Genitourinary Flashcards
When taking a prostate history, what are some symptoms of obstructive problems?
Poor flow
Hesitancy
Post micturitional dribbling
Incomplete voiding
When taking a prostate history, what are some symptoms of inflammatory problems?
Dysuria
What can cause acute urinary retention?
- Prostatic obstruction
- Urethral strictures
- Anticholinergics
- Constipation
- Post-op
- Infection
What can cause chronic urinary retention?
- Prostatic enlargement (carcinoma, BPH)
- Pelvic malignancy
- CNS disease
What is BPH?
Nodular or diffuse proliferation of the prostate - typically the inner zone enlarges (in contrast to peripheral layer in carcinoma), fuelled by testosterone.
What are the symptoms of BPH?
Nocturia, frequency, urgency, dribbling, poor flow, hesitancy, overflow incontinence, haematuria, bladder stones, UTI
How is BPH managed?
Conservative - avoid caffeine, alcohol
Medical - a-blocker, 5a-reductase inhibitors (finasteride)
Surgical - catheters, resection/incision of prostate
What investigations should be done in somebody with urinary symptoms, in which you suspect prostate problems?
- International prostate symptom score
- Urinalysis
- FBC, U&E, PSA
- Flow rate and residual volume
- DRE
What are you assessing in a DRE?
Anal tone
Rectal wall and contents
Prostate surface, size, symmetry and consistency
What causes a raised PSA?
BPH, prostatitis, prostate cancer
What is prostatitis?
Inflammation of the prostate causing UTI, retention, pain, haematospermia and a swollen/boggy prostate
What organism commonly causes prostatitis?
E. coli and S. faecalis
Treat with levofloxacin
What is epididymo orchitis?
Pain, swelling and inflammation of the epididymus and testes, most commonly due to:
- STD (gonorrhoea/chlamydia)
- UTI (E.coli)
What is balanitis, and what is it associated with?
Acute inflammation of the foreskin and glans.
Associated with staph and strep infections and diabetes
What is phimosis and what is it associated with?
Narrowing of the foreskin so that it can’t be retracted, causing recurrent banalities.
Associated with painful intercouse
What is paraphimosis?
Foreskin can no longer be pulled forward over the penile tip, leading to oedema and ichaemia
Describe the typical prostate cancer, and its risk factors?
Adenocarcinoma, arising in the peripheral zone of the prostate
RF: family history, high testosterone
What are the symptoms of prostate cancer?
Nocturia, hesitancy, poor stream, terminal dribbling (immediate), obstruction
How would a prostate cancer feel on DRE?
Hard, irregular prostate
What is a varicocele?
Dilated veins of the pampiniform plexus, associated with subfertility
What is an epididymal cyst?
Cyst containing clear or milky fluid which lies above the testis
A boy comes in with acute, tender enlargement of the testis. What is the likely diagnosis?
Testicular torsion - this is a medical emergency
What does renal pain feel like and what causes it?
Dull ache from loin to groin
Causes - pyelonephritis, nephrotic syndrome, polycystic kidneys, renal infarction
What does renal colic feel like and what causes it?
Extreme intermittent loin to groin pain, associated with fever and vomiting
Causes - renal stones, clots
What can cause haematuria?
- GU malignancy
- Infections
- Glomerular nephritis
- Kidney stones
- Prostate disorders
What causes high urea?
Dehydration GI bleed (blood meal - releases urea)
What are the functions of the kidney (A WET BED)?
Acid-base balance Water removal Erythropoeisis Toxin removal Blood pressure control Electrolyte balance D (vit) activation
How much urine do the kidneys usually produce?
1ml/kg/hr (1.5L/day)
What is the definition of oliguria?
<400 ml/24 hours
What is the role of PTH?
Promotes calcium reabsoprtion in the distal convoluted tubule
What is the role of aldosterone?
Promotes sodium, chloride and water reabsorption in the distal convoluted tubule
What is the role of ADH?
Promotes water reabsorption in the collecting duct, by formation of aquapores
What are the actions of angiotensin II?
Secreted in response to low BP, causing:
- Increased sympathetic activity
- Tubular Na/CL reabsorption via aldosterone
- Arteriolar vasoconstriction
- Water reabsorption via ADH
What is an AKI?
Rapid deterioration or loss of renal function, causing urea and creatinine retention and subsequent fluid and electrolyte and acid-base imbalance
How is AKI diagnosed?
- Rise in creatine >26umol/L in 48hrs
- Rise in creatinine >1.5x baseline
- Urine output <0.5ml/kg/h for >6 hours
What are the symptoms and signs of an AKI?
Symptoms - dysuria, oliguria, anuria, haematuria, generally unwell with fever, nausea and vomiting
Signs - hypo/hypervolaemia, leukonchyia, rash, AV fistula, polycystic kidneys
What are the pre-renal causes of an AKI?
HYPOPERFUSION (dehydration, hypotension, heart/liver failure)
What are the renal causes of an AKI?
Tubular damage - drugs
Glomerular - autoimmune, drugs, infection (glomerulonephritis)
Interstitial - drugs, infection
Vascular - vasculitis, malignancy
What are the post-renal causes of an AKI?
Urinary tract obstruction causing pressure on the kidney - stones, BPH, stricutres
Name some nephrotoxic drugs (cause AKI but fine to use in CKD)
ACE inhibitors Diuretics NSAIDS Immunosuppresants Antibiotics (penicillins, quinolones, sulphonamides, aminoglycosides) Omeprazole
How should an AKI be managed generally?
- Assess volume status and aim for euvolaemia
- Stop nephrotoxic drugs
- MONITOR!!!!
- Maintain nutrition
How should a pre-renal AKI be managed?
General measures + rehydration
What is acute tubular necrosis?
Hypoperfusion of they kidneys causing ischaemia, build up of nephrotoxins and renal tubular damage
What causes acute tubular necrosis?
Nephrotoxic drugs CT contrast Untreated pre-renal AKI Shock Rhabdomyolysis
How should a renal AKI be managed?
General measures + REFER and potential dialysis
How should a post-renal AKI be managed?
General measures + catheterise and CT renal tract
What are the complications of an AKI?
These require urgent dialysis:
- Hyperkalaemia (>6.5)
- Metabolic acidosis
- Symptoms of uraemia (encephalopathy, pericarditis)
- Fluid overload
- Pulmonary oedema (SOB)
What is the definition of CKD?
Impaired renal function for >3 months based on abnormal structure of function
OR
GFR <60mL/min for >3 months with no evidence of kidney damage
What causes CKD?
- Diabetes Mellitus
- Glomerulonephritis
- Hypertension
- AKI
- Polycystic kidney disease (related to stroke)
- Genetics - Alport syndrome
What is Alport’s syndrome?
A rare inherited disorder affecting only MALES causing a triad of:
- Kidney disease
- Hearing loss
- Visual problems
What are the symptoms of CKD and why do these occur?
Before stage 4 - asymptomatic
Stage 4:
- Low erythropoietin - weakness, fatigue, easily brushing, anaemia
- Pulmonary oedema - breathlessness
- Uraemic toxins - headaches, altered mental status, encephalopathy
- Low vit D production - itching, bone pain, fractures
What blood tests are raised and decreased in CKD?
Raised - urea, glucose, phosphate, ALKP, PTH, ESR (increased inflammation)
Decreased - Hb, calcium
What imaging should be done for CKD?
Renal USS, then biopsy if severe (although this will cause bleeding so should only be done if it will influence management)
(also do MSU)
How is CKD staged?
Stage 1 (>90) Stage 2 (60-89) Stage 3a (45-59) b (30-44) Stage 4 (15-29) Stage 5 (<15)
How is mild CKD managed?
Lifestyle advice
Blood pressure control (below 140/90)
Low cholesterol (4.5)
The main cause of death for CKD is cardiovascular
What medications should someone with severe CKD be on?
BP - aceinhibitors/ARB Cholesterol - statin Fluid overload - loop diuretic Bone - phosphate binder + VitD(alfacalcidol) Anaemia - ferrous sulphate/EPO Cramps - quinine sulphate
At what GFR should dialysis be considered?
GFR<8-10
How is dialysis set up?
Create AV fistula in the arm, or graft/catheter if not possible
This will provide a strong access point for dialysis
How does haemodialysis work?
Blood is passed over a semi-permeable membrane, outside of the body, against dialysis fluid in the opposite direction
How does peritoneal dialysis work?
Uses the peritoneum as a semi-permeable membrane - add osmotic agents to the fluid to promote ultra-filtration
What are the absolute contraindications for renal transplant?
Active infection, cancer, severe comorbidity
What is glomerulonephritis?
Inflammation of the glomeruli and nephrons causing:
- Restricted blood flow so BP increases
- Damage to filtration mechanism, so proteinuria and haematuria
- AKI
Name 4 types of glomerulonephritis
Nephrotic syndrome
IgA nephropathy
HSP
SLE
What is nephrotic syndrome?
A triad of:
- Proteinuria
- Hypoalbuminaemia
- Oedema
What is the pathophysiology behind nephrotic syndrome?
Damage to the podocyte causes heavy protein loss.
This is primary or secondary to hepatitis, diabetes, SLE or paraneoplastic
How do loop diuretics work, and when are they used?
Block the Na/K/2Cl cotransporters in the loop of henle –> reduce water reabsorption
Uses - pulmonary/peripheral oedema, severe hypercalcaemia
Eg. furosemide, bumetanide
How do thiazide diuretics work, and when are they used?
Block the Na/Cl transporter in the DCT –> reduce water reabsorption
Uses - hypertension, heart failure
Eg. bendroflumethiazide
How do potassium-sparing diuretics work and when are they used?
Spironolactone - aldosterone antagonists (slow onset)
Amiloride - blocks Na channels in collecting tubules (fast onset)
Uses - alongside other diuretics to control K+ wasting
How do osmotic diuretics work and when are they used?
Remain in lumen and hold water in by osmotic effect
Uses - haemolysis, rhabdomyolysis, reduction in intra-ocular and ICP
Eg. Mannitol
What is the most common cancer of the bladder?
Transitional cell carcinoma (can also arise n the ureter or renal pelvis)
How does a TCC present?
Painless haematuria, frequency, urgency, recurrent UTIs
How is TCC diagnosed?
Cystoscopy with biopsy
What is a KUB and what is it used for?
Kidneys, ureters, bladder x-ray
Uses - Investigation of bowel obstruction, gallstones and renal stones
What is cystoscopy used for?
Bladder cancer Haematuria Frequent UTIs Chronic pelvic pain Urinary blockage Urinary incontinence
What is the causative agent for chancroid ?
Haemophilius ducreyi
