Nephrology and GU Flashcards
What is BPH and how might it present?
- BPH= Benign Prostatic Hyperplasia. Testosterone fuelled hyperplasia/ hypertrophy in transitional zone.
- Presentation:
- Frequency
- Urgency
- Nocturia
- Incontinence
- Voiding Sx- hesitancy, poor stream, dribble, intermittence, abdo strainging
- PR- smooth enlarged prostate
Complications of BPH
- UTI
- Acute/ chronic retention –> ?palpable bladder
- Haematuria
- Stone formation
- Obstructive renal failure
- NOT PROSTATE CA
Ix and Tx of BPH
- Ix: (need to rule out cancer)
- Bedside- PR, MSU
- Bloods- U+Es, PSA
- Imaging- Transrectal USS + biopsy
- Advanced- cystoscopy, renal USS ?hydronephrosis
- Tx:
- Cons- reduce caffeine/ alcohol, bladder training, relax when voiding, watchful waiting
- Medical (monotherapy/ combo):
- Tamsulosin (alpha blockers)- reduce tone
- Finasteride- reduce testosterone. SE ED
- Surgical- transurethral. ?resection ?prostatectomy. Risk= impotence
Prostate cancer RF
- = Adenocarcinoma
- Hormonal- testosterone/ IGF-1
- Age
- FHx (BRCA1/2)
- Vasectomy
- Prostatitis
- Ethnicity
- Obesity
- Diet- high calcium/ cadmium
Prastate Cancer 2 week wait
- Feels malignant on PR
- ?PSA in:
- Lower urinary tract Sx
- ED
- Visible haematuria
- –> 2ww if PSA above age-specific range
Presentation of prostate cancer
- 30% men 40-65y
- Incidental - increased PSA
- Lower UT Sx- Hesitance, dribbling, nocturia, poor stream
- Haematuria
- Pain- hips, pelvis, spine
- ED
- Pain on ejaculation
- Renal failure
- Metastatic spread - back pain, weight loss, anaemia
Diagnosis + Ix of prostate cancer
- Bedside- DRE (large + craggy, no sulcus), MSU
- Bloods- FBC, serum PSA >4ng/mL –> 2ww for USS
- Imaging:
- Transrectal USS - size and stage
- X-ray + isotope bone scan
- CT/ MRI - spread
- Special - needle biopsy + histology
Management of prostate cancer by stage
- Confined to prostate:
- Cons- active monitoring + PSA
- Med- hormonal therapy/ tamsulosin for Sx
- Surg- severe Sx/ obstruction. ?radical prostatectomy ?radiotherapy ?brachytherapy (radioactive pellets). Complications of resection- incontinence, retrograde ejac, impotence
- Locally advanced= incurable –> palliation
- 80% adrogen dependent –> hormone therapy. Tx= LHRH agonists (abiraterone, goserelin), anti-androgens. SE: hot flushes, lethargy, ED, gynaecomastia
- Metastatic: Hormone therapy, chemo, radio
- Bone pain- radiotherapy/ bisphosphonates
Presentation, Ix and Tx of prostatitis
- Acute/ chronici infection/ inflammation
- Usually present >35y
- Acute causes= S. faecalis, E. coli
- Presentation:
- Flu like Sx
- Pain - perianal, lower back
- UTIs
- Retention
- Haematospermia
- DRE- swollen/ boggy
- Ix- rule out DDx (abscess, BPH, UTI)
- Tx- analgesia, ABx- levofloxacin
- Chronic = >3m. May not be infective. Tx= NSAIDs, tamsulosin, prostatic massage.
What is renal calculus and what types/ causes are there?
- = Renal stone. crystal aggregates form in collecting ducts –> deposited anywhere in renal tract. Types:
- Calcium oxalate- high PTh, hypercalcaemia, kidney disease, sarcoid, cancer
- Struvite- post-UTI
- Uric acid - gout, high protein diet
- Cystin- abnormal anatomy
Different presentation of renal stones
- ASx
- Renal colic- loin- groin. N+V. Can’t lie still
- Renal obstruction. Upper ureter- mimics appendicitis. Lower- bladder irritability. Bladder/ urethra- pelvic pain, dysuria, inability to void, interrupted flow
- UTI/ pyelonephritis
- Haematuria
- Proteinuria
- Sterile pyuria
- Aneuria
Signs and Sx of renal stones
- ASx
- Aneuria
- Dysuria
- Frequency
- Proteinuria/ Haematuria
- Colic - loin-groin. Restless
- N+V
- +/- UTI
RF for renal stones + prevention
- Dehydration
- Foreign body
- Drugs- ABx, antacides, diuretics
- FHx
- Frequent UTIs
- UT abnormalities
- Diet - high ammonia (red meat), oxalate (chocolate, tea, rhubarb, strawberries)
- Hypercalcaemia
- Prevention- hydration, normal Ca2+ intake, thiazide diuretic, allopurinol in gout
Ix and Tx of renal calculus
- Ix:
- Bedside- urine dip + MSU
- Bloods- FBC, U+Es, Ca2+, PO43-, glucose, bicarbonate, urate
- Imaging- CT KUB, (AXR monitoring known stones)
- Tx:
- Cons- fluids. Stones <5mm pass spont.
- Med- analgesia, nifedipine/ tamsulosin for stones >5mm not passing
- Surg- Stones >5mm not passing with IVT and med managment. Extracorporeal shockwave lithotripsy –> keyhole nephrolitotomy
Diagnosis of AKI
- Serum creatinine 1.5x baseline
- Serum creatinine >26 mmol/L
- UO <0.5mL/kg/h over 6 hours
Raised creatinine and low UO = severe!
Causes of AKI
- Pre-renal:
- Hypotension- absolute (D+V, burns) and relative (HF, sepsis) loss
- Drugs that reduce BF - ACEi
- Renal artery stenosis
- Renal:
- Acute tubular necrosis- contrast, NSAIDs, aminoglycosides
- Gomerulonephritidies (blood, protein)
- Drugs- PPI, cisplatin
- Vasculitis- GPA
- Goodpasture’s
- Systemic- HTN, DM, SLE
- Post-renal:
- Compression- malignancy, BPH, strictures
- Blockage- kidney stones, clots, blocked catheter
Presentation of AKI
- Non-specific! Signs of cause?
- Reduced UO
- Dehydration
- Overload- pulm. + peripheral oedema, raised JVP
- Lethargy
- Acidosis
- Confusion
- Arrhythmias
Nephrotoxic drugs
- NSAIDs
- ACEi
- Contrast
- Aminoglycoside eg gentamicin
- Metformin
- Methotrexate
- Lithium
- ?Diuretics
- DAMN- Diuretics, Aminoglycosides, Metformn, NSAIDs
Ix of AKI
- Bedside- ECG, urine: dip, MSU, ouput, albumin:creatinine. Catheter flushing?
- Bloods- FBC, U+Es, CRP, LFTs, CK, ESR, clotting, phosphate
- Imaging- CXR, renal USS
Tx of AKI
- Cons- encourage oral intake, IVT, catheter for obstruction
- Med:
- Sepsis - ABx
- HF/ overload - furosemide
- Shock - IVT +/- inotropes
- Hyperkalaemia - calcium gluconate, insulin, salbutamol
- Surg- remove blockage
Complications of AKI
AHOPE = indications for renal replacement therapy
- Acidosis <7.15
- Hyperkalaemia
- Oedema
- Pericarditis
- Encephalopathy/ uraemia
Other complications of renal failure- loss of lean body mass, anaemia, bone disease (high PTH, low Ca2+), HTN
Definition of CKD and end stage renal failure
- eGFR <60ml/min/1.732 for >3m
- End stage renal failure= GFR <15mL/min/1.732 or need for renal replacement therapy
Causes and screening of CKD
- Causes:
- DM
- HTN
- Hypercholesterolaemia
- Glomerulonephritis
- Drugs- NSAIDs, lithium, omeprazole
- Polycystic kidneys
- Screening in those at risk: DM, HTN, CVS disease, stones, BPH, frequent UTIs, VUR, FHx
Classification/ stages of CKD
Based on GFR
- >90
- 60-89
- a= 45-59, b= 30-44
- 16-29
- <15
Stages 1-3 can be managed in GP
Signs and Sx of CKD
- Oligouria/ nocturia/ polyuria
- Weight loss
- Oedema + SOB
- Amenorrhoea
- Bone pain
- Fatigue
- Pruritis
- Yellow- uraemic tinge
- Asterixis
- N+V
- Muscle cramps
Ix of CKD
- Bedside- urine: dip, C+S, albumin:creatinine ratio, bence jones protein
- Bloods- FBC (aneamia), U+Es, ESR, glucose, hypocalcaemia, high phosphate, high ALP, high PTH. Immune- ANA, dsDNA, ANCA, GMB, C3/4, Ig, Hep
- Imaging- CXR, AXR/CT KUB, renal USS (usually small), bone x-ray
- Special- renal biopsy
Management of CKD
- Tx the cause! Stop nephrotoxic drugs. Manage the Sx
- Cons- healthy eating, exercise, Na/phosphate/fluid restriction. Phosphate= milk, cheese, eggs
- Med:
- CVS risk- statins, aspirin
- HTN- BP target <140/90 (130/80 in DM)
- Oedema- furosemide
- Bone disease- calcichew, vit D, ca supplements
- Anaemia
- Restless legs- clonazepam
- Renal replacement
What is renal replacement?
- Dialysis: (risk= infection)
- Haemodialysis
- Peritoneal dialysis
- Renal transplant= gold standard.
- Types- deceased, live donor
- Before- check ABO blood group, HLA match
- Contraindications- active infection, cancer, severe heart disease
- After- NB immunosuppression- steroid, monoclonal Ab, tacrolimus
- Complications- bleeding, graft thrombosis, infection, urinary leaks, CVD, rejection
Renal causes of hypertension (and hypotension)
- Chronic glomerulonephritis
- Recurrent pyelonephritis
- Renal artery stenosis
- ADPKD - Autosomal dominant polycystic kidney disease.
- Genetic- Liddle’s, Gordon’s
- Genetic –> hypotension- Gittleman’s, Bartter’s
Features, Ix and Tx of ADPKD
- = Genetic. PKD1/2. ESRF by 50/70
- Features:
- Renal enlargement with cysts
- Abdo pain
- +/- haematuria
- Renal calculi
- HTN
- Progressive renal failure
- Also- SAH, diverticulitis, liver/ overian cysts
- Ix: BP, U+Es, USS, Biopsy, genetics
- Tx: More water, less sodium. –> Dialysis/ transplant
Causes, features, Ix and Tx of renal artery stenosis
- Causes- Atherosclerosis, fibromuscular dysplasia, antiphospholipid, post-renal transplant, VTE, external compression
- Presentation- refractory HTN, flash pulm oedema, bruit, weak leg pusles
- Ix- USS, CT/MR angiography
- Tx- antihypertensive, surgical angioplasty/stent/revascularisation
What is a UTI?
- Symptomatic with positive urine culture/ dipstick
- >105 organisms/ mL fresh MSU
What makes a UTI complicated?
- Male
- Pregnancy
- Abnormal renal anatomy - stones, duplex
- Abnormal renal function eg CKD
- Immunocompromised
UTI organisms
- E. Coli (gut flora)
- Proteus (stones)
- S. saphrophyticus (sex)
- Klebsiella
UTI RF
- Age
- Neuropathic bladder/ reduced emptying eg MS
- Female
- VUR
- Catheter
- Stones
- Poor immunity
UTI presentation
- Abdominal/ suprapubic/ back pain
- LUT Sx- frequency, urgency, hesistancy
- Dysuria
- Haematuria
- Fever
- Tachycardia
- Foul smelling cloudy urine
- Confusion
- Pyelonephritis - loin- groin pain, vomiting, rigors, fever
Ix and Tx for UTI
- Ix- urine dip + MSU, FBC, U+Es, cultures, USS (children, men, recurrent, pyelonephritis)
- Tx:
- Conservative- hydration, urinate often, hygiene
- Med: ABx 3 days uncomplicated, 7 days complicated
- Nitrofurantoin (not in renal impairment)
- Trimethoprim (not in 1st trimester)
- Alt- cefalexin, co-amox
- Pyelonephritis- 7-10d ABx. cefalexin/co-amox
- ?prophylaxis- trimeth/nitro
- Catheter associated- REPLACE, ABx
Causes and presentation of urethritis
- Causes- Gonorrhoea, chlamydia, HPV, HSV, CMV
- Presentation:
- Frequency
- Dysuria
- Burning/ irritation at urethral opening
- Discharge
Organism, presentation and complications of chlamydia
- Organism- chlamydia trachomatis
- Presentation:
- Vaginal discharge
- Dysuria
- Lower back pain
- Fever
- IMB/ PCB
- Deep dyspareunia
- Cervicitis
- Adnexal tenderness
- Males- urethritis, epididymo-orchitis, mucopurulent discharge
- Complications- PID, infertility, ectopic
Ix and Tx of chlamydia
- Ix:
- Women- vulvovaginal swab
- Men- 1st catch urine sample –> NAAT
- Tx:
- Cons- partner notification, screen for other STIs
- 1g azithromycin 1 dose
- OR Doxycycline 100mg BD for 7 days
Organism and presentation of gonorrhoea
- Neisseria gonorrhoea
- Presentation: Usually ASx!
- Vaginal discharge
- Lower abdominal pain
- IMB/ menorrhage
- Dysuria
- Men- penile discharge, dysuria, irritation, redness at opening
Ix and Tx of gonorrhoea + complications
- Ix:
- Men- Urine NAATs, swab of penile discharge
- Women- high vaginal + cervical swab +/- urethra
- Tx: ceftriaxone 500mg IM + 1g azithromicin
- Complications- PID, chronic pelvic pain, infertility, ectopic
Presentation, Ix and Tx of trichomonas vaginalis
- Pres- offensive, bubbly, fish smelling discharge
- Signs- strawberry cervic
- Ix- wet vaginal film (motile protozoan)
- Tx- metronidazole + Tx partner
Organisms + presentation/ stages of syphilis
- Organism- treponema pallidum
- Primary- Primary lesion= indurated ulcer (chancre)
- Secondary- 6w after primary lesion. Generalised maculopapular rash on soles and palms
- Latent syphilis - +ve serology, no Sx
- Tertiary syphilis:
- Neurosyphilis- tabes dorsalis, dementia
- CVS- aortitis/ aneurysm, angina
- Gumma
Ix and Tx of syphilis
- Ix:
- Bloods- IgG + IgM
- HIV screening - facilitates transmission of HIV
- Tx:
- Benzathine penicillin
- 2nd line- 1g azithromicin
Organism, presentation, Ix and Tx of genital herpes
- Organism= HSV. 1= oral, 2= genital
- Presentation:
- Primary- blisters –> open sores. Flu like Sx, discharge, dysuria, malaise
- Recurrent infection- reactivation –> tingling, blisters, sores, ulcers
- Ix- swabs, screen for other STI
- Tx- primary infection= aciclovir. Outbreaks- clean with salty water, ice packs, fluids. >6 outbreaks/ year –> prophylactic aciclovir
Organism, presentation, Ix and Tx of genital warts
- Organism= HPV (6, 11)
- Presentation= visible painless warts. Flat/ raised, smooth/ lumpy
- Ix- Examination. ?biopsy
- Tx- topical creams, cryotherapy, electrocautery.
Risk factors and presentation of bladder cancer
- RF:
- Occupational exposure to rubber
- Male
- Smoking
- Chronic cystitis
- >50y
- Diet
- Pelvic irradiation
- Presentation:
- Painless haematuria
- LUT Sx- frequency, urgency, dysuria, voiding irritability
- Frequent UTIs
2 ww referral criteria for bladder cancer
- >45y with unexplained haematuria (no UTI/ treated)
- >60y with non-visible haematuria + dysuria or raised WCC
- ?>60y with recurrent UTIs
Ix and Tx of bladder cancer
- Ix:
- Bedside- urine microscopy + cystology
- Bloods- WCC, CRP
- Imaging- cystoscopy, CT/ MRI
- Tx:
- Cons- palliation
- Med- radio/ chemo
- Surg- radical cystectomy
NB things to assess in Hx and exam of a patient with urinary incontinence?
- Hx:
- Urinary Sx- urgency, frequency, leakage, dysuria, poor stream, haematuria
- Fluid intake + caffeine consumption
- SHx- effect on lifestyle
- PMH- Obs, pelvic trauma, DM, chronic cough, faecal incontinence, MS, PD, stroke
- ??Cord compression/ cauda equina??
- O/E:
- Ask to cough - ?leakage
- Abdo/ pelvic masses
- Prolapse
Types of urinary incontinence and their treatments
- Stress - leakage on exercise, coughing, laughing. Overactive bladder. Tx: lifestyle, pelvic floor traing, fluid restriction, transvaginal tape, duloxetine
- Urge- overactive detrusor. Tx- pelvic floor training, accupuncture, electrical stimulation, topical oeatrogen, anticholinergics- oxybutinin, tolterodine. Intravesicular botulinum. ?Surgical
- Mixed= stress + urge. Tx= magnetic stimulation of nerves in sphincter and pelvic floor
- Overflow= chronic retention. Tx= catheter
- Function- reduced mobility, can’t get to toilet
- Nocturnal- ?chronic retention. Tx- bladder training, ?anticholinergics
Ix of urinary incontinence + general lifestyle management
- Bedside- urine: MSU, glucose, urine diary
- Bloods- PSA
- Imaging- USS, cystoscopy
- Special-
- urodynamics: uroflowometry + cystometry
- Sphincter electromyography
- Residual vol after voiding
- Lifestyle- weight loss, reduce caffeine, stop smoking, treat prolapse
Complications of renal failure
- Uraemia- pruritis, N+V, lethargy, confusion, bleeding, fits, coma, yellow
- Protein loss and Na+ retention- polyuria, polydipsia, SOB, oedema, raised JVP, HTN
- Acidosis- SOB, confusion, kussamul breathing
- Hyperkalaemia- Palpitations, chest pain, tented T waves
- Anaemia- SOB, lethargy, pallow, tachycardia
- Vitamin D deficiency - bone pain, osteopoenia
What is glomerulonephritis and how might it present? + Causes
- Group of disorders resulting from glomerular damage.
- Presentations:
- ASx haematuria
- Nephrotic syndrome
- Nephritic sundrome
- Causes:
- Idiopathic
- Amyloid
- Immune- SLE, vasculitis, goodpasture’s
- Infection- HBV, HCV, strep, HIV
- Drugs- penicillamine, gold
Ix and general Tx of glomerulonephritidies
- Ix:
- Bedside- Urine- dipstick, C+S, RBC casts, bence jones protein. ECG.
- Bloods- FBC, U+Es (esp eGFR), C3/4, Abs (ANA, dsDNA, ANCA, GBM), immunoglobulins, electrophoresis, culture, ASOT (strep), HBC, HCV, albumin, CRP
- Imaging- CXR, renal USS +/- biopsy. ?CT/MRI (avoid contrast)
- General Tx:
- Refer to nephrologist!
- Keep BP <130/80 (ACEi)
What is nephrotic syndrome? + complications
- Pathology- injury to podocytes
- Triad of:
- Proteinuria >3.5g/24h (urine albumin:creatinine + plasma albumin)
- Oedema - pitting, periorbital
- Hypoalbuminaemia <25g/L
- Signs- leukonychia, corneal arcus, xanthelasma, frothy urine
- Complications:
- More susceptible to infection
- Hypercoaguable
- Dyslipidaemia
- Progressive renal impairment
General management of nephrotic syndrome
- Oedema- loop diuretics
- Proteinuria- ACEi, ARB
- Complications- anticoagulation, statin, vaccinations
- TREAT THE UNDERLYING CAUSE
What are the conditions that might cause nephrotic syndrome?
- Secondary to systemic disease - SLE, amyloid, DM
- Minimal change GN
- Membranous GN
- Focal segmental GN
- Mesangioglomerulonephritis
Key features of DM nephropathy
- Nephrotic
- Glomerulosclerosis
- LM- kimmel stiel wilson nodules (clover)
- Monitor urine dip –> ACEi
Key features of minimal change disease
- Nephrotic
- Common in children. Usually idiopathic (or drugs eg NSAIDs)
- Histology - LM normal, EM effacement of podocytes
- Tx- steroids –> cyclophosphamide
Key features of FSGN
- Nephrotic
- Usually idiopathic. Associations- sickle cell, HIV, heroin, vasculitis
- Histology- hyalinosis, focal deposits of IgM and complement
Key features of Membranous Nephropathy
- Nephrotic
- More common in adults
- Autoantibodies/ IC deposition
- Cause- usually idiopathic. Associations- malignancy, HBV, drugs (gold, penicillamine, NSAIDs), AI eg SLE
- Histology- LM= thickened GBM, EM- GBM spikes. widespread granular appearance
- Tx- cause. steroids.
Key features of mesangioglomerulonephritis
- Nephrotic
- Immune complex/ complement mediated
- Associated with Hep C
- Nephrotic/ nephritis
- Histology- thickened BM with track appearance
- Tx= steroids
What is nephritis syndrome and it’s causes?
- Triad of:
- Azotaemia (high urea)
- Haematuria (+ red cell casts)
- Proteinuria <3.5g/L
- Histology- crescent formation, breaks in GBM
- Causes:
- Post-streptococcal
- Goodpasture’s
- IgA nephropathy
- Pauci immune- Wegner’s, churg-straus
Key features of Post-streptococcal GN
- Nephritic
- 1-12w after infection eg throat/ skin
- Strep antigen deposited on glomerulus –> host reaction + IC formation
- Bloods- high ASOT, low C3
- Histology- LM- crescents, EM- subepithelial deposits
- Biopsy- IgC + C3 deposition
- Tx= supportive
Key features of Goodpasture’s
- Nephritic
- =Anti-GBM
- Cause= auto Ab to type 4 collaged in glomerulus and lung
- Presentation- haematuria, haemoptysis
- CXR- infiltrates
- Tx= ASAP! Plasmapheresis, immunosuppression (steroid +/- cytotoxics)
Key features of IgA nephropathy
- Nephritic
- IgG against abnormal IgA –> imparied IgA breakdown
- Urine- red cast cells
- Histology- LM- mesangial proliferation. EM- IC deposition, IgA positive
- Tx= steroids after 1w
What is Acute Tubulointerstitial Nephritis + Ix + Tx?
- = Nephritis affected the areas between the renal tubules
- Causes:
- Drugs- NSAIDs, ABx (cephs, penicillin), diuretics, allopurinol
- Infection- staph, strep
- Immune disorder- SLE, Sjogren’s
- Ix:
- Urine- high WCC, white cell casts, high protein. no bacteria.
- Bloods- High IgE, eosinophilia
- Biopsy- ++ eosinophils
- Tx- stop cause. Prednisolone
What is haematuria and what causes it? + Ix
- = >1 microL blood lost in urine/ day
- Causes:
- Malignancy- kidney, bladder
- Kidney stones
- UTI (+WCC)
- Rhabdomyeolysis –> ++CK –> haemoglobinuria
- Glomerulonephritis (RBC casts + proteinuria)
- Ix:
- 2ww for renal/ bladder Ca? Imaging of renal tract + cystoscopy
- No urological cause –> quntify amount of haematuria and proteinuria
What is proteinuria and what causes it? + Ix
- Microalbuminuria= >2.5 (3 for women)
- Proteinuria= >30mg/mol
- Causes:
- Significant= >1g/d = GLOMERULAR
- <1g/day= damage to tubules- tubulointerstitial disease, UTI, kidney stones. Transient- fever, exercise, HF, pre-eclampsia, orthostatic
- Ix:
- Quantify- (24h urine collection), albumin:creatinine ratio
- BP
- Bloods + GFR
- USS
- ??biopsy- with haematuria + persistent