Renal Flashcards
1
Q
sx of BPH
A
- weak/intermittent urine flow
- hesitancy
- terminal dribbling
- incomplete emptying
- urgency
- frequency
- nocturia
- urgency incontinence
2
Q
Investigations of BPH
A
- urine dip
- PSA
- U&E
- IPSS
3
Q
What is the IPSS
A
International Prostate Symptom Score (IPSS): classifying the severity of lower urinary tract symptoms and assessing the impact on quality of life
4
Q
Management of BPH
A
1ST LINE: alpha-1 antagonists e.g. tamsulosin, alfuzosin
- 5 alpha-reductase inhibitors e.g. finasteride
Surgery : transurethral resection of prostate (TURP)
5
Q
What is cystitis
A
inflammation of the bladder
6
Q
Sx of cystitis
A
- urinary urgency
- dysuria
- polyuria
- haematuria
- suprapubic pain
7
Q
Cystitis investigations
A
- urinalysis
- urine culture
- cystoscopy if underlying cause is suspected
8
Q
Cystitis management
A
Nitrofurantoin/Trimethoprim
9
Q
What is balanitis?
A
inflammation of the glans penis
10
Q
Management of cystitis in pregnancy
A
Nitrafurantoin (trimethoprim contraindicated)
11
Q
How is balanitis diagnosed?
A
clinical diagnosis
- swabs taken if suspected infective cause
- extensive skin change and doubt about cause = biopsy
12
Q
Management of balanitis if ?candidiasis
A
topical clotrimazole
13
Q
Bacterial balanitis management
A
oral flucloxacillin or clarithromycin (penicillin allergic)
14
Q
Anaerobic balanitis management
A
saline washing and metronidazole if not settling
15
Q
Management of dermatitis balanitis
A
topical corticosteroids
16
Q
Lichen sclerosus balanitis management
A
high potency topical steroids or circumcision
17
Q
Most common causes of balanitis
A
infective (bacterial and candidal)
18
Q
Sx of balanitis
A
- penile soreness and itch
- urinary sx (dysuria, dypareunia)
19
Q
Clinical signs of balanitis
A
- redness and swelling of glans penis
- tightening of foreskin/ unable to retract (phimosis)
- meatal stenosis (often in Lichen Sclerosus)
20
Q
Most common pathogen associated with prostatitis
A
E.coli
21
Q
Clinical features of prostatitis
A
- pain maybe be referred to perineum, penis, rectum, back
- obstructive voiding sx
- fever
- tender, boggy prostate gland
22
Q
Investigation in suspected acute prostatitis
A
- MSU (urine dip, culture, sensitivity)
- blood culture
- FBC
- DRE
- consider STI screen
23
Q
Management of acute prostatitis
A
14 day course quinolone - ciprofloxacin
24
Q
Management of chronic prostatitis
A
- analgesia (paracetemol/NSAIDs)
- alpha blocker - doxazosin
- abx (trimethoprim/doxycyline)
25
What is urethritis?
inflammation of the urethra
26
How is urethritis categorised
gonococcal and non-gonococcal urethritis (NGU)
27
Investigations for urethritis
urethral swab
| NAAT
28
Management of urethritis
7/7 doxycline / single dose azithromycin
29
What is pyelonephritis?
a type of UTI where one or both kidneys become infected
30
Common symptoms of acute pyelonephritis
- fever
- flank pain (usually unilateral)
- N&V
- UTI sx (urinary urgency, frequency, dysuria)
31
Investigation in suspected pyelonephritis
- MSU
- urine culture BEFORE starting empirical abx
- urine dip
32
Management of pyelonephritis
Cefalexin / Co-amox / Trimethoprim /Ciprofloxacin
change according to sensitivities
33
When should you admit a patient with pyelonephritis to hospital
Severe sx = ?sepsis
- tachy
- hypotension, - breathless
- confusion
34
Management of acute pyelonephritis in pregnant women
Cefalexin
35
What is epididymitis?
inflammation of the epididymis
36
Sx of epididymitis
- pain in 1 or both testicles
- tenderness
- swollen, red, warm scrotum
- discharge from penis
- blood in semen
- pain in suprapubic region
37
Which investigations should be ordered for suspected epididymitis?
- urine dipstick
| - urine culture
38
Common causes of epididymitis
STI (gonorrhoea or chalmydia)
Enteric organisms
Amiadorone
39
Tx of epididymitis STINA CROSS CHECK ANSWER PLS THX BBS
Gonorrhoea/chlamydia suspected:
Ceftriaxone and doxycyline
Enteric organisms suspected
Levofloxacin
40
What causes AKI
PRERENAL: ischaemia
- poor cardiac output
- hypovolaemia (diarrhoea and vomiting)
- renal artery stenosis
INTRINSIC: intrinsic damage by toxins or immune-mediated
- glomerulonephritis
- rhabdomyolysis
- acute tubular necrosis
POSTRENAL: obstruction causing 'backing up' of urine
- kidney stone in ureter/bladder
- BPH
- external compression of ureter (tumours)
41
Define oliguria
urine output less than 0.5 ml/kg/hour
42
Which drugs can cause AKI
NSAIDs, aminoglycosides, ACEi, ARBs, diuretics
43
Clinical signs of AKI
- Reduced urine output
- pulmonary and peripheral oedema
- arrhythmias
- uraemia = encephelopathy or pericarditis
44
Which criteria are recommended by NICE to diagnose an AKI
a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults
45
Investigations for suspected AKI
- U&E
- urinalysis
- renal ultrasound
46
How should a patient with an AKI be investigated if there is no identifiable cause or the patient is at risk of a urinary tract obstruction
renal ultrasound within 24 hours of assessment
| prompt review by urologist
47
AKI Management
largely supportive
- fluid balance
- medication review
48
Which complication of an AKI needs prompt treatment
Hyperkalaemia
49
When is renal replacement therapy used (e.g haemodialysis)?
when a patient is not responding to medical treatment of complications (e.g hyperkalaemia, oedema, acidosis, uraemia)
50
How to differentiate between AKI and CKD
Renal US - CKD = Bilayeral small kidneys
| Hypocalcaemia in CKD due to lack of vitD
51
Common causes of CKD
- diabetic nephropathy
- chronic glomerulonephritis
- chronic pyelonephritis
- hypertension
- adult polycystic kidney disease
52
Aetiology of bladder cancer
1. Transitional cell = smoking
| 2. Squamous cell = chronic infection, schistosomiasis
53
Symptoms of bladder cancer
1. Haematuria: Can be NVH (asymptomatic) or VH
- Rose/merlot/ ribena - urine
2. Irritative LUTS: dysuria, urinary frequency
3. associated clots
54
Investigations for bladder cancer
1. Cystoscopy with biopsy– gold standard for bladder cancer.
2. White light cystoscopy current standard for diagnosis and follow up
55
Management of bladder cancer
1. Chemotherapy
| 2. Surgery - cystectomy
56
Referral criteria for bladder cancer
Refer people for 2WWR:
1. < 45 y/o and have:
a) Unexplained visible haematuria without urinary tract infection, or
b) Visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
2. > 60 y/o and have:
a) unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
• non-urgent referral = > 60 years with recurrent or persistent unexplained urinary tract infection.
57
Mots common type of prostate cancer
Adenocarcinoma
58
Symptoms of prostate cancer
1. LUTs overlapping with BPH:
2. Nocturia, urinary frequency, hesitancy, urinary retention
3. Haematuria can occur and erectile dysfunction
4. Pain: back, perineal or testicular / bone pain
59
Where does prostate cancer commonly metastasise to?
Bone
60
Investigations for prostate cancer
1. DRE- palpable
- -> asymmetrical, hard, nodular enlargement with loss of median sulcus
2. PSA
3. Biopsy for definitive diagnosis
61
Management for prostate cancer
1. Watch and wait
2. Radiotherapy
3. Radical prostatectomy
4. Hormonal therapy
62
Referral for prostate cancer
1. 2WWR for prostate cancer if their prostate feels malignant on digital rectal examination.
2. Consider a prostate-specific antigen (PSA) test and DRE to assess for prostate cancer in men with:
- -> Any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention, or
- -> Erectile dysfunction, or
- -> Visible haematuria.
3. 2WWR for prostate cancer if their PSA levels are above the age-specific reference range.
63
Symptoms of renal cell carcinoma
Classic triad:
1. Haematuria
2. Loin pain
3. Mass in the flanks (abdominal mass)
- Pyrexia of unknown origin, left varicocele (due to occlusion of left testicular vein)
- Polycythaemia
64
Investigation for renal cell carcinoma
1. USS of kidneys
| 2. Definitive diagnosis - histology
65
Management of renal cell carcinoma
1. Partial or total nephrectomy (resection due to resistance to chemo and radiation)
2. Alpha-interferon and interleukin-2 to reduce tumour size
3. Receptor tyrosine kinase inhibitors (sorafenib, sunitinib)
66
Referral for renal cell carcinoma
2WWR for renal cancer if they are >45 y/o and have:
1. Unexplained visible haematuria without urinary tract infection
or
2. Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
67
Most common type of testicular cancer
germ-cell tumours:
1. seminomas
2. non-seminomas
68
Features of testicular cancer
1. a painless lump
2. pain
3. hydrocele
4. gynaecomastia
69
Diagnosis of testicular cancer
1st line = USS
70
Management of testicular cancer
1. treatment depends on whether the tumour is a seminoma or a non-seminoma
2. orchidectomy
3. chemotherapy and radiotherapy may be given depending on staging and tumour type
71
Features of Wilm's Tumour
1. abdominal mass (most common presenting feature- flank mass)
- large, palpable, unilateral
2. painless haematuria
3. flank pain
4. other: anorexia, fever, hypertension
72
Most common metastatic location for Wilm's tumour
lungs
73
Investigation for Wilm's tumour
* Bloods
* USS and/or IV pyelogram
* Renal angiography
74
Management of Wilm's tumour
- dependent on the extent of metastasis
- nephrectomy + chemotherapy
- radiotherapy if advanced disease
75
Referral for Wilm's tumour
children with an unexplained enlarged abdominal mass in children - possible Wilm's tumour - arrange paediatric review with 48 hours
76
Define urinary incontinence
Involuntary leakage of urine
77
Types of urinary incontinence
1. Functional incontinence – unable to reach toilet in time
2. Stress incontinence – on effort or exertion
3. Urge incontinence – sudden desire to urinate
4. Mixed incontinence
5. Overflow incontinence – due to bladder outlet obstruction, e.g. due to prostate enlargement
6. overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
78
Investigations for urinary incontinence
1. bladder diaries should be completed for a minimum of 3 days
2. vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises)
3. urine dipstick and culture
4. urodynamic studies
79
Management of urinary incontinence
1. Bladder retraining
2. Bladder stabilising drugs
- Antimuscarinics is 1st line = oxybutynin (avoid in frail older women)
3. Mirabegron (beta-3 agonist)
Stress incontinence:
1. Pelvic floor muscle training
2. Surgical procedure (retropubic mid-urethral)
3. Duloxetine – combine noradrenaline an SSRI
80
Define cryptorchidism
A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age.
81
Diagnosis for cryptorchidism
physical examination
82
Treatment for Cryptorchidism
1. Orchidopexy at 6- 18 months of age.
2. Intra-abdominal testis should be evaluated laparoscopically and mobilised.
3. Orchidectomy after 2 years
83
Complications of Cryptorchidism
untreated can lead to testicular cancer
84
Definition of hydrocele
Accumulation of fluid within the tunica vaginalis.
85
Features of hydrocele
- Onset can be acute or chronic.
- Painless and non-tender
- soft, non-tender swelling of the hemi-scrotum.
- Will transilluminate with a pen torch
86
Diagnosis of hydrocele
May be clinical
| USS if doubt
87
Management of hydrocele
1. Infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
2. in adults a conservative approach may be taken depending on the severity of the presentation.
3. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
88
Define varicocele
abnormal enlargement of the testicular veins.
89
Features of varicocele
- classically described as a 'bag of worms'
- Onset is chronic
- Painless and non-tender but maybe dull, dragging discomfort
90
Diagnosis of varicocele
USS with Doppler studies
91
Management of varicocele
- Conservative
| - Surgery – if patient is trouble by pain
92
Define Nephrolithiasis + Urolithiasis
```
Nephrolithiasis = kidney stones
Urolithiasis = stone in the urinary tract
```
93
Features of Nephrolithiasis/ Urolithiasis
Classic triad:
1. Acute flank pain
2. Fever
3. Nausea/Vomiting
- Urinary frequency / urgency
- Haematuria
94
Imaging of choice for Nephrolithiasis/ Urolithiasis
Non-enhanced CT-Scan
95
Other investigations for renal stones
1. FBC, CRP
2. Urinalysis
3. 24h urine levels – calcium, phosphate, oxalate, urate
4. X-ray
5. USS
96
Type of renal stones
Radio-opaque:
1. Calcium oxalate
2. Mixed calcium oxalate/phosphate stones
3. Triple phosphate stones*
4. Calcium phosphate
Radio-lucent:
1. Urate stones
2. Cystine stones : Semi-opaque, 'ground-glass' appearance
3. Xanthine stones
97
Management of renal stones
1. Analgesia – NSAID (diclofenac IM)
2. Anti-emetic
3. IV Fluids
4. Most small stone pass naturally (<5mm)
5. Surgery – depends on location and size
98
Define Phimosis + Paraphimosis
Phimosis = non-retractile foreskin at birth (does not retract before the age of 2 years):
--> Not a problem until difficulties – urinary obstruction, haematuria or local pain
Paraphimosis = tight prepuce is retracted and unable to be replace as the glans swells.
99
Management of Paraphimosis
Gentle compression with saline-soaked swab followed by reduction of the prepuce over the glans
100
Define testicular torsion
Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
101
Features of testicular torsion
1. pain is usually severe and of sudden onset
- may be referred to the lower abdomen
2. nausea and vomiting may be present
O/E:
1. swollen, tender testis retracted upwards. The skin may be reddened
2. cremasteric reflex is lost
3. elevation of the testis does not ease the pain (Prehn's sign)
102
Management of testicular torsion
1. Admit immediately
2. treatment is with urgent surgical exploration
- Reduction and orchidopexy
- if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.
103
Types of haematuria
Microscopic haematuria = non-visible blood
Macroscopic haematuria = visible blood
104
Investigating haematuria
1. urine dipstick
2. persistent non-visible haematuria: blood being present in 2 out of 3 samples tested 2-3 weeks apart
3. renal function, albumin: creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked
4. urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected
105
Urgent referral criteria for haematuria
Urgent (2WWR)
Aged >= 45 years AND:
1. unexplained visible haematuria without urinary tract infection, or
2. visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged >= 60 years AND:
- have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test
106
Non-urgent referral criteria for haematuria
Aged >= 60 years with recurrent or persistent unexplained urinary tract infection
patients < 40 years with normal renal function, no proteinuria and who are normotensive do not need to be referred and may be managed in primary care
107
Define acute urinary retention
Acute urinary retention is when a person suddenly (over a period of hours or less) becomes unable to voluntarily pass urine.
108
Symptoms of acute urinary retention
1. Inability to pass urine
2. Lower abdominal discomfort
3. Considerable pain or distress
4. an acute confusional state may also be present in elderly patients
109
Signs of acute urinary retention
1. Palpable distended urinary bladder either on an abdominal or rectal exam
2. Lower abdominal tenderness
3. All men and women should have a rectal and neurological examination to assess for the likely causes above. Women should also have a pelvic examination.
110
Investigations for acute urinary retention
1. Urine sample – urinalysis + culture
- Urinary catheterisation
2. Serum U + E’s, Creatinine: assess AKI
3. FBC + CRP: look for infection
4. USS – confirm diagnosis – a volume of >300 cc
111
Management of acute urinary retention
1st episode = admission, catheterize and investigate cause
- Recurrent = admission, urethral catheter
- -> Treatment to prevent or manage recurrent retention:
- -> Alpha-blocker (alfuzosin 10 mg a dat)
- -> Intermittent urethral catheterization
- -> Long-term indwelling catheter
112
Define Chronic Urinary retention
Gradual (over months or years) development of the inability to empty the bladder completely.
113
Symptoms of Chronic Urinary retention
Painless and insidious
114
Management of Chronic Urinary retention
1. Exclude non-obstructive causes of reduced urine flow (such as chronic heart failure).
2. Check serum creatinine to assess renal function.
3. Refer the man for specialist assessment.
- Consider seeking specialist for imaging of the upper urinary tract and kidneys
4. Advise the man about management options in secondary care, including:
- No catheterization, but follow up with regular monitoring of renal function, volume of urinary retention, and any changes in imaging of upper renal tract.
- Intermittent urethral catheterization (performed by the man or his carer).
- A permanent indwelling catheter.
- Surgery to divert the urine externally (urostomy).
115
What is orchitis
inflammation of one or both testicles
116
investigations for orchitis
- STI screen
- urine test
- US
117
management of orchitis
treat cause
118
nephrotic syndrome triad
1. proteinuria
2. Hypoalbuminaemia
3. oedema
119
sx of nephrotic syndrome
- hypertension
- frothy urine
- swelling of feet, hand and around eyes
- weight gain
120
diagnosis of nephrotic syndrome
- urinalysis
- FBC, U&E
- kidney biopsy
121
What is nephrotic syndrome
a kidney disorder that causes your body to pass too much protein in your urine
122
management of nephrotic syndrome
sodium and fluid restriction
high-doe diuretics
refer to nephrology
123
What is nephrotic syndrome associated with
hyperlipidaemia and hypercoagulability
