MET3 Revision: Urology III Flashcards
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
A 34-year-old female presents to her General Practitioner after noticing sudden-onset hair growth, particularly in the facial region. She is becoming increasingly embarrassed by this. She is keen to have the problem sorted. Blood tests were performed, with the only abnormality being a testosterone level of 10.4 nmol/l l (reference range 0.8–3.1 nmol/l).
What is the next step in her management? [1]
A 34-year-old female presents to her General Practitioner after noticing sudden-onset hair growth, particularly in the facial region. She is becoming increasingly embarrassed by this. She is keen to have the problem sorted. Blood tests were performed, with the only abnormality being a testosterone level of 10.4 nmol/l l (reference range 0.8–3.1 nmol/l).
Refer to Endocrinology as a suspected cancer referral
This patient’s history of sudden-onset hair growth and her raised testosterone level necessitates an urgent referral for suspected malignancy.
A 38-year-old male arrives at the Emergency Department complaining of intense left flank pain that extends to the groin area. The presence of blood in the urine, as indicated by urinalysis, raises suspicion of a renal stone. An ultrasound scan of the kidneys, ureters, and bladder (KUB) reveals a likely stone in the left ureter.
What is the most appropriate imaging modality to visualise a ureteric renal stone?
Non-contrast computed tomography (CT) KUB
Micturating cystourethrogram
Magnetic resonance imaging (MRI) KUB
Plain radiography KUB
Intravenous urography (IVU)
A 38-year-old male arrives at the Emergency Department complaining of intense left flank pain that extends to the groin area. The presence of blood in the urine, as indicated by urinalysis, raises suspicion of a renal stone. An ultrasound scan of the kidneys, ureters, and bladder (KUB) reveals a likely stone in the left ureter.
What is the most appropriate imaging modality to visualise a ureteric renal stone?
Non-contrast computed tomography (CT) KUB
Micturating cystourethrogram
Magnetic resonance imaging (MRI) KUB
Plain radiography KUB
Intravenous urography (IVU)
A 30-year-old male has a right inguinal mass. On examination, the left testis is palpated in the scrotum and is of normal size, but the right testis cannot be palpated in the scrotum. An ultrasound scan shows that the inguinal mass is consistent with a cryptorchid testis.
What is the most appropriate treatment?
Put it into the scrotum surgically (orchidopexy)
Remove it (orchidectomy)
Remove it along with the opposite testis (bilateral orchidectomy)
Start the patient on testosterone
Perform a chromosome analysis
A 30-year-old male has a right inguinal mass. On examination, the left testis is palpated in the scrotum and is of normal size, but the right testis cannot be palpated in the scrotum. An ultrasound scan shows that the inguinal mass is consistent with a cryptorchid testis.
What is the most appropriate treatment?
Remove it (orchidectomy)
Orchidectomy of the undescended testis is the most appropriate option since it eliminates the risk of subsequent development of seminoma
Which of the following stone type appears as smooth, can be large and radio-opaque on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as smooth, can be large and radio-opaque on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as smooth, brown & radiolucent on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as smooth, brown & radiolucent on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as a spiky & radio-opaque on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as a spiky & radio-opaque on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which drug classes increase the chance of urinary tract calculi? [5]
allopurinol (treat gout)
loop-diuretics
antacids
acetazolamide
corticosteroids
aspirin
What causes an increased risk of infection from urinary tract calculi? [1]
If voiding impaired
How does pain present in urinary tract calculi?
How does pain presentation differ if the stone is
- Obstructing the kidney [2]
- Obstructing mid ureter [1]
- Obstructing lower ureter [2]
- Obstructing bladder or urethra [3]
Obstructing the kidney:
- felt in loin;
- between rib 12 and lateral edge of lumbar muscles
Obstructing mid ureter:
- mimics appendicitis / diverticulitis
Obstructing lower ureter
- may lead to symptoms of bladder iritability and pain in scrotum, penile tip or labia
Obstructing bladder or urethra:
- pelvic pain
- dysuria
- strangury
What differential will CT-KUB help to exclude? [1]
Ruptured AA
How does pain present in urinary tract calculi?
Excruciating pain that spreads from loin to groin that can cause nausea and vomiting in colicky fashion
Describe the analgesic therapy offered for urinary tract calculi [1]
IM diclofenac
IV paracetamol 2nd line
Describe the treatment algorithim for a patient who has a confirmed obstructed kidney stone? [2]
1.urgent decompression:
- ureteric stent past the obstruction and achieve drainage.
- a percutaneous nephrostomy tube can be placed by interventional radiology.
- urgent antibiotics
Calcium phosphate stones are commonly found in which structure? [1]
Bladder - found with urinary stasis
Calcium phosphate stones are clinically associated with which 3 conditions? [3]
Hyperparathyroidism
Medullary Sponge Kidney (MSK)
Distal Renal Tubular Acidosis (Type 1)
How are urate stones formed? [1]
How do they appear? [1]
Yellow
Acidic urine forms stones; uric acid entering urine
Struvite stones are associated with what type of infection? [1]
Bacterial infection; (form when bacteria meet a surface and make urine more alkali; Mg binds and builds up): UTI
When lasering a kidney stone is smells of egg. Which type of renal stone is this? [1]
Cysteine
Describe the free theory of stone formation [4]
Free theory:
- Unsaturated urine increases in concentration; goes beyond the solubility product, at which point the urine becomes saturated
- Above this level, the urine is saturated but crystals are prevent from forming by inhibitors
- Above the formation product, crystals form spontaneously
- Stone formers sit at both the metastable and spontaneous regions; they have less inhibitors
Describe the formation of stones via fixed theory [2]
Normally, need high energy to form crystal lattice
But, if have rough surface, e.g. from urate crystals, then energy required to form lattice is lower
Describe how uric acid stones are formed [2]
Urate stones are formed from both theories:
Free theory:
- Urate has pK value of 5.4 (crystals will form when pH meets pK value); urate crystal formation is pH dependent
Fixed theory:
- Prescence of urate crystals forming acts as a nidus for stone formation
What is a Randall’s plaque? [1]
Where do they form? [1]
Wn attachment site over which calcium oxalate stones form, begins in the basement membranes of thin limbs of the loop of Henle.
Label A
What is a Duct of Bellini? [1]
How are stones formed here? [2]
The duct of Bellini represents the most distal portion of the collecting duct.
- Stones formed within the tubules
- Duct of Bellini narrows
- Stones gets “stuck” at papillary surface
Name a stone inhibitor [1] and how it works [1]
Tamm Horfshall Protein (aka uromodulin)
Bind to crystal structures and prevent from binding to renal epithelial cells
How do you differentiate between a bowel colic and uteric colic [1]
Ureteric colic pain
- usually comes and goes with a background of pain completely between bouts
Bowel colic
- pain comes and goes, going away completely between bouts
State reasons why hypercalciuria [4] and hyperoxaluria [3] may be occurring and thus causing calcium stones
Hypercalciuria:
- Hyperparathyroidism
- Excess Ca2+ intake
- Increased Ca2+ gut absorption
- Poylcystic ovaries or medullary sponge disease
Hyperoxaluria:
- High diet in oxalates
- Low dietary Ca2+ (leading to decreased binding to oxalate)
- Increased intestinal resorption (e.g Crohns)
Name 3 foods high in oxalate [3]
spinach
tea
rhubarb
Important differential diagnoses? [6]
AAA: older patients
Bilary colic (presents more with RUQ pain)
Ectopic pregnancy
Pyelonephritis
MI
Pneumonia
What (non-radiological) investigations would you conduct for renal stones? [3]
Urine dipstick:
- 80% have blood
- check for infection (nitrates; leukocytes)
- urine pH (will indicate urate stones if low)
MSU
- check for microbiology culture and sensitivity
Bloods:
- serum urea, electrolytes
- FBC and CRPs
- Check calcium and urate levels
Which radiological investigations would you conduct for renal stones? [5]
1. CT-KUB - Non-contrast Computerised Tomography
- GOLD STANDARD
- can measure how hard stone is (can determine treatment), position and size
- If CT-KUB is postive; then perform KUBXR to look at stone position
3. Ultrasound:
- Shows kidney stones and renal pelvis dilatation well but ureteric stones can be missed
- useful in pregnant and younger recurrent stone-formers (no radiation risk)
- IVU (intravenous urogram)
- Rarely used - MRI
- used for pregnancy
Which anti-emetics are prescribed for kidney stones? [3]
Anti-emetics to prevent vomiting: metoclopramide, prochlorperazine or cyclizine
State 4 surgical interventions for kidney stones [4]
Extracorporeal shock wave lithotripsy (ESWL)
Ureteroscopy and laser lithotripsy
Percutaneous nephrolithotomy (PCNL)
Open surgery
Extracorporeal shock wave lithotripsy (ESWL):
* ESWL involves an external machine that generates shock waves and directs them at the stone under x-ray guidance. The shockwaves break the stone into smaller parts to make them easier to pass.
Ureteroscopy and laser lithotripsy:
* A camera is inserted via the urethra, bladder and ureter, and the stone is identified. It is then broken up using targeted lasers, making the smaller parts easier to pass.
Percutaneous nephrolithotomy (PCNL):
* PCNL is performed in theatres under a general anaesthetic. A nephroscope (small camera on a stick) is inserted via a small incision at the patient’s back. The scope is inserted through the kidney to assess the ureter. Stones can be broken into smaller pieces and removed. A nephrostomy tube may be left in place after the procedure to help drain the kidney.
Open surgery:
- Open surgery can be used to access the kidneys and remove the stones. This is rarely needed as other, less invasive, methods are usually effective.
A 48-year-old women presents with recurrent loin pain and fevers. Investigation reveals a staghorn calculus of the left kidney. Infection with which of the following organisms is most likely?
Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
E-Coli
Staphylococcus epidermidis
A 48-year-old women presents with recurrent loin pain and fevers. Investigation reveals a staghorn calculus of the left kidney. Infection with which of the following organisms is most likely?
Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
E-Coli
Staphylococcus epidermidis
Infection with Proteus mirabilis accounts for 90% of all proteus infections. It has a urease producing enzyme. This will tend to favor urinary alkalinisation which is a relative per-requisite for the formation of staghorn calculi.
State the medical expulsive therapy that can be used for treating kidney stones [2]
Medical expulsive therapy:
- nifedipine
- tamulosin (alpha blocker)
Describe the treatment plan for a renal stone < 10 mm that fails to pass despite initial conservative management [3]
Offer shock wave lithotripsy (SWL)
Consider ureteroscopy if SWL is contraindicated, fails, or is not indicated because of anatomical reasons
Consider percutaneous nephrolithotomy (PCNL) if SWL and ureteroscopy are not suitable options or have failed.
Name two AEs of shock wave litrotripsy [2]
The passage of shock waves can result in the development of solid organ injury.
Fragmentation of larger stones may result in the development of ureteric obstruction
What is the first line treatment for pregnant person with stone? [1]
If the patient has no evidence of infection, the specialist will arrange ureteroscopy. Ureteroscopy has been demonstrated to be safe in pregnancy.[74]
Describe the treatment plan for a renal stone > 20 mm [1]
Percutaneous nephrolithotomy
A 32-year-old female with a history of Crohn’s disease presents for review with left loin pain consistent with renal colic. On examination she has a large midline abdominal scar suggestive of previous small bowel resection. Plain abdominal X-ray reveals multiple renal calculi.
What type of renal calculi fit best with this clinical picture?
Uric acid stones
Cystine stones
Calcium oxalate stones
Calcium carbonate stones
Magnesium carbonate stones
A 32-year-old female with a history of Crohn’s disease presents for review with left loin pain consistent with renal colic. On examination she has a large midline abdominal scar suggestive of previous small bowel resection. Plain abdominal X-ray reveals multiple renal calculi.
What type of renal calculi fit best with this clinical picture?
Uric acid stones
Cystine stones
Calcium oxalate stones
Calcium carbonate stones
Magnesium carbonate stones
Increased urinary oxalate may be genetic (primary oxaluria), idiopathic or enteric (either due to severe bowel inflammation and malabsorption or to extensive small bowel resection, as is the case here).
Namet two contraindications for shockwave lithotripsy? [2]
Pregnancy and coagulopathy
Which of the following best describes
radiolucent, so they are not seen on X-ray. [2]
Uric acid stones
Cystine stones
Calcium oxalate stones
Calcium carbonate stones
Magnesium carbonate stones
Which of the following best describes
radiolucent, so they are not seen on X-ray.
Uric acid stones
Cystine stones
Calcium oxalate stones
Calcium carbonate stones
Magnesium carbonate stones
Which of the following are related to urinary tract infections
Uric acid stones
Cystine stones
Calcium oxalate stones
Calcium carbonate stones
Magnesium carbonate stones
Which of the following are related to urinary tract infections
Uric acid stones
Cystine stones
Calcium oxalate stones
Calcium carbonate stones
Magnesium carbonate stones
What imaging modility is first line for non-pregnant patients for suspected kidney stones?
MRI
XR-KUB
CT-KUB
US
What imaging modility is first line for non-pregnant patients for suspected kidney stones?
MRI
XR-KUB
CT-KUB
US
Pregnant: US
What imaging modility is first line for pregnant patients for suspected kidney stones?
MRI
XR-KUB
CT-KUB
US
What imaging modility is first line for pregnant patients for suspected kidney stones?
MRI
XR-KUB
CT-KUB
US
What is the first line treatment for pregnant person with stone? [1]
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
What is the first line treatment for pregnant person with stone? [1]
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
What is the first line treatment for pregnant person with stone size of less than 2cm?
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting
What is the first line treatment for pregnant person with stone size of less than 2cm?
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting
What is the first line treatment for pregnant person with stone size of < 5mm?
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting
What is the first line treatment for pregnant person with stone size of < 5mm?
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting
What is the first line treatment for person with stone size of 12 mm?
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting
What is the first line treatment for person with stone size of 12 mm?
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting
What is the first line treatment for person with stone size of 24 mm?
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting
What is the first line treatment for person with stone size of 24 mm?
Open surgery
Percutaneous nephrolithotomy (PCNL)
Ureteroscopy (URS)
Shockwave lithotripsy (SWL)
Watchful waiting
State the 4 most common causes of UTIs
Escherichia coli (E. coli)
Proteus mirabilis
Klebsiella pneumoniae
Staphylococcus saprophyticus
Haematogenous spread of UTIs is more often seen with uncommon urinary microorganisms such as [3]
Haematogenous spread is more often seen with uncommon urinary microorganisms such as Staphylococcus aureus, Candida albicans and Mycobacterium tuberculosis.
Pyelonephritis has a similar presentation to lower urinary tract infections plus the additional triad of symptoms of which symptoms? [3]
Which sign also indicates pyelonephritis? [1]
Symptoms:
* Fever
* Loin or back pain (bilateral or unilateral)
* Nausea or vomiting
AND
* Renal angle tenderness on examination
Explain which investigations should be given for UTIs? [2]
Urine dipstick:
- Nitrates suggest bacteria in urine (E. coli breaks down nitrates into nitrites)
- Leukocytes
- Haematuria
Midstream urine sample:
- sample sent for microscopy, culture and sensitivity testing will determine the infective organism and the antibiotics that will be effective in treatment.
FYI:
Where only nitrites are present, it is worth treating as a UTI. Where only leukocytes are present, a sample should be sent to the lab for further testing. Antibiotics may be considered where there is clinical evidence of a UTI.
What is the management of lower UTIs causing uncomplicated cystitis: (include length of time)
First line? [2]
Second line? [3]
Length of treatment? [1]
3-5 day course of standard antibiotics to local guidance:
First line:
* Nitrofurantoin
* Trimethoprim
Second line:
* co-amoxiclav
* cephalosporin
* ciprofloxacin
A patient presents with recurring UTIs.
You have investigated using urine dipstick and MSU. What are the next most appopriate steps for investigation? [2]
USS renal tract or CT KUB (kidney, ureter, bladder)
Describe the differing length of treatment time for different patient populations for UTIs [3]
3 days of antibiotics for simple lower urinary tract infections in women
5-10 days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function
7 days of antibiotics for men, pregnant women or catheter-related UTIs
NICE guidelines (2018) recommend the which first-line antibiotics for 7-10 days when treating pyelonephritis in the community? [5]
Cefalexin
Co-amoxiclav (oral or IV if more serious; if culture results are available)
Trimethoprim (if culture results are available)
Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)
IV Gentamicin (if severe)
How long should antibiotic treatment of pyelonephritis be provided for? [1]
7-10 days
Urinary tract infections in pregnancy increase the risk of w which pathologies? [3]
pyelonephritis
premature rupture of membranes
pre-term labour.
Urinary tract infection in pregnancy requires [] days of antibiotics.
All women should have an what additional investigation? [1]
Urinary tract infection in pregnancy requires 7 days of antibiotics.
All women should have an MSU for microscopy, culture and sensitivity testing.
Why should nitrofurantoin be avoided in the 3rd trimester of pregnancy? [1]
Why should trimethoprim be avoided in the 1st trimester of pregnancy? [1]
Nitrofurantoin:
* should be avoided in the third trimester as there is a risk of neonatal haemolysis
Trimethoprim:
* should be avoided in the first trimester as it works as a folate antagonist. Folate is essential in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (e.g., spina bifida). It is not known to be harmful later in pregnancy but is generally avoided unless necessary.
Which conditions should trimethoprim be avoided in? [1]
Renal impairment
Those with HLA-[] blood group antigen - tend to have recurrent UTIs
Those with HLA-A3 blood group antigen - tend to have recurrent UTIs
State 4 categoriesand examples of risk factors for UTIs
Increase in bacterial innoculation:
* sexual activity
* urinary incontinence
* faecal incontinence
Increased binding of uropathogenic bacteria:
- spermicide use
- decreased oestrogen
- menopause
Decreased urine flow
Increased bacterial growth:
- DM
- I/S
- Stones
- Obstruction
- Pregnancy
If vaginal discharge is present, what is your most likely differential? [1]
PID
Which pathogen is the most common cause of UTI? [1]
Name two other causes
E. coli
Staph. saprophyticus
Klebsiella pneumoniae
How do you manage UTIs in non-pregnant women? [2]
If 3+ symptoms of cystitis and no vaginal discharge:
- 3 day course of trimethoprim or nitrofurantoin
- If fails, take a MSU and send for culture
How do you manage UTIs in pregnant women? [1]
Which drugs should be avoided [3] and in which semesters? [3]
Get expert help: associated with pre-term babies
Avoid:
* trimethoprim & ciprofloxacin in trimester 1
* nitrofurantoin in 3rd trimester
How do you manage UTIs in men:
- If lower UTI [2]
- If suspected prostatic involvement [1]
If lower UTI:
* 7 day course of trimethoprim or nitrofurantoin
If suspected prostatic involvement:
- Ciprofloxacin
- Cefalexin (the typical choice)
The typical duration of antibiotics is:
[] days of antibiotics for simple lower urinary tract infections in women
[] days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function
[] days of antibiotics for men, pregnant women or catheter-related UTIs
The typical duration of antibiotics is:
3 days of antibiotics for simple lower urinary tract infections in women
5-10 days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function
7 days of antibiotics for men, pregnant women or catheter-related UTIs
What risk does giving nitrofurantoin in 3rd trimester risk? [1]
Nitrofurantoin should be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).
What risk does giving trimethoprim in 1st trimester risk? [1]
Trimethoprim should be avoided in the first trimester as it works as a folate antagonist.
Folate is essential in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (e.g., spina bifida). It is not known to be harmful later in pregnancy but is generally avoided unless necessary.
Two things to keep in mind with patients that have significant symptoms or do not respond well to treatment are? [2]
Two things to keep in mind with patients that have significant symptoms or do not respond well to treatment are:
Renal abscess
Kidney stone obstructing the ureter, causing pyelonephritis
NICE guidelines (2018) recommend which first-line antibiotics for 7-10 days when treating pyelonephritis in the community? [4]
Cefalexin
Co-amoxiclav (if culture results are available)
Trimethoprim (if culture results are available)
Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)
