GU top tier Flashcards
1
Q
renal colic epidemiology
- age
- gender
- commonness
- recurrence
A
- 30-50 (young) but rare in children
m>f
common
recurrent often
2
Q
risk factors for renal colic
A
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
3
Q
prevention of renal colic. name 5
A
- Hydration
- Low calcium diet
- low salt (na) diet (lowers ca)
- Normal dairy intake
- Low protein diet
- Reduced BMI
- active lifestyle
4
Q
renal colic cause
made from
A
renal stones form when solute concentrations exceed saturation + trigger
Most = calcium oxalate and second most = calcium phosphate. Also stones made of uric acid/ cystine
5
Q
name some high oxalate foods
A
spinach
rhubarb
choc
tea
6
Q
stones in the urinary tract (renal colic)
- where
- which in where
A
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
7
Q
hydronephrosis vs pyonephrosis
A
both result from renal colic stone obstruction
kidney swells, unable to drain
hydro= water; pyo = pus (= infected!!)
8
Q
presentation of renal colic
A
- most= asymptomatic
- recurrent UTIs
- pain
- – radiates: loin to groin; to ipsilateral testis/labia
- – colic (waves, with peristalsis)
- – rapid onset
- – severe
- restless/writhing
- naus/vom
9
Q
renal colic investigations
A
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
10
Q
renal colic management
A
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
11
Q
infected obstructed kidney- sepsis
- =?
- prognosis
- presentation
- treatment
A
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
12
Q
kidney cancer
- gender
- age
- commonness
- race
A
m>f
Age related - commonly presents late 50s, peak 80-85
Common
Czech republic
13
Q
kidney cancer risk factors
A
smoking Obesity Environmental : leather, petroleum, asbestos Hormonal estrogen level high Genetic Von hippel lindau (VHL) mutation Hypertension Renal failure + hemodialysis Polycystic kidneys
14
Q
upper tract TCC=
treatment
A
- 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 )
15
Q
kidney cancer presentation
- classic triad (3)
- signs (4)
- symptoms (5)
A
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)
16
Q
kidney cancer investigations
A
- 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
17
Q
kidney cancer management
A
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
18
Q
bladder cancer
- age
- gender
- commonness
A
Increased risk with age. Incidence peaks in 80s
Male
Common
19
Q
bladder cancer risk factors
A
- 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
20
Q
what type of cancer is bladder cancer
A
transitional cell carcinoma
- most common TCC
21
Q
bladder cancer symptoms
A
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
22
Q
bladder cancer investigations
A
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
23
Q
bladder cancer management
- non -muscle invasive (Ta/T1)
- localised muscle invasion (T2)
- metastatic
- +… for aggressive cancer
A
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
24
Q
bladder cancer metastases, via different routes
A
Local → pelvic structures
Lymphatic → to iliac and para-aortic nodes
Haematogenous → to liver and lungs
25
testicular cancer
- prognosis
- age
- gender
Most common cancer in young males (20-44)
- Rare below 15
- Rare over 60
Nicely curable
men, silly!!
26
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
```
27
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
28
testicular torsion=
twisting of spermatic cord, which supplies blood to testis
29
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!)
30
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
31
testicular cancer management
- Radical orchiectomy (testes removal)
- Seminomas with metastases below diaphragm = radiotherapy
- Widespread tumour = chemo
- Teratomas = chemotherapy
- Sperm storage (sterility)
32
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
33
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
34
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
35
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
36
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
37
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)
38
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
39
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
40
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
41
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
42
BPH
- commonnes
- age
- race
- castration?
Common
Increases with age
A-C
castration is protective as testosterone needed (although not the cause)
43
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??
44
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)
45
bph symptoms
```
= LUTS
Nocturia
Frequency
Post-micturition dribbling
Hesitancy
Overflow incontinence
Haematuria
Bladder stone
Incomplete emptying of bladder
```
46
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
47
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
48
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
49
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
50
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
51
indications for bph surgery
```
RUSHES
Retention
UTIs
Stones
Haematuria
Elevated creatinine due to BOO (bladder outflow obstruction)
Symptom deterioration
```
52
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
53
syphillis pathogen
treponema pallidum
54
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
```
55
genital ulcer = what til proven otherwise
syphilis
56
syphilis
- gender
- age
- high risk =
m>f
broad age range
MSM (then hetero m)
57
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
58
syphilis treatment
- Prevent spread (highly infectious)
- Prevent complications (see late syphilis)
- Penicillin injection (usually just 1 if early syph)
- Partner notification
59
chlamydia pathogen
Chlamydia trachomatis
60
gonorrhea pathogen
Neisseria gonorrhoeae
61
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
62
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)
63
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
64
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)
65
diagnosis of chlamydia
NAAT nucleic acid amplification test (PCR)
f- vaginal swab (or first void urine but less sensitive)
m- first void urine
66
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
67
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
68
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
69
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
```
70
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
71
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
72
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)
73
what is in pyuria
pus - leukocytes
74
types of bacteriuria
asymptomatic
Uncomplicated (= non-pregnant women (small category))
Complicated
- Pregnant
- Men
- Catheter
- Children
- Recurrent / persistent
- Immunocompromised
75
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)
76
pyelonephritis
- pathogen
- routes of infection
- gender
- age
```
e coli
Ascending bladder up to kidneys
Haematogenous
Lymphatics (rare)
women
<35
```
77
pyelonephritis
- classic triad
- other symtpoms
Loin pain (+tender)
Fever
Pyuria
```
oliguria
significant bacteriuria
Rigors
Sepsis
Fluid depleted
-- Headaches
-- Malaise
-- naus/vom
```
78
pyelonephtiris investigation
- abdominal exam
- Blood inc cultures
- U/S to rule out obstruction
- MSU - urine analysis
79
pyelonephritis treatment
Fluid replacement
- + water
- + cranberry juice
IV antibiotics
- Co-amoxiclav = 1st line
- 7-14d
Analgesia
Drain kidney
Catheter - monitor output
80
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
81
cystitis
- infection of?
- pathogen?
- risk factors
bladder
E coli
- Urinary obstruction/ Poor emptying → stasis
- Bladder epithelial damage
82
cystitis signs and symptoms
- Foul smelling urine
- Cloudy urine
- abdom/loin tenderness
- Haematuria
- Dysuria
- Frequency
- Urgency
- Suprapubic pain
83
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)
84
prostatitis symptoms
- Fever, rigors, malaise
- Pain on ejaculation
- Voiding LUTS (poor/intermittent stream, incomplete emptying, dribble, straining, dysuria)
- Pelvic pain
- Recurrent UTIs
85
urethritis causes
- Primarily sexually acquired
- Chlamydia (most common for young people)
- Gonorrhea
- Trauma
- Irritation
- Urinary calculi
- Urethral stricture
86
urethritis symptoms
- Skin lesions
- Penile discomfort
- Dysuria
- Discharge, blood, pus
87
UTI symptoms - general
LUTS
- Dysuria
- Frequency
- Urgency
UUTS
- Pyrexia
- Haematuria
- May be microscopic
Urine smells foul
88
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
89
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
90
what does epithelium cells in urine sample indicate
= poorly taken sample. Need to repeat. No diagnosis available
91
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
92
Upper UTI treatment
Co-amoxiclav = 1st line!!!!
Fluid replacement
Analgesia
Drain kidney / abscesses
Catheter - monitor output
93
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)
94
what aspects of history suggest non-organic cause of erectile dysfunction
sudden onset
still early morning erections/ masturbation
95
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
96
what is required before PSA testing
counselling for it
97
IIEF questionnaire
| is high or low score good
erectile dysfunction
How often do you experience …
Also tracks treatment
Lower score = worse
98
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
99
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
100
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
101
priapism =
= prolonged (4h+), often painful erections without stimulus/desire
102
premature ejaculation
| - definition
= ejaculation within 1 min of penetration
+ inability to delay it
+ negative consequences (distress, frustration, avoidance of sexual intimacy)
103
premature ejaculation causes
Psychological mainly
Endocrine
Parkinsons
Opioid withdrawal
104
premature ejaculation treatment
Counselling = main
Quiet vagina (woman lies very still and quiet)
Squeeze technique
Local topical anaesthetic
105
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)
```
106
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
```
107
overactive bladder defintion
Urgency with frequency (and possibly incontinence - (wet vs dry OAB)/nocturia) in the ABSENCE of local pathology
108
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
109
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
110
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
111
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
```
112
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
113
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
114
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
115
CKD complications
```
bone disease
heart disease (hypertension)
iron def anaemia
```
116
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
117
3 most common causes of AKI
Ischemia
Sepsis
Nephrotoxins
118
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
119
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
120
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
121
AKI =
sudden decline in renal function -- hours-days
122
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
123
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
124
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
125
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)
126
nephrotoxic drugs affect how? (specific examples)
NSAIDs - afferent arteriole vasoconstriction
ACEi - decrease GFR
aminoglycosides - tubular necrosis
127
types of RRT
dialysis = renal replacement therapy (RRT)
haemofiltration = more common, removes solutes by convection
haemodialysis= removes solutes by diffusion
128
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
129
budd chiari
- triad
- pathophysology
ascites
liver enlargement
abdominal pain
hepatic vein obstruction (thrombus normally, tumour) causes liver ischaemia and therefore liver failure
130
coeliac 1st line test
IgA TTG
| small bowel history also NEEDED for diagnosis (but not 1st line)
131
what is the 1st line investigation for renal stones if the patient is young/ pregnant
renal ultrasound
132
first line treatment for erectile dysfunction
| then what
phosphodiesterase inhibitors -- viagra
then intravenous injections / vacuum device
then penile prostethis
133
type of flow with prostate cancer
hesitant, weak flow
