Genitourinary Flashcards
What is renal colic?
An acute and severe loin pain, usually caused when a urinary stone moves from the kidney into the ureter causing acute obstruction.
Define urolithiasis?
process of stone formation
How can stones be formed?
Stones form from crystals in supersaturated urine
Foreign body in the urine or stasis forms stones
What is hydroureter and hydronephrosis ?
When can this occur?
hydroureter (dilation of the ureter)
hydronephrosis (kidney swelling caused by urine failing to drain properly in the bladder)
During passage, a kidney stone may become lodged obstructing urine flow.
Name three things that kidney stones can be made from?
80% Calcium based (calcium oxalate or calcium phosphate)
10% caused by uric acid
10% caused by struvite - infection stones
Rarely - cystine stones
What is the main cause of kidney stone formation
Dehydration!
Idiopathic
Name 2 other reasons, beside dehydration, that can cause kidney stone formation?
Anatomical features
- Congenital e.g horseshoe kidney, spina bifida
- Acquired e.g obstruction, trauma, reflux
Urinary factors - the biochemistry
Metastable urine, promoters and inhibitors
Calcium, oxalate, urate and cystine
Majority are calcium based stones and can be caused by hypercalcaemia or hyperparathyroidism
Name the three most common areas that a kidney stone may become lodged
Ureteropelvic junction
Distal ureter (at the level of the iliac vessels)
Ureterovesical junction
Name 5 symptoms of renal colic
Majority are asymptomatic and found incidentally on a scane
- unilateral severe loin pain
- may have UTI symptoms (dysuria, strangury, urgency, frequency, recurrent UTIs)
- Haematuria
- unable to get comfortable
- nausea/vomiting
What is the pain like in renal colic patients?
“Loin to groin pain - radiates to the ipsilateral testis/labia”
Classically is a sudden onset of pain
Pain is colicky (intermittent)
Exacerbation: fluid loading
Name 4 signs of renal colic?
Ashen
Sweating heavily
Cannot sit still
Tender abdomen on the affected side as palpation increases
What investigations would you do in a patient with renal colic?
ABCs
Urinalysis of mid stream urine if possible
Macroscopic or microscopic haematuria is common
Pyuria +/- bacteria may be present
FBC, U&Es, Calcium, Uric acid
Non-contrast CT of kidney, ureter and bladder
Stones are bright white
99% sensitive and 90% specific
Ultrasound
Sensitive for hydronephrosis
But poor at visualising stones in the ureter
Useful in pregnant and younger recurrent stone-formers
Name 3 measures you can do to prevent and decrease the likelihood of developing stones?
Overhydration Low salt diet Normal dairy intake Healthy protein intake Reduce BMI Active lifestyle
What is the immediate management for a patient with renal colic?
Analgesia - NSAID or opiates (morphine / fentanyl)
Antiemetic (metoclopramide to treat nausea)
May need to admit
May need fluids but this can make the pain worse
Observe for sepsis
What are three treatment options for renal stones?
Conservative treatment
Lithotripsy
Nephrectomy (open or laparoscopic)
What are three treatment options for ureteric stones?
Conservative (allow 2 weeks to pass)
Medical expulsive therapy
Extracorporeal shock wave lithotripsy
Ureteroscopy
What are two treatment options for bladder stones?
Conservative if asymptomatic
Litholapaxy - crushing or disintegrating of stones in your bladder using a telescopic fragmentation device or a laser passed through your urethra
What is the definition of acute kidney injury?
Syndrome of decreased renal function. It is the abrupt loss of kidney function resulting in the retention of urea and other nitrogenous waste products and in the dysregulation of extracellular volume and electrolytes.
What are the KDIGO stages of AKI?
Stages l Urine output
Stage 1 < 0.5 ml/kg/hr for 6-12 hrs
Stage 2 < 0.5 ml/kg/hr for 12 or more hours
Stage 3 < 0.3 ml/kh/hr for 24 or more hours or…
Anuria for >12 hours
What is the underlying pathology of pre-renal AKI?
Decreased nitric oxide and prostaglandins Increased angiotensin II Increased adrenergic nerves Increased ADH Leads to a decreased GFR
What is the overall underlying pathology of intrinsic renal aki?
Damage to the tubules, glomerulus or the interstitium. Kidneys lose the ability to filter the blood properly and the cells are damaged in a way where reabsorption/secretion are impaired.
what is the pathology of nephrotoxic tubular disease?
Substances that damage the epithelial tubular cells and cells die generating higher pressures as necrosis in the tubules
Decreased pressure gradient so there is less fluid filtered
Decreased GFR
what is the pathology of glomerulonephritis?
Increased membrane permeability
Decreased pressure difference
Decreased GFR
What is the underlying pathology of post-renal aki?
Characterised by acute obstruction to urinary flow.
Increased intratubular pressure
Decreased GFR
What are the three major classifications of AKI?
Pre-renal
Intrinsic renal
Post-renal
Name the four sub-categories that can cause pre-renal AKI and give an example cause for each?
Decrease in vascular volume : haemorrhage, severe dehydration, vomiting and diarrhoea
Decrease in cardiac output : congestive heart failure
Systemic vasodilation: sepsis
Renal vasoconstriction : NSAIDs
What are the 4 sub-categories that can cause intrinsic renal damage?
Give an example that can cause each?
Tubular damage : ischaemic, nephrotoxic (aminoglycosides, heavy metals, radiocontrast dye)
Glomerular damage : glomerulopnephritis caused by an inappropriate immune system response
Interstitial damage : infection/infiltration. Can be a hypersensitivity response to NSAIDs
Vascular damage : vasculitis
Name three causes of post-renal AKI?
Stone Renal malignancy Stricture Clot Pelvic malignancy
Name 4 signs/symptoms of AKI?
Rise in serum creatinine Oliguria or anuria Nausea, vomiting Dehydration Confusion
What are the three diagnostic criteria for AKI?
Rise in serum creatinine > 26μmol/L within 48 hours
Rise in serum creatinine > 1.5 x baseline within 7 days
Urine output of less than 0.5 ml/kg/hr for over 6 consecutive hours
What investigations should you do in a patient with AKI?
History - nephrotoxic drugs
Examination - signs of infection or sepsis, signs of acute or chronic heart failure, fluid status, palpable bladder or abdominal/pelvic mass, features of underlying systemic disease
Urinalysis - dipstick urine for blood, nitrates, leukocytes, glucose and protein
Urine output
Blood tests - creatinine! CROm FBC
Imaging - ultrasound when obstruction is suspected
What are the principles of treatment for AKI?
There is no specific treatment for AKI so management is largely supportive.
Treating the cause (where possible).
Monitor fluid and electrolyte balance closely
Stop nephrotoxic drugs where possible
Monitor creatinine, sodium, potassium, calcium, phosphate and glucose
Identify and treat infection - strict sepsis control!
Urgent relief of urinary tract obstruction
Refer to a nephrologist for a specific treatment of underlying intrinsic renal disease where appropriate
Why are NSAIDs contraindicated in AKI?
NSAIDs lead to the decreased synthesis of prostaglandins.
In the nephrons the macular densa cells measure the Na+ concentration and communicate to the granular cells (VIA PROSTAGLANDINS) that there is a decrease in sodium and to release renin for the RAAS system which aims to increase blood pressure. Cannot happen if NSAIDs block the synthesis. Leads to vasoconstriction of the afferent arteriole, decreasing perfusion to the kidney and decreasing GFR which can increase the severity of the AKI.
What abnormality caused by AKI can be seen on ECG? What would you see?
Hyperkalaemia
Tall tented T waves
Bradycardia
Wide QRS complex
What treatment would you use to correct hyperkalaemia caused as a complication of AKI?
How does it work?
What do you have to give with it?
And why?
IV insulin
Insulin shifts potassium into cells by stimulating the activity of the Na+-H+ antiporter on the cell membrane which promotes sodium to enter cells. Leads to activation of Na+-K+-ATPase causing an influx of potassium.
Dextrose
Insulin isn’t given to lower glucose levels so we give dextrose to counteract the effects that insulin has on blood glucose levels.
What is the most common cancer of the kidney?
Renal cell carcinoma
What cells does renal cell carcinoma arise from?
It arises from the proximal renal tubular epithelium
Where can kidney cancer spread to?
Locally to adjacent structures: adrenal glands, liver, spleen, colon or pancreas or local lymph nodes
May extend into the renal vein and then in the IVC.
Lungs are a common site of mets
Can spread to bone
What are kidney cancers associated with?
Structural abnormalities of the short arm of chromosome 3
Name 5 risk factors that can increase your risk of developing kidney cancer?
Smoking Obesity Hypertension Environmental - petrol, phenacetin, cadmium Occupational - leather tanners
What are the is the classic triad of symptoms that are suggestive of kidney cancer?
Haematuria
Loin pain
Abdominal mass
What other systemic symptoms can you get with kidney cancer?
Anorexia
Malaise
Weight loss
What investigations should you do when investigating kidney cancer?
Blood pressure - will be increased from increased renin secretion
Bloods
- FBC : polycythaemia from erythropoietin secretion
- ESR
- U&Es
Urine
- Blood
- Cytology, culture and sensitivity to exclude a renal tract infection
Imaging
- Ultrasound
- CT renal scanning
- Chest X-Ray (looking for cannonball mets in the lungs)
Briefly outline the stages of kidney cancer?
Stage I
Tumour less than 7cm in largest dimension
Limited to kidney
Stage II
Tumour more than 7cm in the largest dimension
Limited to the kidney
Stage III
Tumour in the major veins or adrenal gland with an intact renal fascia
OR regional lymph nodes are involved
Stage IV
Tumour beyond the anterior renal fascia
Distant mets
What is the management for Stage I kidney cancer?
partial nephrectomy or radical nephrectomy
If neither are possible, active surveillance or ablative therapies in selected patients with small masses
What is the management for Stage II kidney cancer?
Radical nephrectomy
Partial nephrectomy in selected patients in whom the procedure is feasible
What is the management for Stage III kidney cancer?
Radical nephrectomy plus adrenalectomy, tumour thrombus excision (if appropriate) and/or lymph node dissection
Systemic treatment if inoperable, or owing to poor performance status
What is the management for Stage IV kidney cancer?
Systemic treatment
Elective cytoreductive nephrectomy
Combine with interferon alpha
Immunotherapy may be high dose IL-2
What type of carcinoma are the majority of bladder cancers?
transitional cell carcinomas
- Increased number of epithelial cell layers
- Abnormal cell maturation
Name 5 risk factors that increase your likelihood of developing bladder cancer?
Increasing age
Paraplegic
Smoking
Occupational exposure to aromatic amines, polycyclic aromatic hydrocarbons and chlorinated hydrocarbons
Drugs (phenacetin, aspirin)
Bladder stones (squamous cell carcinoma is associated with chronic irritation)
In what occupations would you be exposed to aromatic amines, polycyclic aromatic hydrocarbons and chlorinated hydrocarbons that increase your likelihood of developing cancer?
in industrial plants processing paint, dye, metal, rubber and petroleum products
Why does smoking increase your risk of bladder cancer?
Half of bladder cancers are caused by smoking as tobacco smoke contains aromatic amines and polycyclic aromatic hydrocarbons which are renally excreted
Name 5 clinical features that may be seen in bladder cancer?
Painless visible haematuria Irritative voiding - Can be caused by carcinoma in situ Recurrent UTIs Flank pain if the bladder cancer is invading into the ureteric orifice causing pain Lower limb oedema Pelvic mass Weight loss 15% present with metastasis - Bone pain
What is the diagnostic test for bladder cancer?
cystoscopy with biopsy of the bladder tumour. The biopsied specimen must include muscle to be able to stage the cancer
What investigations would you do in bladder cancer?
Cytoscopy + biopsy Bloods - FBC - U&E - PSA - Glucose Urine - Dipstix test - Microscopy, culture and sensitivity - exclude infection Imaging - USS - CT urogram is diagnostic and provides staging
Why do we have to grade bladder cancer?
70% of non-muscle invasive bladder cancer will recur
15% will progress to muscle invasive cancer
What are the treatment options for non-invasive bladder cancers?
Diathermy (medical and surgical technique involving the production of heat in a part of the body by high-frequency electric currents) via transurethral cystoscopy
Transurethral resection of bladder tumour (TURBT)
Consider a regimen of intravesical BCG for multiple small tumours of high grade tumours + one of the above treatments. (Bacillus Calmette-Guerin or BCG is the most common intravesical immunotherapy for treating early-stage bladder cancer. It’s used to help keep the cancer from growing and to help keep it from coming back - it is very toxic so ⅓ of people usually have adverse effects)
What is the treatment for invasive bladder cancer?
Radical cystectomy + neoadjuvant chemotherapy using a cisplatin combination regimen (involves removal of local lymph nodes)
What type of carcinoma are the majority of prostate cancers?
adenocarcinomas
In what regions can you get prostate cancer? Which is the most common site?
Peripheral zone (outside) - in the majority of cases (70%)
Transitional zone
Central zone
Why is the fact that the majority of prostate cancers are in the peripheral zone of clinical importance?
can feel this cancer easier during a digital rectal exam
outline the Gleason grading system?
There are 5 grades of glandular morphology
Take 12 biopsy samples and grade their morphological pattern
The two most prominent glandular patterns are graded 1-5
The sum of these two grades will range from 2-10
2 - most differentiated
10 - least differentiated tumours
Need to pick up the tumours that are a grade 7 and above
What are the routes of spread of prostate cancer?
Direct
Lymphatic
Haematogenous
Where can prostate cancer spread to directly?
Intrinsic - involves the rest of the prostate
Extrinsic - upward → ureter
Downward → urethra
Laterally → sciatic nerve and iliac blood vessels
Forward → pubic bone
What is the primary lymphatic drainage of the prostate?
Lymphatic drainage of the prostate primarily drains to the obturator and internal iliac lymphatic channels
Name 3 places that prostate cancer commonly spreads to via the blood which can indicate quite late disease?
Bone
Liver
Lung
Kidneys
Name 4 risk factors that increase a person’s likelihood of having prostate cancer?
Increasing age
- The MOST important risk factor!
Family history
- 2-3 times increased risk if a first degree relative is affected.
- If they were aged 50 at the time of diagnosis then it is more relevant and important
Ethnicity
50% more prostate cancer in afro-caribbean compared to white populations
Genetic
What genetic polymorphisms are associated with prostate cancer?
Genetic polymorphisms are more common in younger patients
BRCA1, BRCA2, mismatch repair and HOXB13 which interacts with androgen receptor
Name 5 symptoms associated with prostate cancer?
Nocturia Hesitancy Poor stream Terminal dribbling Obstruction
General systemic symptoms Fatigue Weight loss Anorexia Night sweats
What symptoms can indicate that prostate cancer has spread and disease is more advanced?
Bone pain
Can be with or without a pathologic fracture
Neurological deficits from spinal cord compression
Lower extremity pain and oedema
What investigations would you do for prostate cancer?
Digital rectal examination
PSA (prostate specific antigen)
MRI prostate
Prostate biopsy
What are advantages and disadvantages of measuring PSA?
It is specific to the prostate.
Low sensitivity - not specific to prostate cancer. Elevated PSA can be a sign of a prostate cancer but can also be raised for other reasons:
- UTI
- recent ejaculation
- vigorous exercise
Name four treatment options for prostate cancer?
Active surveillance
Radical prostatectomy
Radiotherapy
Hormone therapy
when would you use radical prostatectomy as a treatment option for prostate cancer?
Used in patients less than 70 years old who are fit for surgery and have disease confined to the prostate
what types of hormone therapy are there for prostate cancer treatment?
luteinizing hormone-releasing hormone agonists e.g leuprolide, goserelin
Antiandrogens e.g flutamide
Orchiectomy : surgical procedure to remove both testicles as this is the main source of testosterone
what is the mechanism of action of luteinizing hormone-releasing hormone agonists in the treatment of prostate cancer?
Basic action is that it overloads the pituitary gland with signals which causes the pituitary gland to stop stimulating the testes to produce testosterone.
what is the action of antiandrogens in treatment of prostate cancer?
block the action of testosterone at the receptor level on the testes
What are treatments can you use for more advanced/metastatic prostate cancer?
Chemotherapy
Bisphosphonates
Radiotherapy for bone pain
TURP to relieve symptoms of bladder outflow obstruction
Nephrostomies for ureteric obstruction (palliative)
what are two main classifications of testicular tumours? What type of tumours are they? What are the differences between them?
The majority of these tumours are germ cell tumours. Two main classifications are:
Seminoma (affect 35-40 year olds, slow growing)
Nonseminomatous germ cell tumour (affect 20-35 year olds, rapid growth and mets)
Where does testicular cancer usually spread to?
Usually spread locally first to the epididymis, spermatic cord and sometimes rarely the scrotal wall
What is the difference in lymphatic drainage of the scrotal wall and the testicles?
scrotal wall (inguinal lymph nodes)
testicles (para-aortic lymph nodes)
Name 3 risk factors that increase a man’s likelihood of developing testicular cancer?
Cryptorchidism (one or both of the testes fail to descend from the abdomen into the scrotum)
Family history
If have a first degree relative with testicular cancer, means they have a 9 times increased risk
Previous testicular tumour
Infertility
Infant hernia
What is the clinical presentation of confined testicular cancer (i.e with no mets) ?
Typically painless testis lump
- Hard/craggy
- Lies within the testes
- Can be felt above
- Does not transilluminate
Usually a painless, short history
Often found incidentally
Secondary hydrocele : may contain bloodstained fluid
Pain : unexplained in one testis
What additional symptoms may a man with testicular cancer experience if he has metastatic disease?
Dyspnoea caused by lung mets
Abdominal mass due to enlarged para-aortic lymph nodes
Cervical nodes
What investigations do you do in testicular cancer?
Testicular ultrasound Excision biopsy Tumour markers AFP B-hcg (young man presents with a positive pregnancy test) Chest X-ray if have respiratory symptoms
What are the treatment options for testicular cancer?
Radical inguinal orchiectomy Testis and spermatic cord excised Biopsy and frozen section for assess further treatment Seminomas are very radiosensitive For all stages except 4
How do we measure kidney function?
Measure creatinine
What is creatinine and why can we use it to estimate GFR?
waste product of muscle metabolism and is detected in a U&Es blood test
It is purely excreted by the kidneys (no where else in the body) so can be used as a measure of the GFR
What is a disadvantage of using creatinine to measure GFR?
not everyone’s muscle mass is the same
I.e someone who has a high muscle mass will have a higher creatinine level and vice versa
why do we use the albumin:creatinine ratio when idetifying proteinuria?
Using concentration of proteinuria is determined by the volume
I.e if you are drinking more and weeing more the concentration of protein would be lower (opposite is also true)
Do a ratio of the protein in the urine to creatinine
Use creatinine as it is excreted by the kidneys in the urine at a constant rate
Gives us a more precise estimate of how much protein a patient is passing in their urine in 24 hours
Means that ratio of albumin to creatinine should be constant irrespective of urine volume
define chronic kidney disease?
What GFR value confirms CKD?
Abnormal kidney structure or function present for longer than 3 months with implications for health
GFR BELOW 60 = CKD
Name 5 causes of chronic kidney disease?
Diabetes Hypertension Glomerulonephritis Polycystic kidney disease Enlarged prostate or malignancy or obstructive uropathy Acute Kidney Injury
What is the main symptom of chronic kidney disease?
Usually asymptomatic and often unrecognised because there are no specific symptoms and it is often diagnosed at an advanced stage
Name three symptoms that may be present in severe chronic kidney disease?
Anorexia Nausea Vomiting Fatigue Weakness Peripheral oedema
What is the main consequence of chronic kidney disease?
Cardiovascular consequences
what investigations do you do in chronic kidney disease?
eGFR
U&Es
FBC
Urinalysis (albumin: creatinine ratio)
Imaging
- Renal ultrasound can show any structural abnormalities or any obstruction
- CT scan to identify any renal masses or cysts
What lifestyle advice can you give to chronic kidney disease patients?
Stop smoking
Exercise advice
Diet advice → Reduce salt intake!
Asides from lifestyle advice, what other management can you do for chronic kidney disease patients to slow the progression of renal disease?
Blood pressure control
Glycaemic control (If diabetics have greater glycaemic control then they have a lower incidence of macro and microvascular complications )
Statins
Fluid management
What are the two treatment options for kidney disease, when patients GFR falls below 15 usually?
Renal Replacement therapy
- Haemodialysis
- Peritoneal dialysis
Kidney transplant
How does haemodialysis work?
3 times a week for 4 hours
Patients have a fistula (join artery to vein to make a bigger blood vessel) or a tunnelled lines (these have an increased risk of infection)
Blood is passed over a semi-permeable membrane against dialysis fluid flowing in the opposite direction
Dialyzer is a plastic tube with lots of tiny fibres in it through which the blood goes. This increases the surface area.
Waste moves from the blood into the dialysate by diffusion
How does peritoneal dialysis work?
Patients can have this at home
Plastic tube into the peritoneum through which we drain sugary water
Uses the peritoneum as a semipermeable membrane
Waste diffuses from the patient’s circulation to the PD fluid
Water moves from circulation to the PD fluid (osmosis)
Sugar moves into the patient’s circulation
Sugar gets metabolized and eventually all the sugar moves and is gone
Lost osmotic gradient so water drains back into the circulation from the PD fluid
Name three complications of renal replacement therapy?
CVD effects - increased blood pressure - phosphate and calcium dysregulation -inflammation Renal bone disease Infection Amyloid
Name three complications of kidney transplants?
Delayed function
- 1/3 of kidneys do not work immediately so continue dialysis
Surgical complications
- thrombosis, obstruction of blood vessels, drains
Infection
- UTI, chest
Rejection
- 12% of people get rejection in their first year
Name two contra-indications in a transplant patient that means they could not have it?
Cancer with metastases
Active infection, HIV with viral replication, unstable CKD
Congestive heart failure
Name three of the normal functions of the lower urinary tract?
Convert a continuous process of excretion (urine production) to an intermittent process of elimination
Store urine insensibly (unaware that you are storing urine)
Void urine when it is convenient and socially acceptable
during storage of urine what is the mechanism of the detrusor muscle and distal sphincter mechanism?
Detrusor : relaxes
Distal sphincter mechanism : contracts
during the voiding process what is the detrusor and distal spincter mechanism?
detrusor : contracts
distal sphincter : relaxes
what are the two normal functions of the bladder?
storage - 99% of the time
voiding - 1% of the time
name 4 storage lower urinary tract symptoms?
Frequency
Urgency
Nocturia
Incontinence
What is the normal frequency for voiding?
2-8 times in a day
Name 6 lower urinary tract symptoms that relate to voiding?
slow stream splitting or spraying intermittency hesitancy straining terminal dribble
what is straining?
using the abdominal muscles to empty the bladder if the detrusor muscle is not working properly
what is terminal dribble?
patient describes a prolonged final part of micturition when the flow has slowed to a trickle/dribble
name 2 lower urinary tract symptoms that relate to post-micturition?
post-micturition dribble : once finished urinating have a final dribble. This is caused by a column of urine that has stayed in the ureter that is released when relaxed
feeling of incomplete emptying
what is the blood supply to the kidney?
renal artery that comes straight off the aorta
how much urine is normal to produce per day?
1-1.5 L
what spinal level to the kidneys span?
T11-L3
how is the reflux of urine from the bladder back up the ureters avoided?
valvular mechanism as the vesicoureteric junction. when the bladder fills it compresses the ureter where it enters the bladder so it cannot reflux.
what are the 4 nerves involved in the neural control of the bladder?
pelvic nerve (parasympathetic) hypogastric plexus (sympathetic) pudendal nerve (somatic nerve) - Onuf's nucleus Afferent pelvic nerve (sensory nerve)
what are the nerve roots of the pelvic nerve?
S2, 3, 4 (keeps pee off the floor)
what is the main centre for voluntary control over the bladder?
pontine micturition centre
what is the normal adult capacity of the bladder?
400-500mls
Outline the storage phase of micturition?
bladder fills continuously
as volume in the bladder increases the pressure remains low due to receptive relaxation - smooth muscle cells in detrusor are sympathetic mediated so they are able to stretch without causing any tension.
Outline the filling phase in micturition?
pelvic nerve sends SLOW signals to the sacrum which send signals up to the pontine micturition centre which tells brain that the bladder is filling but doesn’t need to empty just yet
Sympathetic nerve is stimulated and maintains the detrusor muscle to stay relaxed
Pudendal nerve is stimulated which keeps the urethra contracted
Outline the voiding reflex in micturition?
Reflex is co-ordinated by sacral micturition centre.
When you have a higher volume in bladder the pelvic nerve sends faster signals to the sacral micturition centre in spinal cord.
The pelvic parasympathetic nerve is stimulated and the detrusor muscle contracts (positive feedback)
Inhibit the pudendal nerve and the external sphincter relaxes
Usually the sphincter relaxes then detrusor muscle contracts for a co-ordinated void.
when do you initiate the guarding reflex?
when it is not appropriate to void
outline the guarding reflex
It is the voluntary Onuf’s nucleus initiated by higher cortical centres.
you continue to stimulate the sympathetic nerve and pudendal nerve
what is the epithelium of the bladder?
transitional
umbrella cells above
what do you need to diagnose benign prostatic hyperplasia
Histology of the hyperplasia
what is BPE?
benign prostatic enlargement (DRE findings)
What is the pathology of BPH?
Benign nodular or diffuse proliferation of muscular fibrous and glandular layers of the prostate.
Increase in epithelial and stromal cell numbers in the periurethral area of the prostate
What zone of the prostate enlarges in BPH?
Inner transitional zone
What are the possible causes for BPH?
Increase in cell number of these cells
Or due to decrease in apoptosis
What are the symptoms of BPH?
Will have lower urinary tract symptoms - are they storage or voiding?
Nocturia
Urinary frequency is often a presenting problem
Urinary urgency
Symptom scoring - IPSS score
What is a sign of BPH?
Smooth enlarged prostate detected from a DRE
What investigations would you do in BPH?
Urine dipstick and MSU for microscopy and culture to exclude infection
Bloods - U&E to exclude renal damage, FBC, LFTs
Flow rates and residual volume
Frequency volume chart
Imaging - ultrasound if there is any suggestion of urinary tract obstruction
What flow rate results is suggestive of BPH?
Flow rates can be reduced due to obstruction within the lower urinary tract
Max flow rate that is less than 10 ml/s is suggestive of bladder outflow obstruction due to BPH
What lifestyle advice can you give to patients with BPH?
Avoid caffeine and alcohol to reduce urgency and nocturia
Relax when voiding
Void twice in a row to aid emptying
What pharmacological management can you give to patients with BPH?
Alpha-adrenergic antagonists or alpha-blockers
- Reduce the tone in the muscle of the neck of the bladder
- Oral tamsulosin
5-alpha reductase inhibitor
- Drugs e.g finasteride that block the synthesis of dihydrotestosterone from testosterone
- Can reduce symptoms
What are the indications for surgery in a patient with BPH?
RUSHES - indications for surgery
Retention UTIs Stones Haematuria Elevated creatinine due to benign obstructive outflow Symptom deterioration
What surgical options are there for patients with BPH?
Trans-urethral resection of prostate (TURP)
What are the causative organisms that can cause UTIs?
E.Coli (most common)
Proteus mirabilis (associated with renal stones)
Klebsiella spp. (hospital/catheter associated)
Enterococci
Staphylococcus saprophyticus
What is the most common type of bacteria that can cause UTIs
E.Coli
What can cause the infection of a UTI? Not the organisms (i.e introduction of organisms to the UT)
Sexual intercourse Catheterisation and other instrumentation Enlarged prostate Renal tract tumours Renal stones
Name 3 risk factors that can increase your likelihood of developing a UTI?
Sexual activity Urinary incontinence Faecal incontinence Constipation Increase of binding of uropathogenic bacteria - Spermicide use - Decreased oestrogen Decreased urine flow - Dehydration - Obstructed urinary tract Increased bacterial growth - Diabetes - Immunosuppression - Obstruction Stones Catheter Renal tract malformation Pregnancy Female
What are the symptoms of acute pyelonephritis?
Fever Loin Pain Pyrexial Occasional haematuria Pyuria Rigor Vomiting
What investigations do you do in someone with a UTI?
Mid stream urine
Microscopy
Culture
Ultrasound to rule out any urinary obstruction
Why do you collect a mid stream urine sample for a patient with a UTI?
Avoids contamination from the perineum or vagina
What are you looking for during microscopy of a urine sample when investigating a UTI?
If urine is infected often there will be neutrophils in the film.
A significant pyuria is defined as > 10 pus cells per high power field
Red blood cells
What do you culture urine samples on when investigating UTIs? What represents a significant bacterial growth?
CLED or MacConkey agar
37 degrees celsius
More than 10^5 pure growth of bacteria/ml (more than 1000 colonies = significant bacteria)
What is the treatment for acute pylonephritis?
Oral ciprofloxacin for 7-10 days
Paracetamol for symptomatic relief
what type of infection is cystitis
lower urinary tract infection
what are 4 symptoms of cystitis ?
Dysuria
Frequency
Urgency
Polyuria
What is the treatment for asymptomatic bacteriuria over the age of 65 ?
None!
What is the treatment for cystitis?
Nitrofurantoin
Paracetamol and/or NSAIDs are of use for symptomatic relief
Name three examples of patients who have complicated UTIs?
Pregnant Men Catheterized Children Recurrent Immunocompromised
What is the only example of an uncomplicated UTI?
- normal renal tract structure and function
Non-pregnant woman!
Name 2 bacterial causes of bacterial prostatitis?
Usually gram negative : E. coli, Enterobacter, Pseudomonas and Proteus
STIs may also be a cause e.g Neisseria gonorrhoeae and Chlamydia trachomatis
What are the symptoms of prostatitis?
Pain - Perineum - Rectum - Scrotum - Penis - Bladder - Lower back Fever Malaise Nausea Urinary symptoms Swollen or tender prostate on PR
What is the treatment for prostatitis?
4 week course of a fluoroquinolone e.g ciprofloxacin - acute
If patient needs to be hospitalized : IV ciprofloxacin
Critically ill patient : Iv ciprofloxacin + IV gentamicin
Paracetamol and / or NSAIDs are of use for symptomatic relief
What are the 5 classifications of urinary incontinence?
Overactive bladder Stress incontinence Continuous Overflow Social
What is an overactive bladder?
urgency with frequency with or without nocturia when appearing in the absence of local pathology
What is stress incontinence?
Associated with coughing or straining. More common in women post child-birth.
What is overflow incontinence?
involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to void.
What is social incontinence?
Occurs in those with dementia who have lost their cortex function and so are unaware when it is socially acceptable to void.
Main cause of stress incontinence?
Common In females is usually secondary to birth trauma caused by denervation of pelvic floor and urethral sphincter
Causes of continuous incontinence?
Caused by a fistula either between the vagina and bladder or the rectum and bladder
What investigations would you do into urinary incontinence?
Bladder diary
Investigations to rule out any other pathology that may be causing incontinence
What management options are there in urinary incontinence
Behavioural Anti-muscarinic agents B3 agonists Botox Sacral neuromodulation Surgery
What behavioural management would you use for urinary incontinence?
Avoid drinking caffeine and alcohol
Bladder drill
What do anti-muscarinic agents do to help urinary incontinence?
Decrease parasympathetic activity by blocking M2/M3 receptors
What do B3 agonists do to help urinary incontinence?
Increase sympathetic activity at B3 receptor in bladder
Enables bladder to hold more urine
What does botox do to help urinary incontinence?
Blocks neuromuscular junction for acetylcholine release
What is sacral neuromodulation?
Insertion of an electrode to S3 nerve root to modulate afferent signals from bladder
What types of stress incontinence surgery are there?
Tension free vaginal tape Transobturator tape procedure Autologous sling Bulking agents Artificial urinary sphincter
What can glomerular diseases go on to cause?
chronic kidney disease
what is the difference between nephrotic and nephritic glomerular disease?
(differences in pathology)
Nephrotic
- injury to podocytes
- changed architecture : scarring, deposition of matrix or other elements
Nephritic
- inflammation
- reactive cell proliferation
- breaks in glomerular basement membrane
- Crescent formation
what is the main difference in how nephritic and nephrotic glomerular diseases present?
Nephrosis (proteinuria due to podocyte pathology)
Nephritis (haematuria due to inflammatory damage)
Name the 3 causes of nephritic syndrome?
Anti-Glomerular Basement Membrane Mediated
Immune complex mediated
Non-immune mediated (ANCA+) - Rapidly progressive GN
What are the two different subtypes of Anti-Glomerular Basement Membrane Mediated and what differentiates them?
With lung hemorrhage → Goodpasture’s disease
Without lung haemorrhage → Anti-GBM disease
What are the different types of Immune complex mediated nephritic syndrome?
Normal C3 complement levels:
IgA nephropathy → COMMONEST CAUSE IN THE DEVELOPED WORLD
Henoch-Schonlein Purpura
C3 complement is decreased
Membranoproliferative GN
SLE
Post-streptococcal GN - e.g Streptococcus pyogenes, occurs classically 2 weeks after tonsilitis
What are the two different types of Non-immune mediated (ANCA+) nephritic disease?
C-ANCA Granulomatosis with polyangiitis P-ANCA Churg-Strauss Microscopic polyangiitis
What are the symptoms of nephritic syndrome?
Haematuria more predominantly presents than proteinuria!
Proteinuria
Less than 3.5g/1.73m/day
Haematuria
Abrupt onset
Can be visible or non-visible (red cell casts seen on microscopy)
Azotemia
Increased creatinine and urea
RBC casts
Oliguria - little urine
Hypertension
Peripheral oedema
Puffy eyes
Smoky urine
What investigations would you do for nephritic syndrome?
Need to assess damage and find a potential cause via a history
Bloods FBC, U&Es, LFT, CRP, immunoglobulins, electrophoresis, complement (C3 and C4), autoantibodies (ANA, ANCA)
Blood culture
Measure eGFR
Urine
Microscopy, culture and sensitivity
RBC casts
Dipstick to detect proteinuria and haematuria
Imaging
Chest X-ray (pulmonary haemorrhage)
Renal ultrasound (size, anatomy and for biopsy)
Renal Biopsy Required for a diagnosis Examination of glomerular lesions provides GN diagnosis Proportion of glomeruli involved How much of each glomerulus is involved Hypercellularity Sclerosis Immunohistology for deposits (IgG)
What is the treatment for nephritic syndrome glomerular disease?
Pulse steroid treatment
Immunosuppression
depends on histological diagnosis, disease severity, disease progression, comorbidity
Control blood pressure
salt restriction, loop diuretics
Inhibition of RAAS (ACE-i, ARBs)
Monitor for progression to end stage renal disease
What is the pathology of nephrotic disease?
Injury to podocytes and change in the glomerular architecture
Abnormal function in minimal change disease
Immune mediated damage in membranous nephropathy
Podocyte injury/death in focal segmental glomerulosclerosis
Proteinuria can also result from pathology in the glomerular basement membrane/endothelial cell e.g Membranoproliferative glomerulonephritis
What are the primary causes of nephrotic syndrome glomerular disease ?
Primary renal disease
- Minimal change disease
- Membranous nephropathy
- Focal segmental glomerulosclerosis
- Membranoproliferative GN
What are the secondary causes of nephrotic syndrome glomerular disease?
Secondary to a systemic disorder Diabetes - most common secondary cause Lupus nephritis Myeloma Amyloid Pre-eclampsia
What is the clinical presentation of nephrotic syndrome glomerular disease?
Triad of…
Proteinuria > 3g/24hr
Hypoalbuminemia
Oedema
- Generalised pitting oedema which can be rapid and severe
- Look in dependent areas : ankles, sacral pad, elbows
Systemic symptoms Joint pain General fatigue Lethargy Poor appetite
What are the investigations for nephrotic syndrome glomerular disease?
Bloods
- FBC,
- U&Es,
- LFT,
- CRP,
Measure eGFR
Urine
Microscopy, culture and sensitivity
RBC casts
Dipstick to detect proteinuria and haematuria
Imaging
- Renal ultrasound
RENAL BIOPSY is required for diagnosis to also be able to consider treatment options
What are the treatment options for nephrotic syndrome glomerular disease?
Reduce oedema
Fluid and salt restriction
Diuresis with loop diuretics
Treat the underlying cause
Reduce proteinuria
ACE-i or ARBs
What complications can arise from nephrotic syndrome in glomerular disease?
Why?
How would you treat them?
Thromboembolism
- due to increased clotting factors and platelet abnormalities
Treat with heparin and warfarin
Infection
- Increase risk of UTIs, resp infections and CNS infection
- Pneumococcal vaccination
Hyperlipidemia
- Increased cholesterol caused by hepatic synthesis in response to the decrease in oncotic pressure
- Statins
Define erectile dysfunction?
Persistent inability to attain and maintain an erection that is sufficient for satisfactory sexual performance
What is the normal physiology of an erection?
Stimulus (Auditory, visual, tactile)
Stimulation of cavernosal nerve which releases nitrous oxide
Smooth muscle relaxation.
Increased blood flow into cavernosus
Compression of venous outflow due to the cavernosus filling up with blood
Contraction of the ischiocavernosus muscle - causes a rigid erection
Cavernous nerve is stimulated to release NO
NO pairs with gunylase cyclase
Allows conversion of GTP to cGMP
This causes a protein complex which allows relaxation of the cavernosus muscle so it can dilate and you get arterial inflow
PDE-5 degenerates cGMP and that’s how you get detumescence after ejactulation
Name 5 causes of erectile dysfunction
Diabetes Smoking Hypertension Hypercholesterolaemia Obesity MS thyroid dysfunction
What investigations would you do in erectile dysfunction
Examination
External genitalia (palpable plaques, atrophy of testicles)
DRE (prostate tenderness)
Bloods FBC Fasting glucose and lipids - first time someone presents with hypercholesterolemia Prolactin LH and FSH TFTs Consider a PSA Testosterone
Validated questionnaire
Give you an idea of severity
Lower the score the worse it is
Specialised tests
Penile doppler USS
Nocturnal penile tumescence - rarely used, usually only used in hard to diagnose cases. Can tell if the cause is psychological as man will still have nocturnal erections.
What lifestyle factors can you advise someone with erectile dysfunction to do ?
Stop smoking Weight loss if overweight Exercise Avoid alcohol excess Counselling if non-organic cause
What medication is used to manage erectile dysfunction ?
How does it work?
PDE-5 inhibitor
Vardenafil (viagra), Sildenafil, Tadalafil
Stops breakdown of cGMP by PDE-5 leading to smooth muscle relaxation leading to prolonged erection
Still need a stimulus
Have to take 30 minutes before intercourse
If medication fails, what other options are there for the management of erectile dysfunction?
Need to have tried it 4 times at the highest dose
MUSE → intraurethral therapy. Increases cAMP therefore activates a secondary pathway for erection
Intracavernosal injections
Last line: Inflatable penile prosthesis
What is the pathology of epididymal cysts ?
Smooth extratesticular spherical cyst in the head of the epididymis
What are the symptoms that point towards a epididymal cyst?
Lump in the testicles
The lump is separate to the testicle (lies above and behind the testis) and is cystic
Usually multiple lumps and is well defined and transilluminates.
What investigation would you do in an epididymal cyst?
Scrotal ultrasound
What is the treatment of an epididymal cyst?
Surgically remove if it is painful and symptomatic
What is a hydrocele?
Fluid within the tunica vaginalis
What are the different pathologies of a hydrocele?
Overproduction of fluid in the tunica vaginalis (simple hydrocele)
Processus vaginalis fails to close allowing peritoneal fluid to communicate freely with the scrotal portion
What is the aetiology of hydroceles?
Primary
Occur in absence of disease in testis
More common, larger and usually in younger men
Secondary to testis tumour/trauma/infection
Rarer and present in older boys and men
What is the presentation of a hydrocele?
Scrotal enlargement with a non-tender swelling
What is the investigation for a hydrocele?
scrotal ultrasound
what is the treatment of a hydrocele?
usually resolves spontaneously
what is a varicocele?
Dilated veins of pampiniform plexus
Why is the left testicle more likely to be affected by a varicocele?
The angle at which the testicular vein enters the left renal vein
Lack of effective valves between the testicular and renal veins
Increased reflux from compression of the renal vein
What is the presentation of a varicocele?
Distended scrotal blood vessels that feel like a “bag of worms”
Dull ache
Scrotal heaviness
when would people need surgery for a varicocele?
if there is any pain, infertility or testicular atrophy
what is epididymitis?
inflammation of the epidiymis
Name three bacteria that can cause epididymitis ?
Chlamydia trachomatis
Neisseria gonorrhoeae
E. coli (mainly in men over 35)
Name two risk factors that increase a man’s likelihood for developing epididymitis
Sexual intercourse
Catheterisation
What is the clinical presentation of epididymitis?
Unilateral scrotal pain and swelling of relatively acute onset
May be urethral discharge in sexually transmitted infections
Tenderness to palpation on the affected side
Palpable swelling of the epididymis
What investigations do you do in suspected epididymitis?
Need to exclude a sexually transmitted cause
Gram-stained urethral smear
Microscopy and culture of midstream specimen of urine for bacteria
What is the treatment of epididymitis?
Empirical therapy given and then antibiotics chosen based on sensitivities
Ofloxacin
Partner notification is recommended for epididymitis secondary to gonorrhoea, chlamydia
What is the pathology of polycystic kidney disease?
Cystic expansion of the kidneys producing progressive kidney enlargement and renal insufficiency as well as other various extrarenal manifestations`
What is the inheritance pattern for polycystic kidney disease?
Autosomal dominant
What are the three recognised forms of polycystic kidney disease? And what genetic abnormality are they associated with?
PKD1 with an abnormality on chromosome 16 (majority of patients)
Reach end stage kidney failure by 50s
PKD2 with an abnormality on chromosome 4
Slower progression
PKD3
They are mutations in polycystin 1 and 2
What is the clinical presentation of polycystic kidneys?
May be clinically silent unless cysts become symptomatic due to size/haemorrhage
Loin pain Visible haematuria Cyst infection Renal calculi Increased blood pressure Progressive renal failure
Extra renal Liver cysts Intracranial aneurysm Mitral valve prolapse Ovarian cyst Diverticular disease
What tests do you do in polycystic kidney disease?
Urinalysis Blood - FBC (can produce excess erythropoietin leading to raised Hb) - U&E, creatinine - eGFR
Imaging
- ultrasound for diagnosis
what is the difference in diagnostic criteria for polycystic kidney disease in age?
15-39 years = 3+ cysts
40-59 years = Over 2 cysts in each kidney
What is the treatment for polycystic kidney disease?
Water intake 3-4L a day may suppress cyst growth
Increased blood pressure should be treated
1st line : ACE-i/ARB
2nd line : thiazides
3rd line : Beta blockers
Treat infections
Plan for RRT as they reach end stage kidney disease
what is the treatment for Neisseria gonorrhoeae?
Ceftriaxone + azithromycin
A elderly gentleman present to GP with History of hesitance, back pain and tiredness. The GP decides to perform a DRE (Digital rectal exam). What will he most likely find on examination? *
Hard and irregular mass
A 15 year old boy has been brought by his mum to A&E after being kicked in groin by football earlier today. Boy describes the pain in left testical as 9/10 and he fells like he is going to throw up. Upon examination left testical is inflamed and painful on palpation. What would be the most appropriate action? *
Refer to urology for surgery immediately
What antibiotic would you prescribe to a pregnant woman with a urinary tract infection?
Cephalexin
What is the most appropriate treatment for testicular cancer that has the serum tumour marker alpha feto protein ?
Chemotherapy
What does a boggy and very tender prostate suggest in the presence of the patient presenting as systemically unwell, significant voiding urinary lower tract symptoms and pain passing stool?
Prostatitis
A 60 year old man presents with a dull pain and heaviness in his left scrotum. Upon examination the testicle appears swollen and feels like a “bag of worms”. What is the name given to this condition? *
Varicocele
An 82 year old presents to your clinic, embarrassed he admits that he is having issues urinating. Reporting signs of post micturition dribbling, poor stream and hesitancy. What would be your first investigation? *
Digital Rectal Examination
What is an appropriate treatment for adult onset minimal change disease?
Prednisolone
