Renal Flashcards
What is the normal physiology of the bladder?
- As the bladder fills with urine there are two mechanisms that control the continence before the next emptying:
1. The intra vesicle pressure remains low and the detrusor muscles remain stable.
2. The spinchter muscles remain stable at the bladder neck and the urethral muscles. - During the onset of voiding the spinchter muscles relax and the destrusor muscles contract in order to create voiding.
What is stress incontinence?
- Due to spinchter weakness - can be iatrogenic in men and childbirth in women.
- When intra abdominal pressure rises it causes small amounts of urine to leak.
- Management in women is pelvic floor exercises, oestrogen creams and surgery and in men artifical spinchters and slings.
What is urge incontinence?
- Urgency with frequency, with or without nocturia, when appearing in absence of local pathology.
- Strong desire to void and may be unable to hold
- Caused by detrusor instability.
- Management = Behavioural therapy, decreased use alcohol and caffeine, as well as the use anti muscarnic agents and botox.
Definition of prostate cancer
- Malignant tumour of glandular origin within the prostate
- Adenocarcinoma
- Most common malignant tumour in men.
Aetiology of prostate cancer
- Increasing age, family history, genetic predisposition with BRAC2, afro caribbean descent and diet high in fat in association with red meat.
Risk factors of prostate cancer
- Over 50, family history and black ancestry.
Histology of prostate cancer
- Usually found in the peripheral zone with it feeling craggy and enlarged in a DRE.
Investigations of prostate cancer
- Usually asymptomatic
- PSA
- Biopsies
- CT scanning
Management of prostate cancer
- Active surveillance, radical/partial prosecectomy, radio, chemo or hormone treatment.
Definition of renal cell carcinoma
- Malignancy of the renal parenchyma/cortex and accounts for more than 85% of renal cancers.
- Most commonly seen in patients over the age of 50 with peak incidence being 80 to 85.
Aetiology of renal cell carcinoma
- Smoking, hypertension/obesity, renal transplant, family history
Presentation of renal cell carcinoma
- Classic triad: mass, haematuria, loin pain in the flank.
- Incidental finding in more than 50% of cases.
- Malaise, weight loss and fatigue.
Investigations of renal cell carcinoma
- Ultrasonography
- CT
- MRI for staging
Management of renal cell carcinoma
- Surveillance
- Radical/partial nephrocetomy
- Ablatative techinques
Definition of bladder cancer
- Most commonly uroethelial carcinoma.
- Usually non muscle invasive tumours
- Low grade - papillary and easy to visualise
- High grade - flat and in situ and harder to visualise
- Common, more common in men than women
Aetiology of bladder cancer
- Smoking, exposure to chemicals such as aromatic amines including rubbers and dyes.
- Patients that are type 2 diabetics are at risk.
Presentation of bladder cancer
- Painless haematuria
- Dysuria and urinary frequency
Investigations of bladder cancer
- CT urography and cytoscopy
Management of bladder cancer
- If non muscle invasive then transurethral resection and post op chemo.
- If locally invasive then radical/partial cytoscotmy and pre/post op chemo.
Definition of testicular cancer
- Most common type of malignancy in young males between the ages of 20 and 34 but highly curable when caught early.
- Pre cancerous condition known as carcinoma in situ that is highly specific of the condition.
- Rare
Aetiology of testicular cancer
- Unknown
- Patients with undescended testes are at risk
- Either teratomes or seminomas
Presentation of testicular cancer
- Painless lump
- Mets include lungs leading to cough and dyspnoea and also paraaortic lymph nodes causing backpain.
Investigations of testicular cancer
- Ultrasound
- Teratomes = increased AFP and hCG
- Seminomas = no increased AFP
Management of testicular cancer
- Orchidectomy for histological grading
- Chemo/radio
Definition of pyelonephritis
- Infection of the renal parenchyma and soft tissues of renal pelvis and upper ureter.
- Usually seen in women over the age of 35.
Pathophysiology of pyelonephritis
- Ascending (intercourse) or haematogenous (Staph aureus)
Presentation of pyelonephritis
- Classical triad: fever, pyrexia and loin pain.
Investigations of pyelonephritis
- Abdo exam, bloods and culture of MSU and ultrasound scan.
Management of pyelonephritis
- Fluid, IV antibiotics, drain any obstructed kidney and analgesia.
Definition of Urolithiases
- Nephrolithiasis presence of crystalline stones within either the kidneys or the ureter.
- Mostly in the kidney and then pass down into the ureter.
- Urolithiases is when it passes into the ureter.
Pathology of Urolithiases
- Most stones are calcium - either calcium phosphate or calcium oxalate.
- Calcium stones usually due to hypercaciuria (increased calcium excretion) and hyperoxoria (increased calcium oxalate excretion).
Risk factors of Urolithiases
- Increased protein intake, increased salt intake, male, white, dehydration, obesity, occupational expsure, family history and preciptant meds.
Presentation of Urolithiases
- Can be asymptomatic or present with symptoms such as haematuria, recurrent UTI’s or obstruction urinating.
- Pain caused by obstruction usually.
- Classic renal colic - unilateral sudden intense pain that radiates from the loin to the groin. Patient withering in pain, which is made worse with fluid and associated with nausea.
Investigations of Urolithiases
- Mid stream urine for culture
- Plain abdo XR
- CT is diagnostic
- Potential NCCT - ICUB for females of child bearing age.
Management of Urolithiases
- Conservative
- Analegesics
- Lithoroscopy
- Surgery
- Prevention
Definition of benign prostatic hyperplasia
- Lower urinary tract infections that are caused by urether obstruction due to narrowing of the lumen because of increasing cells or decrease in apoptosis in the transitional zone.
- It increases the prostatic smooth muscle tone mediated by alpha adrenergic receptors.
- Usually seen in patients over the age of 70.
Aetiology of benign prostatic hyperplasia
- Due to an increase in age and also hormonal changes.
Risk Factors of benign prostatic hyperplasia
- Over 50, family history, non asian race, cigarette smoking, metabolic syndrome, male pattern baldness.
Presentation of benign prostatic hyperplasia
- Storage symptoms including frequency of micturition, nocturia and urgency.
- Delay in initiation of micturition, weak stream, hesitancy, intermittency, straining, incomplete emptying and post void dribbling.
Investigations of benign prostatic hyperplasia
- Flow rates and residual volume
- Frequency volume chart
- Renal biochem
- PSA/DRE to rule out prostate cancer
Management of benign prostatic hyperplasia
- Mild symptoms: ‘watchful waiting’
- Selective a1 - adrenoreceptor antagonists used to relax the smooth muscle in the bladder neck and prostate to increase the lumen of the ureter.
- 5a reductase inhibitors, block the conversion of testerterone.
- Surgery
Definition of erectile dysfunction
- The inability to achieve or maintain an erection that is sufficient enough for sexual performance.
- Usually seen in men over the age of 50
Aetiology of erectile dysfunction
- Metabolic syndrome: diabetes, hypertension, hyperlipidaemia, obesity.
- Non organic causes such as sexual or relationship dysfunction or performance anxiety
Taking a history of erectile dysfunction
- Ask about onset, severity, duration, as well as early morning erections and masturbation.
- Examination
Investigations of erectile dysfunction
- PSA and FBC
- Fasting plasma glucose
- Validated questionaires
- Penile doppler USS
Management of erectile dysfunction
- Vaccum devices, penile prosthesis
- Lifestyle changes
- Medications such as PDE 5 inhibitors, intra urethral therapy and injectable therapies.
Definition of CKD
- Progressive and irreversible decline in renal function which is classified in 3 stages depending on the eGFR.
- A normal function is more than 90
- It differs from AKI as it is defined as persistent kidney damage and/or impaired GFR for more than 3 months.
Aetiology of CKD
- Diabetic nephropathy and hypertension most commonly.
Risk factors of CKD
- Smoking, hypertension, diabetes, more than 50, obesity
Presentations of CKD
- Can be asymptomatic at first with declining GFR and increasing urea and creatine.
- As it progresses patient may present with lethargy, fatigue and bone disease, which can be due to anaemia, bone disease and neurological conditions.
- Patients may have secondary hyperparathyroidism due to decrease in calcium and increase in phosphate.
Investigations of CKD
- Increased creatine and urea, as well as identifying serum microalbumin.
- Renal ultrasound
- Severe CKD would be classified as GFR of less than 60, as well as normochromic anaemia, small kidneys and renal osteodystrophy.
Management of CKD
- Renoprotective (Use of ACE inhibitors and CCB)
- Decrease in CVD risk
- Correction of complications
- Refer
What is nephrotic syndrome?
- Caused by 5 main reasons minimal change disease, primary/secondary glomerular disease, diabetic nephropathy or amyloidosis.
- Symptoms include proteinuria, oedema, hypoalbuminaemia, lipiduria and hyperlipidaemia.
- Management is about diuretics, ACE/ARBs, steroids
What is acute glomerulonephritis?
- Often an immune response triggered by an infection.
- Most common patient would be a child post strep infection around 1 to 3 weeks later, they might also be post infective endocarditis
- Presentation with visible or non visible haematuria ,hypertension/oedema, proteinuria, oliguria and uraemia
- Management, its often self limiting - supportive management, steroid use.
What is IgA nephropathy?
- Presence of dominant or co dominant mesangial IgA immune deposits,
- Presents with microscopic haematuria that is episodic
- Mangement is supportive with steriods
Definition of UTI
- Urinary tract infection
- Can be lower tract or kidneys/bladder/urethera
- Clinical features and bacteria in urine
- Women > men
Aetioloy of UTI
- E.coli
Risk factors of UTI
- Women, postmenopausal, new sexual activity, family history, history of UTIs, catheters
Presentation of UTI
- Cardinal signs: dysuria, frequency, urgency
- Suprapubic pain/tenderness, haematuria and smelly urine
Investigations of UTI
- Uncomplicated no need - with 2/3 cardinal symptoms
- MSU - culture
- Urine dipstick - red colour due to gram negative reducing nitrates into nitrites.
Management of UTI
- Uncomplicated, treat imperically, with 3 days - trimethoprim or nitrofuratoin
- Asymptomatic bacteriaumia over 65 or pregnant - don’t treat
Definition of Chlamydia
- Most common bacterial STI
- Caused by chlamydia trachomatis which is gram negative
Risk factors of Chlamydia
- Under the age of 25 and sexually active, new/multiple partners, lack of condoms, previous STI’s
What is the incubation period of chlamydia?
- 7 to 21 days
Presentation of chlamydia
- Most commonly asymptoamtic
- Can be cervical discharge, friable cervix, abnormal vaginal bleeding, vaginal/penile discharge
Investigations of chlamydia
- NAAT - vaginal swab/first morning void
Mangement of chlamydia
- Doxycycline for 7 days
- Partner notification
Definition of gonorrhoea
- Neisseria gonnorrhoea is a gram negative diplococcus
- STI usualyl seen in MSM and black patietns
Aetiology of gonorrhoea
- Sexual contact without a condom
- Includes penetrative sex that involves the mucosa lined orifice
Presentation of gonoorhoea
- In men, urethral discahrge as well as tenderness and/or swelling of the epididymis
- Pelvic pain in women
Investigations of gonorrhoea
- NAAT
Management of gonorrhoea
- Contact tracing
- Ceftriaxone and azithroymic
Definition of syphillis
- STI caused by spirochaetal bacterium Treponema pallidum, sub species paludium
- Usually seen in MSM
- Can be primary or secondary
Presentation of syphilis
- Any genital ulcer is syphilis until proven otherwise
- Can also present with lymphadenopathy, diffuse rash, fever and malaise
Investigations of syphilis
- Serology
- Screening EIA
- TPPA
Management of syphilis
- Penicilin
- Partner tracing
