GU and Renal Flashcards
What causes renal colic?
Usually caused by renal calculi.
Stones can be due to infection, anatomical factors (e.g. spina bifida) and urinary factors e.g. dehydration
What is the pathophysiology involved in renal colic?
Stones form in the collecting duct and can get stuck producing pain.
What are the three common sites for stones to get stuck?
Pelviureteric junction
Pelvic brim
Vesicoureteric junction
What is the epidemiology involved in renal colic?
Male:female ratio 2:1
What are the symptoms of renal colic?
Rapid onset unilateral loin pain, radiates to ipsilateral testis/labia and groin, unable to get comfortable, nausea and vomiting, spasmodic/colicky pain
What are the signs of renal colic?
Pallor, sweating
What tests are used in the diagnosis of renal colic?
MSU and urinalysis
Bloods: FBC, U&Es, calcium, uric acid, creatinine
Imaging: non-contrast CT KUB
What is the treatment for renal colic?
Analgesia, anti-emetics, possibly admit +/- IV fluids (can make pain worse, observe for signs of sepsis)
Stones <5mm: 90% pass spontaneously
Stones >5mmm: medical therapy (nifedipine or tamsulosin)
Procedures: ESWL (extra-corporeal shockwave lithotripsy)
PCNL (percutaneous neprolithotomy)
Stent may be required if infection is present
What is the aetiology involved in AKI?
Dehydration, scan contrast, new drugs, sepsis, decreased renal perfusion, damaged renal parenchyma, outflow obstruction
What is the pathophysiology involved in AKI?
There is a sudden, sustained decline in renal function associated with nitrogenous waste, electrolyte and fluid balance disorders
What is the epidemiology associated in AKI?
The elderly are vulnerable to AKI
What are the symptoms of AKI?
Lethargy, nausea, anorexia, itch, confusion, joint pains, rash, red eyes, nasal stuffiness, haemoptysis
What are the signs of AKI?
Skin rash, suprapubic percussion is dull, pericardial rub if the patient is very uraemic, oligouria
What tests are used to diagnose AKI?
Bloods: U&E, bicarbonate, bone profile, Glu, LFTs, CRP, FBC, coagulation MSU: urinalysis +/- MC&S USS ECG - hyperkalaemic changes, CXR If sick, consider ABG
What are the treatments for AKI?
Identify precipitating cause, stop nephrotoxins, IV fluids, monitor U&Es, input and output, senior review
What are the indications for dialysis?
K+ resistant to medical therapy, fluid overload resistant to diuretics, metabolic acidosis resistant to medical therapy, pericarditis or encephalopathy, toxin removal
What is the aetiology involved in nephrotic syndrome?
Primary: minimal change disease, membranous nephropathy, focal segmental glomerulosclerosis
Secondary: hepatitis, DM, drug-related
What is the pathophysiology involved in nephrotic syndrome?
Injuries to the podocyte foot processes cause proteinuria, hypoalbuminaemia and oedema (+ hyperlipidaemia)
What is the epidemiology of nephrotic syndrome?
It is a common glomerular disease in children
What are the symptoms of nephrotic syndrome?
In children, facial swelling is common, oedema, frothy urine, general fatigue, lethargy, poor appetite, weakness, episodic abdominal pain
What are the signs of nephrotic syndrome?
Oedema, fatigue, leukonychia, dyspnoea (pleural effusion), high JVP, MI or DVT due to hypercoagulability, dyslipidaemia
What tests are used to diagnose nephrotic syndrome?
MSU: urinalysis, MC&S
Bloods: FBC, U&Es, LFTs, renal function tests, ESR and CRP, fasting glucose, immunoglobulins, Hep B, Hep C and HIV screen
CXR
Abdominal or renal USS +/- biopsy
What is the treatment involved in nephrotic syndrome?
Sodium and fluid restriction, high dose diuretics for adults
Children: corticosteroids (as most likely cause is minimal change disease)
What are the complications involved in nephrotic syndrome?
Infections (due to Ig being lost in the urine), thromboembolism (due to a hypercoagulable state)
What is the aetiology of CKD?
Hypertension, DM, glomerulonephritis, hypercalcaemia, SLE, neoplasms, myeloma, infective, obstructive and reflux nephropathies, obesity
What is the pathophysiology involved in CKD?
There is a progressive loss of renal function over a period of months or years, the exact mechanism depends on the cause of CKD
What are the symptoms of CKD?
Pallor, lethargy, nausea, vomiting, diarrhoea, bone pain, SOB on exertion, bruising, epistaxis, pruritis
What are the signs of CKD?
Anorexia, amenorrhoea, nocturia, polyuria, oedema, hypertension, polyneuropathy
What tests are used to diagnose CKD?
Bloods: FBC, U&Es, eGFR, creatinine, PTH, glucose, LFTs, serology for autoantibodies, HIV and hepatitis
MSU: urinalysis
ECG and echo
Imaging: USS, CT +/- biopsy
What is the treatment for CKD?
Lifestyle modification e.g. weight loss, good BP and BM control, avoid nephrotoxins, regular monitoring, antiplatelets, monitor for bone disease
What are the complications involved in CKD?
Anaemia, bone disease, pruritis, GI complications, gout, cardiovascular disease, malignancy
What is the aetiology involved in polycystic kidney disease?
It is a genetic disease that can be autosomal dominant (PKD1 and PKD2) or autosomal recessive (nephronophthisis)
What is the pathophysiology involved in PKD?
Mutations in genes affecting cell polarity and defective ciliary signalling causes cyst formation in the kidneys and other organs e.g. liver
What are the symptoms of PKD?
Loin pain, haematuria, nocturia, chronic loin pain
What are the signs of PKD?
Urinary tract stones and infections, hypertension, fever if the cyst is infected, renal colic, palpable kidneys on examination, renal stones
What are the tests used to diagnose PKD?
MSU: urinalysis (may be microalbuminaemia and haematuria) and MC&S
Bloods: FBC (increased Hb due to increased Epo production), U&E, eGFR, creatinine and bone profile
Imaging: USS, CT or MRI
Genetic testing
What is the treatment involved in PKD?
Treat hypertension, UTIs and pain as needed
Dialysis as kidney function declines
Tolvaptin delays progression in ADPKD - it’s a vasopressin 2 receptor antagonist - can cause deranged LFTs
What is the aetiology involved in epididymal cysts?
They can originate from a diverticulum in the tubules, epididymitis, physical trauma or vasectomy
What is the pathophysiology involved in epididymal cysts?
They are smooth, extra testicular, spherical cysts in the head of the epididymis; they are benign and are not usually treated
What are the symptoms of an epididymal cyst?
A lump in the scrotum, there can be multiple and they can be bilateral. They are often asymptomatic
What are the signs of an epididymal cyst?
A well defined, fluctuant and transilluminant lump, the testis is palpable separately from the cyst, should feel smooth
What are the tests used to diagnose epididymal cysts?
A full history and examination should confirm the diagnosis, scrotal USS can be used if there’s any uncertainty
What is the treatment of an epididymal cyst?
Treatment is not usually necessary, just reassurance and advice to seek further help if it increases in size or is painful
What complications can arise from an epididymal cyst?
Torsion of the cyst
What is the aetiology involved in a hydrocele?
It can be congenital - a patent processus vaginalis, acquired or due to impaired lymphatic drainage e.g. elephantiasis
What is the pathophysiology involved in a hydrocele?
It can be produced in 4 ways: by excessive fluid production within the sac, through defective resorption of fluid, by interference with lymphatic drainage and by connection with a hernia in the peritoneal cavity.
What are the symptoms of a hydrocele?
Scrotal enlargement with a non-tender, smooth, cystic swelling, can vary in size and with ambulation
What are the signs of a hydrocele?
Lies anterior to and below the testis, will transilluminate, the testis is usually palpable unless the hydrocele is large
What tests are used to diagnose a hydrocele?
Full history and examination are usually sufficient, can use USS if unsure of the diagnosis
What is the treatment for a hydrocele?
Conservative: most hydroceles in infancy resolve
Aspiration for large hydroceles
Surgical removal
What are the complications of a hydrocele?
Infection of the hydrocele, this is uncommon.
What is the aetiology involved in a varicocele?
They are more common on the left due to the angle the left testicular vein enters the left renal vein, lack of effective valves between the testicular and renal veins, increased reflux from compression of the renal vein.
What is the pathophysiology involved in a varicocele?
There is dilatation and tortuosity of the pampiniform plexus, the network of veins that drains the testis due to a backflow of blood.
What are the symptoms of a varicocele?
Most are asymptomatic, pain is rarely a symptom, patients can complain of scrotal heaviness
What are the signs of a varicocele?
Feels like a “bag of worms”, increases with standing, decreases with lying down, cough impulse
What tests are used to diagnose a varicocele?
Fertility investigations including sperm count, colour doppler, CT, clinical examination
What is the treatment of a varicocele?
Conservative management or surgical repair
What are the complications of a varicocele?
Infertility
What are the risk factors of testicular torsion?
A larger testicle, a congenital abnormality of the processus vaginalis (“bell clapper deformity”), trauma - rare
What is the pathophysiology involved in testicular torsion?
Torsion is due to a mechanical twisting process and it causes occlusion of testicular blood vessels and rapidly leads to ischaemia. It is a common UROLOGICAL EMERGENCY!
What is the epidemiology of testicular torsion?
It is most common in the adolescence and young men
What are the symptoms of testicular torsion?
Sudden, severe pain in one testis, lower abdominal pain, nausea and vomiting, history of previous attacks
What are the signs of testicular torsion?
Reddening of the scrotal skin, swollen tender testis retracted upwards, absence of cremasteric reflex
What tests are used to diagnose testicular torsion?
USS with colour doppler, MRI if unsure, urinalysis to exclude UTI and epididymitis
What is the treatment for testicular torsion?
IMMEDIATE REFERRAL
Manually reduced the testis
Surgery: orchidopexy
What is the differential diagnosis of testicular torsion?
Epididymitis, orchitis, epididymo-orchitis, incarcerated hernia, testicular tumour, mumps
What are the complications of testicular torsion?
If treatment is delayed the testis can infarct, can leading to subfertility and infertility
What is the aetiology of BPH?
It is thought that androgens play a permissive role in BPH development, it’s an age related disease
What is the pathophysiology of BPH?
Hyperplasia affects the glandular and connective tissue elements of the prostate, enlargement of the gland stretches and distorts the urethra, obstructing bladder outflow.
What are the symptoms of BPH?
Increased urinary frequency, nocturia, urinary urgency, hesitancy, dribbling, incomplete bladder emptying, having to strain
What are the signs of BPH?
Palpable bladder possibly, a firm, smooth prostate on DRE - no nodules and an easily palpable median sulcus
What tests are used to diagnose BPH?
MSU: urinalysis, MC&S
Bloods: FBC, U&Es, creatinine, LFTs,
PSA - requires counselling, not diagnostic but is an indicator
IPSS questionnaire
USS of the prostate
What is the treatment of BPH?
Watchful waiting (providing malignancy is excluded)
Drugs: alpha-adrenergic antagonists e.g. tamsulosin (floppy iris syndrome)
5-alpha reductase inhibitors e.g. finasteride (may have an adverse effect on sexual performance)
Surgery: prostatectomy (open), transurethral resection of the prostate (standard technique)
What are the risk factors for renal cell carcinoma?
Smoking, obesity, hypertension, renal failure and dialysis, polycystic and horseshoe kidney, von Hippel-Lindau disease
What is the physiology involved in RCC?
RCC is an adenocarcinoma of the renal cortex and it arises from the distal convoluted tubule
What are the symptoms of RCC?
Classic triad, not often seen - loin pain, haematuria, loin mass
Fatigue, weight loss, varicocele
What are the signs of RCC?
Palpable mass, bilateral ankle oedema, hypertension, pyrexia of unknown origin, symptoms of metastatic disease
What tests are used to diagnose RCC?
MSU: urinalysis, cytology and MC&S
Bloods: FBC (anaemia or polycythaemia), eGFR, U&Es, creatinine
CT scan of KUB, renal biopsy (percutaneous)
What is the treatment for RCC?
Surgery: partial nephrectomy or total nephrectomy
Drugs: RCC is resistant to most chemotherapies but is VEGF driven so can be treated with VEGF blockers e.g. Avastin
What are the risk factors for prostate cancer?
Increasing age, ethnic origin (higher incidence in men of African-Caribbean origin) and genetic predisposition
What is the pathophysiology involved in prostate cancer?
Most prostate cancers are adenocarcinomas arising in the peripheral zone of the prostate, most are slow growing
What are the symptoms of prostate cancer?
LUTS, haematuria, dysuria, incontinence, haematospermia, perineal or suprapubic pain, impotence, rectal symptoms
What are the signs of prostate cancer?
General malaise, weight loss, palpable bladder, hard irregular prostate gland on DRE, increased PSA on screening
What tests are used to diagnose prostate cancer?
MSU: urinalysis and MC&S
Prostate biopsy
Transrectual USS (TRUSS)
MRI or CT, PET scan for metastases
What is the treatment for prostate cancer?
Surgical: radical prostatectomy
Radiotherapy, cryotherapy, chemotherapy (docetaxel), anti-androgen therapy (enzalutamide)
What are the risk factors of bladder cancer?
Increasing age, exposure to aromatic amines, polycyclic aromatic hydrocarbons, chlorinated hydrocarbons
SCC can be caused by schistosomiasis
What is the pathophysiology involved in bladder cancer?
Cancer arising from the transitional cells of the mucosal urothelium may present as a non-invasive, papillary tumour protruding from the mucosal surface or as a solid non-papillary tumour that invades the bladder wall
What is the epidemiology involved in bladder cancer?
Men:women ratio 3:1
What are the symptoms of bladder cancer?
Painless haematuria (gross in 80-90%), voiding symptoms, dysuria, abdominal pain, weight loss
What are the signs of bladder cancer?
Lower-extremity oedema, flank pain, rarely a palpable mass can be felt on examination
What tests are used to diagnose bladder cancer?
MSU - urinalysis
Bloods: FBC, U&Es, LFTs, clotting screen
Flexible cystoscopy +/- biopsy
Imaging: CT, USS, KUB XR and CT/PET for metastases
What is the treatment for bladder cancer?
Transurethral resection of bladder tumour, cyst(oprostat)ectomy)
Intravesical chemotherapy: mitomycin and BCG
Conventional chemotherapy
Radical radiotherapy
What risk factors are involved in testicular cancer?
Cryptochordism or testicular maldescent, Klinefelter’s syndrome, family history, male infertility, infantile hernia and testicular microlithiasis
What is the pathophysiology of testicular cancer?
Tumours can be seminomas, teratomas and yolk sac tumours - most common prepubertal germ cell tumours
What is the epidemiology of testicular cancer?
Most common ages are 15-40
What are the symptoms of testicular cancer?
A lump in the body of the testis, usually painless, testicular pain and/or abdominal pain, dragging sensation, hydrocele, recent history of trauma
What are the signs of testicular cancer?
A palpable lump, gynaecomastia from beta-hCG production, inguinal lymph nodes unlikely to be enlarged
What tests are used to diagnose testicular cancer?
Bilateral testicular USS, tumour markers - beta-hCG and alpha-fetoprotein (AFP), CXR - preoperatively
What is the treatment for testicular cancer?
Radical orchidectomy +/- testicular prosthesis, offer sperm storage for patients who may need chemotherapy or radiotherapy
Chemotherapy: bleomycin, etoposide, cisplatin
Radiotherapy
Counselling and support organisations
What is the aetiology of pyelonephritis?
Risk factors include structural renal abnormalities, calculi, catheterisation, stents, pregnancy, DM, primary biliary cirrhosis, immunocompromised patients
What is the pathophysiology involved in pyelonephritis?
There is infection of the renal parenchyma and soft tissues of the renal pelvis/upper ureter. The majority is caused by uropathogenic E. coli
What is the epidemiology involved in pyelonephritis?
Females>males
What are the symptoms of pyelonephritis?
Loin pain, fever, pyuria, headache, rigors, malaise, nausea, vomiting, anorexia, occasionally diarrhoea
What are the signs of pyelonephritis?
Fever, pyuria, systemically unwell, pain on firm palpation of one or both kidneys, moderate suprapubic tenderness without guarding
What tests are used to diagnose pyelonephritis?
MSU - urinalysis (+ve for blood, protein, leukocyte esterase and nitrites), MC&S
Bloods: FBC, U&E, ESR, CRP, plasma viscosity, blood cultures
Imaging: USS or CT
What is the treatment of pyelonephritis?
IV fluids and IV antibiotics - gentamicin and Co-amoxiclav
Drain obstructed kidney if necessary, possibly catheterise, analgesia +/- anti-emetics if feeling unwell/nauseous
Observe for signs of sepsis
What are some causative organisms of cystitis?
Uropathogenic E. coli, coagulase negative Staphylococcus spp. Proteus spp. Enterococci and Klebsiella spp.
What is the pathophysiology involved in cystitis?
Bacteria can enter the bladder via the urethra, this can be caused by sexual intercourse, catheterisation and voiding dysfunction
What is the epidemiology of cystitis?
Females > males
What are the symptoms of cystitis?
Dysuria, increased urinary frequency, urinary urgency, suprapubic pain, haematuria, offensive/cloudy urine
What are the signs of cystitis?
No obvious physical signs
What tests are used to diagnose cystitis?
Full history, MSU for urinalysis (nitrite +ve and leukocyte +ve), MC&S (takes time), clean catch urine in children +/- suprapubic aspirate of urine
What is the treatment for cystitis?
3/7 trimethoprim or nitrofurantoin, if MSU is sent then alter accordingly
Increase fluid intake
Regular voiding
Void pre- and post-intercourse
