Renal Flashcards
sx of BPH
- weak/intermittent urine flow
- hesitancy
- terminal dribbling
- incomplete emptying
- urgency
- frequency
- nocturia
- urgency incontinence
Investigations of BPH
- urine dip
- PSA
- U&E
- IPSS
What is the IPSS
International Prostate Symptom Score (IPSS): classifying the severity of lower urinary tract symptoms and assessing the impact on quality of life
What is cystitis
inflammation of the bladder
Sx of cystitis
- urinary urgency
- dysuria
- polyuria
- haematuria
- suprapubic pain
Cystitis investigations
- urinalysis
- urine culture
- cystoscopy if underlying cause is suspected
What is balanitis?
inflammation of the glans penis
How is balanitis diagnosed?
clinical diagnosis
- swabs taken if suspected infective cause
- extensive skin change and doubt about cause = biopsy
Most common causes of balanitis
infective (bacterial and candidal)
Sx of balanitis
- penile soreness and itch
- urinary sx (dysuria, dypareunia)
Clinical signs of balanitis
- redness and swelling of glans penis
- tightening of foreskin/ unable to retract (phimosis)
- meatal stenosis (often in Lichen Sclerosus)
Most common pathogen associated with prostatitis
E.coli
Clinical features of prostatitis
- pain maybe be referred to perineum, penis, rectum, back
- obstructive voiding sx
- fever
- tender, boggy prostate gland
Investigation in suspected acute prostatitis
- MSU (urine dip, culture, sensitivity)
- blood culture
- FBC
- DRE
- consider STI screen
What is urethritis?
inflammation of the urethra
How is urethritis categorised
gonococcal and non-gonococcal urethritis (NGU)
Investigations for urethritis
urethral swab
NAAT
What is pyelonephritis?
a type of UTI where one or both kidneys become infected
Common symptoms of acute pyelonephritis
- fever
- flank pain (usually unilateral)
- N&V
- UTI sx (urinary urgency, frequency, dysuria)
Investigation in suspected pyelonephritis
- MSU
- urine culture BEFORE starting empirical abx
- urine dip
When should you admit a patient with pyelonephritis to hospital
Severe sx = ?sepsis
- tachy
- hypotension, - breathless
- confusion
What is epididymitis?
inflammation of the epididymis
Sx of epididymitis
- pain in 1 or both testicles
- tenderness
- swollen, red, warm scrotum
- discharge from penis
- blood in semen
- pain in suprapubic region
Which investigations should be ordered for suspected epididymitis?
- urine dipstick
- urine culture
Common causes of epididymitis
STI (gonorrhoea or chalmydia)
Enteric organisms
Amiadorone
Tx of epididymitis
Gonorrhoea/chlamydia suspected or unknown organism:
Ceftriaxone and doxycyline
Enteric organisms suspected
Levofloxacin
Admit – severe symptoms and pt has diabetes or is immunocompromised
Refer for same-day or next day assessment by sexual health specialist
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)
Define oliguria
urine output less than 0.5 ml/kg/hour
Which drugs can cause AKI
NSAIDs, aminoglycosides, ACEi, ARBs, diuretics
Clinical signs of AKI
- Reduced urine output
- pulmonary and peripheral oedema
- arrhythmias
- uraemia = encephelopathy or pericarditis
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
Investigations for suspected AKI
- U&E
- urinalysis
- renal ultrasound
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
Which complication of an AKI needs prompt treatment
Hyperkalaemia
When is renal replacement therapy used (e.g haemodialysis)?
when a patient is not responding to medical treatment or complications (e.g hyperkalaemia, oedema, acidosis, uraemia)
How to differentiate between AKI and CKD
Renal US - CKD = Bilateral small kidneys
Hypocalcaemia in CKD due to lack of vitD
Common causes of CKD
- diabetic nephropathy
- chronic glomerulonephritis
- chronic pyelonephritis
- hypertension
- adult polycystic kidney disease
Aetiology of bladder cancer
- Transitional cell = smoking
2. Squamous cell = chronic infection, schistosomiasis
Symptoms of bladder cancer
- Haematuria: Can be NVH (asymptomatic) or VH
- Rose/merlot/ ribena - urine - Irritative LUTS: dysuria, urinary frequency
- associated clots
Investigations for bladder cancer
- Cystoscopy with biopsy– gold standard for bladder cancer.
- White light cystoscopy current standard for diagnosis and follow up
Referral criteria for bladder cancer
Refer people for 2WWR:
- < 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 - > 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.
Mots common type of prostate cancer
Adenocarcinoma
Symptoms of prostate cancer
- LUTs overlapping with BPH:
- Nocturia, urinary frequency, hesitancy, urinary retention
- Haematuria can occur and erectile dysfunction
- Pain: back, perineal or testicular / bone pain
Where does prostate cancer commonly metastasise to?
Bone
Investigations for prostate cancer
- DRE- palpable
- -> asymmetrical, hard, nodular enlargement with loss of median sulcus - PSA
- 1st line = Multiparametric MRI
- Biopsy (TRUS)
Referral for prostate cancer
- 2WWR for prostate cancer if their prostate feels malignant on digital rectal examination.
- 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. - 2WWR for prostate cancer if their PSA levels are above the age-specific reference range.
Symptoms of renal cell carcinoma
Classic triad:
- Haematuria
- Loin pain
- Mass in the flanks (abdominal mass)
- Pyrexia of unknown origin, left varicocele (due to occlusion of left testicular vein)
- Polycythaemia
Investigation for renal cell carcinoma
- USS of kidneys
2. Definitive diagnosis - histology
Referral for renal cell carcinoma
2WWR for renal cancer if they are >45 y/o and have:
- Unexplained visible haematuria without urinary tract infection
or
- Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
Most common type of testicular cancer
germ-cell tumours:
- seminomas
- non-seminomas
Features of testicular cancer
- a painless lump
- pain
- hydrocele
- gynaecomastia
Diagnosis of testicular cancer
1st line = USS
Features of Wilm’s Tumour
- abdominal mass (most common presenting feature- flank mass)
- large, palpable, unilateral - painless haematuria
- flank pain
- other: anorexia, fever, hypertension
Most common metastatic location for Wilm’s tumour
lungs
Investigation for Wilm’s tumour
- Bloods
- USS and/or IV pyelogram
- Renal angiography
Referral for Wilm’s tumour
children with an unexplained enlarged abdominal mass in children - possible Wilm’s tumour - arrange paediatric review with 48 hours
Define urinary incontinence
Involuntary leakage of urine
Types of urinary incontinence
- Functional incontinence – unable to reach toilet in time
- Stress incontinence – on effort or exertion
- Urge incontinence – sudden desire to urinate
- Mixed incontinence
- Overflow incontinence – due to bladder outlet obstruction, e.g. due to prostate enlargement
- overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
Investigations for urinary incontinence
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
Define cryptorchidism
A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age.
Diagnosis for cryptorchidism
physical examination
Treatment for Cryptorchidism
- Orchidopexy at 6- 18 months of age.
- Intra-abdominal testis should be evaluated laparoscopically and mobilised.
- Orchidectomy after 2 years
Complications of Cryptorchidism
untreated can lead to testicular cancer
Definition of hydrocele
Accumulation of fluid within the tunica vaginalis.
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
Diagnosis of hydrocele
May be clinical
USS if doubt
Define varicocele
abnormal enlargement of the testicular veins.
Features of varicocele
- classically described as a ‘bag of worms’
- Onset is chronic
- Painless and non-tender but maybe dull, dragging discomfort
Diagnosis of varicocele
USS with Doppler studies
Define Nephrolithiasis + Urolithiasis
Nephrolithiasis = kidney stones Urolithiasis = stone in the urinary tract
Features of Nephrolithiasis/ Urolithiasis
Classic triad:
- Acute flank pain
- Fever
- Nausea/Vomiting
- Urinary frequency / urgency
- Haematuria
Imaging of choice for Nephrolithiasis/ Urolithiasis
Non-enhanced CT-Scan
Other investigations for renal stones
- FBC, CRP
- Urinalysis
- 24h urine levels – calcium, phosphate, oxalate, urate
- X-ray
- USS
Type of renal stones
Radio-opaque:
- Calcium oxalate
- Mixed calcium oxalate/phosphate stones
- Triple phosphate stones*
- Calcium phosphate
Radio-lucent:
- Urate stones
- Cystine stones : Semi-opaque, ‘ground-glass’ appearance
- Xanthine stones
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.
Define testicular torsion
Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
Features of testicular torsion
- pain is usually severe and of sudden onset
- may be referred to the lower abdomen - nausea and vomiting may be present
O/E:
1. swollen, tender testis retracted upwards. The skin may be reddened
- cremasteric reflex is lost
- elevation of the testis does not ease the pain (Prehn’s sign)
Types of haematuria
Microscopic haematuria = non-visible blood
Macroscopic haematuria = visible blood
Investigating haematuria
- urine dipstick
- persistent non-visible haematuria: blood being present in 2 out of 3 samples tested 2-3 weeks apart
- renal function, albumin: creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked
- urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected
Urgent referral criteria for haematuria
Urgent (2WWR)
Aged >= 45 years AND:
1. unexplained visible haematuria without urinary tract infection, or
- 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
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
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.
Symptoms of acute urinary retention
- Inability to pass urine
- Lower abdominal discomfort
- Considerable pain or distress
- an acute confusional state may also be present in elderly patients
Signs of acute urinary retention
- Palpable distended urinary bladder either on an abdominal or rectal exam
- Lower abdominal tenderness
- 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.
Investigations for acute urinary retention
- Urine sample – urinalysis + culture
- Urinary catheterisation - Serum U + E’s, Creatinine: assess AKI
- FBC + CRP: look for infection
- USS – confirm diagnosis – a volume of >300 cc
Define Chronic Urinary retention
Gradual (over months or years) development of the inability to empty the bladder completely.
Symptoms of Chronic Urinary retention
Painless and insidious
Management of Chronic Urinary retention
- Exclude non-obstructive causes of reduced urine flow (such as chronic heart failure).
- Check serum creatinine to assess renal function.
- Refer the man for specialist assessment.
- Consider seeking specialist for imaging of the upper urinary tract and kidneys - 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).
What is orchitis
inflammation of one or both testicles
investigations for orchitis
- STI screen
- urine test
- US
nephrotic syndrome triad
- proteinuria
- Hypoalbuminaemia
- oedema
sx of nephrotic syndrome
- hypertension
- frothy urine
- swelling of feet, hand and around eyes
- weight gain
diagnosis of nephrotic syndrome
- urinalysis
- FBC, U&E
- kidney biopsy
What is nephrotic syndrome
a kidney disorder that causes your body to pass too much protein in your urine
What is nephrotic syndrome associated with
hyperlipidaemia and hypercoagulability
