Nephrology + Genitourinary Disease Flashcards
1
Q
What is the effect of parasympathetic innervation on the lower urinary tract?
A
Causes detrusor muscle contraction and smooth muscle urethral sphincter relaxation to allow for urine voiding.
2
Q
What nerve and roots are responsble for the parasympathetic innervation of the lower urinary tract?
A
Pelvic nerve, roots S2-S4
3
Q
What is the effect of sympathetic innervation on the lower urinary tract
A
Detrusor muscle relaxation
Contraction of internal urethral sphincter
4
Q
What nerve and roots are responsble for the sympathetic innervation of the lower urinary tract?
A
Hypogastric nerve, T12-L2
5
Q
What are the 3 types of urinary incontinence?
A
Stress incontinence
Urge incontinence
Overflow incontinence
6
Q
Aetiology of stress incontinence
A
Weakened pelvic floor muscles or urethral sphincters
7
Q
Pathophysiology of stress incontinence
A
Coughing or sneezing can cause increased intra-abdominal pressure causing leakage of urine.
8
Q
Who can be especially affected by stress incontinene?
A
Postpartum women
Post-prostatectomy men
9
Q
Management of stress incontinence
A
Females:
Pelvic floor exercises
Urethral slings
Males:
Artificial urethral sphincter
10
Q
Aetiology of urge incontinence
A
Detrusor muscle and bladder overactivity
Can be primary, due to UTIs or neural factors like parkinson’s.
11
Q
Pathophysiology of urge incontinence
A
Rise in detrusor pressure upon bladder filling causes urgency and leakage.
12
Q
Management of overactive/reflex bladder and urge incontinence
A
Bladder exercise therapy
Anti-muscarinics - e.g oxybutynin to reduce detrusor contraction.
B3 agonists - increase sympathetic detrusor relaxation.
Botox - blocks neuromuscular junction
Sacral neuromodulation - insertion of electrode in S3 to modulate afferent impulses.
Intermittent self-catheterization.
Surgery - cystoplasty
13
Q
What is the effect of somatic innervation on the lower urinary tract?
A
Voluntary contraction/relaxation of the external urethral sphincter.
14
Q
What nerve and nerve roots are responsbible for the somatic innervation of the lower urinary tract?
A
Pudendal nerve, S2-4
15
Q
Side effect of urinary botox use?
A
Urinary retention
16
Q
What are the spinal urinary reflexes?
A
Reflex blader contraction
Guarding reflex
Bladder receptive relaxation
17
Q
What is reflex bladder contraction?
A
When bladder fills it automatically triggers contraction.
Pelvic nerve mediated.
18
Q
What is the urinary guarding reflex?
A
Urine in proximal urethra causes impulse to spinal cord to tell Onuf’s nucleus to close proximal urethreal sphincter to store urine.
19
Q
What is receptive relaxation of the bladder?
A
The detrusor muscle relaxes as the bladder fills with urine in order to maintain constant bladder pressure.
Hypogastric nerve mediated.
20
Q
What is the role of the pontine micturition center?
A
Coordinates the central and peripheral neuromodulation of voiding.
21
Q
What is the role of the cortical micturition center?
A
Mediates voluntary micturition.
22
Q
Pathophysiology of urinary effects of spastic (supra-conal) spinal cord injury
A
Loss of pontine co-ordination of voiding.
Can result in detrusor-sphincter dyssenergia.
Poorly sustained and involuntary bladder/bowel contraction
Can potentially result in unsafe bladder if both contract.
23
Q
Pathophysiology of urinary effects of flaccid (conal) spinal cord injury
A
Loss of reflexes (bladder contraction, guarding, RR)
Arreflexic bladder and bowel.
Bladder filling without detrusor compliance can lead to an unsafe bladder.
Can result in stress incontinence.
24
Q
What can cause a conal spinal cord injury?
A
Ischaemia such as transversus myelitis or diabetic neuropathy
25
Aetiology of autonomic dysreflexia
Requires almost complete spinal injury.
Occurs in lesions at or above T6.
26
Pathophysiology of autonomic dysreflexia
Overstimulation of sympathetic nervous system below level of lesion in response to a noxious stimulus (stimulus causing pain/discomfort) such as full blader.
Due to lack of sensation due to lesion.
Can cause constriction of splanchnic vessels (T6) causing significant hypertension.
27
Clinical presentation of autonomic dysreflexia
Patient will feel dizzy, headache, body below lesion is white and above will be red (flushing).
Bradycardia in response to hypertension.
28
What is an unsafe bladder?
A bladder with high pressure that is at risk of damaging the kidneys.
29
Aetiology of an unsafe bladder
Decreased detrusor compliance
Vesico-ureteric reflux
Bladder obstruction - stones, residual urine, etc.
30
Complications of an unsafe bladder
Renal failure
31
What type of urinary obstructions (obstructive uropathy) are there?
Luminal
Mural
Extraluminal
32
Aetiology of luminal urinary obstruction
Renal calculi
Thrombus
Tumour of renal pelvis, ureter, bladder
33
Aetiology of mural urinary obstruction
Ureteric stricture
Neuropathic bladder
Congenital bladder neck obstruction
34
Aetiology of extraluminal urinary obstruction
Retroperitoneal tumours
Benign prostatic hyperplasia
Phimosis
35
Clinical presentation of upper urinary tract obstruction
Renal colic
Loin pain
Complete anuria - complete bilateral obstruction/that of a single kidney
36
Clinical presentation of lower urinary tract obstruction
LUTS:
Issues with storage:
Frequency
Urgency
Nocturia (> 30% voided volume @ night)
Overflow incontinence (leaking urine during day/wetting bed)
Issues with voiding:
Straining
Hesitancy
Incomplete emptying
Poor intermittent stream
Post micturition dribbling
Haematuria
Dysuria (painful urination)
37
Pathophysiology of urinary obstruction (obstructive uropathy)
Buildup of urine can lead to increased pressure in bladders, ureters and kidneys leading to renal pelvis dilation (hydronephrosis) which can lead to renal failure.
38
What is urinary retention?
Inability to pass urine with over 500ml left in the bladder.
39
What is the most common form of bladder cancer?
Transitional cell/urothelial carcinoma
40
Aetiology/risk factors for bladder cancer
Smoking
Age > 55
Male
Occupational exposure to chemicals e.g napthylamine
Drugs like cyclophosphamide
Schistosomiasis
41
Clinical presentation of bladder cancer
Weight loss
Painless haematuria
LUTS
Recurrent UTIs
Hydronephrosis if obstruction
42
Investigation of bladder cancer
Urinalysis - can show pyuria
GS - Flexible cystoscopy (bladder endoscopy) + biopsy
CT urogram - can stage and is also diagnostic
43
Management of bladder cancer
Non-muscle invasive:
Transurethral tumour resection
With chemotherapy - mitomycin and BCG
Muscle invasive:
Radical cystoprostatectomy
With radiotherapy
CAN METASTASIZE TO LUNGS, LIVER, BONE.
44
What are the different types of renal cancer?
Clear cell carcinomas (most common)
Papillary carcinoma
Chromophobe carcinoma
Collecting duct carcinoma
45
Aetiology/risk factors for renal cancer
Smoking
Hypertension
Haemodialysis
Male
Obesity
46
What type and location is most common for renal cancer?
Clear cell carcinoma, proximal convoluted tubule.
47
Clinical presentation of renal cancer
Haematuria
Loin pain
Palpable Abdominal Mass
Varicocele
48
Investigation of renal cancer
First line - Abdominal ultrasound
GS - CT kidney with renal mass protocol
Staging - CT CAP
49
What are some paraneoplastic effects of renal cell carcinomas?
FBC - polycythaemia due to increased erythropoetin secretion
Raised BP due to renin secretion
Hypercalcaemia due to increased Vit.D activation
50
Management of renal cell carcinoma
If less than 4cm - ablation/crytherapy
GS - partial nephrectomy
Can also do nephrectomy
Then immunotherapy such as tyrosine kinase inhibitors
51
Aetiology/Risk Factors of Testicular Cancer
Cryptorchidism - abnormal descending of testicle
Family history
HIV
Caucasian males
Common in younger patients
Klinefelter's syndrome
52
Types of Testicular Tumours
Germ Cell - Seminoma, Teratoma, Yolk Sac tumour, Choriocarcinoma
Non-Germ Cell - Leydig, Sertoli, testicular lymphoma
53
Clinical Presentation of Testicular cancer
Painless testicular mass
54
Investigation of Testicular cancer
Same day testicular ultrasound - GS
Serum alpha fetoprotein, Beta-hCG, lactate dehydrogenase - tumour markers.
CXR if respiratory symptoms
Staging - CT CAP
55
Management of testicular cancer
Radical inguinal orchidectomy with chemotherapy
56
What are areas that renal cancers can metastasize to?
Liver, lungs, bones.
57
What is Glomerulonephritis?
Group of parenchymal kidney diseases that all result in the inflammation of the glomeruli and nephrons.
Common cause of end stage renal failure.
58
What conditions are under Nephritic Syndrome (Acute Glomerulonephritis)?
IgA Nephropathy - most common
SLE, systemic sclerosis
Post strep GN
Small vessel vasculitis
Goodpasture's/anti-GMB disease
Henoch Schonlein purpura
59
Pathophysiology of Nephritic Syndrome
Damage to glomerular basement membrane causing RBCs to not be filtered and pass into urine.
60
Clinical Presentation of of Nephritic Syndrome
Haematuria
Proteinuria (mild)
Oliguria - low urine output
Hypertension
Nosebleeds
Haemoptysis
61
Investigation of Nephritic Syndrome
Urinalysis - haematuria, albuminuria
Blood pressure - hypertension
Oliguria due to decreased GFR
Diagnostic is kidney biopsy
62
Aetiology of IgA Nephropathy
Associated with respiratory and GI conditions such as tonsilitis.
63
Pathophysiology of IgA Nephropathy
Abnormal IgA glycosylation causes deposition of IgA into the mesangium of the kidney.
This results in inflammation and damage
64
Clinical Presentation of IgA Nephropathy
Presents asymptomatically with episodic visible haematuria.
65
Investigation of IgA Nephropathy & Henoch Schonlein Purpura
Renal biopsy - mesangial IgA deposits.
66
Management of IgA Nephropathy & Henoch Schonlein purpura
Steroids (e.g prednisolone) + immunosuppression
BP control - ACE inhibitors/ARBs
67
Pathophysiology of Goodpasture’s Disease
Type II Hypersensitivity reaction
Caused by autoantibodies to Type IV collagen (anti-BM antibodies) in glomerular and alveolar membrane.
68
Clinical Presentation of Goodpasture’s Disease
Normal nephritic syndrome symoptoms, but can present with resp symptoms like dyspnoea, haemoptysis.
69
Investigation of Goodpasture’s Disease
Serology - anti-GBM antibodies
70
Management of Goodpasture's Disease
Remove antibody through plasma exchange
Steroids e.g prednisolone + immune suppression e.g cyclophosphamide
71
Investigation of SLE
Anti-nuclear antibody (ANA) positive and Double stranded DNA positive
Low complement C3 & C4 levels
72
Pathophysiology of Henoch Schonlein Purpura
This is a small vessel vasculitis that affects the kidney and joints due to IgA deposition
73
Clinical Presentation of Henoch Schonlein Purpura
Presents with a purpuric rash on legs, nephritic symptoms, and abdominal/joint pain due to IgA deposition.
74
Pathophysiology of ANCA Associated Vasculitis:
Multisystem small vessel vasculitis attack small vessels in the kidney and eye
ANCA = anti-neutrophil cytoplasmic antibodies
75
Clinical Presentation of ANCA Associated Vasculitis
Systemic inflammatory features.
76
Investigation of ANCA Associated Vasculitis
Serology - raised ANCA
Raised ESR, CRP
Renal biopsy - macrophages and lymphocyte infiltration of glomerulus
77
Management of ANCA Associated Vasculitis
Steroids e.g prednisolone + immunosuppression e.g cyclophosphamide
78
Investigation of Systemic Sclerosis
Serology: Anti nuclear antibody positive
Renal biopsy: Onion skin’ changes on renal biopsy, raynauds phenomenon, fibrotic skin, oesophageal dysmotility
79
Management of Systemic Sclerosis
ACE inhibitors
80
Aetiology of Nephrotic Syndrome
Primary:
Membraneous nephropathy
Focal segmental glomerulosclerosis
Minimal change disease
Secondary:
Amyloidosis
Diabetic nephropathy
81
What is the most common cause of Nephrotic Syndrome in children?
Minimal change disease
82
Pathophysiology of Nephrotic Syndrome
Issue with the filtration barrier and podocytes results in leaking of protein into the urine.
Loss of plasma proteins causes increased activation of the liver which can result in increased hepatic lipogenesis.
83
Clinical Presentation of Nephrotic Syndrome
Proteinuria - frothy urine
Hypoalbuminemia
Oedema
Dyslipidaemia
Mild/absent haematuria
84
Investigation of Nephrotic Syndrome
Protein:creatinine ratio
Urinalysis - Proteinuria
LFT - Hypoalbuminemia
Renal biopsy - diagnostic
85
General Management of Nephrotic Syndromee
Fluid management - diuretics, ACEi/ARBs to reduce BP
Dyslipidaemia - Statins
Loss of anticoagulant factors - anticoagulants
Loss of immunoglobulins - Antibiotics
Treatment of underlying cause
86
Investigation of Minimal Change Disease
Light microscopy of renal biopsy - No change
Electron microcroscopy of renal biopsy - Fusion and effacement of podocyte foot processes.
87
Management of Minimal Change Disease
Steroids e.g prednisolone + immunosuppression e.g cyclophosphamide
88
Aetiology/risk factors for Membraenous Nephropathy
NSAIDs
Autoimmune conditions such as SLE
Infections - schistosomiasis
Malignancy - lung
89
Pathophysiology of Membraneous Nephropathy
Thickening of glomerular capillary wall
Immunoglobulin (IgG) and complement deposition in sub-epithelial surface.
Results in leaky glomerulus.
90
Investigation of Membraneous Nephropathy
Serology - PLA2 receptor antibody
Renal biopsy - Thickened glomerular basement membrane.
91
Management of Membraneous Nephropathy
ACE Inhibitors e.g ramipril
Steroids e.g Prednisolone + immunosuppression e,g Cyclophosphamide
Anti CD-20 antibodies e.g Rituximab
92
Aetiology/Risk Factors of Focal Segmental Glomerulosclerosis
Can be idiopathic or secondary to HIV, heroin, lithium
Higher prevalence in Black people
93
Investigation of Focal Segmental Glomerulosclerosis
Renal biopsy - Segmental scarring of glomeruli
94
Management of Focal Segmental Glomerulosclerosis
Steroids e.g prednisolone + Immunosuprresion e.g cyclophosphamide
ACE inhibitors
95
What is Erectile Dysfunction?
Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.
96
What corpus surrounds the urethra?
Corpus spongiosum
97
What corupus fills with blood during an erection?
Corpus spongiosum
98
What corpus surrounds the corpus spongiosum?
Corpus cavernosum
99
What is the name of the fibrous membrane that surrounds both the corpus cavernosum and spongiosum?
Tunica albuginea
100
What is the effect of parasympathetic stimulation on the penis?
Causes an erection.
101
What nerve and nerve roots are responsible for parasympathetic stimulation of the penis?
Cavernous nerve, S2-S4
102
What is the effect of sympathetic stimulation on the penis?
Causes ejaculation.
103
What nerve and nerve roots are responsible for sympathetic stimulation of the penis?
Dorsal nerve, S2-S4
104
Physiology of an erection
Parasympathetic stimulation causes arteriolar dilation.
Nitric oxide release from endothelium causes intracellular cyclic GMP rise
This which decreases cytoplasmic calcium allowing for smooth muscle relaxation.
105
What androgen is needed for erectile function?
Testosterone
106
Aetiology of Erectile Dysfunction
Neurogenic issues - failure to initiate
Arteriogenic issues - failure to fill
Venogenic issues - failure to store
Psychogenic issues - anxiety, depression
107
Risk Factors for Erectile Dysfunction
Smoking
Obesity
Old age
Diabetes
Trauma - pelvic fracture, prostatectomy
108
First Line Management of Erectile Dysfunction
Phosphodiesterase 5 (PDE5) inhibitors
Eg. sildenafil (viagra), tadalafil, vardenafil
109
Pharmacodynamics of PDE5 inhibitors
Phosphodiesterase is the enzyme that degrades cyclic GMP so inhibition causes prolonged smooth muscle relaxation allowing for erections to last longer.
110
Side Effects of PDE5 Inhibitors
Headache
Dyspepsia
111
Second Line Management of Erectile Dysfunction
Sublingual apomorphine
Vacuum constriction devices - can cause inability to ejaculate, petechiae
Intracavernous injections
112
Surgical Management of Erectile Dysfunction
Prosthetic Penile Implant
113
What is Prostate Specific Antigen (PSA)?
Protease responsible for the liquefaction of semen.
114
Causes of Raised PSA Levels
BPH
Prostate cancer
UTI
Prostatitis
Exercise
Recent ejaculation/prostate stimulation.
115
Aetiology/Risk Factors of Prostate Cancer
Family history
BRCA2 confers a 5-7 times higher risk
Increasing age
Black ethnicity
Smoking
High animal fat diet
116
Pathophysiology of Prostate Cancer
Usually originates in the periphery of the prostate
Mostly adenocarcinomas
117
Clinical Presentation of Prostate Cancer
LUTS
Frequency
Urgency
Nocturia
Incomplete Voiding
Straining
Hesitancy
Intermittency
Post-micturition dribbling
Weight loss, bone pain, anaemia suggest metastasis.
118
Investigation of Prostate Cancer
FL - Digital rectal exam - Hard, irregular prostate, or multi-parametric prostate MRI
Raised PSA
GS - Trans-rectal ultrasound + biopsy
Biopsy goes through gleason staging
119
TNM Staging of Prostate Cancer
T1- no palpable tumour on DRE
T2 - palpable tumour, confined to prostate
T3 - palpable tumour extending beyond prostate capsule
T4 – invading local structures (sphincter/ rectum
120
Management of Localised Prostate Cancer
Radical prostatectomy if <70yrs - excellent disease free survival
Radiotherapy = brachytherapy (implantation of radioactive material targeted at tumour)
Active surveillance if >70yrs and low risk
121
Management of Metastatic Prostate Cancer
Surgical castration - takes away testosterone
If castration resistant - Androgen deprivation therapy
122
What Drugs can be used in Androgen Deprivation Therapy for Prostate Cancer?
Androgen receptor antagonists such as abiraterone, enzalutamide
GnRH agonists such as goserelin which inhibit androgen circulation through negative feedback loops.
123
What is an uncomplicated urinary tract infection?
When a non-pregnant, under 65 y/o woman gets inefected.
124
What is a complicated urinary tract infection?
When there is potential for a structural abnormality in the urinary tract such as:
Male gender
Pregnancy
Catheterized patients
Immunocompromised patients
Children
125
What organisms most commonly cause UTIs?
KEEPS
Klebsiella pneumoniae
Eschericha coli (uropathogenic e.coli so UPEC)
Enterococci
Proteus mirabilis
Staphylococcus saprophyticus
Staphylococcus aureus
Pseudomonas aeruginosa
126
Aetilogy/Risk Factors for UTIs
Pregnancy
Female gender
Catherization
Urinary tract stones
Sexual activity
127
Virulence Factors of UPEC
Fimbriae for surface adherence
Flagellum for motility
Haemolysin for pore formation
Aerobactin for iron acquisition
128
Pathophysiology of UTIs
Catherisation allows direct bacterial entry and formation of biofilm on catheter.
Urinary obstruction from stones, BPH, etc can cause stasis of urine flow resulting in bacterial proliferation.
Low urinary volume (e.g not drinking enough) causes less urine through the bladder to flush out any bacteria.
Pregnancy can cause stasis of urine.
129
Clinical Presentation of Lower UTI (Urethritis, Cystitis)
Suprapubic pain
Frequency
Urgency
Dysuria - burning sensation when peeing
Fever
130
Clinical Presentation of Upper UTI (Pylonephritis)
Loin Pain
Haematuria
Swinging Fever
Cloudy urine (pyuria)
Confusion
Chils
More systemic effects.
131
Investigation of UTIs
First line: Urine dipstick - nitrates, leukocyte, haematuria positive
Gold standard: Mid stream urine microscopy, culture and sensitivity
132
Why does the urine sample for testing UTIs have to be mid stream?
Cannot be first void because it includes peroneal bacteria which can contaminate sample.
133
How can a urine sample be obtained for kids?
Clean catch
134
What can be deduced from urine microscopy for UTIs?
Pyuria - >10^4 leukocytes/mil
Bacteriuria - >10^5 colony forming units/mil
135
Investigation of Catheter Associated UTI
Direct mid stream urine culture, no dipstick or microscopy.
136
Why is urine microscopy not performed on catheter associated UTIs?
A urinary catheter will produce a urethral inflammatory response even in the absence of infection so microscopic pyuria will not be a specific result.
137
Investigation of asymptomatic/symptomatic pregnant women with UTI
Urine dipstick + mid stream urine culture
If positive results on culture, confirm with second sample.
138
Why are all pregnant women screened with urine dipsticks and mid stream urine cultures?
Dipstick - To check for pre-eclampsia
MSUC - To check for asymptomatic bacteraemia which could potentially lead to a UTI
139
Management of a lower UTI (Cystitis)
First line is nitrofurantoin (if renal function is good or if non-pregnant)/trimethoprim
Uncomplicated: Nitrofurantoin/trimethoprim for 3 days
Complicated: Nitrofurantoin/trimethoprim for 7 days.
140
Side effects of nitrofurantoin
Nausea/Vomiting
Headaches
Syncope
Neuropathy risk
141
Contraindications of nitrofurantoin
Cannot be used in third trimester of pregnancy due to increaed risk of infantile jaundince and HDFN
Should not be used in renal impairment (eGFR/creatinine clearance <45ml/min)
142
Contraindications of trimethoprim
Cannot be used in first trimester of pregnancy
143
Pathophysiology of Pylonephritis
Infection of the renal parenchyma and soft tissues of renal pelvis /upper ureter
Can be ascending spread - urethra colonised with bacteria.
Massage of the urethra during intercourse can force bacteria into the female bladder
Can be haematogenous spread - S.aureus
Lymphatic spread (rare)
144
Examination of Pylonephritis
Renal angle and loin tenderness
145
Investigation of Pylonephritis
Urine dipstick - leukocyte, nitrates, haematuria positive
Midstream urine microscopy, culture and sensitivity
FBC - leukocytosis
ESR, CRP - elevated
Renal Ultrasound - rule out obstruction
Renal CT - wedge shaped areas of inflammation
146
Management of Pylonephritis
Fluid resuscitation
Oral ciprofloxacin + co-amoxiclav for 7-14 days
If non-responsive then IV co-amoxiclav + gentamicin for 7-14 days
147
Complications of Pyelonephritis
Renal abscess formation
Emphysematous pyelonephritis
148
What regions are urinary stones usually found in?
Pelviureteric junction
Pelvic brim
Vesicoureteric junction
149
Aetiology/Risk Factors for Urinary Stones
Dehydration
Hypercalcaemia - calcium based stones
Hyperuricaemia - uric acid stones
Recurrent UTIs - struvite stones
Diuretics
150
What is the composition of urinary stones?
80% Ca based - calcium oxalate/calcium phosphate - radioopaque.
10% uric acid - cannot be seen on on KUB XR (radiolucent) but can be seen on CT
5-10% struvite (magnesium ammonium phosphate) - infection stones, usually in kidney
1% cystine - congenital defect in cystein transporter system.
151
Pathophysiology of urinary stone formation
Nucleation theory - stones form crystals in supersaturated urine.
Proteus mirabilis UTI - secretes urease causing increasing urinary pH which can result in increased likelihood of stone formation.
152
Clinical presentation of nephrolithiasis
Renal colic - severe loin to groin pain that comes in waves.
Worse with fluid intake
Visble haematuria
Can have UTI symptoms susch as dysuria, frequency
Recurrent UTIs
153
Investigation of nephrolithiasis
Urinalysis - haematuria
KUB XR
Pregnant women and children - FL is renal ultrasound
GS: Non contrast CT KUB (NCCT-KUB)
154
Lifestyle management of urinary stones
Proper hydration
Low Na diet
Increased exercise
Reduce BMI
155
Medical management of urinary stones
FL - Fluid hydration and strong analgesics e.g IV diclofenac
If UTI symptoms, antibiotis e.g oral cefalexin + co-amoxiclav or IV gentamicin + co-amoxiclav for pyelonephritis.
For uric acid stones: sodium bicarbonate tablets for urine deacidifcation
156
Interventional management of nephrolithiasis
If < 5mm, exrete it during urine passing.
If large stone (<4mm will pass normally), consider
Endoscopic sound wave lithotripsy (ESWL)
Ureteroscopy
Percutaneous nephrolithectomy (PCNL)
157
Differential diagnoses for renal colic/loin pain
Abdominal aortic aneurysm
Appendicitis
Ectopic pregnancy, ovarian torsion
Testicular torsion
158
Complications of urinary stones
Pyelonephritis/cystitis
Sepsis
159
Aetiology/Risk Factors for BPH
Increasing age
Afro-carribean ethnicity
160
Pathophysiology of BPH
Enlargement of inner (transitional) zone of the prostate gland.
Can compress on the prostatic urethra to cause obstruction.
161
Clinical Presentation of BPH
LUTS
Frequency
Urgency
Nocturia
Incomplete voiding
Straining
Hesitancy
Intermittency
Post-micturition dribbling
162
Investigation of BPH
FL: Digital rectal exam - smooth, diffuse enlargement.
PSA - prostate specific antigen (elevated)
163
Management of BPH
Reduce caffeine intake
FL: Alpha 1 receptor antagonists e.g tamsulosin
5-alpha-reductase inhibitors such as finasteride
164
Side effects of tamsulosin
Side effects: retrograde ejaculation, postural hypotension, syncope.
165
What is AKI?
Sudden decline in kidney function over a period of hours or days.
166
KDIGO Classification of AKI
Uses serum creatinine and urine output to assess severity
Level 1:
Increase of >26micromols/L or 1/5x baseline level over 48 hours.
<0.5/kg/ml urine output for >6 consecutive hours
167
Pre-renal Aetiology of AKI
Hypovolaemia
Dehydration
Haemhorrage
Diuretic usage
168
Intra-Renal Aetiology of AKI
Parenchymal damage
Acute tubular necrosis
Glomerulonephritis
PKD
Trauma
169
Post-Renal Aetiology of AKi
Urinary tract obstruction
Urolithiases
BPH
Bladder tumour
170
Pathophysiology of AKI
Can cause accumulation of excreted substances like electrolytes.
Can cause uraemia which can lead to pericarditis/cardiac tamponade.
171
Clinical Presentation of AKI
Oliguria (low urine output)
Can have cola colored urine (rhabdomyolysis) if traumatic cause.
Fatigue, dizziness, vomiting - uraemia
Dyspnoea - pulmonary oedema due to salt and fluid retention.
Palpitations - arrhythmias due to hyperkalaemia
Palpable/enlarged bladder if obstructed
172
Investigation of AKI
U & E - can show hyperkalaemia,
FBC & ESR/CRP - check for infection]
ABG - metabolic acidosis
Renal biopsy for intrarenal causes.
Renal ultrasound/NCCT-KB for obstruction and post renal causes.
173
Management of AKI
Manage underlying disease
Sodium and potassium restriction
Hyperkalaemia: IV calcium gluconate or IV insulin/dextrose infusion with nebulised salbutamol if no ECG changes.
IV fluids if hypovolemic
May need renal replacement therapy.
174
What are the 2 types of PKD?
Autosomal dominant PKD - most commonly inherited kidney disorder.
Autosomal recessive PKD - less common.
175
Aetiology of PKD
ADPKD:
Mutation in PKD1 gene on chromosome 16 - most common
Mutation in PKD2 gene on chromosome 4
ARPKD:
Mutation in PKHD1 gene on chromosome 6
176
Pathophysiology of ADPKD
Disruption of the polycystin pathway results in reduced cytoplasmic Ca2+.
In principal cells of the collecting duct this causes defective ciliary signalling and disorientated cell division.
Results in cyst formation
177
Pathophysiology of ARPKD
Mutation in PKHD1 which encodes for fibrocystin causes cystic dilation of collecting ducts.
Cyst formation can also cause obstruction of urine flow and UTI.
178
Clinical Presentation of PKD
BETWEEN AGES OF 30-40
Hypertension
Bilateral flank loin pain.
Painless Haematuria - bursting of cyst
Polyuria
Subarachnoid haemhorrage due to berry aneurysm rupture
Can also have UTI presentations.
179
Investigation of PKD
GS: Renal ultrasound - enlarged kidneys with cysts.
U + E
Genetic testing for PKD gene mutations
180
Management of PKD
Medical:
Vasopressin receptor antagonists e.g tolvaptan
Somatostain analogues e.g ocreotide
These reduce cAMP in principal cells to reduce cyst growth.
ACE inhibitors e.g ramipril for hypertension.
Surgical:
Laparoscopic cyst removal
RRT
Nephrectomy
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Conditions associated with PKD
SAH
Liver abscesses
Mitral valve prolapse
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Aetiology of Prostatitis
Streptococcus faecalis
Chlamydia trachomatis
UPEC
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Clinical Presentation of Prostatitis
Fever
Chills
Malaise
Pain upon ejaculation
Pelvic pain
Voiding LUTS
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Investigation of Prostatitis
DRE: tender and hot prostate.
Elevated PSA
Trans-rectal ultrasound
Urine dipstick: positive for leukocytes, nitrates, haematuria
Mid stream urine culture microscopy sensitivity
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Management of Prostatitis
IV ciprofloxacin
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Aetiology of Urethritis
Primarily a STI
Non gonoccocal - chlamydia, trichomonas vaginalis
Chlamydia is most common.#
Gonoccocal - neisseria gonorrhoeae
Male to male sex
Unprotected sex
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Clinical Presentation of Urethritis
Dysuria
Urethral discharge - blood, pus.
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Investigation of Urethritis
Culturing of genital secretions (black swab)
Nucleic acid amplification test (NAAT)
If suspected UTI, urine dipstick + mid stream urine microscopy culture sensitivity.
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Management of Urethritis
Gonorrhoea: IM ceftriaxone + oral azithromycin
Chlamydia: Oral doxycycline + oral azithromycin
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Clinical Presentation of Epididymal Cyst
Palpable lump(s) in the posterior aspect of the testicle.
Are transilluminate (will allow light to pass through) since fluid-filled.
If sperm filled - spermatocele.
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Investigation of Epididymal Cyst
Scrotal ultrasound
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What is a hydrocele?
Accumulation of fluid within the tunica vaginalis.
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Aetiology of Hydroceles
Primary - Patent processus vaginalis during testicular descent.
Secondary - testicular cancer, testicular torsion
oedema
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Pathophysiology of Hydrocele
Overproduction of fluid in the tune vaginalis (non-communitcating hydrocele)
Processus vaginalis fails to close, allowing peritoneal fluid to drain into the scrotum (communicating hydrocele)
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Clinical Presentation of Hydrocele
Enlargement of scrotum with non-tender, smooth cystic swelling.
Testes should be palpable
Swelling will normally be antero-inferior and will be transilluminate.
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Investigation of Hydrocele
Scrotal ultrasound
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What is a Varicocele
Abnormal dilation of the testicular veins in the pampiniform venomous plexus, caused by venous reflux
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Aetiology of Varicocele
Testicular/renal vein thrombosis/compression.
Pelvic tumour
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Pathophysiology of Varicocele
More common in left testes because testicular vein drains into left renal vein at a perpendicular angle before entering IVC.
Right testicular vein enters directly into IVC
Compression causes increased backpressure and swelling.
200
Clinical Presentation of Varicocele
Swollen and distended scrotal blood vessels - looks and feels like a bag of worms around the testes.
Typically painless
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What is testicular torsion?
Twisting (torsion) of the spermatic cord
202
Aetiology of Testicular Torsion
Can be due to congenital deformities such as belt-clapper deformity.
Cryptorchidism
Rough sexual activity
Trauma
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Pathophysiology of Testicular Torsion
Can cause occlusion of testicular blood vessels leading to ischaemic infarction.
Left testicle more commonly affected
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Clinical Presentation of Testicular Torsion
Sudden severe unilateral testicular pain
Unilateral testicular inflammation
Nausea/vomiting
205
Examination of Testicular Torsion
Negative cremasteric reflex - no proximal movement of testicle upon stroking of inner thigh.
Negative Prehn’s sign - no pain relief upon elevation of scrotum.
206
Investigation of Testicular Torsion
Doppler ultrasound to check testicular blood-flow
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Management of Testicular Torsion
FL: Surgical exploration & orchidoplexy
Orchidectomy
If within 6 hours, 90-100% chance of saving the testicle.
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What is chronic kidney disease?
CKD is longstanding, usually progressive, impairment in renal function
(haematuria, proteinuria or anatomical abnormality) for more than 3 months
Defined as a GFR < 60mL/min/1.73 m for more than 3 months with/without
evidence of kidney damage (haematuria, proteinuria or anatomical abnormality)
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What are the stages of chronic kidney disease?
Stage 1: eGFR >90 ml/min
Stage 2: eGFR 60-89 ml/min
Stage 3a: eGFR 45-59 ml/min
Stage 3b: eGFR 30-44 ml/min
Stage 4: eGFR >15-29 ml/min
Stage 5: eGFR < 15 ml/min
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Pathophysiology of chronic kidney disease
In CKD filtration is performed by fewer functioning nephrons.
These experience hyperfiltration which can lead to accelerated nephronic decline.
In order to compensate for decreased GFR the RAAS system is activated, but this increases the effect of hyperfiltration and increases glomerular basement membrane permeability.
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Investigation of CKD
Urinalysis - haematuria, proteinuria
U + E - high urea, creatinine, potassium, low calcium
FBC - normochromic normocytic anaemia (ACD)
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Management of CKD
Symptomatic management.
Diuretics
If in end stage, renal replacement therapy
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What are the different types of renal replacement therapy available?
Haemoialisis
Haemofiltration
Peritoneal dialysis
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What is haemodialysis?
Blood is passed over a semi-permeable membrane against dialysis fluid flowing in the opposite direction, thus blood is always meeting a less-concentrated solution and diffusion small solutes occurs down the concentration gradient.
Taken from artery and returned to vein through AV fistula.
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Pros and cons of haemodialysis
Pros
Can be commenced quickly, used during emergencies.
Patient doesn’t need training.
Cons
Cannot be performed at home - must be in hospital.
Risk of issues with vascular access.
Does not work for haemodynamically unstable patients.
216
What is peritoneal dialysis?
Process insert catheter into patient’s abdomen and use peritoneum in the abdomen as a membrane across which fluid and solutes are exchanged with blood
217
Pros and cons of peritoneal dialysis
Pros
Can be done at home - more convenient.
Lesser risk of hypotension
Cons
Requires training
Increased infection risk - peritonitis.
Does not work for ;arge patients or those with poor residual function
218
What is haemofiltration?
Most commonly used
Achieves blood flow using a blood pump to draw and return blood from the lumen of a dual-lumen catheter placed in the jugular, subclavian or femoral vein.
Ultrafiltrate is continuously removed from patient combined with simultaneous infusion of replacement solution
219
Pros and cons of haemofiltration
Pros
Is more hemodynamically stable compared to other methods.
Allows for larger range of uraemic solute removal.
Cons
Shorter circuit life
More expensive
220
Aetiology/Risk factors of haemolytic uraemic syndrome
Post-EHEC infenction.
221
Pathophysiology of haemolytic uraemic syndrome
Shiga toxin released by EHEC causes small vessel thrombosis, leading to platelet depletion (thrombocytopaenia), haemolysis and pre-renal AKI.
222
Clinical presentation of haemolytic uraemic syndrome
Haemolytic anaemia - pallor, dyspnoea
Thrombocytopaenia - easy bleeding, bruising
Acute Kidney Injury - oliguria
223
Investigation of haemolytic uraemic syndrome
Blood film - schistiocytes and helmet cells.
224
Management of haemolytic uraemic syndrome
Supportive management.
Antihypertensives
Diuretics
Blood transfusions
225
Aetiology/risk factors for CKD
Polycystic kidney disease
Hypertension
Diabetes mellitus
Chronic pyelonephritis
226
Aetiology of epidiymo-orchitis
UTI - KEEPS
STI - chlamydia
227
Clinical Presentation of epidiymo-orchitis
Unilateral testicular pain and swelling.
228
Investigation of epidiymo-orchitis
If <35, STI test
If >35, mid stream urine microscopy and culture.
229
Mangement of epidiymo-orchitis
If STI - IM ceftriaxone + oral doxycycline
If UTI - ciprofloxacin
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Pharmacodynamics of 5-alpha-reductase inhibitors
E.g finasteride.
Reducess size of prostate through
inhibits conversion of testosterone to dihydrotestosterone which is the active form needed for prostatic growth.
231
Pharmacodynamics of alpha-1-antagonists
E.g tamsulosin
Causes smooth muscle relaxation in the bladder neck to reduce obstruction and improve urinary flow.
232
Antimicrobial managment of chlamydia
Oral doxycycline + oral azithromycin
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Antimicrobial management of gonorrhoea
IV ceftriaxone + oral azithromycin
