Immediate management is supportive - Treat hypovolaemia & correct electrolyte imbalances STOP AKI Sepsis Toxins Optimise volume status & BP Prevent harm - identify & treat causes & complications

GU Flashcards by Chloe D

2 differentials for renal cell carcinoma & how to differentiate between them?

Ureteric cancer

Gross haematuria more common
Ureteroscopy: ureteric mass

Bladder cancer

Gross haematuria more common
Dysuria
Urine cytology: positive in most patients

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What is another term for transitional cell carcinoma?

Urothelial carcinoma

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Most common cancer in the urinary bladder?

Urothelial carcinoma/transitional cell carcinoma

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1 differential to prostate cancer & how to differentiate between them?

Benign prostatic hyperplasia - prostate will feel rubbery with no palpable nodules. Prostate biopsy is the best test to distinguish between them.

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Typical presentation of testicular cancer

A hard, painless nodule on one testis noticed by the pt or at a regular clinic exam.

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Management of testicular cancer

Radical inguinal orchidectomy

75% curative

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What tests do you do in patients you suspect have CKD

Renal chemistry - Na, K, Cl, bicarbonate, urea, creatinine, glucose.

Result: elevated serum creatinine; electrolyte abnormalities

Estimation of GFR - <60mL/minute/1.73m²

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Define nephrolithiasis

Presence of crystalline stones (calculi) within the urinary system (kidneys & ureter)

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Key diagnostic feature of nephrolithiasis

Acute, severe flank pain

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3 differentials to nephrolithiasis & how to distinguish between them

Acute appendicitis - urinalysis is negative & NCCT shows no renal stones & dilation of appendix

Ectopic pregnancy - urine pregnancy test +ve. USS shows mass in fallopian tubes

Ovarian cyst - palpable mass on exam. USS shows free fluid in peritoneum. NCCT shows absence of renal stones

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Define acute kidney injury (AKI)

Acute kidney injury (AKI), previously known as acute renal failure (ARF), is an acute decline in kidney function, leading to a rise in serum creatinine and/or a fall in urine output.

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Key diagnostic factors for AKI

Hypotension

Risk factors

Kidney insults, eg sepsis, recent surgery

Reduced urine production

LUTS

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4 risk factors for AKI

Advanced age

Underlying kidney disease

Diabetes mellitus

Sepsis

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Management of AKI

Immediate management is supportive

Treat hypovolaemia & correct electrolyte imbalances

STOP AKI

Sepsis
Toxins
Optimise volume status & BP
Prevent harm - identify & treat causes & complications

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A 65-year-old male smoker with diabetes mellitus, hypertension, dyslipidaemia, and chronic kidney disease presents with chest pain. ECG changes suggest an acute myocardial infarction. He is taken for an urgent coronary angiogram. Three days later, he is noticed to have developed an elevated serum creatinine, oliguria, and hyperkalaemia.

What diagnosis do you suspect?

What investigations will you do?

AKI

Look for signs of sepsis & manage promptly

Establish the cause

Bloods
Urinalysis
Renal tract USS to find cause

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A 60-year-old man presents to his primary care physician with a 3-month history of increasing urinary frequency without burning and nocturia 3 times each evening. He has limited his fluid consumption and caffeine intake in the evening without much benefit. There is no personal or family history of prostate cancer. Examination demonstrates no suprapubic mass or tenderness. A rectal examination demonstrates normal rectal tone and a moderately enlarged prostate without nodules or tenderness.

What diagnosis do you suspect?

BPH

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A 60-year-old black man presents to his general practitioner with complaints of difficulty with urination. He describes a weak stream and a sense of incomplete voiding. He describes nocturia (5 episodes per night) and has been taking an alpha-blocker for this with minimal improvement. He says he can last about 60 to 90 minutes without urinating. He denies any suprapubic tenderness, dysuria, or haematuria. He further denies any back pain or gastrointestinal complaints. Rectal examination reveals his prostate to be approximately 60 mL, asymmetrical, with a large 2-cm nodule at the right base.

What investigation would you order?

What do you suspect?

Prostate cancer

Serum prostate-specific antigen (PSA) - likely to be raised

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A 35-year-old man presents with non-specific testicular discomfort and the feeling of a mass in the testis. On examination, a 2 cm by 1 cm smooth, painless mass is palpated in the right testis. The mass does not transilluminate with light. There is no lymphadenopathy.

What diagnosis do you suspect & how can you test for it?

Testicular cancer

Ultrasound with colour Doppler of testis is almost 100% sensitive

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A 45-year-old man presents to the emergency department with a 1-hour history of sudden onset of left-sided flank pain radiating down towards his groin. The patient is writhing in pain, which is unrelieved by position. He is nauseous and has been vomiting.

What tests would you run?

What diagnosis do you suspect?

Nephrolithiasis

Urinalysis

FBC

Serum chemistry

Pregnancy test (in women of childbearing age)

Urgent non-contrast computed tomography (NCCT) scan for non-pregnant adults

Urgent USS for under 16

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A 54-year-old man with a 10-year history of diabetes and hypertension, with complications of diabetic retinopathy and peripheral neuropathy, presents to his primary care physician with complaints of fatigue and weight gain of 4.5 kg over the past 3 months. He denies any changes in his diet or glycaemic control but does state that he has some intermittent nausea and anorexia. He states that he has noticed that his legs are more swollen at the end of the day but improve with elevation and rest. Physical examination reveals an obese man with a sitting blood pressure of 158/92 mmHg. The only pertinent physical examination findings are cotton wool patches and micro-aneurysms bilaterally on fundoscopic examination and pitting, bilateral lower-extremity oedema.

What diagnosis do you suspect?

Chronic kidney disease.

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A 64-year-old man presents with painless haematuria. He had a similar episode 1 year ago and was given antibiotics for a presumed urinary infection and his bleeding resolved. He has a decreased urinary stream and nocturia twice a night. He has smoked a pack of cigarettes daily for 45 years. Physical examination shows only moderate enlargement of the prostate. Urinalysis is positive for 10 to 15 red blood cells and 5 to 10 white blood cells per high-power field with no bacteria detected.

What do you suspect & what investigation would you order?

Bladder cancer/transitional cell carcinoma.

Urine analysis

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A thin 65-year-old man with no significant past medical history presents with a 5-month history of right-sided flank discomfort and abdominal fullness. He finally seeks medical attention because of 2 weeks of lower extremity oedema, and 4 days of gross haematuria with clots. On examination, his blood pressure is 160/90 mmHg, heart rate is 120 bpm and regular, and he is afebrile. He is found to have a palpable right-sided lower abdominal mass, and pitting oedema to the mid-shins bilaterally, which is worse on the right.

What do you suspect & what tests will you do?

Renal cell carcinoma (RCC)

FBC
Abdo/pelvic ultrasound

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Define pyelonephritis

A severe infectious inflammatory disease of the renal parenchyma, calices and pelvis that can be acute, recurrent or chronic

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Aetiology of acute pyelonephritis

Gram-negative bacteria, eg E.coli

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Give 3 risk factors for pyelonephritis

* UTI * DM * Stress incontinence * Foreign body in urinary tract, eg calculus, catheter * Immunosuppression * Pregnancy * Frequent sexual intercourse

Key symptoms of acute pyelonephritis

Flank pain New or different myalgia Fever Nausea Vomiting Typically develop rapidly within hours or a day.

1st line investigations to order when you suspect pyelonephritis

Urinalysis Urine culture & sensitivity FBC ESR & CRP U+Es Creatinine Blood culture (in hospital)

1 differential to acute pyelonephritis & how to distinguish between them

Lower UTI - Does not display systemic signs or symptoms (fevers, chills, nausea, vomiting and back pain) - Urine culture & urinalysis

Treatment of uncomplicated acute pyelonephritis

Oral antibiotics

Treatment of complicated acute pyelonephritis

Admit to hospital for treatment with IV antibiotics & supportive care

Define chronic pyelonephritis

Chronic pyelonephritis is a complex renal disorder characterised by chronic tubulointerstitial inflammation & deep segmental cortical renal scarring and clubbing of the pelvic calyces as the papillae retract into the scars.

Aetiology of chronic pyelonephritis

- Inadequate treatment or recurrence of acute pyelonephritis - Anatomical abnormalities, eg vesicoureteral reflux and obstruction

Significance of costovertebral angle tenderness

A pain that results from touching the region inside the costovertebral angle Indicates kidney pathology

A 55-year-old man presents with a long history of uncontrolled hypertension, increased urinary albumin excretion, and benign prostatic hypertrophy. He reports a past history of bladder infections and surgery on the bladder as an infant. For the past 1 to 2 weeks he has been feeling unwell, and he noted some blood in his urine last night. On physical examination the physician notes the patient is obese, in mild distress, with blood pressure 150/90 mmHg, regular pulse 84 beats per minute, and temperature 37°C (98.6°F). The patient has no costovertebral angle tenderness. What investigations would you order?

Urinalysis Renal function Urine culture FBC Renal USS CT abdo

Define acute cystitis

An infection of the urinary bladder

Risk factors for acute cystitis

Frequent sexual intercourse History of UTIs Congenital abnormality Urinary catheter

Most common aetiological organism for acute cystitis

E.coli

A 26-year-old female newlywed presents complaining of painful urination, feeling of urgent need to urinate, and more frequent urination for 2 days. She denies any fever, chills, nausea, vomiting, back pain, vaginal discharge, or vaginal pruritus. What diagnoses do you suspect & what tests will you do?

UTI causing acute cystitis - Urinalysis - Urine microscopy - Urine culture with sensitivity

Treatment for cystitis

Antibiotics

Define acute prostatitis

A painful inflammation within the prostate Usually accompanied by the evidence of recent or ongoing infection

Risk factors for acute prostatitis

UTI BPE Urinary tract instrumentation/manipulation, eg prostate biopsy, catheterisation

1st line investigations to order when you suspect acute prostatitis

- Urinalysis - Urine culture - Culture of prostatic secretions - Blood cultures - Serum prostate-specific antigen (PSA)

Classical presentation of urethritis

Acute urethral discharge following unprotected sex.

Define urethritis

Urethritis is usually a sexually transmitted disease that typically presents with dysuria, urethral discharge, and/or pruritus at the end of the urethra.

Confirming diagnosis of urethritis

Urinalysis is positive for leukocyte esterase Gram stain of the discharge (≥2 white blood cells per oil immersion field) OR Sediment of the first-voided urine (≥10 white blood cells per high power field) reveals abnormal numbers of polymorphonuclear leukocytes

Key difference between nephritic and nephrotic syndrome?

The key with nephr**_o_**tic syndrome is an excess amount of _protein_ in the urine Nephr**_i_**tic syndrome is where there is an excess amount of _blood_ in the urine.

Commonest cause of nephritic syndrome in the developed world?

IgA nephropathy

Treatment of IgA nephropathy

BP control - ACEi/ARBs

Describe Goodpasture's disease

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

Treatment of Goodpasture's disease

Remove antibody via plasma exchange Immunosuppression Steroids/cyclophosphamide

Describe Goodpasture's disease as if you were talking to a patient

In Goodpasture's Syndrome the body makes antibodies that attack and damage the lining of your lungs and kidney. As a result, if you have this disease, you may start to experience fatigue, weakness and loss of appetite. However, the disease may quickly progress and you may bleed from the lungs and cough up blood. It may also lead to inflamed kidneys (glomerulonephritis).

Define glomerulonephritis

Denotes glomerular injury Applies to a group of disease that are generally characterised by inflammatory changes in the glomerular capillaries and the glomerular basement membrane.

Is glomerulonephritis an example of a nephritic or nephrotic syndrome?

Nephritic

Most common cause of nephrotic syndrome in younger children?

Minimal change disease

Define Minimal Change Disease

A type of nephrotic syndrome. There is damage to the glomeruli which cannot be seen under a regular microscope.

Aetiology of MCD

Primary - idiopathic Secondary - Allergic reaction, NSAIDs, tumours, infections caused by a virus

Peripheral nerve in charge of detrusor relaxation.

Hypogastric

Origin of the hypogastric nerve

T10 - L2

Is the effect of the hypogastric nerve on the detrusor muscle sympathetic or parasympathetic?

Sympathetic - detrusor relaxation

Peripheral nerve which causes detrusor contraction

Pelvic nerve

Origin of pelvic nerve

S2-4

Is the effect of the pelvic nerve on the detrusor muscle (contraction) sympathetic or parasympathetic?

Parasympathetic

Peripheral nerve responsible for external sphincter contraction?

Pudendal

Origin of pudendal nerve?

S2-4