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SCA > Kidney/Urology > Flashcards

Kidney/Urology Flashcards

1
Q

AKI - definition

A

Serum creatinine rise of ≥26 μmol/L within 48 hours.
≥50% rise in serum creatinine known or presumed to have occurred within the past 7 days.
A fall in UO to <0.5 mL/kg/hour for >6 hours in adults or >8 hours in children and young people. 25% or greater fall in eGFR in children and young people within the past 7 days.

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2
Q

AKI Management

A

Urinalysis +/- urg. USS
RV. nephrotoxic drugs -ACEi, ARB, Metformin, Diuretics, NSAIDs

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3
Q

What is CKD?

A

ACR ≥3 (any eGFR)
eGFR <60

Repeat test in 2 weeks to exclude AKI

Repeat test in 3 months to confirm diagnosis

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4
Q

When should ACR be done, and what needs to be avoided?

A

ACR - 1st urine of the day
Avoid meat 12hr pre-test

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5
Q

When is CKD progressive?

A

Change in CKD category/12 months or ↓eGFR 25% or 15 mL/min/1.73 m2/year.1

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6
Q

What other investigations should be done in CKD?

A

FBC (?Anaemia) and if eGFR <30, calcium, phosphate, PTH and vitamin D.
Urine dip for haematuria. Use ACR (not dipstick) for protein measurement.
Renal USS if eGFR <30, progressive CKD, haematuria, FH PCKD or obstruction or may require a renal biopsy.

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7
Q

What is the management of CKD?

A

Offer Statin as primary prevention

BP <140/90 in diabetics <130/80 (SBP >120)

Consider starting ACEi - for renal protection: if ACR (mg/mmol): ≥70 or ≥ 30 + HTN or ≥3 + DM and K <5 mmol/L. Stop if change of eGFR ↓25% or creatinine ↑30% or K ≥6 mmol/L.

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8
Q

When to refer CKD

A

-eGFR<30
-ACR >70
-ACR >30 + haematuria.
-Progressive CKD
-Suspected renal artery stenosis
-≥4 antihypertensives.

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9
Q

When to check PSA

A
  • Associated LUTS.1
  • Visible haematuria.1
  • Erectile dysfunction.1
  • Unexplained symptoms (such as lower back ache, weight loss and bone pain) – might be due to
    secondaries.
  • Men aged >50 afer counselling (even if asymptomatic*).
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10
Q

PSA counselling points

A
  • Prostate cancer is not the only cause of a raised PSA.
  • PSA cannot distinguish between aggressive and slow-growing cancers that would never have caused a
    problem.
  • 15% of men with prostate cancer will have normal PSA.
  • Prostate biopsies are negative in three out of four men with raised PSA.
  • Prostate biopsy may cause infection and bleeding.
  • Treatment of prostate cancer includes surgery, radiotherapy, hormones with side efects of incontinence,
    ED and fertility loss.
  • NOT having test will avoid side efects of treatment–but may mean that early treatable cancers are
    missed
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11
Q

When should a 2WW referral be sent for prostate

A
  1. Abnormal PSA levels. Normal is 0–4 but the PSA test is not diagnostic and the upper level varies accord- ing to race and age. NICE recommends 2WW referral for any man with PSA > age-specifc range.1
  2. Suspicious prostate on DRE.1
    Signifcant rise in PSA whilst taking a 5-alpha reductase inhibitor.3
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12
Q

When could a PSA be artificially raised

A

PSA rises in cancer, BPH, UTI, exercise (e.g. cycling), ejaculation, urinary retention or surgical intervention, e.g. fexible cystoscopy.

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13
Q

Acute prostatitis
-What are 3 sx

A

Febrile illness, urinary symptoms + perineal/suprapubic pain.

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14
Q

Acute prostatitis:
-What is found on exam?
-What investigations are needed?

A

Exquisitely tender prostate, leucocytes on urine dipstick.
MSU and STI screening. Blood cultures.

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15
Q

Chronic prostatitis:
-What are the two types?

A
  1. Chronic bacterial prostatitis (10%).
  2. Chronic prostatitis/chronic pelvic pain syndrome (CPPS = 90%).
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16
Q

What are 3 different areas of symptoms that can be found in chronic prostatitis?
How is symptom severity assessed?

A

Pain: Perineum, inguinal, suprapubic, penis, scrotum, testes, rectum, lower back or abdomen.
LUTS: Hesitancy, urgency, poor stream, terminal dribbling, frequency, nocturia or dysuria.
Sexual: ED, painful ejaculation, premature ejaculation or decreased libido.

National Institute of Health Chronic Prostatitis Symptom Index or IPSS.

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17
Q

What investigations are indicated in chronic prostatitis?

A

-Urine dip and MSU (try sending MSU afer DRE to increase microbiology yield). -Consider full STI screen (esp. if <35 years or new partner).
-Bloods: Consider PSA testing and routine bloods, e.g. FBC, U&E and CRP.
NB: MSU may be negative in chronic bacterial prostatitis so look for old MSUs.

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18
Q

what is the mgt of chronic prostatitis?

A

4–6 weeks antibiotic (check local guidance).
NICE – ciprofoxacin, ofoxacin or trimethoprim if quinolones not tolerated/allergy. Trial alpha-blocker if LUTS present.
Paracetamol ± NSAID, laxatives if constipation also present.

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19
Q

Describe the conservative mgt of overactive bladder/storage LUTS?

A
  • Bladder training.
  • Avoid cafeine and alcohol. Carbonated sof drinks and fruit juice may aggravate symptoms.
  • Avoidance of dehydration (concentrated urine can exacerbate the problem).
  • Weight loss may help.
  • Pelvic foor exercises may help men, especially if history of stress incontinence as well.
  • Ofer containment devices, e.g. pads or external sheaths to help whilst problem is being investigated.
20
Q

Describe 1st line pharmacological mgt of overactive bladder

A

Ofer antimuscarinic (anticholinergic) – oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation) can be used frst line. If frst line fails, ofer alternative.

21
Q

What are common sid effects of antimuscarinics?

A

Common side efects of antimuscarinics: dizziness, drowsiness, dry mouth, blurred vision, constipation, headache, indigestion and abdominal pain. Do not ofer oxybutynin (immediate release) to frail older men due to the risk of impairment of daily functioning, chronic confusion, or acute delirium (less common).

22
Q

Describe 2nd line pharmacological mgt of overactive bladder?

A

Second line (if antimuscarinic contraindicated or inefective): mirabegron.

23
Q

When to refer to urology for UTI?

A

UTI fails to respond to antibiotics.1
Recurrent UTI – two or more in a 3-month period and no haematuria.
‘Even if >60 years – NICE advise this is a non-urgent referral.’
Genitourinary history suggests a cause or risk factor: e.g. stones, operations, bladder outfow obstruction.1 Persistent microscopic haematuria and normal renal function.1
If renal function impaired or proteinuria – refer to renal.

24
Q
A
24
Q

When to refer to urology under 2WW

A

> 45 - unexplained visible haematuria, visible haematuria which persists/recurs after tx for UTI
60 unexplained non-visible haematuria AND dysuria or raised WCC
Mass - clinically or on imaging

Remember to use dipstick (not microscopy) to assess for haematuria and if one dipstick is positive → TWO more dipsticks are required. If EITHER of these shows a haematuria → refer (speed of referral depends on age as above).3 1+ on dipstick or more is signifcant. Routine referral if persistent non-visible haematuria which doesn’t meet the above criteria for suspected cancer pathway referral.

25
Q

Erectile dysfunction - what should be done for assessment?

A

Hba1c, lipids, Serum testosterone (9-11am), If the serum testosterone level is low or borderline, arrange a repeat serum testosterone, together with follicle-stimulating hormone (FSH), luteinizing hormone (LH), sex hormone binding globulin, and prolactin levels.

25
Q

How is perisistent invisible haematuria in absence of proteinuria followed up?

A

Haematuria follow-up. ‘Persistent invisible haematuria in the absence of proteinuria should be followed up annually with repeat testing for haematuria, proteinuria or albuminuria, GFR and BP monitoring as long as the haematuria persists.’ 3

26
Q

Sildenafil:
-What are the contraindications
-What are the side effects?
-What are the drug interactions?

A

CI include: already on a nitrate, unstable angina, recent MI or stroke, optic neuropathy.
Side efects: headaches, fushing, N&V, dizziness and visual disturbances. Interactions: no alpha-blocker within 4 hours.

26
Q

What is involved in the assessment of erectile dysfunction?

A

HbA1c, Lipids, Testosterone (between 9-11am), offer PSA screening
Physical exam (BP/BMI/ signs low testosterone/genital exam) and DRE

If the serum testosterone level is low or borderline, arrange a repeat serum testosterone, together with follicle-stimulating hormone (FSH), luteinizing hormone (LH), sex hormone binding globulin, and prolactin levels.

27
Q

Sildenafil:
-Contraindication
-Side effects
-Interactions

A

CI include: already on a nitrate, unstable angina, recent MI or stroke, optic neuropathy.
Side efects: headaches, fushing, N&V, dizziness and visual disturbances. Interactions: no alpha-blocker within 4 hours.

28
Q

What are second line options to treat erectile dysfuntion?

A

2nd line tadalafl (Cialis) with a longer duration of effect (also helps outflow sx)
Vacuum pumps. MUSE (alfraprostadil per urethra) and caverject.2
Relationship counselling3 or a referral to psychosexual medicine may be helpful. Show you have recognised the opportunity for health screening and promotion.

29
Q

What is involved in the well man check?

A

CVD RFs, prostate and testicular screening, weight and bowel changes, stress/mood.

30
Q

Describe conservative mgt of BPH

A

Reduce caffeine, alcohol, bladder exercises

31
Q

Tamsulosin
-What is this?
-What are the side effects?

A

Alpha blocker

Explanation to patient: ‘Acts by relaxing the prostate.’

Side efects: drowsiness, light-headedness from low BP and retrograde ejaculation, which
some men fnd very troublesome. Review afer 4–6 weeks.

32
Q

Finasteride
-What is this?
-Side effects?
-How quickly does this work?
-contraindications?

A

5-alpha reductase inhibitor
Explanation to patient: ‘Acts by blocking the conversion of testosterone to a stronger hormone
which increases the size of the prostate.’
Side efects: loss of libido, ED, ejaculation problems and gynaecomastia. Review in 3–6 months but can take up to 6 months to work.
Reduces PSA so avoid use if watchful waiting.

33
Q

TURP - what are the risks?

A

90% risk of retrograde ejaculation. Other risks: incontinence, infection, retention, need for re-TURP, ED, strictures, bleeding, TURP syndrome and death.2

34
Q

What is the conservative mgt of prostate ca?

A

Watchful waiting (usually frail elderly) or active surveillance (regular MRIs ± biop- sies) – usually in men with low-risk cancers.

35
Q

What are the hormonal tx of prostate ca, what is the other tx?

A

Bicalutamide or cyproterone acetate prior to giving goserelin analogue.3

Goserelin – check LFTs 6 monthly.

Chemotherapy (increasing role of chemotherapy in metastatic prostate cancer) and radiotherapy.

Total/radical prostatectomy.

36
Q

Bedwetting:
-when is bed wetting normal up to?
-What is primary vs secondary?
-What needs to be established?
-What is involved in examination

A

-Age 5
-Primary, never been continent
-Secondary, previously continence for 6mths
-Pattern of bedwetting, daily fluid intake. Can use a diary. Any stressors?
-Urinalysis glucose

37
Q

what treatments can be used for bed wetting?

A

if child over 5:
-rapid/short term can use desmopressin
-If long-term tx use enuresis alarm.
-Wait and see if infrequentWh

37
Q

What advice should be given to parents for bedwetting?

A

Diet/fluid - don’t restrict diet, adequate fluids, avoid caffeine
Toileting patterns - empty bladder 4-7 times and before bed. waterproof mattress/duvet cover, quilted sheets, bed pads. Easy acces to toilet/potty. If a child toilet trained by day, trial 2 nights in a row with no nappies.
Lifting/waking - if wakes take to toilet but waking is only appropriate in short term
Positive reward systems for dry nights/emptying bladder at night

38
Q

When to refer for bed wetting

A

Not responded to at least 2 complete courses of tx of either enuresis alarm/desmopressin

39
Q

Desmopressin
-how is this used?
-how is this prescribed?

A

-Rapid or short term improvement, take at bedtime, only have sips fluid 1hr prior to taking and eight hrs post
-Use 1 week before event
-Start with low dose (desmotabs 200mcg)
-Inc dose if not full effective after 2 weeks (desmotabs 400mcg)

40
Q

Desmopressin
-Monitoring

A

-Rv after 4 weeks
-Cont for 3mths if improvement
-stop for 1 wk after 3 mths
-rpt course if needed
-if partial improvement increase dose or take 1-2hrs before bedtime
-continue for another 6mths if needed

41
Q

Desmopressin
-Advice for carers

A

-avoid swallowing pool water
-avoid NSAIDs
-stop during D+V
-safety net in asthmatics, can worsen SOB/wheeze due to fluid retention.

42
Q
A

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