Renal 2 Flashcards
what is an epididymal cyst?
a common cause of scrotal swelling
smooth, extratesticular, spherical cysts in the head of the epididymis
they are benign and do not usually require treatment
how does an epididymal cyst present?
- small cysts which are separate from the testical
- patient usually present having noticed a lump
- often multiple and may be bilateral
what investigations would you perform for epididymal cysts?
scrotal USS will assist the diagnosis if there is any uncertainty
how are epididymal cysts managed?
usually treatment is not necessary
surgical excision if they become painful or suddenly start increasing in size.
what is epididymo orchitis?
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling. It is most commonly caused by local spread of infections from the genital tract (such as Chlamydia trachomatis and Neisseria gonorrhoeae) or the bladder.
*** The most important differential diagnosis is testicular torsion. This needs to be excluded urgently to prevent ischaemia of the testicle.
what are features of epididymo-orchitis?
unilateral testicular pain and swelling
urethral discharge may be present, but urethritis is often asymptomatic
factors suggesting testicular torsion include patients < 20 years, severe pain and an acute onset
what is a hydrocele?
A hydrocele describes the accumulation of fluid within the tunica vaginalis (the layers of membrane which surrounds the testis or along the spermatic cord) .
hey can be divided into communicating and non-communicating:
communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum.
> Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
> non-communicating: caused by excessive fluid production within the tunica vaginalis
what may hydrocele develop secondary to?
epididymo-orchitis
testicular torsion
testicular tumours
what are the features of hydrocele?
soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large
how do you manage hydrocele?
infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
what conditions are epididymal cysts associated with?
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome
what is a varicocele?
An abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis.
Majority of cases occur on the left side
how does a varicocele present?
often will present with subfertility
scrotal mass often described as a bag of worms
what investigations would you perform for varicocele?
usually a clinical diagnosis
scrotal USS with colour flow doppler imaging
how is a varicocele managed?
if small - reassurance and observation
if larger or pain - surgery
what is testicular torsion?
twist of the spermatic cord resulting in testicular ischaemia and necrosis.
most common in males aged between 10 and 30 (peak incidence 13-15 years)
**medical emergency
how does testicular torsion present?
pain is usually severe and of sudden onset
the pain may be referred to the lower abdomen
nausea and vomiting may be present
on examination, there is usually a 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)
what investigations would you perform fort testicular torsion?
grey-scale USS
doppler USS
how is testicular torsion managed?
treatment is with urgent surgical exploration
if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.
what is benign prostatic hyperplasia?
This is a very common benign condition in men of increasing age. It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms in older men.
how do men with benign prostatic hyperplasia present?
Lower Urinary Tract Symptoms (LUTS) Hesitancy Urgency Frequency Intermittency Straining to void Terminal dribbling Incomplete emptying
what investigations would you perform for benign prostatic hyperplasia?
Urine analysis (exclude infection as a major differential) PSA done prior to rectal examination can help with assessing potential for prostate cancer Rectal exam to assess prostate size, shape and characteristics international prostate symptom score
how is benign prostatic hyperplasia managed?
Reassurance and monitoring if manageable symptoms
Medications
Alpha-blockers (relax smooth muscle; e.g. tamsulosin 400 mcg once daily)
5-alpha reductase inhibitors (block testosterone and actually help reduce the size of the prostate; e.g. finasteride)
Surgery
Transurethral resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate (TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via abdominal or perineal incision
what is TURP?
Transurethral Resection of the Prostate (TURP)
Involves accessing the prostate through the urethra and “shaving” off prostate tissue from inside using diathermy
The aim is to create a wider space for urine to flow through, thereby improving symptoms
Major complications: Bleeding, Infection, Incontinence. Retrograde ejaculation (semen goes backwards and is not produced from the urethra during ejaculation), Urethral strictures, Failure to resolve symptoms, Erectile dysfunction
Alternatives (similar to TURP but different methods for removing prostate tissue)
> TUVP – prostate tissue is removed using a laser
> HoLEP – prostate tissue is removed using an electrical current
what is renal tubular acidosis?
Renal tubular acidosis is where there is a metabolic acidosis due to pathology in the tubules of the kidney. The tubules are responsible for balancing the hydrogen and bicarbonate ions between the blood and urine and maintaining a normal pH. There are four types each with different pathophysiology.
what are the different types of renal tubular acidosis ?
Type 1 RTA (distal)
> inability to generate acid urine (secrete H+) in distal tubule
> causes hypokalaemia
> complications include nephrocalcinosis and renal stones
> causes include idiopathic, rheumatoid arthritis, SLE, Sjogren’s, amphotericin B toxicity, analgesic nephropathy
Type 2 RTA (proximal)
> decreased HCO3- reabsorption in proximal tubule
> causes hypokalaemia
> complications include osteomalacia
> causes include idiopathic, as part of Fanconi syndrome, Wilson’s disease, cystinosis, outdated tetracyclines, carbonic anhydrase inhibitors (acetazolamide, topiramate)
Type 3 RTA (mixed)
> extremely rare
> caused by carbonic anhydrase II deficiency
> results in hypokalaemia
Type 4 RTA (hyperkalaemic)
> reduction in aldosterone leads in turn to > a reduction in proximal tubular ammonium excretion
> causes hyperkalaemia
> causes include hypoaldosteronism, diabetes
Types 1 and 4 most likely to come up in ecam
what investigations would you perform for renal tubular acidosis?
serum bicarb serum chloride serum sodium serum potassium ABG uring pH
how is renal tubular acidosis managed?
type 1 (distal):
- sodium alkali or potassium containing alkali solution
- potassium supplementation
Type 2 (proximal - e.g. fanconi syndrome):
- sodium alkali
- potassium supplementation
- hydrochlorothiazide
type 3 - rare probs wont need to treat
type 4
- loop diuretic and potassium restriction and increased salt diet
- sodium alkali therapy
what is CKD?
Chronic kidney disease describes a chronic reduction in kidney function. This reduction in kidney function tends to be permanent and progressive.
what are some causes of CKD?
Diabetes Hypertension Age-related decline Glomerulonephritis Polycystic kidney disease Medications such as NSAIDS, proton pump inhibitors and lithium
risk factors for CKD?
Older age Hypertension Diabetes Smoking Use of medications that affect the kidneys
how does CKD present?
Usually chronic kidney disease is asymptomatic and diagnosed on routine testing. A number of signs and symptoms might suggest chronic kidney disease: Pruritus (itching) Loss of appetite Nausea Oedema Muscle cramps Peripheral neuropathy Pallor Hypertension
what investigations should you perform for CKD?
Estimated glomerular filtration rate (eGFR) can be checked using a U&E blood test. Two tests are required 3 months apart to confirm a diagnosis of chronic kidney disease.
Proteinuria can be checked using a urine albumin:creatinine ratio (ACR). A result of ≥ 3mg/mmol is significant.
Haematuria can be checked using a urine dipstick. A significant result is 1+ of blood. Haematuria should prompt investigation for malignancy (i.e. bladder cancer).
Renal ultrasound can be used to investigate patients with accelerated CKD, haematuria, family history of polycystic kidney disease or evidence of obstruction.
what are the stages of CKD?
The G score is based on the eGFR:
G1 = eGFR >90 G2 = eGFR 60-89 G3a = eGFR 45-59 G3b = eGFR 30-44 G4 = eGFR 15-29 G5 = eGFR <15 (known as “end-stage renal failure”)
The A score is based on the albumin:creatinine ratio:
A1 = < 3mg/mmol
A2 = 3 – 30mg/mmol
A3 = > 30mg/mmol
The patient does not have CKD if they have a score of A1 combined with G1 or G2. They need at least an eGFR of < 60 or proteinuria for a diagnosis of CKD.
what are the complications of CKD?
Anaemia Renal bone disease Cardiovascular disease Peripheral neuropathy Dialysis related problems
how is CKD managed?
AIMS of management
slow the progression of the disease (diabetic and hypertensive control)
Reduce the risk of cardiovascular disease and reduce risk of complciations (exercise, stop smoking, atorvastatin 20mg)
Treating complications (sodium bicarb to treat metabolic acidosis, iron and EPO to treat anaemia, VD for bone disease, dialysis for end stage)
how should hypertension be managed in CKD?
ACE inhibitors are the first line in patients with chronic kidney disease
Serum potassium needs to be monitored as chronic kidney disease and ACE inhibitors both cause hyperkalaemia
what are the features of renal bone disease?
Osteomalacia (softening of bones)
Osteoporosis (brittle bones)
Osteosclerosis (hardening of bones)
what x-ray changes do you get in renal bone disease?
Spine xray shows sclerosis of both ends of the vertebra (denser white) and osteomalacia in the centre of the vertebra (less white). This is classically known as “rugger jersey” spine after the stripes found on a rugby shirt.
how is renal bone disease managed?
Active forms of vitamin D (alfacalcidol and calcitriol)
Low phosphate diet
Bisphosphonates can be used to treat osteoporosis
why do people with CKD get bone disease?
Basic problems in chronic kidney disease (CKD):
1-alpha hydroxylation normally occurs in the kidneys → CKD leads to low vitamin D
the kidneys normally excrete phosphate → CKD leads to high phosphate
This, in turn, causes other problems:
the high phosphate level ‘drags’ calcium from the bones, resulting in osteomalacia
low calcium: due to lack of vitamin D, high phosphate
secondary hyperparathyroidism: due to low calcium, high phosphate and low vitamin D
what is dialysis?
Dialysis is a method for performing the filtration tasks of the kidneys artificially in patients with end stage renal failure or complications of renal failure. It involves removing excess fluid, solutes and waste products.
what are indications for acute and long term dialysis?
Indications for Acute Dialysis
The mnemonic is AEIOU can be used to remember the indications for acute dialysis in patients with a severe AKI:
A – Acidosis (severe and not responding to treatment)
E – Electrolyte abnormalities (severe and unresponsive hyperkalaemia)
I – Intoxication (overdose of certain medications)
O – Oedema (severe and unresponsive pulmonary oedema)
U – Uraemia symptoms such as seizures or reduced consciousness
Indications for Long Term Dialysis
End stage renal failure (CKD stage 5)
Any of the acute indications continuing long term
