Genitourinary Flashcards
What are the major functions of the Kidney?
- Filter or secrete waste/excess substances
- Retain albumin and circulating cells
- Reabsorb glucose, amino acids and bicarbonates
- Control BP, fluid status and electrolytes
- Activates 25-hydroxy vitamin D (by hydroxylating it to form 1,25 dihydroxy
vitamin D) - Synthesis erythropoietin
What is the Glomerular Filtrate rate?
The volume of fluid filtered from the glomeruli into Bowman’s space per unit
time (minutes)
What is the normal GFR?
120ml/min
What is Nephrolithiasis?
Renal Stones (calculi) commonly made from Calcium Oxalate (90%) which form in the CD and can be deposited anywhere from the renal pelvis to the urethra.
What are some other types of renal stone compared to calcium oxalate?
Calcium phosphate/oxalate (80%)
Uric Acid (10%)
Cysteine Stones
Struvite (infection often from proteus)
What are the 3 main narrowing’s where renal stones may be found?
- Pelviureteric junction
- Pelvic brim
- Vesicoureteric junction
What is the epidemiology of Renal Stones?
10-15% lifetime risk
More common in males
Peak age 20-40 yrs
Increasing Incidence
What are the risk factors for renal stones?
Chronic Dehydration
Low urine output
Primary kidney disease
HyperPTH/Hypercalcaemia
UTIs
Hx of previous renal stone
Drugs
What are the main causes for renal stones?
Anatomical:
Congenital - horseshoe kidney
Acquired - Obstruction, trauma, reflux
Urinary Factors:
Metastable urine
Increased Calcium oxalate, urate, cystine
Dehydration
What is the pathophysiology of renal stones?
Excess solute in the collecting duct
Supersaturated urine - favours crystallisation
Stones cause regular outflow obstruction - lead to hydronephrosis
Subsequent dilation of the renal pelvis will lead to lasting kidney damage
What are the 2 key complications of renal stones?
Obstruction - leading to AKI
Infection - causing obstructive pyelonephritis
What is the presentation of Renal Stones?
Maybe ASx and never cause issue
Renal colic is presenting complain in Symptomatic kidney stones:
Loin to groin pain that is colicky (peristaltic waves leading to fluctuations in severity)
LUTs (dysuria, strangury Urgency, Frequency)
Px cant lie still
What is Colicky Pain?
Pain that fluctuates in severity often due to peristalsis causing contaction of gallstones/renal stones which then settles when the contraction stops
What are the symptoms of Renal Colic?
Loin to groin pain
Px cannot lie still
Haematuria/dysuria
Nausea or vomiting
Reduced urine output (LUTS)
Symptoms of sepsis, if infection is present
What are the primary investigations for Renal stones?
1st Line - KUB (kidney, Ureter, Bladder) XR - 80% specific
Gold Standard - NCCT (non-contrast CT) KUB - 99% specific (diagnostic)
Bloods:
FBC
U&Es - raised creatinine in AKI
Urinalysis -Microscopic haematouria
Pregnancy test
Urine dipstick - UTI
What investigation would be used for hydronephrosis from a suspected renal stone for a Px who is pregnant?
Ultrasound as they cannot have CT
How can a kidney be drained if infected?
Ureteric stend
Nephrostomy
What is the Treatment for Renal Stones?
Sx management:
Strong Analgesic - IV/PR Diclofenac for severe pain (opiates in poor renal function Px)
Hydrate - oral or IV
Anti-emetics
Abx if infection present:
Cefuroxime / IV Gentamicin
Stones normally pass spontaneously if small enough (<5mm)
Elective Surgical Tx if too big to pass
What is a key complication of kidney stones?
Pyonephrosis
- Pus filled fluid caused by infection and obstruction together.
Tx with septic six
What Treatment is used if a stone is too large to pass spontaneously?
ESWL:
Extracorporeal shockwave lithotripsy - ultrasound that fragments the stones (does not clear the stone so Px still has to pass stone)
Ureteroscopy - laser
PCNL:
Percutaneous nephrolithotomy - keyhole surgery to remove large/complex stones
Nephrectomy - if kidney contributes to less than 15% renal function
What is a big issue once you have had one renal stone?
Recurrence is very common and therefore take steps to prevent it:
Overhydration
Low Ca dietary intake
Low sodium diet
Reduce BMI
Active lifestyle
Potassium Citrate and Thiazide diuretics may also help
What are some differential Diagnoses for Loin pain other than Renal Colic?
Vascular accident - Ruptured AAA
Bowel Pathology - diverticulitis, appendicitis
Gynae - Ectopic pregnancy
Testicular torsion
MSK pain
What is the treatment for bladder stones?
Conservative - asymptomatic
Endoscopic + BOO Tx
Open Laparoscopic surgery - for large stones
What is Acute Kidney Injury (AKI)?
Abrupt decline in kidney function that occurs within hrs to days.
This is characterised by a increase serum creatinine and urea and a reduced urine output due to a decline in GFR failing to maintain acid base homeostasis
What is the mortality rate for AKI?
25-30%
What are the NICE criteria for AKI
Rise in creatinine of ≥ 25 micromol/L in 48 hours
Rise in creatinine of ≥ 50% in 7 days
Urine output of < 0.5ml/kg/hour for > 6 hours
What system is used to classify the stage of AKI?
KDIGO:
Rise in creatinine of ≥ 25 micromol/L in 48 hours
Rise in creatinine of ≥ 50% in 7 days
Urine output of < 0.5ml/kg/hour for > 6 hours
What is the old staging classification system for AKI?
RIFLE:
* Risk
* Injury
* Failure
* Loss
* End-stage renal disease
What is the epidemiology of AKI?
Common - affects 15% of all hospital admissions
25% of Px with sepsis and 50% of Px with septic shock will have AKI
Common in elderly
What are the risk factors for AKI?
CKD - acute on chronic kidney disease
Increased age >75yrs
Liver disease
Diabetes Mellitus
Nephrotoxic Drugs
Organ failure - HF
Sepsis
What are the different groups of causes of AKI?
Pre-renal (most common) - due to inadequate blood supply reaching the kidneys reducing filtration of blood.
Renal - where there is intrinsic disease within the kidney that leads to the reduced filtration of blood
Post renal - caused by obstruction to the outflow of urine from the kidney, causing back-pressure into the kidney and reduced kidney function. This is called an obstructive uropathy
What are the commonest causes of AKI?
Cardiogenic shock
Major Surgery
Nephrotoxins
Sepsis
Give some Pre-renal causes of AKI?
Dehydration
Hypotension (shock)
Heart failure
Give some Renal Causes of AKI?
Glomerulonephritis
Interstitial nephritis
Acute tubular necrosis
Nephrotoxic Drugs (DAMN)
What are the DAMN drugs that cause nephrotoxicity?
Diuretics
ACEis/ARBs
Metformin
NSAIDs
Give some Post renal Causes of AKI?
Kidney stones
Masses such as cancer in the abdomen or pelvis
Ureter or uretral strictures
Enlarged prostate or prostate cancer
Give some examples of drugs that are nephrotoxic
NSAIDs
ACEi
ARBs
Aminoglycosides - gentamicin
Diuretics
What is the pathophysiology of AKI?
Impaired ability of the kidneys to filter the blood.
This leads to accumulation of substances that are usually excreted
Can lead to damage of the nephron and kidney
What substances will accumulate in AKI?
K+ - hyperkalaemia - arrythmias
Urea - Hyperuraemia - Pruritis and confusion
Fluid - oedema - pulmonary and peripheral
H+ - acidosis
What are the symptoms of AKI?
Sx of underlying cause:
Sx of accumulation of substances:
Encephalopathy - confusion/drowsiness
Pericarditis
Skin manifestations
Oedema
Dyspnoea
Oligouria
Metabolic acidosis
Arrythmias
Haematuria/proteinuria
What are some clinical signs of AKI?
Signs of hypovolaemia may be present:
reduced BP
Reduced skin turgor
Uraemic skin changes
Signs of volume overload may be present:
Bibasal crackles
Raised JVP
Peripheral oedema
Palpable bladder
What are the primary investigations for AKI?
Establish cause - Pre/Renal/Post
+ diagnose with KDIGO classification
U&Es + electrolytes
FBC/CRP check for infection
Kidney biopsy - intra renal damage
Uss - post renal obstruction
What is a good way to establish whether AKI is caused by pre/renal/post renal cause?
Urea:Creatine Ratio
U:Cr > 100:1 = pre-renal
U:Cr < 40:1 = renal
U:Cr 40-100:1 = Post renal
What is the treatment for AKI?
Tx complications:
Hyperkalaemia - Calcium gluconate
Metabolic acidosis- Sodium Bicarbonate
Give IV fluids - if hypovolaemic
Tx underlying cause - STOP nephrotoxic drugs
Last resort - Renal Replacement Therapy (dialysis)
What are the indications for RRT?
Acidosis (pH < 7.1)
Fluid overload (oedema)
Uremia that is symptomatic
Hyperkalaemia >6.5 or ECG changes
What are some potential complications of RRT?
CVD - MI
Infection
What are the major complications of AKI?
Hyperkalaemia
Fluid overload, heart failure and pulmonary oedema
Metabolic acidosis
Uraemia (high urea) can lead to encephalopathy or pericarditis
What is Chronic Kidney Disease (CKD)?
Progressive decline in renal Function where GFR <60ml/Min for more than 3 months
What are the common causes of CKD?
Diabetes
Hypertension
Age-related decline
Glomerulonephritis
Polycystic kidney disease
Medications such as NSAIDS, proton pump inhibitors and lithium
What are the risk factors for CKD?
Older age
Hypertension (most common)
Diabetes (most common)
Smoking
Renal artery stenosis
PKD
Use of medications that affect the kidneys
Nephrotoxic Drugs
What are the stages of CKD?
Classified based on eGFR:
G1 = eGFR >90 w/Renal signs
G2 = eGFR 60-89 w/ Renal signs
G3a = eGFR 45-59
G3b = eGFR 30-44
G4 = eGFR 15-29
G5 = eGFR <15 (known as “end-stage renal failure”)
What are the best readings to quantify CKD?
eGFR
Urine Albumin:Creatine Ratio (ACR)
What is the pathophysiology of CKD?
Many nephrons are damaged in CKD which reduces GFR
Increased burden on remaining functional nephrons
Compensatory RAAS in response to lower GFR which increases transglomerular pressure.
This leads to shearing and loss of basement membrane selective permeability leading to proteinurea (loss of filtration ability)
Angiotensin II upregulates TGF-B and PAI-1 which leads to increased scarring of functional nephrons
What are the symptoms of CKD?
Early - ASx due to lots of nephrons in reserve
Sx of CKD arise secondary to substance accumulation and renal damage:
Pruritus (itching)
Lethargy
Anorexia
Nausea
Oedema
Muscle cramps
Peripheral neuropathy
What are the clinical signs of CKD?
Hypertension
Pallor
Fluid Overload
Evidence of underlying aetiology
What is the prognosis of CKD correlated with?
Poorly controlled HTN
Proteinuria
Degree of scarring on histology
What are the key complications of CKD?
Anaemia - due to reduced EPO
Renal bone disease (osteodystrophy due to lack of Vit D activation)
Cardiovascular disease
Peripheral neuropathy
Dialysis related problems
What are the primary investigations in CKD?
U&E - eGFR
Urine Albumin:Creatine Ratio (ACR) - >3mmol/l
Urine Dipstick - Haematuria/Proteinuria
Renal USS - Bilateral atrophied Kidneys
FBC - Normocytic Normochromatic Anaemia (due to Dec EPO)
What are the differences Ix findings between AKI and CKD?
Hx:
AKI shorter Sx onset
CKD - 3 month Hx
AKI - Serum Creatine Inc : Urine output Dec
CKD - Decreased eGFR
AKI - no Anaemia
CKD - Anaemia due to EPO
AKI USS - normal
CKD USS - Bilateral atrophied kidneys
What is the aim of management in CKD?
Slow the progression of the disease
Reduce the risk of cardiovascular disease
Reduce the risk of complications
Treating complications
What is the management of CKD?
Tx underlying cause to prevent further deterioration
Tx complications:
Oral sodium bicarbonate to treat metabolic acidosis
Iron supplementation and erythropoietin to treat anaemia
Vitamin D to treat renal bone disease
Dialysis in end stage renal failure
Renal transplant in end stage renal failure
How can CKD progression be slowed?
Optimise diabetic control
Optimise hypertensive control
Treat glomerulonephritis
How can the risk of CKD complications be reduced?
Exercise, maintain healthy weight, stop smoking
Special dietary advice
Offer Atorvastatin for primary prevention of CVD
What is a Urinary Tract Infection (UTI)?
Inflammation in response to an infection that occurs anywhere along the Urinary Tract from the kidneys to the urethra
What are the classifications of UTIs?
Upper UTI:
Kidneys - Pyelonephritis
Lower UTI:
Bladder - Cystitis
Prostate - Prostatitis
Epidiymo-Orchiditis
Urethra - Urethritis
Uncomplicated Vs Complicated
What are the organisms that generally cause UTIs?
KEEPS:
Klebsiella (10% - catheter associated)
E.coli - (UPEC) most common > 50%
Enterobacter
Proteus 10-15%
S.Saprophyticus
P. aeruginosa - recurrent UTI/underlying pathology
What is the most common cause of a UTI?
UPEC:
Uropathogenic Escherichia coli (80% of uncomplicated UTIs)
Who are most affected by UTIs?
Women - Due to a shorter urethra and closer to the anus therefore it is easier for bacteria to colonise and cause and infection
Post-menopause - Absence of Oestrogen increases risk
What are some pathological mechainisms of getting UTIs?
Catheterisation allowing colonisation
Bowel Flora from perineum (often females)
Reduced flow:
Obstruction (prostate, stones)
Low Urinary volume
Stasis during pregnancy
What are the general symptoms of a UTI?
Fever may be only Sx
Abdominal pain, particularly suprapubic pain/discomfort
Vomiting
Dysuria (painful urination)
Urinary frequency
Incontinence
Nocturia
Delirium/Confusion in elderly Px
How are UTIs Diagnosed / what would you find?
1st Line: Urine Dipstick
+tve Leukocytes
+tve Nitrites (bacterial breakdown product)
+/- Haematuria
Gold Standard: Mid-stream Urine Microscopy, Culture and Sensitivity (MC+S)
This confirms UTI and IDs pathogen
What would you look for on microscopy in a MC + S)?
WBC >10^4 wbc/ml
Bacteria >10^5 cfu/ul = infection
RBCs
What are some common Abx used to treat UTIs in the community?
Nitrofurantoin (now more commonly used)
Trimethoprim
+ Amoxicillin, Cefalexin
Why is Trimethoprim used less to treat UTIs these days?
Due to much higher levels of antibiotic resistance
What is the treatment for someone who is 65yrs + and has asymptomatic bacteriuria?
Do NOT treat
What is the treatment for someone who is pregnant and has asymptomatic bacteriuria?
Give treatment (Nitro/Trim depending on trimester) as 20-40% will go on to develop pyelonephritis
What is Pyelonephritis?
Upper UTI of the renal parenchyma and upper ureter at the renal pelvis
When would you avoid treating a UTI with Trimethoprim?
First trimester of pregnancy as it interferes with folic acid synthesis
When would you avoid treating a UTI with Nitrofurantoin?
Third trimester of pregnancy as there is a risk of Neonatal Haemolysis
What do UTIs during pregnancy increase the risk of?
Pyelonephritis
Premature rupture of membranes
Pre-term Labour
What is a major risk of catheterisation?
Become colonised with bacteria within a few days.
Can cause serious UTIs
What are some complications of long term cathetisation?
UTIs/Pyelonephritis
Stones
Obstruction
Chronic Inflammation
What are risk factors for Pyelonephritis?
Female sex <35yrs
Urine stasis (due to stones)
Catheters
Structural urological abnormalities
Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
Diabetes
What is the most common causative organism of Pyelonephritis?
E.coli
What is the pathophysiology of Pyelonephritis?
- Infection is mostly due to bacteria (primarily E.coli) from own patients bowel
flora - Most common via the ascending transurethral route
Other causes can be via Haematogenous/lymphatic spread
What is the classical presentation of Pyelonephritis?
Triad:
Loin Pain
Fever
Pyuria - pus in pee
+ nausea/vomiting
Anorexia
Haematuria
Renal angle Tenderness
What is the primary investigation for Pyelonephritis?
1st Line: Urine Dipstick
Gold Standard: Urine MC+S
USS - rule out obstructions
What is the management of pyelonephritis?
Hydration/fluid replacement
IV antibiotics – broad spectrum e.g. Co-amoxiclav ± Gentamicin
Ciprofloxacin
Pregnancy - Cefalexin
Drain obstructed kidney
Catheter
Analgesia
Complete 7-14 days (depending on choice of antibiotic)
What are some complications for Pyelonephritis?
Renal Abscesses (common in diabetics)
Emphysematous Pyelonephritis
What are the main symptoms of lower UTI?
Dysuria
Frequency
What is Cystitis?
Urinary infection of the bladder
Commonly due to UPEC
Who is affected by Cystitis?
More common in women
Can occur in children
What are the risk factors for Cystitis?
- Urinary obstruction resulting in urinary stasis
- Previous damage to bladder epithelium
- Bladder stones
- Poor bladder emptying
What is a classical presentation of Cystitis?
Suprapubic tenderness + discomfort
Increased frequency
Increase urgency
Visible Haematuria
What is the primary Investigations to diagnose Cystitis?
1st Line: Urine Dipstick
Gold Standard: Urine MC+S
What is the treatment for Cystitis?
First line:
Trimethoprim/Nitrofurantoin
Cefalexin
Second Line:
Co-amoxiclav/Ciprofloxacin
What is Urethritis?
Inflammation in the urethra due to infection
What is the most common cause of Urethritis?
Sexually acquired condition:
Non-Gonococcal (Chlamydia) - More common
Gonococcal - Less common
Non infective - trauma
What are the risk factors for Urethritis?
Male Gay sex
Unprotected sex
What is the presentation of Urethritis?
Dysuria +/- urethral discharge (blood/pus)
Urethral pain
What is the diagnostic test for Urethritis?
NAAT (Nucleic Acid Amplification Test) - detects STI pathogen (NG/CT)
Urine Dipstick + Urine MC+S if UTI
What is the treatment for urethritis?
N.G - IM Ceftriaxone + Azithromycin
C.T - Azithromycin (or Doxycycline)
What is Epididymo-Orchitis?
Inflammation of the epididymus which extends to the testes often secondary to urethritis (STI) or Cystitis.
What are the symptoms of Epididymo-Orchitis?
Unilateral scrotal pain and swelling
Pain relieved when elevating testes
(DDx - testicular Torsion which is much more acute and N+v)
What diagnostic investigations are done for Epididymo-Orchitis?
NAAT
Urine Dipstick
Urine MC+S
What is the treatment for Epididymo-Orchitis?
Depends on underlying cause:
STI/UTI to determine Abx
What is an uncomplicated UTI?
A UTI in a healthy NON-PREGNANT women with a normally functioning urinary tract
What is a complicated UTI?
Most other UTIs (not in non-preggo women)
A UTI in a man
A Px who has abnormal urinary tract (eg. stones)
Systemic disease involving the kidney
What is significant about complicated UTIs?
Treatment failure is more likely
Complications are more likely:
Renal papillary necrosis
Renal Abscesses
What is Benign Prostatic Hyperplasia (BPH)?
A common urological condition in elderly men
where there is increased size of the prostate gland
without the presence of malignancy
that results in lower urinary tract symptoms
What are the risk factors for BPH?
Increased age
Afro-Caribbean (increased testosterone)
Castration is protective
What is the pathophysiology of BPH?
Inner transition zone of the prostate gland proliferates
This can lead to compression on the urethra to narrow/block it leading to urinary Symptoms
What are the typical Symptoms that occur in BPH?
Lower Urinary Tract Symptoms (LUTS):
- Nocturia (>30% voided volume at night)
- Frequency
- Urgency
- Post-micturition dribbling
- Poor stream/flow
- Hesitancy
- Overflow incontinence
- Haematuria
- Delay in initiation of micturition
- Incomplete emptying of bladder
What are symptoms of Urinary Storage?
Fequency
Urgency
Nocturia (>30%)
Incontinence
What are symptoms of urinary Voiding?
Poor stream
Dribbling
Incomplete emptying
Straining
Dysuria
What complications may arise in BPH if the urethra is completely occluded?
Auria - no urination
Retention
Hydronephrosis
UTI
Stones
What is PSA?
Prostate Specific Antigen
serine protease responsible for liquefaction of semen
Prostate specific but not condition specific (essentially any condition affecting the prostate will cause a rise in PSA)
What are the Diagnostic investigations of BPH?
DRE - Digital Rectal exam:
Smooth and enlarged (hard/irregular = cancer)
PSA - may be raised but also raised in cancer
Abdo Exam - enlarged bladder
Urine Dipstick - assess for other pathology
What is the treatment for PBH?
If Sx minimal - Watch and Wait
Lifestyle advice:
Reduce caffeine
Relax when voiding
Medication:
1st Line - alpha blocker - Tamsulosin
2nd Line - 5-alpha Reductase inhibitors - Finasteride
Surgery (last resort)
Transurethral resection of prostate
What is the mechanism of action of Tamsulosin?
Alpha blocker that will relax the bladder neck increasing urinary flow rate and improving obstructive Sx of BPH
What is a side effect of Tamsulosin?
Postural Hypertension
What is the mechanism of action of Finasteride?
5-alpha reductase inhibitor that will block conversion of testosterone to dihydrotestosterone to reduce prostatic growth
What is a common complication of transurethral resection of prostate surgery?
Retrograde ejaculation.
What is Glomerular Disease?
Glomerulonephritis refers to groups of parenchymal kidney diseases that all result in the inflammation of glomeruli and nephrons
Explain the Structure of the glomerulus?
Tuft of capillaries that has 3 components:
Epithelium – composed of podocytes which only makes contact with GBM via foot processes
Glomerular BM
Fenestrated endothelium – lining of capillaries
Mesangial cells holding it all together
What are the classifications of Glomerulonephritis?
Nephrotic Syndrome
Nephritic Syndrome (acute GN)
Rapidly Progressive GN
What is Nephritic syndrome?
inflammation of the blood vessels of the glomerulus leads to blood leaking out but Px does not have a specific underlying cause.
What are the features of a patient with Nephritic Syndrome?
Haematuria
Proteinuria - <3g/24
Oliguria
Oedema - due to Fluid overload
Hypertension
Reduced GFR - (hypercellular glomeruli 🡪 decreased blood flow and leaky BM 🡪 reduced filtration rate)
Give some conditions that present with a clinical picture of nephritic syndrome?
IgA Nephropathy
Post Strep Glomerulonephritis
Good Pasture’s Syndrome
SLE Nephropathy
Haemolytic Uremic Syndrome
These are all examples of TYPE 3 Hypersensitivity reactions (except good pasture’s Syndrome). They are the result of immune complex deposition
What is the most common cause of Nephritic Syndrome?
IgA Nephropathy
What is the pathophysiology of Nephritic/Nephrotic Syndrome?
They are often caused by an immune response that is triggered from another disease leading to glomerulonephritis.
These then present with Nephritic or Nephrotic syndrome features
If not treated then these can lead to AKI/CKD.
What is IgA Nephropathy?
(also called Berger’s Disease)
Commonest cause of glomerulonephritis worldwide
IgA levels rise 1-2 days after a viral infection (tonsilitis, gastroenteritis etc).
These IgA deposit in the mesangium (part of glomerulus) activating C3. A Type 3 hypersensitivity Rxn occurs and this causes Glomerulonephritis.
Presents with Nephritic Syndrome
What is Glomerulonephritis?
umbrella term used to describe inflammation of the Glomerulus/nephrons of the kidney.
Conditions causing glomerulonephritis typically present with either a nephritic or Nephrotic syndrome picture which are a group of symptoms.
What is Nephrotic Syndrome?
Inflammation of Podocytes leads to protein leaking out of kidneys.
Nephrotic syndrome has a set criteria to fit to be classified as NEPHROTIC.
What are the features of Nephrotic Syndrome?
Proteinuria (>3.5g/day) – damaged glomerulus more permeable 🡪 more protein come across from blood into nephron 🡪 proteinuria
Hypoalbuminaemia – albumin leaves blood
Oedema (periorbital and arms) – oncotic pressure falls due to less protein in blood 🡪 lower osmotic pressure 🡪 water driven out of vessels into tissues
Hyperlipidaemia and lipiduria – loss of protein = less lipid synthesis 🡪 more lipids in blood 🡪 more in urine
What is the criteria for Nephrotic syndrome?
A Px must Fulfil:
Peripheral oedema - due to 3rd spacing
Proteinuria more than 3g / 24 hours
Serum albumin less than 25g / L
Hypercholesterolaemia
What is the main Difference between Nephritic and Nephrotic syndrome?
In Nephritic syndrome - Haematuria predominates
In Nephrotic Syndrome - Proteinuria Predominates
What is the characteristic Presentation Nephritic Syndrome?
Visible Haematuria
(Ribena/coke coloured Pee)
What are the primary investigations for IgA nephropathy?
Immunofluorescence - staining for IgA and C3
Microscopy shows IgA complex deposition
What is the Treatment for IgA nephropathy?
Rapid progression of condition with approx 30% developing ESRF.
ACEi/ARB to control BP and reduce the damage to kidneys.
(can be tried on corticosteroids but doesnt always work)
What is Post strep Glomerulonephritits (PSGN)?
Immunologically-mediated delayed consequence of pharyngitis or skin infections caused by streptococcus pyogenes that leads to glomerulonephritis and consequential Nephritic Syndrome
How long does it take to develop PSGN after infection?
2 weeks after pharyngitis from S. pyogenes
How is PSGN Diagnosed?
Light microscope - hypercellular glomeruli
Immunofluorescence staining - IgG, IgM and C3 deposits along glomerular basement membrane.
Low C3 levels compared to Berger’s Disease which has normal.
What is the treatment of PSGN?
Only Sx management
Self limiting usually
May progress to rapidly progressive GN
Could Use furosemide for HTN
How can SLE cause Nephropathy?
Cause Lupus nephritis secondary to SLE
Deposition of Antigen-antibody complexes and ANA in the kidneys leads to nephritis and a nephritic picture
How is Lupus Nephritis diagnosed?
GS:
renal Biopsy - showing diffuse proliferative glomerulonephritis
Light Microscopy - Hypercellular glomerulus
What is the most common form of Lupus Nephritis?
Diffuse proliferative glomerulonephritis
How is Lupus Nephritis treated?
Lifestyle - stop smoking, exercise, dietary advice
Medication:
Corticosteroids -
Immunosuppressive agents - Azathioprine
Hydroxychloroquine
What is good Pasture’s Syndrome?
Autoimmune disease where there are anti-GBM antibodies that target the lungs and the kidneys causing pulmonary haemorrhage and glomerulonephritis
What is the diagnosis of good pasture’s Syndrome?
Light microscopy may show crescentic glomerulonephritis
Immunofluorescence staining shows linear deposition of IgG along glomerular capillaries
What is the treatment for Goodpasture’s Syndrome?
plasmapheresis,
steroids and cyclophosphamide.
What conditions lead to a nephrotic syndrome clinical pitcutre?
Primary:
Minimal Change Disease
Focal Segmental Glomerulosclerosis
Membranous Nephropathy
Secondary:
Diabetic Nephropathy
What is Minimal Change disease?
Most common cause of nephrotic syndrome in children:
often due to a benign excessive response to steroids
What is the diagnostic findings for Minimal change disease?
Light microscopy - normal/no change
Electron Microscopy - Podocyte effacement + fusion
What is Focal Segmental Glomerulonephritis (FSG)?
Most common cause of nephrotic syndrome in adults:
Associated with HIV, heroin use, sickle cell
What are the diagnostic findings for focal segmental glomerulonephritis?
Light Microscopy - Segmental sclerosis
What is Membranous Nephropathy?
The most common cause of nephrotic syndrome in the elderly:
Associated with malignancy, hepatitis B, NSAIDs, SLE
What are the diagnostic Findings of Membranous Nephropathy?
Light microscopy - Thickened Glomerular BM
Electron Microscopy - Sub epithelial immune complex deposition
Spike + Domeappearance.
What is the characteristic clinical picture of Nephrotic syndrome?
Frothy urine (proteinuria)
Facial and peripheral oedema
Predisposition to thromboembolic disease
+ specific nephrotic signs
How nephrotic syndrome generally treated?
Corticosteroids w/ variable response
Minimal change - very responsive
FSG - responds well generally
Membranous Nephropathy - less responsive
What conditions can cause both a Nephritic and Nephrotic syndrome clinical picture?
Diffuse Proliferative glomerulonephritis
Membranoproliferative Glomerulonephritis
What is obstructive uropathy?
Blockage of urine flow that can affect one or both kidneys depending on the level/site of the blockage
What conditions can cause obstructive uropathy?
BPH and stones
What is the pathogenesis of obstructive uropathy?
Obstruction causes retention of urine.
This increases KUB pressure leading to reflux of backlogged urine into the renal pelvis.
This will lead to hydronephrosis which is more prone to infection
What is the treatment of obstructive uropathy?
Relieve kidney pressure:
Catheterise / ureteral stent
Tx BPH or stones.
What are the main types of GU cancer?
Renal Cell Carcinoma
Bladder Cancer
Prostate Cancer
Testicular Cancer
What is Renal cell Carcinoma?
Renal cell carcinoma (RCC) is the most common type of kidney tumour.
It is a type of adenocarcinoma that commonly arises from the epithelium of the PCT
What is Wilms Tumour?
A specific renal mesenchymal stem cell tumour that affects children typically under 5 years old
(A.K.A Nephroblastoma)
What are the main subtypes of Renal cell carcinoma?
Clear cell (80%)
Papillary (15%)
Chromophobe (5%)
What are the risk factors for Renal cell carcinoma?
Smoking
Obesity
Hypertension
End-stage renal failure
Von Hippel-Lindau Disease
Tuberous sclerosis
How does Renal cell carcinoma typically present?
Often ASx - 25% metastasised at Dx
Typical Triad of Sx:
Flank pain
Haematuria
Abdominal palpable mass
What are the primary investigations for renal cell carcinoma?
1st Line: USS
Gold Standard: CT CAP - Diagnostic
Bloods:
U&Es - renal dysfunction
LFTs - liver mets
LDH - if increased = poor prognosis
What is the treatment for Renal Cell carcinoma?
25% have Mets at Presentation
Partial/Full Nephrectomy
What is the the most common type of kidney cancer in adults?
Renal Cell Carcinoma
What is bladder cancer?
Often a transitional cell carcinoma of the bladder due to the transitional epithelium that lines the renal pelvis, bladder, ureter and urethra
When is a patient more likely to have squamous cell carcinoma of the bladder?
If they have Schistosomiasis infection
What is the most common Transitional cell carcinoma?
Transitional urothelium cancer (bladder cancer)
This lines the renal pelvis and bladder
What are the risk factors for Bladder cancer?
Age >40yrs
Male
Smoking
Occupational Exposure - Dyes/paints/rubber
FHx
What are the symptoms of Bladder cancer?
PAINLESS haematuria (macro/microscopic)
Dysuria (occasionally)
Constitutional Symptoms - weight loss
What are the primary investigations for bladder cancer?
Gold Standard:
Flexible Cytoscopy + biopsy
CT AP - for staging
What is the treatment of bladder cancer?
Conservative - support
Surgical:
Transurethral Resection of Bladder Tumour (TURBT)
Cystectomy - last resort
Medical:
Chemotherapy
Radiotherapy
What is the most common cancer in males?
Prostate cancer
What is the most common type of prostate cancer?
Adenocarcinoma that arises from the peripheral prostate.
These are often neoplastic and malignant which spread to bones
What are the risk factors for prostate cancer?
Environmental
Genetics
Increasing age
Afro-Caribbean ethnicity
FHx - accounts for 8% of cases
Why is there an increase in the prevalence of prostate cancer?
Ageing population
Increased detection
What genetic factors increase a patients risk of prostate cancer?
BRCA2
HOXB13
What is the presentation of prostate cancer?
LUTs (Frequency, Hesitancy, terminal dribbling)
Systemic Cancer Sx (weight loss, fatigue night pain)
Bone pain - suggests metastasised to bone (typically lumbar back pain)
What are the investigations for prostate cancer?
DRE + PSA in community
New First Line:
Multiparametric MRI
Previously Gold Standard:
Transrectal USS + biopsy - Diagnostic
What is the grading system used for prostate cancer?
Gleason Score
High = worse prognosis
What area of the prostate is commonly affected by prostate cancer?
Peripheral zone
What are the common metastatic sites for prostate cancer?
Bones - sclerotic lesions
Brain
Liver
Lungs
What are the primary prevention methods for Prostate cancer?
Screening? - PSA test (benefits dont necessarily outweigh harms of screening)
Chemoprevention - 5 alpha reductase inhibitors
Diet and Supplements
Exercise and weight control
What is the treatment for Prostate cancer?
Local - Prostatectomy/radiotherapy
Advanced- Hormone therapy
Metastatic - surgical/medical castration
What is the purpose of Hormone Therapy in prostate cancer?
Reduce testosterone - reduce cancer growth
What are some options for hormone therapy for prostate cancer?
Surgical:
Bilateral Orchidectomy - Testicular removal (castration)
Medical:
GnRH receptor agonists - Goserelin
Androgen Receptor Blockers - Enzalutamide
How do GnRH receptor agonists work?
Goserelin:
Agonist GnRH and therefore these increase LH and FSH
but this leads to exogenous suppression of the HPG axis
What is the treatment for metastatic prostate cancer?
Surgical Castration
Medical castration (GnRH agonists)
Palliative care
What is the most hormone sensitive cancer?
Prostate cancer
What are the two classes of testicaular tumour?
Germ cell (90%):
Seminoma - most common
Teratoma
Non-Germ Cell (10%):
Sertoli
Leydig
Sarcoma
What is the most common cancer in young men (20-40yrs)
Testicular Cancer
What are the risk factors for testicular cancer?
Cryptorchidism - undescended teste
Infertility
FHx
What is the presentation of Testicular Cancer?
Painless lump in testicle which does NOT transilluminate
May also have:
Sx of hyperthyroidism - BhCG mimics TSH
Bone pain - if bone Mets
Breathlessness - if Lung Mets
What are the primary investigations for testicular cancer?
Urgent (doppler) USS testes (90% diagnostic)
Raised tumour markers:
AFP
BhCG
LDH (Raised non-specifically in tumours)
What is the treatment of Testicular cancer?
ALWAYS 1ST LINE:
Urgent orchidectomy
offer sperm storage
Adjuvant chemotherapy/radiotherapy
What is Polycystic Kidney Disease (PKD)?
Cyst formation throughout the renal parenchyma often leading to bilateral enlargement and damage
Why may a patient have left sided varicocele in renal cell carcinoma?
(and not Right sided)
Left testicular vein drains into the left renal vein; a left RCC can invade the renal vein causing backpressure and varicocele formation
Right testicular vein drains directly into the IVC, therefore a right RCC does not cause a varicocele
What are the types of PKD?
Autosomal Dominant PKD (ADPKD)
Autosomal Recessive PKD (ARPKD)
When does ADPKD typically present?
Often presents in later life/adults
When does ARPKD typically present?
Often presents in neonates and is found on antenatal uss
Which is more common ADPKD or ARPKD?
ADPKD is more common
What are the genetic factors leading to ADPDK?
Mutated PKD1 (85%) or PKD2 (15%) on chromosome 16 and chromosome 4 respectively
Who is typically affected by ADPKD?
More males
What are some features of ARPKD?
Much less common that ADPKD
A disease of infancy/prebirth
High mortality rate
Many congenital abnormalities
What are the genetic factors leading to ARPKD?
Mutation in PKHD1 on chromosome 6
What is the pathogenesis of ARPKD?
Mutation in PKHD1 on chromosome 6
Encodes for Fibrocystin/polyductin protein complex (FPC) which is responsible for the creation of tubules.
Also responsible for maintenance of healthy kidneys liver and pancreas
What are some consequential features of ARPKD?
affects birth development leading to potters syndrome:
Dysmorphic features such as a flattened nose and Clubbed feet
Most Px with ARPKD develop ESRF before adulthood
What is the pathophysiology of ADPKD?
Mutation in PKD1/PKD2 which encode for polycystin Ca channel.
In normal circumstances:
Cilia move when filtrate passes and this causes polycystin to open and allows Ca influx to inhibit excessive growth.
In ADPKD the mutation does not open polycystin so Ca cannot inhibit excessive growth leading to cyst formation
What is the presentation of ADPKD?
Bilateral flank pain
Back or Abdo pain
+/- HTN and Haematuria
Can also cause extra-renal cysts - berry aneurysms
What is the diagnostic investigation of PKD?
Kidney Uss - Enlarged bilateral kidneys with multiple cysts
Genetic testing for PKD mutations
FHx of PKD
What is the management of PKD?
Non-curative
Manage Sx:
HTN - ACEi
ESRF - RRT
What are some ongoing problems throughout life that Px with PKD may have?
Liver failure due to liver fibrosis
Portal hypertension leading to oesophageal varices
Progressive renal failure
Hypertension due to renal failure
Chronic lung disease
What are the common STIs?
Chlamydia
Gonorrhoea
Syphilis
What is Chlamydia?
Chlamydia Trachomatis is a gram negative obligate intracellular parasite.
It is responsible for the STI chlamydia which is the most common STI in the UK
What are risk factors for Chlamydia?
Age < 25
Multiple Sexual partners
Unprotected Sex
Sharing unwashed sex toys
What are the symptoms of Chlamydia?
Commonly ASx (70% of women and 50% of men)
Can present with:
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)
What is the primary investigation for chlamydia?
NAAT
looks for DNA/RNA of chlamydia
What is the treatment for Chlamydia?
doxycycline 100mg twice a day for 7 days.
What are some complications of Chlamydia?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
What is Gonorrhoea?
Caused by Neisseria Gonorrhoea (a gram -tve diplococci) it is the second most common STI in the UK.
It infects columnar epithelium lined mucous membranes of the urethra, rectum, conjunctiva and pharynx and endocervix
What are the risk factors for Gonorrhoea?
Frequent uprotected sex
MSM (men who have sex with men)
multiple sexual partners
What are the symptoms of Gonorrhoea?
More commonly Symptomatic (90% males and 50% females)
Odourless purulent discharge, possibly green or yellow
Dysuria
Pelvic pain
Testicular pain or swelling (epididymo-orchitis)
What are the primary investigations for gonorrhoea?
NAAT
Charcoal endocervical swab and microscopy and culture
What is the treatment for gonorrhoea?
High levels of Abx resistance - why culture is important:
A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
What is Syphilis?
An STI caused by the bacteria Treponema Pallidum.
This can get into the mucous membranes and then disseminate throughout the body
How can Syphilis be contracted?
Oral, vaginal or anal sex involving direct contact with an infected area
Vertical transmission from mother to baby during pregnancy
Intravenous drug use
Blood transfusions and other transplants
What are the stages of syphilis infection?
Primary:
a painless ulcer called a chancre at the original site of infection (usually on the genitals).
Secondary: Systemic Infection
Fever, headaches, maculopapular skin rash and damage to mucous membranes
Tertiary:
Affects many organs of the body and develops gummas, CVD and neurological complications
What are gummas?
granulomatous lesions that can affect the skin, organs and bones
What are the primary diagnostic investigations of syphilis?
Treponemal Antibody testing
Dark Field Microscopy
PCR
What is the treatment for Syphilis
Full screening for other STIs
Advice about avoiding sexual activity until treated
Contact tracing
Prevention of future infections
A single deep intramuscular dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis.
What are some non-cancerous scrotal diseases?
Varicocele
Testicular Torsion
Epididymal Cyst
Hydrocele
What is a Hydrocele?
A hydrocele is a collection of fluid within the tunica vaginalis that surrounds the testes
What are the Examination findings of a Hydrocele?
The testicle is palpable within the hydrocele
Soft, fluctuant and may be large
Irreducible and has no bowel sounds (distinguishing it from a hernia)
Transilluminated by shining torch through the skin, into the fluid (the testicle floats within the fluid)
What is the definitive diagnostic Ix for Hydrocele?
USS scrotum
What is the management of Hydrocele?
Exclude serious causes
Surgery/aspiration to remove fluid
What are some causes of Hydrocele?
Idiopathic
Testicular cancer
Testicular torsion
Epididymo-orchitis
Trauma
What is an Epididymal Cyst?
An extra-testicular cyst found above and behind the testes that WILL transilluminate.
What is the Presentation, Diagnosis and Treatment of an Epididymal Cyst?
Sx - often asymptomatic
Dx - Scrotal Uss
Tx - none (they are harmless). Removal considered if painful
What is a varicocele?
A varicocele occurs where the veins in the pampiniform plexus become swollen. They are common, affecting around 15% of men
What is the pathophysiology of a varicocele?
Varicoceles are the result of increased resistance in the testicular vein.
Incompetent valves in the testicular vein allow blood to flow back from the testicular vein into the pampiniform plexus.
What may a left sided Varicocele suggest?
Renal Cell Carcinoma
therefore check for this.
What are the examination findings of a varicocele?
A scrotal mass that feels like a “bag of worms”
More prominent on standing
Disappears when lying down
Asymmetry in testicular size if the varicocele has affected the growth of the testicle
What is the diagnostic investigation for a varicocele?
Clinical Dx
Doppler USS of Scrotum
What is the management of a Varicocele?
Conservative Mx
Can be surgically treated if painful
What are some potential complications of a Varicocele?
Testicular atrophy
Infertility
What is Testicular Torsion?
Twisting of the spermatic cord with rotation of the testicle.
Can lead to occlusion of the testicular artery leading to ischaemia and necrosis of the testicle
It is a urological emergency, and a delay in treatment increases the risk of ischaemia and necrosis of the testicle, leading to sub-fertility or infertility.
Who is typically affected by Testicular Torsion?
Typical patient is a teenage boy but can occur at any age
What are the symptoms of Testicular Torsion?
Acute rapid onset unilateral testicular pain
abdominal pain
vomiting
What are the examination findings for testicular torsion?
Firm swollen testicle
Elevated (retracted) testicle
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation, so that epididymis is not in normal posterior position
What are risk factors for testicular torsion?
Bell clapper deformity:
what is a bell clapper deformity?
A bell-clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent.
the testicle can the rotate within the tunica vaginalis causing twisting of the spermatic cord
What is the diagnostic Ix of testicular torsion?
if suspected the medical emergency and surgical exploration is always first line
USS doppler can confirm diagnosis but this will delay treatment
What is the treatment for Testicular torsion?
Surgical treatment within 6hrs:
Viable testicle - orchioplexy (untwisting and fixing to scrotal sac)
Unviable testicle - Orchiectomy
What is a testicular appendage torsion?
Twisting of a vestigial appendage (remnant of Mullerian duct) that is located along the testicle.
This appendage has no function, yet more than half of all boys are born with one.
Torsion of this small bit of tissue can cause intense pain that mimics testicular torsion and characteristically causes a ‘blue-dot’ sign, but is often managed conservatively
What are the classifications of lower urinary tract symptoms (LUTS)
Storage Symptoms: FUNI
Frequency
Urgency
Nocturia
Incontinence
Voiding Symptoms: SHIT
Stream poor
Hesitancy
Incomplete Emptying/Straining
Terminal Dribbling
Post Micturition:
Sensation of incomplete voiding.
Post micturition Dribbling
When do storage symptoms and voiding symptoms occur
Storage Sx:
Occur when bladder should be storing urine and therefore Px needs to pee
Voiding Sx:
Occur when bladder outlets obstructed and therefore its hard for Px to pee
What is generally affected by incontinence?
Females
Who is generally affected by Urine retention?
(overflow incontinence)
Males
What are the different types of Incontinence?
Stress (sphincter weakness from pregnancy/trauma) - pee leaks with increased abdo pressure
Urge - detrusor muscle overactivity
Spastic paralysis - UMN lesion
What is the treatment for incontinence?
surgery
Anticholinergic drugs
What are the causes of urinary retention?
Obstruction:
Stones
BPH
Neurological flaccid paralysis
What is the treatment for Urinary retention?
Tx underlying cause
Catheterise
What are the Red flags LUTS?
Haematuria
Proteinuria
What is Detrusor overactivity
urodynamic observation characterized by involuntary detrusor contractions during the filling phase that may be spontaneous or provoked
What drug class are used to treat overactive bladder?
Anti-Cholinergics (inhibit Detrusor contraction)
Oxybutynin
Solifenacin
Mirabegron (beta 3 agonist that Activate relaxation of the detrusor muscle)
What surgical procedure could be used for overactive detrusor muscle?
Cystoplasty
What are the 3 classifications for for neuro-urophysiological dysfunction?
Brain Problems
Supra-sacral spinal problems
Sacral Spinal Problems
What are the 3 spinal reflexes involved in bladder function?
Reflex Bladder Contraction - Sacral micturition centre
Guarding - Onuf’s Nucleus
Receptive relaxation (sympathetic)
Where does co-ordination of voiding occur?
Pontine micturition centre
Allows for completion of voiding.
(However there is a Higher cortical control to decide when to void.)
Peraquductal grey
What is Detrusor Sphincter Dyssynergia?
When there is a supra-sacral spinal cord injury that means that the innervation to the detrusor muscle and external urethral sphincter is lost.
This means the bladder with automatically contract when it fills.
The sphincter will go into the guarding reflex which also leads to contraction of the sphincter
This means that the bladder is contracting whilst the sphincter contracts which can lead to increased pressures and potential serious kidney damage.
What are the aims of management of a neurogenic bladder
Prevent autonomic dysreflexia
Bladder safety
Continence and Sx control.
What is autonomic dysreflexia?
Occurs lesions above T6
Overstimulation of sympathetic NS below level of lesion in response to noxious stimulus
Sx are headache, Severe HTN, Flushing
What is the most common cause of Autonomic Dysreflexia
A full Bladder
How is Autonomic Dysreflexia treated?
Catheterise and the bladder will drain reducing the dysreflexia
What is an Unsafe bladder?
A bladder that will damage the kidneys most commonly due to prolonged high bladder pressure.
What is the target urine output for an adult?
0.5-1.5ml/kg/hr
