Genitourinary Flashcards
What is nephrolithiasis?
- kidney stones
- slightly more common in men → testosterone = increased oxalate
What are kidney stones made of?
- calcium oxalate → radio-opaque
- uric acid → radio-lucent
- struvite → radio-opaque
- cystine
Risk factors for nephrolithiasis
- chronic dehydration
- obesity
- high protein/salt diet
- recurrent UTIs
- hyperparathyroidism → hypercalciuria
- congenital abnormalities
Presentation of nephrolithiasis
renal colic
- severe unilateral abdominal pain
- starts in loin, radiates to ipsilateral groin/testicle/labia
- sudden onset early in morning
- restlessness
- N&V
- haematuria
- dysuria
Investigations for nephrolithiasis
- dipstick → haematuria, leukocutes, nitrites
- bloods → FBC, CRP, U&E
GOLD STANDARD = non-contrast CT KUB
- US in pregnancy
- radio-opaque only visible on US
Management of nephrolithiasis
- symptomatic relief → hydration, NSAIDs, opioids
- small pass spontaneously
if too big:
- EWSL → break stone into smaller fragments using shockwaves
- uteroscopy
- PCNL → percutaneous access, use nephroscope to remove stone
lifestyle advice
- decrease Na and protein
- increase citrus fruit
- adequate fluid intake
When should treatment be provided immediately for nephrolithiasis?
- intolerable pain/vomiting
- signs of obstruction/infection/AKI
What are the functions of the kidney?
- water/hormone homeostasis
- waste/toxin removal
- RBC production
- activated vitD
Risk factors of CKD and AKI
- emergency surgery → risk of sepsis/hypovolaemia
- CVD risk
- diabetes
- HF
- age >65
- liver disease
- use of nephrotoxic drugs
Which drugs are nephrotoxic?
- NSAIDs
- aminoglycides
- ACEi
- ARBs
- loop diuretics
- metformin
- digoxin
- lithium
What is AKI?
- sudden decline in renal function
- determined by increased serum creatinine +/- decreased urine output
Causes of pre-renal AKI
- hypovolaemia secondary to D&V
- renal artery stenosis
Causes of intrinsic AKI
- glomerulonephritis
- acute tubular necrosis ATN
- acute interstitial nephritis AIN
- rhabdomyolysis
- tumour lysis syndrome
Causes of post-renal AKI
- kidney stone in ureter or bladder
- BPH
- external compression of ureter
Presentation of pre-renal AKI
- normal Na+
- raised urea and creatinine
- responds well to fluid therapy
Presentation of intrinsic AKI
- T1DM
- HTN
- low urine osmolality
- high urine Na+
- high blood K+
Presentation of post-renal AKI
- acute colicky pain radiating from loin to groin
- microscopic haematuria
Diagnosis of AKI
- rise in creatinine to 1.5-1.9 times baseline
- > 50% rise in creatinine over 7 days
- fall in urine output to less than 0.5 for >6hrs in adults (8hr in kids)
Management of AKI
- fluid balance
- remove nephrotoxic drugs
- treat hyperkalaemia → risk for arrythmia
- treat underlying cause
- RRT if no response to medical treatment
Complications of AKI
- end stage renal failure
- metabolic acidosis
- uraemia
- CKD
What is CKD
- abnormal kidney structure/function
- present for >3 months with implications for health
Causes of CKD
- diabetes
- HTN
- glomerulonephritis
- PDK
- VHL
- persistent pyelonephritis
- obstruction → stones, BPH, tumours
- nephrotoxic drugs
Presentation of CKD
- often asymptomatic until ESRF
- fluid retention → oedema, raised JVP
- oliguria
- uraemia → pruritus, uraemic frost, yellow-grey complexion, reduced appetite
- cardiac arrythymias
- fatigue
- pallor
- bone pain
Diagnosis of CKD
- eGFR <60
- eGFR <90, signs of renal damage
- albuminuria >30, albumin:creatinine >3
Management of CKD
- treat DM, HTN, glomerulonephritis
- reduce risk of CVD → atorvastatin
- manage complications
Managing complications of CKD
- mineral bone disease → low vitD
- HTN
- proteinuria
- anaemia → ESA
- RRT
When should renal replacement therapy be considered?
- ESRF
- acidosis not responsive to bicarb
- persistent electrolyte disturbances
- persistent oedema
- severe symptoms of uraemia
What are the types of RRT?
- haemodialysis
- peritoneal dialysis
- renal transplant
Physiology of prostate
- produces testosterone and dihydrotestosterone
- production of PSA → liquefies semen
What is BPH?
- hyperplasia of inner transitional zone of prostate gland
- partially blocks urethra
- normal part of ageing for men
Presentation of BPH
LUTS
storage
- frequency
- urgency
- nocturia
- urgency incontinence
voiding
- poor/intermittent stream
- post-micturition dribbling
- straining
- incomplete emptying
- hesitancy
Investigations for BPH
- DRE → smooth but enlarged prostate
- PSA → not very accurate
- bladder diaries
Management of BPH
- lifestyle → reduce caffeine/alcohol, relax when voiding
- alpha blockers eg tamsulosin
- 5-alpha reductase inhibitors eg finasteride
- consider surgery if no response to drugs
GOLD STANDARD = TURP
- required if acute urinary retention, gross haematuria,
Features of prostate cancer
- most common male malignancy
- most slow growing but can be aggressive/malignant
Risk factors for prostate cancer
- Afro-Caribbean
- family history/genetics
- increasing age
- anabolic steroids
Presentation of prostate cancer
- LUTS
- weight loss
- fatigue
- night sweats
- bone pain
Whee does prostate cancer metastasise to?
- bone → sclerotic bony lesions
- brain
- liver
- lung
Investigations for prostate cancer
- community → DRE, PSA
- DIAGNOSTIC = transrectal USS and biopsy
- gleason grading system
Management of prostate cancer
local
- prostatectomy <70
- active surveillance >70, low risk
- radiotherapy
metastatic
- chemo
- radiotherapy
- bilateral orchidectomy
- goserelin
- palliative care to relieve symptoms
What is urethritis?
- uretheral inflammation due to infectious or non-infectious cause
- non-gonococcal uretheritis more common than gonococcal
Causes of urethritis
- N.gonorrhoea
- chlamydia
- trauma
- urethral stricture
- urinary calculi
Presentation of urethritis
- skin lesion
- dysuria +/- discharge (blood/pus)
- urethral pain
- penile discomfort/pruritus
Investigations for urethritis
- STI testing
- M&C urethral discharge
- bood cultures
- urine dipstick
- urethral smear
Management of urethritis
- management of underlying cause → Abs, partner notification
What condition is important to think about with urethritis?
reactive arthritis
- conjunctivitis
- urethritis
- arthritis
can’t see, can’t pee, can’t climb a tree
What is cystitis?
- infection of urinary bladder
- most common in sexually active young women
Risk factors of cystitis
- history of UTI
- diabetes
- pregnancy
- catheterisation
Microorganisms that cause cystitis
KEEPS
- klebsiella
- E.coli → most common
- enterococci
- proteus species
- staph aureus
Presentation of cystitis
- dysuria
- frequency
- urgency
- suprapubic pain
- haematuria and polyuria
- incontinence
- confusion in elderly
- cloudy smelly urine
Investigations for cystitis
- urine dipstick → high leukocytes/nitrates, blood
GOLD STANDARD = mid-stream MC&S
Management of cystitis
- trimethoprim/nitrofurantoin → 3 days (f), 7 days (m)
- in pregnancy → amoxicillin, cefalexin
What is variocele?
- abnormal dilation of testicular veins in pampiniform venous plexus
- left side more commonly affected
Presentation of variocele
- feels like a bag of worms
- dragging/soreness/heaviness of scrotum
Management of variocele
- conservative
- surgical repair if pain infertility, testicular atrophy
Diagnosis of variocele
US and Doppler
What is testicular torsion?
- medical emergency
- twisting of spermatic cord with rotation of testicle
Presentation of testicular torsion
- acute severe pain
- unilateral, swollen, tender
- retracted upwards
Diagnosis of testicular torsion
examination
- firm swollen testicle
- rotation → epididymis is not in normal posterior position
- Prehn’s -ve
can do US but not essential → whirlpool sign
Management of testicular torsion
de-torsion → orchiopexy
What is nephrotic syndrome?
issue with filtration barrier
What is the characterising triad in nephrotic syndrome?
- proteinuria >3
- hypoalbuminaemia → loss of albumin in urine
- oedema → loss of oncotic pressure
Presentation of nephrotic syndrome
- frothy urine
- infection
- xanthelasma
- xanthomata
- athersclerosis
- fatigue
- dyspnoea
- leukonychia
Pathophysiology of nephrotic syndrome
- inflammation
- damage to podocytes → protein leakage
- increased liver activity → increases albumin and then cholesterol, coag factors
- reduced oncotic pressure
Causes of nephrotic syndrome
occurs due to renal disease disrupting kidney function
- minimal change disease
- focal segmental glomerulosclerosis
- membranous nephropathy
Secondary causes of nephrotic syndrome
- diabetic nephropathy
- SLE
- amyloidosis
- hepB,C
- HIV
Investigations of nephrotic syndrome
- urinalysis
- urine protein:creatinine → degree of proteinuria
- blood tests → renal function, elevated lipids
GOLD STANDARD = needle biopsy and microscopy
- looks for changes in glomerulus
- gives cause
Management of nephrotic syndrome
- fluid/salt resuscitation
- treat cause → 12 weeks prednisolone
- treat complications
- protein loss → ACEi/ARBs
Treatment of complications in nephrotic syndrome
- oedema → loop diuretics
- hyperlipidaemia → statins
- VTE → heparin
- infection → Abs
Minimal change disease
- mainly kids
- unclear cause → immune mediated
- normal appearance in microscopy but abnormal function
- diagnosis = biopsy → EM = loss of podocytes
Membranous glomerulonephritis
more common in adults
causes
- antibodies again PLA2R
- SLE
- NSAIDs
- HBV/HCV
diagnosis = renal biopsy EM → thickened glomerular basement membrane
Focal segmental glomerulosclerosis
adults
causes
- idiopathic
- HIV
- sickle cell
- heroin
diagnosis = presence of scarring on glomeruli
Risk factors of testicular cancer
- 20-45
- male
- caucasian
- cryptorchidism
- previous testicular cancer
- HIV
- family history
Presentation of testicular cancer
- palpable lump within the testis
- non-transilluminable
- haematospermia
- often found on self-examination
Investigations for testicular cancer
- urgent US of testes
- chest xay for pulmonary mets
- tumour markers → not always raised
Management of testicular cancer
- urgen radical inguinal orchidectomy +/- testicular prosthesis
- semen cryopreservation
- treat metastatic disease → chemo, radiotherapy, lymph node dissection
Features of kidney cancer
- most common type is RCC → malignant cancer of PCT epithelium
- often asymptomatic and discovered incidentally
- 25% have metastasis at presentation
Risk factors of kidney cancer
- haemodialysis
- smoking
- HTN
Presentation of kidney cancer
classic triad
- haematuria
- flank pain
- palpable abdominal mass
- classic cancer symptoms
- may present with varicocele
Investigations for kidney cancer
- US
CT chest/abdomen/pelvis
DIAGNOSTIC = renal biopsy
Management of kidney cancer
- full/partial nephrectomy
- mayo prognostic risk score → predict survival, guide treatment
Complications of kidney cancer
- polycythaemia
- HTN
- hypercalcaemia
- Cushings
Features of bladder cancer
- most common GU tract malignancy
- most common type = transitional cell carcinoma of bladder
Risk factors of bladder cancer
- 50-80
- male
- caucasian
- smoking
- pelvic radiation
- bladder stone due to chronic inflammation
- exposure to dye/rubber/leather/textiles/paint → hairdresser, painter
Presentation of bladder cancer
- painless haematuria → visible or non-visible
- urgency
- suprapubic/pelvis mass/pain
- recurrent UTI without bacteriuria
- systemic symptoms
Investigations for bladder cancer
haematuria clinic
- urinalysis → sterile pyuria
- CT urogram → staging
- bloods
- DIAGNOSTIC = flexible cystoscopy
Treatment for bladder cancer
- chemo
- radiotherapy
- symptomatic relief
- transurethral resection of bladder tumour
- cystodiathermy
- cystectomy
What is pyelonephritis?
- infection of kidneys/upper ureter
- most commonly acquired by ascending transurethral spread
- can be via blood or lympatics
- majority caused by uropathic e.coli
Presentation of pyelonephritis
- triad of loin pain, fever, pyuria
- costovertebral joint pain
- severe headache
- N&V
- septic shock if advanced
Investigations of pyelonephritis
- urine dipstick → WBC, microscopic haematuria
- bloods → inflammatory markers
- urgent US → stones, obstruction
GOLD STANDARD = mid-stream MC&S → diagnosis of causative agent
Treatment of pyelonephritis
Abs
- cefalexin 7-10 days
- trimethoprim/amoxicillin if sensitive
analgesia → PCM
What is prostatitis?
- inflammation and swelling of prostate gland
- most common cause = e.coli
Presentation of prostatitis
- very tender prostate → seen on DRE
- systemic symptoms → fever, chills, malaise
- voiding symptoms
Investigations for prostatitis
- U&C → blood and WBCs, bacteria
- bloods cultures if patients febrile
Management of prostatitis
Abs
- ciprofloxacin/levofloxacin 14 days
Which Abs should you avoid in pregnancy?
- trimethoprim = teratogenic
- nitrofurantoin → avoid at full term
Features of UTIs
- presence of microorganisms in the urinary tract
- name depends on location
- can occur from untreated urolithiasis
What are the 5 most common pathogens causing UTIs
KEEPS
- klebsiella
- e.coli → most common
- enterococci
- proteus
- staph coagulase -ve
Presentation of UTIs
voiding symptoms = FUND
- frequency
- urgency
- nocturia
- dysuria
What is an epididymal cyst?
- smooth extra testicular spherical cyst at the epididymis
- contains clear and milky fluid
- may be multiple and bilateral
- painful if large
- most common cause of scrotal swelling
Investigation for epididymal cyst
- lump found in posterior aspect of testicle
- can palpate cyst and testis separately
- US
no treatment needed → dissolve in 10 days
Epididymitis
- acute pain, unilateral
- could be due to previous infection
- Prehn’s sign +ve
- treatment = IM ceftriaxone (organism unknown) and doxycycline
What is hydrocele?
- abnormal collection of fluid in tunica vaginalis
What are the two types of hydrocele?
- simple = overproduction of fluid
- communicating = peritoneal fluid and scrotum are connected
Presentation of hydrocele
- non tender smooth cystic swelling
- painless unless infected
- transluminates
Treatment of hydrocele
- most resolve spontaneously
- similar to testicular cancer → rule out
What is nephritic syndrome?
syndrome presenting as inflammation within the kidney
Key features of nephritic syndrome
- haematuria → kidney inflammation
- oliguria → decreased GFR
- proteinuria
- HTN → fluid overload
Causes of nephritic syndrome
- SLE
- post strep glomerulonephritis
- small vessel vasculitis
- Goodpasture’s
- IgA nephropathy
Investigations for nephritic syndrome
DIAGNOSTIC = kidney biopsy → cause
- urinalysis → haematuria
- bloods → high ESR, CRP
Management of nephritic syndrome
- treat underlying cause
- ACEi/ARB → reduced proteinuria, preserves renal function
- corticosteroids → reduce inflammation
What is IgA nephropathy
- AKA Berger disease
- deposition of IgA into mesangium of kidney → inflammation and damage
Presentation of IgA nephropathy
- asymptomatic
- microscopic haematuria
Diagnosis of IgA nephropathy
- biopsy
- same management as nephritic syndrome
What is post strep GN?
- nephritic syndrome following infection 3-6 weeks before
- deopsition of atrep antigen in glomeruli → inflammation and damage
Presentation of post strep GN
- haematuria
- acute nephritis
diagnosed by evidence of strep infection
Treatment of post strep GN
- Abs to clear strep
- supportive care
What is Goodpasture’s
- autoantibodies to type4 collagen in glomerular and alveolar membrane
- can cause rapidly progressing glomerulonephritis → renal failure
Presentation of Goodpasture’s
- SOB
- oliguria
Diagnosis of Goodpasture’s
anti-GBM autoantibodies in bloods and biopsy
Management of Goodpasture’s
- plasma exchange
- steroids
- cyclophosphamide → immune suppression
What is PKD
- clusters of cysts develop within kidneys
- autosomal dominant
- PKD1 and PKD2 genes on Cr16
Pathophysiology of PKD
- cysts develop and grow over time in tubular part of nephron
- compression of renal architecture and vasculature
3 progressive impairment
Risk factors of PKD
- family history of PKD/CVS events
- male
- caucasian
Presentation of PKD
- HTN
- abdominal/flank pain
- headaches
- LUTS
- palpable cysts
Investigations for PKD
renal US then biopsy
- <30 → 2 cysts
- 30-59 → 2 cysts in each kidney
- > 60 → 4 cysts in each kidney
Management of PKD
- treat HTN
- infected - Abs, drain
- surgical removal → nephrectomy
- chronic → dialysis/transplant
Complications of PKD
- berry aneurysms → rupture causes sub-arachnoid haemorrhage
- cysts on other organs
- ventricular hypertrophy
What is chlamydia?
- most common bacterial STI
- caused by chlamyrdia trachomatis
Presentation of chlamydia
men
- testicular pain
- voiding synptoms, dysuria
- 50% asymptomatic
women
- vaginal discharge and dysuria
- white/yellow/green discharge
- 70% asymptomatic
Diagnosis of chlamydia
nucleic acid amplification testing
Management of chlamydia
- avoid sex until treatment finished
- contact tracing
- single dose azithromycin
- 7 days doxycycline
What is gonorrhoea?
- caused by Neisseria gonorrhoea
- second most common STI
Presentation of gonorrhoea
- more likely to be asymptomatic
- men → dysuria, frequency , discharge
- women → vaginal discharge, dysuria, pelvic pain
Investigations for gonorrhoea
- NAAT
- microscopy → gram =ve diplococci
- culture → all infected areas with a swab
Treatment of gonorrhoea
- single ceftriaxone IM dose
