GU Flashcards
Female
Increased urinary frequency, urgency, and dysuria . Suprapubic pain, temperature. No vaginal discharge.
Most likely diagnosis and first line management?
(2)
Uncomplicated UTI
3 day course of Nitrofurantoin (1st line for women with three or more symptoms of cystitis and no vaginal discharge)
Pt w/ autosomal dominant polycystic kidney disease which he inherited from his mother. Partner does not have the condition.
Probability their child will inherit ADPKD?
50%
What does NCCT-KUB stand for? When is it indicated?
Non-contrast computerised tomography of the kidneys, ureter and bladder.
Indicated when suspect stones! Helps differentiate from other abdo causes eg AAA
Describe the Gleason groups
1 = well formed and uniform glands
2 = predominantly well formed glands
3 = predominantly portly formed glands
4 = poorly formed glands
5 = necrosis
What antibiotic is most appropriate for treating chlamydia?
Doxycycline 100mg BD for 7 days
Which of the following is not a risk factor for testicular torsion?
A. Bell Clapper Deformity
B. Larger testicle
C. Age >25years
D. Trauma or exercise
E. Cryptorchidism
C. Age >25years
Age <25 is a risk factor of testicular torsion
13yr old male. Presents with rash (palpable purpura, non-blanching), peripheral oedema, haematuria, proteinuria, recent resp infection, abdo pain.
Likely diagnosis?
Henoch-Schoenlein purpura
Pt presents: gross haematuria, foamy appearing urine and peripheral oedema. He had a BP of 142/93. Urine dipstick shows proteinuria and haematuria. Hearing problems.
Family history: Grandad had kidney problems.
Most likely diagnosis? Mutation that leads to the disease causes abnormalities in what?
Alport syndrome.
Type IV collagen
EGFR categories:
G1 = >90
G2 = 60-89
G3a = 45-59
G3b = 30-44
G4 = 15-29
G5 = <15
39F.
Frequency, urgency, nocturia.
No pain, fit and well.
Most appropriate first line treatment?
Oxybutynin
For urgency incontinence!
Pregnant pt.
Vomiting, right flank pain.
UTI symptoms, no bleeding.
Allergic to penicillin.
Diagnosis and first line medication?
Complicated UTI
Cefalexin
What is the second most common mineral composition of calculi?
Magnesium ammonium phosphate
You elicit a positive clinical sign in which there is relief of pain upon elevation of the left scrotum.
What is the name of this clinical sign?
Prehn’s sign
53F
Px: 12yrs T2DM - treated with metformin.
Presents with raised BP, proteinuria.
Kimmelstiel-Wilson lesions seen on renal biopsy.
Diagnosis and most appropriate management?
Diabetic nephropathy
BP control: ACEi or ARB, in this case answer is Ramipril.
Where does the left testicular (gonadal) vein drain into?
Left renal vein
Pt presents in kidney failure.
What is the most important drug to stop on this patient’s drug chart?
A. Paracetamol
B. Diclofenac
C. Tramadol
D. Morphinesulphate
E. Co-amoxiclav
B. Diclofenac - an NSAID… nephrotoxic!!
32F. Recently diagnosed with Conn’s. Investigation shows benign tumour in the adrenal grand. This tumour has caused an overproduction of aldosterone.
Within which specific region of the adrenal gland will the tumour lie?
Zona glomerulosa
40F, Px: diabetes, hyperthyroidism and autosomal dominant polycystic kidney disease.
CT: a large, right-sided intracerebral bleed.
Most likely cause of the bleed?
Ruptured berry aneurysm
What marker is raised in testicular cancer?
AFP (alpha feto protein)
What is the GS investigation for transitional cell carcinoma?
Cystoscopy
What kind of haemorrhage is PKD associated with?
Sub arachnoid haemorrhage
What is nephrotic syndrome?
Damage to glomerular filtration barriers
What will be found on investigation of nephrotic syndrome?
- high levels of anticoagulants
- low plasma albumin
- proteinuria
- high serum triglycerides
What are the classic features of nephrotic syndrome?
- proteinuria
- hypoalbuminea
- oedema
What are the eGFR categories for CKD? Give values
G1 = >/=90
G2 = 60-90
G3a = 30-44
G3b = 30-44
G4 = 15-29
G5 = <15
What antibody is affected in Goodpasture’s ?
Anti glomerular basement membrane
What qualifies as complicated UTI? (7)
- pregnant female
- male
- elderly
- children
- recurrent UTI
- abnormal urinary tract
- systemic disease including the kidney
What is acute pyelonephritis ?
Infection in the renal pelvis.
What symptoms are caused by acute pyelonephritis?
- fever
- rigor
- vomiting
- loin pain
- septic shock
- loss of appetite
- headache
- oliguria
- associated cystitis pain
What are the two potential antibiotics of choice to treat chlamydia? Which one is preferred?
- Doxycycline 100mg
- Azithromycin 1g
Doxycycline is preferred due to concerns about resistance to azithromycin
What are the first and second line treatment options for benign prostatic hyperplasia?
1st line = α bockers
2nd line = add 5a-reductase inhibitor to the α blocker
What is the most likely histological origin of renal cancer?
Renal cell carcinoma arising from the proximal renal tubular epithelium
What is the classic triad seen in renal cell carcinoma?
- haematuria
- loin pain
- abdominal mass
List 4 other symptoms seen in renal cell carcinoma (not those within the classic triad)
- anorexia
- weight loss
- bone pain
- malaise
- enlarged lymph nodes
- pyrexia
- bilateral ankle oedema
- varicocele
How can renal cell carcinoma cause hypertension?
RAAS activation via renin secretion raises blood pressure
What system is used to stage renal cell carcinoma?
TNM
How is renal cell carcinoma diagnosed?
CT / MRI
What is a hydrocele?
A collection of fluid within the tunica vaginalis (remnant of processus vaginalis)
What is the first line management of hydrocele?
Wait and watch. Normally corrects itself
List 3 DD for hydrocele
- partially descended teste
- inguinal hernia
- testicular torsion
How would you investigate a potential diagnosis of testicular torsion?
Clinical - no time for imaging !
- Cremasteric reflex is lost and elevation of the testis does not ease the pain
What is the treatment for testicular torsion?
Surgical!!!
Manual detorsion
What is a potential complication of testicular torsion?
Testicular infarction
Infertility
Recent childbirth, incontinence when coughing/laughing. What kind of incontinence?
Stress incontinence
What muscle is the main muscle in the bladder wall which contracts when urinating?
Detrussor muscle
What class of medication is used to treat urge incontinence?
Antimuscarinics e.g. oxybutynin
Describe the pathology behind nephrotic syndrome
glomerulus basement membrane becomes highly permeable to protein, causing loss of protein from the blood into the urine
What is the classic triad that indicated nephrotic syndrome?
- proteinuria
- hypoalbuminia (low serum albumin)
- oedema
What is the most common form of nephrotic syndrome in children?
Minimal change disease
What is the mainstay treatment for nephrotic syndrome?
High dose oral steroids e.g. Prednisolone
Name 3 causes of nephrotic syndrome
- minimal change disease
- focal segmental glomerulosclerosis
- membranous glomerulonephritis
- amyloidosis
- diabetic nephropathy
- Henoch Schonlein purpura
- infection e.g. HIV
Name 4 classes of diuretic
- Thiazide diuretic
- Loop diuretic
- K+ sparring diuretic
- Osmotic diuretic
- Carbonic anhydrase inhibitor
What is the MOA / target of thiazide diuretics?
Act on the distal convoluted tubule (DCT)
Inhibit Na+ and Cl- cotransporter
Inhibit sodium reabsorption
What is the MOA / target of loop diuretics?
Act on the ascending limb of the loop of Henle
Inhibit the Na+ / K+ / Cl- cotransporter
Reduce NaCL reabsorption
What is the MOA / target of potassium sparing diuretics ?
Aldosterone antagonists
Acts on the cortical collecting duct
Name 3 RFs for CKD
- alcohol
- obesity
- older age
- diabetes mellitus
- AKI
- smoking
- Nephrotoxic drugs
As CKD progresses kidney function begins to reduce, what hormone secretion might begin to reduce?
- vitamin D
- erythropoietin
What is the first line treatment in CKD?
ACEi e.g. ramipril
What dietary advice is offered to pts in renal failure?
- low protein
- low phosphate
- low sodium
- low potassium
7 yrs old pt, pharyngitis 2 weeks ago. Presents with a fever, nausea & vomiting, and dark urine. His BP is 160/100 mmHg. On examination, there is swelling in his face and legs.
Suspected diagnosis and 1 DD?
Diagnosis = post streptococcal glomerulonephritis
DD = Minimal change disease
Describe the pathology of post streptococcal glomerulonephritis
Immune complex deposition in the glomeruli
List 3 investigations that would be done to confirm a diagnosis of suspected post streptococcal glomerulonephritis
Blood tests - reduced eGFR
Urinalysis - haemeaturia and proteinuria
Biopsy - presence of antibodies and evidence of recent bacterial infection
What does a positive PKD 1 or 2 gene mutation indicate?
The pt is at a high risk of developing poly cystic kidney disease
Possible signs/symptoms of CKD? (5)
- pruritis
- anorexia
- nausea
- oedema
- peripheral neuropathy
70yr old pt. Presenting with: fall causing fracture to femur, severe pain from loin to groin, reduced GCS. Kidney stones on investigation
What condition is the pt presenting with?
Hypercalcaemia!
Name the 3 ways in which AKI can be classified
- pre renal
- intra renal / intrinsic
- post renal
List 3 condition that fall into pre-renal causes of AKI?
- intra renal vasoconstriction: diuretics, NSAIDs etc
- hypovolaemia due to diarrhoea, vomiting, burns, sweating, traumatic blood loss
- sepsis / shock
Give 3 examples of intra renal causes of AKI
- Glomerulonephritis
- Interstitial nephritis
- Acute tubular necrosis
Give 3 examples of post renal causes of AKI
- kidney stones
- enlarged prostate
- masses in the abdomen / pelvis
What ratio would be used to monitor renal function?
Urea:creatinine
Pt with glomerulonephritis. Under immunofluorescence, you could identify Ig A deposits within the glomerulus & mesangial cells. Which condition does this point to?
IgA nephropathy
Pt has glomerulonephritis. Blood results show ANCA positive. What condition does this point to?
Vasculitis
What medications are given to patients with ANCA positive disease?
Oral steroids and immunosuppressants e.g. Prednisolone and Methotrexate
What are the three most common areas for a renal stone to become lodged?
- Pelviureteric junction
- pelvic brim
- vesicoureteric junction
Give 4 risk factors that would make someone more susceptible to renal stone formation.
- dehydration
- infection
- hypercalcaemia
- Hyperuricaemia
- primary renal disease
…
Give 4 examples of lifestyle changes pt could make to prevent renal stones
- maintain hydration
- low calcium intake
- low salt diet
- reduced protein intake
- reduce BMI
Name 2 bacteria that you would expect to find in pyelonephritis.
KEEPS
- Klebsiella spp
- E. coli
- Enterococcus spp
-Proteus spp
- Coag negative staphylococcus spp
What type of bacteria is Neisseria Gonorrhoeae ?
Gram negative diplococci
What antibiotic would you give to treat the Neisseria gonorrhoeae?
Ceftriaxone and azithromycin
Where is the excess fluid located in hydrocele?
Tunica vaginalis
Name 3 causes of hydrocele
- patent processus vaginalis
- testis tumour
- trauma
- infection
- testicular torsion
- generalised oedema
Give 2 DD of hydrocele
- testicular torsion
- inguinal hernia
How is hydrocele diagnosed?
Scrotal ultrasound
Name 2 tests that would be done to exclude a malignant teratoma and confirm Hydrocele
- serum αlpha feto protein
- serum human chorionic gonadotropin
What is the first line test for diagnosing renal stones and what is the gold standard diagnostic test for them?
1st line = Kidney, ureter, bladder ultrasound.
Gold standard = Non-contrast computerised tomography (NCCT) of kidney, ureter, and bladder
Name 4 different stone compositions
- Calcium oxalate
- calcium phosphate
- cysteine
- uric acid
If the patients stone is less than 5mm what treatment should be given to them
Watch and wait for spontaneous passage/ give a strong analgesic (IV diclofenac)
Give 4 bits of advice to reduce risk of future stones
- Drink plenty of water
- decrease calcium in diet
- decrease salt in diet
- decrease BMI
85M difficulty passing urine. PSA is raised. Name 3 further tests that can be done
- digital rectal exam
- biopsy
- endoscopy
What is the difference between benign prostatic hyperplasia and benign prostatic enlargement?
Hyperplasia is a histological diagnosis and enlargement is a clinical diagnosis
BPH - lifestyle advice to help relieve symptoms
- decrease caffeine intake
- decrease alcohol intake
- relax when voiding
BPH GS treatment ?
Transurethral resection of the prostate
Suspected STD
What test would be performed to confirm this and how would a sample be collected?
First void urine and NAAT/culture
OR
swab urethral secretions and microscopy
Gonorrhoea appearance on microscopy?
Gram negative diplococci
Treatment of gonorrhoea ?
IM ceftriaxone with Azithromycin
What does DRE stand for?
DIgital rectal exam
What is the usual function of PSA?
To liquify the semen after ejaculation
What cells in the prostate produce PSA?
Luminal cells
How is prostate cancer staged from biopsy?
Gleason grading
Name 4 histological findings consistent with prostate cancer
- infiltrative medium sized glands
- nuclear enlargement
- prominent nucleoli
- proliferation of glandular epithelium
What would electron microscopy show in IgA nephropathy?
Immune deposits in the mesangium
What causes IgA nephropathy?
Galactose deficient IgA antibodies are not recognised as foreign so accumulate.
Anti-glycan IgG antibodies bind forming immune complexes These immune complexes deposit in the kidney
What can IgA nephropathy progress to?
Kidney failure
How to corticosteroids prevent immune complex formation and therefore help treat IgA nephropathy ?
Prevent the production of IgA
Other than a rise in creatinine, give 3 signs of AKI
- HTN
- raised JVP
- pulmonary oedema
- peripherla oedema
- oligouria
What physiological process is the internal pudendal artery involved in?
Erection
Describe how selective αlpha 1 adrenoreceptor antagonists e.g. Tamsulosin cause postural hypotension
Dilation of the venous capacitance vessels
What is the most common renal stone composition?
Calcium oxalate
Give 4 causes of PSA increase that are not a pathology of the prostate
- ejaculation
- digital rectal examination
- UTI
- high levels of physical activity
What is the Pathophysiology of BPH?
Benign nodular or diffuse proliferation
Of musculofibrous and glandular layers of prostate
Inner/transitional zone enlarges
Name 4 storage LUTS
- nocturia
- frequency
- urgency
- overflow incontinence
Name 4 voiding LUTS
- post-micturition dribble
- poor stream
- hesitancy
- incomplete emptying
Describe the pathogenesis of CKD
Scarred nephrons fail
Burden of filtration falls to remaining healthy nephrons/hyperfiltration/glomerular hypertrophy occurs
Increased glomerular capillary pressure and strain cases damage to remaining nephrons
Give 2 pharmacological therapies for BPH - type and example
5-alpha reductase inhibitor e.g. Finasteride
Αlpha blocker e.g. TamsuloSIN
Give 2 difference felt on digital rectal examination between BPH and prostate adenocarcinoma
Cancer = hard + irregular shaped
BPH = smooth + regular shaped
What is the classical triad of symptoms of pyelonephritis?
Loin pain, high fever, pyuria
GS investigation of pyelonephritis?
Midstream specimen of urine culture
What is increased in urine dipstick of pyelonephritis ?
Nitrates and leukocytes
First line antibiotic in pyelonephritis ?
Cephalexin or co-amoxiclav
What is epididymo-orchitis? What commonly causes it?
An acute inflammation of the epididymis, often involving the testis
Usually caused by bacterial infection eg. Gonorrhoea, chlamydia
What is the most common composition of renal stones?
Calcium oxalate
