GU Flashcards
1
Q
Define benign prostatic hyperplasia (BPH)
A
Increase in cell number and size in transitional/peri-urethral prostate area WITHOUT the presence of malignancy
2
Q
Describe the pathophysiology of Benign prostatic hyperplasia
A
Epithelial and stomal cell increase
Increased A1 adrenoreceptors –> smooth muscle contraction and mass effect of prostate size = obstruction
3
Q
Give 4 symptoms of BPH
A
- Increased frequency of micturition
- Nocturia,
- Hesitancy
- Post-void dribbling
- acute urinary retention or retention with overflow incontinence
- enlarged smooth prostate
4
Q
What investigations might you do in someone who you suspect has BPH?
A
- Digital rectal exam - show smooth but enlarged prostate
- PSA - not overly accurate but usually done for completion (remember you can’t do this at the same time as DRE)
- Bladder diaries etc.
5
Q
What are the aims of the management of BPH?
A
Improve urinary symptoms
Improve QOL
Reduce complications of bladder outflow obstruction
6
Q
What lifestyle changes can be made to manage symptoms of BPH?
A
Reduce caffeine and alcohol intake
Distraction methods
Bladder training
7
Q
Describe the treatment for BPH
A
1st line = Alpha-1-antagonists (A-blockers) e.g. tamulosin
- relaxes smooth muscle in bladder neck & prostate
2nd line = 5-alpha-reductase inhibitors e.g. finasteride
- blocks conversion of testosterone to dihydrotestosterone -> decreases prostate size
TURP = gold standard
8
Q
Give the surgical treatment for BPH
A
Transurethral resection of prostate (TURP)
9
Q
What are the indications in someone with BPH to do a TURP?
A
RUSHES
- Retention
- UTI’s
- Stones
- Haematuria
- Elevated creatinine
- Symptom deterioration
10
Q
What is the function of the prostate?
A
Secretes proteolytic enzymes into the semen which breaks down clotting factors in the ejaculate
11
Q
Define prostate cancer
A
Adenocarcinoma in the peripheral zone of the prostate gland
12
Q
Where can prostate cancer metastasise to?
A
Lymph nodes and bone
Rarely = brain, liver, lung
13
Q
By what routes can prostate cancer spread?
A
- Lymphatic - to external iliac and internal iliac and presacral node
- Haematogenous - to bone, lung. liver, kidneys
- Direct - within in the prostate capsule
14
Q
What can cause prostate cancer?
A
- High testosterone levels
2. Family history - 2/3x increased risk if 1st degree relative is affected
15
Q
what are the symptoms of prostate cancer?
A
- LUTS
- Bone pain, weight loss, night sweats anaemia = mets
Most picked up in asymptomatic stage
16
Q
What investigations might you do in someone who you suspect has prostate cancer?
A
Digital Rectal Exam and PSA are done in community,
Transrectal USS and biopsy = DIAGNOSTIC
Gleason grading system - higher the score the worse the prognosis
17
Q
What grading system is used in prostate cancer?
A
Gleason grading = higher the score, the more aggressive the cancer
18
Q
What is the treatment for localised prostate cancer?
A
radical prostatectomy
chemotherapy
radiotherapy
19
Q
What is the treatment for metastatic prostate cancer?
A
- prostatectomy
- chemotherapy
- radiotherapy
- zoladex (GnRH agonist)
20
Q
Give 2 advantages and 1 disadvantage of radical treatment for localised prostate cancer
A
Advantages:
- Curative
- Reduced patient anxiety
Disadvantages:
1. Can have adverse effects
21
Q
How do LH antagonists work in treating prostate cancer?
A
First stimulate and then inhibit pituitary gonadotrophin E.g. Leuprolide
22
Q
Is a raised PSA confirmatory of prostate cancer?
A
NO
Prostate cancer indication
23
Q
Other than prostate cancer, what can cause an elevated PSA?
A
- Benign prostate enlargement
- UTI
- Prostatitis
24
Q
Give 2 advantages and 2 disadvantages of screening in prostate cancer
A
Advantages:
- Early diagnosis of localised disease (cure)
- Early treatment of advanced disease (effective palliation)
Disadvantages:
- Over diagnosis of insignificant disease
- Harm caused by investigation/treatment
25
What is PSA?
A glycoprotein secreted by the prostate into the blood stream
26
Name the 2 types of testicular cancers that arise from germ cells
1. Seminoma = most common, slow growing
| 2. Non-seminoma = yolk sac carcinoma/teratoma, rapid growth
27
Where does testicular cancer spread?
Locally into epididymis, spermatic cord and scortal wall Pelvic and inguinal Metastasises
28
what are the risk factors for testicular cancer?
1. Cryptorchidism (undescended testes)
2. Family history
3. previous testicular cancer
4. HIV
5. age 20-45
6. Caucasian
7. infant hernia
29
Give 3 symptoms of testicular cancer
1. Painless testis lump - hard and craggy (non-transilluminable)
2. Testicular or abdominal pain
3. haematospermia,
4. Abdominal mass
5. Dyspnoea and cough - lung mets
30
What investigations might you do on someone you suspect to have testicular cancer?
1. Tumour markers = Alpha-fetoprotein (a-FP) and Beta subunit of human chorionic gonadotrophin (B-hCG)
2. Testicular biopsy
3. Imaging = US, CT/MRI
31
How is testicular cancer staged?
```
1 = no mets
2 = nodes under diaphragm
3 = above diaphragm
4 = lungs
```
32
What is the treatment for testicular cancer?
Orchidectomy = testis and spermatic cord excised Chemo and radiotherapy
33
What is epididymitis?
Inflammation of the epididymis
| Occurs mainly in young males
34
Give 2 causes of epididymitis
1. E. coli
| 2. Chlamydia
35
What is an epididymal cyst?
Smooth extra-testicular, spherical cyst in the head of the epididymus
36
What is hydrocele?
Scrotal swelling as a result of excessive fluid in the tunica vaginalis
37
what is primary hydrocele?
In absence of disease in testis
Large and tense testis
Young boys mainly effected
Associated with a patent processus vaginalis, which typically resolves during the 1st year of life
38
Name 3 causes of secondary hydrocele
1. Testicular tumours
2. Infection
3. Testicular torsion
4. TB
5. trauma - is rarer and present in older boys and men
39
What is varicocele?
An abnormal enlargement of the pampiniform venous plexus in the scrotum
Caused by venous reflux
40
Why might renal cell carcinoma cause left sided varicocele?
If the renal tumour obstructs where the gonadal vein drains into the renal vein blood can back up and so you may see left sided varicocele
41
What is testicular torsion?
Twisting of the spermatic cord resulting in occlusion of testicular blood vessels
Leads to ischaemia and postnatal loss of testis
42
Define glomerular disease
= Glomerulonephritis
| Group of parenchymal kidney diseases that all result in the inflammation of the glomeruli and nephrons
43
Give 3 consequences of glomerulonephritis
1. Damage to filtration mechanism --> haematuria and proteinuria
2. Damage to glomerulus restricts blood flow --> hypertension
3. Loss of usual filtration capacity --> AKI
44
Briefly describe the pathophysiology of glomerulonephritis
Immunologically mediated --> immunoglobulin deposits and inflammatory cells
45
How can glomerulonephritis present?
1. Nephritic syndrome
2. Nephrotic syndrome
3. Asymptomatic haematuria
46
what are the causes of nephritic syndrome?
Renal causes
- IgA nephropathy
Systemic causes
- SLE
- Post strep GN
- Small vessel vasculitis
- Goodpasture's/anti-GMB disease
47
what is the clinical presentation of nephritic syndrome
This is a syndrome fitting a clinical picture of inflammation within the kidney.
characterised by:
Haematuria- reflects inflammation of the kidney (red casts on microscopy)
Oliguria- due to reduced GFR
Proteinuria- less than 3g/24 hours
Hypertension –due to fluid overload
48
What investigations might you do in someone who has nephritic syndrome?
- Urinalysis (dipstick) = haematuria and proteinuria
- Blood tests = high creatinine and urea
- Kidney biopsy = diagnostic (crescent shaped glomeruli, Ig depositions, glomerulosclerosis)
- serology = anti-GBM antibodies, c-ANCA, p-ANCA
49
How do you manage nephritic syndrome?
Treat underlying cause
Blood pressure control- ACE-I/ARB. This reduces proteinuria and preserves renal function
Corticosteroids- this is to reduce the inflammation causing damage to the kidney
50
Describe the pathophysiology behind nephritic syndrome
Kidney inflammation --> large podocytic pores --> RBC, WBC, protein leaks into urine
51
What are the signs needed in order to make a diagnosis of nephrotic syndrome?
proteinuria (>3.5g/day)
hypercholesterolaemia
hypoalbuminemia - results in severe oedema
52
Describe the pathophysiology of nephrotic syndrome
1. Inflammation – from immune cells (Ab’s, Ig’s - IgG), complement proteins, HTN, atherosclerosis, medications/immunisations, infection
2. Damage to podocytes – protein leakage (albumin, Ab’s)
3. Increased liver activity – to increase albumin, - Consequential increase in cholesterol + coagulation factors
4. Reduced oncotic pressure – oedema - Consequential blood volume decrease, RAAS stimulation, exacerbation
53
What can nephrotic syndrome be secondary to?
1. DM
2. SLE
3. Amyloidosis
4. Infection
5. Drugs
54
what are the primary causes of nephrotic syndrome?
- Minimal change disease
- Membranous glomerulonephritis
- focal segmental glomerulosclerosis
55
What would you see on the needle microscopy taken from someone with minimal change disease?
LM - normal
FM - normal
EM - Fused podocyte foot processes
56
How is minimal change disease treated?
High dose corticosteroids = prednisolone
- Frequent relapse or steroid-dependent disease is treated with CYCLOPHOSPHAMIDE or CICLOSPORIN/TACROLIMUS
57
What is membranous nephropathy?
Thickening of glomerular capillary wall
| IgG and C3 complement deposition in sub-epithelial surface --> leaky glomerulus
58
How would you diagnose membranous nephropathy?
Serum anti-PLA2R antibodies
| Renal biopsy = thickened glomerular basement membrane (sub epithelial IgG and C3 complement deposits)
59
What is the management of membranous nephropathy?
Managed with ACE-I/ARB in all.
| In patients with high risk of progression, prednisolone and cyclopshosphamide.
60
What are the main symptoms of nephrotic syndrome?
Pitting oedema (periorbital, ascites, peripheral)
frothy urine - reflects proteinuria
61
What investigations might be carried out in someone with nephrotic syndrome?
Urinalysis (dipstick) = proteinuria
Blood tests
- hyperlipidaemia and hypoalbuminaemia
- protein:creatinine ratio
USS kidney
Needle biopsy and microscopy = GOLD STANDARD
- light microscopy (LM)
- fluorescence microscopy (FM)
- electron microscopy (EM)
62
Describe the treatment for nephrotic syndrome
Fluid and salt restriction
Loop diuretics- to manage oedema
Treat cause
ACE-I/ARB to reduce protein loss
Manage complications
63
Give 3 complications of nephrotic syndrome
1. Infections (Ig loss, complement activity decrease)
2. Thromboembolism (more clotting factor) manage with heparin
3. Hyperlipidaemia - loss of albumin increases cholesterol formation. Manage with statins
64
What is IgA nephropathy?
This is where there is deposition of IgA into the mesangium of the kidney. This results in inflammation and damage
65
What is the treatment for IgA nephropathy?
- BP control - ACEi / ARB
| - steroids if renal function declines
66
Where can urinary tract stones be found?
Upper = renal and ureteric
Lower = bladder, prostatic and urethral
They most commonly are deposited at the pelviureteric junction, pelvic brim and vesicouretertic junction
67
What are urinary tract stones composed of?
80-85% = calcium oxalate (radio-opaque),
68
Describe the pathophysiology of stone formation in the upper urinary tract?
Stones form from crystals in supersaturated urine
69
Describe the epidemiology of stones in the urinary tract
```
10-15% lifetime risk
Males > females (2:1)
Higher prevalence in Middle East due to higher oxalate and lower calcium, containing diet
Peak prevalence 20-40yrs
50% risk of recurrence
```
70
Give 5 potential causes of urinary tract stones
1. Congenital abnormalities - horseshoe kidney, spina bifida
2. Hypercalcaemia/high urate/high oxalate
3. Hyperuricaemia
4. Infection
5. Trauma
71
what is the clinical presentation of urinary tract stones?
- Renal colic = severe unilateral abdominal pain starting in loin + radiating to ipsilateral groin/ testicle/ labia, classically sudden onset early in morning
- Restlessness,
- nausea + vomiting,
- haematuria,
- dysuria
72
Give 3 differential diagnosis of urinary tract stones
1. AAA (until proven otherwise)
2. Diverticulitis
3. Appendicitis
4. Ectopic pregnancy
5. Testicular torsion
73
What investigations might you do on some who you suspect has a urinary tract stone?
- First line = KUB XR - can see stone in renal tract
- Gold standard = non-contrast CT KUB, USS KUB in pregnancy (can only see radiopaque stones with USS)
- Dipstick: haematuria, leucocytes, nitrites
- Bloods: FBC, CRP, U&Es
74
Give 5 ways in which urinary tract stones can be prevented
thiazide diuretics - reduce Ca levels
1. Stay well hydrated
2. Low salt diet
3. Healthy protein intake
4. Reduced BMI
5. Active lifestyle
6. Urine alkalisation
75
When are urinary tract stone removed?
<5mm = watch and wait
>5mm:
- Oral nifedipine (CCB) or alpha blocker (tamsulosin)
- Extracorporeal shock wave lithotripsy (ESWL) - break stone into smaller fragment using shockwaves
- Ureteroscopy (laser/basket)
76
What is renal colic?
Pain due to obstruction in the urinary tract
77
What investigations might you do to find out what is causing someone's renal colic?
1. Bloods - including calcium, phosphate, urate
2. Urinalysis
3. MSU MCS (mid-stream urine microscopy, culture & specificity)
4. NCCT-KUB (non-contrast CT scan of kidney, ureter and bladder) = gold standard
78
Describe the treatment for renal colic
1. Analgesia - NSAIDS (diclofenac)
2. Anti-emetics
3. Check for sepsis
79
Give 3 causes of renal colic
1. Urinary tract stones
2. UTI
3. Pyelonephritis
80
Give 3 places where urinary tract stones are likely to get stuck
1. Ureteropelvic junction
2. Pelvic brim
3. Vesoureteric junction
81
Give 5 functions of the kidney
1. Filters and secretes waste/excess substances
2. Blood volume/fluid management (BP control)
3. Synthesises Erythropoietin
4. Acid base regulation (reabsorption go Na, Cl, K, glucose, H2O, AA's)
5. Converts 1-hydroxyvitamin D --> 1,25-dihydroxyvitamin D (active)
82
What is the GFR?
Volume of fluid filtered from the glomeruli into Bowman's space pre unit time
83
What would you expect a typical GFR to be?
120 ml/min
84
Write an equations for GFR
(Um X urine flow rate) / Pm
```
Um = conc of marker substance in urine
Pm = conc of marker substance in plasma
```
85
Give an example of a marker substance for estimating GFR
Creatinine
86
Give 3 essential features of a marker substance for estimating GFR
1. Not metabolised
2. Freely filtered
3. Not reabsorbed/secreted
87
Name a drug that can inhibit creatinine secretion and what is the affect of this on GFR?
Trimethoprim (antibiotic to treat UTIs)
| Serum creatinine rises and so kidney function (GFR) appears worse
88
What is the affect on GFR of afferent arteriole vasoconstriction?
Decreased GFR
89
What is the affect on GFR of efferent arteriole vasoconstriction?
Increased GFR
90
What does the eGFR require to be calculated?
Steady state
91
What is the effect of NSAIDs on the afferent arteriole of glomeruli?
NSAIDs inhibit prostaglandins and so lead to afferent arteriole vasoconstriction = reduced GFR
92
What is the effect of AECi on the efferent arteriole of glomeruli?
ACEi cause efferent arteriole vasodilation = reduced GFR
93
Define chronic kidney disease
Long standing, usually progressive, impairment in renal function for more than 3 months
94
How is CKD diagnosed?
- eGFR < 60mL/min/1.73m2,
or:
- eGFR < 90mL/min/1.73m2 + signs of renal damage,
or:
- Albuminuria > 30mg/24hrs (Albumin:Creatinine > 3mg/mmol)
95
Briefly describe the pathophysiology causes CKD
Hyper-filtration for nephrons that work --> glomerular hypertrophy and reduced arteriolar resistance --> raised intraglomerular capillary pressure and strain --> accelerates remnant nephron failure (progressive)
96
Name 4 cause of CKD
1. DM - 24% of patients
2. Hypertension
3. Glomerulonephritis
4. Congenital - polycystic kidney disease
5. Urinary tract obstruction
6. drugs - NSAIDs, ACEi, antidepressants, many antibiotics
97
Give 3 signs of CKD
Often asymptomatic until very low kidney function
- Fluid retention
- oedema and raised JVP
- Oliguria - 0.5 mL/kg/h or <500mL/day
- Effects of uraemia
- pruritus = ureamic frost, yellow/grey complexion, nausea, reduced appetite
- cardiac arrhythmias - hyperKa
- Fatigue, pallor - anaemia
- Bone pain - hyperphosphatemia (CKD-MBD)
98
What investigations might be done in someone who has CKD?
FBC = anaemia
U+Es = raised phosphate, uric acid, urea, creatine and decreased Calcium
Urine dipstick = haematuria and proteinuria
GFR Imaging - USS, CT KUB, ECG, Xrays
99
Describe the management of CKD
Slow progression of disease
- DM treatment
- HTN treatment
- Glumeronephritis treatment
Reduce risk of CVD
- Atorvastatin- 20mg
Manage complications
- Mineral bone disease- low Vit D
- HTN
- Proteinuria
- Anaemia-> ESA
- RRT- haemodialysis, peritoneal dialysis, transplant
100
What is renal replacement therapy?
Dialysis or renal transplantation
101
Name 2 types of dialysis?
1. Haemodialysis
| 2. Peritoneal dialysis
102
What is the access point in haemodialysis?
AV fistula or tunelled catheter
103
How does haemodialysis work?
Exchange of waste solutes through diffusion into dialysate most common (40%), typically 3x4hrs per week
104
Give 3 examples of waste products that are removed from the blood in dialysis
1. Urea
2. Creatinine
3. Potassium
4. Phosphate
105
Give 5 potential complications of haemodialysis
1. Hypotension
2. Cramps
3. Nausea
4. Chest pain
5. Fever
6. Blocked or infected dialysis catheter
106
Give 3 groups of people who haemodialysis is good for?
1. People who live alone/frail/elderly
2. People who fear operating machines
3. People who are unsuitable for peritoneal dialysis (abdominal surgery/hernia)
107
What is the access point for peritoneal dialysis?
A peritoneal catheter is placed into the peritoneal cavity through a SC tunnel
108
what is peritoneal dialysis?
peritoneal catheter inserted
Glucose solution pumped in to peritoneum for exchange of solutes across peritoneal membrane
removal of dialysis solution
Continuous or overnight typically
109
Give 4 potential complications of peritoneal dialysis
1. Infection (peritonitis/catheter exit site infection)
2. Peri-catheter leak
3. Abdominal wall herniation
4. Intestinal perforation
110
Give 3 groups of people who peritoneal dialysis is good for
1. Young people/those in full time work
2. People who want control/responsibility of their care
3. People with severe HF
111
Where in the abdomen does a transplanted kidney lie?
In the iliac fossa
112
What has to be assessed for a renal transplant to occur?
Virology status = CMV, hepatitis, EBV
CVD
TB
ABO and HLA haplotype
113
What tests can be done to evaluate kidney function in a potential kidney donor?
1. Serum creatinine
2. Creatinine clearance
3. Urinalysis
4. Urine culture
5. GFR
114
Give 3 contraindications for renal transplant
1. ABO incompatibility
2. Active infection
3. Recent malignancy
4. Morbid obesity
5. Age >70
6. AIDS
115
What are the 2 main causes of death after a kidney transplant?
1. CV disease
| 2. Infection
116
Name 4 potential complications of a kidney transplant
1. Thrombosis
2. Obstruction
3. Infections - URTI, chest
4. Rejection (12% in 1st year)
117
Why do advanced CKD patients need regular fluid assessment?
They may be oliguric or anuric
118
Name a loop diuretic
Furosemide - acts on NKCC2 transporter
119
Give 3 potential side effect of furosemide
1. Hypokalaemia
2. Hypotension
3. Dehydration
120
What other drug might you prescribe with furosemide in someone with poorly controlled potassium?
A potassium sparing diuretic e.g. spironolactone
| Work on RAAS not ion channels so help control potassium levels in the blood
121
On which part of the nephron do thiazides act?
The distal tubule Act on NCC channels
122
On which part of the nephron do aldosterone antagonists act on?
Collecting ducts
123
Define Acute Kidney Injury (AKI)
Sudden decline in renal function determined by increased serum creatinine +/- ↓ urine output.
Results in imbalance in electrolytes and azotaemia (↑ creatinine / nitrates)
124
what are the different types of AKI?
1. Pre-renal = decreased blood flow to kidneys --> decreased GFR
2. Renal = kidney damage
3. Post-renal = Urinary tract obstruction
125
Give 5 risk factors for AKI
1. Increasing age
2. CKD
3. HF
4. DM
5. Nephrotoxic drugs - NSAIDs, ACEi
6. hypertension
126
Give 2 pre-renal causes of AKI
low blood volume (bleeding, dehydration, shock, D&V)
low effective circulating volume (cirrhosis, congestive HF)
127
Give 2 renal (intrinsic) causes of AKI
```
glomerulonephritis
acute tubular necrosis (ATN)
acute interstitial nephritis (AIN), respectively
rhabdomyolysis
tumour lysis syndrome
```
128
Give 2 post-renal causes of AKI
- kidney stone in ureter or bladder
- benign prostatic hyperplasia
- external compression of the ureter
129
How does AKI present?
1. Uraemia (high urea) = fatigue, weakness, vomiting, seizures
2. Acidosis
3. Arrhythmias
4. Oliguria
5. Oedema
6. high creatinine
130
What investigations might you do to determine whether someone has AKI?
1. Check potassium
2. Bloods - Creatinine, U+Es
3. Urine output and urinalysis
4. Distinguish whether pre-renal, renal or post renal using imaging (USS, microscopy)
131
What is the affect of AKI on creatinine and urine output?
Creatinine = raised
| Urine output = reduced
132
What is the diagnostic criteria for AKI?
1/3 = diagnostic
1. Rise in CR >26 mmol/L in 48 hours
2. Rise in Cr >50% in 48 hours
3. Urine output fall to < 0.5 ml/kg/h for 6 hours
133
How do you treat AKI?
Treat underlying cause – hypotension, infection, stones, obstruction
Stop drugs – NSAIDs, ACEi, ARBs, metformin, lithium, digoxin, loop diuretics
Treat underlying complications – electrolyte imbalances (K+)
Severe = dialysis
134
What is the major complication someone with AKI might develop?
Hyperkalaemia
| Can lead to arrhythmias ECG = tall tented T waves, increase PR interval and wide QRS complex
135
How can hyperkalaemia be prevented in someone with AKI?
Give calcium gluconate to protect myocardium
| Give insulin and dextrose (insulins drives K+ into cells and dextrose is to rebalance the blood sugar)
136
Define urinary tract infection
Inflammatory response of the urothelium to bacterial invasion, usually associated with bacteriuria and pyuria
137
What determines if a UTI is complicated or uncomplicated?
A UTI is deemed complicated if it affects:
- Someone with an abnormal urinary tract
- A man
- Pregnant lady
- Children
- Immunocompromised
- If it is recurrent
138
Describe the pathophysiology of UTI's
Organisms colonise the urethral meatus --> bacterial sent --> bacteriuria
139
Name 3 UTI causative organisms
The 5 most common pathogens can remembered with KEEPS:
- Klebsiella
- E coli- most common causing >50% of cases
- Enterococci
- Proteus
- Staphylococcus coagulase negative
140
Describe the epidemiology of UTI's
More common in women due to short urethra and its proximity to the anus
141
Give 4 risk factors of UTI's
1. Catheter
2. Female
3. Prostatic hypertrophy (obstructs)
4. Low urine volume
5. Urinary tract stones
6. Pregnancy
142
Give 3 bacterial virulence factors that aid their ability to cause UTI's
1. Fimbriae/pili that adhere to urothelium
2. Acid polysaccharide coat resists phagocytes
3. Toxins (e.g. UPEC releases cytotoxins)
4. Enzyme production (e.g. urease)
143
What type of pili would you associate with lower UTI?
Type 1
| Bind to uroplakin
144
What type of pili would you associate with upper UTI?
Type P
| Bind to glycolipids on urothelium
145
The vagina is heavily colonised with lactobacilli, what is the function of this?
Helps maintain a low pH = host defence mechanism
146
Give 2 reasons why a post-menopausal women is more susceptible to a UTI
1. pH rises --> increased colonisation by colonic flora
| 2. Reduced mucus secretion
147
Give 3 host defence mechanisms against UTIs
1. Antegrade flushing of urine
2. Tamm-horsfall protein
3. GAG layer
4. Low urine pH
5. Commensal flora
6. Urinary IgA
148
Define pyuria
Presence of pus in urine
149
Name 3 lower urinary tract infections
1. Cystitis
2. Prostatitis
3. Urethritis
150
Name a upper urinary tract infection
Pyelonephritis
151
what are the classic UTI symptoms
```
FUNDS:
frequency,
urgency,
nocturia,
dysuria
```
Haematuria
Abdominal pain
Malaise
Confusion (old patients)
152
What investigations might you do in someone who you suspect has a UTI?
1. Take a good history
2. Urinalysis --> haematuria, proteinuria, increased WCC, pH, nitrates, ketones
3. Microscopy, culture and sensitivity of MSU
4. In recurrent/complicated UTI = imaging (bladder scan, USS, XR)
153
What is the first line treatment for an uncomplicated UTI?
Trimethoprim or nitrofurantoin for 3 days
| Increase fluid intake and regular voiding
154
How does trimethoprim work?
It affects folic acid metabolism
155
Describe the management for a complicated UTI
Culture sample --> Abx for 7 days
156
Define recurrent UTI
>2 episodes in 6 months or >3 in 12 months
157
Describe the management for someone who is having recurrent UTIs
1. Increase fluid intake
2. Regular voiding
3. Void pre and post intercourse
4. Abx prophylaxis
5. Vaginal oestrogen replacement
158
What is cystitis?
Inflammation of the bladder secondary to infection
159
what are the risk factors for cystitis?
1. Urinary obstruction
2. Previous damage to bladder epithelium
3. Poor bladder emptying
4. bladder stones
160
what are the symptoms of cystitis?
1. Dysuria
2. Frequency and urgency
3. Suprapubic pain
4. Offensive smelling/cloudy urine
5. Haematuria
161
What is the treatment for cystitis?
1st line = Trimethoprim or nitrofurantoin (avoid trimethoprim in pregnancy -> teratogenic)
2nd line = ciprofloxacin or Co-amoxiclav
162
what are the causes of prostatitis?
acute:
- streptococcus faecalis
- e.coli
- chlamydia
chronic:
- bacterial (as above)
- non-bacterial - elevated prostatic pressure, pelvic floor myalgia
163
Give 4 symptoms of acute prostatitis
1. Fever
2. Rigors
3. Malaise
4. Voiding LUTS
5. Pelvic --> anal pain
6. pain on ejaculation
very tender prostate
164
Give 3 symptoms of chronic prostatitis
1. Recurrent UTI's
2. Pelvic --> anal pain
3. acute symptoms
Symptoms for > 3 months
165
What investigations might you do in someone with prostatitis?
1. Urinalysis and MSU = blood, WBC and bacteria
2. DRE = boggy, tender and hot to touch
3. STI screen
4. Microbiology = uropathogens in urine
5. Imaging - TRUSS +/- CT abdo/pelvis
166
How would you treat prostatitis?
Quinolone (ciprofloxacin) or trimethoprim (if unable to take quinolones) for 4-6 weeks
Treat pain = paracetamol/ibuprofen
167
what are the causes of urethritis?
- N. gonorrhoea
- chlamydia
- trauma
- urethral stricture
- irritation
- urinary calculi
168
what are the symptoms of urethritis?
- skin lesion
- dysuria +/- discharge (blood/pus)
- urethral pain
- penile discomfort/Pruritis
169
what is the treatment for urethritis?
STI treatment = Abx - ceftriaxone and doxycycline
| partner notification
170
Define pyelonephritis
Infection of the renal pelvis and upper ureter, most commonly acquired by ascending transurethral spread, but can be via blood or lymphatics
171
What can cause pyelonephritis?
- majority caused by UPEC (uropathogenic E.coli)
- main organisms = KEEPS
- Klebsiella
- E.coli - majority
- Enterococcus
- Proteus
- Staphylococcus
172
Give 3 symptoms of pyelonephritis
triad of:
- loin pain (back pain)
- fever
- pyuria
may also have:
- severe headache
- rigors
- nausea and vomiting
173
What investigations might you do in someone with pyelonephritis?
1. urine dipstick (1st line)
2. mid-stream urine MC+S (gold standard)
3. urgent USS to detect stones, obstruction or incomplete bladder emptying
174
Describe the treatment for pyelonephritis
Antibiotics: cefalexin for 7-10 days. Trimethoprim or amoxicillin if sensitive.
Analgesia- paracetamol
175
What can a prolonged pyelonephritis infection cause?
Renal abscess
Treatment = drainage
176
what is the management for urinary tract stones?
- Strong analgesia- diclofenac
- Antibiotics
- Tamsulosin/nifedipine- relaxes smooth muscle and helps expulsion
- Percutaneous nephrolithotomy- used to expulse stones over 10mm
177
what are the risk factors for urinary tract stones?
- chronic dehydration
- obesity
- high protein/salt diet
- recurrent UTIs
- hyperparathyroidism (hypercalcaemia)
- congenital abnormalities
178
what are the signs for treatment of urinary tract stones?
- intolerable pain/vomiting
- signs of obstruction/infection
- AKI (and hyperkalaemia)
179
what is the pathophysiology of pre-renal AKI?
- low blood volume or low effective circulating volume causes decreased perfusion
- this decreases GFR and creatine clearance which activates RAAS- this increases Na+, urea and BP
180
what is the pathophysiology of post-renal AKI?
obstruction
- stones, prostate enlargement or infection causes back pressure into tubules
- this decreases hydrostatic pressure which decreases GFR`
181
what is the pathophysiology of intra-renal AKI?
- glomerular - glomerulonephritis
o this causes barrier damage and protein leakage
o this decreases oncotic pressure which decreases GFR- tubular
- necrosis
o complex blood supply causes cells to infarct, break away and plug tubules
o this decreases hydrostatic pressure and decreases GFR
- vascular - vasculitis
o damaged vasculature decreases O2 which causes necrosis
- interstitial - acute interstitial nephritis
o inflammation and immune cells cause damage
182
what are the risk factors for prostate cancer?
- family history
- increasing age
- black
- genetic
- HOXB13, BRCA2
183
what is the epidemiology of prostate cancer?
- commonest male malignancy
- 7% of all cancer
- by age of 80, 80% have malignant prostatic change
- in most cases malignant foci remain dormant
184
what is the epidemiology of testicular cancer?
● Most common cancer in young men
● More than 96% arise from germ cells
● 10% occur in undescended testes
● Main types are seminomas and teratomas
185
what is the epidemiology of benign prostate hyperplasia (BPH)?
- common
- affects 24% of men 40-60 and 40% of over 60
- afro-Caribbean men affected more
186
what is the pathophysiology of varicocele?
● Abnormal dilation of the testicular veins in the pampiniform venomous plexus caused by venous reflux
● Increased reflux from compression of the renal vein
● Lack of effective valves between testicular and renal veins
187
what is the clinical presentation of varicocele?
● 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
188
what are the investigations for varicocele?
● Venography
| ● Colour doppler ultrasound to see blood flow
189
what is the management for varicocele?
● Surgery if there is pain, infertility or testicular atrophy
190
what is the epidemiology of varicocele?
● Left side more commonly affected
● Unusual in boys under 10
● Incidence increases after puberty
● Associated with sub fertility
191
what are the causes of testicular torsion?
Underlying congenital malformation
- belt-clapper deformity - where the testis is not fixed to the scrotum completely, allowing for free movement leading to twisting
192
what is the epidemiology of testicular torsion?
- common urological emergency in adolescent boys
- most common 11-30yrs
- left side is more commonly affected
193
what is the clinical presentation of testicular torsion?
- sudden onset pain in one testis (walking uncomfortable)
- pain often starts during sport
- pain in abdomen
- nausea and vomiting
- inflammation of one testis - very tender, hot and swollen
194
what are the investigations for testicular torsion?
- doppler ultrasound - lack of blood flow to testis
- urinalysis - exclude infection and epididymis
- prehn's sign = negative (raising scrotum exacerbates pain)
- DO NOT DELAY SURGICAL EXPLORATION
195
what is the treatment for testicular torsion?
- surgery
- expose and untwist testis (6 hour window to save testis)
- orchidectomy (removal of testis) and bilateral fixation
196
what are the investigations for cystitis?
- dipstick urinalysis = positive leucocytes, blood and nitrites
- microscopy and sensitivity of mid-stream urine = GOLD STANDARD
197
what are the risk factors for pyelonephritis?
- renal structural abnormalities
- calculi (stones)
- catheterisation
- pregnancy
- diabetes
- immunocompromised
198
what is the pathophysiology of pyelonephritis?
- infection mostly due to bacteria from patients bowel flora
| - most common via ascending transurethral route but can be blood stream or lymphatics
199
what is the epidemiology of pyelonephritis?
- predominantly females under 35
| - unusual in men
200
what is prostatitis?
infection and inflammation of the prostate gland
| can be acute or chronic
201
what are the risk factors for prostatitis?
```
STI
UTI
indwelling catheter
post-biopsy
increasing age
```
202
what is simple hydrocele?
- overproduction of fluid in the tunica vaginalis
203
what is communicating hydrocele?
processus vaginalis fails to close, allowing peritoneal fluid to communicate with the scrotal portion
204
what is the clinical presentation of hydrocele?
- non-tender, smooth cystic swelling
- no pain unless infected
- transluminates
205
what are the investigations for hydrocele?
- USS
| - serum alpha-fetoprotein and hCG to exclude malignant teratomas and germ cell tumours
206
what is the treatment for hydrocele?
- most resolve spontaneously
| - therapeutic aspiration or surgical removal
207
what is the epidemiology of epididymal cyst?
- usually develop around 40yrs
- rare in children
- not uncommon
208
what is the pathophysiology of epididymal cyst?
contain clear and milky fluid - spermatocele
| - lie above and behind the testis
209
what is the clinical presentation of epididymal cyst?
- lump
- may be multiple/bilateral (may be painful)
- transluminate
- testis is palpable separately from cyst
210
what are the investigations for epididymal cyst?
USS
211
what is the treatment for epididymal cyst?
- usually not necessary
| - if painful/symptomatic then surgical excision
212
what is the pathophysiology of post strep nephritic syndrome?
- most common = strep pyogenes (lancefield group A beta haemolytic)
- classically occurs 2 weeks after tonsillitis
- This is nephritic syndrome following an infection, 3-6 weeks prior. This is due to deposition of strep antigens in the glomeruli leading to inflammation and damage.
213
what is the treatment for nephritic syndrome caused by post strep infection?
antibiotics - penicillins
| supportive therapy
214
what are the clinical features of nephritic syndrome that is specific to SLE?
- rash
- arthralgia
- kidney failure
- neurological symptoms
- pericarditis
- pneumonitis
215
what are the investigations for nephritic syndrome that is specific to SLE?
ANA positive
DsDNA positive
low complement C3 and C4
216
what is the treatment for nephritic syndrome caused by SLE?
- immunosuppression
- steroids
- cyclophosphamide
- rituximab
217
what is a complicated UTI?
- infection in patients with abnormal urinary tract
- pregnant women
- most UTIs in men
- treatment is more likely to fail and complications are more likely
218
what is an uncomplicated UTI?
UTI in a healthy non-pregnant women with normally functioning urinary tract
219
what is urethritis?
urethral inflammation due to infectious or non-infectious cause
non-gonococcal > gonococcal
220
what are the investigations for urethritis?
- STI testing
- microscopy and culture of urethral discharge
- urine dipstick
- urethral smear
- ?flexible cystoscopy
221
what is the clinical presentation of nephrotic syndrome?
- Normal-mild increase in BP
- Proteinuria > 3.5g/day
- Normal-mild decrease in GFR
- Hypoalbuminaemia
- Pitting oedema of ankles, abdominal wall and sometimes face(periorbital)
- Frothy urine
222
what are the causes membranous nephropathy?
- idiopathic
- drugs
- penicillamine, gold, NSAIDs
- autoimmune
- SLE, thyroiditis
- infection, hep B or C, schistosomiasis
- cancer
- lung, colon. stomach, breast
223
what are the causes of focal segmental glomerulosclerosis?
- idiopathic
secondary
- HIV
- sickle cell anaemia
- heroin
- interferon treatment
224
what are the investigations for focal segmental glomerulosclerosis?
needle biopsy = focal sclerosis and GBM thickening
225
what is the pathophysiology of focal segmental glomerulosclerosis?
- Scarring that is focal and only some glomeruli involved and segmental (only part of glomerulus affected)
- CD80 in podocytes resulting in increased permeability in glomeruli and thus proteinuria and haematuria
- Secondary hypertension and renal impairment
226
what is the treatment for nephrotic syndrome caused by focal segmental glomerulosclerosis?
Give steroids in idiopathic disease
| All patients should receive ACE-I/ARB blood pressure control
227
which is the most common cause of nephrotic syndrome in children?
minimal change disease
228
what are the risk factors/causes of minimal change disease in nephrotic syndrome?
- can be idiopathic
- atopy - allergic reaction can trigger
- drugs - NSAIDs, lithium, antibiotics, bisphosphonates, sulfasalazine
- hep C, HIV, TB
- associated with hodgkins lymphoma
229
what is the clinical presentation of minimal change disease?
- Proteinuria
- Oedema, predominantly around the face
- Fatigue
- Frothy urine
230
what is the most common cause of nephrotic syndrome in adults?
focal segmental glomerulosclerosis
231
what is the epidemiology of autosomal dominant polycystic kidney disease?
- most common inherited kidney disease
- autosomal dominant inheritance with high penetrance
- male > female
232
if 1 parent is affected by autosomal dominant polycystic kidney disease what is the chance of transmission?
50% chance
233
if both parents are affects by autosomal dominant polycystic kidney disease, what is the chance of transmission to offspring?
50% chance of being affected
25% = normal
25% = homozygous for disease (die in the womb)
234
what are the causes of autosomal dominant polycystic kidney disease?
- mutations in PKD1 gene on chromosome 16 = 85%
| - mutations in PKD2 gene on chromosome 4
235
what are the risk factor for autosomal dominant polycystic kidney disease?
- family history of ADPKD- ESRF
| - hypertension
236
what is the pathophysiology of autosomal dominant polycystic kidney disease?
Cysts develop and grow over time in the tubular portion of the nephron
Compression of renal architecture and vasculature
Progressive impairment - gets bigger and worse with age
237
what is the clinical presentation of autosomal dominant polycystic kidney disease?
- hypertension
- abdo/flank pain (haemorrhage)
- LUTS (dysuria, urgency, pain)
- palpable
238
what are the investigations for autosomal dominant polycystic kidney disease?
Renal USS then renal biopsy for genes
<30yrs – at least 2 unilateral or bilateral cysts
30-59yrs – 2 cysts in each kidney
>60yrs – 4 cysts in each kidney
239
what is the treatment for autosomal dominant polycystic kidney disease?
- Treat hypertension – lifestyle, ACEi (ramipril)
- Infected – Abx or drain
- Surgical – removal (nephrectomy)
- Chronic – dialysis or transplant
240
what are the complications of polycystic kidney disease?
berry aneurysms
cysts on other organs
50% have ventricular hypertrophy
pre-malignant
241
what is the epidemiology of autosomal recessive polycystic kidney disease?
- rarer than autosomal dominant
- autosomal recessive inheritance
- disease of infancy
242
what are the causes of autosomal recessive polycystic kidney disease?
PKHD1 mutation on long arm (q) of chromosome 6
243
what is the clinical presentation of autosomal recessive polycystic kidney disease?
- variable
- many present in infancy with multiple renal cysts and congenital hepatic fibrosis
- enlarged polycystic kidneys
- 30% develop kidney failure
244
what are the investigations for autosomal recessive polycystic kidney disease?
- Diagnosed antenatally or neonatally
- Ultrasound - to see cysts
- CT & MRI to monitor liver disease
- Genetic testing
245
what are the treatments for autosomal recessive polycystic kidney disease?
- Currently no treatment available
- Genetic counselling for family members
- Laparoscopic removal of cysts to help with pain/nephrectomy (remove entire kidney)
- Blood pressure control with ACE-inhibitor e.g. RAMIPRIL
- Treat stones and give analgesia
- Renal replacement therapy for ESRF
- Counselling and support
246
what is the specific clinical presentation of pre-renal AKI?
- hypotension (D&V, syncope, pre-syncope)
| - signs of liver or heart failure (oedema)
247
what is the specific clinical presentation of intra-renal AKI?
infection, signs of underlying disease (vasculitis, glomerulonephritis, DM)
248
what is the specific clinical presentation of post-renal AKI?
LUTS (BPH)
249
what are the complications of AKI?
end stage renal failure
metabolic acidosis
uraemia
CKD
250
how does diabetes cause CKD?
Glycation of glomerular endothelium and efferent arteriole leading to fibrosis (diabetic nephropathy)
251
how does hypertension cause CKD?
thickening of afferent arteriole leading to ischaemia. Further fluid overloading due to activation of RAAS
252
what is the treatment for urinary tract stones?
- strong analgesic (IV diclofenac)
- antibiotics if infection (IV cefuroxime or IV gentomycin)
- antiemetics
- stone removal
253
what is stage 1 CKD?
eGFR > 90ml/min
254
what is stage 2 CKD?
eGFR 60-89ml/min
255
what is stage 3a CKD?
eGFR 45-59ml/min
256
what is stage 4 CKD?
eGFR 29-15ml/min
257
what is stage 5 CKD?
eGFR < 15ml/min
258
which drugs are classed as nephrotoxic?
- NSAIDs
- aminoglycosides
- ACEi
- ARB
- loop diuretics
- metformin
- digoxin
- lithium
259
what is the clinical presentation of epididymitis?
acute pain
unilateral
? previous infection
260
how can you tell the difference between epididymitis and testicular torsion?
prehn's sign - lift scrotum
- epididymitis = positive (relieves pain)
- testicular torsion = negative (exacerbates pain)
261
what is the management for epididymitis?
- IM ceftriaxone (if organism is unknown) + doxycycline
262
how does IgA nephropathy present?
Presents asymptomatically with microscopic haematuria
263
what are the investigations for IgA nephropathy?
diagnosed via biopsy
264
what is the most common cause of nephritic syndrome in high income countries?
IgA nephropathy
265
what is goodpastures disease?
Caused by autoantibodies to Type IV collagen in glomerular and alveolar membrane
266
what is the clinical presentation of goodpastures disease?
Presents with SOB and oliguria due to respiratory and renal damage
267
what are the investigations for goodpasture's disease?
Diagnose with anti-GBM antibodies in bloods and biopsy
268
what is the management for goodpasture's disease?
plasma exchange
steroids
cyclophosphamide (for immune suppression)
269
what is the most common cause of post strep glomerulonephritis?
- most common = strep pyogenes (lancefield group A beta haemolytic)
270
what is the clinical presentation of post strep glomerulonephritis?
Presents with haematuria. Can present with acute nephritis
271
what are the investigations for post strep glomerulonephritis?
Diagnosed by evidence of strep infection
272
what is the management for post strep glomerulonephritis?
Treated with antibiotics to clear the strep, and supportive care.
273
what are the secondary causes of nephrotic syndrome?
```
DDANI
diabetes
drugs
autoimmune
neoplasia
infection
```
274
what is the difference between nephritic syndrome vs nephrotic syndrome?
NEPHRITIC
- proteinuria +
- hypertension
- haematuria
- very reduced GFR
- oedema +
NEPHROTIC
- proteinuria ++++++
- hypoalbuminaemia
- oedema ++++
- slightly reduced/normal GFR
- hyperlipidaemia
275
where does bladder cancer spread to?
spreads to the iliac and para-aortic nodes, and to the liver and lungs
276
what are the causes/risk factors of bladder cancer?
- Smoking = increases risk 2-4 times, accounts for half of male cases of bladder cancer
- Age over 55
- Pelvic radiation
- Exposure to occupational carcinogens
- Bladder stone- due to chronic inflammation
277
what is the presentation of bladder cancer?
- Painless haematuria- this is the most common presenting symptom for bladder cancer, assume pt has urothelial tumour till proven otherwise
- Ask about RF in history
- UTI symptoms without bacteriuria
278
what are the investigations for bladder cancer?
Urinalysis- sterile pyuria
Cystoscopy and biopsy- diagnostic
CTT urogram- allows staging
279
what is the management for bladder cancer?
T1: transurethral resection or local diathermy
T2-3: radical cystectomy
T4: palliative chemotherapy and radiotherapy
280
what is the most common bacterial STI?
chlamydia
281
what is the bacteria that causes chlamydia?
chlamydia trachomatis
282
what is urolithiasis?
presence of stones in urinary tract
283
what is the equation for net filtration pressure for the glomerulus?
NFP = GHP - (GCOP + CHP)
```
NFP = net filtration pressure
GHP = glomerular hydrostatic pressure
GCOP = glomerular colloid oncotic pressure
CHP = capsular hydrostatic pressure
```
284
what is the gold standard for measuring GFR?
inulin
285
which part of the loop of henle is permeable to water?
descending limb
286
what is the innervation of the external urinary sphincter?
pudendal nerve S2-S4
287
what is the innervation of internal urinary sphincter?
pelvic splanchnic nerve S2-S4
288
what is the innervation of the bladder?
```
sympathetic = sympathetic chain T11-L2
parasympathetic = pelvic splanchnic S2-S4
```
289
what is the role of intercalated cells of the collecting duct?
Intercalated cells are responsible for acid/base balance
Alpha = acid
Beta = basic
290
what cells line the collecting duct?
principal cells and intercalated cells
291
what is the physiology of micturation?
Pontine micturition centre promotes micturition by activating parasympathetic and deactivating sympathetic and somatic motor activity
Detrusor muscle contracts and sphincters open
292
what is stage 3b CKD?
eGFR 30-44ml/min
