427
Q

pyelonephritis: aetiology, KEEPS

A 
Klebsiella spp.
E.coli = majority
Enterococcus spp.
Proteus spp.
Staphylococcus spp. coagulase neg
428
Q

pyelonephritis: epidemiology

A

predominantly in females <35 y/o
associated with significant sepsis and systemic upset
main cause= UPEC

429
Q

pyelonephritis: risk factors

A 
structural renal abnormalities
calculi
catheterisation
pregnancy
diabetes
immunocompromised
430
Q

pyelonephritis: pathophysiology

A

mainly due to E.coli from own patient’s bowel flora

ascend transurethral route

431
Q

pyelonephritis: presentation

A 
triad: loin pain, fever, pyuria
headache
rigors
bacteriuria
malaise, nausea, vomiting
432
Q

pyelonephritis: differentials

A

diverticulitis
AAA
kidney stones
cystitis/prostatitis

433
Q

pyelonephritis: treatment

A

rest
analgesia
antibiotics- oral ciprofloxacillin
surgery to drain abscesses or relieve calculi

434
Q

pyelonephritis: urine dipstick

A

detects nitrites (bacteria breakdown nitrates-> nitrites)
detects leukocyte elastase
foul smelling urine

435
Q

pyelonephritis: midstream urine microscopy

A

culture and sensitivity

gold standard

436
Q

pyelonephritis: bloods

A

FBC- elevated white cell count

CRP and ESR may be raised

437
Q

pyelonephritis: urgent ultrasound

A

detect calculi, obstruction, abnormal anatomy and incomplete bladder emptying

438
Q

cystitis

A

urinary infection of bladder

439
Q

cystitis: epidemiology

A

much more common in women
can occur in children
most common cause is e.coli

440
Q

cystitis: risk factors

A

urinary obstruction resulting in urinary stasis
previous damage to bladder epithelium
bladder stones

441
Q

cystitis: presentation

A 
dysuria
frequency
urgency
suprapubic pain
haematuria
offensive smelling/cloudy urine
442
Q

cystitis: investigation

A

gold standard= microscopy and sensitivity of sterile mid-stream urine

443
Q

cystitis: first line antibiotic treatment

A

trimethoprim or cefalexin

444
Q

cystitis: second line antibiotic treatment

A

ciprofloxacin or co-amoxiclav

445
Q

prostatitis

A

infection and inflammation of prostate gland

446
Q

prostatitis: epidemiology

A

common in men of all ages

most common UTI in men <50

447
Q

prostatitis: acute aetiology

A

streptococcus faecalis
e.coli
chlamydia

448
Q

prostatitis: chronic aetiology

A

bacterial- streptococcus, faecalis, e.coli, chlamydia

non-bacterial- elevated prostatic pressure, pelvic floor myalgia

449
Q

prostatitis: risk factors

A

STI
UTI
indwelling catheter
increasing age

450
Q

prostatitis: acute presentation

A

systemically unwell
fever, rigor, malaise
pain on ejaculation
LUTS

451
Q

prostatitis: chronic presentation

A

same as acute for >3 months

452
Q

prostatitis: differentials

A

cystitis
BPH
calculi
bladder neoplasia

453
Q

prostatitis: diagnosis

A

tender and/or hard prostate on DRE
urine dipstick
blood cultures
STI screening

454
Q

prostatitis: acute treatment

A

IV gentamicin + IV co-amoxiclav
or IV tazocin
abscess drainage if necessary

455
Q

prostatitis: chronic treatment

A

4-6 week course of quinolone e.g. ciprofloxacin

maybe alpha blocker- tamsulosin

456
Q

prostatitis: complication

A

urinary retention

457
Q

urethritis

A

urethral inflammation due to infectious or non-infectious causes
primarily sexually acquired

458
Q

urethritis: epidemiology

A

most commonly diagnosed condition and treated in men @ GUM clinics

459
Q

urethritis: gonococcal cause

A

neisseria gonorrhoea

460
Q

urethritis: non-gonococcal causes

A

chlamydia trachomatis= most common

mycoplasma genitalium

461
Q

urethritis: non infective causes

A

trauma
urethral stricture
irritation
calculi

462
Q

urethritis: risk factors

A

sexually active

unprotected sex

463
Q

urethritis: presentation

A 
90-95% asymptomatic with gonorrhoea
dysuria
urethral pain
penile discomfort
skin lesions
464
Q

urethritis: differentials

A 
candida balantis
epididymitis
cystitis 
prostatitis
malignancy
465
Q

urethritis: investigations

A

NAAT
microscopy of gram stained smears of genital secretion
blood cultures
urine dipstick to exclude UTI

466
Q

urethritis: NAAT

A

nucleic acid amplification test
female- self collected vaginal swab
male- first void volume

467
Q

urethritis: chlamydia treatment

A

oral azithromycin stat
test for other STIs
erythromycin for 14 days if pregnant
partner notification

468
Q

urethritis: gonorrhoea treatment

A

IM ceftriaxone with azithromycin

partner notification

469
Q

epididymo-orchitis

A

acute is a clinical syndrome of pain, swelling and inflammation of epididymis that can extend to testis

470
Q

epididymo-orchitis: epidemiology

A

most common in males 15-30 and >60

471
Q

epididymo-orchitis: aetiology

A

mumps
trauma
predominantly catheter related in elderly

472
Q

epididymo-orchitis: under 35 aetiology

A

CT and GN

473
Q

epididymo-orchitis: over 35 aetiology

A

UTI, KEEPS

474
Q

epididymo-orchitis: risk factors

A

previous infection
indwelling catheter
structural/functional abnormality of urinary tract
anal intercourse

475
Q

epididymo-orchitis: presentation

A

subacute onset of unilateral scrotal pain and swelling

may be urethritis or discharge in STI

476
Q

epididymo-orchitis: differential diagnosis

A

testicular torsion- must be ruled out first as emergency

hydrocele, trauma, abscess

477
Q

epididymo-orchitis: investigations

A

NAAT
dipstick
ultrasound
STI screening

478
Q

epididymo-orchitis: chlamydia treatment

A

oral doxycycline 7 days

479
Q

epididymo-orchitis: gonorrhoea treatment

A

IM ceftriaxone and oral azithromycin

480
Q

epididymo-orchitis: UTI treatment

A

oral ciprofloxacin

481
Q

epididymo-orchitis: general treatment

A

antibiotics should be for 2-4 weeks
NSAID analgesia
scrotal support- underwear
abstain from sex

phase 2a clinical (8 decks)

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