Nephro 2 Flashcards
How would you investigate a testicular lump?
Testicular lump = cancer until proven otherwise
- can you get above it?
- is it separate from the testis?
- cystic or solid?
Cannot get above - inguinoscrotal hernia
Separate and cystic - epididymal cyst
Separate and solid - epididymitis or varicocele
Testicular and cystic - hydrocele
testicular and solid - tumour , haematocele
What is an Epididymal cyst?
smooth, extratesticular, spherical cyst on head of the epididymis
develops around 40
How would an epididymal cyst present?
often multiple and bilateral
asymp until large
well defined and will transluminate since fluid-filled
testis palpable separately from cyst
scrotal USS investigation
How would you treat an epididymal cyst?
none needed
if painful then surgical excision
What is a primary hydrocele? Whom do you normally see it in?
Abnormal collection of fluid within the tunica vaginalis
more common in younger men
assoc. with patent processus vaginalis
What are causes of secondary hydroceles?
older boys and older men
testis tumour trauma infection TB testicular torsion
How does a hydrocele present? How would you investigate?
scrotal enlargement with a non-tender smooth cystic swelling
no pain unless infected
usually clinical or USS
What is a varicocele? Whom do you normally see it in?
abnormal dilation of the testicular veins in pampiniform venomous plexus - caused by venous reflux
usually around 40 y/o
How does a varicocele present?
Often visible as distended scrotal blood vessels - bag of worms
Dull ache or scrotal heaviness
scrotum hangs lower on the side of the varicocele
How would you investigate varicocele?
scrotal USS
semen analysis
serum FSH
What is testicular torsion? How urgent is treatment needed?
torsion of spermatic cord resulting in occlusion of testicular blood vessels = ischaemia and infarct
Typically neonates or post-pubertal boys 11-30
surgery <6 hrs salvage rate is 90-100%
> 24 hrs 0-10%
How does testicular torsion present? What treatment is needed?
Any boy presenting with abdo pain - check testis
Sudden onset pain in one testis
testis - very tender, hot and swollen
emergency scrotal exploration - manual detorsion
What are some causes of acute urinary retention?
Prostatic obstruction Urethral strictures Anti-cholinergics Alcohol Constipation Post-op Infection Neurological
What examinations would you carry out in a presentation of acute urinary retention?
Abdomen exam
Prostate exam (DRE)
Perineal sensation (check for cauda equina)
What investigations would you do for acute urinary retention? management?
normal renal biochem
renal USS
PSA - for BPH/prostate cancer
Manage - catheter, Tamsulosin (alpha-1 blocker, relaxes smooth muscle neck to aid voiding)
What are some causes/RFs of chronic urine retention?
Prostatic enlargement
Pelvic malignancy or rectal surgery
Diabetes
low pressure - detrusor failure
high pressure - interactive obstructive uropathy
How would chronic urinary retention present?
Overflow incontinence
Loss of appetite
Constipation
Distended abdomen
UTI
What is the function of the prostate?
secretes 70% of the volume of seminal fluid and is hormone dependent
How does BPH present?
Nocturia Frequency Urgency Post-micturition dribbling Poor stream/flow Hesitancy haematuria Bladder stones Abdo exam = enlarged bladder
How would you investigate BPH?
PSA
Urinalysis
International Prostate Symptom score
Treatment of BPH?
Watchful waiting
Alpha-blocker - Tamsulosin
5-alpha-reductase inhibitor - finasteride
Phosphodiesterase-5 inhibitor - sildenafil
Anticholinergic - tolterodine
TURP - transurethral resection of prostate
What some characteristics of Renal Cell Carcinoma?
Also known as hypernephroma/Grawitz tumour
Arises from proximal convoluted tubular epithelium
Most common renal tumour in adults
Usually after 50 y/o
What are risk factors for RCC?
Smoking Obesity Hypertension Renal failure PKD Von Hippel Lindau syndrome
Presentation of RCC?
Asymp haematuria, loin/flank pain anorexia, malaise and weight loss can cause varicocele hypertension anaemia (erythropoietin suppression)
How would you investigate RCC?
lactate dehydrogenase - poor prognostic marker
corrected calcium - poor prognostic marker
LFTs - if deranged may indicate metastases
Abdo USS
Abdo/Pelvis CT
Treatment for RCC?
surgery
interleukin-2 and interferon alpha
What are some characteristics of bladder cancer?
type of transitional cell carcinoma
calyces, renal pelvis, ureter, bladder and urethra are ALL lined by transitional epithelium
more common in males, peaks in 8th decade
What are some risk factors for bladder cancer?
Smoking
Occupational exposure - beta-napthylamine, benzidine, workers in petroleum, chemical, cable and rubber industries
Drugs - phenacetin and cyclophosphamide
Schistomiasis
What are presentations of bladder cancer?
Painless haematuria - over 40 always assume it is tumour
Recurrent UTIs
Voiding irritability
How would you investigate bladder cancer?
urine cytology - positive in 90% of patients with carcinoma, sterile pyuria
Renal and bladder USS
Cystoscopy
Intravenous urogram
FBC
Alk Phos
Treatment for bladder cancer?
Transurethral resection - non-invasive
Radical or partial cystectomy - locally invasive tumour
Intravesical chemo - mitomycin, cisplastin
What type of cancer is prostate carcinoma? Most common metastases?
Adenocarcinomas - in peripheral zone of prostate
Common metastases - bone and lymph nodes
Risk factors for prostate cancer?
Increases testosterone
Family Hx
Black
How does prostate carcinoma present?
All BPH symps
Weight loss
Bone pain
Anaemia
How would you investigate prostate carcinoma?
DRE - hard, irregular prostate
PSA
Transrectal USS & Prostate biopsy
How would you treat prostate carcinoma?
Bracytherapy - transperineal impnat - radioactive source into prostate gland
External-beam radiotherapy
Radical prostatectomy and lymph node dissection
What are the characteristics of testicular tumours?
15-44 y/old
96% from germ cells - seminomas 25-40 and 60 y/o, teratomas -infancy
4% non-germ cells - Leydig, Sertoli, sarcomas
What are risk factors for testicular tumours?
Undescended testis
Infant hernia
Infertility
Family Hx
How does a testicular tumour present?
Painless lump in the testicle
Testicular pain
Hydrocele
Cough and dyspnoea
Back pain
Abdo mass
How would you investigate a testicular tumour?
USS
CT scan
Serum beta-human chorionic gonadotrophin - elevated in choriocarcinoma
Serum AFP - elevated in embryonal, teratoma, yolk sac tumours or combined tumours
Serum lactate dehydrogenase
Serum LDH - elevated in 50% of cases
How would you treat testicular tumours?
Radical orchiectomy
External beam radiation post orchiectomy
What organisms normally cause UTIs?
KEEPS
Klebsiella E.coli (most common) Enterococci Proteus Staphylococcus
Risk factors for UTI?
Female Sex Pregnancy Menopause Decrease in host defence Urinary tract obstruction Catheter
What is pyelonephritis?
Infection of the renal parenchyma and soft tissues or renal pelvis and upper ureter
How does pyelonephritis present?
TRIAD : loin pain, fever and pyuria
Rigors
Significant bacteriria
Malaise, nausea, vomiting
Oliguria
Investigations of pyelonephritis?
Urinalysis Gram stain Urine culture FBC ESR & CRP Blood culture
Treatment for pyelonephritis?
Ciprofloxacin
Ceftriaxone
Cranberry juice
Analgesia
RFs for Cystitis?
Women/children
Urinary obstruction
Previous damage to bladder
Bladder stones
Poor bladder emptying
Presentation of cystitis?
dysuria frequency urgency suprapubic pain haematuria offensive smelling/cloudy urine
Investigations for cystitis?
MC&S of sterile mid-stream urine
Dipstick
Treatment for cystitis?
Trimethoprim
Ciprofloxacin
Risk factors for prostatitis?
Streptococcus faecalis
E.coli Chlamydia STI Indwelling catheter Post-biopsy Increasing age
How would prostatitis present?
Systemically unwell
Fevers, rigor, malaise
Pain on ejaculation
Significant voiding issues - poor intermittent stream, hesitancy, incomplete emptying
How would you investigate prostatitis?
DRE - prostate is tender or hot to touch
Hard from calcification
Urine dipstick
Mid-stream MC&S
Blood cultures
How would you treat prostatitis?
Gentamicin + Co-amoxiclav + IV tazocin
TRUSS guided abscess drainage if necessary
What are causes/RFs for urethritis?
Normally sexually acquired disease
Neisseria gonorrhoea Chlamydia Trichomonas vaginalis Trauma Urethral stricture Urinary calculi Unprotected sex Male to male sex
Presentation of urethritis?
Asymp Dysuria Urethral pain Penile discomfort Skin lesions
Investigation of urethritis?
Nucleic acid amplification test (NAAT) - female (self-collected vaginal swab) male (first void volume)
Microscopy of gram-stained smears
Blood cultures
Urine dipstick
Urethral smear
Indications for dialysis? Long term and short
Short - AEIOU Acidosis Electrolyte (unresponsive hyperkalaemia) Intoxication (overdose) Oedema (severe unresponsive pulm oedema) Uraemia symps (seizures, reduced consciousness)
Long - end stage renal failure
Types of peritoneal dialysis? complications?
Continuous Ambulatory Peritoneal Dialysis - dialysis solution in peritoneum at all times
Automated - dialysis overnight (8-10 hrs)
peritonitis, peritoneal sclerosis, ultrafiltration failure, weight gain, psychosocial
What is haemodialysis? What is needed? Complications?
Blood filtered by machine - from 4hrs a day to 3 days a week
Need tunnelled cuffed catheter (infection) or arterior-venous fistula (aneurysm, infection, thrombosis, stenosis, STEAL syndrome)
