Genitourinary Flashcards
What is nephrolithiasis
kidney stones
what are kidney stones made up of
calcium oxalate stones
where are kidney stones deposited
in the collecting duct
where can kidney stones be deposited
anywhere in the renal pelvis to the urethra
what are 90% of the kidney stones in the form of
radio opaque stones
other than radio opaque stones what other types of kidney stones are there
struvite
calcium phosphate
uric acid
cysteine
what are risk factors of nephrolithiasis
chronic dehydration
kidney inherited disease
hyperPTH (hypercacaemia)
UTIs
history of previous renal stones
what is the pathophysiology of nephrolithiasis
there is an excess of solute in the collecting ducts which causes super saturated urine. This favours crystalisation. The stones forms then cause regular outflow obstruction and hydronephrosis
how do you treat hydronephrosis
surgical decompression ASAP
what does obstruction of regular renal outflow cause
dilation and obstruction of the renal pelvis, increasing damage and infection risk
what is the presentation of nephrolithiasis
loin to groin pain that is colicky - peristaltic waves
the patient cant lie still
haematuria
dysuria
can have a fever is a suprarenal infection is present
what is a differential diagnosis for nephrolithiasis
peritonitis - same symptoms except there is rigidity
how do you diagnose nephrolithiasis
1st line = Kidney, ureters, bladder X-RAY (80% specific)
GOLD = CT kidney, ureters, bladder (99% specific) and therefore diagnostic
bloods: FBC, U&E and urine dipstick
how do you treat nephrolithiasis
if symptomatic = hydrate, analgesia (didofenac) IV for severe pain
Abx if UTI present (gentamycin)
Stones normally pass spontaneously if small enough (<5mm)
elective surgical Tx is too big to pass and causing pain
how do you surgically remove a kidney stone
Endoscopic sound wave Lithotripsy
Percutaneous nephrolithotomy (keyhole)
what is acute kidney injury
Abrupt decline in kidney infection (hrs to days) characterised by an increase in serum creatinine and urea and a decreased urine output
what is the classification of acute kidney injury
KDIGO
Serum creatinine increase 26umol/L within 48hrs OR 1.5X baseline in 7 days
Urine output <0.5ml/kg/hr for 6hrs consecutive
how do you stage acute kidney injury
use AKIN
stage 1, 2, 3, and the higher the stage the reduced likelihood of kidney injury
what are the three causes of acute kidney injury
pre-renal
renal
post-renal
what are the renal causes acute kidney injury
nephron and parenchyma damage
- tubular - acute tubular nephrosis
- interstitial cell death - fever, rashes eosinophilia
- glomerular
- toxins (sepsis)
what are pre-renal causes of AKI
Hypoperfusion
total body - decreased cardiac output (shock)
liver failure - hepatorenal syndrome
Renal artery stenosis or blockage
drugs - NSAIDs, ACE-i (decrease GFR)
IV contrast
what are causes of post renal AKI
obstructive uropathy
stones
BPH - common in elderly men
Drugs - anticholinergics, CCBc
Occluded indwelling
what are risk factors for AKI
increased age, comorbidities, hypovolemia of any cause, nephrotoxicity drugs, decreased blood filtration and urine output
What is the pathophysiology of acute kidney injury
there is an accumulation of usually excreted substances
- K+ causing arrhythmias
- Urea causes pruritis, uremic frost, confusion if severe
- fluid causes oedema
- H+ causes acidosis
why does ACEi cause nephrotoxicity
causes constriction of afferent arterioles and therefore decreases perfusion to the glomerulus
what is the presentation of acute kidney injury
as a result of substance accumulation:
uremia causes encephalopathy, pericarditis, skin manifestations
fluid overload causes oedema or hypovolemic shock
H+ causes metabolic acidosis
K+ causes arrhythmias
how does hyperkalaemia present on an ECG
tall tented T waves
P wave flattening
Wide QRS
how do you diagnose AKI
establish the cause pre/utra/post with KDIGO classification - serum creatinine and urine output
- check K+, H+, urea, creatinine, FBC and CRP
- renal biopsy and USS for post renal
how do you treat acute kidney injury
treat the complications (hyperkalaemia, metabolic acidosis, fluid overload)
treat underlying cause
last resort - RRT and haemodialysis
how do you differentiate between a pre-renal, renal or post-renal cause of AKI using the urea: creatinine ratio
Urea: creatinine
>100:1 = prerenal
<40:1 = renal
40-100 = postrenal
what is chronic kidney disease
eGFR is less than 60mL/min/1.73m^2 for over three months (normal = 120)
what are the 5 stages of chronic kidney disease
1) 90+ with renal signs
2) 60-89 with renal signs
3)a 45-59, b 30-44
4) 25-29
5) <15
what are the 4 parameters used to determine chronic kidney disease
creatinine
age
gender
ethnicity
what are risk factors for chronic kidney disease
diabetes mellitus and hypertension
also glomerulonephritis, PKD, nephrotoxic drugs such as NSAIDs
what is the pathophysiology behind CKI
there is a decrease in GFR due to damage. this leads to an increased burden and therefore compensatory RAAS to help increase the GFR. This increases the transglomerular pressure causing shearing and loss of BM selectivity causing proteinurea and haematuria
what are the symptoms of chronic kidney disease
early on asymptomatic
symptoms then start as substances accumulate and there is renal damage
anaemia
osteodystrophy
neuropathy and encephalopathy
CVD
how do you diagnose CKD
FBC - anaemia of chronic disease
U+E
urine dip for proteinurea
USS
GFR function staging 1-5
albumin: creatinine ratio
what is the differences between AKI and CKI
in AKI there is an increase in serum creatinine with decreased urine output and CKI is reduced GFR
AKI is shorter with no anaemia and the ultrasound is often normal
how do you treat CKI
there is no cure so you have to treat the complications
- Anaemia: EPO and Fe
- osteodystrophy: Vitamin D supplements
- CVD: ACEi and statins
- oedema: diuretics
When GFR is in stage 5 what has to happen
dialysis and ultimately renal transplant will be used as a cure
what is benign prostate hyperplasia
non malignant prostate hyperplasia which is normal with aging
what are risk factors for benign prostate hyperplasia
an increase in age
ethnicity - Afro-Caribbean
family history
cigarette smoking
male pattern baldness
castration is protective
what is the pathophysiology of benign prostate hyperplasia
inner transitional zones of the prostate (muscular, gland) proliferates and narrows the urethra
What is the presentation of benign prostate hyperplasia
Storage = frequency, urgency, nocturia, incontinence
Voiding = poor stream, dribbling, incomplete emptying, straining, dysuria
ariuria if the urethra is totally occluded leading to retention issues such as UTI, stones and hydrophores
how do you diagnose benign prostate hyperplasia
DRE- rectal exam - smooth and enlarged
PSA - rule out prostate cancer however this can be quite unreliable
how do you treat benign prostate cancer
lifestyle: reduce caffeine
Drugs: 1st line is alpha blocker (tamsulosin) and 2nd line is 5 alpha reductase inhibitors (finasteride)
last resort is surgery (transurethral resection of prostate)
what is the action of tamsulosin
it relaxes the bladder neck
what is the action of finasteride
it reduces testosterone production and therefore the size of the prostate
what is renal cell carcinoma
it is a proximal convoluted tubule epithelial carcinoma
what are the risk factors for renal cell carcinoma
smoking
haemodialysis
hereditary: Von hippel lindau
what is Von Hippel lindau disease
it is an autonomic dominant loss of a tumour suppressor gene
- can cause bilateral renal and pancreas cysts
- can cause cerebellum cancers
what are are symptoms of renal cell cariconoma
it is often asymptomatic
Triad: flank pain, haematuria, abdominal mass
may have left left sided varicocele
patients may also have anaemia due to low EPO and hypertension as the tumour releases renin
how do you diagnose renal cell carcinoma
1st line - USS (ultrasound)
Gold - CT chest/abdominal/pelvis (more sensitive)
how do you stage renal cell carcinoma
staging - Robinson staging 1-4
what is the treatment for renal cell carcinoma
nephrectomy (full or partial if blocked)
what is a Wilms tumour
it is a renal mesenchymal stem cell tumour seen in children under the age of three (rare)
- nephroblastoma
what type of cancer is bladder cancer
it is a transitional cell carcinoma of the cancer
what are the risk factors of developing bladder cancer
occupational exposure to dyes/paints/rubber
painter, hairdresser, mechanic
smoking
chemotherapy and radiotherapy
age (mean age is about 33)
male
what type of bladder cancer is a patient more likely to have if they have schistosomiasis
squamous cell carcinoma rather than transitional
what are the symptoms of bladder cancer
painless haematuria (micro/macroscopic)
UTI symptoms without bacteriuria
How do you diagnose bladder cancer
flexible cystoscopy (gold standard)
urinalysis
biopsy
CTT urogram - allows staging
how do you treat bladder cancer
conservative - support
medical - chemo or radiotherapy
surgery - TURBT - transurethral resection of bladder tumour or cystectomy as a last resort
what type of cancer is bladder cancer
it is a cancer of the outer zone of the peripheral prostate
- adenocarcinoma
- shows neoplastic malignant proliferation
what are risk factors for developing prostate cancer
Genetic - BRCA2 and HOXB13
increase in age
Afro-Caribbean ethnicity
what are the symptoms of prostate cancer
lower urinary tract symptoms
systemic cancer symptoms - weight loss, fatigue, pain, bone pain
where does prostate cancer typically metastisise to
bone, liver, lung, brain
how do you diagnose prostate cancer
DRE - prostate exam
PSA test
transrectal USS and biopsy is diagnostic
use the gleason score for grading where the higher the score the worse the prognosis
how do you treat prostate cancer
local - prostatectomy
metastatic - hormone therapy to reduce testosterone, bilateral orchidectomy and GnRH receptor agonis leading to suppression of HPG axis (goserelin)
what is a side effect of Goserelin
erectile dysfunction and libido loss
what is the most hormone sensitive cancer
prostate cancer
what are the two types of testicular cancer
- Germ cell (90%) - seminoma teratoma
- Non germ cell - sertoli, leydig sarcoma
what are the risk factors for testicular cancer
cryptorchidism = undescended testis
infertility
family history
what is the symptoms of testicular cancer
painless lump in the testicle which does NOT transilluminate
how do you diagnose testicular cancer
urgent (doppler) USS tests (90% diagnostic)
Tumour markers such as AFP and BhCG
what types of testicular cancer is AFP and BhCG raised in
- AFP is raised in teratoma
- bHCG is raised in seminomas
what is the treatment for testicular cancer
urgent radical orchidectomy (+offer sperm storage) always
as an extra can have chemo or radiotherapy
what is obstructive uropathy
it is a blockage of urine flow and can affect one or both kidneys depending on the level obstruction
what are the causes of obstructive uropathy
benign prostatic hypertrophy - obstructions
stones
what is the pathophysiology of obstructive uropathy
obstruction causes retention and therefore an increase in kidney, ureter, bladder pressure. This causes refluxing of the urine into the renal pelvis and causes hydronephrosis (dilated renal pelvis)
what are the symptoms of obstructive uropathy
With the obstruction
difficulty passing urine.
a slowed stream, sometimes described as a “dribble”
a frequent urge to urinate, especially at night (nocturia)
the feeling that your bladder isn’t empty.
decreased urine output.
blood in your urine
what is the treatment for obstructive uropathy
relieve kidney pressure - catherterise and ureteral stent
treat the benign prostate hyperplasia or the stones (plus infection if that has occured)
what are the different locations for UTI
Upper (kidney) - pyelonephritis
Lower (bladder onward) - cystitis, prostatitis, urethritis, epidydymo-orchiditis
what organisms cause UTI
KEEPS
Klebsiella
Enterobacter
E.coli
Proteus
S. Saprophytic
what is the most common bacterial cause of UTI
E.Coli
How do you diagnose UTI
1st line: urine dipstick
- leukocytes, nitrites and haemoturia
Gold standard: Midstream MC+S to confirm the UTI and the pathogen causing it
what is pyelonephritis
it is infection of the renal parenchyma and upper ureter.
what type of spread does pyelonephritis have
ascending transurethral spread
what is the usual cause of pyelonephritis
uropathic E.Coli
what are the risk factors of pyelonephritis
urine status - stones
renal structural abnormalities
catheters
what is the presentation of pyelonephritis
Triad
loin pain
fever
pyuria (pus containing urine)
how do you diagnose pyelonephritis
1st line: urine dipstick
gold: MC+S (microscopy, culture, sensitivity)
what is the treatment for pyelonephritis
Analgesia, paracetamol
antibiotics: ciprofloxacin or co-amoxiclav
what is cystitis
uropathic E.coli infection of the bladder
what are risk factors for cystitis
Frequent sexual intercourse
History of UTIs
Congenital abnormality
Urinary catheter
Asymptomatic bacteruia
DM
Spinal cord injuries
Pregnancy
Immunodeficiency
Older age
Lack of circumcision
what are the symptoms of cystitis
suprapubic tenderness and discomfort
increased frequency and urgency
visible haematuria
can cause confusion in elderly
how do you diagnose cystitis
urine dip stick
urine culture and sensitivity - gold standard for diagnosis
how do you treat cystitis
Antibiotics - 3 days of trimethoprim or nitrofurantoin (amoxicillin if the patient is pregnant)
what is Urethritis
it is urethral inflammation plus or minus infection
what is the most common way of getting urethritis
Sexually acquired infection
what infections can cause urethritis
Gonococcal - Neisseria gonorrhoea
Non - gonococcal - Chlamydia trachomatis
what are non infective causes of urethritis
trauma
what are risk factors for urethritis
unprotected sex
MSM
what are symptoms of urethritis
dysuria +/- urethral discharge (blood or pus
urethral pain
orchalgia
how do you diagnose urethritis
nucleic acid amplification test to detect STI
Urine dip
MC+S - will detect pathogen ID if UTI
how do you treat urethritis
Neisseria - IM ceftriaxone and azithromycin
Chlamydia - Doxycycline (or azithromycin)
what type of bacteria is chlamydia
obligate intracellular gram negative aerobe (bacillus)
What type of bacteria is Neisseria
gram negative diplococcus
What disorder is urethritis associated with
reactive arthritis
- conjunctivitis
- urethritis
- arthritis
what is epididymo-orchitis
it is inflammation of epididymis extending to the testis. Usually due to urethritis (STI) or cystitis extension
What ages is urethritis or cystitis causing epididymo-orchitis more common in
- Urethritis - more in under 35
- Cystitis - more in over 35
what are the symptoms of Epididymo-orchitis
unilateral scrotal pain and swelling
pain is relieved with elevating testes
cremaster reflex is intact
positive prehns sign
how do you diagnose Epididymo-orchitis
Nucleic acid amplification test
urine dip
MC + S
what is the treatment for Epididymo-orchitis
dependent of its an STI or UTI
STI - Ceftriaxone and azithromycin or azithromycin
what are the two types of Glomerulopathology
Nephrotic or nephritic
what are the signs of nephrotic Glomerulopathy
proteinuria
hypoalbuminemia
oedema - due to 3rd spacing
hyperlipidemia
hypogammaglobulinemia (low Ig)
hypercoagulable blood - due to loss of antithrombin 3
what are signs of nephritic glomerulopathology
Haematuria
oliguria - little urine: salt and water retention
hypertension
oedema - due to fluid overload
what causes nephritic glomerulopathology
when there is breakdown of the glomerular basement membrane
- inflammation
- bowman crescents
what can present as both nephrotic and nephritic glomerulopathology
diffuse proliferative glomerulonephritis
membrano-proliferative glomerulonephritis
what are primary causes of nephrotic syndrome
minimal change disease (MC in children)
focal segmental glomerulosclerosis
membranous nephropathy
what are secondary causes of nephrotic syndrome
diabetic nephropathy
what are symptoms of nephrotic syndrome
proteinuria
hypoalbuminemia
oedema
hyperlipidemia with wt gain
how do you diagnose nephrotic syndrome - minimal change disease
light microscopy - no change
electron microscopy - podocyte effacement and fusion
how do you diagnose focal segmental glomerulosclerosis
light microscopy - segmental sclerosis; less than 50% glomeruli affected
how do you diagnose membranous nephropathy
light microscopy - thickened glomerular basement membrane
electron microscopy - sub podocyte immune complex deposition, spike and dome appearance
how do you treat nephrotic syndrome
steroids with variable response
- minimal change disease responds well
- FSG and MN responds less well
what are causes of nephritic syndrome
IgA nephropathy (Berger’s syndrome)
Post strep glomerulonephritis
SLE
Goodpasture’s syndrome
haemolytic uremic syndrome
what are the symptoms of IgA nephropathy
visible haematuria - looks like ribena or coke
-normally occurs 1-2 days after tonsilitis viral infection (or gastroenteritis)
how do you diagnose IgA nephropathy
immunofluorescence
microscopy shows IgA complex deposition
what is the treatment for IgA nephropathy
non curative: 30% progresses to ESFR
BP control (ACEi)
what are the symptoms of post strep glomerulonephritis
visible proteinuria
- 2 weeks after pharyngitis from Group A, B hemolytic strep (S.Pyogenes)
how do you diagnose post strep glomerulonephritis
light microscopy - hypercellular glomeruli
electron microscopy - subendothelial immune complex deposition
immunofluorescence shows stary sky appearance - IgG, IgM and C3 deposit along the GBM
what is the treatment for post strep glomerulonephritis
self limiting usually
sometimes may progress to rapidly progressive glomerulonephritis
what is a differential diagnosis for IgA nephropathy
Henoch schonlein purpura - small cell vasculitis
diagnosis gives the same result but the difference is that IgA is only kidney deposition, and HSP is systemic (kidney, liver, skin)
How do you diagnose SLE
ANA+ve and anti dsDNA positive
how do you treat SLE
steroids
hydroxychloroquine
immunosuppressants
how does SLE cause nephritic syndrome
lupus nephritis - ANA deposition in the endothelium
how does goodpastures cause nephritic syndrome
there is pulmonary and alveolar haemorrhage as well as glomerulonephritis due to autoantibodies (anti-GBM)
how do you treat Goodpastures syndrome
steroids and plasma exchange
what are causes of haemolytic uremic nephritis
normally about 5 days post infection vs shiga toxin (E.coli, shigella)
- hameolytic anaemia
- AKI causing uremia
Thrombocytopenia
how do you treat haemolytic uremic nephritis
mostly self limiting - but symptoms mean a medical emergency so support with fluids and antibiotics
what is rapidly progressing glomerulonephritis
it is a subtype of glomerulonephritis which progresses to ESRF very fast (weeks to months)
how do you diagnose RPGN
inflammatory crescents in bowmans space
what are causes of rapidly progressing glomerulonephritis
wegner’s granulomatosis (GPA)
MPA (pANCA positive)
Goodpastures (c-ANCA positive)
what is polycystic kidney disease
there is cyst formation throughout the renal parenchyma causing bilateral enlargement and damage
what are the types of polycystic kidney disease
FAMILIAL INHERITED
Auto rec - less common, disease of infancy or prebirth with increased mortality
Auto dom - mutated PKD1 (85%) or PKD2
what is the pathophysiology of polycystic kidney disease
PKD1+2 code for polycystin (calcium channel)
When filtrate passes through nephron cilia move and the polycystin on the cilia open.
calcium influx inhibits excessive growth
In the mutation there is less calcium influx and therefore there is excessive cilia growth leading to cyst formation
what are the symptoms of polycystic kidney disease
Bilateral flank/ back or abdominal pain
could have hypertension and haematuria
extrarenal cysts - particularly in the circle of willis leading to berry aneurysms
How do you diagnose polycystic kidney disease
kidney ultrasound - enlarged bilateral kidneys with multiple cysts
genetic testing
family history of PKD
what is the treatment of polycystic kidney disease
Non curative
manage the symptoms
- Hypertension (ACEi)
- ESRF (RRT transplant)
if you find a scrotal mass what do you assume it is until you prove otherwise
Cancer until proved otherwise
what is an epididymal cyst
it is an extratesticular cyst (above and beyond testis) that will transilluminate
- smooth, extratesticular spherical cyst
how do you diagnose an epididymal cyst
ultrasound the scrotum
what is hydrocele
it is fluid collection in the tunica vaginalis
- cyst that testicle sits within that will transilluminate
how do you diagnose hydrocele
ultrasound scrotum
what is varicocele
distended pampiniform plexus due to increased left renal vein pressure causing reflux
-typically painless
how do you diagnose varicocele
clinical examination
what is testicular torsion
the spermatic cord twists on itself causing occlusion of the testicular artery - ischemic and gangrene of testis if not delt with
is testicular torsion a medical emergency
YES
what is a risk factor for testicular torsion
Bell clapper deformity
what are the symptoms of testicular torsion
severe unitesticular pain
abdominal pain
nausea and vomiting
cremasteric reflex is lost
no pain relief with elevating testis
How do you diagnose testicular torsion
ultrasound to check testicular bloodflow
surgical exploration if there is increased risk
what is the treatment for testicular torsion
urgent surgery within 6 hours
- surgical exploration always 1st line if clinical suspicion of testicular torsion
how do you overcome the bell clapper deformity
all cases require bilateral orchiopexy (fixing of testis to scrotal sac)
what are types of incontinence
stress
urge
spastic paralysis
what is stress incontinence
it is due to sphincter weakness
- pee leaks with intraabdominal pressure rise
what is urge incontinence
it is detrusor muscle overactivity
what is spastic paralysis incontinence
neurological upper motor neuron lesion
- overactive reflexes plus hypertonia of detrusor
is incontinence more common in females or males
females
what is the treatment for incontinence
surgery
anticholinergic drugs
what is retention
it is the inability to pas urine even when bladder full
- overflow incontinence
what are causes of retention
obstruction
- stones
- BPH
- neurological flaccid paralysis
what is the treatment for retention
catheterize
is retention common in males or females
males
what are the storage symptoms (lower urinary tract symptoms)
Urgency
Frequency
Incontinence
Nocturia
why do storage symptoms occur (lower urinary tract symptoms)
they occur when the bladder should be storing urine and therefore you need to pee
what are voiding symptoms (lower urinary tract symptoms)
poor stream
incomplete emptying
dribbling
hesitancy
why do voiding symptoms occur
when the bladder outlet is obstructed and therefore it makes it hard to pee
what are risk factors for CKD and AKI
emergency surgery i.e risk of sepsis or hypovolemia
CVD risk
CKD -eGFR <60
diabetes mellitus
heart failure
age >65 years
Liver disease
use of nephrotoxic drugs
what are the different stages of CKD
1, 2, 3a, 3b, 4, 5
what is CKD stage 1
GFR is > 90ml/min
What is CKD stage 2
GFR range is 60-90
some sign of kidney damage
what is CKD stage 3a
45-59ml/min
moderate reduction in kidney function
what is CDK stage 3b
30-44 ml/min
moderate reduction in kidney disease
what is CDK stage 4
15-29ml/min
severe reduction in kidney function
what is CKD stage 5
less than 15ml/min
established kidney failure - dialysis of kidney transplant may be needed
what is the NICE diagnostic guideline for kidney injury
rise in creatinine of equal to or over 26umol in 48 hour
over 50% rise in creatinine over 7 days
fall in urine output to less than 0.5ml/kg/hour for more than 6 hours in adults (8 hours in children)
what are signs of intrinsic kidney injury
type 2 diabetes mellitus
hypertension
low urine osmolarity
high urine sodium
high blood potassium
what are levels of sodium, urea and creatinine in pre-renal kidney injury
normal sodium
raised urea
raised creatinine
responds well to fluid therapy
what are signs of post-renal kidney injury
loin to groin acute colicky pain
microscopic haematuria
what are causes of pre-renal kidney injury
hypovolaemia secondary to diarrhoea and vomiting
renal artery stenosis
that are intrinsic causes of kidney injury
glomerulonephritis
acute tubular necrosis
acute interstitial nephritis
rhabdomyolysis
tumour lysis syndrome
what are post renal causes of kidney injury
kidney stone in ureter or bladder
benign prostatic hyperplasia
external compression of the ureter
what is stage 1 of AKI
increase in creatinine to 1.5-1.9 times the baseline
or
reduction in urine output to <0.5 ml/kg/hour for equal to or over 6 hours
whats stage 2 of AKI
increase in creatinine to 2.0 to 2.9 times the baseline
or
reduction in urine output to <0.5mL/kg/hour for equal to or over 12 hours
what is stage 3 of AKI
increase in creatinine to equal to or over 3 times baseline
or
increase in creatinine > 353.6 umol/l
or
reduction in urine output to <0.3 mL/kg/hour for over 24 hours
what are examples of nephrotoxic drugs
NSAIDs
Aminoglycosides
ACE-i
ARB
loop diuretics
metformin?
Digoxin?
lithium?
how do you reduce the risk of CVD in CDK management
Atorvastatin - 20mg
what is the physiology of the prostate
produces testosterone and dihydrotestosterone
production of PSA - liquefies semen
what type of cancer is prostate cancer
adenocarcinoma
what is the management of benign prostatic hyperplasia
- tamsulosin
- finasteride
what is the treatment for prostate cancer
localised - radial prostatectomy
advanced - zoladex (GnRH agonist)
what is hydrocele
it is fluid in the tunica vaginalis
soft, non-tender transluminous swelling
what are varicocele
it is abnormal enlargement of the testicular veins
what are signs of testicular torsion
unilateral
swollen
tender
retracted upward
prehns sign negative
how do you treat epididymitis
IM ceftriaxone plus doxycycline
what is the most common cause of scrotal swelling
epididymal cyst
what are signs of testicular cancer
a painless lump with hydrocele and gynacomastia
what is nephritic syndrome
it is inflammation within the kidney
what are features which defines nephritic syndrome
haematuria
oliguria
proteinuria
hypertension
what causes nephritic syndrome
an inflammatory disease affecting the kidney - it can arise from both systemic and renal limited disease
what investigations are done for nephritic syndrome
kidney biopsy - diagnostic
urinalysis
bloods - elevated ESR and CRP
how do you manage nephritic syndrome
treat underlying cause
blood pressure control - ACE-i/ARB
corticosteroids
why does goodpasture’s disease cause glomerulonephritis
because there are autoantibodies to type IV collagen in the glomerular and alveolar membrane
how does Goodpasture’s present
shortness of breath
oliguria
how do you manage Goodpasture’s disease
plasma exchange
steroids
cyclophosphamide
why does IgA nephropathy cause glomerulonephritis
there is deposition of IgA into the mesangium of the kidney leading to inflammation and damage
what is the most common cause of nephritic syndrome in high income families
IgA nephropathy
how does IgA nephropathy present
asymptomatically with microscopic haematuria
what is the pathophysiology behind post streptococcal glomerulonephritis
This is nephritic syndrome following an infection, 3-6 weeks prior. This is due to deposition of strep antigens in the glomeruli leading to inflammation and damage.
how does a patient with post streptococcal glomerulonephritis present
with haematuria
can also present with acute nephritis
what is Henoch Schoenlein purpura
it is a small vessel vasculitis that affects the kidney and joints due to IgA deposition
how does Henoch Schoenlein purpura present
Presents with a purpuric rash on legs, nephritic symptoms, and joint pain due to IgA deposition
how do you treat Henoch Schoenlein purpura
Managed with corticosteroids and ACE-I/ARB
what is nephrotic syndrome
this is where there is an issue with the filtration barrier, with the podocytes being primarily implicated, which results in leaking of protein into the urine
what is the triad which characterises nephrotic syndrome
proteinuria - >3g/24 hours
hypoalbuminaemia - loss of albumin in urine
Oedema - loss of oncotic pressure
what are the primary causes of nephrotic syndrome
Minimal change disease
Focal segmental glomerulosclerosis
Membranous nephropathy
what are some secondary causes of nephrotic syndrome
diabetes
drugs
autoimmune
neoplasia
infection
how does nephrotic syndrome present
oedema
frothy urine
what investigations are done for nephrotic syndrome
Urinalysis
Urine Protein: creatinine ratio- to quantify the degree of proteinuria
Blood tests- renal function, elevated lipids
Renal biopsy- gives cause
what is the management for nephrotic syndrome
Management
Fluid and salt restriction
Loop diuretics- to manage oedema
Treat cause
ACE-I/ARB to reduce protein loss
Manage complications
what are the complications of nephrotic syndrome
hyperlipidaemia - loss of albumin increases cholesterol formation = treat with statins
VTE - due to increased clotting factors = treat with heparin
how do you treat minimal change disease
high dose steroids such as prednisolone
what can focal segmental glomerulosclerosis be secondary to
HIV
Heroin
Lithium
what should all patients with focal segmental glomerulosclerosis receive
ACE-i or ARBs to control blood pressure
how do you manage membranous nephropathy
Managed with ACE-I/ARB in all. In patients with high risk of progression, prednisolone and cyclopshosphamide.
what antibody is found in 70-80% of membranous nephropathy patients
Anti phospholipase A2 receptor antibody
what are the differences between nephritic and nephrotic syndrome
nephritic has slight proteinuria, hypertension and haematuria, with oedema, low GFR and can have a rash, abdominal pain and N&V
nephrotic has high proteinuria, hypoalbuminaemia and high level of oedema. It can have a reduced or normal GFR and hyperlipidaemia
what percentage of nephrotic syndrome shows no visible change on biopsy
25% of cases
what is the most common GU tract malignancy
bladder cancer
what is the most common bladder cancer
90% are urothelial carcinomas
where does urothelial carcinoma spread to
the iliac and para-aortic nodes and then to the liver and the lungs
what are risk factors for bladder cancer
Smoking increases risk 2-4 times, accounts for half of male cases of bladder cancer
Age over 55
Pelvic radiation
Exposure to occupational carcinogens
Bladder stone- due to chronic inflammation
what is the management for bladder cancer
T1 - transurethral resection or local diathermy
T2-3 - radical cystectomy
T4 - palliative chemotherapy and radiotherapy
where are 90% of renal cancers found to be arising from
proximal tubular epithelium (carcinomas)
what is the epidemiology of renal cancer
mean age of diagnosis is 55
2:1 male to female diagnosis ratio
where does renal cancer spread to
bone
liver
lungs
what are risk factors for renal cancer
haemodialysis
smoking
hypertension
how does renal cancer present
Classic triad of symptoms: haematuria, flank pain, palpable abdominal mass
what investigations are done for renal cancer
Bloods: polycythaemia from erythropoietin secretion
Raised BP: due to renin secretion
Ultrasound
CT/MRI
CXR- shows cannon ball mets
what score is used to predict survival in renal cancer
Mayo prognostic risk score
what are the 4 stages of the mayo prognostic risk score
Stage I: partial or radical nephrectomy
Stage II: radical nephrectomy
Stage III: radical nephrectomy and adrenalectomy
Stage IV: systemic treatment
what is the definition of a UTI
Defined as the presence of microorganisms in the urinary tract which produces clinical features. It can affect the lower tract causing cystitis (bladder), urethritis and prostatitis, and the upper causing pyelonephritis. It can also occur from untreated urolithiasis
what are the 5 most common UTI causing pathogens
The 5 most common pathogens can remembered with KEEPS:
Klebsiella
E coli- most common causing >50% of cases
Enterococci
Proteus
Staphylococcus coagulase negative
what is the treatment for pyelonephritis
Antibiotics: cefalexin for 7-10 days. Trimethoprim or amoxicillin if sensitive.
Analgesia- paracetamol
what is prostatitis most commonly caused by
E.coli
what are risk factors for cystitis
History of UTI
Diabetes
Frequent sexual intercourse
Pregnancy
what is the presentation of prostatitis
Very tender prostate: on DRE intensely tender prostate gland
Systemic Sx: fever, chills, malaise
Voiding Sx
what investigations are done for prostatitis
Urinalysis and culture- shows blood and WBCs, and bacteria
Blood cultures- in patients who are febrile
what is prostatitis
inflammation and swelling of the prostate gland
how do you manage prostatitis
ciprofloxacin or levofloxacin for 14 days
what is the most common bacterial STI
chlamydia trachomatis
how does chlamydia present in men
Men- testicular pain
voiding symptoms, dysuria
50% are ASX
how does chlamydia present in women
Women- vaginal discharge and dysuria
white, yellow or green discharge
70% are ASX
how do you diagnose STIs
nucleic acid amplification test
how do you manage chlamydia
avoid sex until the treatment is finished
contact tracing
single 1g dose of azithromycin plus 7 days of doxycycline
what is the second most common STI in the UK and what is it caused by
Gonorrhoea and its caused by neisseria gonorrhoea
what is the presentation of gonorrhoea
more likely to be ASX
Men: dysuria, frequency, discharge
Female: vaginal discharge dysuria, pelvic pain
what investigations are done for gonorrhoea
NAAT
Microscopy: shows gram-negative diplococci
Culture: all infected areas with a swab
how do you treat gonorrhoea
single ceftriaxone IM dose
what is urolithiasis
it is the presence of crystalline stones in the urinary tract
where are the three places youre most likely to find crystalline stones in urolithiasis
pelvicoureteric junction
pelvic brim
vesicouretral junction
what are the stones made from in urolithiasis
supersaturated urine - mostly formed of calcium oxalate
what are the risk factors of urolithiasis
Dehydration
High salt intake
Obesity- lowers pH
Congenital horseshoe kidney
Oxalate rich diet
Gout- uric acids stones
how does urolithiasis present
Most are asymptomatic
Causes severe colicky unilateral pain from loin to groin
Associated with nausea and vomiting
Haematuria- 85% of cases
Assume ruptured AAA until proven otherwise!
what investigations are done for urolithiasis
KUBXR- first line and diagnostic for 80% of stones
Non contrast CTKUB- gold standard
Urine dip stick- for haematuria
Blood tests- raised calcium and phosphate
what is the management for urolithiasis
Strong analgesia- diclofenac
Antibiotics
Tamsulosin/nifedipine- relaxes smooth muscle and helps expulsion
Percutaneous nephrolithotomy- used to expulse stones over 10mm
what can be given to help prevent urolithiasis
thiazide diuretics- this helps with recurrent stones by reducing calcium levels
Hydration, reduce salt and oxalate intake
what type of cancer is kidney cancer
renal cell carcinoma - arises from the renal parenchyma or cortex
what are the risk factors for kidney cancer
Smoking
Male sex
>55yo
Black/Native American ethnicity
Obesity
Hypertension
Family history
what are the signs and symptoms of kidney cancer
More than 50% asymptomatic
Haematuria
Flank pain
Palpable abdo mass
Non-specific systemic symptoms
Signs of hepatic dysfunction
Myoneuropathy
Lower limb oedema
Scrotal varicocele
Derm manifestations/vision loss
how do you diagnose kidney cancer
Elevated creatinine (reduced clearance)
Haematuria and/or proteinuria
Abdo/pelvic US (mass)
CT abdo/pelvis (mass)
MRI abdo/pelvis (mass)
what is the differential diagnosis for kidney cancer
Benign renal cyst
Ureteric cancer
Bladder cancer
Upper urinary tract urothelial tumour
Angiomyolipoma
Oncocytoma
Secondary mets
Congenital renal parenchymal abnormalities
Renal infarction
Renal infection
how is kidney cancer managed
surgery
what are the complications of kidney cancer
Anaemia
Hypercalcaemia
Erythrocytosis
SIADH
Hepatic dysfunction
what are the symptoms of prostate cancer
Nocturia
Urinary frequency
Urinary hesitancy
Dysuria
Abnormal digital rectal examination
PSA more widely used
Asymmetrical, nodular prostate
Haematuria
Weight loss/anorexia
Lethargy
Bone pain
Palpable lymph nodes
how do you diagnose prostate cancer
raised PSA
prostate biopsy
what are the differential diagnosis for prostate cancer
BPH
Chronic prostatitis
how do you manage prostate cancer
Active surveillance
Androgen deprivation therapy
External-beam radiotherapy
Brachytherapy
Radical prostatectomy
what are risk factors for testicular cancer
Cryptochidism
Gonadal dysgenesis
Family/personal history
Testicular hypertrophy
White ethnicity
HIV infection
what are signs of testicular cancer
Lump/enlargement of one testicle
Feeling of heaviness in the scrotum
Dull ache in the abdomen or groin
Sudden collection of fluid in the scrotum
Pain or discomfort in a testicle or the scrotum
Enlargement/tenderness of the breasts
Back pain
what are the complications of testicular cancer
infertility
what is the differential diagnosis for testicular cancer
Testicular torsion
Epididymo-orchitis
Scrotal hernia
Hydrocele
Epididymal cyst
Haematomas
Spermatocele
Intratesticular benign cysts
Syphilitic gumma
what are complications of benign prostatic hyperplasia
UTI
renal insufficiency
bladder stones
haematuria
sexual dysfunction
acute urinary retention
overactive bladder
what are possible complications of pyelonephritis
renal failure
sepsis
renal abscess formation
emphysematous pyelonephritis
parenchymal renal scarring
recurrent UTIs
what is the pathophysiology behind chronic pyelonephritis
there is a slow progressive renal damage due to chronic inflammation or infection.
This causes thinning of the adrenal cortex with scarring
The scarring can be in one or both kidneys and it often causes atrophic tubules with no glomeruli
what is the most common mechanism of renal scarring in chronic pyelonephritis
vesicoureteral reflux
what are causes of chronic pyelonephritis
Recurrent infections resulting from anatomical abnormalities
Vesiculoreteral reflux
Inadequate treatment/recurrence of acute pyelonephritis
what are risk factors for chronic pyelonephritis
Acute pyelonephritis
Vesicoureteral reflux
Obstruction
Renal caliculi
DM
what are signs or symptoms of chronic pyelonephritis
Nausea
Elevated blood pressure
Weight loss
Fatigue
Malaise
Cloudy urine
Fever
Back/flank pain + tenderness
How is chronic pyelonephritis diagnosed
renal function tests
electrolyte panel
FBC
renal ultrasound
kidney-ureter-bladder X ray
CT abdomen
what is a differential diagnosis for chronic pyelonephritis
Acute pyelonephritis
Renal caliculi
Renal cancer
how is chronic pyelonephritis managed
no specific treatment available
renal damage isnt reversible
can help to repair anatomical or functional problems
what are the possible complications of chronic pyelonephritis
AKI
Hyperparathyroidism
Acute pyelonephritis
Obstruction
CKD
what are the symptoms of cystitis
Dysuria
Urgency
Frequency
Suprapubic pain
Abdo pain
Fever
Vaginal discharge
Vaginal pruritis
Dyspareunia (painful intercourse)
Structurally or functionally abnormal bladder
what are the possible complications of cystitis
Pyelonephritis
Preterm delivery
Urinary retention
Recurrent UTIs
what are risk factors of prostatitis
UTI
benign prostatic enlargement
urinary tract instrumentation or manipulation
what are possible complications of urethritis
Chronic non-gonococcal urethritis
Genitourinary abscess
Urethral stricture/fistula
Reactive arthritis
Disseminated gonococcal infection
Epididymitis
Acute conjuctivitis
Pneumonia
what are causes of urethritis
N gonorrhoeae (gonococcal urethritis)
C trachomatis
M genitalium
U urealyticum
what are the differential diagnosis of urethritis
UTI
Candida balanitis or vaginitis
Non-infectious urethritis
Nephrolithiasis
Interstitial cystitis
Reactive arthritis
Chronic prostatitis
what is the pathophysiology behind nephritic syndrome
Largely triggered by immune-mediated injury exhibiting both humoural and cellular components
A variety of non-immunological metabolic, haemodynamic and toxic stress can also induce glomerular injury
what are signs and symptoms of Polycystic kidney disease
Renal cysts
Hypertension
Abdo/flank pain
Haematuria
Palpable kidney/abdo mass
Headaches
Dysuria
Urgency to pee
Suprapubic pain
Fever
Cardiac murmur
Abdo hernia or rectus abdominis diastasis
Hepatomegaly
what drug can be given to help slow progression of cysts in polycystic kidney disease
Tolvaptan
what are possible complications of PKD
Cardiac complications
GORD
Ruptured intracranial aneurysm
sepsis
complications during pregnancy
what are the signs and symptoms of a epididymal cyst
Lump
Multiple, may be bilateral
May be painful if large
Well defined and will transluminate since fluid
filled
Testis palpable separate to the cyst
what is a communicating hydrocele
patent processus vaginalis connects the peritoneum with the tunica vaginalis, allowing peritoneal fluid to flow freely between both structures. Risk of inguinal herniation
what is a non communicating hydrocele
processus vaginalis closed, more fluid produced by tunica vaginalis than is being absorbed
what are risk factors for hydrocele
Male sex
Prematurity/low birth weight
Infant (<6mths)
Late descent of testes
Increased intraperitoneal fluid/pressure
Inflammation/injury within scrotum
Testicular cancer
Connective tissue disorders
how do you manage hydrocele
surgery if large or uncomfortable
aspiration can be considered
what are possible complications of hydrocele
Haematoma
Inguinal hernia
Pain in inguinal area radiating to abdomen
Lower extremity oedema
Testicular atrophy
Hydronephrosis
Infertility
what is varicocele associated with
Abnormal gonadotropin levels
Impaired spermatogenesis
Histological changes to sperm
Infertility
Describe the lower neural pathways involved with filling of the urinary bladder, including the nerve root levels involved
there is sympathetic innervation via hypogastric nerve (T10-L2) which causes relaxation of detrusor muscle via the beta 1 receptors .There is also contraction of the IUS via alpha 1 receptors
what is the nerve responsible for somatic control of micturition including the nerve root
S2-4 - pudendal nerve
