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Phase 2A > Genitourinary > Flashcards

Genitourinary Flashcards

1
Q

What is renal colic?

A

An acute and severe loin pain, usually caused when a urinary stone moves from the kidney into the ureter causing acute obstruction.

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2
Q

Define urolithiasis?

A

process of stone formation

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3
Q

How can stones be formed?

A

Stones form from crystals in supersaturated urine

Foreign body in the urine or stasis forms stones

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4
Q

What is hydroureter and hydronephrosis ?

When can this occur?

A

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.

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5
Q

Name three things that kidney stones can be made from?

A

80% Calcium based (calcium oxalate or calcium phosphate)
10% caused by uric acid
10% caused by struvite - infection stones
Rarely - cystine stones

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6
Q

What is the main cause of kidney stone formation

A

Dehydration!

Idiopathic

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7
Q

Name 2 other reasons, beside dehydration, that can cause kidney stone formation?

A

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

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8
Q

Name the three most common areas that a kidney stone may become lodged

A

Ureteropelvic junction
Distal ureter (at the level of the iliac vessels)
Ureterovesical junction

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9
Q

Name 5 symptoms of renal colic

A

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
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10
Q

What is the pain like in renal colic patients?

A

“Loin to groin pain - radiates to the ipsilateral testis/labia”
Classically is a sudden onset of pain
Pain is colicky (intermittent)
Exacerbation: fluid loading

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11
Q

Name 4 signs of renal colic?

A

Ashen
Sweating heavily
Cannot sit still
Tender abdomen on the affected side as palpation increases

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12
Q

What investigations would you do in a patient with renal colic?

A

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

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13
Q

Name 3 measures you can do to prevent and decrease the likelihood of developing stones?

A 
Overhydration 
Low salt diet 
Normal dairy intake 
Healthy protein intake 
Reduce BMI 
Active lifestyle
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14
Q

What is the immediate management for a patient with renal colic?

A

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

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15
Q

What are three treatment options for renal stones?

A

Conservative treatment
Lithotripsy
Nephrectomy (open or laparoscopic)

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16
Q

What are three treatment options for ureteric stones?

A

Conservative (allow 2 weeks to pass)
Medical expulsive therapy
Extracorporeal shock wave lithotripsy
Ureteroscopy

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17
Q

What are two treatment options for bladder stones?

A

Conservative if asymptomatic
Litholapaxy - crushing or disintegrating of stones in your bladder using a telescopic fragmentation device or a laser passed through your urethra

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18
Q

What is the definition of acute kidney injury?

A

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.

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19
Q

What are the KDIGO stages of AKI?

A

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

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20
Q

What is the underlying pathology of pre-renal AKI?

A 
Decreased nitric oxide and prostaglandins 
Increased angiotensin II 
Increased adrenergic nerves
Increased ADH
Leads to a decreased GFR
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21
Q

What is the overall underlying pathology of intrinsic renal aki?

A

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.

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22
Q

what is the pathology of nephrotoxic tubular disease?

A

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

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23
Q

what is the pathology of glomerulonephritis?

A

Increased membrane permeability
Decreased pressure difference
Decreased GFR

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24
Q

What is the underlying pathology of post-renal aki?

A

Characterised by acute obstruction to urinary flow.
Increased intratubular pressure
Decreased GFR

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25
Q

What are the three major classifications of AKI?

A

Pre-renal
Intrinsic renal
Post-renal

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26
Q

Name the four sub-categories that can cause pre-renal AKI and give an example cause for each?

A

Decrease in vascular volume : haemorrhage, severe dehydration, vomiting and diarrhoea

Decrease in cardiac output : congestive heart failure

Systemic vasodilation: sepsis

Renal vasoconstriction : NSAIDs

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27
Q

What are the 4 sub-categories that can cause intrinsic renal damage?
Give an example that can cause each?

A

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

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28
Q

Name three causes of post-renal AKI?

A 
Stone
Renal malignancy
Stricture
Clot
Pelvic malignancy
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29
Q

Name 4 signs/symptoms of AKI?

A 
Rise in serum creatinine 
Oliguria or anuria 
Nausea, vomiting
Dehydration
Confusion
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30
Q

What are the three diagnostic criteria for AKI?

A

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

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31
Q

What investigations should you do in a patient with AKI?

A

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

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32
Q

What are the principles of treatment for AKI?

A

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

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33
Q

Why are NSAIDs contraindicated in AKI?

A

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.

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34
Q

What abnormality caused by AKI can be seen on ECG? What would you see?

A

Hyperkalaemia
Tall tented T waves
Bradycardia
Wide QRS complex

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35
Q

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?

A

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.

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36
Q

What is the most common cancer of the kidney?

A

Renal cell carcinoma

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37
Q

What cells does renal cell carcinoma arise from?

A

It arises from the proximal renal tubular epithelium

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38
Q

Where can kidney cancer spread to?

A

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

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39
Q

What are kidney cancers associated with?

A

Structural abnormalities of the short arm of chromosome 3

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40
Q

Name 5 risk factors that can increase your risk of developing kidney cancer?

A 
Smoking 
Obesity
Hypertension
Environmental - petrol, phenacetin, cadmium 
Occupational - leather tanners
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41
Q

What are the is the classic triad of symptoms that are suggestive of kidney cancer?

A

Haematuria
Loin pain
Abdominal mass

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42
Q

What other systemic symptoms can you get with kidney cancer?

A

Anorexia
Malaise
Weight loss

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43
Q

What investigations should you do when investigating kidney cancer?

A

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)
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44
Q

Briefly outline the stages of kidney cancer?

A

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

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45
Q

What is the management for Stage I kidney cancer?

A

partial nephrectomy or radical nephrectomy

If neither are possible, active surveillance or ablative therapies in selected patients with small masses

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46
Q

What is the management for Stage II kidney cancer?

A

Radical nephrectomy

Partial nephrectomy in selected patients in whom the procedure is feasible

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47
Q

What is the management for Stage III kidney cancer?

A

Radical nephrectomy plus adrenalectomy, tumour thrombus excision (if appropriate) and/or lymph node dissection

Systemic treatment if inoperable, or owing to poor performance status

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48
Q

What is the management for Stage IV kidney cancer?

A

Systemic treatment
Elective cytoreductive nephrectomy
Combine with interferon alpha
Immunotherapy may be high dose IL-2

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49
Q

What type of carcinoma are the majority of bladder cancers?

A

transitional cell carcinomas

  • Increased number of epithelial cell layers
  • Abnormal cell maturation
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50
Q

Name 5 risk factors that increase your likelihood of developing bladder cancer?

A

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)

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51
Q

In what occupations would you be exposed to aromatic amines, polycyclic aromatic hydrocarbons and chlorinated hydrocarbons that increase your likelihood of developing cancer?

A

in industrial plants processing paint, dye, metal, rubber and petroleum products

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52
Q

Why does smoking increase your risk of bladder cancer?

A

Half of bladder cancers are caused by smoking as tobacco smoke contains aromatic amines and polycyclic aromatic hydrocarbons which are renally excreted

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53
Q

Name 5 clinical features that may be seen in bladder cancer?

A 
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
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54
Q

What is the diagnostic test for bladder cancer?

A

cystoscopy with biopsy of the bladder tumour. The biopsied specimen must include muscle to be able to stage the cancer

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55
Q

What investigations would you do in bladder cancer?

A 
Cytoscopy + biopsy 
Bloods 
- FBC
- U&amp;E
- PSA
- Glucose 
Urine 
- Dipstix test
- Microscopy, culture and sensitivity - exclude infection 
Imaging 
- USS
- CT urogram is diagnostic and provides staging
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56
Q

Why do we have to grade bladder cancer?

A

70% of non-muscle invasive bladder cancer will recur

15% will progress to muscle invasive cancer

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57
Q

What are the treatment options for non-invasive bladder cancers?

A

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)

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58
Q

What is the treatment for invasive bladder cancer?

A

Radical cystectomy + neoadjuvant chemotherapy using a cisplatin combination regimen (involves removal of local lymph nodes)

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59
Q

What type of carcinoma are the majority of prostate cancers?

A

adenocarcinomas

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60
Q

In what regions can you get prostate cancer? Which is the most common site?

A

Peripheral zone (outside) - in the majority of cases (70%)
Transitional zone
Central zone

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61
Q

Why is the fact that the majority of prostate cancers are in the peripheral zone of clinical importance?

A

can feel this cancer easier during a digital rectal exam

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62
Q

outline the Gleason grading system?

A

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

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63
Q

What are the routes of spread of prostate cancer?

A

Direct
Lymphatic
Haematogenous

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64
Q

Where can prostate cancer spread to directly?

A

Intrinsic - involves the rest of the prostate
Extrinsic - upward → ureter
Downward → urethra
Laterally → sciatic nerve and iliac blood vessels
Forward → pubic bone

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65
Q

What is the primary lymphatic drainage of the prostate?

A

Lymphatic drainage of the prostate primarily drains to the obturator and internal iliac lymphatic channels

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66
Q

Name 3 places that prostate cancer commonly spreads to via the blood which can indicate quite late disease?

A

Bone
Liver
Lung
Kidneys

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67
Q

Name 4 risk factors that increase a person’s likelihood of having prostate cancer?

A

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

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68
Q

What genetic polymorphisms are associated with prostate cancer?

A

Genetic polymorphisms are more common in younger patients

BRCA1, BRCA2, mismatch repair and HOXB13 which interacts with androgen receptor

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69
Q

Name 5 symptoms associated with prostate cancer?

A 
Nocturia 
Hesitancy 
Poor stream 
Terminal dribbling 
Obstruction 
General systemic symptoms 
Fatigue 
Weight loss 
Anorexia 
Night sweats
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70
Q

What symptoms can indicate that prostate cancer has spread and disease is more advanced?

A

Bone pain
Can be with or without a pathologic fracture

Neurological deficits from spinal cord compression

Lower extremity pain and oedema

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71
Q

What investigations would you do for prostate cancer?

A

Digital rectal examination
PSA (prostate specific antigen)
MRI prostate
Prostate biopsy

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72
Q

What are advantages and disadvantages of measuring PSA?

A

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
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73
Q

Name four treatment options for prostate cancer?

A

Active surveillance
Radical prostatectomy
Radiotherapy
Hormone therapy

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74
Q

when would you use radical prostatectomy as a treatment option for prostate cancer?

A

Used in patients less than 70 years old who are fit for surgery and have disease confined to the prostate

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75
Q

what types of hormone therapy are there for prostate cancer treatment?

A

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

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76
Q

what is the mechanism of action of luteinizing hormone-releasing hormone agonists in the treatment of prostate cancer?

A

Basic action is that it overloads the pituitary gland with signals which causes the pituitary gland to stop stimulating the testes to produce testosterone.

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77
Q

what is the action of antiandrogens in treatment of prostate cancer?

A

block the action of testosterone at the receptor level on the testes

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78
Q

What are treatments can you use for more advanced/metastatic prostate cancer?

A

Chemotherapy
Bisphosphonates
Radiotherapy for bone pain
TURP to relieve symptoms of bladder outflow obstruction
Nephrostomies for ureteric obstruction (palliative)

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79
Q

what are two main classifications of testicular tumours? What type of tumours are they? What are the differences between them?

A

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)

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80
Q

Where does testicular cancer usually spread to?

A

Usually spread locally first to the epididymis, spermatic cord and sometimes rarely the scrotal wall

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81
Q

What is the difference in lymphatic drainage of the scrotal wall and the testicles?

A

scrotal wall (inguinal lymph nodes)

testicles (para-aortic lymph nodes)

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82
Q

Name 3 risk factors that increase a man’s likelihood of developing testicular cancer?

A

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

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83
Q

What is the clinical presentation of confined testicular cancer (i.e with no mets) ?

A

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

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84
Q

What additional symptoms may a man with testicular cancer experience if he has metastatic disease?

A

Dyspnoea caused by lung mets
Abdominal mass due to enlarged para-aortic lymph nodes
Cervical nodes

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85
Q

What investigations do you do in testicular cancer?

A 
Testicular ultrasound 
Excision biopsy
Tumour markers 
AFP
B-hcg (young man presents with a positive pregnancy test) 
Chest X-ray if have respiratory symptoms
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86
Q

What are the treatment options for testicular cancer?

A 
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
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87
Q

How do we measure kidney function?

A

Measure creatinine

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88
Q

What is creatinine and why can we use it to estimate GFR?

A

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

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89
Q

What is a disadvantage of using creatinine to measure GFR?

A

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

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90
Q

why do we use the albumin:creatinine ratio when idetifying proteinuria?

A

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

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91
Q

define chronic kidney disease?

What GFR value confirms CKD?

A

Abnormal kidney structure or function present for longer than 3 months with implications for health

GFR BELOW 60 = CKD

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92
Q

Name 5 causes of chronic kidney disease?

A 
Diabetes 
Hypertension
Glomerulonephritis 
Polycystic kidney disease
Enlarged prostate or malignancy or obstructive uropathy 
Acute Kidney Injury
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93
Q

What is the main symptom of chronic kidney disease?

A

Usually asymptomatic and often unrecognised because there are no specific symptoms and it is often diagnosed at an advanced stage

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94
Q

Name three symptoms that may be present in severe chronic kidney disease?

A 
Anorexia 
Nausea 
Vomiting 
Fatigue 
Weakness
Peripheral oedema
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95
Q

What is the main consequence of chronic kidney disease?

A

Cardiovascular consequences

96
Q

what investigations do you do in chronic kidney disease?

A

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

97
Q

What lifestyle advice can you give to chronic kidney disease patients?

A

Stop smoking
Exercise advice
Diet advice → Reduce salt intake!

98
Q

Asides from lifestyle advice, what other management can you do for chronic kidney disease patients to slow the progression of renal disease?

A

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

99
Q

What are the two treatment options for kidney disease, when patients GFR falls below 15 usually?

A

Renal Replacement therapy

  • Haemodialysis
  • Peritoneal dialysis

Kidney transplant

100
Q

How does haemodialysis work?

A

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

101
Q

How does peritoneal dialysis work?

A

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

102
Q

Name three complications of renal replacement therapy?

A 
CVD effects 
- increased blood pressure
- phosphate and calcium dysregulation
-inflammation 
Renal bone disease
Infection 
Amyloid
103
Q

Name three complications of kidney transplants?

A

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

104
Q

Name two contra-indications in a transplant patient that means they could not have it?

A

Cancer with metastases
Active infection, HIV with viral replication, unstable CKD
Congestive heart failure

105
Q

Name three of the normal functions of the lower urinary tract?

A

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

106
Q

during storage of urine what is the mechanism of the detrusor muscle and distal sphincter mechanism?

A

Detrusor : relaxes

Distal sphincter mechanism : contracts

107
Q

during the voiding process what is the detrusor and distal spincter mechanism?

A

detrusor : contracts

distal sphincter : relaxes

108
Q

what are the two normal functions of the bladder?

A

storage - 99% of the time

voiding - 1% of the time

109
Q

name 4 storage lower urinary tract symptoms?

A

Frequency
Urgency
Nocturia
Incontinence

110
Q

What is the normal frequency for voiding?

A

2-8 times in a day

111
Q

Name 6 lower urinary tract symptoms that relate to voiding?

A 
slow stream
splitting or spraying 
intermittency
hesitancy 
straining
terminal dribble
112
Q

what is straining?

A

using the abdominal muscles to empty the bladder if the detrusor muscle is not working properly

113
Q

what is terminal dribble?

A

patient describes a prolonged final part of micturition when the flow has slowed to a trickle/dribble

114
Q

name 2 lower urinary tract symptoms that relate to post-micturition?

A

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

115
Q

what is the blood supply to the kidney?

A

renal artery that comes straight off the aorta

116
Q

how much urine is normal to produce per day?

A

1-1.5 L

117
Q

what spinal level to the kidneys span?

A

T11-L3

118
Q

how is the reflux of urine from the bladder back up the ureters avoided?

A

valvular mechanism as the vesicoureteric junction. when the bladder fills it compresses the ureter where it enters the bladder so it cannot reflux.

119
Q

what are the 4 nerves involved in the neural control of the bladder?

A 
pelvic nerve (parasympathetic) 
hypogastric plexus (sympathetic) 
pudendal nerve (somatic nerve) - Onuf's nucleus 
Afferent pelvic nerve (sensory nerve)
120
Q

what are the nerve roots of the pelvic nerve?

A

S2, 3, 4 (keeps pee off the floor)

121
Q

what is the main centre for voluntary control over the bladder?

A

pontine micturition centre

122
Q

what is the normal adult capacity of the bladder?

A

400-500mls

123
Q

Outline the storage phase of micturition?

A

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.

124
Q

Outline the filling phase in micturition?

A

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

125
Q

Outline the voiding reflex in micturition?

A

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.

126
Q

when do you initiate the guarding reflex?

A

when it is not appropriate to void

127
Q

outline the guarding reflex

A

It is the voluntary Onuf’s nucleus initiated by higher cortical centres.

you continue to stimulate the sympathetic nerve and pudendal nerve

128
Q

what is the epithelium of the bladder?

A

transitional

umbrella cells above

129
Q

what do you need to diagnose benign prostatic hyperplasia

A

Histology of the hyperplasia

130
Q

what is BPE?

A

benign prostatic enlargement (DRE findings)

131
Q

What is the pathology of BPH?

A

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

132
Q

What zone of the prostate enlarges in BPH?

A

Inner transitional zone

133
Q

What are the possible causes for BPH?

A

Increase in cell number of these cells

Or due to decrease in apoptosis

134
Q

What are the symptoms of BPH?

A

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

135
Q

What is a sign of BPH?

A

Smooth enlarged prostate detected from a DRE

136
Q

What investigations would you do in BPH?

A

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

137
Q

What flow rate results is suggestive of BPH?

A

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

138
Q

What lifestyle advice can you give to patients with BPH?

A

Avoid caffeine and alcohol to reduce urgency and nocturia
Relax when voiding
Void twice in a row to aid emptying

139
Q

What pharmacological management can you give to patients with BPH?

A

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
140
Q

What are the indications for surgery in a patient with BPH?

A

RUSHES - indications for surgery

Retention 
UTIs
Stones 
Haematuria 
Elevated creatinine due to benign obstructive outflow 
Symptom deterioration
141
Q

What surgical options are there for patients with BPH?

A

Trans-urethral resection of prostate (TURP)

142
Q

What are the causative organisms that can cause UTIs?

A

E.Coli (most common)
Proteus mirabilis (associated with renal stones)
Klebsiella spp. (hospital/catheter associated)
Enterococci
Staphylococcus saprophyticus

143
Q

What is the most common type of bacteria that can cause UTIs

A

E.Coli

144
Q

What can cause the infection of a UTI? Not the organisms (i.e introduction of organisms to the UT)

A 
Sexual intercourse
Catheterisation and other instrumentation 
Enlarged prostate 
Renal tract tumours 
Renal stones
145
Q

Name 3 risk factors that can increase your likelihood of developing a UTI?

A 
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
146
Q

What are the symptoms of acute pyelonephritis?

A 
Fever
Loin Pain
Pyrexial 
Occasional haematuria
Pyuria 
Rigor
Vomiting
147
Q

What investigations do you do in someone with a UTI?

A

Mid stream urine

Microscopy

Culture

Ultrasound to rule out any urinary obstruction

148
Q

Why do you collect a mid stream urine sample for a patient with a UTI?

A

Avoids contamination from the perineum or vagina

149
Q

What are you looking for during microscopy of a urine sample when investigating a UTI?

A

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

150
Q

What do you culture urine samples on when investigating UTIs? What represents a significant bacterial growth?

A

CLED or MacConkey agar
37 degrees celsius
More than 10^5 pure growth of bacteria/ml (more than 1000 colonies = significant bacteria)

151
Q

What is the treatment for acute pylonephritis?

A

Oral ciprofloxacin for 7-10 days

Paracetamol for symptomatic relief

152
Q

what type of infection is cystitis

A

lower urinary tract infection

153
Q

what are 4 symptoms of cystitis ?

A

Dysuria
Frequency
Urgency
Polyuria

154
Q

What is the treatment for asymptomatic bacteriuria over the age of 65 ?

A

None!

155
Q

What is the treatment for cystitis?

A

Nitrofurantoin

Paracetamol and/or NSAIDs are of use for symptomatic relief

156
Q

Name three examples of patients who have complicated UTIs?

A 
Pregnant
Men 
Catheterized 
Children 
Recurrent 
Immunocompromised
157
Q

What is the only example of an uncomplicated UTI?

A
  • normal renal tract structure and function

Non-pregnant woman!

158
Q

Name 2 bacterial causes of bacterial prostatitis?

A

Usually gram negative : E. coli, Enterobacter, Pseudomonas and Proteus
STIs may also be a cause e.g Neisseria gonorrhoeae and Chlamydia trachomatis

159
Q

What are the symptoms of prostatitis?

A 
Pain 
- Perineum 
- Rectum 
- Scrotum 
- Penis
- Bladder 
- Lower back 
Fever 
Malaise 
Nausea 
Urinary symptoms 
Swollen or tender prostate on PR
160
Q

What is the treatment for prostatitis?

A

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

161
Q

What are the 5 classifications of urinary incontinence?

A 
Overactive bladder
Stress incontinence 
Continuous
Overflow 
Social
162
Q

What is an overactive bladder?

A

urgency with frequency with or without nocturia when appearing in the absence of local pathology

163
Q

What is stress incontinence?

A

Associated with coughing or straining. More common in women post child-birth.

164
Q

What is overflow incontinence?

A

involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to void.

165
Q

What is social incontinence?

A

Occurs in those with dementia who have lost their cortex function and so are unaware when it is socially acceptable to void.

166
Q

Main cause of stress incontinence?

A

Common In females is usually secondary to birth trauma caused by denervation of pelvic floor and urethral sphincter

167
Q

Causes of continuous incontinence?

A

Caused by a fistula either between the vagina and bladder or the rectum and bladder

168
Q

What investigations would you do into urinary incontinence?

A

Bladder diary

Investigations to rule out any other pathology that may be causing incontinence

169
Q

What management options are there in urinary incontinence

A 
Behavioural 
Anti-muscarinic agents 
B3 agonists 
Botox 
Sacral neuromodulation 
Surgery
170
Q

What behavioural management would you use for urinary incontinence?

A

Avoid drinking caffeine and alcohol

Bladder drill

171
Q

What do anti-muscarinic agents do to help urinary incontinence?

A

Decrease parasympathetic activity by blocking M2/M3 receptors

172
Q

What do B3 agonists do to help urinary incontinence?

A

Increase sympathetic activity at B3 receptor in bladder

Enables bladder to hold more urine

173
Q

What does botox do to help urinary incontinence?

A

Blocks neuromuscular junction for acetylcholine release

174
Q

What is sacral neuromodulation?

A

Insertion of an electrode to S3 nerve root to modulate afferent signals from bladder

175
Q

What types of stress incontinence surgery are there?

A 
Tension free vaginal tape 
Transobturator tape procedure
Autologous sling 
Bulking agents 
Artificial urinary sphincter
176
Q

What can glomerular diseases go on to cause?

A

chronic kidney disease

177
Q

what is the difference between nephrotic and nephritic glomerular disease?

(differences in pathology)

A

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
178
Q

what is the main difference in how nephritic and nephrotic glomerular diseases present?

A

Nephrosis (proteinuria due to podocyte pathology)

Nephritis (haematuria due to inflammatory damage)

179
Q

Name the 3 causes of nephritic syndrome?

A

Anti-Glomerular Basement Membrane Mediated

Immune complex mediated

Non-immune mediated (ANCA+) - Rapidly progressive GN

180
Q

What are the two different subtypes of Anti-Glomerular Basement Membrane Mediated and what differentiates them?

A

With lung hemorrhage → Goodpasture’s disease

Without lung haemorrhage → Anti-GBM disease

181
Q

What are the different types of Immune complex mediated nephritic syndrome?

A

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

182
Q

What are the two different types of Non-immune mediated (ANCA+) nephritic disease?

A 
C-ANCA 
Granulomatosis with polyangiitis 
P-ANCA 
Churg-Strauss 
Microscopic polyangiitis
183
Q

What are the symptoms of nephritic syndrome?

A

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

184
Q

What investigations would you do for nephritic syndrome?

A

Need to assess damage and find a potential cause via a history

Bloods 
FBC, 
U&amp;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)
185
Q

What is the treatment for nephritic syndrome glomerular disease?

A

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

186
Q

What is the pathology of nephrotic disease?

A

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

187
Q

What are the primary causes of nephrotic syndrome glomerular disease ?

A

Primary renal disease

  • Minimal change disease
  • Membranous nephropathy
  • Focal segmental glomerulosclerosis
  • Membranoproliferative GN
188
Q

What are the secondary causes of nephrotic syndrome glomerular disease?

A 
Secondary to a systemic disorder 
Diabetes - most common secondary cause 
Lupus nephritis 
Myeloma 
Amyloid 
Pre-eclampsia
189
Q

What is the clinical presentation of nephrotic syndrome glomerular disease?

A

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
190
Q

What are the investigations for nephrotic syndrome glomerular disease?

A

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

191
Q

What are the treatment options for nephrotic syndrome glomerular disease?

A

Reduce oedema
Fluid and salt restriction
Diuresis with loop diuretics
Treat the underlying cause

Reduce proteinuria
ACE-i or ARBs

192
Q

What complications can arise from nephrotic syndrome in glomerular disease?
Why?
How would you treat them?

A

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
193
Q

Define erectile dysfunction?

A

Persistent inability to attain and maintain an erection that is sufficient for satisfactory sexual performance

194
Q

What is the normal physiology of an erection?

A

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

195
Q

Name 5 causes of erectile dysfunction

A 
Diabetes
Smoking 
Hypertension 
Hypercholesterolaemia
Obesity 
MS
thyroid dysfunction
196
Q

What investigations would you do in erectile dysfunction

A

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.

197
Q

What lifestyle factors can you advise someone with erectile dysfunction to do ?

A 
Stop smoking
Weight loss if overweight
Exercise
Avoid alcohol excess 
Counselling if non-organic cause
198
Q

What medication is used to manage erectile dysfunction ?

How does it work?

A

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

199
Q

If medication fails, what other options are there for the management of erectile dysfunction?

A

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

200
Q

What is the pathology of epididymal cysts ?

A

Smooth extratesticular spherical cyst in the head of the epididymis

201
Q

What are the symptoms that point towards a epididymal cyst?

A

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.

202
Q

What investigation would you do in an epididymal cyst?

A

Scrotal ultrasound

203
Q

What is the treatment of an epididymal cyst?

A

Surgically remove if it is painful and symptomatic

204
Q

What is a hydrocele?

A

Fluid within the tunica vaginalis

205
Q

What are the different pathologies of a hydrocele?

A

Overproduction of fluid in the tunica vaginalis (simple hydrocele)

Processus vaginalis fails to close allowing peritoneal fluid to communicate freely with the scrotal portion

206
Q

What is the aetiology of hydroceles?

A

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

207
Q

What is the presentation of a hydrocele?

A

Scrotal enlargement with a non-tender swelling

208
Q

What is the investigation for a hydrocele?

A

scrotal ultrasound

209
Q

what is the treatment of a hydrocele?

A

usually resolves spontaneously

210
Q

what is a varicocele?

A

Dilated veins of pampiniform plexus

211
Q

Why is the left testicle more likely to be affected by a varicocele?

A

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

212
Q

What is the presentation of a varicocele?

A

Distended scrotal blood vessels that feel like a “bag of worms”

Dull ache

Scrotal heaviness

213
Q

when would people need surgery for a varicocele?

A

if there is any pain, infertility or testicular atrophy

214
Q

what is epididymitis?

A

inflammation of the epidiymis

215
Q

Name three bacteria that can cause epididymitis ?

A

Chlamydia trachomatis
Neisseria gonorrhoeae
E. coli (mainly in men over 35)

216
Q

Name two risk factors that increase a man’s likelihood for developing epididymitis

A

Sexual intercourse

Catheterisation

217
Q

What is the clinical presentation of epididymitis?

A

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

218
Q

What investigations do you do in suspected epididymitis?

A

Need to exclude a sexually transmitted cause
Gram-stained urethral smear

Microscopy and culture of midstream specimen of urine for bacteria

219
Q

What is the treatment of epididymitis?

A

Empirical therapy given and then antibiotics chosen based on sensitivities

Ofloxacin

Partner notification is recommended for epididymitis secondary to gonorrhoea, chlamydia

220
Q

What is the pathology of polycystic kidney disease?

A

Cystic expansion of the kidneys producing progressive kidney enlargement and renal insufficiency as well as other various extrarenal manifestations`

221
Q

What is the inheritance pattern for polycystic kidney disease?

A

Autosomal dominant

222
Q

What are the three recognised forms of polycystic kidney disease? And what genetic abnormality are they associated with?

A

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

223
Q

What is the clinical presentation of polycystic kidneys?

A

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
224
Q

What tests do you do in polycystic kidney disease?

A 
Urinalysis 
Blood 
- FBC (can produce excess erythropoietin leading to raised Hb) 
- U&amp;E, creatinine
- eGFR

Imaging
- ultrasound for diagnosis

225
Q

what is the difference in diagnostic criteria for polycystic kidney disease in age?

A

15-39 years = 3+ cysts

40-59 years = Over 2 cysts in each kidney

226
Q

What is the treatment for polycystic kidney disease?

A

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

227
Q

what is the treatment for Neisseria gonorrhoeae?

A

Ceftriaxone + azithromycin

228
Q

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? *

A

Hard and irregular mass

229
Q

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? *

A

Refer to urology for surgery immediately

230
Q

What antibiotic would you prescribe to a pregnant woman with a urinary tract infection?

A

Cephalexin

231
Q

What is the most appropriate treatment for testicular cancer that has the serum tumour marker alpha feto protein ?

A

Chemotherapy

232
Q

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?

A

Prostatitis

233
Q

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? *

A

Varicocele

234
Q

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? *

A

Digital Rectal Examination

235
Q

What is an appropriate treatment for adult onset minimal change disease?

A

Prednisolone

Phase 2A (11 decks)

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