Renal and Genitourinary Flashcards

Question

KDIGO severity criteria: what is stage 2 AKI?

Answer 1

- Rise in creatinine to 2.0 to 2.9 times baseline, or - Fall in urine output to <0.5 mL/kg/hour for ≥12 hours

Answer 2

- Rise in creatinine to ≥ 3.0 times baseline, or - Rise in creatinine to ≥353.6 µmol/L or - Fall in urine output to <0.3 mL/kg/hour for ≥24 hours

Answer 3

Investigations aim to establish underlying cause. Primary investigations: - Urea and electrolytes: to confirm the diagnosis and check serum potassium (hyperkalemia) - Full blood count and CRP: establishes infection - Venous blood gas: particularly to assess for metabolic acidosis - Chest X-ray: to investigate for pulmonary oedema - Ultrasound urinary tract: to investigate for obstruction or hydronephrosis

Answer 4

Mainly supportive, depends on the underlying cause. - Treat complications: such as hyperkalemia - IV fluids: to rehydrate the patient - Abx if infection/sepsis, stop offending drug, remove the obstruction. - Loop diuretics not recommended, only when the patient is significantly overloaded

Answer 5

Renal-replacement therapy (dialysis or transplant): when medical treatment fails, indicated in the following events: - Hyperkalaemia refractory to medical management - Severe metabolic acidosis refractory to medical management - Volume overload refractory to diuretic agents - Uraemic manifestations such as encephalopathy or pericarditis

Answer 6

- Severe AKI requiring renal-replacement therapy - AKI due to severe underlying processes such as vasculitis, glomerulonephritis, myeloma - Patients who already have CKD stage 4 or 5

Answer 7

Chronic kidney disease (CKD) describes a progressive deterioration in renal function. NICE defines CKD as abnormalities of kidney function or structure present for more than 3 months: - Markers of kidney damage - GFR <60 on at least 2 separate occasions at least 90 days apart (+/- markers of kidney damage)

Answer 8

- Diabetes (most common) - Hypertension (second most common) - Medications such as NSAIDS, proton pump inhibitors and lithium - Age-related decline - Glomerulonephritis - Polycystic kidney disease

Answer 9

Stage and eGFR (ml/min/1.73m2 ) Stage 1: ≥ 90: not considered CKD unless evidence of renal damage* = Normal and high Stage 2: 60 - 89: not considered CKD unless evidence of renal damage* 3A: 45 - 59: Mild to moderate reduction 3B: 30 - 44: Moderate to severe reduction 4: 15 - 29: Severe reduction 5: < 15: dialysis or renal transplantation may be required: End-stage kidney failure

Answer 10

- Increasing age: Natural decline in kidney function > 50 - Afro-Caribbean - Diabetes mellitus - Hypertension - Autoimmune conditions: e.g. SLE - Glomerulonephritis - Nephrotoxic drugs: e.g. NSAIDs

Answer 11

Non-specific and usually as a result of toxic waste product build-up. Symptoms: - Lethargy - Pruritus - Frothy urine - Swollen ankles Signs: - Hypertension - Fluid overload - Uraemic sallow: a yellow or pale brown colour to the skin

Answer 12

Stages 1 -5, based on estimated glomerular filtration rate (eGFR - ml/min/1.73m2)

Answer 13

Serum creatinine is a waste product of muscles, removed by the kidneys with little or no tubular reabsorption, therefore, raised levels in patients with deranged kidney function. However, not reliable on its own, as it can be affected by age, the difference in muscle mass etc. So the Modification of Diet in Renal Disease (MDRD) formula incorporates: - Serum creatinine - Age - Gender - Ethnicity to calculate the eGFR

Answer 14

Primary investigations: - Urine dip: screen for proteinuria and haematuria - Urine albumin: creatinine ratio (ACR): >3 mg/mmol is clinically significant proteinuria - U&Es: serum creatinine (elevated) and eGFR (<60) - 2 tests 90 days apart to confirm the diagnosis - FBC: anaemia of chronic disease - Renal ultrasound: bilateral kidney atrophy in CKD

Answer 15

- Smoking cessation, exercise, drinking alcohol in moderation - Avoid nephrotoxic medications, e.g. NSAIDs - Diet: low salt and potassium diets, with fluid restriction if there is evidence of overload

Answer 16

Treat complications: - CKD-mineral bone disease - CKD causes hypocalcemia, so aim to reduce serum phosphate and PTH levels. - 1st line: dietary reduction of phosphate (e.g. meat) - Vitamin D replacement (early stage) CVD: - Hypertension - 1st line is ACEi e.g. ramipril - Hypercholestrolimia - statins (atorvastatin) - Antiplatelet - for secondary prevention Anaemia: - 1st line is Iron replacement: oral or IV Renal replacement therapy: - When eGFR indicates CKD stage 5 - Dialysis then kidney transplant if patient eligible

Answer 17

Cardiovascular disease - leading cause of death in CKD - Heart failure: due to fluid overload and anaemia MSK: - CKD-metabolic bone disease Endocrine: - Secondary hyperparathyroidism > tertiary hyperparathyroidism

Answer 18

Infectious inflammation of the kidneys, affecting the renal pelvis (joint between kidney and ureter) and renal parenchyma (tissues).

Answer 19

Gram-negative bacteria - E.coli accounts for 60 - 80% of uncomplicated infections - Klebsiella species (20%) - Proteus mirabilis (15%) The infection typically spreads to the kidney via the ascending lower urinary tract infection, can be haematogenous spread in septic patients

Answer 20

Pyelonephritis is considered uncomplicated if the patient is: - non-pregnant, pre-menopausal women with no known relevant urological abnormalities or comorbidities Pyelonephritis is considered complicated if the patient is/has: - Pregnant - Uncontrolled diabetes - Kidney transplants - Acute or chronic kidney failure - Immunocompromised - Hospital-acquired bacterial infections

Answer 21

- Women 6x more likely to develop pyelonephritis - Urinary tract infection - Uncontrolled diabetes mellitus: glucosuria provides bacteria with a source of energy - Urinary tract outlet obstruction - Immunocompromised patients - Pregnancy: increased chance of urinary tract infection - End-stage renal failure (ESRF)

Answer 22

Symptoms: - Flank pain - Myalgia - Dysuria (painful urination) - Haematuria - Confusion Signs: - Renal angle tenderness - Fever - Tachycardia - Hypotension - Altered mental state

Answer 23

1st line: urine dipstick - shows signs of infection, including nitrites, leukocytes and blood. Gold standard: midstream urine (MSU) - microscopy, culture and sensitivity testing to establish the causative organism. Before abx.

Answer 24

Oral antibiotics (mild disease not requiring hospitalisation): - Cefalexin: 7-10 days - Ciprofloxacin: 7 days Intravenous antibiotics (severe disease/sepsis): - Gentamicin - Ciprofloxacin Adjuvant therapy: - Hydration: oral or IV - Analgesia: diclofenac PR effective for renal angle tenderness

Answer 25

For septic patients, follow the sepsis six pathway! Three tests and three treatments. Three tests: - Blood lactate level - Blood cultures - Urine output Three treatments: - Oxygen - 94-98% (or 88-92% in COPD) - Empirical broad-spectrum IV antibiotics - IV fluids

Answer 26

- Sepsis - Parenchymal renal scarring from frequent infections (normally in chronic pyelonephritis) - Recurrent urinary tract infections

Answer 27

Chronic pyelonephritis presents with recurrent kidney infection > scarring of the renal parenchyma > CKD > end-stage renal failure

Answer 28

Infection of the bladder, usually caused by bacteria from the gastrointestinal tract ascending through the urethra into the bladder (retrograde).

Answer 29

The 5 most common pathogens can be remembered with KEEPS: - Klebsiella - E coli- most common causing 70 - 95% of cases - Enterococci - Proteus - Staphylococcus coagulase negative

Answer 30

- Female sex: the urethra is much shorter and closer to the anus - Post-menopause: the absence of oestrogen is a risk factor for UTIs Recurrent UTI: In young and pre-menopausal women: - Sexual intercourse - A mother with a history of UTI - History of UTI in childhood In elderly and post-menopausal women: - History of UTI before menopause - Urinary incontinence - Catheterisation

Answer 31

Symptoms: - Dysuria: painful or uncomfortable urination - Frequency: passing urine more often than usual - Urgency: a strong desire to urinate, which may result in urinary incontinence Changes in urine appearance/consistency: - A cloudy or pungent odour - Haematuria Suprapubic discomfort Signs: Suprapubic tenderness

Answer 32

- Delirium, lethargy, reduced appetite - Delirium or confusion once other sources of infection have been excluded (e.g. lower respiratory tract infection)

Answer 33

1st line: urine dipstick: positive nitrite OR leukocyte, AND positive RBCs: UTI is likely Negative nitrite AND positive leukocyte: UTI is equally likely to other diagnoses Gold standard: urine microscopy, culture and sensitivity (MC&S)

Answer 34

1st line: nitrofurantoin (if eGFR ≥45ml/minute), or trimethoprim 3 days course

Answer 35

1st line: nitrofurantoin (if eGFR ≥45ml/minute; avoid near term) 2nd line: if no improvement within 48 hours or if first-line is unsuitable Amoxicillin (only if culture results are available and susceptible), or Cefalexin 7 day course

Answer 36

1st line: nitrofurantoin (if eGFR ≥45ml/minute; avoid near term) 2nd line: if no improvement within 48 hours or if first-line is unsuitable Amoxicillin (only if culture results are available and susceptible), or Cefalexin 7-day course

Answer 37

Be aware that cystitis in men is more likely due to an underlying cause. 1st line: trimethoprim, or nitrofurantoin (if eGFR ≥45ml/minute) 7-day course

Answer 38

Urethritis is inflammation of the urethra with/without infection.

Answer 39

- Gonococcal - caused by Neisseria gonorrhoeae - Non-gonococcal (NGU) - commonly caused by Chlamydia trachomatis and Mycoplasma genitalium

Answer 40

- Age 15 to 24 years - Female sex - Men who have sex with men - Low socio-economic status

Answer 41

- Dysuria +/- urethral discharge (blood/pus) - Urethral pain

Answer 42

- 1st line: nucleic acid amplification test (NAAT) - most sensitive test to detect gonorrhoea. Also recommended for chlamydial infection and mycoplasma genitalium - Gram stain of urethral discharge: to check for the presence of gonorrhoeal infection (gram-negative) - Culture of urethral discharge - positive for the causative organism

Answer 43

NG - IM ceftriaxone/IM gentamicin + azithromycin CT - azithromycin or doxycycline

Answer 44

Reactive arthritis - Can't see - conjuctivitis - Cant pee - urethritis - Can't climb a tree - arthritis

Answer 45

Inflammation of the epididymis is referred to as epididymitis, whilst orchitis is inflammation of the testicle. The two may co-exist, and this is referred to as epididymo-orchitis.

Answer 46

Sexually active males - STI microorganisms most common cause - Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium - In older males, enteric pathogens most commonly cause epididymo-orchitis e.g. E.coli

Answer 47

- STI-related: young, multiple partners, unprotected sex - Enteric-related: elderly, bladder outflow obstruction, catherisation - Tuberculosis: can cause epididymo-orchitis

Answer 48

Symptoms: - Unilateral tender, red, and swollen testicle - Pain develops over a few days, torsion must always be ruled out - Lower urinary tract symptoms e.g. dysuria - Pyrexia +/- Signs: - Cremasteric reflex (scrotum shrinks when the inner thigh is stroked due to contraction of cremasteric muscle) preserved (unlike torsion)

Answer 49

Testicular torsion

Answer 50

- Urinalysis using gram-staining: first void sample is most useful and should be sent for microscopy and culture. Detects presence/absence of gonococcal infection - Nucleic Acid Amplification Test (NAAT): first void urine sample for NAAT to detect the DNA/RNA of the causative organism - A swab of urethral secretions: less sensitive than NAAT but must also be performed in symptomatic men

Answer 51

Patients should be treated empirically without waiting for test results. First-line for STI: - Empirical: ceftriaxone 500 mg IM single dose and doxycycline for 10-14 days - Additional management: no sex until review and partner notification to confirm STI causing epididymo-orchitis First-line for enteric organisms: - Empirical: fluoroquinolone e.g. Ofloxacin or ciprofloxacin for 10-14 days .

Answer 52

Prostatitis refers to inflammation of the prostate. It can be classed as: - Acute bacterial prostatitis – presents with a more rapid onset of symptoms - Chronic prostatitis – symptoms lasting for at least 3 months

Answer 53

- Chronic prostatitis or chronic pelvic pain syndrome (no infection) - Chronic bacterial prostatitis (infection)

Answer 54

- Pelvic pain - Lower urinary tract symptoms, such as dysuria, hesitancy, frequency and retention - Sexual dysfunction, such as erectile dysfunction, pain on ejaculation and haematospermia - Systemic symptoms of infection: fever, myalgia, fatigue Signs - Tender and enlarged prostate on examination (although examination may be normal)

Answer 55

Symptoms present for at least 3 months: - Pelvic pain - Lower urinary tract symptoms, such as dysuria, hesitancy, frequency and retention - Sexual dysfunction, such as erectile dysfunction, pain on ejaculation and haematospermia (blood in the semen) - Pain with bowel movements - Systemic symptoms: fever, myalgia - Tender and enlarged prostate on examination (although examination may be normal)

Answer 56

- Urine dipstick testing can confirm evidence of infection. - Urine microscopy, culture and sensitivities (MC&S) can identify the causative organism and the antibiotic sensitivities. - Chlamydia and gonorrhoea NAAT testing on first pass urine, if STI

Answer 57

- Hospital admission for systemically unwell or septic patients (for bloods, blood cultures and IV antibiotics) - Oral antibiotics, typically for 2-4 weeks (e.g., ciprofloxacin, ofloxacin or trimethoprim) - Analgesia (paracetamol or NSAIDs) - Laxatives for pain during bowel movements

Answer 58

- Alpha-blockers (e.g., tamsulosin) relax smooth muscle - Analgesia (paracetamol or NSAIDs) - Psychological treatment, where indicated (e.g., CBT and/or antidepressants) - Antibiotics if a history of infection (e.g., trimethoprim or doxycycline for 4-6 weeks) - Laxatives for pain during bowel movements

Answer 59

UTI caused by typical pathogens in people with a normal urinary tract and kidney function and no predisposing co-morbidities.

Answer 60

UTI with an increased likelihood of complications such as persistent infection, treatment failure and recurrent infection. Risk factors: - Structural abnormalities of the urinary tract - Urinary catheters - Virulent or atypical infecting organisms - Co-morbidities such as poorly controlled diabetes mellitus or immunosuppression

Answer 61

This is a syndrome fitting a clinical picture of inflammation within the kidney. Characterised by: - Haematuria- reflects inflammation of the kidney. Nephritic syndrome is dominated by haematuria - Oliguria (urine output < 400ml a day)- due to reduced GFR - Hypertension – due to fluid overload

Answer 62

Systemic causes: - Systemic lupus erythematosus - Post strep glomerulonephritis - Goodpasture's/anti-GBM (glomerular basement membrane) disease Renal causes: - IgA nephropathy

Answer 63

The diagnostic test for the cause of nephritic syndrome is a kidney biopsy Urinalysis- shows haematuria in nephritic syndrome Bloods- elevated ESR and CRP in inflammation. Anaemia might be present to reflect systemic disease

Answer 64

- Treat underlying cause - Blood pressure control- ACE-I/ARB - anti-hypertensive and anti-proteinuric - This reduces proteinuria and preserves renal function - Corticosteroids- this is to reduce the inflammation causing damage to the kidney

Answer 65

Most common primary glomerulonephritis worldwide. Characterised by the presence of IgA immune complexes in the mesangium of the glomerulus, resulting in nephritic syndrome and progressing to end-stage renal disease (ESRD) over many decades if untreated.

Answer 66

Type 3 hypersensitivity reaction. The deposition of IgA immune complexes in the mesangium causes glomerulonephritis. Activation of complement pathway > glomerular injury Episodes usually occur after an infection of the mucosal lining e.g. upper respiratory tract infection (URTI). Likely due to increased IgA > subsequent IgG recognition and deposition in the kidneys

Answer 67

Symptoms: - Pink, red or “coke” tinged urine (haematuria) - Foamy urine (proteinuria) - Sore throat: suggests a URTI as a recent trigger (common) Signs: - Haematuria - Oedema: due to proteinuria - Cervical lymphadenopathy: suggests an URTI as a recent trigger - Hypertension

Answer 68

- Urine dipstick: blood and protein would be expected - U&Es: allows the assessment of baseline renal function, as well as monitoring for deterioration - C3 and C4 complement levels - normal (excludes other immune complex nephropathies) - Renal biopsy: definitive diagnostic investigation; demonstrates mesangial hypercellularity with positive immunofluorescence for IgA

Answer 69

Aim to prevent further deterioration of renal function: - 1st line: ACE-inhibitor/ARB (anti-hypertensive and anti-proteinuric) - Statins: control of high cholesterol has been shown to slow kidney damage

Answer 70

A severe manifestation of SLE, which is a type 3 hypersensitivity reaction. Deposition of antibody-antigen complexes in the kidneys can lead to lupus nephritis. This can result in end-stage kidney disease. Diffuse proliferative glomerulonephritis is the most common form of lupus nephritis.

Answer 71

It will share risk factors with SLE as it develops secondary to SLE - Middle-aged: peak onset: 15 and 45 years old - Female gender: SLE is 12 times more common in females - African and Afro-Caribbean: SLE is more common and more severe in these patients - Family history

Answer 72

- Diffuse proliferative glomerulonephritis presents with nephritic syndrome: - Haematuria - Hypertension - Oedema. Non-specific symptoms of renal impairment include: - Lethargy - Features of SLE - MSK pain, "butterfly" rash

Answer 73

It is classified and sub-divided by renal biopsy findings: Class I = minimal mesangial = normal renal function. Mild or incidental Class II = Mesangial proliferative = usually presents with microscopic haematuria +/- proteinuria > steroids. Class III = focal segmental = usually presents with nephrotic syndrome > high-dose steroids Class IV = diffuse proliferative = the most common and severe form > nephritic syndrome > steroids and immunosuppressants. Class V = diffuse membranous > presents with nephrotic syndrome: extreme oedema and +/- hypertension Class VI = sclerosing = slowly progressive renal failure with proteinuria.

Answer 74

- Urinalysis: haematuria and proteinuria - U&Es: reduced eGFR as renal failure progresses - Renal USS: exclude structural pathology - Renal biopsy: gold-standard investigation shows hypercellular glomerulus, thickened basement membrane, "wired-loop" thickened capillary walls in severe disease

Answer 75

Lifestyle: stop smoking, exercise Medical management: - Corticosteroids - Immunosuppressive agents: such as cyclophosphamide or azathioprine - Hydroxychloroquine - Dialysis then kidney transplant: if eGFR continues to deteriorate - ACE inhibitor: preferred for patients with hypertension

Answer 76

PSGN is the inflammation of the glomeruli (where filtering occurs in the kidneys) after infection by streptococcal bacteria - usually arises ~2 weeks after infection.

Answer 77

Group A beta-haemolytic streptococci - the specific antigen on the bacteria classifies it into "group A". Beta-haemolytic because the bacteria produce an enzyme called streptolysin break down (lysis) RBCs on a petri dish

Answer 78

Strep infection triggers type III hypersensitivity reaction - Immune complexes composed of antigens and antibodies (usually IgG or IgM) > travels in the bloodstream to the glomerulus > deposits end up in the glomerular basement membrane (GBM) or - Bacterial antigens are first trapped in the glomeruli, and then antibodies there - Activation of C3 complement, inflammatory cytokines, oxidants, and proteases > podocyte damage - Kidney injury > allows larger molecules into urine e.g. RBCs, proteins > haematuria and proteinuria - Haematuria = cola/dark-coloured urine

Answer 79

General nephritic syndrome symptoms: - Haematuria - Oliguria - Oedema - Hypertension Other symptoms: - Fever - Malaise - Anorexia - Headach

Answer 80

Kidney biopsy - glomerulus looks enlarged and hypercellular under light microscopy, subepithelial deposits "humps" under EM Urinanalysis - proteinurina and haemotauria Immunofluorescence - immune complexes give a starry sky granular appearance along GBM FBC - normochromic, normocytic anaemia associated with systemic disease eGFR - normal or reduced Blood tests - show antibodies against group A streptococcus—called anti-DNase B, and decreased complement levels (C3 and CH50)

Answer 81

- Usually affects children and self-limiting so supportive management - Sometimes oral antibiotics are given

Answer 82

Rare, but some children might develop renal failure 25% of adults might develop rapidly-progressing glomerulonephritis > renal failure

Answer 83

Goodpasture’s disease, also known as anti-glomerular basement membrane antibody (anti-GBM) disease, is caused by an autoantibody to the alpha-3 chain of type IV collagen. Usually found in basement membranes of alveoli and glomeruli. Goodpature's disease is an important cause of pulmonary-renal syndrome, which consists of glomerulonephritis and pulmonary haemorrhage. A nephritic syndrome

Answer 84

Autoimmune disease caused by autoantibodies against the alpha-3 chain of type IV collagen - causing glomerular injury.

Answer 85

- Reduced urine output (renal damage) - Haemoptysis (coughing up blood) (respiratory damage) - Oedema (renal damage) - SOB (respiratory damage) - Cough and fever might also be present

Answer 86

- Definitive diagnostic test - anti-GBM antibodies in bloods and biopsy - Renal biopsy - when viewed with immunofluorescence, characteristic linear IgG staining seen

Answer 87

- Plasma exchange - removes pathogenic anti-GBM antibodies - Corticosteroids (i.e. steriods) - Cyclophosphamide (for immune suppression)

Answer 88

Rare, but Goodpasture's disease can lead to rapidly progressing glomerulonephritis, which can cause renal failure within days/weeks

Answer 89

Nephrotic syndrome occurs when the glomerular basement membrane becomes highly permeable to protein, allowing protein to leak from the blood to urine. This results in the triad characterising nephrotic syndrome: - Proteinuria (>3.5 g/24 hours) - nephrotic syndrome is dominated by proteinuria - Hypoalbuminaemia (<30 g/L) - due to loss of albumin in the urine - Peripheral oedema - loss of oncotic pressure. This can be rapid and severe

Answer 90

- Hyperlipidaemia - the liver increases the synthesis of lipids in response to low albumin - Hypogammaglobulinemia: due to loss of immunoglobulin in the urine - Hypercoagulability: due to loss of anticoagulation factors in the urine

Answer 91

It is caused by a number of primary and secondary diseases, including: - Minimal change disease - most common in children - Focal segmental glomerulosclerosis (FSGS) - most common in adults - Membranous nephropathy - most common in the elderly

Answer 92

The signs and symptoms depend on the exact underlying cause but some general signs and symptoms include: Symptoms: - Frothy urine - Facial and peripheral oedema - Proteinuria - Recurrent infections: due to hypogammaglobulinemia (low Ig levels) Signs: Limited or absent haematuria (differentiates it from nephritic syndrome in which haematuria dominates)

Answer 93

Primary investigations: - Urinalysis: proteinuria predominates over haematuria; lipid casts - 24-hour urine protein collection: > 3.5 g protein - Urine albumin-creatinine ratio (ACR): raised due to proteinuria - U&Es: monitor eGFR and creatinine to assess for renal failure - LFTs: hypoalbuminemia < 25 g/L - Lipid profile: hypercholesterolaemia

Answer 94

Primary investigations: Urinalysis: proteinuria predominates over haematuria; lipid casts 24-hour urine protein collection: > 3.5 g protein - Urine albumin-creatinine ratio (ACR): raised due to proteinuria - U&Es: monitor eGFR and creatinine to assess for renal failure - LFTs: hypoalbuminemia < 25 g/L - Lipid profile: hypercholesterolaemia and hypertriglyceridemia - Renal ultrasound: exclude structural pathology

Answer 95

The management varies between different causes of nephrotic syndrome. Below are the basic principles: Lifestyle - Low salt, protein and fat diet - Improve cardiovascular risk factors Corticosteroids and immunosuppressants: - Minimal change disease: very responsive to steroids - FSGS: response to steroids is variable - Ciclosporin may be used in steroid-resistant case - Membranous nephropathy: corticosteroids are combined with an immunosuppressant; cyclophosphamide first-line Adjunctive therapies - Diuretics: symptomatic relief of fluid overload - ACE inhibitor: used to reduce proteinuria

Answer 96

Light microscopy: normal glomeruli on light microscopy Electron microscopy (EM): effacement of podocyte foot processes (flattened out due to damage)

Answer 97

- Light microscopy: focal and segmental glomerular sclerosis (scar tissue) - EM: effacement of foot processes

Answer 98

- Light microscopy: thick glomerular basement membrane - EM: subepithelial immune complex deposition (spike and dome pattern)

Answer 99

- My be preceded by upper respiratory tract infection - Associated with Hodgkin lymphoma

Answer 100

- HIV - Heroin use - Sickle cell disease - SLE

Answer 101

- Malignancy - Hepatitis B - NSAIDs - SLE

Answer 102

- Malignancy - Hepatitis B - NSAIDs - SLE

Answer 103

- Lifestyle: low salt diet + fluid restriction - 1st line is corticosteroids: very responsive to steroids, with a 90% response rate - Corticosteroids + Immunosuppressant (e.g. cyclophosphamide) for frequent relapses - Adjuvant therapies: diuretics (furosemide) for symptomatic relief of fluid overload

Answer 104

Lifestyle - Low salt and fat diet - as sodium can block the effects of ACEi or ARB, and patients can have hyperlipidemia - Weight loss can decrease proteinuria in obese patients - 1st line: ACE inhibitors (preferred) or ARB as they are anti-hypertensive and reduce proteinuria - Treat underlying cause if secondary FSGS - Diretics e.g. furosemide for oedema - The response variable,~50% achieving remission.

Answer 105

- 1st line: low salt and protein diet - low sodium reduce oedema, and low protein reduces proteinuria. - Corticosteroids + immunosuppressant (1st line is cyclophosphamide) - ACEi or ARB for hypertension - Diuretics e.g. furosemide for oedema

Answer 106

Benign prostatic hyperplasia is a very common condition affecting men in older age (usually over 50 years). It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms (LUTS) - such as post-void dribbling, hesitancy and urgency.

Answer 107

- In men aged 51-60, 50% have BPH. - In men over 80, 80% have BPH. - Increasing age: particularly >50 years old - Family history - Ethnicity: more common in Afro-Caribbean men; black > white > Asian - Diabetes - Obesity: due to increased circulating oestrogens

Answer 108

Characterised by an increased stromal: epithelial ratio. BPH = hyperplasia of glandular epithelial cells and stromal (connective tissue) cells. Increasing age = increased activity of the enzyme 5-alpha reductase. This increases dihydrotestosterone (DHT) and oestrogen > DHT causes hyperplasia within the prostate by acting on androgen receptors. Mainly affects the peri-urethral region of the prostate, called the transition zone, resulting in compression of the prostatic urethra.

Answer 109

Symptoms: Lower urinary tract symptoms (LUTS) - Voiding: hesitancy, weak stream, straining, incomplete emptying, terminal dribbling - Storage: urgency, frequency, nocturia, urgency incontinence - Lower abdominal pain and inability to urinate - urinary retention Signs - Digital rectal examination findings: Smooth, enlarged, and non-tender Not accurate for predicting prostate volume - Lower abdominal tenderness and palpable bladder: - Indicates acute urinary retention which require a bladder scan and urgent catheterisation

Answer 110

Primary investigations: - Urinalysis: the presence of pyuria suggests infection - Prostate-specific antigen (PSA): predicts prostate volume, progression and may suggest cancer if significantly raised; remember BPH can also raise PSA - U&Es: renal failure if there is significant obstruction - International Prostate Symptom Score (I-PSS): a 7-symptom questionnaire with an additional bother score (QOL) to predict progression and outcome

Answer 111

1st line: lifestyle advice and modification if the patient has mild (non-bothersome) symptoms: treat constipation, reduce caffeine and fluid intake, medication review, bladder retraining.

Answer 112

Bothersome symptoms but no indications for surgery: - 1st line: α-1 adrenergic antagonists: relaxes the smooth muscle in the prostate and bladder neck, e.g. tamsulosin - 5-α reductase inhibitors: inhibits DHT (dihydrotestosterone) formation to reduce prostate size, thus slowing progression (unlike α-blockers); e.g. finasteride. - Phosphodiesterase-5 inhibitor: used for severe LUTS, e.g. sildenafil

Answer 113

Enhances the effect of nitric oxide (NO - vasdilation) by inhibiting phosphodiesterase-5 in the penile corpus cavernosum.

Answer 114

Arrhythmias; asthenia (weakness, lack of energy) ; chest pain;

Answer 115

1) Postural hypertension due to vasodilation 2) Retrograde ejaculation (30%) due to over-relaxation of the bladder muscles allowing retrograde leakage of semen into the bladder

Answer 116

- Reduced libido - Erectile dysfunction, - Reduced ejaculate volume - Gynaecomastia

Answer 117

- Alopecia - Anaemia - Anxiety - Cough - Diarrhoea - Dizziness

Answer 118

PSA is usually used to screen for prostate cancer. However, many things can also raise PSA levels, such as benign prostate hyperplasia, prostatitis or UTI. Therefore, it is not a specific test for prostate cancer as it can be raised even if the patient does not have prostate cancer.

Answer 119

Bothersome symptoms and indications for surgery: Indications for surgery (RUSHES) R - Recurrent or refractory urinary retention U - Recurrent UTIs S - Bladder stone H - Haematuria refractory to medical therapy E - Elevated creatinine due to bladder outflow obstruction S - Symptom deterioration despite maximal medical therapy - Prostate <30 g: transurethral incision of the prostate (TUIP) - Prostate 30-80 g: transurethral resection of the prostate (TURP) - Prostate >80 g: open prostatectomy Laser enucleation (HoLEP) is an alternative - a laser is used to remove tissue blocking urine flow

Answer 120

- Retrograde ejaculation - TUIP and TURP - 70% patients - Open prostatectomy - 80 - 90% patients

Answer 121

Prostate cancer is the most common cancer in males in the UK. Adenocarcinomas are the most common type of prostate cancer, which most commonly arise from the peripheral zone of the prostate.

Answer 122

Thought to be associated with BRCA1 and BRCA2. Risk factors: - Increasing age: men > 75 years ols - Family history: 5-10% - Afro-Caribbean ethnicity - Obesity and high-fat diet - Cadmium exposure: found in cigarettes, batteries and those working in the welding industry

Answer 123

- Adenocarcinomas - most common type, usually arise from the peripheral zone of the prostate. - High-grade prostatic intraepithelial neoplasia is considered the histological precursor of invasive prostate cancer. - Spread normally occurs along the capsular surface of the prostate, metastasising via the lymphatics and blood.

Answer 124

Initially, it might not cause symptoms as it starts in the peripheral zones. Later it causes LUTS as it compresses the urethra. Symptoms: - Common LUTS: - Frequency - Hesitancy - Terminal dribbling - Nocturia - Bone pain: e.g. lumbar back pain > suggests metastatic disease - Constitutional symptoms: e.g. weight loss

Answer 125

- Asymmetrical, hard, nodular prostate on digital rectal examination - Palpable lymphadenopathy - indicates metastatic disease - Urinary retention - presents with lower abdominal pain and tenderness, inability to urinate and a palpable bladder

Answer 126

Primary investigations: Prostate-specific antigen (PSA) - often increased in patients with prostate cancer. 1st line: multiparametric MRI identifies candidates for biopsy and differentiates clinically significant and non-significant tumours (≥3 points = biopsy, < 3 = discuss pros and cons) Gold standard: prostate biopsy needed to confirm the diagnosis

Answer 127

Option 1: Active surveillance or observation (higher risk of progression but lower risk of complications) Active surveillance is preferred in low-risk disease. Option 2: Radical prostatectomy Using robots, removing the prostate, seminal vesicles, ampulla, and vas deferens, +/- pelvic lymph node dissection. Commonly performed.

Answer 128

Option 1: Radical prostatectomy Pelvic lymph node dissection is more frequently considered. Option 2: Radical radiotherapy with anti-androgen therapy OR Option 3: Radical radiotherapy with brachytherapy i.e. internal radiotherapy direct to prostate (can also be used in intermediate-risk cases)

Answer 129

- Treated with docetaxel chemotherapy and antiandrogen therapy - Bilateral orchiectomy should be offered as an alternative to LHRH (luteinizing hormone-releasing hormone) agonists

Answer 130

Testicular cancer is the most common malignancy in young males and usually presents with a firm, painless testicular lump. Divided into: - Germ cell tumours (95% of cases) - Non-germ cell tumours (sex-cord stromal tumours) - Lymphomas

Answer 131

Germ cell tumours arise from haploid germ cells which partake in spermatogenesis. Divided into: - Seminoma - most common and best prognosis - Embryonal carcinoma - aggressive and metastasises early - Teratoma - composed of tissue from different germinal layers e.g. teeth. Common in children

Answer 132

Non-germ cell tumours arise from diploid sex-cord stroma cells, and are divided into: - Leydig cell tumour: androgen secreting causing precocious puberty - Sertoli cell tumour: usually clinically silent

Answer 133

- Non-Hodgkin lymphoma is the most common and it is rare. - Most common in elderly

Answer 134

- Young males: seminoma > 35 years; non-seminoma < 35 years - Caucasian - Family history - Infertility: 3x - Cryptorchidism (absence of one or more testicles) - Mumps orchitis (testicle swelling after mumps) - Testicular atrophy: often following trauma

Answer 135

Symptoms: - Painless testicular lump: most common presenting complaint - Symptoms related to raised β-hCG (human chorionic gonadotropin) - Hyperthyroidism as β-hCG mimics TSH. - Gynaecomastia (breast tissue swelling in males) - Bone pain: indicates skeletal metastasis. - Breathlessness: indicates lung metastasis. Signs: - Firm, non-tender testicular mass - Does not transilluminate (shining light does not go through) - Supraclavicular lymphadenopathy (swelling of lymph nodes above clavicles)

Answer 136

- 1st line and diagnostic: in over 90% of cases: ultrasound testicular doppler - Tumour markers: β-hCG, AFP (alpha-fetoprotein) and LDH must be measured prior to surgery. LDH is raised non-specifically in most testicular cancers Germ cell tumour: Tumour marker Seminoma: Occasionally β-hCG (20%) Embryonal carcinoma: AFP Teratoma: AFP

Answer 137

1st line: orchiectomy. - Seminomas are radiosensitive = adjuvant radiotherapy - Non-seminomas undergo chemotherapy. Post orchiectomy: Seminoma: - active surveillance for low-risk disease - radiotherapy for locally-invasive disease. Non-seminoma: localised - active surveillance for low-risk disease - Adjuvant chemotherapy for high-risk disease Advanced or metastatic disease: - Seminoma: adjuvant combination chemotherapy or radiotherapy - Non-seminoma: combination chemotherapy

Answer 138

- >90% transitional cell carcinoma (TCC) aka urothelial carcinoma - Transitional epithelium lines the renal pelvis, ureter, bladder, and urethra. - Squamous cell carcinoma (rare, 1-7% in the UK) associated with chronic cystitis secondary to schistosoma haematobium infection (most commonly seen in Egypt). - Adenocarcinoma occurs in 2% of patients.

Answer 139

- Papillary: the majority of cases, usually superficial with finger-like projections, often non-invasive - Flat: lie flat against the bladder tissue and are more prone to invasion

Answer 140

TCC is associated with loss of function of tumour suppressor genes p53 and retinoblastoma (Rb) gene. TCCs may occur as solitary or multifocal lesions.

Answer 141

Risk factors for urothelial carcinoma: - Increasing age: most common at 50 to 80 years old - Male - Family history - Smoking Occupational exposure - Aromatic amines: rubber, dye and textile industries - Painters and hairdressers Risk factors for squamous cell carcinoma: - Schistosoma haematobium: causes chronic bladder inflammation, most common in Egypt

Answer 142

The classic history of bladder cancer is an elderly patient with a history of smoking presenting with painless, macroscopic haematuria. Symptoms - ‘Painless’ haematuria: microscopic or macroscopic - Dysuria - mostly ‘painless’, occasionally can cause dysuria - Frequency - Constitutional symptoms e.g. weight loss Signs - Anaemia e.g. pallor, if chronic bleeding present - Palpable suprapubic mass in advanced cases

Answer 143

NICE recommends: Aged 45 and over and have: - Unexplained visible haematuria without UTI OR - Visible haematuria that persists after successful treatment of UTI - Aged 60 and over and have: unexplained microscopic haematuria and either dysuria or a raised WCC - Non-urgent referral - aged 60 and over with recurrent or persistent unexplained UTI

Answer 144

Primary investigations : - Gold standard: flexible cystoscopy: under local anaesthetic to confirm the presence of a bladder tumour - Urinalysis: haematuria - CT urogram - allows staging Bloods: - FBC: assess Hb in patients with chronic haematuria - U&Es: renal failure if significant bladder outflow obstruction - Bone profile: hypercalcaemia and raised ALP with bone metastasis - LFTs and coagulation screen: deranged in liver metastasis and to rule out coagulopathy

Answer 145

Superficial / non-muscle invasive (T1): - Trans-urethral resection of bladder tumour (TURBT). Muscle-invasive (T2) or locally-advanced (T3): - Radical cystectomy with neoadjuvant chemotherapy; patients will require an ileal conduit (urostomy) - Radical radiotherapy with neoadjuvant chemotherapy is an alternative to surgery. Metastatic (T4): - Palliative chemotherapy: cisplatin-based chemotherapy or radiotherapy for symptoms

Answer 146

PKD is part of a heterogeneous group of disorders characterised by renal cysts and numerous systemic and extrarenal manifestations. There are two types: - Autosomal-dominant PKD (ADPKD) Autosomal-recessive PKD (ARPKD)

Answer 147

Autosomal recessive polycystic kidney disease (ARPKD) presents in neonates and is usually picked up on antenatal ultrasound scans. It results from a mutation in the polycystic kidney and hepatic disease 1 (PKHD1) gene on chromosome 6. This gene codes for the fibrocystin/polyductin protein complex (FPC), which is responsible for maintaining healthy epithelial tissue in the kidneys, liver and pancreas.

Answer 148

The most commonly affected genes are PKD1 or PKD2 in autosomal dominant polycystic kidney disease. Patients with ADPKD often carry germline mutation in one allele of either PKD1 or PKD2, which causes pathogenic changes in tissue and organ development.

Answer 149

The underlying pathology causes: - Cystic enlargement of the renal collecting ducts - Oligohydramnios (too little amniotic fluid), pulmonary hypoplasia and Potter syndrome (syndrome associated with oligohydramnios and kidney failure) - Congenital liver fibrosis

Answer 150

The underlying pathology causes renal cysts to develop, which compresses the kidneys and intrarenal vessels > obstruction and apoptosis occur > increased kidney size, fibrosis and progressive renal impairment. The kidneys progressively enlarge and become distorted with little recognisable parenchyma (tissue) on imaging

Answer 151

Often present in neonates and picked up on antenatal screening (ultrasound scan): - Oligohydramnios (lack of amniotic fluid due to low urine production from fetus) and polycystic kidneys - Oligohydramnios > Potter syndrome and underdeveloped fetal lungs (pulmonary hypoplasia) > respiratory failure shortly after birth. - Patients need renal dialysis shortly after birth and develop end-stage renal failure before adulthood

Answer 152

- Liver failure due to liver fibrosis - Portal hypertension leading to oesophageal varices - Progressive renal failure - Hypertension due to renal failure - Chronic lung disease

Answer 153

- Family history of autosomal-dominant PKD (ADPKD) or end-stage renal disease - Family history of cerebrovascular events (strong association between ADPKD and intracranial aneurysm or subarachnoid haemorrhage) Symptoms: - Abdominal/flank pain - Haematuria - Headaches - Dysuria Signs - Renal cysts - Extrarenal cysts (e.g. berry aneurysms particularly in the circle of Willis) - Hypertension - Palpable kidneys/abdominal mass

Answer 154

Kidney ultrasound - bilateral kidney enlargement with multiple cysts can be seen - Genetic testing for PKD1 or PKD2 mutation if imagining inconclusive

Answer 155

Renoprotective lifestyle changes - - Weight loss (or maintaining a healthy weight) - Regular cardiovascular exercise - Avoid smoke Medical management: Tolvaptan - vasopressin antagonist used to treat hyponatremia. ACEi or AN-II antagonist for hypertension Antibiotic therapy for UTI or infected renal cysts Analgesia (paracetamol or opioids) for renal pain End-stage kidney disease: - 1st line: renal transplant - 2nd line: dialysis

Answer 156

Varicoceles occurs when there is abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis They can cause impaired fertility, probably due to disrupting the temperature in the affected testicle. They may result in testicular atrophy, reducing the size and function of the testicle.

Answer 157

Symptoms: - Painless scrotal mass - Scrotal or groin pain - Left-sided signs and symptoms (90% of varicoceles left-sided) - Dragging sensation - Infertility Signs: - A scrotal mass that feels like a “bag of worms” - More prominent on standing - Disappears when lying down - Asymmetry in testicular size if the varicocele has affected the growth of the testicle

Answer 158

- Mostly diagnosed through clinical presentation, but below are some investigations to consider: - Ultrasound with Doppler imaging can be used to confirm the diagnosis - Semen analysis if there are concerns about fertility

Answer 159

- Mostly diagnosed through clinical presentation, but below are some investigations to consider: Ultrasound with Doppler imaging can be used to confirm the diagnosis. - Semen analysis if there are concerns about fertility - Hormonal tests (e.g., FSH and testosterone) if there are concerns about function

Answer 160

- Uncomplicated cases can be managed conservatively. - Surgery such as open repair, laparoscopic repair or percutaneous embolisation may be indicated for pain, testicular atrophy or infertility.

Answer 161

Testicular torsion is a urological emergency caused by the twisting of the testicle on its spermatic cord, leading to ischaemia and eventually necrosis.

Answer 162

Testicular appendage torsion, mimics testicular torsion. The Hydatid of Morgagni is an embryonic remnant of the Mullerian duct. Torsion of this small tissue can cause intense pain and characteristically causes a ‘blue-dot’ sign at the centre of the testicles but is often managed conservatively.

Answer 163

- Key risk factor = "bell clapper" abnormality: high riding testicle with a horizontal lie - Young age: peaks in the neonatal period and around puberty - Cryptorchidism: undescended testis - Trauma: trauma-induced torsion (>10% cases)

Answer 164

This is when the tunica vaginalis - peritoneum covering the testicles does not attach to the scrotum properly, allowing the testicles to lie horizontally and hang and swing freely like a clapper in a bell

Answer 165

Symptoms: - Testicular pain - usually unilateral, sudden onset and excruciatingly painful. - Nausea and vomiting secondary to pain is common - Lower abdominal pain: referred pain Signs: - Swollen, high-riding and tender testicle - Prehn’s sign negative: pain is not relieved on lifting the ipsilateral testicle, unlike in epididymitis - Absent cremasteric reflex

Answer 166

Epididymo-orchitis

Answer 167

NICE recommends imagining studies NOT to be performed in patients where the history and physical examination suggests torsion because the treatment might be delayed. - Diagnosis is usually clinical - physical examination - Testicular ultrasound: ‘whirl-pool’ sign suggests torsion, as does decreased blood flow in the affected testicle on colour doppler - Surgical exploration: diagnostic and performed within 6 hours to prevent irreversible damage - Urinalysis: an abnormal result such as the presence of leukocytes and nitrites may suggest an alternative diagnosis, e.g. epididymo-orchitis

Answer 168

Viable testicle: - Bilateral orchiopexy: the affected testicle is untwisted and fixed to the scrotal sac. The contralateral testicle should always be fixed to prevent contralateral torsion. Non-viable testicle (e.g. necrotic): - Ipsilateral orchiectomy and contralateral orchiopexy In cases of surgical delay: - Manual detorsion: a temporary measure that should only be performed if surgery is not available within 6 hours.

Answer 169

Epididymal cysts occur at the head of the epididymis (at the top of the testicle). A cyst is a fluid-filled sac. An epididymal cyst that contains sperm is called a spermatocele. Transilluminates when light shines through.

Answer 170

Most cases are asymptomatic. - Patients may present having felt a lump, - Or found incidentally on ultrasound Examination findings are (i.e. signs): - Soft, round lump - Typically at the top of the testicle - Associated with the epididymis - Separate from the testicle - May be able to transilluminate large cysts (appearing separate from the testicle)

Answer 171

Clinical diagnosis usually: Examination findings are: - Soft, round lump - Typically at the top of the testicle - Associated with the epididymis - Separate from the testicle - May be able to transilluminate large cysts (appearing separate from the testicle) - Sometimes ultrasound of scrotum if clinical examinations not definitive.

Answer 172

Usually, they are harmless and not associated with infertility or cancer. Occasionally, they may cause pain or discomfort. Exceptionally rarely, there may be torsion of the cyst, causing acute pain and swelling. In these cases, removal will be considered

Answer 173

Lower urinary tract symptoms (LUTS) - Storage symptoms: occurs when bladder should be storing urine - need to pee FUNI Frequency, Urgency, Nocturia, (urgency) Incontinence - Voiding symptoms - occurs when the bladder outlet obstructed SHID - Voiding: (poor) Stream, Hesitancy, Incomplete emptying, Dribbling

Answer 174

A hydrocele is a collection of serous fluid between the layers of the membrane (tunica vaginalis) that surrounds the testis or along the spermatic cord. The tunica vaginalis is a sealed pouch of membrane that surrounds the testes.

Answer 175

- Simple - fluid is trapped in the tunica vaginalis. Reabsorbed over time and the hydrocele disappears. Common in newborn males. - Communicating - the tunica vaginalis around the testicle is connected with the peritoneal cavity via a pathway (processus vaginalis). This allows fluid to travel from the peritoneal cavity into the hydrocele, allowing the hydrocele to fluctuate in size.

Answer 176

- Soft, smooth, non-tender swelling around one of the testes. - In front and below the affected testicle - Simple hydroceles - one size - Communicating hydroceles - size fluctuation - Transilluminate - hold the pen torch flat against the skin, and it will light up like a bulb

Answer 177

Ultrasound is a useful investigation for confirming the diagnosis and excluding other causes.

Answer 178

The key differential diagnoses of scrotal or inguinal swelling: - Hydrocele - Partially descended testes (neonates) - Inguinal hernia - Testicular torsion - Haematoma - Tumours (rare)

Answer 179

Simple hydroceles will usually resolve within 2 years. Parents can be reassured and followed up routinely. They may be offered surgery if it persists beyond two years of age, or if associated with other problems, such as a hernia. Communicating hydroceles can be treated with a surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis).

Answer 180

Rhabdomyolysis - Damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death.

Answer 181

1) Thiazide diuretic - oedemia, hypertension 2) Thiazide diuretics act primarily by inhibiting the Na+-Cl− cotransporter in the distal tubule, promoting sodium excretion. 3) Postural hypotension; risk of hypokalaemia; dizziness

Answer 182

1) Urinary frequency, Urinary urgency, Urinary incontinence, neurogenic bladder instability 2) Antimuscarinic (anticholinergic) that relaxes the smooth muscle of the bladder wall 3) Diahoerra Oral: dry eye Transdermal: GI discomfort

Answer 183

Renal cell carcinoma (RCC) is an adenocarcinoma most commonly arising from the epithelium of the proximal convoluted tubule. RCC is the most common type of kidney cancer in adults

Answer 184

Symptoms: - 50% asymptomatic - Classic triad: haematuria, flank pain, abdominal mass - Weight loss, fatigue, fever Signs: - Flank mass - Left-sided varicocele (left testicular vein drains into left renal vein = back pressure, right testicular vein > directly to IVC) - Hypertension (risk factor) - Evidence of metastatic disease: SOB, Chronic liver disease, Bone pain

Answer 185

- CT abdomen/pelvis with contrast: the definitive test for diagnosis - Urinalysis: microscopic haematuria or proteinuria Bloods: - FBC: anaemia of chronic disease or polycythaemia - U&Es: assess for renal dysfunction - LFTs and coagulation profile: deranged = liver mets - Bone profile: hypercalcaemia = bone mets LDH: elevated LDH non-specifically in cancer

Answer 186

Localised disease: Partial nephrectomy: T1 tumours (i.e. ≤ 7cm) Radical nephrectomy: standard for T2-T3 tumours (i.e. > 7cm). Minimally-invasive procedures: reserved for patients unfit for surgery, e.g. radiofrequency ablation Metastatic disease: Immunotherapy: 1st line are Sunitinib and Pazopanib (receptor tyrosine kinase inhibitors) Radiotherapy

Answer 187

- Benign renal cyst - Ureteric cancer - Bladder cancer

Answer 188

Von Hippel-Lindau syndrome