GU top tier Flashcards
renal colic epidemiology
- age
- gender
- commonness
- recurrence
- 30-50 (young) but rare in children
m>f
common
recurrent often
risk factors for renal colic
anatomical abnormalities
- congenital (eg shape or duplex kidney (two ureters)
- aquired (trauma, obstruction, reflux)
urinary factors
- hypercalciuria (hypercalcaemia /primary hyperparathyroidism)
- hyperoxaluria
- hyperuricaemia
- cystine in urine
- dehydration ** = most common factor
infection
prevention of renal colic. name 5
- Hydration
- Low calcium diet
- low salt (na) diet (lowers ca)
- Normal dairy intake
- Low protein diet
- Reduced BMI
- active lifestyle
renal colic cause
made from
renal stones form when solute concentrations exceed saturation + trigger
Most = calcium oxalate and second most = calcium phosphate. Also stones made of uric acid/ cystine
name some high oxalate foods
spinach
rhubarb
choc
tea
stones in the urinary tract (renal colic)
- where
- which in where
UUT>LUT
most form in collecting ducts of kidney and may be deposited anywhere
UUT - renal stones (most) / ureteric
LUT - bladder stones (most)
may cause obstruction
hydronephrosis vs pyonephrosis
both result from renal colic stone obstruction
kidney swells, unable to drain
hydro= water; pyo = pus (= infected!!)
presentation of renal colic
- most= asymptomatic
- recurrent UTIs
- pain
- – radiates: loin to groin; to ipsilateral testis/labia
- – colic (waves, with peristalsis)
- – rapid onset
- – severe
- restless/writhing
- naus/vom
renal colic investigations
urine dipstick - haematuria
NCCT - KUB (non contrast (=safe!) CT)- diagnostic, first line, gold standatd. stones= bright white
Xray (KUBXR) - see stone. not too sensitive so not 1st line but maybe ok if you know where to look (previous stones)
ultrasound (less good for ureteric )
bloods
renal colic management
conservative (small- pass spontaneously, safe, asymptomatic, comorbidities)
- analgesia
- observe for sepsis
- anti-emetics
surgery
- ESWL - (extracorporeal shockwave lithotripsy) = Ultrasound fragments, shock waves break into smaller pieces from many directions
- endoscopy/ureteroscopy – laser/basket
- PCNL (percutaneous nephrolithotomy) =keyhole surgery for large/multiple/complex stones– break up and fish out
Through kidney tissue, so higher risk
infected obstructed kidney- sepsis
- =?
- prognosis
- presentation
- treatment
v bad- fatal/quick
pyonephrosis
systemic sepsis signs (tachy, febrile, low BP, high RR, malaise)
IV antibiotics
Oxygen
Drainage - nephrostomy (percutaneous) / ureteric stent
can –> gangrene
kidney cancer
- gender
- age
- commonness
- race
m>f
Age related - commonly presents late 50s, peak 80-85
Common
Czech republic
kidney cancer risk factors
smoking Obesity Environmental : leather, petroleum, asbestos Hormonal estrogen level high Genetic Von hippel lindau (VHL) mutation Hypertension Renal failure + hemodialysis Polycystic kidneys
upper tract TCC=
treatment
- Upper tract TCC (transitional cell carcinoma)
- Transitional cells = urinary tract down to bladder
- Malignancy in urinary tract
- Not curable if gone beyond kidney
- Nephroureterectomy = get rid of whole urinary tract lining (removes kidney and ureter )
kidney cancer presentation
- classic triad (3)
- signs (4)
- symptoms (5)
Classic triad (for more advanced, most don’t have this)
- Mass in abdomen
- Haematuria
- Pain
- Fever
- Hypertension
- Polycythaemia (if kidney cancer cells make EPO)
- or anaemia !
- Pain
- Can be asymptomatic - often found incidentally
- Symptoms of metastatic disease (often metastases on presentation)
- Paraneoplastic syndrome (= consequence of cancer)-PTH, erythropoietin, prolactin = related hormones
- – Stones, groans, bones, moans (hyperCa)
- Varicocele (rare)- enlargement of veins in scrotum (Slow drain of gonadal vein, compression of vein → varicole. If on R, you worry more – Cancer may potentially invade into IVC)
kidney cancer investigations
- Often found incidentally
- Fbc
- – Polycythaemia and anaemia due to EPO decrease
- – ESR may be raised
- –liver tests may be abnormal
- BP
- ultrasound/ CT/ MRI
- – if simple cyst : discharge
- – if small risk of malignancy, follow up
- – if medium/high/ already malignant : treat (bosniak classsification)
- Biopsy
- – Histology
- –Different types of renal carcinoma, distinguished with histology
- – = different cell types
- – Different levels of aggression
- –Looking for loss of architecture, = loss of function
- Bone scan
kidney cancer management
Surveillance
- Old
- Low aggression cancer
surgery
- Radical nephrectomy (remove one whole kidney – Aims to cure
- Partial nephrectomy– If small tumour / bilateral involvement
- Ablative techniques (For comorbidities - can’t tolerate surgery )
- – Radiofrequency ablation
- – Cryotherapy
- Tyrosine kinase inhibitors
- Interleukin 2 and interferon alpha
- Angio-genesis targeted therapy (Sunitinib, bevacizumab, sorafenib)
Palliative care
bladder cancer
- age
- gender
- commonness
Increased risk with age. Incidence peaks in 80s
Male
Common
bladder cancer risk factors
- Smoking
- Exposure to carcinogens (eg industrialized regions)
- – Benzidine, azo dyes, petroleum, chemical, cable, rubber
- Chronic inflammation of urinary tract
- –Schistosomiasis (worms infection)
- –Indwelling catheter
- Chronic HPV in immunocomprimised
- Pelvic irradiation
- Age - above 40
- Male
- Family history
what type of cancer is bladder cancer
transitional cell carcinoma
- most common TCC
bladder cancer symptoms
Painless!! Haematuria = most common symptoms
- Painless as no stimulus. Blood just from shed/ popped cancer cells
- May be pain due to clot retention
Recurrent UTIs
-Void irritability/ irritable LUTS
Symptoms of metastases (uncommon but worrying)
- Flank pain + tenderness
- Lower limb oedema
- Pelvic mass
- Weight loss
- Bone pain
bladder cancer investigations
Cystoscopy (bladder endoscopy ) + Biopsy = best diagnostic
Urine microscopy /cytology
– Sterile pyuria = pus in urine
CT urogram , = diagnostic
–Staging of cancer
MRI/CT/lymphangiography - show pelvic involvement
bladder cancer management
- non -muscle invasive (Ta/T1)
- localised muscle invasion (T2)
- metastatic
- +… for aggressive cancer
Non- muscle invasive Ta/T1
- Surgical resection,
- Resect endoscopically
- +/- chemo to reduce recurrence
Localised muscle invasion - T2
- Radical cystectomy (bladder removal) = gold standard, advised (some do not want)
- Post op chemo
- Radical radiotherapy - if not fit for surgery
- Chemotherapy
Metastatic
- Palliative chemotherapy and radiotherapy
Intravesical Immunotherapy (BCG)
- Aggressive cancer, not surgery
- Toxic, hard to tolerate for entire course
bladder cancer metastases, via different routes
Local → pelvic structures
Lymphatic → to iliac and para-aortic nodes
Haematogenous → to liver and lungs
testicular cancer
- prognosis
- age
- gender
Most common cancer in young males (20-44)
- Rare below 15
- Rare over 60
Nicely curable
men, silly!!
testicular cancer risk factors
Previous testicular cancer Undescended testis (10% of testis cancer is in this) = cryptorchidism Infant hernia Infertility Family history HIV Maternal oestogen exposure
testicular cancer causes and thus types
Vast majority arise from germ cells
- Seminomas (older adults in range adult) - slow growing
- Teratomas (younger adults in range) - fast growing /metastases
Small number arise from non-germ cells
- Leydig cells
- Sertoli cells
- sarcomas
testicular torsion=
twisting of spermatic cord, which supplies blood to testis
testicular cancer signs and symptoms
- Hydrocele = swollen scrotum (secondary)
- abdominal mass
- Painless lump in testicle/scrotum =Hard, non- tender
- Testicular/scrotal pain,
- Abdominal pain
- Cough, dyspnoea (indicative of lung metastases)
- Back pain (indicative of para-aortic lymph node metastases - where testicle drains into!)
testicular cancer investigations
US : Differentiate between intrascrotal swelling and testes masses
Biopsy and histology
Serum tumour markers
- AFP = alpha fetoprotein
- B-hCG : beta subunit of human chorionic gonadotropin
- Which are raised is different depending on type (see causes)
- –Teratomas - both raised
- –Seminomas - b-hcg sometimes raised, but not afp
- LDH
CXR/CT CAP (chest, abdo, pelvis) -to assess tumour staging
testicular cancer management
- Radical orchiectomy (testes removal)
- Seminomas with metastases below diaphragm = radiotherapy
- Widespread tumour = chemo
- Teratomas = chemotherapy
- Sperm storage (sterility)
testicular cancer metastases and routes
- Lymphatic → paroaortic nodes intitially
- Local → epididymis, spermatic cord. Scrotal wall, then on to pelvic and inguinal nodes
- Distant (lungs, liver, bones) , once tunica albuginea breached
prostate cancer
- commonness
- age
- gender
- race
- common
- M>F (skene gland referred to as female prostate)
- Peak incidence in 80s
- More common: A-c /black (higher testosterone)
- Less common : far east
prostate cancer risk factors
- Age
- Family history - 2/3x risk
- Ethnicity
- – More common: A-c /black (higher testosterone)
- – Less common : far east
- Genetic
- –More common in younger patients than older
- –BRCA2
- –HOXB13
- Obesity
type of cancer in prostate cancer
where is it
Majority = adenocarcinoma
Majority on outside - peripheral zone (also transitional zone, central zone). these are easier to detect DRexam
prostate cancer symptoms
Most prostate cancers are diagnosed at an asymptomatic stage
History - if these things are picked up - more likely advanced disease
- Specific/local = urinary problems - due to pressing on urethra- obstruction mainly!! – LUTS
if cancer invades up to ureters…
- Uraemic symptoms –confusion
- kidney failure
Symptoms at site of metastasis
- Bony pain
- Lower extremity pain
- Oedema
- Neurological deficits from spinal cord compression
general systemic cancer symptoms
prostate cancer investigations
PSA testing - prostate specific antigen
- Not specific to prostate cancer
- You risk picking up someone who would have been otherwise asymptomatic/fine but then they are exposed to the side effects of treatment
DRE - Feel prostate
- Hard
- Nodules
- Irregularity
- Asymmetry
- Bogginess
- anal tone and anal sensation (May be spinal compression → paralysis )
Neurological examination - Inc external anal sphincter tone
MRI
- Between examination/PSA and biopsy
- Good for target lesions for biopsy (rather than random sites, local staging (local invasion, metastases)
Biopsy
- If suspicious MRI/ palpable DRE / PSA high
- With ultrasound
Transrectal (TRUS) / transperineal (better). Both ways probe goes up bum, needle goes in via bum to prostate or past outer skin to bum - can reach anterior too
- Histopathology
may check other organs for metastases (kidney function, lymph node oedema)
gleason grading system
for prostate cancer histology
- Patterns can be categorised 1-5
- The two most prominent/common patterns seen are summed. This grade (2-10) indicates level of differentiation
- 2= most differentiated
- 10 = least differentiated.
- Higher = more serious. 6 and below in general are unlikely to spread
prostate cancer staging
not gleason
gives idea of prognosis
T = tumour itself
- T1 - cant feel, incidental finding on biopsy
- T2 - can feel
- T3 - invade through prostate capsule
- T4 - invade to adjacent structures
N = nodes
- N1 - metastases in regional lymph nodes
M = metastases
- M1 distant metastases – Can be categorized as to where - a/b/c
prostate cancer metastases- and route
Direct spread (local surroundings)
- Rest of prostate — intrinsic
- Upward =Bladder , ureter
- back/up = Seminal vesicles
- Downward = urethra
- Forward = pubic bone
- Laterally = sciatic nerve , iliac blood vessels
- Backward = rectum – late, and rare
- Not testes (outside- scrotum)
Lymphatics
- External, internal iliac and presacral nodes. Obturator nodes = ext iliac?
- Occasionally thoracic duct → supraclavicular nodes
Haematogenous
- Bone = most common
- Lung
- Liver
- Kidneys
- Late in disease
prostate cancer treatment
Activity surveillance
- Low risk patients / old
- No treatment (reduce toxicity), close monitoring until see features of invasion/aggression
surgery
- radical prostatectomy
- TURP (resection)
- nephrostomies (for ureteric obstruction – drains kidneys to urine bag to prevent renal failure (palliative))
radiotherapy (localised / locally advanced)
hormone therapy (locally advanced/ metastatic) =block testosterone
- remove testicles (orchiectomy)
- LHRH agonist (goserelin, leuproelin) - overload pit (transient flare) then it stops
- antiandrogens (bicalutamide) - block testosterone at testes receptor level
- hormone resistance can occur, so a temporary delay
chemo - once hormone-resistant
bisphosphonates - reduce osteoclast activity (bone pain reduced)
radiotherapy - palliative for bone pain
BPH
- commonnes
- age
- race
- castration?
Common
Increases with age
A-C
castration is protective as testosterone needed (although not the cause)
bph vs. bpe
BPH- benign prostatic hyperplasia (histological)
BPE - benign prostatic enlargement (DRE)
BPE= benign enlargement (found on DRE) that isnt cancerous (histological) and isnt hyperplasia. cause is unknown
??? or maybe the same thing??
bph pathophysiology
- Increase in prostate size without presence of malignancy
- The transitional zone enlarges (rather than outer peripheral zone that gets bigger in prostate cancer)
- Increase in epithelial and stromal cells : Increase in cell number and/or decrease in cell apoptosis
- Prostate gland surrounds the urethra so an causes obstruction to lower urinary tract as its size gets bigger → outflow obstruction (BOO= bladder outflow obstruction), causing LUTS (benign prostatic obstruction)
bph symptoms
= LUTS Nocturia Frequency Post-micturition dribbling Hesitancy Overflow incontinence Haematuria Bladder stone Incomplete emptying of bladder
bph investigations
- DRE= Enlarged but SMOOTH
- Raised PSA (prostate specific antigen) - not specific
- Imaging (US/MRI)
- Biopsy (rule out cancer)
- Endoscopy
- Renal biochemistry/urinalysis / renal ultrasound/electrolytes
- – to rule out kidney cause
- – Mid stream urine sample - to exclude infection
- Flow rates (pee on to weight/spinning disk) – BPH has lower peak and longer peak in rate
- Residual volume (scan after weeing)
- Frequency-volume chart / bladder diary
bph conservative management
- Fluid intake - Less in evening, Less alcohol, caffeine, sweeteners, fizzy drinks
- Regular bladder emptying
- —Double voiding - aids emptying
- –Wear pads/sheath
- –Bladder training /bladder drill
- Weight loss
- Exercise
- Urethral milking
- Diet - Fruit and fibre
- Relax when voiding
main 2 pharmacological bph treatments
Alpha blocker (tamsulosin, alfuzosin )
- Vasodilate outflow
- Relax prostate and base of bladder (smooth muscle)
- quicker action
- symptoms improved but no effect on actual prostate hyperplasia
- s/e: drowsy, dizzy, depression, ejaculatory failure (vasodilator), wight increase, nasal congestion
- Avoid in postural hypertension (a vasodilator)
5-ARI (5 alpha reductase inhibitors) (finasteride, dutasteride)
- Shrink prostate, by blocking conversion of testosterone → dihydrotestosterone
- effects progrression, reduces size and maintains it
- s/e: impotence, decreased libido
combination therapy = good
other (non main) pharmacological bph treatment
PDE5 inhibitor
- Relaxes bladder neck
Anticholinergic
- Relax bladder muscle (good for overactive detrusor)
Hormone replacement therapy
- Orchiectomy = remove testical
- LHRH antagonist: Overload pituitary gland so LH stops being produced (transient flare up of cancer)
- Antiandrogens - Block testosterone at testes receptor level
Diuretics
- Speed up urine production so more done in day and less in night
Desmopressins
- Slow urine production down → less produced at night
surgical/mechanical bph interventions
catheters
surgery
- TURP (gold standard)
- prostatectomy (all removed) - s/e - haemorrhage, sepsis, erectile dysfunction, retrograde ejaculation, infertility, urethral stricture
- TUIP (incision rather than resection- good for smaller prostates, less destruction and less s/e
- Prostatic urethral lift - prostate held away from urethra to stop blockage
- Cystoplasty = bladder size increased
- Urinary diversion
indications for bph surgery
RUSHES Retention UTIs Stones Haematuria Elevated creatinine due to BOO (bladder outflow obstruction) Symptom deterioration
complications of bph
inc what is NOT a complication
- Infections
- Bladder stones = bladder calculi (Can’t crush -too hard)
- Symptoms worsen
- Haematuria
- Acute retention AUR = cannot void - Pain, Relieved with catheter, alpha blockers
- Chronic retention CUR. Less pain, infection, stones risk
- Interactive obstructive uropathy
Nocturnal enuresis = bladder spontaneously contracts
Collecting duct insensitive to ADH → more urine
NOT infertility
NOT erection problems
NOT prostate cancer
syphillis pathogen
treponema pallidum
early and late syphillis
Early syphilis = infectious - <2 y since infection - High transmission rates - Easily transferred orally - Vertical transmission = across placenta (Late miscarriage / stillbirth/ congenital syphilis) types Primary! - invades epithelium to blood -Chancre - painless ulcer (macule → papule → ulcer). Usually on genital skin (also nipples, mouth). Heals alone but quicker with treatment Secondary ! 6-8 w after infection \+/- previous chancre - Skin rash !!! = key symptom (can be on palms, soles)- lots of circular-ish things, wide spread - also - Hair loss, bone pain, mucous membrane lesions (sores), hoarseness, lymphadenopathy - Early latent= no symptoms!
Late syphilis = not infectious - 2+ y since infection - types: Late latent/CNS / CVS/ gummatous CNS → dementia CVS → AAA → HF Gummatous → skin lesion
genital ulcer = what til proven otherwise
syphilis
syphilis
- gender
- age
- high risk =
m>f
broad age range
MSM (then hetero m)
syphilis diagnosis
- Serology (blood test)
- –EIA enzyme immunoassay
- –TPPA to confirm — if EIA +ve
- –VDRL/RPR to assess disease activity
- Look at ulcers - microscopy??
- Rash
syphilis treatment
- Prevent spread (highly infectious)
- Prevent complications (see late syphilis)
- Penicillin injection (usually just 1 if early syph)
- Partner notification
chlamydia pathogen
Chlamydia trachomatis
gonorrhea pathogen
Neisseria gonorrhoeae
chlamydia vs gonrrhea:
- commonness
- asymtpomaticness male/female
- transmission rate
- chalmydia more common
- chlamydia more asymtpmatic
- women asymptomatic more for both
- both C and G high
chlamydia vs gonrrhea
- asymptomaticness
- symptoms in men
- symptoms in women
- chlamydia more asymptomatic
- -C.men - 50% C women - 70%
- G men -10% G women 50%
- male symptoms = dysuria, urethral discharge.
- – C - less obvious (present with complications),
- – G more obvious
-female symptoms = discharge, menstrual irregularity, dysuria (non-specific)
chlamydia vs gonnorhea complications
- male
- female
MALE - CHLAMYDIA ONLY
- Reactive arthritis
- Epididymo Orchitis (epididymis / testicle inflammation)
FEMALE - BOTH C+G
- Pelvic inflammatory disease= Infection spread from cervix
- –Tubal factor infertility (infertility due to fallopian damage - prevents passageway of egg)
- –Ectopic pregnancy
- –Chronic pain
- Fitz hugh curtis syndrome
- –Inflamed around liver (perihepatitis)
- Neonatal transmission
- –Ophthalmia neonatorum (= newborn conjunctivitis)
- –Atypical pneumonia with chlamydia
chlamydia and gonnorrhea - where do they affect
Adults : urethra, endocervical canal, rectum, pharynx, conjunctiva
Neonate (vertical transmission via birth act) : conjunctiva
(atypical pneumonia also in neonatal chlamydia)
diagnosis of chlamydia
NAAT nucleic acid amplification test (PCR)
f- vaginal swab (or first void urine but less sensitive)
m- first void urine
diagnosis of gonorrhea
swab → microscopy
Look for gram negative diplococci within the cytoplasm of polymorphs
Then : culture on medium to confirm diagnosis
Sensitivity testing
f- vaginal smear - endocervix
m- urethral discharge
chlamydia treatment
- Partner management
- Test for other STIs
- 1st line = doxycycline
Or erythromycin
Or azithromycin in pregnancy - Antibiotic resistance is not a clinically important problem
gonorrhea treatment
- Partner notification
— Gon is more associated with partner change - Test for other STIs
- Antibiotic sensitivity tested
- Single dose treatment
Ceftriaxone IM = 1st line
Cures 95% at first visit
GU infections risk factors
Catheter - introduces bugs - Bugs grow up it easily - All become colonised -- so v common - At risk of infection up until 24h after removal BPE - More difficult to empty bladder Pregnancy - stasis and urine retention - Less flushed out Obstruction eg kidneys stones - Stasis - Less flushed out Poor hygiene - Sweat - Poo - Nappy change irregular - Wipe wrong way - Sex - Infrequent washing Immunocompromised / antibiotic use Female - shorter urethra Menopause
GU infection causes
KEEPS
- Klebsiella (hospital/catheter)
- E Coli = most common!!!
- –Fimbriae - adhesion and bladder colonisation
- –Others have this too
- Enterococci (less symptomatic)
- Proteus (associated with renal stones)
- Staph
- -sapro (young women)
- -Aureus
bacteria features that aid GU infection
- Fimbriae/pili - adhesion
- Fimbriae attachments - glycocalyx
- Acid polysaccharide coat/capsule- resists phagocytosis
- Enzyme production - secrete urease
- Toxins: E coli release toxic cytokines
host features that try to prevent GU infection
- Urinary IgA, in mucosa
- Antregrade flushing of urine- mechanical
- Low urine pH
- Urine contains competitive inhibitors for attachment of urothelial cells
- Mucosa polysaccharide lining
- Mucosa secretes cytokines and chemokines
- Prostate secretions include zinc (bactericidal)
what is in pyuria
pus - leukocytes
types of bacteriuria
asymptomatic
Uncomplicated (= non-pregnant women (small category))
Complicated
- Pregnant
- Men
- Catheter
- Children
- Recurrent / persistent
- Immunocompromised
name the different infections of the upper and lower urinary tract
Upper tract:
- Pyelonephritis (kidney)
Lower tract
- Cystitis (bladder)
- Prostatitis (prostate)
- Epididymo-orchitis (epididymis/testicle)
- Urethritis (urethra)
pyelonephritis
- pathogen
- routes of infection
- gender
- age
e coli Ascending bladder up to kidneys Haematogenous Lymphatics (rare) women <35
pyelonephritis
- classic triad
- other symtpoms
Loin pain (+tender)
Fever
Pyuria
oliguria significant bacteriuria Rigors Sepsis Fluid depleted -- Headaches -- Malaise -- naus/vom
pyelonephtiris investigation
- abdominal exam
- Blood inc cultures
- U/S to rule out obstruction
- MSU - urine analysis
pyelonephritis treatment
Fluid replacement
- water
- cranberry juice
IV antibiotics
- Co-amoxiclav = 1st line
- 7-14d
Analgesia
Drain kidney
Catheter - monitor output
pyelonephritis complications
- Renal abscesses
- –slow/ no antibiotic response suggests this
- – More common in diabetes
- – Imaging
Emphysematous pyelonephritis = gas accumulates in tissues
- – Rare
- – Life threatening
- – May need nephrectomy
cystitis
- infection of?
- pathogen?
- risk factors
bladder
E coli
- Urinary obstruction/ Poor emptying → stasis
- Bladder epithelial damage
cystitis signs and symptoms
- Foul smelling urine
- Cloudy urine
- abdom/loin tenderness
- Haematuria
- Dysuria
- Frequency
- Urgency
- Suprapubic pain
prostatitis
- acute vs chronic causes
Acute
- Strep
- E coli
- Chlamydia
Chronic
- Strep
- E coli
- Chlamydia
- Pelvic floor myalgia
- Elevated prostatic pressure
usual UTI ones + STI ones (chlamyd/ gonnor)
prostatitis symptoms
- Fever, rigors, malaise
- Pain on ejaculation
- Voiding LUTS (poor/intermittent stream, incomplete emptying, dribble, straining, dysuria)
- Pelvic pain
- Recurrent UTIs
urethritis causes
- Primarily sexually acquired
- Chlamydia (most common for young people)
- Gonorrhea
- Trauma
- Irritation
- Urinary calculi
- Urethral stricture
urethritis symptoms
- Skin lesions
- Penile discomfort
- Dysuria
- Discharge, blood, pus
UTI symptoms - general
LUTS
- Dysuria
- Frequency
- Urgency
UUTS
- Pyrexia
- Haematuria
- May be microscopic
Urine smells foul
UTIS investigation
Urine sample
- Dipstick
- – Nitrites (Bacteria break down nitrates → nitrites
- – Leukocytes
- – Blood
- – pH
- – Smells foul
- Microscopy - Midstream urine MSU = gold standard!!!
- – Bacteria
- – Epithelium cells
- – Wbc (pyuria)
- – Rbc
- – Casts - renal pathogen
- Culture + sensitivities (Tx)
Bloods
- FBC - raised wbc
- CRP/ESR
Imaging - US
- Rule out obstruction/ abnormal urinary anatomy and can see incomplete bladder emptying
- STI screen :Chlamydia → prostatitis, urethritis
types of urine sample
- MSU = mid stream urine (best)
- CSU= catheter - no good for urine sample
- Clean catch - anything, for kids
- SPA = suprapubic aspirate
- Early morning urine - good for TB
what does epithelium cells in urine sample indicate
= poorly taken sample. Need to repeat. No diagnosis available
Lower UTI treatment
Antibiotics
- Avoid broad spectrum (we know most causes)
- 1st line = nitrofurantoin
- Not if preggers
- Also : fosfomycin, pivmecillinam
If asymptomatic
- If >65y = no treatment
- if pregnant - treat
If uncomplicated (non-preg women) - Antibiotics 3d
If complicated
- Antibiotics 7d+
change/remove catheter
Upper UTI treatment
Co-amoxiclav = 1st line!!!!
Fluid replacement
Analgesia
Drain kidney / abscesses
Catheter - monitor output
erectile dysfunction causes
- organic
- non-organic
ORGANIC
- Smoking
- High BP
- Endocrine
- –DM
- –Thyroid
- –Hypogonadism
- –Hyperprolactinemia
- Inflammatory
- Alcohol
- Chronic disease
- Arterial disease
- Loads more
- Metabolic syndrome is a triad of these:
- – High cholesterol
- –Insulin resistance / high BP
- –Overweight /obese
NON ORGANIC
- ED is sudden + often still have early morning erections and non-coital erections (masturbation)
- Relationship difficulties
- Performance anxiety
side effects from medication eg vasodilators (B blockers, ACEi)- (i think this is organic)
what aspects of history suggest non-organic cause of erectile dysfunction
sudden onset
still early morning erections/ masturbation
erectile dysfunction investigations
history
examination
- –Palpable plaques
- –Testes size
- –DRE - prostate tender? Cancer?
- –CV examination - ECG
- –Neurological - eg MS
- –Gynaecomastia (= swelling of breast tissues in men due to hormonal imbalance
bloods
- –FBC
- – fasting glucose, fasting lipid
- – hormones (prolactine, LH, FSH, TFTs, PSA, testosterone
ultrasound/doppler penis (Rare)
nocturnal penile tumescence (Rare)
- how many erections per night and how rigid
what is required before PSA testing
counselling for it
IIEF questionnaire
is high or low score good
erectile dysfunction
How often do you experience …
Also tracks treatment
Lower score = worse
erectile dysfunction non - pharmacological treatment
Treat underlying cause if identified by investigations (eg correct hormone imbalance)
Lifestyle
- Smoking cessation
- Weight loss
- Exercise
- Lower alcohol intake
Optimise medication (if some are causing it)
Counselling - if non-organic
Vacuum device → induces erections
erectile dysfunction pharmacological treatment
inc s/e
PDE5 inhibitor —- “-afil”
- Eg viagra
- First line
- Inhibits PDE5 enzyme, so stops breakdown of cGMP
- Prolonged erection. But does not cause them (not erectogenic)- still need stimulus
- s/e: Headaches, flushing, Imparied colour vision, nasal congestion, priapism
Intraurethral therapy = medicated urethral system for erection (MUSE)
- Insert something into urethra
- Increases cAMP – activates secondary pathway for erections
Injectable therapy
- S/E: Pain, Priapism, Penile fibrosis
erectile dysfunction surgical treatment
Penile prosthesis
- Last line, rare
- Transgender, other treatments failed, priapism
1) inflatable - pump in scrotum
2) malleable - bend penis up and down
Risks - malfunction, infection, urethral perforation
priapism =
= prolonged (4h+), often painful erections without stimulus/desire
premature ejaculation
- definition
= ejaculation within 1 min of penetration
+ inability to delay it
+ negative consequences (distress, frustration, avoidance of sexual intimacy)
premature ejaculation causes
Psychological mainly
Endocrine
Parkinsons
Opioid withdrawal
premature ejaculation treatment
Counselling = main
Quiet vagina (woman lies very still and quiet)
Squeeze technique
Local topical anaesthetic
peyronies
- what is it
- symtpoms
- management
- fibrotic plaque causing bend on erection . (inner curve is where the plaque is, often on top side (facing heaven))
Aetiology unknown
- Deformity
- Pain on erection
- Can’t have penetrative intercourse
pain relief surgery - Nesbit’s = stitches on outer bend to even it out - Lue’s = remove plaque , put graft in - Penile prosthesis (if ED too)
penile fracture =
cause
symptoms
Cause = excessive bending when erect → rupture of tunica albunginea
Sudden pain (may hear a snap/pop) Immediate detumescence (loss of erection) Inability to gain erection
overactive bladder defintion
Urgency with frequency (and possibly incontinence - (wet vs dry OAB)/nocturia) in the ABSENCE of local pathology
OAB symptoms and investigations
- Urgency = always
- Frequency = always or often idk
Maybe = Incontinence (wet vs dry OAB) / Nocturia - Bladder diary
- Urodynamics - measures pressure in bladder
Detrusor overactivity - contracts suddenly, without control
OAB management
Behavioural therapy
- Bladder drill
- Try to extend storage time (reduce frequency) with bladder diary
- Decrease caffeine
- Decrease alcohol
Antimuscarinic drugs
- Block parasympathetic (detrusor contraction) by blockin M2/3receptors
- First line
B3 agonists
- Increase sympathetic activity (relaxed detrusor) at B3 receptor in bladder
Botox
- Toxin blocks neuromusculor junction for ACh release (parasympathetic nerve → bladder blocked)
catheterisation
Surgery
- Augmentation cystoplasty = bladder enlargement, using small bowel/colon/stomach
- Sacral neuromodulation = Electrode permanently inserted at S3 nerve root. Modulated afferent signals from bladder
CKD
- aka
- =?
- classification
- risk factors
chronic kidney disease / chronic renal failure
- Abnormal kidney structure or function. Present >3months. Implications for health usually progressive and irreversible
Classification - stages 1-5. Based on GFR, presence of albuminuria
- Age -Kidney function declines naturally with age
- Male
- Hypertension
- Smoking
- Diabetes
- L ventricle hypertrophy and other CV
- Dyslipidaemia
- Ethnicity =A-c
CKD causes
- most common 3
- relating to what systems
Diabetes
Hypertension
Chronic Glomerulonephritis
Congential- inherited - Polycystic kidney disease Renal - Glomerular disease - Acute kidney injury - Obstructive uropathy/ urinary tract eg enlarged prostate CVS : - Renal stenosis - Hypertension Systemic inflammatory disease - SLE - Vasculitis Interstitial disease - TB - Reflux nephropathy - myeloma
CKD presentation
Fluid overload
- SOB
- Oedema (peripheral and pulmonary)
- Anorexia
- nausea/ vomiting
- Restless legs
- Malaise
- Weakness
- hypertension
anaemia
- Pallor
- lethargy
CNS
- Confusion
- Seizures
- Coma
Renal
- Nocturia
- Polyuria (Oliguria in later stages)
- Haematuria
- smaller kidneys (bilateral)
Jaundice + pruritus
Bone
- pain
- osteomalacia
- hyperparathyroidism
CKD investigations
Blood
- u/e
- Anaemia (normochromic, normocytic)
- Glucose (Diabetes)
- Increase in phosphate
- Decrease in calcium
- Increase in PTH (in response)
Urine dipstick
- Haematuria
- Proteinuria
- Albuminuria monitored annually /6m if high risk
- – Along with GFR
Imaging - Ultrasound
- Check for kidney damage
- CKD - bilaterally small
ckd management
- 6 certi ones
- 6 other ones
- BP medication
- bisphosphonates
- vit D supplements
- stop smoking
- less salt diet
- RRT (renal replacement therapy)- dialysis.
- diuretics (not K sparing - hyperkalemia)
- fluid + salt restriction
- kidney transplant
- EPO and iron supplements
- glycaemic control (diabetes)
- statins
CKD complications
bone disease heart disease (hypertension) iron def anaemia
aki risk factors
- 10 x certis
- 7 others
- Age above 75
- Male
- Poor fluid intake
- Fluid loss -hypovolemia
- CKD, low GFR
- major surgery
- heart failure
- PVD
- sepsis
- diabetes
- nephrotoxic drugs
- prostate cancer
- chronic liver disease
- immunosuppressed
- haematological malignancy
- radiological contrast
- history of urinary symptoms
3 most common causes of AKI
Ischemia
Sepsis
Nephrotoxins
pre-renal AKI causes
Decreased renal perfusion
- Volume depletion (vom/ diar/ bleed /burns)
- hypotension, heart failure
- new drugs
- nephrotoxic drugs (Renal hypoperfusion)
- renal artery stenosis
- renal vein thrombosis
- liver failure
intrinsic renal AKI causes
disease affects structure: renal parenchyma damaged
- glomerulonephritis (inflammation of glomeruli or small vessels causing damage and leakage)
- autoimmune
- medications
- vasculitis
- acute tubular necrosis
- tumour lysis syndrome
- acute interstitial nephritis
- renal thrombosis/emboli
- infections
- contrast nephropathy
post renal AKI causes
outflow obstruction - urinary tract. stones, malignancy, external compression
- Kidney stone
- Ureter cancer
- Obstructed urinary catheter
- Retroperitoneal fibrosis
- Bladder stones
- Bladder cancer
- Prostate cancer
- Benign prostatic hyperplasia
AKI =
sudden decline in renal function – hours-days
aki signs/symptoms
- postural hypotension
- urine retention
- oliguria
- naus/vom/diarrhea
- haemoptysis
- dehydration- condusion
- thirst
- SOB
- high urea –> Fatigue, weakness, anorexia, naus/vom, confusion ,seizure, coma
- oedema
- infection
- hyperkalemic irregular heart beats
- bruising
diagnostic criteria for AKI
1 of :
- increase in SCr >26micromol/L above baseline in 48h
- Increase in SCR > 1.5xbaseline in 7 days
- Urine output <0.5ml/hg/hr for >6 consecutive days
aki investigations
medication review - esp recently started ones
bloods
- raised SCr
- liver enzymes
- u/e
- cultures- exclude infection
- autoantibodies (antiGBM, ANCA)
- albumin levels,
- eGFR
- FBC
urine
- output amount
- dipstick
- cultures - exclude infection
ultrasound (/CT)
- Size
- Obstruction
- Cysts
- Masess
examination for fluid balance
- oedema
- skin turgor
- pulse
aki treatment :
general and for each cause
Pre renal
- Correct fluid balance/ volume depletion
- Increase renal perfusion via circulatory/cardiac support
- Treat sepsis with antibiotics
Intrinsic renal
- Refer to nephrology for biopsy and specialist treatment
Post-renal
- Catheterise
- Maybe CT renal tract
- Urological intervention
- Treatment of stones
- Nephrostomy = tube from kidney out to skin to collect urine
general
- Stop nephrotoxins
- dialysis = renal replacement therapy (RRT)- haemofiltration and haemodialysis
treat symptoms/ complications
- Treat acidosis - sodium bicarbonate
- for oedema/ fluid overload= diuretics
- fluid resuscitation/ fluid restrict in hypovolemia.
- if Hyperkalemic =
- – Insulin + dextrose
- – Salbutamol
- – Calcium gluconate (cardio-protective)
nephrotoxic drugs affect how? (specific examples)
NSAIDs - afferent arteriole vasoconstriction
ACEi - decrease GFR
aminoglycosides - tubular necrosis
types of RRT
dialysis = renal replacement therapy (RRT)
haemofiltration = more common, removes solutes by convection
haemodialysis= removes solutes by diffusion
CKD stages (based on GFR)
and what is normal
normal = 120
Stage 1 > 90 ml/min with evidence of renal damage
Stage 2 60-89 ml/min with evidence of renal damage
Stage 3a 45-59 ml/min with or without renal damage
Stage 3b 30-44 ml/min with or without renal damage
Stage 4 15-29 ml/min with or without renal damage
Stage 5 <15 ml/min, established renal failure
budd chiari
- triad
- pathophysology
ascites
liver enlargement
abdominal pain
hepatic vein obstruction (thrombus normally, tumour) causes liver ischaemia and therefore liver failure
coeliac 1st line test
IgA TTG
small bowel history also NEEDED for diagnosis (but not 1st line)
what is the 1st line investigation for renal stones if the patient is young/ pregnant
renal ultrasound
first line treatment for erectile dysfunction
then what
phosphodiesterase inhibitors – viagra
then intravenous injections / vacuum device
then penile prostethis
type of flow with prostate cancer
hesitant, weak flow
