Genitourinary Flashcards

1
Q

What are the major functions of the Kidney?

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the Glomerular Filtrate rate?

A

The volume of fluid filtered from the glomeruli into Bowman’s space per unit
time (minutes)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the normal GFR?

A

120ml/min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is Nephrolithiasis?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are some other types of renal stone compared to calcium oxalate?

A

Calcium phosphate/oxalate (80%)
Uric Acid (10%)
Cysteine Stones
Struvite (infection often from proteus)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the 3 main narrowing’s where renal stones may be found?

A
  • Pelviureteric junction
  • Pelvic brim
  • Vesicoureteric junction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the epidemiology of Renal Stones?

A

10-15% lifetime risk
More common in males
Peak age 20-40 yrs
Increasing Incidence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the risk factors for renal stones?

A

Chronic Dehydration
Low urine output
Primary kidney disease
HyperPTH/Hypercalcaemia
UTIs
Hx of previous renal stone
Drugs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the main causes for renal stones?

A

Anatomical:
Congenital - horseshoe kidney
Acquired - Obstruction, trauma, reflux

Urinary Factors:
Metastable urine
Increased Calcium oxalate, urate, cystine
Dehydration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the pathophysiology of renal stones?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the 2 key complications of renal stones?

A

Obstruction - leading to AKI

Infection - causing obstructive pyelonephritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the presentation of Renal Stones?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is Colicky Pain?

A

Pain that fluctuates in severity often due to peristalsis causing contaction of gallstones/renal stones which then settles when the contraction stops

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the symptoms of Renal Colic?

A

Loin to groin pain
Px cannot lie still

Haematuria/dysuria
Nausea or vomiting
Reduced urine output (LUTS)
Symptoms of sepsis, if infection is present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the primary investigations for Renal stones?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What investigation would be used for hydronephrosis from a suspected renal stone for a Px who is pregnant?

A

Ultrasound as they cannot have CT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

How can a kidney be drained if infected?

A

Ureteric stend
Nephrostomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is the Treatment for Renal Stones?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is a key complication of kidney stones?

A

Pyonephrosis
- Pus filled fluid caused by infection and obstruction together.

Tx with septic six

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What Treatment is used if a stone is too large to pass spontaneously?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is a big issue once you have had one renal stone?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are some differential Diagnoses for Loin pain other than Renal Colic?

A

Vascular accident - Ruptured AAA
Bowel Pathology - diverticulitis, appendicitis
Gynae - Ectopic pregnancy
Testicular torsion
MSK pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is the treatment for bladder stones?

A

Conservative - asymptomatic
Endoscopic + BOO Tx
Open Laparoscopic surgery - for large stones

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is Acute Kidney Injury (AKI)?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What is the mortality rate for AKI?
25-30%
26
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
27
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
28
What is the old staging classification system for AKI?
RIFLE: * Risk * Injury * Failure * Loss * End-stage renal disease
29
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
30
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
31
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
32
What are the commonest causes of AKI?
Cardiogenic shock Major Surgery Nephrotoxins Sepsis
33
Give some Pre-renal causes of AKI?
Dehydration Hypotension (shock) Heart failure
34
Give some Renal Causes of AKI?
Glomerulonephritis Interstitial nephritis Acute tubular necrosis Nephrotoxic Drugs (DAMN)
35
What are the DAMN drugs that cause nephrotoxicity?
Diuretics ACEis/ARBs Metformin NSAIDs
36
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
37
Give some examples of drugs that are nephrotoxic
NSAIDs ACEi ARBs Aminoglycosides - gentamicin Diuretics
38
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
39
What substances will accumulate in AKI?
K+ - hyperkalaemia - arrythmias Urea - Hyperuraemia - Pruritis and confusion Fluid - oedema - pulmonary and peripheral H+ - acidosis
40
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
41
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
42
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
43
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
44
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)
45
What are the indications for RRT?
Acidosis (pH < 7.1) Fluid overload (oedema) Uremia that is symptomatic Hyperkalaemia >6.5 or ECG changes
46
What are some potential complications of RRT?
CVD - MI Infection
47
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
48
What is Chronic Kidney Disease (CKD)?
Progressive decline in renal Function where GFR <60ml/Min for more than 3 months
49
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
50
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
51
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”)
52
What are the best readings to quantify CKD?
eGFR Urine Albumin:Creatine Ratio (ACR)
53
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
54
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
55
What are the clinical signs of CKD?
Hypertension Pallor Fluid Overload Evidence of underlying aetiology
56
What is the prognosis of CKD correlated with?
Poorly controlled HTN Proteinuria Degree of scarring on histology
57
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
58
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)
59
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
60
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
61
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
62
How can CKD progression be slowed?
Optimise diabetic control Optimise hypertensive control Treat glomerulonephritis
63
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
64
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
65
What are the classifications of UTIs?
Upper UTI: Kidneys - Pyelonephritis Lower UTI: Bladder - Cystitis Prostate - Prostatitis Epidiymo-Orchiditis Urethra - Urethritis Uncomplicated Vs Complicated
66
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
67
What is the most common cause of a UTI?
UPEC: Uropathogenic Escherichia coli (80% of uncomplicated UTIs)
68
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
69
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
70
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
71
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
72
What would you look for on microscopy in a MC + S)?
WBC >10^4 wbc/ml Bacteria >10^5 cfu/ul = infection RBCs
73
What are some common Abx used to treat UTIs in the community?
Nitrofurantoin (now more commonly used) Trimethoprim + Amoxicillin, Cefalexin
74
Why is Trimethoprim used less to treat UTIs these days?
Due to much higher levels of antibiotic resistance
75
What is the treatment for someone who is 65yrs + and has asymptomatic bacteriuria?
Do NOT treat
76
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
77
What is Pyelonephritis?
Upper UTI of the renal parenchyma and upper ureter at the renal pelvis
78
When would you avoid treating a UTI with Trimethoprim?
First trimester of pregnancy as it interferes with folic acid synthesis
79
When would you avoid treating a UTI with Nitrofurantoin?
Third trimester of pregnancy as there is a risk of Neonatal Haemolysis
80
What do UTIs during pregnancy increase the risk of?
Pyelonephritis Premature rupture of membranes Pre-term Labour
81
What is a major risk of catheterisation?
Become colonised with bacteria within a few days. Can cause serious UTIs
82
What are some complications of long term cathetisation?
UTIs/Pyelonephritis Stones Obstruction Chronic Inflammation
83
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
84
What is the most common causative organism of Pyelonephritis?
E.coli
85
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
86
What is the classical presentation of Pyelonephritis?
Triad: Loin Pain Fever Pyuria - pus in pee + nausea/vomiting Anorexia Haematuria Renal angle Tenderness
87
What is the primary investigation for Pyelonephritis?
1st Line: Urine Dipstick Gold Standard: Urine MC+S USS - rule out obstructions
88
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)
89
What are some complications for Pyelonephritis?
Renal Abscesses (common in diabetics) Emphysematous Pyelonephritis
90
What are the main symptoms of lower UTI?
Dysuria Frequency
91
What is Cystitis?
Urinary infection of the bladder Commonly due to UPEC
92
Who is affected by Cystitis?
More common in women Can occur in children
93
What are the risk factors for Cystitis?
- Urinary obstruction resulting in urinary stasis - Previous damage to bladder epithelium - Bladder stones - Poor bladder emptying
94
What is a classical presentation of Cystitis?
Suprapubic tenderness + discomfort Increased frequency Increase urgency Visible Haematuria
95
What is the primary Investigations to diagnose Cystitis?
1st Line: Urine Dipstick Gold Standard: Urine MC+S
96
What is the treatment for Cystitis?
First line: Trimethoprim/Nitrofurantoin Cefalexin Second Line: Co-amoxiclav/Ciprofloxacin
97
What is Urethritis?
Inflammation in the urethra due to infection
98
What is the most common cause of Urethritis?
Sexually acquired condition: Non-Gonococcal (Chlamydia) - More common Gonococcal - Less common Non infective - trauma
99
What are the risk factors for Urethritis?
Male Gay sex Unprotected sex
100
What is the presentation of Urethritis?
Dysuria +/- urethral discharge (blood/pus) Urethral pain
101
What is the diagnostic test for Urethritis?
NAAT (Nucleic Acid Amplification Test) - detects STI pathogen (NG/CT) Urine Dipstick + Urine MC+S if UTI
102
What is the treatment for urethritis?
N.G - IM Ceftriaxone + Azithromycin C.T - Azithromycin (or Doxycycline)
103
What is Epididymo-Orchitis?
Inflammation of the epididymus which extends to the testes often secondary to urethritis (STI) or Cystitis.
104
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)
105
What diagnostic investigations are done for Epididymo-Orchitis?
NAAT Urine Dipstick Urine MC+S
106
What is the treatment for Epididymo-Orchitis?
Depends on underlying cause: STI/UTI to determine Abx
107
What is an uncomplicated UTI?
A UTI in a healthy NON-PREGNANT women with a normally functioning urinary tract
108
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
109
What is significant about complicated UTIs?
Treatment failure is more likely Complications are more likely: Renal papillary necrosis Renal Abscesses
110
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
111
What are the risk factors for BPH?
Increased age Afro-Caribbean (increased testosterone) Castration is protective
112
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
113
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
114
What are symptoms of Urinary Storage?
Fequency Urgency Nocturia (>30%) Incontinence
115
What are symptoms of urinary Voiding?
Poor stream Dribbling Incomplete emptying Straining Dysuria
116
What complications may arise in BPH if the urethra is completely occluded?
Auria - no urination Retention Hydronephrosis UTI Stones
117
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)
118
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
119
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
120
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
121
What is a side effect of Tamsulosin?
Postural Hypertension
122
What is the mechanism of action of Finasteride?
5-alpha reductase inhibitor that will block conversion of testosterone to dihydrotestosterone to reduce prostatic growth
123
What is a common complication of transurethral resection of prostate surgery?
Retrograde ejaculation.
124
What is Glomerular Disease?
Glomerulonephritis refers to groups of parenchymal kidney diseases that all result in the inflammation of glomeruli and nephrons
125
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
126
What are the classifications of Glomerulonephritis?
Nephrotic Syndrome Nephritic Syndrome (acute GN) Rapidly Progressive GN
127
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.
128
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)
129
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
130
What is the most common cause of Nephritic Syndrome?
IgA Nephropathy
131
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.
132
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
133
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.
134
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.
135
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
136
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
137
What is the main Difference between Nephritic and Nephrotic syndrome?
In Nephritic syndrome - Haematuria predominates In Nephrotic Syndrome - Proteinuria Predominates
138
What is the characteristic Presentation Nephritic Syndrome?
Visible Haematuria (Ribena/coke coloured Pee)
139
What are the primary investigations for IgA nephropathy?
Immunofluorescence - staining for IgA and C3 Microscopy shows IgA complex deposition
140
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)
141
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
142
How long does it take to develop PSGN after infection?
2 weeks after pharyngitis from S. pyogenes
143
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.
144
What is the treatment of PSGN?
Only Sx management Self limiting usually May progress to rapidly progressive GN Could Use furosemide for HTN
145
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
146
How is Lupus Nephritis diagnosed?
GS: renal Biopsy - showing diffuse proliferative glomerulonephritis Light Microscopy - Hypercellular glomerulus
147
What is the most common form of Lupus Nephritis?
Diffuse proliferative glomerulonephritis
148
How is Lupus Nephritis treated?
Lifestyle - stop smoking, exercise, dietary advice Medication: Corticosteroids - Immunosuppressive agents - Azathioprine Hydroxychloroquine
149
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
150
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
151
What is the treatment for Goodpasture's Syndrome?
plasmapheresis, steroids and cyclophosphamide.
152
What conditions lead to a nephrotic syndrome clinical pitcutre?
Primary: Minimal Change Disease Focal Segmental Glomerulosclerosis Membranous Nephropathy Secondary: Diabetic Nephropathy
153
What is Minimal Change disease?
Most common cause of nephrotic syndrome in children: often due to a benign excessive response to steroids
154
What is the diagnostic findings for Minimal change disease?
Light microscopy - normal/no change Electron Microscopy - Podocyte effacement + fusion
155
What is Focal Segmental Glomerulonephritis (FSG)?
Most common cause of nephrotic syndrome in adults: Associated with HIV, heroin use, sickle cell
156
What are the diagnostic findings for focal segmental glomerulonephritis?
Light Microscopy - Segmental sclerosis
157
What is Membranous Nephropathy?
The most common cause of nephrotic syndrome in the elderly: Associated with malignancy, hepatitis B, NSAIDs, SLE
158
What are the diagnostic Findings of Membranous Nephropathy?
Light microscopy - Thickened Glomerular BM Electron Microscopy - Sub epithelial immune complex deposition Spike + Domeappearance.
159
What is the characteristic clinical picture of Nephrotic syndrome?
Frothy urine (proteinuria) Facial and peripheral oedema Predisposition to thromboembolic disease + specific nephrotic signs
160
How nephrotic syndrome generally treated?
Corticosteroids w/ variable response Minimal change - very responsive FSG - responds well generally Membranous Nephropathy - less responsive
161
What conditions can cause both a Nephritic and Nephrotic syndrome clinical picture?
Diffuse Proliferative glomerulonephritis Membranoproliferative Glomerulonephritis
162
What is obstructive uropathy?
Blockage of urine flow that can affect one or both kidneys depending on the level/site of the blockage
163
What conditions can cause obstructive uropathy?
BPH and stones
164
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
165
What is the treatment of obstructive uropathy?
Relieve kidney pressure: Catheterise / ureteral stent Tx BPH or stones.
166
What are the main types of GU cancer?
Renal Cell Carcinoma Bladder Cancer Prostate Cancer Testicular Cancer
167
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
168
What is Wilms Tumour?
A specific renal mesenchymal stem cell tumour that affects children typically under 5 years old (A.K.A Nephroblastoma)
169
What are the main subtypes of Renal cell carcinoma?
Clear cell (80%) Papillary (15%) Chromophobe (5%)
170
What are the risk factors for Renal cell carcinoma?
Smoking Obesity Hypertension End-stage renal failure Von Hippel-Lindau Disease Tuberous sclerosis
171
How does Renal cell carcinoma typically present?
Often ASx - 25% metastasised at Dx Typical Triad of Sx: Flank pain Haematuria Abdominal palpable mass
172
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
173
What is the treatment for Renal Cell carcinoma?
25% have Mets at Presentation Partial/Full Nephrectomy
174
What is the the most common type of kidney cancer in adults?
Renal Cell Carcinoma
175
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
176
When is a patient more likely to have squamous cell carcinoma of the bladder?
If they have Schistosomiasis infection
177
What is the most common Transitional cell carcinoma?
Transitional urothelium cancer (bladder cancer) This lines the renal pelvis and bladder
178
What are the risk factors for Bladder cancer?
Age >40yrs Male Smoking Occupational Exposure - Dyes/paints/rubber FHx
179
What are the symptoms of Bladder cancer?
PAINLESS haematuria (macro/microscopic) Dysuria (occasionally) Constitutional Symptoms - weight loss
180
What are the primary investigations for bladder cancer?
Gold Standard: Flexible Cytoscopy + biopsy CT AP - for staging
181
What is the treatment of bladder cancer?
Conservative - support Surgical: Transurethral Resection of Bladder Tumour (TURBT) Cystectomy - last resort Medical: Chemotherapy Radiotherapy
182
What is the most common cancer in males?
Prostate cancer
183
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
184
What are the risk factors for prostate cancer?
Environmental Genetics Increasing age Afro-Caribbean ethnicity FHx - accounts for 8% of cases
185
Why is there an increase in the prevalence of prostate cancer?
Ageing population Increased detection
186
What genetic factors increase a patients risk of prostate cancer?
BRCA2 HOXB13
187
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)
188
What are the investigations for prostate cancer?
DRE + PSA in community New First Line: Multiparametric MRI Previously Gold Standard: Transrectal USS + biopsy - Diagnostic
189
What is the grading system used for prostate cancer?
Gleason Score High = worse prognosis
190
What area of the prostate is commonly affected by prostate cancer?
Peripheral zone
191
What are the common metastatic sites for prostate cancer?
Bones - sclerotic lesions Brain Liver Lungs
192
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
193
What is the treatment for Prostate cancer?
Local - Prostatectomy/radiotherapy Advanced- Hormone therapy Metastatic - surgical/medical castration
194
What is the purpose of Hormone Therapy in prostate cancer?
Reduce testosterone - reduce cancer growth
195
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
196
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
197
What is the treatment for metastatic prostate cancer?
Surgical Castration Medical castration (GnRH agonists) Palliative care
198
What is the most hormone sensitive cancer?
Prostate cancer
199
What are the two classes of testicaular tumour?
Germ cell (90%): Seminoma - most common Teratoma Non-Germ Cell (10%): Sertoli Leydig Sarcoma
200
What is the most common cancer in young men (20-40yrs)
Testicular Cancer
201
What are the risk factors for testicular cancer?
Cryptorchidism - undescended teste Infertility FHx
202
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
203
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)
204
What is the treatment of Testicular cancer?
ALWAYS 1ST LINE: Urgent orchidectomy offer sperm storage Adjuvant chemotherapy/radiotherapy
205
What is Polycystic Kidney Disease (PKD)?
Cyst formation throughout the renal parenchyma often leading to bilateral enlargement and damage
206
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
207
What are the types of PKD?
Autosomal Dominant PKD (ADPKD) Autosomal Recessive PKD (ARPKD)
208
When does ADPKD typically present?
Often presents in later life/adults
209
When does ARPKD typically present?
Often presents in neonates and is found on antenatal uss
210
Which is more common ADPKD or ARPKD?
ADPKD is more common
211
What are the genetic factors leading to ADPDK?
Mutated PKD1 (85%) or PKD2 (15%) on chromosome 16 and chromosome 4 respectively
212
Who is typically affected by ADPKD?
More males
213
What are some features of ARPKD?
Much less common that ADPKD A disease of infancy/prebirth High mortality rate Many congenital abnormalities
214
What are the genetic factors leading to ARPKD?
Mutation in PKHD1 on chromosome 6
215
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
216
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
217
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
218
What is the presentation of ADPKD?
Bilateral flank pain Back or Abdo pain +/- HTN and Haematuria Can also cause extra-renal cysts - berry aneurysms
219
What is the diagnostic investigation of PKD?
Kidney Uss - Enlarged bilateral kidneys with multiple cysts Genetic testing for PKD mutations FHx of PKD
220
What is the management of PKD?
Non-curative Manage Sx: HTN - ACEi ESRF - RRT
221
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
222
What are the common STIs?
Chlamydia Gonorrhoea Syphilis
223
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
224
What are risk factors for Chlamydia?
Age < 25 Multiple Sexual partners Unprotected Sex Sharing unwashed sex toys
225
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)
226
What is the primary investigation for chlamydia?
NAAT looks for DNA/RNA of chlamydia
227
What is the treatment for Chlamydia?
doxycycline 100mg twice a day for 7 days.
228
What are some complications of Chlamydia?
Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis
229
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
230
What are the risk factors for Gonorrhoea?
Frequent uprotected sex MSM (men who have sex with men) multiple sexual partners
231
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)
232
What are the primary investigations for gonorrhoea?
NAAT Charcoal endocervical swab and microscopy and culture
233
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
234
What is Syphilis?
An STI caused by the bacteria Treponema Pallidum. This can get into the mucous membranes and then disseminate throughout the body
235
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
236
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
237
What are gummas?
granulomatous lesions that can affect the skin, organs and bones
238
What are the primary diagnostic investigations of syphilis?
Treponemal Antibody testing Dark Field Microscopy PCR
239
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.
240
What are some non-cancerous scrotal diseases?
Varicocele Testicular Torsion Epididymal Cyst Hydrocele
241
What is a Hydrocele?
A hydrocele is a collection of fluid within the tunica vaginalis that surrounds the testes
242
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)
243
What is the definitive diagnostic Ix for Hydrocele?
USS scrotum
244
What is the management of Hydrocele?
Exclude serious causes Surgery/aspiration to remove fluid
245
What are some causes of Hydrocele?
Idiopathic Testicular cancer Testicular torsion Epididymo-orchitis Trauma
246
What is an Epididymal Cyst?
An extra-testicular cyst found above and behind the testes that WILL transilluminate.
247
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
248
What is a varicocele?
A varicocele occurs where the veins in the pampiniform plexus become swollen. They are common, affecting around 15% of men
249
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.
250
What may a left sided Varicocele suggest?
Renal Cell Carcinoma therefore check for this.
251
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
252
What is the diagnostic investigation for a varicocele?
Clinical Dx Doppler USS of Scrotum
253
What is the management of a Varicocele?
Conservative Mx Can be surgically treated if painful
254
What are some potential complications of a Varicocele?
Testicular atrophy Infertility
255
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.
256
Who is typically affected by Testicular Torsion?
Typical patient is a teenage boy but can occur at any age
257
What are the symptoms of Testicular Torsion?
Acute rapid onset unilateral testicular pain abdominal pain vomiting
258
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
259
What are risk factors for testicular torsion?
Bell clapper deformity:
260
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
261
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
262
What is the treatment for Testicular torsion?
Surgical treatment within 6hrs: Viable testicle - orchioplexy (untwisting and fixing to scrotal sac) Unviable testicle - Orchiectomy
263
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
264
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
265
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
266
What is generally affected by incontinence?
Females
267
Who is generally affected by Urine retention?
(overflow incontinence) Males
268
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
269
What is the treatment for incontinence?
surgery Anticholinergic drugs
270
What are the causes of urinary retention?
Obstruction: Stones BPH Neurological flaccid paralysis
271
What is the treatment for Urinary retention?
Tx underlying cause Catheterise
272
What are the Red flags LUTS?
Haematuria Proteinuria
273
What is Detrusor overactivity
urodynamic observation characterized by involuntary detrusor contractions during the filling phase that may be spontaneous or provoked
274
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)
275
What surgical procedure could be used for overactive detrusor muscle?
Cystoplasty
276
What are the 3 classifications for for neuro-urophysiological dysfunction?
Brain Problems Supra-sacral spinal problems Sacral Spinal Problems
277
What are the 3 spinal reflexes involved in bladder function?
Reflex Bladder Contraction - Sacral micturition centre Guarding - Onuf's Nucleus Receptive relaxation (sympathetic)
278
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
279
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.
280
What are the aims of management of a neurogenic bladder
Prevent autonomic dysreflexia Bladder safety Continence and Sx control.
281
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
282
What is the most common cause of Autonomic Dysreflexia
A full Bladder
283
How is Autonomic Dysreflexia treated?
Catheterise and the bladder will drain reducing the dysreflexia
284
What is an Unsafe bladder?
A bladder that will damage the kidneys most commonly due to prolonged high bladder pressure.
285
What is the target urine output for an adult?
0.5-1.5ml/kg/hr