Genitourinary Flashcards
What are the NICE criteria for an AKI?
rise in creatinine >25micromols/L in 48 hrs
rise in creatinine >50% in 7 days
urine output <0.5ml/kg/hr
What are the most common causes of AKI?
pre-renal causes
What are the pre-renal causes of AKI?
due to inadequate perfusion of the kidney
- hypotension
- heart failure
- dehydration
What are the renal causes of AKI?
glomerulonephritis
interstitial nephritis
acute tubular necrosis
rhabdomyolosis
tumour lysis syndrome
what are the post-renal causes of AKI?
obstruction of outflow:
- kidney stones
- abdo/pelvic masses (cancer)
- urethral/ureter strictures
- BPH, prostate cancer
What is the first line investigation for AKI?
urinalysis - protein, blood, leukocytes, nitrites, glucose
What would positive leukocytes and nitrites in urinalysis suggest?
infection
What would protein and blood in urine suggest?
acute nephritis (may also be positive in infection)
What would glycosuria be suggestive of?
diabetes
what is the first line management for AKI?
rehydration - IV
stop nephrotoxic drugs
relive obstruction e.g. insert catheter for post-renal causes
What are the nephrotoxic drugs?
Diuretics
ACEi/ARBs
metformin
NSAIDs
What could uraemia as a result of AKI lead to?
encephalopathy or pericarditis
What are the complications of AKI?
hyperkalaemia
fluid overload - heart failure/pulmonary oedema
metabolic acidosis
uraemia
What are some of the causes of CKD?
diabetes
hypertension
NSAIDs, PPIs, lithium
polycystic kidney disease
glomerulonephritis
What signs/symptoms could be present in CKD?
pruritus
nausea
peripheral neuropathy
oedema
loss of appetite
muscle cramps
pallor
What are the first line investigations for CKD?
eGFR - using U&Es
ACR
urine dipstick - haematuria
What investigation can be used in patients with accelerated CKD?
renal ultrasound (polycystic kidney disease)
How is CKD diagnosed with eGFR?
an eGFR <90 on two occasions three months apart
What two scores are used to determine the stage of kidney disease?
G score - eGFR
A score - ACR
What are some of the complications of CKD?
anaemia
renal bone disease
dialysis related problems
cardiovascular disease
peripheral neuropathy
What is the first line treatment for patients with CKD?
ACEi to treat hypertension
What should be monitored in patients with CKD on ACEi?
potassium
both CKD and ACEi cause hyperkalaemia
What are the aims of management of CKD?
slow progression of disease
Reduce cardiovascular risk
reduce risk of complications
treat complications
How would you treat metabolic acidosis?
oral sodium bicarbonate
How would you treat renal bone disease?
Vit D supplementation
low phosphate diet
bisphosphonates
What active form of Vit D are given in renal bone disease?
calcitriol, alfacalcidol
What are the treatments for end stage renal failure?
dialysis and renal transplant
How would you treat anaemia in CKD?
iron supplementation or exogenous erythropoietin
In what ways does CKD cause bone disease?
less metabolism of Vit D to active form
secondary hyperparathyroidism due to low calcium - more osteoclast activity
What are the symptoms of prostate cancer?
LUTS, haematuria, ED
evidence of metastases
What are some of the treatments for prostate cancer?
radical prostatectomy
radiotherapy
hormone blockers
Give an example of a GnRH agonist used to treat advanced prostate cancer
relugolix
What are the two grading systems used for prostate cancer?
Gleason grading
TNM (Tumour, lymph Nodes, Metastases)
How does the gleason grading system work?
looks at the degree of differentiation from cells from a prostate biopsy
How would you treat BPH?
alpha blockers
5-alpha reductase inhibitor
Give and example of an alpha blocker
tamsulosin, doxazosin
Give an example of a 5-alpha reductase inhibitor
finasteride
What is a variocele?
abnormal enlargement of the testicular veins
What is a hydrocele?
fluid in the tunica vaginalis
What are the key presentations of testicular torsion?
unilateral acute testicular pain
swelling
tenderness
What deformity can be a cause of testicular torsion?
bell-clapper deformity, there is not fixation of the testicle to the tunica vaginalis
What is the treatment for testicular torsion?
analgesia
orchiopexy (correction of position)
orchidectomy if necrosed
What are the key presentations of epididymitis?
unilateral acute testicular pain
What are the causes of epididymitis?
STI pathogens
E. coli
mumps
What is it called when epididymis spreads to the testes?
epididymo-orchitis
What are some of the investigation you could do for epididymitis?
urine microscopy
nucleic acid amplification testing (gonorrhoea/chlamydia)
salival (mumps) /charcoal swabs (discharge)
What antibiotics would you use for epididymitis where it is caused by and enteric organism (e.coli)
doxycycline
OR
ofloxacin
OR
ciprofloxacin
What combination of antibiotics would you use for epididymitis caused by a sexually transmitted infection?
IM ceftriaxone (gonorrhoea)
doxycycline (chlamydia)
Give an example of (fluoro)quinolone antibiotics
ofloxacin
levofloxacin
ciprofloxacin
What type of antibiotic are quinolone antibiotics?
powerful broad spectrum, gram negative cover
What is ofloxacin commonly used to treat?
UTIs, pyelonephritis, epididymo-orchitis and prostatitis
What are the side effects of quinolone antibiotics?
tendon damage/rupture
lower seizure threshold (caution in patients with epilepsy)
Where do epididymal cysts occur?
the head of the epididymis
What is the treatment for uncomfortable or painful epididymal cysts?
removal
What are the two types of testicular cancer?
seminomas
non-seminomas (mainly teratomas)
What are the presentations of testicular cancer?
non-tender, hard, irregular lump with no transillumination
rarely: gynaecomastia
What is the initial investigation for suspected testicular cancer?
scrotal ultrasound
What serum tumour marker may be present in teratomas?
alpha fetoprotein
What serum tumour marker may be present in both seminomas and teratomas?
beta-hCG
What staging system is used for testicular cancer?
Royal Marsden staging system
What surgical procedure can be used to treat testicular cancer?
radical orchidectomy
What are the features of someone with nephritic syndrome?
haematuria
oliguria
proteinuria <3g/24hrs
fluid retention
What are the criteria for a patient to have nephrotic syndrome?
peripheral oedema
proteinuria >3g/24hrs
serum albumin <25g/L
hypercholesterolaemia
What are the presentations of someone with nephrotic syndrome?
oedema
frothy urine (proteinuria)
What is interstitial nephritis?
inflammation between the cells and tubules in the kidney
What are the two specific diagnoses of interstitial nephritis?
acute interstitial nephritis and chronic tubulointerstitial nephritis
What is glomerulosclerosis?
scarring of the tissue in the glomerulus
What can cause glomerulosclerosis?
any type of glomerulonephritis or obstructive uropathy
How is glomerulonephritis normally treated?
steroids (prednisone)
ACEi - to lower bp
What is the most common cause of nephrotic syndrome in children?
minimal change disease
What is the most common cause of nephrotic syndrome in adults?
focal segmental glomerulosclerosis
What is the most common cause of nephrotic syndrome in adults?
focal segmental glomerulosclerosis
How is nephrotic syndrome normally treated?
steroids - prednisone
What is the most common cause of primary glomerulonephritis?
IgA nephropathy
How would you diagnose IgA nephropathy?(bergers disease)
histology - IgA deposits in mesangium
What is the most common cause of glomerulonephritis?
membranous glomerulonephritis
What are the causes of membranous glomerulonephritis?
idiopathic
secondary to malignancy, NSAIDS, rheumatoid disorders
What would biopsy show in membranous glomerulonephritis?
IgG and complement deposits in basement membrane
How does post-streptococcal glomerulonephritis (diffuse proliferative glomerulonephritis) present?
nephritic syndrome 1-3 weeks after strep infection
What causes goodpasture sydrome?
Anti-GBM (glomerular basement membrane) attacks glomerulus and pulmonary basement membranes
What are the key presentations of Goodpasture syndrome?
glomerulonephritis, pulmonary haemorrhage
will present with AKI and haemoptysis (coughing up blood)
How would patients with Wegeners granulomatosis (granulomatosis with polyangiitis) present?
AKI, haemoptysis, wheeze, sinusitis, saddle shaped nose
What are some of the risk factors for bladder cancer?
smoking, exposure to aromatic amines - used to be used in dye and rubber manufacture
What are the two most common types of bladder cancer?
transitional cell carcinoma (90%)
squamous cell carcinoma (5% - often caused by schistosomiasis)
What is the key symptom of bladder cancer?
painless haematuria
What are the NICE guidelines on suspected bladder cancer in over 45 yr olds?
2 week wait referral if:
haematuria without UTI or persisting after UTI treatment
What are the NICE guidelines on suspected bladder cancer in over 60 yr olds?
2 week wait referral if:
haematuria +
dysuria (painful/difficult urination) OR raised WCC
What investigation is used for bladder cancer?
cystoscopy
What staging system is used for bladder cancer?
TNM (tumour, nodes, metastases)
What surgical procedure can be used to treat non-muscle invasive bladder cancer?
transurethral resection of bladder tumour (TURBT)
What more drastic surgical treatment may be used for bladder cancer?
radical cystectomy
What intravesical treatments are there for bladder cancer?
intravesical chemotherapy and BCG
What is the most common procedure to have done after a cystectomy?
urostomy with ileal conduit
What is the classic triad of symptoms associated with renal cell carcinoma?
haematuria, flank pain and palpable mass
Where is a common site for renal cancers to metastasise?
lungs - cannonball metastases
What paraneoplastic features may be present with renal cell carcinoma?
polycythaemia - increased EPO
hypercalcaemia - tumour mimics parathyroid
hypertension - renin increase
Stauffers syndrome - abnormal LFTs without liver metastases
What staging system is used in renal cell carcinoma?
TNM or numbered system (stages 1-4)
What surgical procedures are used for renal cell carcinoma?
radical nephrectomy
partial mephrectomy
What other, less invasive treatments are used for renal cell carcinoma?
arterial embolisation - cut off blood supply
percutaneous cryotherapy
radiofrequency ablation
What are the 5 most common pathogens that cause UTIs? (KEEPS)
Klebsiella
E. coli
enterococcus
proteus
staphylococcus coagulase negative
What are the extra symptoms a patient might present with in pyelonephritis?
fever, loin/back pain, nausea/vomiting
What would urinalysis show in UTIs/pyelonephritis?
nitrites, leukocytes, blood
What is the main investigation for UTIs/pyleonephritis?
midstream urine (MSU) for microscopy, culture and sensitivity testing
What is the treatment for UTIs/pyelonephritis?
cefalexin (pyelonephritis)
nitrofurantoin (UTIs)
What should be immediately done for patients arriving in the hospital with sepsis?
sepsis six
3 tests
3 treatments
What are the three tests that should be done in patients with sepsis?
blood lactate and cultures
urine output
What are the three treatments that should be done for patients with sepsis?
oxygen to maintain sats at 94-98%
empirical broad spectrum abx IV
IV fluids
what could be the problem in a patient with suspected pyelonephritis who is not responding to treatment?
renal abscess
kidney stone obstructing ureter
What are the presentations of cystitis?
dysuria, cloudy, smelly urine, frequency and urgency
how would you investigate cystitis (bladder pain syndrome)?
urinalysis
cytoscopy
swabs (STIs)
DRE
What are the key presentations of prostatitis?
tender prostate on DRE
systemic symps - fever, chills, malaise
What antibiotics are used for prostatitis?
ciprofloxacin or ofloxacin or trimethoprim
What test is used to diagnose chlamydia and gonorrhoea?
nucleic acid amplification test (swab)
What is the antibiotic used for chlamidyia?
doxycycline 100mg twice daily for a week
What type of swab would be taken to allow for microscopy and cultures?
charcoal swab
What is the 1st line treatment for gonorrhoea?
IM ceftriaxone
Where do kidney stones commonly get stuck?
vesico-ureteric junction
What are most kidney stones made of?
calcium oxalate
Name two risk factors for developing kidney stones
hypercalcaemia and low urine output
What is type of kidney stone is usually seen in patients with recurrent UTIs?
struvite
What is it called when a kidney stone forms in the shape of the renal pelvis?
staghorn calculus
What are the typical presentations of kidney stones?
unilateral loin to groin pain
colicky (as the stone moves)
What would a urine dipstick show in kidney stones?
haematuria
What is the initial investigation to diagnose kidney stones?
non contrast CT kidney, ureters and bladder (CTKUB)
What three things could cause kidney stones?
calcium supplementation, hyperparathyroidism, cancer (myeloma, breast/lung cancer)
What is the most effective analgesia to use for kidney stones?
NSAID - IM diclofenac
What alpha blocker can be used to help spontaneous passing of kidney stones?
tamsulosin
Above what size of kidney stones are surgical interventions often necessary?
10mm
What surgical interventions can be used to remove kidney stones?
extracorporeal shock wave lithotripsy (ESWL)
ureteroscopy and laser lithotripsy
What preventative medications can be given to patients with recurring calcium oxalate stone?
potassium citrate
thiazide diuretics (indapamide)
What is the first line treatment for chronic kidney disease?
ACEi - ramipril
How can diabetes effect the kidneys?
high levels of glucose cause scarring of the glomerulus - glomerulosclerosis
What substances can directly damage the kidneys?
radiology contrast dye
gentamycin
NSAIDs
What might cause ischaemia secondary to hypoperfusion in the kidney?
sepsis
shock
dehydration
What would be found in urinalysis that is indicative of renal tubular necrosis?
muddy brown casts
What is the most common cause of renal tubular acidosis?
type 4 - reduced aldosterone
Why might aldosterone be reduced?
Addisons, ACEi, spironolactone, SLE, diabetes, HIV
How would you treat renal tubular acidosis?
fludrocortisone
What is haemolytic uraemic syndrome (HUS)?
thrombosis in the small vessels of the body causing thrombocytopenia
AKI causing uraemia
haemolytic anaemia
What is the usual cause of HUS?
shiga toxin, produced by E. coli
What is rhabdomyolysis?
skeletal muscle breakdown and release of breakdown products in blood
What do muscles release when broken down?
myoglobin
potassium
phosphate
creatine kinase
What can cause rhabdomyolysis?
prolonged immobility
vigorous exercise beyond person capability
crush injuries
seizures
what is the first line management for rhabdomyolysis?
IV fluids
How is polycystic kidney disease diagnosed?
ultrasound and genetic testing
What inheritance patterns can PKD be?
autosomal dominant or recessive
What medication can slow the progression of autosomal dominant PKD?
tolvaptan (vasopressin receptor antagonists)
