Nephrology & Urology Flashcards
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Normal PaCO2
35-45 mmHg
Normal PaO2
85%
Normal HCO3
22-32 mmol/L
Normal PH
7.40-7.45
urinary urgency + urinary frequency + nocturia
Overactive bladder
Peaked T-waves are seen in lead V2,V3,V4 and V5 + widening of QRS, decreased amplitude of P waves
hyperkalaemia
ACE inhibitors + spironolactone
Increased risk of hyperkalaemia
Causes of hyperkalaemia
– Renal failure.
– Metabolic acidosis.
– Addison’s disease.
– Use of aldosterone antagonists like spironolactone.
– ACEi.
– NSAIDs.
Renal stone recurrence management
- Increase water intake about 2.5 to 3 litres/day
- calcium-rich foods
- thiazide diuretics
- lewer oxalate-rich foods (Oxalate stones)
- Allopurinol
- urinary alkaliniser (potassium citrate)
Renal stones initial investigation
1st case: CT KUB
2nd recurrent: ultrasound + X-ray KUB
Renal stones diagnostic investigation
spiral CT KUB non-contrast
alkaline urine + “Staghorn calculi”
Struvite stones
Proteus pathogen renal stone
Struvite
-magnesium ammonium phosphate
Uric acid stone treatment
- Allopurinol
- urine alkalinization
Oxalate stone treatment
Renal stones in renal pelvis management
< 2.5cm: Extracorporeal lithotripsy
< 2.5cm: Percutaneous lithotripsy
Renal stones in ureter
Upper half < 1cm: Lithotripsy
Upper half: >1 cm: Lithotripsy or nephrolithotomy
Lower half < 1cm: Lithotripsy
Lower half > 1cm: Lithotripsy or endoscopy
Renal stones in bladder
< 3cm: Transurethral lithotomy
> 3cm: Cystotomy
Low potassium + hypertension
Investigate serum aldosterone
Most common complication of radical prostatectomy
Erectile Dysfunction (ED)
Premature ejaculation treatment
1st line: SSRI (raises orgasm threshold)
main complication of retroperitoneal lymph node dissection (RPLND)
Retrograde ejaculation
most common complication of TURP
Urinary tract infection (UTI)
UTI requiring hospitalisation
any infant < than 3 months
- increased risk of urosepsis
Infant UTi treatment
- IV trimethoprim/gentamicin, benzyl penicillin
Erectile Dysfunction (ED) management
Initial :
- Optimise modifiable risk factors / related comorbidities (HTN, DM, diet/exercise etc)
- Treat reversible causes
(Low testosterone, Medication-induced erectile dysfunction, Psychogenic erectile dysfunction – consider referral to a therapist)
- Pharmacological/Surgical treatment
- 1st line: phosphodiesterase type 5 inhibitor (sildenafil)
- 2nd line: penile injections, vacuum erection devices, external shock wave lithotripsy
3rd line: penile prosthesis
polycystic kidney disease features
- Polyuria and nocturia
– Renal failure
– Hypertension
– Abdominal wall and inguinal hernias
– Colonic diverticulosis
– Hepatic cysts
– Subarachnoid or cerebral haemorrhage
– Cardiac anomalies including mitral valve prolapse
albuminuria in diabetes
first void spot specimen Urinary albumin to creatinine (ACR) ratio
URTI + proteinuria + haematuria + immediate onset
IgA nephropathy
IgA nephropathy treatment
Asymptomatic microscopic haematuria: 2 positive
UAs out of 3 in 2-3 weeks
Symptomatic: corticosteroids
URTI + proteinuria + haematuria + onset within weeks + facial oedema
Poststreptococcal glomerulonephritis (PSGN)
HIV px + taking indinavir + haematuria + loin pain
Indinavir induced nephrolithiasis
- Only detectable on US
- Remove/Change indinavir
onset within weeks + HIV hx + haematuria + proteinuria
Focal segmental glomerulosclerosis (FSGS)
HIV-associated nephropathy (HIVAN)
-Nephrotic range proteinuria
-Azotaemia
-Normal to large kidneys on ultrasound images
-Focal segmental glomerulosclerosis (FSGS)
shortened QTc interval on ECG
Severe hypercalcaemia
Dialysis indications
- Pericarditis or pleuritis (urgent indication).
- Progressive uraemic encephalopathy or neuropathy (confusion,
asterixis, myoclonus, wrist or foot drop, or, in severe cases, seizures (urgent indication). - A clinically significant bleeding diathesis attributable to uraemia (immediate indication).
- Persistent metabolic disturbances that are refractory to medical therapy (hyperkalemia, metabolic acidosis, hypercalcemia,hypocalcemia,
hyperphosphatemia) - Fluid overload refractory to diuretics
Dialysis metabolic abnormalities
- hyperphosphatemia
- Vitamin D deficiency
- hypocalcaemia
- secondary hyperparathyroidism
- hyperphosphataemia
Dialysis skeletal abnormalities
renal osteodystrophy:
- Osteomalacia
- osteosclerosis
- osteitis fibrosa cystica
Most common acute complication of haemodialysis
Hypotension
Paradoxical hypertension
Increase dialysis duration
Acute renal failure risk
- Advanced liver cirrhosis
- Ascites medication
Chronic renal failure risk
- Ischemic heart disease
- Type 2 DM
Most common neurologic complication of chronic renal failure
Peripheral neuropathy
Hypercalcaemia manifestations
- constipation
- anorexia
- nausea and vomiting
- abdominal pain
- ileus
– Bone pain.
– Muscular weakness - Peptic ulceration.
– Pancreatitis.
– Neurological - Short QT interval on ECG
renal impairment:
- polyuria, nocturia, and
polydipsia
> Ca 3mmol/L:
- emotional labiality
- confusion,
- delirium
- depression/psychosis
- stupor
- coma
Hypercalcaemia risk factors
Paraneoplastic syndromes:
- squamous cell carcinoma of the head and neck
- Renal cell carcinoma
- Carcinoma of lung
- Multiple myeloma
Hypocalcaemia manifestations
- Paraesthesia and numbness of the fingertips and perioral area.
-Chvostek’s sign: Twitching of the ipsilateral facial musculature (perioral, nasal, and eye muscles) by tapping over cranial nerve VII at the ear.
-Trousseau’s sign: carpal spasm induced by inflation of the blood pressure cuff around the arm.
-Spontaneous muscle cramps.
-Tetany is seen in severe hypocalcaemia
Causes of confusion in kidney disease
without spasm: uraemia
with spasms: hypercalcaemia
Treatment of urge incontinence
**1st line: Bladder retraining
2nd line: TCA/intravesical botulism
3rd line: Surgery
Haematuria+ hypertension + bilateral palpable
kidneys + abdomen and flank fullness
Polycystic kidney disease (PCKD)
autosomal dominant polycystic kidney disease (ADPKD) dx
Presence of 2 or more cysts in each kidney
autosomal dominant polycystic kidney disease (ADPKD) complications
cerebral aneurysms
Polycystic kidney disease (PCKD) high BP mechanism
increased activity of renin angiotensin system
Polycystic kidney disease (PCKD) risk factors
– Younger age dx
– Black Race.
– Male sex.
– Presence of polycystin-1 mutation.
– Hypertension.
Good cyst penetration medication
Fluoroquinolones
(lipid soluble)
Painless haematuria investigation protocol
- urine
microscopy and culture to rule out urinary tract infection - serum electrolytes, urinary proteins, red cell casts in the urine and check BP to rule out glomerulonephritis
- urinary tract US and
cystoscopy - CT abdomen non contrast
Scrotal lumps investigation
malignant unless proven otherwise
initial: US
lab test for tumour markers:
1. The beta subunit of beta-hCG
2. AFP
3. actate dehydrogenase (LDH)
most common
cause of lower urinary tract symptoms (LUS)
Benign prostate hyperplasia (BPH)
Benign prostate hyperplasia (BPH) management
- 1st line: Finasteride that needs to be bridged with selective α-blocker such as doxazosin, terazosin, or pprazosin
- gold standard: Transurethral resection of the prostate (TURP)
Benign prostate hyperplasia (BPH) complications
hydronephrosis and kidney damage
Most common expected Longterm complication of TURP
Retrograde ejaculation 80-90%
lower urinary tract symptoms (LUS) symptoms
Filling:
-urinary frequency,
- urgency,
- dysuria,
- nocturia.
Voiding:
- poor stream
- hesitancy
- terminal dribbling,
- incomplete voiding
- overflow incontinence (occurs in chronic retention)
fever + perineal region pain + frequency, urgency, dysuria + oliguria + leukocytosis + prostate tenderness + with/o hypotension and tachycardia
Prostatitis
Prostatitis treatment
Borad spectrum antibiotics for 3 weeks
elderly patient + sclerotic changes in vertebrae and pelvis
Prostatic cancer
Prostate cancer T staging
T1 - impalpable
T2 - confined to one nodule
T3a - outside capsule
T3b - into seminal vesicle
Prostate cancer active surveillance criteria
- PSA ≤ 10.0 ng/mL
- clinical stage T1–2a
- Gleason score ≤ (3 + 4 = 7) and pattern 4 component < 10% after pathological review
Prostate cancer active surveillance protocol
- PSA measurements every 3 months
- PE + DRE every 6 months
- Repeat prostate biopsy within 6–12 months of starting protocol
Prostate PSA
40–49 years: <2.5 ng/mL
50–59 years: <3.5
60–69 years: <4.5
70+ years: <6.5
Gleason grade
1: mild - no intervention
2:-3 moderate - conservative measures
3-5: high - requiring surgical intervention
Gleason score
< 6: low risk
7 (3+4)
7 (4+3)
8
9-10
urethral injury initial investigation
retrograde urethrogram followed by Foley (bladder or urinary) catheter
indwelling catheter (Foley) contraindications
Pelvic injury with urethral meatus blood
suprapubic catheter contraindications
– Coagulopathy
– Urinary Bladder carcinoma
– Pregnancy
– Ascites
– Severe obesity
– Lower abdominal scar tissue, mesh or adhesions from previous surgeries, pelvic cancer or radiation treatment
testicular torsion management
Immediate surgery to prevent infarction
testicular tumour malignancy investigation
- scrotal ultrasound
with colour Doppler - CT abdomen and chest x-ray
- inguinal orchiectomy
HEMATURIA 2 TYPES:
gross = investigations ?
microscopic
hematuria
when? start, end all trough?
clots?
renal medical disease?
hematuria
1. HISTORY AND PHYSICAL EXAMINATION
- INITIAL INVESTIGATION
- INVESTIGATIONS
HEMATURIA
ALGORTIMO - microscopic/macroscopic ? imaging
glomerular vs non glomerular characteristis
Managment hematuria children
recall
ciclofosfamida = CISTITIS (dolor ) + HEMORRAGICA
type of stones
NO X RAY
-A) Struvita stones = staghorn caluculus (proteus, psudomonas, klebsiella)
-B) uric acid stones ( DM, gout, rapid weight loss, hemolitic anemia, chronic diarrea) (dissolvde with urina alkalinizaition >6,5)
- C) Indinavir
- D) Cystine
nephrolitiasis
next step indivanir stones= ULTRASOUND (also pregnant lady)
most appropiate next step = non contrast CT scan
nephrolitiasis
Non-enhanced CT is the ‘gold-standard’ for diagnosis of ureteric colic.
●Low-dose CT protocols can be effectively used in acute renal colic
●Immediate imaging is required when patients do not improve after treatment and / or when there is fever and / or leukocytosis and / or the patient has renal failure or a single kidney
●However, because of concerns about ionisingradiation and because the vast majority ofureteric stones pass without the need for intervention, ultrasound (US) has been increasingly recommended and used as the initial imaging modality, with no sacrifice in patient outcome, thus avoiding the need for CT in about 70% of cases
●Ultrasound is also capable of identifying most of the alternative diagnoses listed as mimickers of renal colic
●US in combination with plain x-ray KUB misses very few clinically important stones
●In pregnant patients US, but it should be borne in mind that unless a calculus is visualized it may be difficult to differentiate obstructive hydronephrosis due to a calculus from ‘physiological’ hydronephrosis of pregnancy. In selected cases, MRI urography may be then required
●Conventional IVP can now be considered almost obsolete for the diagnosis of renal colic
●Ultrasonography may be useful in patients in whom avoiding radiation is necessary (egyoung people, women who are pregnant), but CT is still the preferred imaging modality of urologists as it allows better decision-making for further management. Ultrasonography can be useful for following calyceal stones, butis much less accurate than CT at detecting ureteric stones and at measuring stone size (a key determinant of further management).
●Imaging is important for confirming diagnosis and guiding treatment. Computed tomography (CT) and X-rays of the kidneys, ureters and bladder (KUB) should be ordered and performed on the same day
nephrolitiasis
(Surgical Management) when?
Nephrolithiasis
(Surgical Management)
proximal
distal
mm
**1. laser lithiotripsy / called SWL
**2. extracorporeal shock wace lothotripsy
3. percutaneous nephrolithotomy (>2cm)
Which of the following interventions is most likely to prevent renal calculi formation in the future for this patient?
A.Decreasing calcium intake
B.Decreasing sodium intake
C.Increasing consumption of nuts and seeds
D.Loop diuretic pharmacotherapy
E.Urine acidification with cranberry juice
recall
indications surgery
Nephrolithiasis
indications surgery
key points
Nephrolithiasis
UTI Cystitis Adults
Clinical Presentation?
sterile pyruia?
sterile pyruia
tb
cancer
chlamidia
cistitis + fever = PIELONEFRITIS
MICROBIOLOGY UTI
UTI Cystitis Adults
dx
initial?
confirmatory?
pregnancy test
before ATB always send to culture in:
empirical therapy in :
UTI Cystitis Adults
tx
Non-pregnant adults “symptomatic” Cystitis:
Pregnant women “symptomatic” Cystitis and Asymptomatic bacteuria:
A-symptomatic bacteuria adults:
when to treat?
Screening for and treatment of asymptomatic bacteriuria is Not recommended unless:
●Pregnancy
●Urolithiasis
●Vesicouretericr eflux
●Renal transplant recipients
●The immunocompromised, and ●Before instrumentation of the urinary tract.
elderly and delirius yes treat , if neurological normal dont
UTI Pyelonephritis Adults
clinical presentation?
UTI Pyelonephritis Adults
dx
UTI Pyelonephritis Adults
tx
UTI Pyelonephritis Adults
dx image
when ct contrast?
UTI Children Cystitis and Pyelonephritis
clinical presentation
dx
UTI Children Cystitis and Pyelonephritis
ultrasound when?
voiding cystourethrogram when?
UTI Children Cystitis and Pyelonephritis
tx
oral
iv
UTI Children Cystitis and Pyelonephritis
key points read
never fluoroquinolones in australia
tips cystitis adults
read
This patient’s dysuria, increased urinary frequency, and mild suprapubic tenderness in the absence of fever, malaise, and costovertebral angle tenderness is concerning for an uncomplicated acute cystitis. Uncomplicated acute cystitis is empirically treated with antibiotics without needing further diagnostic evaluation.Acute cystitis describes inflammation of the lower urinary tract and bladder and is caused by ascension of uropathogensvia the urethra and into the bladder. Acute cystitis is said to be uncomplicated if the patient is immunocompetent, premenopausal, not pregnant, and there is no evidence that the infection has extended beyond the bladder (e.g., flank pain or costovertebral angle tenderness) or having symptoms suggestive of systemic illness (e.g., fever, rigors, significant fatigue, and sepsis). Women with acute uncomplicated cystitis present with dysuria, increased urinary frequency, urinary urgency, and suprapubic discomfort. The diagnosis is clinically made and often further evaluation (e.g., urinalysis with urine culture, cystography) is not necessary. Most women with symptoms highly suggestive of acute uncomplicated are empirically treated with first-line antibiotics such as nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin. If symptoms resolve with antibiotic treatment, follow-up urine studies are not necessary.
urethritis
first pass of urine test
urethritis
tx
prostatitis
prostatitis
renal TB
scrotal swelling
painful
vs
painless
Hidrocele
vs
Varicocele
definition, clinic, dx, tx
hidrocel
varicocele
think of renal cell carcinoma
retroperitoneal tumor
portal hypertension
tip: left testicular vein drains to **left RENAL VEIN **
varicocele
clinic, physical exam , investigations, TX
CT with contrast (look for malignancy
cyst of epididymis
epididymitis and orchitis
theory
diagnostic to approach a scrotal mass
Testicular Torsion
and
Torsion of the testicular appendix
hematocele
testicular cancer
Benign prostatic hyperplasia
Benign prostatic hyperplasia
TURP complications
Benign prostatic hyperplasia
when PSA
This patient presents with signs and symptoms consistent with benign prostatic hypertrophy (BPH); this condition places one at increased risk for hydronephrosis.BPH is a common condition seen in older men. It typically presents with any number of lower urinary tract symptoms (“LUTS”), including: increased frequency, nocturia, hesitancy, urgency, and weak stream. Enlarged prostate on examination can confirm the diagnosis. Over time, the retrograde pressure caused by BPH can cause hydronephrosis and even renal failure; this is also associated with bladder diverticula. Patients with BPH are at increased risk for developing urinary tract infections, but not prostate cancer.Incorrect Answers:Answers A, C, D: All of these are not associated with BPH, whereas hydronephrosis is.Answer E: Although bladder stones can be associated with BPH, nephrolithiasis is not.
This patient is presenting with syncope whenever he tries to urinate, suggesting a diagnosis of situational syncope secondarytobenign prostatic hyperplasia (BPH).Situational syncope is a type of vasovagal syncope that only occurs during certain situations such as dehydration or during straining with bowel movements or urination in BPH. Situations that increase intra-abdominal pressure can lead to a vagal response that causes sudden bradycardia and hypoperfusion of the CNS resulting in syncope. Patients presenting with syncope should be worked up for acardiac or neurologic process before making the diagnosis of situational syncope.
Incorrect Answers:
Answer 1: Transient ischemic attack presents with sudden stroke-like symptoms (loss of vision and unilateral weakness) that typically self-resolve by the time the patient presents. This patient’s symptoms are reproducible with urination, suggesting an alternate diagnosis.
Answer 2: Postural hypotension presents with syncope when a patient stands up suddenly. A slow increase in vascular tone resultsin temporary blood pooling in the lower extremities and hypoperfusion of the CNS which can cause syncope. This patient’s symptoms only occur when he tries to urinate.
Answer 3: Seizure presents with symptoms during the episode and a post-ictal state. This patient does not seem to have a post-ictal state and has symptoms reproducible with urination.
Answer 4: Cardiac arrhythmia is a possible diagnosis in this patient, and an EKG should be performed to rule out a cardiac diagnosis. In the setting of syncope specific to certain situations, situational syncope is a more likely diagnosis.
Bullet Summary:Situational syncope is a type of vasovagal syncope that only occurs in certain circumstances (most commonly dehydration or straining).
This patient is presenting with sudden-onset urinary retention in the setting of benign prostatic hyperplasia (BPH) and startingan alpha-1 agonist (phenylephrine), suggesting his symptoms are secondary to this medication.Urinary retention typically presents in men with BPH and can present with straining to urinate, a painful and distended bladder,and incomplete voiding. Chronic treatment for BPH is finasteride, which is a 5-alpha-reductase inhibitor that can slow the progression of BPH. Acute treatments include tamsulosin, which is an alpha-1 antagonist which can aid in voiding. Patients who start medications with anticholinergic properties or alpha-1 agonist medications can worsen their urinary retention. Anticholinergics decrease cholinergic tone on the bladder which is required for urination.On the other hand, alpha-1 agonists increase the tone of the urinary tract sphincters making it more difficult to urinate. The treatment of medication-induced urinary retention is to stop the offending agent and to potentially start tamsulosin if symptomspersist.
Incorrect Answers:
Answer A: Constipation is a potential etiology of urinary retention and could possibly be worsening this patient’s symptoms of urinary retention. However, the patient’s symptoms started 3 days ago, and his symptoms did not improve with a bowel movement 2 days ago. Though this patient’s constipation should be better managed, it is not the most likely etiology of his urinary retention.
Answer C: Prostatic adenocarcinoma is unlikely to cause urinary retention when compared to benign prostatic hypertrophy. Prostatic adenocarcinoma typically presents with a rock hard and nodular prostate in contrast to a soft, symmetric, and enlarged prostate in BPH and is less likely to obstruct the urinary tract.
Answer D: Urinary tract infection would present with symptoms of dysuria including urinary urgency, burning, and increased frequency rather than urinary retention.Answer E: Worsening benign prostatic hyperplasia is a possible contributing etiology to this patient’s urinary retention; however, it would not cause a sudden onset of urinary retention as was seen in this patient. Rather, it would be a gradual worsening of urinary retention
Erectile dysfunction
ED is common in men with systemic disorders such as hypertension, ischemic heart disease, and diabetes mellitus, and its prevalence increases with age. Although sexual dysfunction is more common in older men, it also affects younger men (ages 18 to 25 years)
**phosphodiesterase-5 (PDE5) inhibitors,
**
Sildenafil can cause :
Erectile dysfunction
labs
tilogy
stepwise approach to erectile dysfunction tx
infertility in males
DEFINITION?
oligo
azo
asthenoazo
teratoazo
infertility in males symptoms
physycal exam
syndrome?
infertility investigation
infertility males
2 syndromes labs?
klinefelter syndrome
clinical
labs
drugs potential male infertility
chemotherapy, lithium, SSRs
URINE INCONTINECE
STRESS INCONTINENCE:
URGE INCONTINENCE OR OVERACTIVE BLADDER:
overflow incontinence
