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renal and gu Flashcards

1
Q

What is nephroliathiasis?

A

Renal stones (kidney or ureteric)
Calcium oxalate stones form in CD (collecting duct), deposited anywhere (renal pelvis —> ureter)
V common! Also recurrence is v common!

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2
Q

What are the 5 most common types of renal stone? And which can be seen on x-ray?

A
  • Calcium oxalate
  • Calcium phosphate
  • Struvite (RF = UTI)
  • Uric acid
  • Cysteine
    90% = radio-opaque, but uric acid (urate) stones are radiolucent!
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3
Q

What are the risk factors for nephroliathiasis?

A

Chronic dehydration
Kidney 1˚ diseases (eg. PKD)
hyperPTH (HYPERCALCAEMIA + HYPERCALCIURIA)
UTIs
Hx of previous stone

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3
Q

What is the pathophysiology of nephroliathiasis?

A

Excess solute in CD —> supersaturated urine, favours crystallisation
Stones cause regular outflow obstruction, HYDRONEPHROSIS (complication - stretched + swollen kidney)

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4
Q

What is hydronephrosis? And how do you treat it?

A

Dilation (obstruction causes prostaglandin release - results in natural diuresis) + obstruction of renal pelvis (↑ DAMAGE + infection risk)
Requires surgical decompensation ASAP

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5
Q

Who is most likely to present with nephroliathiasis?

A

Males (slightly more)
20-40 yo
(Uncommon in children)

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6
Q

What are the symptoms and signs of nephroliathiasis?

A

UNILATERAL LOIN TO GROIN PAIN that is COLICKY - peristaltic waves
Patient CAN’T LIE STILL
Haematuria + dysuria
Red flags = fever - suggests superimposed infection (eg. pyelonephritis)
Pain worse with diuretics + fluid!

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7
Q

How should you investigate suspected nephroliathiasis?

A

1st line = KUB XR (80% specific for renal stones, cheap + easy)
Gold standard = NCCT KUB (non contrast CT - 99% specific for stones ∴ DIAGNOSTIC!)
- contrast would need to be excreted by kidney —> HARMFUL (NEVER DO CONTRAST IF SUSPECTED KIDNEY DISEASE)
- Pro - rapid, Con - each scan = around 18 months background radiation
Bloods: FBC, U&E - deranged suggest HYDRONEPHROSIS
Urine dipstick: UTI
Urinalysis - haematuria, pregnancy test

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8
Q

How do you treat nephroliathiasis?

A

Symptomatic: hydrate, analgesia (eg. Diclofenac IV for severe pain - an NSAID not opiate)
Antibiotics if UTI present (eg. Gentamicin for pyelonephritis)
Stones normally pass spontaneously if small enough <5mm (watch + wait!)
Surgical: elective Tx if too big (ESWL / PCNL) to pass + causing pain
- Extracorporeal Shock Wave Lithotripsy - break stone w/ shock waves, smaller stones 6-10mm unto 20mm
- Percutaneous nephrolithotomy - keyhole removal of stone, larger stones >20mm
Also consider: ureteroscopy - pass ureteroscope up into ureter + retrieve stone”

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8
Q

What are the 3 commonest obstruction sites of nephroliathiasis?

A
  1. PUJ (pelvi-ureteric junction)
  2. Pelvic brim - ureters cross over iliac vessels
  3. VUJ (vesico-ureteric junction - where ureter enters bladder)
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9
Q

What is an acute kidney injury (AKI)?

A

Abrupt decline in kidney function (hrs-days)
Characterised by:
↑ serum creatinine + urea
↓ urine output

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10
Q

How are AKIs classified? And what is the system?

A

KDIGO (Kidney Disease Improving Global Outcomes)!
(1) Serum creatinine ↑ 26 μmol/L within 48h
(2) Serum creatinine 1.5 x baseline in 7 days
(3) Urine output <0.5 ml/kg/h for 6≤h (consecutive)

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11
Q

How do you stage an AKI?

A

AKIN score (acute kidney injury network):
- Stage 1, 2, 3
- Higher stage - mortality, ↓ likelihood of kidney recovery
Used to be RIFLE:
- Risk
- Injury
- Failure
- Loss
- ESRF (end stage renal failure)

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11
Q

What are the 3 broad categories of AKI?

A

PRE-RENAL = hypoperfusion
RENAL = nephron + parenchyma damage
POST-RENAL = obstructive uropathy

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11
Q

What is a pre-renal AKI?

A

HYPOPERFUSION
- Total body - ↓ CO (cardiorenal syndrome, congestive heart failure, cardio shock)
- Liver failure - hepatorenal syndrome, 3rd spacing of fluid due to hypoalbuminemia
Renal artery blockage or stenosis
Drugs - NSAIDs + ACE-i + IV contrast (↓GFR)

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12
Q

What is a renal AKI? What are its causes? And how does this make it present?

A

NEPHRON + PARENCHYMA DAMAGE
- Tubular - most common, acute tubular necrosis, pathognomonic (specific)- presents with MUDDY BROWN CASTS IN URINE! (Dead tubular cells)
- Interstitial - triad of fever, rashes, eosinophilia
- Glomerular - often presents w/ glomerular nephritis
- Toxins (sepsis)

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13
Q

What is a post-renal AKI? And what are its causes?

A

OBSTRUCTIVE UROPATHY
- Stones (ureteral / bladder / urethra)
- BPH (common in elderly men)
- Drugs (anticholinergics, CCB)
- Occluded indwelling catheter

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14
Q

What are the risk factors for an AKI?

A

↑ Age
Comorbidities (hypertension, T2DM, CHF - congestive heart failure)
Hypovolaemia of any cause
Nephrotoxic drugs
(ACE-i = causes constriction of afferent arteriole ∴ ↓ perfusion to glomerulus)”

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15
Q

What is the pathophysiology of an AKI?

A

Decreased blood filtration and urine output ∴ accumulation of (usually excreted) substances
- K+ = HYPERKALAEMIA - arrhythmias
- UREA = HYPERURAEMIA - pruritis (urea deposits in the skin, itching) + uraemia frost, confusion if severe (link to hepatic encephalopathy in liver failure - ammonia is a byproduct of urea metabolism)
- FLUID = OEDEMA - pulmonary + peripheral
- H+ = acidosis”

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15
Q

What are the top 3 causes of AKI?

A
  1. Sepsis
  2. Cariogenic shock
  3. Major surgery
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16
Q

What are the symptoms and signs of an AKI?

A

The RESULT OF SUBSTANCE ACCUMULATION
- Uraemia —> encephalopathy, pericarditis, skin manifestations
- Fluid overload —> oedema (or HYPOVOLEMIC SHOCK! - if pre renal cause), oliguria (/anuria) + palpable bladder
- H+ —> metabolic acidosis
- K+ —> arrhythmias (AKI massively related to hyperkalaemia)
- Haematuria / proteinuria

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17
Q

How does hyperkalaemia present on an ECG?

A

Tall tented T waves
P wave flattening
Wide QRS

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18
Q

How should you investigate a suspected AKI?

A

Establish cause (pre/intra/post) + diagnosed w/ KDIGO classification (serum, urine)
- best way = urea:creatinine!
- >100:1 —> PRERENAL
- <40:1 —> RENAL
40-100:1 —> POSTRENAL
Check K+, H+, urea, creatinine w/ U&E, FBC + CRP check for infection
Renal biopsy will confirm intrarenal cause, USS for postrenal
(So many you can do, too many to learn them all - ECG, urine dipstick, CXR, ABG…)

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19
Q

How do you treat an AKI?

A

Treat complication (hyperkalemia w/ calcium gluconate - stabilises cardiac membrane, met acidosis w/ sodium bicarb, fluid overload w/ diuretics)
Treat underlying cause
Last resort
- RRT (renal replacement therapy),
- HAEMODIALYSIS - indicated in AFUK: acidosis (pH <7.1), fluid overload (oedema eg. pulmonary), uraemia (symptomatic), K+ >6.5 / ECG change

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20
Q

What is CKD?

A

eGFR <60ml /min /1.73m2 for 3+ months

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21
Q

What is eGFR? And what is the ‘normal’ value?

A

Estimated glomerular filtration rate
120ml /min /1.73m2

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22
Q

What 4 parameters are used to classify CKD?

A

CAGE
1. Creatinine
2. Age
3. Gender
4. Ethnicity

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23
Q

Which drug is contraindicated when eGFR is low? Who is this likely to affect?

A

Metformin contraindicated, eGFR <30
This is a T2DM drug

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24
Q

How are the stages of CKD defined?

A

Stages 1-5 (based on eGFR)
1. 90+ w/ renal signs (if normal = no CKD!)
2. 60-89 w/ renal signs
3. (A) 45-59 (B) 30-44
4. 15-29
5. <15”

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25
Q

What are the best clinical readings to quantify CKD?

A

eGFR
ACR (albumin:creatinine ratio) - more sensitive than just PCR (protein:creatinine ratio)

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26
Q

What are the risk factors for CKD? And which are most common?

A

DM + Hypertension (these are most common)
Glomerulonephritis
PKD

Nephrotoxic drugs (NSAIDs)

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27
Q

What is the pathophysiology of CKD?

A

~1mil nephrons, in CKD many damaged, resulting in ↓ GFR ∴ increased burden on remaining nephrons
Compensatory RAAS to ↑GFR BUT ↑ transglomerular pressure = shearing + loss of BM selective permeability —> PROTEINURIA / HAEMATURIA
Angiotensin 2 unregulated TGF-β and plasminogen activator-inactivation 1 causing MESANGIAL (SUPPORTIVE TISSUE) SCARRING

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28
Q

What are the symptoms and signs of CKD?

A

Early on asymptomatic (lots of nephrons = reserve supply!)
Sx due to substance accumulation + renal damage (diabetic nephropathy)

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29
Q

What are the potential complication of CKD?

A
  • ANAEMIA (↓EPO)
  • OSTEODYSTROPHY (↓VIT D ACTIVATION_
  • NEUROPATHY + ENCEPHALOPATHY
  • CVD (most mortality complication!)
  • Haematuria / Proteinuria
  • Brown tumour (bone tumour 2˚ to CKD)
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30
Q

How should you investigate suspected CKD?

A

FBC (anaemia of chronic disease)
U+E
Urine dipstick (proteinuria)
USS (bilateral renal atrophy)
And, GFR function staging 1-5 + (albumin:creatine ratio >3 = SIGNIFICANT PROTEINURIA)

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31
Q

How do you treat CKD?

A

No cure so treat complications AND STOP NSAIDs!
- Anaemia = Fe + EPO (must give Fe first, before erythropoietin)
- Osteodystrophy = Vit D supps
- CVD = ACE-i + statins (↓ atherosclerosis)
- Oedema = diuretics
(ACE-i = exacerbation cause of AKI, HOWEVER used in Tx of CKD)

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32
Q

How do you treat a patient in ESRF (end stage renal failure)? And which stage of CKD is this?

A

RRT (dialysis) —> ultimately renal transplant (cure!)
Stage 5 based of GFR

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33
Q

What are the differences between AKI and CKD?

A

AKI: ↑ serum creatinine + ↓ urine output // CKD: ↓eGFR
AKI: shorter Sx onset // CKD: 3+ months of Sx
AKI: no anaemia // CKD: anaemia of CKD
AKI: USS = normal // CKD: USS = bilateral small atrophied kidneys

(*CAST)

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34
Q

How are UTIs divided?

A

Location:
UPPER (KIDNEY) —> PYELONEPHRITIS
LOWER (BLADDER ONWARD) —> CYSTITIS, PROSTATITIS, URETHRITIS, EPEIDYDYMO-ORCHITIS

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35
Q

What are the main causative organisms of UTIs? And which is most common?

A

KEEPS
- Klebsiella
- Enterobacter
- E. coli = most common (80% = UPEC, uropathogenic E. coli)
- Proteus
- Staph. saprophyticus

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36
Q

Who is most likely to present with a UTI?

A

FEMALES - shorter urethra ∴ closer to anus and easier for bacteria to colonised

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37
Q

How should you investigate a suspected UTI?

A

1st line = URINE DIPSTICK
- +ve leukocytes
- +ve nitrites (bacteria break down nitrates —> nitrites)
- +/- haematuria
Gold standard = midstream MC+S (microscopy, culture + sensitivity) - confirm UTI + ID pathogen

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38
Q

What is pyelonephritis?

A

Infection of renal parenchyma + upper ureter, ascending transurethral spread
Usually UPEC (uropathogenic E. coli)

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39
Q

What are the risk factors for pyelonephritis?

A

Urine stasis (stones)
Renal structural abnormalities
Catheters

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40
Q

Who is most likely to present with pyelonephritis?

A

Female <35

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41
Q

What are the symptoms and signs of pyelonephritis?

A

NICE Triad: LOIN PAIN + FEVER + N&V
Pyuria (pus in urine)
WBC in urine

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41
Q

How should you investigate suspected pyelonephritis?

A

1st line = URINE DIPSTICK
Gold standard = MC+S (microscopy, culture + sensitivity)
Ix for stones if suspected

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42
Q

How do you treat pyelonephritis?

A

Analgesia, paracetamol
Antibiotics - ciprofloxacin or co-amoxiclav (cefalexin if pregnant)

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43
Q

What is cystitis?

A

UPEC infection of bladder (uropathogenic E. coli)

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44
Q

Who is most likely to present with cystitis?

A

Females

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45
Q

What are the risk factors for cystitis?

A

Urine stasis, bladder lining damage, catheters

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46
Q

What are the symptoms and signs of cystitis?

A

Suprapubic tenderness + discomfort
↑ frequency + urgency
Visible haematuria
(Confusion in elderly?)

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47
Q

How should you investigate suspected cystitis?

A

1st line = urine dipstick
Gold standard = MC+S (microscopy, culture + sensitivity)

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48
Q

How do you treat cystitis?

A

Antibiotics - trimethoprim or nitrofurantoin (amoxicillin if pregnant)

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49
Q

What is urethritis? And how are you most likely to you get it?

A

Urethral inflammation +/- infection
Most commonly = SEXUALLY ACQUIRED CONDITION

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50
Q

What are the main causes of urethritis?

A

INFECTIVE
- non-gonococcal (Chlamydia trachomatis) - most common
- gonococcal (Neisseria gonorrhoea)
NON-INFECTIVE
- trauma

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51
Q

What type of bacterium is Chlamydia trachomatis?

A

Obligate intracellular (requires a host cell to replicate)
Gram -ve aerobe
Bacillus

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52
Q

What type of bacterium is Neisseria gonorrhoea?

A

Gram -ve diplococcus

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53
Q

What are the risk factors for urethritis?

A

MSM
Unprotected sex

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54
Q

What are the symptoms and signs of urethritis?

A

DYSURIA (pain weeing) +/- URETHRAL DISCHARGE (blood/pus), urethral pain

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55
Q

How should you investigate suspected urethritis?

A

STI testing alongside normal UTI Ix:
- NAAT nucleic acid amplification test —> detect STI (NG or CT)
- URINE DIPSTICK +ve if infectious UTI indicated
- MC+S will detect pathogen ID if UTI (microscopy, culture + sensitivity)”

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56
Q

How do you treat urethritis?

A

Neisseria gonorrhoea = IM ceftriaxone + azithromycin
Chlamydia trachomatis = azithromycin (or doxycycline)

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57
Q

What are the symptoms and signs of reactive arthritis?

A

TRIAD:
Can’t see (CONJUNCTIVITIS)
Can’t wee (URETHRITIS)
Can’t climb a tree (ARTHRITIS)

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58
Q

What is epididymo-orchitis?

A

Inflammation of epididymus, extending to testes

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59
Q

What are the main causes of epididymo-orchitis? And who is most likely to present with each?

A
  1. Urethritis (STI) - more in <35 yo MALE
  2. Cystitis (‘KEEPS’) extension - more in >35 yo MALE
    (Elderly MALE = due to catheter)
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60
Q

What are the symptoms and signs of epididymo-orchitis?

A

Unilateral scrotal pain + swelling
PAIN RELIEVED W/ ELEVATING TESTIS (+ve PREHN’S SIGN)
Cremaster reflex intact

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61
Q

How should you investigate suspected epididymo-orchitis?

A

NAAT (nucleic acid amplification test)
Urine dipstick
MC+S (microscopy, culture + sensitivity)

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62
Q

How do you treat epididymo-orchitis?

A

ANTIBIOTICS
Depend on STI (NG / CT) or UTI
- Neisseria gonorrhoea - IM ceftriaxone + azithromycin
- Chlamydia trachomatis = azithromycin (or doxycycline)

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63
Q

What are the symptoms and signs of prostatitis?

A

Perianal pain when orgasming

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64
Q

What is the aetiology of nephritic syndrome? What are they all examples of? And which is most common?

A
  • IgA nephropathy (Berger’s disease) - most common
  • Post strep glomerulonephritis
  • SLE
  • Goodpasture’s syndrome
  • Haemolytic uraemic syndrome
    All examples of TYPE 3 HYPERSENSITIVITY! (Except GOODPASTURE’S - T2)
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65
Q

Who is most likely to present with IgA nephropathy?

A

Asian populations
Associated w/ HIV

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66
Q

What are the symptoms and signs of IgA nephropathy?

A

Visible haematuria (Ribena / Coke)

67
Q

When are you most likely to present with IgA nephropathy?

A

1-2 DAYS after tonsillitis VIRAL INFECTION (or gastroenteritis viral infection)

68
Q

How should you investigate suspected IgA nephropathy?

A

Immunofluorescence microscopy shows IgA complex deposition (ONLY IN KIDNEY)

69
Q

How do you treat IgA nephropathy?

A

Non curative, 30% progress to ESRF
1st line = BP control (ACE-i)

69
Q

What are the symptoms and signs of post strep glomerulonephritis?

A

Visible haematuria (Ribena / Coke)

70
Q

When are you most likely to present with post strep glomerulonephritis?

A

2 WEEKS after pharyngitis from GROUP α, β HAEMOLYTIC STREP (S. pyogenes)

71
Q

How should you investigate suspected post strep glomerulonephritis?

A

Light microscope —> hyper cellular glomeruli
e- microscope —> sub endothelial immune complex deposition
Immunofluorescence shows STARRY SKY appearance —> IgG, IgM and C3 deposits along GBM and mesangium

72
Q

How do you treat post strep glomerulonephritis?

A

Usually self limiting
Can progress to RPGN (rapidly progressing glomerulonephritis)

72
Q

How does SLE cause nephritic syndrome?

A

Lupus nephritis 2˚ to SLE (ANA deposition in endothelium) (antinuclear antibody)

73
Q

What is an ANA?

A

Antinuclear antibody
Antibodies that target ‘normal’ nuclear proteins
Can indicate autoimmune disease

74
Q

How should you investigate suspected nephritic syndrome caused by SLE?

A

ANA +ve
Anti dsDNA +ve (anti-double stranded DNA antibodies - v specific SLE marker)

75
Q

How do you treat nephritic syndrome caused by SLE?

A

Steroids, hydroychloroquine + immunosuppressants (cyclophosphamide)

76
Q

What is a DMARD? And give an example?

A

Disease-modifying anti-rheumatic drug
Blocks the effects of chemicals released when your immune system attacks your body
- hydroxychloroquine
- methotrexate”

77
Q

What is Goodpasture’s syndrome?

A

Pulmonary + alveolar haemorrhage AND glomerulonephritis due to autoantibodies (anti-GBM) (anti-glomerular basement membrane)

78
Q

How do you treat Goodpasture’s syndrome?

A

Steroids + plasma exchange

79
Q

What causes haemolytic uraemic syndrome?

A

5 days post infection against SHIGA TOXIN (E. coli, Shigella)

80
Q

What are the symptoms and signs of haemolytic uraemic syndrome?

A

Triad:
Haemolytic anaemia
AKI (glomerulonephritis) ∴ uraemia
Thrombocytopenia

81
Q

How do you treat nephritic syndrome caused by haemolytic uraemic syndrome?

A

Mostly self limiting
But as medical emergency - SUPPORTIVE FLUIDS + antibiotics

82
Q

What is rapidly progressing glomerulonephritis (RPGN)?

A

Subtype of GN that progresses to ESFR v fast - weeks to months

83
Q

How should you investigate suspected rapidly progressing glomerulonephritis (RPGN)?

A

INFLAMMATORY CRESCENTS IN BOWMAN’S SPACE

84
Q

What are the causes of rapidly progressing glomerulonephritis (RPGN)?

A

Wegener’s granulomatosis (GPA)

MPA (pANCA +ve)
Goodpasture’s (c-ANCA +ve)

85
Q

What is the aetiology of nephrotic syndrome? And which is most common?

A

1˚
- MINIMAL CHANGE DISEASE (most common in children)
- FOCAL SEGMENTAL GLOMERULOSCLEROSIS (most common in adults)
- MEMBRANOUS NEPHROPATHY (caucasian adults)
2˚
- Most commonly to DIABETES (nephropathy)

86
Q

What are the symptoms and signs of nephrotic syndrome?

A

Proteinuria (FROTHY APPLE JUICE)
Hypoalbumineruia
Oedema (puffy face)
Hyperlipidemia
Weight gain

87
Q

How should you investigate suspected 1˚ nephrotic syndrome?

A

TAKE BIOPSY, then
MINIMAL CHANGE
- light microscopy = NO CHANGE
- e- microscopy = PODOCYTE EFFACEMENT + FUSION
FOCAL SEGMENTAL GLOMEULOSCLEROSIS
- light microscopy = segmental sclerosis, less than 50% glomeruli affected though!
MEMBRANOUS NEPHROPATHY
- light microscopy = thickened GBM
- e- microscopy = SUB-PODOCYTE IMMUNE COMPLEX DEPOSITION, SPIKE + DOME APPEARANCE for 12 weeks

88
Q

What is podocyte effacement?

A

Podocytes lose their structure + spread out
Leads to reduction in filtration barrier function
Due to breakdown in the actin cytoskeleton of the foot processes
Associated with proteinuria

89
Q

How do you treat nephrotic syndrome?

A

Steroids for 12 weeks, w/ variable response
- minimal change = responds v well
- FSG + MN = responds less well

90
Q

Who is most likely to present with minimal change disease?

A

Children (e.g. 7yo)

91
Q

Who is most likely to present with focal segmental glomerulosclerosis?

A

Adults

92
Q

What are the key differences between nephrotic and nephritic syndrome?

A

NephrOtic:
- prOteinuria (3.5+ g/24h, +/- haematuria)
- hypOalbuminemia
- oedema (due to 3RD SPACING)
- hyperlipidemia
- hypogammaglobulinemia (↓ Ig)
- hypercoagulable blood (due to loss of antithrombin 3)
- (pOdOcyte injury + scarring)
NephrItic:
- haematuria (+ little proteinuria) - blood IN
- oliguria (little urine, salt + water retention)
- HTN
- oedema (due to FLUID OVERLOAD)
- (GBM BREAKS + inflammation + bowman crescents)

93
Q

Which conditions can present as both nephrotic ad nephritic?

A

Diffuse proliferative glomerulonephritis
Membrano-proliferative glomerulonephritis

94
Q

What is benign prostate hyperplasia?

A

Non malignant prostate hyperplasia
Normal w/ ageing

95
Q

What are the risk factors for benign prostate hyperplasia? And which extreme measure is protective?

A

↑ age (+ Afro-Caribbean ethnicity = ↑ testosterone)
Castration is PROTECTIVE

96
Q

What is the pathophysiology of benign prostate hyperplasia?

A

INNER TRANSITIONAL ZONE of prostate (muscular, gland) proliferate + narrows urethra

97
Q

What are the symptoms and signs of benign prostate hyperplasia?

A

LUTs! (More so VOIDING Sx)
- STORAGE —> frequency, urgency, nocturia (>30%), incontinence
- VOIDING —> poor stream, dribbling, incomplete emptying, straining, dysuria
Anuria if totally occluded urethra —> RETENTION, hydronephrosis, UTI, stones

98
Q

How should you investigate suspected benign prostatic hyperplasia?

A

DRE (digital rectal exam) - SMOOTH ENLARGED
PSA (rule out prostate cancer, v unreliable as can be raised in both but more so in cancer)

99
Q

How do you treat benign prostate hyperplasia?

A

Lifestyle:
- ↓ caffeine
May need catheter acutely
Drugs:
- 1st line = α-BLOCKER (TAMSULOSIN) - RELAXES BLADDER NECK
- 2nd line = 5α-REDUCTASE INHIBITORS (FINASTERIDE) - ↓ testosterone conversion to dihydrotestosterone ∴ ↓ prostate size
Surgery:
- last resort (TURP - transurethral resection of prostate)

100
Q

What is the most common complication of TURP surgery (transurethral resection of prostate)?

A

Retrograde ejaculation

101
Q

What is renal cell carcinoma?

A

PCT epithelium carcinoma (proximal convoluted tubule)

102
Q

What are the risk factors for renal cell carcinoma?

A

SMOKING
Haemodyalysis (15% chance)
Hereditary
VON HIPPEL-LINDAU SYNDROME

103
Q

What are the symptoms and signs of renal cell carcinoma?

A

Triad:
1. FLANK PAIN
2. HAEMATURIA
3. ABDO MASS
May have left sided varicocele
Often asymptomatic
(25% cases metastasised at presentation)
Also:
- Hypertension (tumour releases RENIN)
- Anaemia (↓EPO)

104
Q

How should you investigate suspected renal cell carcinoma?

A

1st line = USS
Gold standard = CT chest / abdo / pelvis (MORE SNESITIVE)

105
Q

How do you treat renal cell carcinoma?

A

Nephrectomy (full / partial if bilateral)
IF METASTASISED = IFN-α or biologics (eg. Sunitinib)

105
Q

How do you stage renal cell carcinoma?

A

ROBSON STAGING
1-4

106
Q

Who is most likely to present with renal cell carcinoma?

A

> 40 yo

107
Q

What is the most common type of renal cancer?

A

Renal cell carcinoma

108
Q

What is Von Hippel-Lindau syndrome? And what are the symptoms and signs?

A

Autosomal dominant
Loss of tumour suppressor gene
BILATERAL RCC (50%)
- renal + pancreas cysts
- cerebellum cancers

109
Q

What is a Wilms’ tumour?

A

Renal mesenchymal stem cell tumour
SEEN IN CHILDREN <3 yo
Rare
AKA nephroblastoma

110
Q

What is bladder cancer?

A

Transitional cell carcinoma (TCC) of bladder

111
Q

What are the risk factors for bladder cancer?

A

Occupational exposure to dyes / paints / rubber
- Painter
- Hairdressers
- Mechanic working w/ tyres
Smoking
Chemo + radiotherapy
Age (mean age @presentation = 73)
Male

112
Q

What are the symptoms and signs of bladder cancer?

A

PAINLESS HAEMATURIA (macro/microscopic)

113
Q

How should you investigate suspected bladder cancer?

A

Gold standard = FLEXIBLE CYSTOSCOPY
Biopsy

114
Q

How do you treat bladder cancer?

A

Conservative = support eg. specialist nurse
Medical = chemo / radio
Surgery = TURBT (transurethral resection of bladder tumour) or cystectomy (last resort)

115
Q

What is the most common subtype of transitional cell carcinoma?

A

Bladder cancer - transitional (urothelium) lines renal pelvis —> bladder

116
Q

If a patient has schistosomiasis what type of carcinoma is more likely than TCC?

A

SQUAMOUS CELL CARCINOMA

117
Q

What is prostate cancer?

A

Adenocarcinoma (malignant tumour formed from glandular structures in epithelial tissue)
Outer zone of peripheral prostate neoplastic, malignant proliferation

118
Q

What is the most common type of male malignancy?

A

Prostate cancer

119
Q

What are the risk factors for prostate cancer?

A

Genetic - BRC12, HOXB13
↑ age
fHx
Afro-caribbean ethnicity

120
Q

What are the symptoms and signs of prostate cancer?

A

LUTs (like BPH) but w/ systemic cancer Sx (weight loss, fatigue, night pain)
Bone pain (lumbar back)- typically metastasises to BONE (thick SCLEROTIC LESIONS), liver, lung, brain

121
Q

How should you investigate suspected prostate cancer?

A

DRE (digital rectal exam - hard irregular) + PSA in community
Gold standard (DIAGNOSTIC) = Transrectal USS (+ biopsy)

122
Q

How do you grade prostate cancer?

A

GLEASON SCORE
Higher = worse prognosis (based on BIOPSY)

123
Q

How do you treat prostate cancer?

A

Local
- PROSTATECTOMY
Metastatic
- Hormone therapy (↓ testosterone = ↓ cancer growth)
- BEST = Bilateral orchidectomy
- GnRH receptor agonist eg. Goserelin (WEIRD - agonises GnRH ∴ ↑LH + FSH BUT results in exogenous suppression of the HPG axis!)
- Radio / chemo

124
Q

What type of cancer is most sensitive to hormone therapy?

A

Prostate cancer

125
Q

What are the side effects of hormone therapy?

A

Erectile dysfunction
Libido loss

126
Q

What are the main types of testicular cancer? And which is most common?

A

GERM CELL (90+ %)
- seminoma teratoma
NON GERM CELL (<10%)
- sertoli leydig sarcoma

127
Q

What is the most common cancer in young men (20-45 yo)?

A

Testicular cancer

128
Q

What are the risk factors for testicular cancer?

A

Cryptorchidism (undescended testes)
Infertility
fHx

129
Q

What are the symptoms and signs of testicular cancer?

A

PAINLESS LUMP IN TESTICLE which does NOT transilluminate (often self-found)
May show lung metastasis signs eg. cough (CONSIDER CXR!)

130
Q

How should you investigate suspected testicular cancer?

A

Urgent (Doppler) USS testes (90% diagnostic!)
Tumour markers AFT (raised in TERATOMA), βhCG (raised in seminomas) (+ LDH —> raised non specifically in tumours)

131
Q

How do you treat testicular cancer?

A

ALWAYS 1st line = Urgent radical orchidectomy (+ offer sperm storage)
Adjuvant chemo or radio

132
Q

What is an obstructive uropathy?

A

Blockage of urine flow, can affect one (OBSTRUCTIVE NEPHROPATHY) or both kidneys depend on level of obstruction

133
Q

What most commonly causes obstructive uropathy?

A

BPH and stones - OBSTRUCTIONS!

134
Q

What is the pathophysiology of obstructive uropathy?

A

Obstruction —> retention + ↑ KUB pressure —> refluxing / backlogged urine in renal pelvis (HYDRONEPHROSIS - dilated renal pelvis, which is more infection prone)

135
Q

What are the symptoms and signs of obstructive uropathy?

A

Obstruction!
May be asymptomatic if only 1 kidney affected!

136
Q

How do you treat obstructive uropathy?

A
  1. Relieve kidney pressure —> catheterise urethra, ureteral stent
  2. Treat BPH or stones (+ infection!)
137
Q

What is polycystic kidney disease?

A

Cyst formation throughout renal parenchyma
Bilateral enlargement + damage

137
Q

What is the aetiology of polycystic kidney disease? What are the 2 main types? And which is most common?

A

FAMILIAL INHERITED
1. AUTO DOM (most common) - mutated PKD1 (85%) or PKD2 (15%)
2. AUTO REC - a disease of infancy or prebirth w/ ↑ mortality

138
Q

Who is most likely to present with autosomal dominant polycystic kidney disease?

A

Males
20-30 yo

139
Q

What is are the complications of autosomal recessive polycystic kidney disease? And give an example?

A

Many congenital abnormalities
Potter’s sequence
- flattened nose
- clubbed feet”

140
Q

What is the pathophysiology of polycystic kidney disease?

A

PKD 1 + 2 code for polycystin (Ca2+ channel)
In cilia of nephron, when filtrate passes, cilia move + polycystin on cilia OPEN, Ca2+ influx INHIBITS EXCESSIVE GROWTH
PKD mutation = Ca2+ ↓ influx ∴ cilia excessive growth
- CYSTS, many = POLYCYSTS”

141
Q

What are the symptoms and signs of polycystic kidney disease?

A

BILATERAL FLANK / BACK OR ABDO PAIN (+/- hypertension and haematuria
EXTRA-RENAL CYSTS - particularly in circle of Willis (Berry aneurysm if ruptured —> SUBARACHNOID HAEMORRHAGE)

142
Q

How should you investigate suspected polycystic kidney disease?

A

Kidney USS - enlarged bilateral kidneys w/ multiple cysts
Also, genetic testing + fHx of PKD

143
Q

How do you treat polycystic kidney disease?

A

Non curative
Manage Sx
hypertension —> ACE-i
ESRF (end-stage renal failure)—> RRT, transplant

144
Q

If you find a scrotal mass, what should you assume until proven otherwise?

A

Cancer

145
Q

What is an epididymal cyst?

A

Extratesticular cyst (above + behind testis) that WILL TRANSILLUMINATE

145
Q

How should you investigate a suspected epididymal cyst?

A

USS scrotum

146
Q

What is a hydrocele?

A

Fluid collection in tunica vaginalis
Cyst that testicle sits within that WILL TRANSILLUMINATE

147
Q

How should you investigate a suspected hydrocele?

A

USS scrotum

148
Q

What is a varicocele?

A

Distended pampiniform plexus due to ↑ left renal vein pressure causing reflux

149
Q

What are the symptoms and signs of a varicocele?

A

BAG OF WORMS (on LHS mostly)
Typically painless, rarely painful (when larger ∴ more severe)

150
Q

How should you investigate a suspected varicocele?

A

Clinical

151
Q

What is the main complication of a varicocele?

A

Infertility

152
Q

What is testicular torsion?

A

Spermatic cord twists on itself
Occlusion of testicular artery
Causes ischaemia —> gangrene of testis if not dealt w/
SURGICAL EMERGENCY

153
Q

What are the risk factors for testicular torsion?

A

Bell clapper deformity (“horizontal lie” of testes)

154
Q

What are the symptoms and signs of testicular torsion?

A

SEVERE uni-testicular pain (HURTS TO WALK)
Abdo pain
N+V
Cremasteric reflex lost
NO PAIN RELIEF W/ ELEVATING TESTIS (-ve PREHN SIGN)

155
Q

What is the cremasteric reflex?

A

Stroke inner thigh
Ipsilateral testicle should elevate (retract upwards)

156
Q

How should you investigate suspected testicular torsion?

A

1st = SURGICAL EXPLORATION IF THERE IS ↑ RISK!
(USS to check testicular blood flow)

157
Q

How do you treat testicular torsion?

A

1st = URGENT SURGERY WITHIN 6H (90-100% SUCCESSFUL)
All cases require bilateral orchiplexy (fixing of testes to scrotal sac to overcome bell clapper deformity
- if testes viable = orchiplexy
- if non-viable = orchidectomy”

158
Q

Who is most likely to present with incontinence?

A

Females
(Stress - post pregnancy trauma)

159
Q

What are the 3 main types of incontinence?

A

STRESS (sphincter weakness) - wee leaks w/ intraabdo pressure rise
URGE (detrusor muscle overactivity)
Spastic paralysis (neurological UMN lesion) - overactive reflexes + hypertonia of detrusor

160
Q

How do you treat incontinence?

A

Surgery
Anticholinergic drugs

161
Q

Who is most likely to present with retention?

A

Males

162
Q

What is retention? And what is another name for it?

A

Inability to pass urine even when bladder full (500+ ml)
“Overflow incontinence”

163
Q

What causes retention?

A

Obstruction
- stones
- BPH
- neurological flaccid paralysis (hypotonia of detrusor, as LMN)

164
Q

How do you treat retention?

A

Catheterise

165
Q

What are the main storage LUT symptoms? And when do they occur?

A

Occur when bladder should be storing urine ∴ NEED TO WEE
FUNI:
- FREQUENCY
- URGENCY
- NOCTURIA
- INCONTINENCE”

166
Q

What are the main voiding LUT symptoms? And when do they occur?

A

Occur when bladder outlet’s obstructed ∴ HARD TO WEE
SHID:
- STREAM IS POOR
- HESITANCY
- INCOMPLETE EMPTYING
- DRIBBLING

167
Q

What are the red flag LUT symptoms?

A

Haematuria
Dysuria

2a (4 decks)

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