Genitourinary tract Flashcards

Question 1

Q

what are the functions of the kidney?

Answer

A

filter or secrete waste/excess substances
maintains acid-base balance
retains albumin and circulating cells
reabsorbs glucose, amino acids and bicarbonates
controls BP, fluid status and electrolytes
activates 25-hydroxy vitamin D (by hydroxylating it to form 1,25 dihydroxy vitamin D)
synthesises erythropoietin

Question 2

Q

what is the GFR?

Answer

A

glomerular filtration rate

the volume of fluid filtered from the glomeruli into Bowman’s space per unit time (minutes)
120ml/min = 7.2L/h = 170L/day

Question 3

Q

what is the creatinine clearance rate?

Answer

A

volume of blood plasma that is cleared of creatinine per unit time
useful measure for approximating the GFR
creatinine clearance exceeds GFR due to creatinine secretion, which can be blocked by cimetidine

Question 4

Q

what is reabsorbed in the proximal tubule?

Answer

A

2/3rds of salt and water (via Na/K ATPase pump)
100% of organic solutes (glucose, amino acids, inorganic phosphate)
65% of potassium
50% of urea
80% of phosphate
70-90% of citrate

Question 5

Q

what is Fanconi syndrome? what does it lead to?

Answer

A

syndrome of inadequate reabsorption in the proximal renal tubules
affects the PCT and proximal straight tubule
glycosuria
acidosis with failure of urine acidification
phosphate wasting resulting in rickets/osteomalacia
aminoaciduria

Question 6

Q

what are some causes of Fanconi syndrome?

Answer

A

cytinosis
Wilson’s
tenofovir
congenital or acquired diseases
toxicity
ADRs

Question 7

Q

what is reabsorbed in the loop of Henle?

Answer

A

thin descending limb has low permeability to ions and urea, and is highly permeable to water
thin ascending limb is impermeable to water but permeable to ions
ascending limb reabsorbs sodium, potassium and chloride via NKCC2, and magnesium and calcium
cortical thick ascending limb drains urine into the DCT

Question 8

Q

what is reabsorbed in the DCT?

Answer

A

regulates pH by absorbing bicarbonate and secreting protons, or by absorbing protons and secreting bicarbonate
secretes potassium and absorbs sodium (mediated by aldosterone and WNK kinases)
reabsorbs calcium (mediated by PTH)
expresses arginine vasopressin receptor 2

Question 9

Q

what is the function of the collecting duct?

Answer

A

does salt handling; by this point, most of the salt has been reabsorbed
tightly regulated by aldosterone (aldosterone increases the transcription of eNac channels which absorb Na+ in exchange for K+)
secrete K+ and H+ into the urine
water handling is also done here and water is absorbed via aquaporin 2 channels (regulated by vasopressin)

Question 10

Q

what are features of renal potassium control?

Answer

A

K+ is freely filtered and mostly reabsorbed in the proximal tubule/loop of Henle
distal tubule secretion determines renal excretion
insulin and catecholamines drive cellular K+ uptake, buffering acute changes

Question 11

Q

what renal medication causes hypokalaemia?

Answer

A

loop diuretics

- thiazide diuretics

Question 12

Q

what renal medication causes hyperkalaemia?

Answer

A

spironolactone (aldosterone antagonist)
amiloride (acts on eNac channels)
ACE inhibitors
angiotensin receptor blockers (ARB)
trimethoprim (acts on eNac channels but milder)

Question 13

Q

how can diuretics affect kidney disease?

Answer

A

diuretics are not nephrotoxic but hypovolaemia is (which they can cause)
in advanced kidney disease you require huge amounts of diuretics to do the work
thiazide and loop diuretics are extremely powerful and effective together resulting in profound diuresis

Question 14

Q

what happens if plasma is too concentrated?

Answer

A

if things are too concentrated then ADH is released resulting in increased aquaporins in the collecting duct and thus more water is absorbed, thereby diluting plasma

Question 15

Q

what are features of erythropoietin in the kidney? when is anaemia seen?

Answer

A

the renal cortex acts as an oxygen sensor; blood flow and oxygen requirement (GFR) are matched
anaemia is mainly seen after eGFR < 30
erythropoietin is hormone that produces haemoglobin, it is produced in response to tissue hypoxia
in advanced kidney disease and anaemia, erythropoietin will be given to help increase O2 transport

Question 16

Q

what is the process of vitamin D hydroxylation in the kidneys?

Answer

A

it takes 25-hydroxy vitamin D and hydroxylates it to form 1,25-dihydroxy vitamin D (calcitriol) by the enzyme 1alpha hydroxylase - this is the active form of vitamin D

Question 17

Q

what are the actions of calcitriol?

Answer

A

increases Ca2+ and phosphate absorption from the gut
increases phosphate absorption to a lesser extent
suppresses parathyroid hormone (PTH)
deficiency results in secondary hyperparathyroidism

Question 18

Q

how does deficiency of calcitriol result in secondary hyperparathyroidism?

Answer

A

low vitamin D results in low Ca2+ and phosphate resulting in increased PTH which causes Ca2+ and phosphate leeching out of the bones
PTH also acts on osteoclasts by increasing their activity and thus increasing their turnover resulting in reduced bone quality

Question 19

Q

what is the function of the lower urinary tract?

Answer

A

to convert the continuous process of excretion (urine production) to an intermittent, controlled volitional process (micturition)

Question 20

Q

what are the essential features of the lower urinary tract?

Answer

A

low pressure and insensible storage of urine of adequate capacity
prevents leakage of the urine stored
allows rapid, low-pressure voiding at an appropriate time and place

Question 21

Q

what is the pressure like in the kidney?

Answer

A

mean arterial pressure 60-70mmHg drives filtration in the Bowman’s capsule
there is progressive reduction in pressure along the nephron due to reabsorption, until at the collecting system pressure is 3-10mmHg

Question 22

Q

what is the neural control of voiding?

Answer

A

pontine micturition centre stimulates excitatory control to detrusor nucleus and inhibits Onuf’s nucleus
signal is transmitted from spinal root S3,4,5 via the parasympathetic nervous system and this results in contraction of detrusor muscles and relaxation of the urethra

Question 23

Q

what is the neural control of storage?

Answer

A

pontine storage centre stimulates and sends inhibitory signals to detrusor muscles and excitatory signals to Onuf’s nucleus
signal is transmitted from spinal root T10, L1 and L2 via the sympathetic nervous system and this results in the relaxation of the bladder and contraction of the urethral sphincter

Question 24

Q

what is the function of the sacral micturition centre?

Answer

A

at the sacral micturition centre there is a reflex that, when bladder is full it initiates voiding - this is inhibited by conscious parts of the brain:
• if the cord is cut above S2,3,4 then will only urinate when the bladder is full, but the descending pathway will not be able to inhibit this with the brain as descending pathway will be destroyed

Question 25

Q

what occurs in voiding? is it parasympathetic or sympathetic?

Answer

A

detrusor muscle contraction of bladder

- parasympathetic (cholinergic) - S3, S4, S5

Question 26

Q

what occurs in storage? is it parasympathetic or sympathetic?

Answer

A

urethral contraction
inhibition of detrusor muscle contraction of bladder
sympathetic (noradrenergic) - T10, L1, L2

Question 27

Q

what is the histology of the bladder?

Answer

A

has urothelium (transitional epithelium):
• highly specialised stratified, 3-7 cells thick
• umbrella structure that is completely impermeable so cannot resorb urine
• able to fold and unfold to increase volume

Question 28

Q

what is the difference between women and men in urethras? what does this mean?

Answer

A

men have a greater voiding pressure due to them having a longer urethra; more likely to develop retention
women have a shorter urethra with lower resistance and thus higher flow rates; more likely to develop incontinence

Question 29

Q

what are renal stones?

Answer

A

nephrolithiasis/urolithiasis
renal stones (calculi) consist of crystal aggregates; stones form in collecting ducts and may be deposited anywhere from the renal pelvis to the urethra

Question 30

Q

where do renal stones classically occur?

Answer

A

occur classically at these 3 narrowings:

pelviureteric junction
pelvic brim
vesicoureteric junction

Question 31

Q

what is the epidemiology of renal stones?

Answer

A

incidence is increasing
10-15% lifetime risk
peak age is between 20-40 yrs
more common in males than females
unusual in children
more than 50% lifetime risk of recurrence once you’ve had them
most stones are composed of calcium oxalate and phosphate

Question 32

Q

what are risk factors and aetiology of renal stones?

Answer

A

anatomical abnormalities that predispose to stone formation e.g. obstruction or trauma
chemical composition of urine that favours stone crystallisation
dehydration resulting in a concentrated urine
infection
hypercalcaemia, hyperoxaluria, hypercalciuria, hyperuricaemia
primary renal disease e.g. polycystic kidneys or renal tubular acidosis
drugs e.g. diuretics, antacids, acetazolamide, corticosteroids, aspirin, allopurinol, vitamin C and D
diet e.g. chocolate, tea, strawberries, rhubarb all increase oxalate levels
gout
family history

Question 33

Q

what are types of renal stones?

Answer

A

renal stone/calculi form from crystals in supersaturated urine:
• calcium oxalate are the most common stones (60-65%)
• calcium phosphate stones are uncommon (10%)

Question 34

Q

what are causes of hypercalcuria?

Answer

A

hyperparathyroidism resulting in hypercalcaemia
excessive dietary intake of Ca2+
idiopathic hypercalciuria - increased absorption in gut
primary renal disease such as polycystic kidneys or medullary sponge kidney

Question 35

Q

what are causes of hyperoxaluria?

Answer

A

high dietary intake of oxalate rich food e.g. spinach, rhubarb, chocolate and tea
low dietary Ca2+ resulting in decreased binding of oxalate (by Ca2+) so increased oxalate absorption and urinary excretion
increased intestinal resorption due to GI disease e.g. Crohn’s

Question 36

Q

what are causes of uric acid stones?

Answer

A

associated with hyperuricaemia with/without gout
dehydration
patients with ileostomies are at particular risk, both from dehydration and from bicarbonate loss from GI secretion resulting in the production of an acidic urine (uric acid is more soluble in alkaline than acidic) thereby stimulating stone formation

Question 37

Q

what causes infection-induced kidney stones?

Answer

A

mixed infective stones are composed of magnesium ammonium phosphate as well as calcium
these are often large
usually due to UTI with an organism such as Proteus mirabilis that hydrolyses urea forming ammonium hydroxide
the increased ammonium ions and the alkalinity both favour stone formation

Question 38

Q

what are cystine stones caused by?

Answer

A

caused by cystinuria

* this results in excessive urinary excretion and formation of cysteine stones

Question 39

Q

what is clinical presentation of kidney stones?

Answer

A

most are asymptomatic
renal colic
loin pain
if urinary tract is obstructed then fluid/diuretics make the pain worse as peristaltic flow increases
bowel sounds may be reduced
BP may be low
dysuria, strangury, frequency
recurrent UTI’s
haematuria
acute pyelonephritis

Question 40

Q

what is the clinical presentation of renal colic?

Answer

A

rapid onset - woken from sleep
pain that results from upper urinary tract obstruction
excruciating ureteric spasms
pain is from loin to groin and comes and goes in waves as the ureters peristalise
associated with nausea and vomiting
worse with fluid loading
radiates to groin and ipsilateral testis/labia
often cannot lie still (differentiates from peritonitis)

Question 41

Q

what are differential diagnoses of kidney stones?

Answer

A

vascular accident e.g. ruptured AAA if over 50 yrs until proven otherwise
bowel pathology e.g. diverticulitis or appendicitis
ectopic pregnancy or ovarian cyst torsion
testicular torsion can present with loin pain and nothing else

Question 42

Q

what is used to diagnose kidney stones?

Answer

A

history and examination
urine dipstick
mid-stream specimen of urine sent for microbiology culture and sensitivity
bloods
KUBXR
NCCT-KUB
ultrasound

Question 43

Q

how is a urine dipstick used to diagnose kidney stones?

Answer

A

usually positive for blood - haematuria

* also looks for red cells, protein and glucose

Question 44

Q

how is KUBXR used to diagnose kidney stones?

Answer

A

Kidney Ureter Bladder X-ray
• first line investigation
• 80% sensitive
• see stone in line of renal tract

Question 45

Q

how is NCCT-KUB used to diagnose kidney stones?

Answer

A

non-contrast CT kidney ureter bladder
• gold standard
• very rapid
• 99% sensitive for stones - diagnostic
• no contrast so no renal damage or allergy
• but no functional info and gives radiation dose equivalent to 18 months background radiation

Question 46

Q

how is ultrasound used to diagnose kidney stones?

Answer

A

shows kidney stones and renal pelvis dilatation well but ureteric stones can be missed
sensitive for hydronephrosis
very poor at visualising stones in ureter
useful in pregnant and younger recurrent stone-formers
rarely used acutely

Question 47

Q

what is the treatment of kidney stones?

Answer

A

strong analgesic
antibiotics if infection e.g. IV cefuroxime or IV gentamicin
antiemetics to prevent vomiting
observe for sepsis
stones less than 5mm in lower ureter 90% pass spontaneously
medical expulsive therapy (oral nifedipine or alpha blocker)

Question 48

Q

what is the treatment if kidney stones are still not passing?

Answer

A

extracorporeal shockwave lithotripsy; ultrasound fragments stone
endoscopy with YAG - laser for larger stones
percutaneous nephrolithotomy; keyhole surgery to remove stones that are large, multiple or complex

Question 49

Q

how can kidney stones be prevented from recurring?

Answer

A

overhydration
normal/low Ca2+ dietary intake
low salt diet
normal daIry intake
reduce BMI
reduction in animal proteins
active lifestyle

Question 50

Q

how can uric acid stones be prevented from recurring?

Answer

A

can be caused by long term allopurinol use
only form in acid urine
deacidification of urine e.g. oral sodium bicarbonate to alkalinise urine

Question 51

Q

how can cysteine stones be prevented from recurring?

Answer

A

overhydration
urine alkalisation
cysteine binders e.g. captopril

Question 52

Q

what is the definition of acute kidney injury/acute renal failure?

Answer

A

an abrupt (over hours to days) sustained rise in serum urea and creatinine due to a rapid decline in GFR leading to a failure to maintain fluid, electrolyte and acid-base homeostasis - it is usually but not always reversible or self-limiting

Question 53

Q

what is the RIFLE classification?

Answer

A

old system that was used to define AKI
uses either an increase in serum creatinine (SCr) or a decrease in urine output
RIFLE describes three levels of renal dysfunction (RIF) and two outcome measures (LE) - these criteria indicate an increasing degree of renal damage and have a predictive value for mortality
risk, injury, failure, loss, end-stage renal disease

Question 54

Q

what is the GFR and urine output criteria for the Risk category of RIFLE for AKI?

Answer

A

GFR criteria: 1.5 fold increase in creatinine or GFR decrease >25%

urine output criteria: UO <0.5 ml kg^-1 h^-1 x6h

Question 55

Q

what is the GFR and urine output criteria for the Injury category of RIFLE for AKI?

Answer

A

GFR criteria: 2 fold increase in creatinine or GFR decrease >50%

urine output criteria: UO <0.5 ml kg^-1 h^-1 x12h

Question 56

Q

what is the GFR and urine output criteria for the Failure category of RIFLE for AKI?

Answer

A

GFR criteria: 3 fold increase of GFR decrease >75% or creatinine >4mg per 100ml (acute rise of >0.5mg per 100ml dl)

urine output criteria: UO <0.3 ml kg^-1 h^-1 x24h or anuria x12h

Question 57

Q

what is the criteria for the Loss category of RIFLE for AKI?

Answer

A

persistent ARF = complete loss of kidney function >4hrs

Question 58

Q

what is the criteria for the ESKD category of RIFLE for AKI?

Answer

A

end-stage kidney disease (>3 months)

Question 59

Q

what is the KDIGO classification for AKI?

Answer

A

staging system for AKI used currently

- also uses serum creatinine and urine output to assess severity

Question 60

Q

what is the serum creatinine (sCr) criteria for AKI in the KDIGO classification?

Answer

A

increase >26umol/L in 48hrs OR increase >1.5 x baseline
increase 2-2.9 x baseline
increase >3 x baseline OR >354umol/L OR commenced on RRT irrespective of stage

Question 61

Q

what is the urine output criteria for AKI in the KDIGO classification?

Answer

A

<0.5mL/kg/h for >6 consecutive hours
<0.5mL/kg/h for >12hrs
<0.3mL/kg/h for >24hrs or anuria for 12hrs

Question 62

Q

what is the epidemiology of AKI?

Answer

A

AKI is common, occurring in 18% of hospital patients
about 25% of patients with sepsis and 50% of patients with septic shock will have AKI
severe AKI (creatinine > 500μmol/L, often requiring dialysis) affects about 130-140 per million population per year
common in the elderly

Question 63

Q

what is AKI associated with?

Answer

A

diarrhoea
haematuria
haemoptysis
hypotension
urine retention

Question 64

Q

what are the causes of AKI?

Answer

A

commonest are ischaemia, sepsis and nephrotoxins
pre-renal (40-70%)
intrinsic renal (10-50%); required renal biopsy for diagnosis
post-renal (10-25%)

Answer 65

A

renal hypoperfusion e.g. hypotension (due to hypovolaemia or sepsis) resulting in a drop in GFR
hypovolaemia of any cause - dehydration or haemorrhage
hypotension without hypovolaemia - cirrhosis or septic shock
low cardiac output - cardiac failure or cardiogenic shock
renal hypoperfusion - NSAIDs, ACE inhibitors

Answer 66

A

renal parenchyma damage
acute tubular necrosis - commonest renal cause of AKI, caused by pre-renal damage or nephrotoxins e.g. NSAIDs, radiological contrast, uric acid crystals, myeloma and increased Ca2+
vascular
glomerular
interstitial

Answer 67

A

renal artery/vein thrombosis
cholesterol/thrombus emboli from angiography
vasculitis e.g. in SLE
haemolytic uraemic syndrome - thrombotic microangiopathy; haemolytic anaemia and reduced platelets
malignant hypertension

Answer 68

A

glomerulonephritis or nephrotic syndrome

- autoimmune (SLE), drugs, infections

Answer 69

A

drugs, infiltration with e.g lymphoma, infection, tumour lysis syndrome following chemo

Answer 70

A

urinary tract obstruction at ureter, bladder or prostate
luminal: stones, clots or sloughed papillae
mural (wall)
extrinsic compression from malignancy especially from pelvis or due to retroperitoneal fibrosis

Answer 71

A

malignancy e.g. ureteric, bladder or prostate
benign prostate hyperplasia (BPH)
strictures

Answer 72

A

age > 75 yrs
heart failure
peripheral vascular disease
chronic liver disease
sepsis
poor fluid intake/increased losses
history or urinary symptoms
chronic kidney disease (CKD) especially if GFR < 60
past history of AKI
hypovolaemia
haematological malignancy
diabetes
prostate cancer
nephrotoxic drugs
repeated use of radiological contrast

Answer 73

A

depends on underlying cause or severity
on examination there may be palpable bladder, palpable kidneys, abdominal/pelvic masses, rashes
oliguria occurs in early sages
arrhythmias due to hyperkalemia
breathlessness occurs from a combination of anaemia and pulmonary oedema secondary to volume overload
pericarditis occurs with severe untreated uraemia and may be complicated by a pericardial effusion, tamponade or pericardial rub
impaired platelet function causes bruising and GI bleeding
infection due to immune suppression
postural hypotension
oedema
thirst - indicated fluid depletion and dehydration (possible cause of AKI)

Answer 74

A

abdominal aortic aneurysm, alcohol toxicity, alcoholic and diabetic ketoacidosis, chronic renal failure, dehydration, GI bleed, heart failure, metabolic acidosis

Answer 75

A

small kidneys on ultrasound, anaemia, low Ca2+, high phosphate or high creatinine/low GFR

Answer 76

A

can suggest infection (leucocytes + nitrites) and glomerular disease (blood + protein)

Answer 77

A

anaemia and very high ESR suggests myeloma or vasculitis as underlying cause

Answer 78

A

urine and blood cultures to exclude infection

- mid-stream-specimen of urine sent for microbiology culture and sensitivity

Answer 79

A

give assessment of renal size (very small indicates CKD)
can be used to distinguish obstruction and hydronephrosis and look for cysts, small kidneys (CKD), masses and corticomedullary differentiation (reduced in CKD)

Answer 80

A

complete anuria is rare but if present it suggests obstructive cause
in elderly men this should be considered prostatic e.g BPH and can be relieved by catheterisation
if catheterisation does not relieve anuria then suspect obstruction above prostate

Answer 81

A

suspect obstruction above prostate
get an urgent ultrasound to look for hydronephrosis
get an urgent CT-KUB which can look for obstructing masses or calculi as well as retroperitoneal fibrosis

Answer 82

A

to look for hyperkalaemic changes

tall tented T waves
prolonged PR interval
widening QRS complex

Answer 83

A

to look for pulmonary oedema

Answer 84

A

intrarenal causes of AKI

* perform for every patient with unexplained AKI and normal kidneys

Answer 85

A

correct volume depletion with fluids

- treat sepsis with antibiotics

Answer 86

A

refer early to nephrology if concern over tubulointerstitial or glomerular pathology

Answer 87

A

catheterise and consider CT of renal tract (CTKUB)
if signs of obstruction and hydronephrosis then do cystoscopy and retrograde stents or nephrostomy insertion; this buys time to allows treatment of cause of obstruction

Answer 88

A

NSAIDs
ACE-inhibitor
gentamicin
amphotericin

Answer 89

A

calcium gluconate; cardioprotective
insulin to drive K+ into cells with glucose and dextrose to prevent hypoglycaemia
use dialysis or haemofiltration

Answer 90

A

hyperkalaemia treatment
diuretics or dialysis/haemofiltration for pulmonary oedema
sodium and potassium restriction and vitamin D supplied

Answer 91

A

symptomatic uraemia including pericarditis or tamponade
hyperkalaemia not controlled by conservative measures
pulmonary oedema thats unresponsive to diuretics
severe acids
high potassium
tall T waves, low flat p waves, broad QRS or arrhythmias on ECG
metabolic acidosis
fluid overload that is resistant to diuretics

Answer 92

A

haemofiltration and haemodialysis

Answer 93

A

cardiovascular disease due to combination of hypertension and calcium/phosphate dysregulation
infection
amyloid accumulates in long-term dialysis and may cause carpal tunnel syndrome, arthralgia and fractures
malignancy is commoner in dialysis patients; may be due to causes of end-stage renal failure e.g. urothelial tumours

Answer 94

A

glomerulonephritis is a broad term that refers to a group of parenchymal kidney diseases that all result in the inflammation of the glomeruli and nephrons

Answer 95

A

damage to the filtration mechanism resulting in haematuria and proteinuria
damage to the glomerulus restricts blood flow, leading to compensatory hypertension
loss of the usual filtration capacity leads to AKI
causes 25% of end stage kidney failure

Answer 96

A

acute nephritic syndrome (acute glomerulonephritis)
nephrotic syndrome
asymptomatic urinary abnormalities; haematuria, proteinuria or both
chronic kidney disease (CKD)
haematuria; visible or non-visible (red cell casts seen on microscopy)
proteinuria (usually < 2g in 24hrs)
hypertension and oedema (periorbital, leg, or sacral)

Answer 97

A

often caused by an immune response triggered by an infection of other disease

Answer 98

A

IgA nephropathy

Answer 99

A

bacterial infection e.g. MRSA, typhoid or secondary syphilis
Hepatitis B and C
schistomiasis
malaria
post-streptococcal infection e.g. Strep. pyogenes
infective endocarditis
SLE
systemic sclerosis
ANCA associated vasculitis
Goodpastures disease
IgA nephropathy

Answer 100

A

occurs classically 2 weeks after tonsillitis

* bacterial antigen becomes trapped in the glomerulus leading to diffuse proliferative glomerulonephritis

Answer 101

A

rash, arthralgia, kidney failure, neurological symptoms, pericarditis and pneumonitis
anti-nuclear antibody (ANA) positive and double stranded DNA positive
low complement C3 and C4

Answer 102

A

immunosuppression; steroids, cyclophosphamide, rituximab

Answer 103

A

ANA positive, Anti-Ro and Anti-La positive
severe hypertension
‘onion skin’ changes on renal biopsy, raynauds phenomenon, fibrotic skin, oesophageal dysmotility

Answer 104

A

immunosuppression, steroids, cyclophosphamide, rituximab, plasma exchange

Answer 105

A

anti-glomerular basement membrane disease
rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs and kidney failure
attacks alpha-3 subunit of type IV collagen
the co-existence of acute glomerulonephritis and pulmonary alveolar haemorrhage and the presence of circulating antibodies directed against an intrinsic antigen to the basement membrane of both kidney and lung
antibodies against glomerular basement membrane
rapidly progressive kidney failure

Answer 106

A

remove antibody via plasma exchange
immunosuppression
steroids/cyclophosphamide

Answer 107

A

IgA nephropathy

Answer 108

A

form of glomerulonephritis
deposition of IgA antibody in the glomerulus
haematuria, IgA deposition in kidney mesangium (provides structural support to glomerulus) and kidney gets attacked
associated with tonsillitis and results in haematuria

Answer 109

A

BP control: ACEi/ARBs

Answer 110

A

haematuria (mild macrocytic)
proteinuria; usually less than 2g in 24 hours
hypertension (moderate-severe increase) and oedema (periorbital (around eyes), leg or sacral) caused by salt and water retention
oliguria (little urine)
uraemia and symptoms of it
deteriorating kidney function
moderate-severe decrease in GFR

Answer 111

A

anorexia
pruritus i.e rash
lethargy and nausea

Answer 112

A

take history to determine cause
measure eGFR, proteinuria, serum urea and electrolytes and albumin to determine current status and monitor progress
culture; swab from throat or infected skin
urine dipstick to detect proteinuria and haematuria
renal biopsy if necessary

Answer 113

A

salt restriction, loop diuretics, calcium channel blockers

Answer 114

A

proteinuria > 3.5g/24 hours
hypoalbuminaemia
oedema
severe hyperlipidaemia is often present

Answer 115

A

liver goes into overdrive due to albumin loss and other protein loss which increases risk of blood clots and produces raised cholesterol

Answer 116

A

collection of symptoms due to kidney damage; includes protein in urine, low blood albumin levels, high blood lipids and significant swelling - don’t develop kidney failure but are leaking huge amounts of protein but kidney function remains the same
caused by structural and functional abnormalities of podocytes

Answer 117

A

relatively rare
diabetes is most common secondary cause
minimal change disease accounts for 10-25% of nephrotic syndrome in adults and is the commonest cause of nephrotic syndrome in children

Answer 118

A

minimal change disease - seen in children and adults
membranous glomerulonephritis - adults
focal segmental glomerulosclerosis
membranoproliferative glomerulonephritis
rapidly progressive glomerulonephritis

Answer 119

A

focal segmental glomerulosclerosis

Answer 120

A

asymptomatic proteinuria/nephrotic syndrome +/- microscopic haematuria, hypertension and renal impairment
deposition of IgG and C3 along outer aspect of glomerular basement membrane
treated with immunosuppression

Answer 121

A

drugs e.g. penicillamine, gold or NSAIDs
autoimmune - SLE, thyroiditis
infection e.g. hepatitis B or C, schistomiasis
neoplasia e.g. lung, colon, stomach and breast

Answer 122

A

unknown aetiology
scarring that is focal and only some glomeruli involved and segmental (only part of glomerulus affected)
CD80 deposited in podocytes resulting in increased permeability in glomeruli and thus proteinuria and haematuria

Answer 123

A

secondary hypertension and renal impairment

Answer 124

A

corticosteroids and immunosuppressants

Answer 125

A

diabetes mellitus - most common secondary cause
amyloid
infections e.g. Hep B or C and HIV
SLE, RA
drugs e.g. gold, penicillamine, NSAIDs and ACE-inhibitors
malignancy

Answer 126

A

diabetes mellitus

Answer 127

A

diabetes mellitus

Answer 128

A

injury to podocyte appears to be the main cause of proteinuria
podocytes wrap around the glomerular capillaries and maintain the filtration barrier, preventing large molecular weight proteins from entering the urine
damage to podocyte foot processes or loss of podocytes can cause heavy protein loss

Answer 129

A

normal-mild increase in BP
proteinuria > 3.5g/day
normal-mild decrease in GFR
hypoalbuniaemia
pitting oedema of ankles, genital, abdominal wall and sometimes face (periorbital)
frothy urine

Answer 130

A

congestive heart failure

- cirrhosis

Answer 131

A

where there is oedema and raised JVP

* in nephrotic syndrome there is normal or low JVP (unless there is renal failure and oliguria)

Answer 132

A

where there is hypoalbuminaemia and oedema

* but there are signs of chronic liver failure e.g. jaundice, fever and loss of body hair

Answer 133

A

establish cause - usually via renal biopsy
urine dipstick shows very high protein
CXR or ultrasound for pleural effusion or ascites
serum albumin is low
BP is usually normal or mildly increased
renal function is usually normal or mildly impaired
serum creatinine, eGFR, lipids and glucose
ANA, double-stranded DNA antibody, C3 and C4 indicates SLE
antiphospholipase A2 receptor antibody indicated membranous nephropathy
HepB surface antigen, HepC antibody or HIV

Answer 134

A

serum creatinine, eGFR, lipids and glucose
ANA, double-stranded DNA antibody, C3 and C4 indicates SLE
antiphospholipase A2 receptor antibody indicates membranous nephropathy
HepB surface antigen, HepC antibody or HIV

Answer 135

A

susceptibility to infection
thromboembolism
hyperlipidaemia

Answer 136

A

cellulitis, Streptococcus infections and spontaneous bacterial peritonitis

Answer 137

A

due to low serum IgG, decreased complement activity and reduced T-cell function due in part to loss of immunoglobulin in urine and also to immunosuppressive treatment

Answer 138

A

hypercoaguable state due to increased clotting factors (produced by liver due to low albumin since liver goes into overdrive) and platelet abnormalities

Answer 139

A

increased cholesterol and triglycerides due to hepatic lipoprotein synthesis in response to low oncotic pressure due to low albumin

Answer 140

A

reduce oedema
reduce proteinuria
reduce risk of complications
treat underlying cause

Answer 141

A

loop diuretics e.g. IV furosemide - IV since gut oedema may prevent oral absorption
thiazide diuretics e.g. IV bendroflumethiazide
fluid and salt restriction while giving diuretics

Answer 142

A

ACE inhibitor e.g. ramipril
angiotensin receptor blocker e.g. candesartan
eat normal rather than high protein diet

Answer 143

A

prophylactic anticoagulation with warfarin, especially when albumin is low (<20g/l)
reduce cholesterol with statins e.g. simvastatin
treat infections promptly and vaccinate

Answer 144

A

minimal change disease

Answer 145

A

disease affecting the kidneys which causes nephrotic syndrome

Answer 146

A

commonest cause of nephrotic syndrome in children
occurs most commonly in boys under the age of 5
accounts for 20% of adult nephritic syndrome

Answer 147

A

can be idiopathic
atopy is present in 30% of cases and allergic reactions can trigger nephrotic syndrome
drugs
Hep C, HIV and TB are rare causes
associated with Hodgkins lymphoma

Answer 148

A

NSAIDs
lithium
antibiotics e.g. cephalosporins, rifampicin and ampicillin
bisphosphonates
sulfasalazine

Answer 149

A

glomeruli appear normal on light microscopy, but on electron microscopy, fusion of the foot processes of the podocytes is seen, consistent with a disrupted podocyte actin cytoskeleton
immature differentiating CD35 stem cells appear to be responsible for pathogenesis

Answer 150

A

proteinuria
oedema, predominantly around the face
fatigue
frothy urine

Answer 151

A

biopsy
• normal under light microscopy
• electron microscopy shows fused podocyte foot processes

Answer 152

A

high dose corticosteroids can reverse proteinuria in 95% cases, however the majority relapse
frequent relapse or steroid-dependent disease is treated with cyclophosphamide or ciclosporin/tacrolimus

Answer 153

A

incidental finding of dipstick haematuria +/- proteinuria
kidney function and blood pressure are normal
diagnosis is usually clinical, don’t biopsy unless kidney function abnormal or significant proteinuria

Answer 154

A

IgA nephropathy

- thin membrane disease

Answer 155

A

abnormality in IgA glycosylation leads to deposition in mesangium (provides structural support for glomerulus)
can present as nephritic, nephrotic, asymptomatic or as progressive chronic kidney disease

Answer 156

A

IgA nephropathy

Answer 157

A

tonsillitis and macroscopic haematuria

Answer 158

A

treated with BP control and immunosuppression in aggressive disease

Answer 159

A

thin basement membrane so more likely to leak blood into urine

Answer 160

A

CKD is longstanding, usually progressive impairment in renal function (haematuria, proteinuria or anatomical abnormality) for more than 3 months
defined as a GFR < 60mL/min/1.73 m2 for more than 3 months with/without evidence of kidney damage (haematuria, proteinuria or anatomical abnormality)

Answer 161

A

between 6% - 11% of people can be defined as having CKD
risk of CKD increases with age; incidence rising as we are living longer
more common in females than males

Answer 162

A

GFR >90mL/min

- normal or raised GFR with other evidence of renal damage

Answer 163

A

GFR 60-89mL/min

- slight decreased GFR with other evidence of renal damage

Answer 164

A

3A GFR: 45-59mL/min
3B GFR: 30-44mL/min
moderate decreased GFR with or without evidence of other renal damage

Answer 165

A

GFR 15-29mL/min

- severe decreased GFR with or without evidence of other renal damage

Answer 166

A

GFR <15mL/min

- established renal failure

Answer 167

A

proteinuria, haematuria or evidence of abnormal anatomy or systemic disease

Answer 168

A

diabetes mellitus - Type II > Type 1
hypertension
atherosclerotic renal vascular disease
polycystic kidney disease
tuberous sclerosis
primary glomerulonephritides e.g. IgA nephropathy
SLE
amyloidosis
hypertensive nephrosclerosis (common in black africans)
small and medium-sized vessel vasculitis
family history of stage 5 CKD or hereditary kidney disease e.g. polycystic kidney disease
hypercalcaemia
neoplasma
myeloma
idiopathic - 20% cases

Answer 169

A

diabetes mellitus
hypertension
old age
CVD
renal stones or benign prostatic hyperplasia (BPH)
recurrent UTI’s
SLE
proteinuria
AKI
smoking
African, Afro-Caribbean or Asian origin
chronic use of NSAIDs

Answer 170

A

in CKD, where many nephrons have failed, and scarred, the burden of filtration falls to fewer functioning nephrons
functioning (remnant) nephrons experience increased flow per nephron (hyperfiltration), as blood flow has not changed, and adapt with glomerular hypertrophy and reduced arteriolar resistance
increased flow, increased pressure and increased shear stress set in motion a vicious cycle of raised intraglomerular capillary pressure and strain, which accelerates remnant nephron failure
this increased flow and strain may be detected as new/increasing proteinuria

Answer 171

A

reduced renal perfusion

> decreased transglomerular pressure
> decreased GFR

Answer 172

A

intrarenal activation of RAAS

> efferent arteriolar vasoconstriction
> increases transglomerular pressure
> restores GFR

Answer 173

A

• produced locally, modulates intraglomerular capillary pressure and GFR, causing vasoconstriction of postglomerular arterioles, and increasing the glomerular hydraulic pressure and
filtration fraction
• by its effect on mesangial cells and podocytes, it increases the pore sizes and impairs the size-selective function of the basement membrane for macromolecules, resulting in increased proteinuria
• also modulates cell growth by upregulating TGF-beta, increasing collagen synthesis and epithelial cell
transdifferentiation to myofibroblasts, leading to excessive matrix formation
• also up regulates plasminogen activator inhibitor-1, which inhibits matrix proteolysis by plasmin, resulting in the accumulation of excessive matrix and scarring in the glomeruli and interstitium

Answer 174

A

hypertension - particularly if poorly controlled
proteinuria
degree of scarring in the interstitium on histology

Answer 175

A

aimed at inhibiting angiotensin II and reducing proteinuria mainly with ACE inhibitors or angiotensin receptor antagonists

Answer 176

A

malaise
anorexia and weight loss
Insomnia
nocturia and polyuria (>40ml/kg/24hours) due to impaired concentrating ability
itching
nausea, vomiting and diarrhoea
symptoms due to salt and water retention; peripheral or pulmonary oedema
amenorrhea in women and erectile dysfunction in men
increased risk of peptic ulceration, acute pancreatitis, hyperuricaemia and incidence of malignancy

Answer 177

A

serum urea and creatinine are used as surrogates of accumulating metabolites (uraemic toxins) since their measurement is easy and there is a rough correlation between toxins and them

Answer 178

A

symptoms are common when the serum urea concentration exceeds 40mmol/L but many patients develop uraemic symptoms at lower levels of serum urea

Answer 179

A

peptic ulceration, acute pancreatitis, hyperuricaemia and incidence of malignancy

Answer 180

A

normochromic normocytic anaemia:

• due to reduced erythropoietin production by diseased kidney

Answer 181

A

• bone pain
• renal osteodystrophy; osteomalacia, osteoporosis,
hyperparathyroidism
• renal phosphate retention and impaired 1,25-dihydroxy vitamin D production lead to a fall in serum Ca2+ and thus a compensatory increase in PTH which can result in skeletal decalcification leading to bone disease

Answer 182

A

occurs in almost all patients with severe CKD
autonomic dysfunction presents as postural hypotension and disturbed GI motility
polyneuropathy resulting in peripheral paraesthesiae and weakness
in advanced uraemia there is depressed cerebral function, myoclonic twitching and seizures

Answer 183

A

highest mortality is from CVD particularly MI, cardiac failure, sudden cardiac death and stroke
occurs due to an increased frequency of hypertension, hyperlipidaemia and vascular calcification
pericarditis and pericardial effusion occurs in severe anaemia
pericardial friction rub
flow murmurs

Answer 184

A

pruritus due to nitrogenous waste products of urea; may be scratch marks
brown discolouration of nails

Answer 185

A

to differentiate it depends on history, duration of symptoms and previous urinalysis or measurement of serum creatinine
a normochromic anaemia, small kidneys on ultrasound and the presence of renal osteodystrophy favour CKD

Answer 186

A

ECG for high potassium signs
urinalysis
urine microscopy
serum biochemistry
bloods
immunology
imaging
biopsy and histology to diagnose condition causing renal failure

Answer 187

A

haematuria - indicates glomerulonephritis
proteinuria - if heavy suggestive of glomerular disease, can also be caused by infection
mid-stream urine sample sent for microscopy and sensitivity
albumin to creatinine ratio or protein to creatine ratio

Answer 188

A

white cells - bacterial UTI
eosinophilia - allergic tubulointerstitial nephritis/cholesterol emboli
granular casts - active renal disease
red cells - glomerulonephritis

Answer 189

A

urea, electrolytes, bicarbonate and creatine - high urea and creatinine
low eGFR
raised alkaline phosphatase (renal osteodystrophy)
raised PTH if CKD stage 3 or more

Answer 190

A

raised phosphate
low Ca2+
Hb low - normochromic normocytic anaemia
raised viscosity - myeloma or vasculitis
fragmented red cells indicate intravascular haemolysis

Answer 191

A

auto-antibody screening for SLE, scleroderma and Goodpastures
Hep B, C, HIV and streptococcal antigen tests

Answer 192

A

ultrasound to check renal size and exclude hydronephrosis:

in CKD kidneys tend to be small
can be large in infiltrative disorders e.g. amyloidosis

Answer 193

A

detect stones, retroperitoneal fibrosis and other causes of urinary obstruction and maybe cortical scarring

Answer 194

A

therapy aimed at the underlying cause of renal disease
slow the deterioration of kidney function
reduce cardiovascular risk
identify and treat reversible causes
limit progression and complications

Answer 195

A

relieve obstruction
stop nephrotoxic drugs
stop smoking and achieve healthy weight to deal with cardiovascular risk
tight glucose control in diabetes

Answer 196

A

< 130/80mmHg

Answer 197

A

ACE-inhibitor
angiotensin receptor blocker
in diabetes start with ARB
diuretic to prevent hyperkalaemia and help reduce BP
calcium channel blocker if goals not met

Answer 198

A

check PTH and treat if raised
restrict diet
give phosphate binders to decrease gut absorption and avoidance of phosphate-rich food e.g. milk, cheese, eggs
vitamin D e.g. calcitriol and Ca2+ supplements

Answer 199

A

statins and aspirin

Answer 200

A

iron/folate/folic acid

Answer 201

A

systemic acidosis accompanies the decline in kidney function and may contribute to increased serum potassium levels as well as dyspnea and lethargy
treat with sodium bicarbonate

Answer 202

A

the ‘best’ form of renal replacement therapy is transplantation, since it can restore 100% renal function, but this involves surgery and it is not always successful
dialysis can maintain stability but has complications

Answer 203

A

symptomatic uraemia including pericarditis or tamponade
hyperkalaemia not controlled by conservative measures
pulmonary oedema unresponsive to diuretics
severe acids
high potassium
tall T waves, low flat p waves, broad QRS or arrhythmias on ECG
metabolic acidosis
fluid overload that is resistant to diuretics

Answer 204

A

most commonly used
achieves blood flow using a blood pump to draw and return blood from the lumen of a dual-lumen catheter placed in the jugular, subclavian or femoral vein
ultrafiltrate is continuously removed from patient combined with simultaneous infusion of replacement solution
has less haemodynamic instability than haemodialysis

Answer 205

A

blood is passed over a semi-permeable membrane against dialysis fluid flowing in the opposite direction, thus blood is always meeting a less-concentrated solution and diffusion of small solutes occurs down the concentration gradient
larger solutes do not clear as effectively
blood is taken from artery the and returned into a vein at an atrioventricular fistula (not suitable for atherosclerotic patients or those who have many fistulas)
allows good clearance of solutes in short periods but requires patient to be haemodynamically stable
time-consuming

Answer 206

A

hypotension/cramps
nausea/headache
chest pain
fever/rigors
infected dialysis catheter

Answer 207

A

mainly used for CKD, rare in AKI
process uses patient’s peritoneum in the abdomen as a membrane across which fluid and solutes are exchanged with blood
all peritoneal dialysis is done at home, at night

Answer 208

A

infection e.g. peritonitis
abdominal wall herniation
intestinal perforation
loss of membrane function over time

Answer 209

A

cardiovascular disease due to combination of hypertension and calcium/phosphate dysregulation
infection
amyloid accumulates in long-term dialysis and may cause carpal tunnel syndrome, arthralgia and fractures
malignancy is commoner in dialysis patients - may be due to the cause of end-stage renal failure

Answer 210

A

a renal cyst is a fluid collection in or on the kidney
solitary or multiple renal cysts are common, especially with advancing age; 50% of those over 50 have one or more such cysts
these cysts are often asymptomatic and are found
incidentally on ultrasound examination
occasionally they may cause pain and/or haematuria if large, or bleeding may occur into the cyst

Answer 211

A

simple cysts - most common form; benign
polycystic; recessive or dominant
hydronephrosis is when ureter is blocked and kidney dilates and gets bigger
dysplasia – when not formed properly
medullary sponge – dilation of collecting ducts
acquired cystic disease – medullary uraemic, dialysis cystic

Answer 212

A

present at birth
uni/bilateral
isolated or multisystem disorder
inherited; autosomal or recessive

Answer 213

A

genetic mutation leads to predisposition for cyst formation
increased abnormal cell hyperproliferation → loss of planar polarity → cyst initiation → fluid secretion by epithelial cells → cyst

Answer 214

A

develop over time
no genetic mutation
bilateral/unilateral
isolated to kidneys
normal/small kidney size
associated with chronic kidney disease
route of development not clear

Answer 215

A

simple cysts develop over time
acquired cysts e.g. CKD
drugs e.g. lithium
autosomal dominant/recessive polycystic kidney disease
syndromic disease; tuberous sclerosis

Answer 216

A

genetic disorder in which the renal tubules become structurally abnormal, resulting in the development and growth of multiple cysts within the kidney
cysts may begin in utero, infancy, childhood or adulthood
multiple cysts develop, gradually and progressively, throughout the kidney eventually resulting in renal enlargement and kidney tissue destruction

Answer 217

A

commonest inherited kidney disease
autosomal dominant inheritance with high penetrance
usually presents in adulthood (20-30)
more common in males than females
if one parent affected then 50% chance of transmission
if both parents affected then 50% chance being affected, 25% normal, 25% being homozygous for disease (these babies die in the womb)

Answer 218

A

mutations in PKD1 (85%) gene on chromosome 16

- mutations in PKD2 (15%) gene on chromosome 4

Answer 219

A

family history of ADPKD, ESRF or hypertension

Answer 220

A

PKD1 encodes polycystin 1 which is involved in cell-cell and/or cell-matrix interactions; regulates tubular and vascular development in the kidneys

Answer 221

A

PKD2 encodes polycystin 2 which functions as a calcium ion channel

Answer 222

A

disruption of the polycystin pathway results in reduced cytoplasmic Ca2+, which, in principal cells of the collecting duct, causes defective ciliary signalling and disorientated cell division resulting in cyst formation

Answer 223

A

mechanical compression, apoptosis of healthy tissue and reactive fibrosis
rate of renal function decline is dependent on the growth and size of cysts; patients with rapidly growing cysts on MRI lose renal function more rapidly

Answer 224

A

can be clinically silent for many years, so family screening is essential
symptoms tend to start to present from 20 yrs onwards
loin pain and/or haematuria from haemorrhage into a cyst, cyst infection or urinary tract stone formation
loin or abdominal discomfort as size of kidneys increase
excessive water and salt loss
nocturia
bilateral kidney enlargement
renal colic due to clots
hypertension
renal stones, mainly uric acid stones
progressive renal failure

Answer 225

A

subarachnoid haemorrhage associated with berry aneurysm rupture
polycystic liver disease (70%)
pancreatitis
male infertility (rare)
mitral valve prolapse
ovarian cysts
diverticular disease

Answer 226

A

acquired and simple cysts of the kidneys
autosomal recessive PKD
medullary sponge kidney
tuberous sclerosis

Answer 227

A

personal history
family history of ADPKD, ESRF, hypertension
BP may be raised
ultrasound
genetic testing for PKD1 and PKD2

Answer 228

A

15-39yrs ≥ 3 cysts (uni/bilateral)
40-59yrs ≥ 2 cysts (each kidney)
60yrs+ and ≥ 4 cysts (each kidney)

Answer 229

A

≥ 40yrs with < 2 cysts

Answer 230

A

if <30yrs

Answer 231

A

no treatment shown to slow disease progression
blood pressure control with ACE-inhibitor
treat stones and give analgesia
laparoscopic removal of cysts to help with pain/nephrectomy
disease progression monitored by serial progression of serum creatinine
renal replacement therapy for ESRF
children and siblings of patients with the disease should be offered screening by renal ultrasound in their 20s
counselling and support

Answer 232

A

individual older case with no family history
atypical cystic disease
very early onset (<2 yrs)
prenatal/pre-implantation genetic diagnosis
to facilitate life choices/reproduction decisions
potential living related kidney donor (<40yrs with positive imaging)

Answer 233

A

recessive form of polycystic kidney disease
associated with a group of congenital fibrocystic syndromes
mutations in PKHD1 causes ARPKD
PKHD1 mutation on long arm (q) of chromosome 6

Answer 234

A

rarer than ADPKD with prevalence at 1 in 40,000
autosomal recessive inheritance
disease of infancy

Answer 235

A

variable
many present in infancy with multiple renal cysts and congenital hepatic fibrosis
enlarged polycystic kidneys
30% develop kidney failure

Answer 236

A

ADPKD
multicystic dysplasia
hydronephrosis
renal vein thrombosis

Answer 237

A

diagnosed antenatally or neonatally
ultrasound to see cysts
CT and MRI to monitor liver disease
genetic testing

Answer 238

A

currently no treatment available
genetic counselling for family members
laparoscopic removal of cysts to help with pain/nephrectomy
blood pressure control with ACE-inhibitor
treat stones and give analgesia
renal replacement therapy for ESRF
counselling and support

Answer 239

A

• cannot get above - inguinoscrotal hernia or
proximally extending hydrocele
• separate and cystic - epididymal cyst
• separate and solid - epididymitis or varicocele
• testicular and cystic - hydrocele
• testicular and solid - tumour, haematocele
- orchitis

Answer 240

A

smooth, extratesticular, spherical collection of fluid in the head of the epididymis

Answer 241

A

usually develop around the age of 40
not uncommon
rare in children

Answer 242

A

contain clear and milky fluid
lie above and behind the testis
normally present having noticed a lump
often are multiple and may be bilateral
small cysts may remain undetected and asymptomatic
once they get large then may be painful
well defined and will transluminate since fluid-filled
testis is palpable quite separately from the cyst (unlike hydrocele where the testis is palpable within the fluid filled swelling)

Answer 243

A

spermatocele
hydrocele
varicocele

Answer 244

A

retention cyst of a tubule of the rete testes or the head of the epididymis, distended with barely watery fluid that contains spermatozoa
fluid and sperm filled cyst in the epididymis
no way clinically to differentiate between a cyst of the epididymis and spermatocele
can be differentiated as sperm are present in the milky fluid aspirate of a spermatocele

Answer 245

A

accumulation of serous fluid in a body cavity
hydrocele testis is the accumulation of fluids around a testicle, within the tunica vaginalis
often caused by fluid secreted from a remnant piece of peritoneum wrapped around the testicle (tunica vaginalis)

Answer 246

A

an abnormal dilation of the testicular veins in the pampiniform venous plexus in the scrotum, caused by venous reflux

Answer 247

A

scrotal ultrasound

Answer 248

A

usually not necessary

- if painful and symptomatic then surgical excision

Answer 249

A

clinically apparent scrotal hydrocele are evident in 6% of term males beyond the newborn period
most paediatric hydroceles are congenital

Answer 250

A

more common and larger
usually in younger men
associated with a patent processus vaginalis, which typically resolves during the 1st year of life

Answer 251

A

rarer and present in older boys and men

Answer 252

A

testis tumour
trauma
infection
TB
testicular torsion
generalised oedema

Answer 253

A

overproduction of fluid in the tunica vaginalis

Answer 254

A

processus vaginalis fails to close, allowing peritoneal fluid to communicate freely within the scrotal portion

Answer 255

A

scrotal enlargement with a non-tender, smooth, cystic swelling
pain is not a feature unless the hydrocele is infected
testis are usually palpable but may be difficult to palpate in large hydrocele
lies anterior to and below the testis and will transluminate

Answer 256

A

must differentiate from testicular torsion and strangulated hernia

Answer 257

A

ultrasound
serum alpha-fetoprotein and human chorionic gonadotrophin to help exclude malignant teratomas or other germ cell tumours

Answer 258

A

resolve spontaneously
many of infancy resolve by 2 yrs
therapeutic aspiration or surgical removal

Answer 259

A

left side more commonly affected
unusual in boys under 10yrs
incidence increases after puberty
associated with sub fertility

Answer 260

A

more common on the left
angle at which the left testicular vein enters the left renal vein
increased reflux from compression of the renal vein
lack of effective valves between the testicular and renal veins

Answer 261

A

often visible as distended scrotal blood vessels that feel like ‘a bag of worms’
patient may complain of a dull ache or scrotal heaviness
scrotum hangs lower on the side of the varicocele

Answer 262

A

secondary to other pathological processes blocking the testicular vein e.g. kidney tumours and other retroperitoneal tumours

Answer 263

A

venography

- colour doppler ultrasound (to see blood flow)

Answer 264

A

surgery if there is pain, infertility or testicular atrophy

Answer 265

A

torsion (twisting) of the spermatic cord resulting in occlusion of the testicular blood vessels which can rapidly lead to ischaemia and infarct and thus there is potential loss of the testis (germ cells are the most susceptible cell line to ischaemia)

Answer 266

A

aim is to recognise this condition before the cardinal symptoms fully manifest, as prompt surgery saves testes
if surgery is performed in < 6hrs the salvage rate is 90-100%; if > 24hrs it is 0-10%

Answer 267

A

common urological emergency among adolescent boys and young men
typically occurs in neonates or post-pubertal boys but can occur in males of all ages, most common at 11-30yrs
left side is more commonly affected than right

Answer 268

A

underlying congenital malformation (belt-clapper deformity) where the testis is not fixed to the scrotum completely, allowing for free movement leading to twisting

Answer 269

A

in any boy presenting with abdominal pain, the testes should be checked
sudden onset of pain in one testis, makes walking uncomfortable
pain often comes on during sport or physical activity
pain in abdomen, nausea and vomiting are common
inflammation of one testis; it is very tender, hot and swollen
testis may lie high and transversely
with intermittent torsion the pain may have passed on presentation, but if it was severe then prophylactic fixing may be wise

Answer 270

A

epididymo-orchitis (main one)
tumour, trauma and an acute hydrocele
torsion of testicular or epididymal appendage (remnant of Mullerian duct)
idiopathic scrotal oedema

Answer 271

A

usually occurs in boys between 7-12yrs and causes less pain
small blue nodule under scrotum
due to the surge in gonadotrophins that signal the onset of puberty

Answer 272

A

benign condition usually occurs between 2-10yrs and is differentiated from torsion by the absence of pain and tenderness

Answer 273

A

doppler ultrasound may demonstrate lack of blood flow to testis
urinalysis to exclude infection and epididymis
do not delay surgical exploration

Answer 274

A

surgery: expose and untwist testis; 6 hour window to save testis
orchidectomy (removal of testis) and bilateral fixation

Answer 275

A

bladder outflow obstruction (urodynamic diagnosis)

urine is unable to flow from the kidneys through the ureters and out of the bladder through the urethra
decreased flow of urine leads to hydronephrosis

Answer 276

A

dilation of the renal pelvis and calyces as a result of obstruction to urine flow

Answer 277

A

functional or anatomical obstruction of urine flow at any level of the urinary tract

Answer 278

A

convert a continuous process of excretion (urine production) to an intermittent process of elimination
store urine insensibly
void urine when convenient

Answer 279

A

• relaxes during storage (compliant)
• contracts during voiding
• parasympathetic cholinergic control via S3,S4 and S5:
- drives detrusor contraction

Answer 280

A

• contracts during storage
• relaxes during voiding
• sympathetic noradrenergic control via T10,L1 and L2:
- sphincter/urethral contraction
- inhibits detrusor contraction

Answer 281

A

urgency
nocturia (> 30% voided volume at night)
frequency
overflow incontinence (leaking urine during day/wetting bed)

Answer 282

A

poor intermittent stream
hesitancy
incomplete emptying
post micturition dribbling
straining
haematuria
dysuria

Answer 283

A

haematuria and dysuria - warning symptoms of infection, stones or cancer

Answer 284

A

Prostate Specific Antigen

glycoprotein that is expressed by normal and neoplastic prostate tissue
small amounts in bloodstream normally

Answer 285

A

BPH
prostate cancer
perianal trauma and mechanical manipulation of the prostate e.g. in cytoscopy (endoscopy of bladder), prostate biopsy or surgery
BMI < 25
taller men
recent ejaculation
black africans
prostatitis
UTI

Answer 286

A

PSA >1.4ng/ml

Answer 287

A

how much urine being passed, how long for and flow rate
maximum flow rate is useful if more than 150ml voided
max flow rate < 10ml per second is suggestive of bladder outflow obstruction due to BPH

Answer 288

A

max flow rate < 10ml per second is suggestive of bladder outflow obstruction due to BPH

Answer 289

A

measure volumes voided and time over minimum of 3 days
calculates whether polyuric (>40ml/kg/24hrs)
calculates whether nocturic (>30% voided volume at night)

Answer 290

A

> 40ml/kg/24hrs

Answer 291

A

> 30% voided volume at night

Answer 292

A

sudden onset of painful inability to pass urine usually with over 500ml in the bladder
bladder is usually tender

Answer 293

A

prostatic obstruction e.g. due to BPH or prostate cancer
urethral strictures
anticholinergics
alcohol
constipation
post-op (pain/inflammation/anaesthetics)
infection
neurological (spinal compression - cauda equina syndrome)

Answer 294

A

abdomen, prostate (DRE), perineal sensation (to check for cauda equina syndrome)

Answer 295

A

normal renal biochemistry, since not affected usually
renal ultrasound if abnormal biochemistry
PSA test to look for BPH/prostate cancer

Answer 296

A

catheter relieves pain
alpha-1 blocker which relaxes smooth muscle in bladder neck to aid voiding
prevent by giving 5-alpha-reductase inhibitor which reduces testosterone conversion to dihydrotestosterone and thus reduces prostate size

Answer 297

A

more insidious and may be painless
more difficult to define
incomplete bladder emptying
results in a increased risk of infection
can be low pressure with detrusor failure
can be high pressure with risk of interactive obstructive uropathy

Answer 298

A

can be low pressure with detrusor failure

* can be high pressure with risk of interactive obstructive uropathy

Answer 299

A

prostatic enlargement due to BPH/prostate cancer
pelvic malignancy or rectal surgery
diabetes

Answer 300

A

overflow incontinence; leaking urine during the day/wetting bed
loss of appetite
constipation
distended abdomen
UTI

Answer 301

A

only catheterise if there is pain, urinary infection or renal impairment

Answer 302

A

common and should be considered in anyone with renal impairment
damage can be permanent if the obstruction is not treated properly
can be partial, complete, unilateral or bilateral

Answer 303

A

stones, blood, clot, sloughed papilla, tumour

Answer 304

A

congenital or acquired stricture, neuromuscular dysfunction or schistomiasis

Answer 305

A

abdominal or pelvic mass/tumour, retroperitoneal fibrosis, BPH, prostate cancer
pregnancy
inflammation e.g. peritonitis or diverticulitis

Answer 306

A

acute upper tract (kidney and ureter) obstruction
chronic upper tract (kidney and ureter) obstruction
acute lower tract (bladder to urethra) obstruction
chronic lower tract (bladder to urethra) obstruction

Answer 307

A

loin pain radiating to groin

Answer 308

A

flank pain, renal failure, infection and polyuria may occur due to impaired urinary concentration

Answer 309

A

acute urinary retention with severe suprapubic pain, often preceded by symptoms of bladder outflow obstruction
distended, palpable bladder that’s dull to percussion

Answer 310

A

urinary frequency, hesitancy, poor stream, terminal dribbling and overflow incontinence
distended, palpable bladder +/- large prostate on rectal exam
complications are UTI and urinary retention

Answer 311

A

bloods: U+Es and monitor creatinine; this will be raised
mid-stream urinary sample; culture and sensitivity
ultrasound: if there is hydronephrosis then arrange CT

Answer 312

A

nephrostomy: artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper tract
alpha-1 antagonist (bladder neck smooth muscle relaxer) improves flow
5-alpha reductase inhibitor inhibits conversion of testosterone to active form and thus reduces prostate size

Answer 313

A

urethral catheter
suprapubic catheter
beware of large diuresis after obstruction relief as can result in a temporary salt losing nephropathy resulting in weight loss; monitor weight and maintain fluid balance

Answer 314

A

less risk of urethral damage and thus UTI
requires general anaesthetic for insertion
small risk of bowel injury during insertion
less likely to be colonised by bacteria than with a long term urethral catheter
long term urethral catheter can lead to urethral erosion and damage to the urethral sphincter

Answer 315

A

transurethral resection of the prostate

• less than 14% impotent, 1% incontinent and 10% erectile dysfunction

Answer 316

A

RUSHES

Retention
UTI’s
Stones
Haematuria
Elevated creatinine due to bladder outflow obstruction
Symptoms deterioration

Answer 317

A

increase in the size of the prostate without the presence of malignancy
prostate secretes 70% of the volume of seminal fluid and is hormone dependent
the prostate gland surrounds the urethra, the tube that carries urine from the bladder out of the body

Answer 318

A

common - 24% of men 40-64 and 40% of men over 60
more common over 60
unusual before the age of 45
affects Afro-Caribbean’s more severely than white men, probably due to the high levels of testosterone

Answer 319

A

increases with age

- castration (removal of testicles) is protective

Answer 320

A

androgens do not cause BPH but are a requirement for BPH
BPH is not seen in those with castration prior to puberty, or those with genetic diseases that inhibit androgen action or production

Answer 321

A

benign nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate
inner (transitional) zone enlarges in contrast to the peripheral layer expansion that is seen in prostate carcinoma
as the prostate gets bigger, it may squeeze or partly block the urethra
this often causes problems with urinating

Answer 322

A

LUTS
abdominal exam reveals enlarged bladder
acute urinary retention
in a small number of cases, BPH may cause the bladder to become occluded leading to anuria, resulting in acute urinary retention leading to UTI’s, bladder stones or kidney damage
BPH does not affect ability to father children
BPH does not cause prostate cancer or erection problems

Answer 323

A

nocturia (>30% voided volume at night)
frequency
urgency
post-micturition dribbling
poor stream/flow
hesitancy
overflow incontinence
haematuria
bladder stones
delay in initiation of micturition
incomplete emptying of bladder

Answer 324

A

bladder tumour
bladder stones
trauma
prostate cancer
chronic prostatitis
UTI

Answer 325

A

digital rectal exam; prostate would feel enlarged but smooth
serum electrolytes and renal ultrasound to exclude renal damage caused by obstruction
transrectal ultrasound to see size of prostate
serum PSA
biopsy and endoscopy
mid-stream urine sample to exclude infection
flow rates and residual volume (max flow rate < 10ml per second is suggestive of BOO due to BPH)
frequency volume chart (measure over 3 days)

Answer 326

A

avoid caffeine and alcohol to reduce urgency and nocturia
relax when voiding
void twice in a row to aid emptying
watchful waiting if minimal symptoms

Answer 327

A

alpha1 antagonists e.g. oral tamsulosin

Answer 328

A

oral tamsulosin
relax smooth muscle in the bladder neck and prostate thereby producing increase in urinary flow rate and improvement in obstructive symptoms

Answer 329

A

drowsiness, dizziness, depression, ejaculatory

failure, extra-pyramidal signs, weight increase and nasal congestion

Answer 330

A

postural hypertension

Answer 331

A

5-alpha-reductase inhibitor e.g. oral finasteride

Answer 332

A

e.g. finasteride
blocks the conversion of testosterone to dihydrotestosterone (responsible for prostatic growth)
alternative to alpha-antagonist especially in men with very large prostate

Answer 333

A

impotence, decreased libido

Answer 334

A

usually reserved for those with a large prostate or failure to respond to an adequate trial of medical therapy
surgery is required if there is acute urinary retention, failed voiding trials, recurrent gross haematuria, renal insufficiency due to obstruction or failure of medical treatment

Answer 335

A

transurethral resection of prostate (TURP):
• gold standard
• less than 14% impotent, 1% incontinent and 10% erectile dysfunction

transurethral incision of prostate (TUIP):
• less destruction than TURP and less risk to sexual function, best for smaller prostate

Answer 336

A

bladder calculi
UTI
haematuria
acute retention

Answer 337

A

also known as hypernephroma and Grawitz tumour
malignant
arises from PCT epithelium

Answer 338

A

most common renal tumour in adults
accounts for 2-3% of all malignancies
more common in males than females
usually present after 50 yrs of age
rare before 40 yrs
average age at presentation is 55 yrs
highest incidence is in the Czech republic

Answer 339

A

renal cell carcinoma

Answer 340

A

smoking
obesity
hypertension
renal failure and haemodialysis (15% develop RCC)
polycystic kidneys
Von Hippel Lindau (VHL) syndrome

Answer 341

A

autosomal dominant
mutation of chromosome 3 on the short arm
loss of both copies or tumour suppressor gene
50% develop RCC that is often bilateral and multifocal
renal and pancreatic cysts as well as cerebellar malignancy also arise

Answer 342

A

malignant cancer of the proximal convoluted tubular epithelium
spread may be direct (renal vein), via lymph or haematogenous (bone, liver, lung)
25% have metastases at presentation

Answer 343

A

often asymptomatic and discovered incidentally
haematuria, loin/flank pain and abdominal mass
anorexia, malaise and weight loss
rarely, invasion of the left renal vein results in the compression of the left testicular vein causing a varicocele
polycythaemia in 5%
hypertension in 30% due to renin secretion by tumour
anaemia due to depression of erythropoietin
fever in around 20%

Answer 344

A

transitional cell carcinoma
Wilms’ tumour
renal oncocytoma
leiomyosarcoma

Answer 345

A

ultrasound (to distinguish cysts from tumour)
CT chest and abdomen with contrast
MRI (for tumour staging)
blood pressure (may be raised due to renin)
bloods
renal biopsy
bone scan (only if there are signs or serum Ca2+ raised)

Answer 346

A

more sensitive than ultrasound in detecting a renal mass and will show involvement of the renal vein of inferior vena cava, if present
using contrast demonstrates kidney function since in normal kidney should see it being taken up and excreted well

Answer 347

A

FBC to detect polycythaemia and anaemia due to EPO decrease
ESR may be raised
liver biochemistry may be abnormal

Answer 348

A

nephrectomy, unless tumours are bilateral

* if bilateral involvement then partial nephrectomy

Answer 349

A

cryoablation and radiotherapy are used in patients with significant comorbidities who would not tolerate surgery
can harm kidney function

Answer 350

A

interleukin-2 and interferon alpha produce remission in 20%
biological angio-genesis targeted therapy: sunitinib, bevacizumab and sorafenib
temsirolimus (mTOR inhibitor) found to improve survival more than interferon
last 2 options given if patients do not respond to 1st

Answer 351

A

childhood tumour of the primitive renal tubules and mesenchymal cells
seen within the first 3 years of life; it is the chief abdominal malignancy in children

Answer 352

A

presents as an abdominal mass and less commonly with haematuria

Answer 353

A

diagnosis is established by ultrasound, CT and MRI

* treated with a combination of nephrectomy, radiotherapy and chemotherapy

Answer 354

A

type of transitional cell carcinoma (TCC)
TCCs are responsible for 3% of deaths from all forms of malignancy
the calyces, renal pelvis, ureter, bladder and urethra are all lined by transitional epithelium and are all susceptible to transitional cell carcinoma
bladder tumours are the most common TCC

Answer 355

A

bladder tumours account for 50% of TCC’s
4th most common cancer in men
8th most common cancer in women
more common in males than females
incidence peaks in the 8th decade
most commonly occurs after the age of 40 yrs

Answer 356

A

smoking
occupational exposure to carcinogens
exposure to drugs e.g. phenacetin and cyclophosphamide
chronic inflammation of urinary tract e.g. schistomiasis (usually associated with squamous carcinoma) or indwelling catheter
> 40 yrs
male
family history

Answer 357

A

beta-napthylamine, benzidine, azo dyes

* workers in the petroleum, chemical, cable and rubber industries are at risk

Answer 358

A

local → to pelvic structures
lymphatic → to iliac and para-aortic nodes
haematogenous → to liver and lungs

Answer 359

A

painless haematuria; most common symptom however, pain may result due to clot retention
any patient over 40 presenting with haematuria should be assumed to have a urothelial tumour until proven otherwise
recurrent UTI’s
voiding irritabiliity

Answer 360

A

haemorrhagic cystitis
renal cancer
UTI
urethral trauma

Answer 361

A

cytoscopy with biopsy; diagnostic
urine microscopy/cytology; cancers may cause sterile pyruria
CT urogram; provides staging and is diagnostic
urinary tumour markers
MRI/lymphangiography may show involved pelvic nodes
CT/MRI of pelvis

Answer 362

A

surgical resection

- and/or chemotherapy: mitomycin, doxorubicin, cisplatin, to reduce recurrence

Answer 363

A

radical cystectomy; gold standard
post-op chemotherapy: m-vac; methotrexate, vinblastine, adriamycin and cisplatin
radical radiotherapy if not fit for surgery
chemotherapy: CMV; cisplatin, methotrexate, vinblastine

Answer 364

A

methotrexate, vinblastine, adriamycin and cisplatin

Answer 365

A

cisplatin, methotrexate, vinblastine

Answer 366

A

palliative chemotherapy and radiotherapy

Answer 367

A

commonest male malignancy
the majority of prostate cancers are adenocarcinomas arising in the peripheral zone of the prostate gland
most are slow growing but some can be aggressive
most common site of metastases is the bone and lymph nodes
malignant change becomes more common with age

Answer 368

A

prostatic carcinoma

Answer 369

A

accounts for 7% of all cancers in men and is the 6th most common in the world
incidence increases with age
by the age of 80 yrs, 80% of men have malignant foci within the gland but most of these appear to lie dormant
more common in black people due to higher testosterone

Answer 370

A

family history
genetics
increasing age
black
hormonal factors
if one first-degree relative has prostate cancer then risk is doubled (3 or more affected relatives or 2 relatives who have developed early onset)

Answer 371

A

HOXB13 is a predisposition gene

* BRCA2 confers a 5-7 times higher risk

Answer 372

A

spread may be:
• local → seminal vesicles, bladder and rectum
• lymph
• haematogenously; bone (sclerotic bony lesions) or less commonly brain, liver and lung

Answer 373

A

LUTS if there is local disease:
• nocturia
• hesitancy
• poor stream
• terminal dribbling
• obstruction - bladder outflow problems similar to BPH e.g. urinary retention
weight loss, bone pain and anaemia suggest metastasis

Answer 374

A

BPH, prostatitis, bladder tumours

Answer 375

A

DRE (hard, irregular prostate)
raised PSA (can be normal in 30% cancers) - if metastatic then will be >16ng/ml
trans-rectal ultrasound and biopsy (diagnostic; uses Gleason score)
urine biomarkers e.g. PCA3 or gene fusion protein
endorectal coil MRI to locally stage tumour

Answer 376

A

radical prostatectomy if <70yrs; excellent disease free survival
radiotherapy + hormone therapy; alternative to surgery
brachytherapy; implantation of radioactive material targeted at tumour
hormone therapy temporarily delays tumour progression
active surveillance if >70yrs and low risk

Answer 377

A

prostate cancer is the most hormone-sensitive malignancy
binding at the androgen receptor stimulates tumour growth
androgen deprivation

Answer 378

A

orchidectomy (removal of testes)
LHRH agonists
androgen receptor blockers

Answer 379

A

SC goserelin or SC leuprorelin

Answer 380

A

they first stimulate and then inhibit the pituitary gonadotrophin, testosterone
due to this they can lead to an initial surge in testosterone which can lead to a tumour ‘flare’ and short worsening of symptoms and an anti-androgen e.g. oral cyproterone acetate is used

Answer 381

A

bicalutamide

Answer 382

A

weakness, nausea, hot flushes, weight changes

Answer 383

A

analgesia
treat hypercalcaemia
radiotherapy for bone metastases/spinal cord compression

Answer 384

A

most common cancer in males aged 15-44 yrs
10% occur in undescended testes
more than 96% arise from germ cells
4% arise from non-germ cells

Answer 385

A

seminomas - 25-40 yrs and 60 yrs

* teratomas - infancy

Answer 386

A

leydig cell tumours
sertoli cell tumours
sarcomas

Answer 387

A

undescended testis
infant hernia
infertility
family history

Answer 388

A

painless lump in testicle
testicular pain and/or abdominal pain
hydrocele
cough and dyspnoea is indicative of lung metastases
back pain is indicative of para-aortic lymph node metastasis
abdominal mass

Answer 389

A

testicular torsion, lymphoma, hydrocele, epididymal cyst

Answer 390

A

ultrasound (differentiates between masses and swellings and tumours)
biopsy and histology
serum tumour markers (alpha-fetoprotein and/or beta-hCG)
CXR and CT to assess tumour staging

Answer 391

A

raised AFP and B-hCG in teratomas
B-hCG in minority of those with seminomas
AFP is not elevated in those with pure seminomas

Answer 392

A

radical orchidectomy via inguinal approach
seminomas with metastases below diaphragm are only treated with radiotherapy
more widespread tumours are treated with chemotherapy
teratomas treated with chemotherapy
sperm storage offered

Answer 393

A

the inflammatory response of the urothelium to bacterial invasion, usually associated with bacteriuria and pyuria
defined as > 10^5 organisms/ml or fresh mid-stream urine

Answer 394

A

KEEPS:

Klebsiella spp.
E.coli (most common)
Entercocci
Proteus spp.
Staphylococcus spp

Answer 395

A

lower urinary tract vs upper
uncomplicated vs complicated
single/isolated vs unresolved
acute vs chronic

Answer 396

A

fimbriae/pilli
afimbrial attachments e.g. glycocalix
acid polysaccharide coat that resists phagocytosis

Answer 397

A

urothelium
vaginal epithelium
vaginal mucus

Answer 398

A

oestrogen depletion due to the loss of lactobacilli and pH change (seen post-menopause where pH rises and there is increased colonisation by colonic flora and reduction in vaginal mucus secretion)
those with HLA-A3 blood group antigen tend to have recurrent UTIs

Answer 399

A

capsule to resist phagocytosis, toxins (E.coli) and enzyme production (Proteus secretes urease)
adhere to urothelium, vaginal epithelium and vaginal mucus

Answer 400

A

Proteus, Klebsiella and Pseudomonas

Answer 401

A

Staphylococci and Mycoplasma

Answer 402

A

antegrade flushing of urine
Tamm-Horsfall protein has antimicrobial properties
low urine pH and high osmolarity
urinary IgA

Answer 403

A

pyelonephritis
cystitis (bladder)
prostatitis
epididymo-orchitis
urethritis

Answer 404

A

medications

- ammonium (via breakdown of glutamine to alpha-ketoglutarate, generating ammonium and bicarbonate ions)

Answer 405

A

more insidious and may be painless
more difficult to define
incomplete bladder emptying
results in a increased risk of infection
can be low pressure with detrusor failure
can be high pressure with risk of interactive obstructive uropathy

Answer 406

A

infection in patients with abnormal urinary tract e.g. stones, obstruction or systemic disease involving the kidney e.g. diabetes mellitus, sickle-cell, or virulent organism e.g. Staphylococcus Aureus
treatment failure is more likely
complications are more likely e.g. renal papillary necrosis and renal abscess
majority of UTI’s in men are considered complicated, associated with urological abnormalities such as bladder outlet obstruction

Answer 407

A

more common in women - affects 1/3rd in lifetime

Answer 408

A

female
sex
pregnancy
menopause
decrease in host defence
urinary tract obstruction resulting in urine stasis
catheter

Answer 409

A

infection of urinary tract via the ascending transurethral route; sex and urethral catheter contribute
women are most susceptible due to shorter urethra and proximity to anus facilitates the transfer of bowel organisms to bladder
E.coli is the most common cause and arises from patients own flora

Answer 410

A

infection of the renal parenchyma and soft tissues of renal pelvis and upper ureter

Answer 411

A

KEEPS
• Klebsiella spp.
• E.coli - majority
• Enterococcus spp.
• Proteus spp.
• Staphylococcus spp - coagulase negative

Answer 412

A

predominantly affects females under 35 yrs
associated with significant sepsis and systemic upset
unusual in men
mainly caused by uropathogenic E.coli, typically with P pilli on surface to all ureteral ascent

Answer 413

A

structural renal abnormalities
calculi (stones)
catheterisation
pregnancy
diabetes
immunocompromised patient

Answer 414

A

infection is mostly due to bacteria (primarily E.coli) from own patients bowel flora
most commonly spread via the ascending transurethral route but can be via the bloodstream or lymphatics

Answer 415

A

P pilli to allow ureteral ascent
aerobactin - for Fe acquisition
haemolysin- for pore formation

Answer 416

A

loin pain, fever and pyuria

Answer 417

A

triad of: loin pain, fever and pyuria
may have severe headache
rigors
significant bacteriuria
malaise, nausea, vomiting
oliguria (small amounts of urine) if it causes AKI

Answer 418

A

diverticulitis, abdominal aortic aneurysm, kidney stones, cystitis, prostatitis

Answer 419

A

tender loin on examination
urine dipstick
midstream urine microscopy, culture and sensitivity; gold standard for diagnosis
bloods
urgent ultrasound

Answer 420

A

nitrites, released by bacteria breaking down nitrates
leucocyte elastase
foul-smelling urine
protein

Answer 421

A

FBC shows elevated white cell count

* CRP and ESR may be raised in acute infection

Answer 422

A

rest
cranberry juice and lots of water
analgesia
antibiotics
surgery to drain abscesses or relieve calculi that are causing infection

Answer 423

A

oral ciprofloxacillin or oral co-amoxiclav

- if severe then IV gentamicin or IV co-amoxiclav

Answer 424

A

urinary infection of the bladder

much more common in women
can occur in children
most common cause is E.coli

Answer 425

A

urinary obstruction resulting in urinary stasis
previous damage to bladder epithelium
bladder stones
poor bladder emptying

Answer 426

A

dysuria
frequency
urgency
suprapubic pain
haematuria
offensive smelling/cloudy urine
abdominal/loin tenderness

Answer 427

A

gold standard is microscopy and sterile midstream urine sample
dipstick urinalysis: positive leucocytes, blood and nitrites

Answer 428

A

1st: trimethoprim or cefalexin
2nd: ciprofloxacin or co-amoxiclav

Answer 429

A

infection and inflammation of the prostate gland

* can be acute or chronic

Answer 430

A

common in men of all ages
most common UTI in men < 50
usually presents > 35 yrs
associated with LUTS

Answer 431

A

bacterial e.g. Streptococcus faecalis, E.coli or Chlamydia

* non-bacterial e.g. elevated prostatic pressure, pelvic floor myalgia

Answer 432

A

STI
UTI
indwelling catheter
post-biopsy
increasing age

Answer 433

A

systemically unwell
fever, rigors, malaise
pain on ejaculation
significant voiding LUTS e.g. poor intermittent stream, hesitancy, incomplete emptying, post micturition dribbling, straining, dysuria
pelvic pain

Answer 434

A

acute symptoms for > 3 months
recurrent UTIs
pelvic pain

Answer 435

A

cystitis, BPH, calculi, bladder neoplasia, prostatic abscess

Answer 436

A

DRE
urine dipstick is positive for leucocytes and nitrites
mid-stream urine microscopy and sensitivity
blood cultures
sexually transmitted infection screen, for chlamydia in particular
trans-urethral ultrasound scan

Answer 437

A

prostate is tender or hot to touch

* hard from calcification

Answer 438

A

IV gentamicin + IV coamoxiclav or IV tazocin or IV carbapenem
2-4 weeks on a quinolone e.g. ciprofloxacin (antibiotic) once well
second line - trimethorpin
TRUSS guided abscess drainage if necessary

Answer 439

A

4-6 week course of quinolone e.g. ciprofloxacin (antibiotic)
but they don’t tend to respond as well to antibiotics
+/- alpha-blocker
NSAIDs

Answer 440

A

urethral inflammation due to infectious or non-infectious causes
primarily a sexually acquired disease

Answer 441

A

most common condition diagnosed and treated in men at GUM clinics
non-gonococcal urethritis is the more common than gonococcal urethritis
chlamydia is the most common STI in young people aged 15-24 yrs

Answer 442

A

Chlamydia

Answer 443

A

Neisseria gonorrhoea
Chlamydia trachomatis (most common cause)
Mycoplasma genitalium
Ureaplasma urealyticum
Trichomonas vaginalis

Answer 444

A

trauma
urethral stricture
irritation
urinary calculi

Answer 445

A

sexually active
unprotected sex
male to male sex
being male

Answer 446

A

may be asymptomatic (90-95% with gonorrhoea, 50% of patients with chlamydia)
dysuria (painful urination) +/- discharge; blood or pus
urethral pain
penile discomfort
skin lesions
systemic symptoms

Answer 447

A

Candida balantis, epididymitis, cystitis, acute prostatitis, urethral malignancy

Answer 448

A

nucleic acid amplification test
microscopy of gram-stained smears of genital secretions
blood cultures
urine dipstick to exclude UTI
urethral smear

Answer 449

A

female: self collected vaginal swab, endocervical swab, first void urine
male: first void volume
high specificity and sensitivity

Answer 450

A

acute epididymo-orchitis is a clinical syndrome of pain, swelling and inflammation of the epididymis that can extend into the testis
caused mainly by the extension of infection from the urethra or bladder

Answer 451

A

most common in male 15-30 yrs olds and those over 60

Answer 452

A

Chlamydia trachomatis

* Neisseria gonorrhoea

Answer 453

A

UTI - KEEPS:

Klebsiella spp
E.coli (most common)
Enterococci
Pseudomonas
Staphylococcus - coagulase negative

Answer 454

A

mumps
trauma
in elderly its predominantly catheter related

Answer 455

A

previous infection
indwelling catheter
structural/functional abnormality of urinary tract
anal intercourse

Answer 456

A

subacute onset of unilateral scrotal pain and swelling
in STD epididymo-orchitis there may be urethritis or urethral discharge
mumps usually presents with headache, fever and unilateral or bilateral parotid swelling
sweats/fever
on examination there is tenderness and palpable swelling of the epididymis and testicles

Answer 457

A

testicular torsion, hydrocele, trauma, abscess formation

Answer 458

A

• must rule this out
• if in any doubt then do surgical scrotal exploration
• features suggestive of torsion:
- short duration of pain - sudden onset
- associated nausea/abdominal pain
- high-riding/bell-clapper testis

Answer 459

A

nucleic acid amplification test
mid-stream urine dipstick for UTI symptoms
ultrasound to rule out abscesses
STD screening
urethral smear and swab

Answer 460

A

chlamydia: oral doxycycline 7 days or stat azithromycin
gonorrhoea: IM ceftriazone and stat oral azithromycin
UTI: oral ciprofloxacin or oral ofloxacin
antibiotics should be used for 2-4 weeks
analgesia - NSAIDs e.g. ibuprofen
scrotal support - supportive underwear
abstain from sexual intercourse
partner notification and testing

Answer 461

A

Chlamydia trachomatis

Answer 462

A

Neisseria gonorrhoea

Answer 463

A

Chlamydia is more common in women and 15-25yr olds
Gonorrhoea is more common in men and is less common than chlamydia
asymptomatic carriage of chlamydia is much more common than gonorrhoea

Answer 464

A

urethra
endocervical canal
rectum
pharynx
conjunctiva

Answer 465

A

conjunctiva

* atypical pneumonia

Answer 466

A

primary site of infection is urethra
dysuria and urethral discharge (mainly gonorrhoea)
CT: 7-21 days
GC: 2-5 days

Answer 467

A

CT - at least 50% - more likely to be asymptomatic thus more likely to get complications since undetected and thus untreated for longer
GC - 10%; 90% men have symptoms

Answer 468

A

CT - 70%

* GC - 60-80% (20% if single encounter)

Answer 469

A

primary site of infection is cervix
non-specific symptoms of dysuria, menstrual irregularity and discharge
CT: ill-defined
GC: up to 10 days

Answer 470

A

CT - over 70%

* GC - 50%

Answer 471

A

CT - 70%

* GC - 50-90%

Answer 472

A

pelvic inflammatory disease
neonatal transmission
Fitz Hugh Curtis syndrome; peri-hepatitis but no decline in liver function

Answer 473

A

infection spreads up to the fallopian tube leading to inflammation and scarring
tubular factor infertility
ectopic pregnancy
chronic pelvic pain

Answer 474

A

often diagnosed in established relationships since there is a long asymptomatic carriage
Nucleic Acid Amplification Tests: high specificity and sensitivity, but negative test doesn’t mean non-infection

Answer 475

A

associated with recent partner change
near patient testing
culture on selective medium to confirm
antibiotic sensitivity testing
NAAT

Answer 476

A

microscopy of gram stained smears of genital secretions, looking for gram negative diplococci
males; sample from urethra
females; sample from endocervix

Answer 477

A

partner management
test for other STIs
oral azithromycin stat (convenient - just 1 dose) or oral doxycycline for 7 days (less convenient, but more effective)

Answer 478

A

erythromycin for 14 days or azithromycin stat

Answer 479

A

partner notification
test for other STIs
continuous surveillance of antibiotic sensitivity
single dose treatment is preferred
IM ceftriaxone with azithromycin stat

Answer 480

A

parasympathetic (cholinergic); S3 ,S4 and S5:
• drives detrusor contraction
sympathetic (noradrenergic); T10, L1, L2:
• urethral contraction (smooth muscle component but remember the main part of the sphincter is skeletal muscle)
• inhibits detrusor contraction

Answer 481

A

caused by sphincter weakness

- small leak of urine when intra-abdominal pressure rises e.g. when coughing, laughing and standing up

Answer 482

A

women; secondary to birth trauma
men; post-prostatectomy
neurogenic or congenital

Answer 483

A

pelvic floor exercises
duloxetine
surgery: sling, artificial sphincter

Answer 484

A

artificial sphincter or male sling

Answer 485

A

detrusor overactivity; rise in detrusor pressure on filling associated with urgency (most common in women)
less commonly by bladder hypersensitivity from local pathology e.g. UTI, bladder stones or tumour

Answer 486

A

bladder exercises; gradually increasing the interval between voids
behavioural therapy; controlling caffeine, alcohol and frequency volume charts
drugs
surgery

Answer 487

A

anticholinergic agents
beta3 agoinst e.g. mirabegron
botox of bladder

Answer 488

A

mirabegron

Answer 489

A

detrusor myectomy

- cystoplasty

Answer 490

A

adding some bowel to bladder to increase surface area
gives increased bladder capacity and reduced detrusor overactivity
may have to self-catheterise due to muscle loss

Answer 491

A

reflex bladder control from sacral micturition centre

- guarding reflex

Answer 492

A

proximal part of sphincter senses urine and sends impulse to spinal cord to tell Onuf’s nucleus to store urine

Answer 493

A

supra-conal (higher in spinal cord) lesion
loss of co-ordination and completion of voiding
reflexes work but are not controlled by the brain

Answer 494

A

reflex bladder contractions
detrusor sphincter dyssynergia; loss of completion of voiding
poorly sustained bladder contraction
potentially unsafe - puts kidneys at risk

Answer 495

A

conus lesion (lower spinal cord injury) - decentralised bladder

Answer 496

A

reflex bladder contraction
guarding reflex
receptive relaxation

Answer 497

A

areflexic bladder
stress incontinence
risk of poor compliance
potentially unsafe - puts kidneys at risk

Answer 498

A

spastic paralysis:

conus (lower end of spinal cord) functioning but not controlled by the brain
reflex bladder - involuntary urination (i.e. when senses full)
reflex bowel - involuntary defecation

flaccid paralysis:

conus destroyed or non-functional
areflexic bladder - fills until it overflows
areflexic bowel - fills until it overflows

Answer 499

A

commonly causes by over-distension of bladder
cccurs in lesions above T6
overstimulation of sympathetic nervous system below the level of lesion in responses to a noxious stimulus
headache, severe hypertension and flushing

Answer 500

A

• an unsafe bladder is one that puts kidneys at risk
• risk factors:
- raised bladder pressure
- vesico-ureteric reflux
- chronic infection e.g. residual urine/stones

Answer 501

A

harness reflexes to empty bladder into incontinence device, but may not keep bladder safe!
suppress reflexes converting bladder to flaccid type and then empty regularly

Answer 502

A

alpha adrenergic blockers e.g. oral tamsulosin or sphincterotomy
cystoplasty
permanent catheterisation

Answer 503

A

give high flow-oxygen via non-rebreathe bag
take blood cultures and consider source control
give IV antibiotics
start IV fluid resuscitation
check lactate
monitor hourly urine output and consider catheterisation
within 1 hour

Answer 504

A

used to replace fluids and try to increase blood pressure

* normal saline is physiologically similar to the normal composition of extracellular fluid

Answer 505

A

around 150mmol of Na+
around 150mmol of Cl-
around 300mmol of osmotically active ions
virtually no K+

Answer 506

A

tamsulosin, alfuzosin, doxazocin

Answer 507

A

first line treatment for benign prostatic hyperplasia where lifestyle changes are insufficient
can be used alongside 5-alpha reductase inhibitors e.g. finasteride or surgery
can be used to aid passage of kidney stones

Answer 508

A

highly selective for the alpha1 adrenoceptor found mainly in smooth muscle including blood vessels and the urinary tract (bladder neck and prostate)
stimulation induces contraction, blockage induces relaxation so thus causes vasodilatation and a fall in blood pressure and a reduced resistance to bladder outflow

Answer 509

A

can cause postural hypertension, dizziness and syncope
should not be used in existing hypotension
combining antihypertensives can provide profound effect so omitting doses of other medications when starting can help avoid first dose hypertension

Answer 510

A

finasteride

Answer 511

A

used for treatment of benign prostatic hyperplasia as an add on to alpha blockers
provides less relief and takes longer for effect

Answer 512

A

5-alpha reductase is the enzyme that converts testosterone to dihydrotestosterone (active form of testosterone), so blocking this conversion results in a dramatic decrease in serum dihydrotestosterone levels
this reduces prostate volume so improves symptoms of the enlarged prostate and reduces the risk of cancer

Answer 513

A

since this treatment lowers PSA it may hide prostate cancer, there is a possible risk of sexual dysfunction
contraindicated for used in women

Answer 514

A

sildenafil

Answer 515

A

erectile dysfunction

- primary pulmonary hypertension

Answer 516

A

sildenafil is selective for phosphodiesterase type 5 (PDE5) which is predominantly found in the smooth muscle of the corpus cavernous of the penis and the arteries of the lung
causes vasodilatation by inhibiting PDE5 which is responsible for the breakdown of cyclic GMP, thus increasing cyclic GMP concentrations which then causes arterial smooth muscle relaxation and vasodilation and penile engorgement

Answer 517

A

flushing, headache, dizziness, nasal congestion and more seriously, hypotension, tachycardia and palpitations
increased risk of MI and stroke
should be avoided where vasodilatation is dangerous i.e. in recent stroke, acute coronary syndrome or other CVD and should be used with caution in hepatic and renal failure
contraindicated with other drugs that increase nitric oxide i.e. nitrates, since combined effect on cyclic GMP can cause severe vasodilation and cardiovascular collapse

Answer 518

A

oxybutynin, tolterodine

Answer 519

A

to reduce urinary frequency, urgency and urge incontinence in an overactive bladder

Answer 520

A

competitively inhibits acetylcholine, blocking the muscarinic receptors and promoting bladder relaxation to increase capacity
this reduces urgency and frequency of urination
these muscarinics are selective for M3 receptor which is the main receptor in the bladder

Answer 521

A

dry mouth, tachycardia, constipation and blurred vision
contraindicated in UTI, use with care in the elderly as can cause drowsiness
use with care in angle closure glaucoma as can cause rise in intraocular pressure, and in patients with arrhythmias and those at risk of urinary retention

Answer 522

A

flutamide, bicalutamide, cyproterone acetate

Answer 523

A

used to treat prostate cancer

Answer 524

A

anti-androgens decrease the body’s response to androgens so are beneficial in prostate cancer, as the cells require androgen for growth
drug competes with circulating androgens for receptors on prostate cells and promote apoptosis and inhibit growth
can be used as monotherapy or with surgery or chemotherapy

Answer 525

A

bicalutamide is better tolerated

- GI disturbance and possible liver injury

Answer 526

A

neurogenic detrusor overactivity
stress incontinence ( e.g. straining at the gym)

Answer 527

A

overactive bladder -
detrusor overactivity

Answer 528

A

OAB is defined as urgency with frequency, with or without nocturia, when appearing in the absence of local pathology

Answer 529

A

using urodynamics

Answer 530

A

they inhibit the parasympathetic pathway which is responsible for bladder contraction → relaxation

Answer 531

A

it is a Beta3 agonist.

B3 receptors in the bladder trigger relaxation thus mirabegron promotes relaxation

Answer 532

A

can cause urinary retention

Answer 533

A

it works on the afferent feedback system to the brain

Answer 534

A

reflex bladder contraction: parasympathetic: S3
guarding reflex: rhabdosphincter tries to keep you dry by contracting: somatic innervation: brain control in Onulf’s nucleus.
receptive relaxation: sympathetic nervous system: S3

Answer 535

A

coordination is lost and loss of completion of voiding

Answer 536

A

when the bladder puts the kidneys at risk due to:

high pressures in the bladder blocking the ureters preventing the kidneys from draining

Answer 537

A

loss of:

reflex bladder contraction
guarding reflex
receptive relaxation → poor compliance → prolonged high pressure in the bladder that can put kidneys at risk.

Answer 538

A

areflexic bladder
stress incontinance
risk of poor compliance → risk to kidneys.

Answer 539

A

they maintain a coordinated void but they may still be incontinent

Answer 540

A

prolonged high pressure

Answer 541

A

a full bladder - look for mechanism of this

Answer 542

A

internal sphincter
external sprinter
pelvic floor muscles
prostate in men

Answer 543

A

layers after the kidney are:
- renal capsule
- perirenal fat
- renal fascia
- pararenal fat

Answer 544

A

False

the right is lower down due to being pushed by the kidney

Answer 545

A

T12 - L3

they are ~ 3 vertebrae in length

Answer 546

A

arteries x3
- superior artery = branch of the inferior phrenic artery
- middle artery = branch of the abdominal aorta
- inferior artery = branch of the renal artery
one vein drains the gland = the adrenal vein
- the right adrenal vein drains directly into the IVC as its is in close proximity
- the left adrenal vein drains into the left renal vein first

Answer 547

A

capsule
cortex
- zona Glomerulosa
  - mineraolcorticoids synthesis
- Zona Fascicularis
  - Glucocorticoids synthesis
- Zona Reticularis
  - androgens synthesis
medulla
- catecholamine synthesis

Answer 548

A

renal vein
renal artery
lymphatics
nerves
ureters

Answer 549

A

right and left renal arteries from the abdominal aorta
right and left renal veins that drain directly into the IVC
- the right vein is shorter than the left

Answer 550

A

right drains directly into IVC

left drains into left renal vein first

Answer 551

A

cortex around the outside
medulla in the middle
- arranged into pyramids
calyces
- minor calyces → major calyces → renal pelvis → ureter

Answer 552

A

a functional unit of the kidney

Answer 553

A

the glomerulus, Bowman’s capsule, proximal and distal tubules and part of the collecting duct are in the cortex
the loop of henle and the rest of the collecting duct are in the renal pyramids

Answer 554

A

the apex of the medulla

it is the opening into a minor calyx for outflow of urine

Answer 555

A

it passes from the kidney to the bladder and travels behind the numerous arteries including the uterine and ovarian arteries.

“water under the bridge”

Answer 556

A

True

they have muscular walls

Answer 557

A

Abdominal aorta → renal artery → segmental arteries → interlobular arteries → arcuate arteries → afferent arteriole → Glomerulus → efferent arteriole → peritubular capillaries → interlobular veins → Arcuate vein → interlobular vein → renal vein → IVC

Answer 558

A

A WET BED

Acid/base balance
Water removal
Erythropoietin
Toxins
Blood Pressure
Electrolyte
D - vitamin D activation

Answer 559

A

The volume of fluid filtered through the from the glomerulus to the bowman’s space

Glomerulus = the collection of capillaries carrying blood to filtered

bowman’s capsule = the space into which filtrate is captured

Answer 560

A

there are no proteins in bowmans space

Answer 561

A

it’s freely filtered
not secreted or reabsorbed
not metabolised

Answer 562

A

Pressure
Size of the molecule
Charge of the molecule
Blood flow
Binding to plasma proteins

Answer 563

A

the glomerular capillaries are fenestrated, meaning they have gaps to allow molecules in the blood to be filtered out, everything except RBCs.
- the endothelial cells have glycocaelyx - proteins - which are -vely charged to repel the passage of proteins [also -vely charged] through.
the afferent arteriole dilates while the efferent one constricts which raises the hydrostatic pressure exerted on the blood in the glomerulus → ultrafiltration.
the filtrate passes into Bowman’s capsule and is basically protein free plasma.
as the filtrate moves through the tubules, certain substances are reabsorbed either by diffusion or by mediated transport[ATP]
whats left enters the collecting duct into the calyces to form the urine

Answer 564

A

To increase GFR;
- Constrict the efferent arteriole (build up pressure before)•Dilate the afferent arteriole (builds up pressure after)
To decrease GFR;
- Constrict the afferent arteriole (reduce blow flow)•Dilate the efferent arteriole (allows blood to escape easier)

Answer 565

A

fenestrated endothelial cells
basement membrane
- made from fusion of capillary and podocyte basement membrane.
podocytes

Answer 566

A

Myogenic; smooth muscle contraction in response to external stretching force, occurs in capillary walls, passive mechanism
Tubuloglomerular feedback;
- constriction of afferent arteriole to increased sodium chloride concentration.
- Dilation in response to decreased concentration.
- Fast response via GFR and slow via RAAS

Answer 567

A

GFR of individual nephron regulated by the rate at which filtered fluid reaches the distal tubule
Cells of macula densa (distal tubule) detect NaCl arrival
Macular densa cells release prostaglandins in response to reduced NaCl delivery.
This acts on granular cells, triggering renin release, activating the renin-angiotensin system

Answer 568

A

False

The only protein that is normally found in urine is Tamm– Horsfall protein (uromodulin) which is produced by the thick ascending limb
otherwise other proteins shouldnt be present in the urine and indicate leaky nephrons

Answer 569

A

Filtration Fraction = GFR / Renal Plasma Flow
i.e. the proportion that gets filtered.

Answer 570

A

renal clearance is the volume of plasma completely cleared of a substance by the kidneys per unit time.

Answer 571

A

bulk reabsorption of essentials:
- Na+
- Cl-
- water
- glucose
- bicarbonate
- amino acids
- phosphate
- lactate
⅔ of all filtrate reabsorbed here

Answer 572

A

via SGLT1 and SGLT2 transporters
- these a co transporters that carry Na+ and glucose into the cell
- SGLT1= 2Na+ and 1glucose
- SGLT2=1Na+ and 1glucose
glucose reenters the blood passively via GLUT channels

Answer 573

A

Pressure within afferent arteriole rises → stretches vessel wall → triggers contraction of smooth muscle → arteriolar constriction

important because it prevents a rise in systemic arterial pressure reaching the capillaries in the nephron THUS it prevents damage and maintains constant level of filtration
revers happens in low pressure to maintain a constant rate of filtration

Answer 574

A

Descending limb = H20 reabsorption
ascending limb = Na, Cl and K reabsorption

Answer 575

A

“fine tuning” of sodium reabsorption, potassium and acid-base balance
impermeable to water
Macula densa located in juxtaglomerular apparatus which is in the DCT-
- detects [Na+] and can activate RAAS.

Answer 576

A

Collecting duct mediates water reabsorption and maintains acid base homeostasis
Principal cells - Na and water reabsorption and K excretion
- site of ADH action
Intercalated cells (alfa and beta) – secrete H or HCO3
- •Essential for acid base homeostasis

Answer 577

A

7.35-7.45
Acidosis: pH<7.35
Alkalosis: pH>7.45

Answer 578

A

located in the distal convoluted tubule next to the glomerulus

macula densa cells
granular cells
afferent arteriole
distal convoluted tubule

Answer 579

A

in the walls of the afferent arteriole

Answer 580

A

The Renin-Angiotensin-Aldosterone System (RAAS) is a hormone system within the body that is essential for the regulation of blood pressure and fluid balance

Answer 581

A

decreased blood pressure
- detected by little or no arteriolar stretch (from low blood volume due to low Na+ and thus H2O).
decreased NaCl detected in the macula densa cells
sympathetic innervation

when any of these happens, then renin is released by the juxtaglomerular cells in the afferent arterioles

Answer 582

A

an enzyme

cleaves angiotensinogen → angiotensin1

Answer 583

A

the liver

Answer 584

A

in the pulmonary and renal endothelium

Answer 585

A

stimulates the adrenal gland → aldosterone secretion
- increases reabsotption of salt and water
- increases K+ excretion
stimulates the posterior pituitary gland → ADH secretion → more conc. urine
stimulates vasoconstriction of systemic arteries and arterioles
stimulates thirst in the hypothalamus
increases total peripheral resistance thus raises BP
stimulates sympathetic nervous system to increase release of noradrenaline
- Increase in cardiac output.
- Vasoconstriction of arterioles.
- Release of renin.

Answer 586

A

hypothalamus

Answer 587

A

principal cells of the collecting duct

Answer 588

A

it binds to the V2R receptors of the principal cells →
upregulation of aquaporin channels in the collecting tubule walls →
increased H2O reabsorption and less urine produced

Answer 589

A

in the kidneys

increases production of RBCs in the bone marrow

Answer 590

A

Aldosterone
cortisol
corticosterone
DHEA
androstenedione

1= glomerulosa

2+3=fasciculata

4+5 = reticularis

Answer 591

A

part of the autonomic nervous system
production of catecholamines
- adrenaline 80% and noradrenaline20%
- main site for adrenaline synthesis
production of catecholamines is dependent on cortisol levels [permissive effect]

Answer 592

A

part of the autonomic nervous system
production of catecholamines
- adrenaline 80% and noradrenaline20%
- main site for adrenaline synthesis
production of catecholamines is dependent on cortisol levels [permissive effect]

Answer 593

A

True - this makes it a good marker of renal function

Answer 594

A

proximal convoluted tubule
bendroflumathiazide

Answer 595

A

distal convoluted tubule
spironolactone [mineralocorticoid antagonist also]
amiloride

Answer 596

A

loop of Henle
furosemide + bumetanide

Answer 597

A

insulin
hyperaldosteronism: Conn’s + Cushings
beta2 antagonists
alkalosis

Answer 598

A

insulin deficiency
aldosterone deficiency - Addison’s
beta2 antagonists
exercise
acidosis
cell lysis
diet - lots of bananas

Answer 599

A

they reduce blood flow to the kidney by causing constriction of the afferent arteriole → reduced oxygen and cell death.

Answer 600

A

proteinuria
oedema - eye sockets, genital region + peripheral limbs
hypoalbuminaemia

Answer 601

A

podocyte damage → widened gaps between them which allows the easy passage of substances through them such as proteins.

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Genitourinary tract Flashcards

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