GU Flashcards
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
What is another term for transitional cell carcinoma?
Urothelial carcinoma
Most common cancer in the urinary bladder?
Urothelial carcinoma/transitional cell carcinoma
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.
Typical presentation of testicular cancer
A hard, painless nodule on one testis noticed by the pt or at a regular clinic exam.
Management of testicular cancer
Radical inguinal orchidectomy
75% curative
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
Define nephrolithiasis
Presence of crystalline stones (calculi) within the urinary system (kidneys & ureter)
Key diagnostic feature of nephrolithiasis
Acute, severe flank pain
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
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.
Key diagnostic factors for AKI
Hypotension
Risk factors
Kidney insults, eg sepsis, recent surgery
Reduced urine production
LUTS
4 risk factors for AKI
Advanced age
Underlying kidney disease
Diabetes mellitus
Sepsis
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
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
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
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
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
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
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.
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
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
Define pyelonephritis
A severe infectious inflammatory disease of the renal parenchyma, calices and pelvis that can be acute, recurrent or chronic
Aetiology of acute pyelonephritis
Gram-negative bacteria, eg E.coli
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 nephrotic syndrome is an excess amount of protein in the urine
Nephritic 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
