Kidney & GU Flashcards
Name an upper UTI
Pyelonephritis
Name the lower UTIs
Cystitis
Prostatitis
Urethritis
Epidydmo-orchitis
Causes of UTI
BACTERIAL!
KEEPS
Klebsiella
E.coli - (uropathogenic E.coli = 80% of UTIs)
Enterobacter
Proteus
Staph. spp - coag neg e.g. saprophiticus
Ix for ALL UTIs
1st - urine dipstick
+ve leukocytes
+ve nitrites
+/-ve haematuria
GS : Midstream (MCS)
Confirms UTI, identifies pathogen
–
Prostatitis has its own GS, Mid MCS is used for its 1st line
What does MCS stand for?
Microscopy
Culture
Sensitivity
Where do the bacteria adhere to in UTI?
Urothelium
Vaginal epithelium
Vaginal mucus
When is a UTI complicated?
Pregnant
Males
Catheterised Pxs
Recurrent/persistent infection
Immunocomp
Structural abnormality
Urosepsis
What is Pyelonephritis?
Infection of renal parenchyma and soft tissues of renal pelvis and upper ureter
Key presentation of Pyelonephritis
TRIAD OF :
1. Loin/flank pain
2. Fever
3. Pyuria
What other symptoms might present in Pyelonephritis?
Back pain
Severe headache
N+V
Associated cystitis symptoms
What other Ix might you do for a patient with Pyelonephritis?
URGENT US to detect stones, obstruction or incomplete bladder emptying
Tx Pyelonephritis
Hydration / Fluid replacement
IV Abx -
broad spectrum e.g. oral co-amoxiclav, oral ciprofloxacillin
if severe - IV gentamicin or IV co-amoxiclav
If pregnant - cefalexin
What is Cystitis?
Infection of the bladder
Cystitis occurs in whom?
Children
Females
Pregnancy
People w catheters
Why are women more susceptible to Cystitis?
Shorter urethra
∴ short proximity to anus
∴ allows bacteria transfer
Key Presentation of Cystitis
HD FUSS
Haematuria
Dysuria
Frequency
Urgency
Suprapubic pain
Smelly urine
+ confusion in elderly
Tx Cystitis
Trimethoprim/Nitofurantoin
(3 day course for women, 7 day for men/complicated women)
In pregnancy
Trimeth cannot be used in 1st tri
Nitrofurantoin cannot be used in 3rd tri
∴ amoxicilin, cefalexin can both be used
What is Urethritis?
Urethral inflammation due to infectious or non-infectious causes
Causes of Urethritis
Sexually acquired disease!
N. Gonorrhoea
Chlamydia
Trauma
Urethral stricture
Irritation
Urinary calculi
Key presentation of Urethritis
Dysuria +/- discharge, blood or pus
Skin lesion
Urethral pain
Penile discomfort/pruritus
What other Ix can be done for Urethritis?
NAAT (Nucleic Acid Amplification Test) - detects STI type for treatment
How is a NAAT taken?
Females - self-collected vaginal swab
endo-cervical swab
first void urine
Males - first void urine
Tx Urethritis
N. Gonorrhoea - IM ceftriaxone and oral azithromycin
Chlamydia trachomatis - Azithromycin or doxycycline
–
Partner notification
Major complication of Urethritis
Reactive Arthritis
What is Epididymo-orchitis?
Inflammation of epididymis extending to tests, usually due to cystitis or urethritis
Key presentation of Epididymo-Orchitis
Unilateral scrotal pain and swelling
Pain relieved with elevating tests - Pos Prehn’s sign!
Cremaster reflex INTACT
What is Prehn’s sign?
Relief when testes is lifted
What is important to rule out with Epididymo-Orchitis? Why?
Testicular torsion! bc urological emergency!!
What other Ix can you do with Epididymo-Orchitis?
NAAT - detest STI type for treatment
Tx Epididymo-Orchitis
Depends on where
What are features that suggest testicular torsion rather than Epididymo-Orchitis?
Short duration of pain - very acute, sudden
Associated nausea, abdo pain
High-riding/bell-clapper testis
Scrotal elevation only relieves pain in epididymitis, NOT IN TORSION (i.e. torsion = Prehn’s sign -ve)
Tx Epididymo-Orchitis
N. Gonorrhoea - IM ceftriaxone and oral azithromycin
UTI - Trimethoprim/Nitofurantoin
(3 day course for women, 7 day for men/complicated women)
Cause of Epididymo-Orchitis
Under 35 years - Urethritis
Over 35 years - Cystitis
Mumps
Trauma
In elderly - catheter!!
What is prostatitis associated with?
LUTS
Causes of Prostatitis
Acute :
Strep. faecalis
E. coli
Chlamydia
Chronic :
Bacterial ^
Non-bacterial e.g. ↑ Prostatic pressure, pelvic floor myalgia
DDx Epididymo-Orchitis
Testicular torsion !!!!!!!!!!!!!
Hydrocele
Trauma
Abscess formation
Presentation of Prostatits
Systemically unwell + Significant voiding LUTs
Chronic is above > 3 months
Describe voiding LUTs
Straining
Poor stream
Hesitancy
Incomplete emptying
Post micturition dribbling
Dysuria
Ix for Prostatitis
GS : DRE !!!!!
prostate is tender or hot, hard from calcification
Tx Prostatitis
Acute :
1st - gentamycin + IV co-amoxiclav
2nd - trimethoprim
Chronic :
4-6 week course of quinolone e.g. ciprofloxacin
+/- a-blocker - Tamsulosin
What is BPH?
Benign proliferation of transitional zone of prostate, WITHOUT MALIGNANCY
Function of prostate
Testosterone and Dihydrotestosterone production
Seminal fluid production
Regulation of urine flow
RF BPH
Age > 60!
Fhx
DM
Heart disease
Obesity
Key presentation of BPH
LUTS (freq, urgency, dribbling, weak stream, nocturia)
Ix BPH
DRE - smooth and enlarged prostate
Prostate specific antigen
Urine test
Tx BPH
Tamsulosin, FInasteride
Nephrotoxic drugs
NSAIDs
Acei
Gentamicin
Amphotericin
Metformin
Types of Prostate cancer
Adenocarcinoma
Transitional cell carcinoma
Small cell prostate cancer
RF Prostate cancer
Mean age = 72
High testosterone levels
FHx
Obesity
Where does prostate cancer usually arise from?
Peripheral zone - far away from urethra
∴ can grow signif before affects anything
What do granular casts indicate?
Active renal disease
Ix prostate cancer
DRE - hard, irregular prostate
PSA (non-specific)
Ultrasound & MRI (trans-rectal ultrasound scann - TRUSS)
GS : BIOPSY!
+ Gleason grading!
Describe Gleason Grading
Histological grades of 2 cell patterns
Add 2 most common together
Higher score = more aggressive
1 - Small, uniform glands
2 - More space between glands
3 - Distinct infiltration of cells from glands at margin
4 - Irregular masses of neoplastic cells, few glands
5 - Lack of/Only occassional glands, sheets of cells
Tx Prostate cancer
Radical prostatectomy (surgery)
Radio/Chemotherapy
Hormonal therapy :
GnRH agonist - Zoladex
RF Bladder cancer
55+
FHx
Smoking = 2-4x risk
Bladder stones
Occupational risk - carcinogen exposure
Male
Key presentation of bladder cancer
Painless haematuria
Frequency
Back pain
Ix bladder cancer
Urinalysis
GS :
Cytoscopy and biopsy
CT urogram - allows staging
Other : CT, MRI, bone scan
Tx Bladder cancer
Depends on staging
NON-muscle invading bladder cancer :
T1 - transurethral resection (TURBT) or local diathermy
Muscle invasion :
T2-3 - radical cystectomy
T4 - palliative chemo and radiotherapy
What is Hydrocele?
Build up of fluid in the tunica vaginalis
Key presentation of Hydrocele
Soft, non-tender lump
Painless swelling
Ix Hydrocele
Shine light through sctorum
FBC - check for infection
Tx Hydrocele
Usually resolves spontaneously
Surgical drainage
What is Varicocele?
Enlargement of testicular veins
“Bag of worms”
Key presentation of Varicocele
Dull ache, scrotal heaviness, mass
“Bag of worms”
Ix Varicocele
Venography
Colour doppler ultrasound
Tx Varicocele
Surgery if pain, infertility or testicular atrophy
What is testicular torsion?
Medical emergency!!
Twisting of spermatic cord
Presentation of Testicular torsion
Acute, severe pain
Unilateral and swollen
Prehn’s sign -ve
Abd pain
N+V
Ix Testicular torsion
DO NOT DELAY SURGERY
Doppler ultrasound
Urine test
Tx Testicular torsion
Surgical intervention!
The quicker, higher the salvage rate
What is epididymitis?
Inflammation of epididymis
Causes of epididymitis
Infection
STI
Trauma
Presentation of epididymitis
Acute pain
Unilateral
Prehn’s sign +ve
Ix epididymitis
STI screening
Ultrasound
Bloods
Urine testing
Tx epididymitis
Abx - IM Ceftriaxone and doxycycline
At what age do epididymal cysts usually occur?
~ 40 years
Where are epididymal cysts positioned in regards to the tests?
Lie above and behind
Key presentation of epididymal cysts
Lumps - often multiple
Can be bilateral
Are transluminate (bc fluid-filled)
How can you differentiate between epididymal cyst and hydrocele?
Transillumination
Testes palpable separately from cysts in epididymal cyst
Ix epididymal cyst
Transillumination
Scrotal ultrasound
Tx epididymal cyst
Usually not necessary
Surgery if painful and symptomatic
What is the most common cancer in males 15 - 44?
Testicular cancer
Key presentation of Testicular cancer
LUMP! (can be painless/painful) in testicle
Heaviness
Dull ache
Swelling
Gynecomastia
Back pain
What does cough and dyspnoea indicate with testicular cancer?
Lung metastases
Testicular torsion can lead to ischaemia. What cells are the most susceptible to ischaemia?
Germ cells
With testicular torsion, when should you aim to perform surgery?
Within 6 hours of presentation
Which testis is more commonly affected with testicular torsion?
Left
DDx of Testicular torsion
Epididymo-Orchitis !
But px tends to be older and symptoms of UTI are also present
More gradual onset of pain
Cause of Torsion of testicular appendage
Surge in gonadotrophins that signal onset of puberty
∴ usually occurs in boys between 7-12 years
How does testicular appendage torsion present?
Less pain than testicular torsion
Small blue nodule under scrotum
BPH is
A histological diagnosis
BPE (benign protastic enlargement)
A clinical diagnosis
Ix Testicular Cancer
Ultrasound
Biopsy and histology - fried-egg cells
Serum tumour markers - AFP (alpha feto-protein) and/or B-hCG)
Lactate dehydrogenase
Normal AFP - seminoma
↑ AFP & ↑ B-hCG - non-seminoma germ cell tumours
Types of Testicular cancer
96% germ cells -
Seminomas - most common! 25 - 40, 60+
Teratomas - infancy
Non-germ cells
Leydig cell tumours
Sertoli cell tumours
Sarcomas
