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!
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!
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
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)
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
5
Q
Who is most likely to present with nephroliathiasis?
A
Males (slightly more)
20-40 yo
(Uncommon in children)
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!
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
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”
8
Q
What are the 3 commonest obstruction sites of nephroliathiasis?
A
- PUJ (pelvi-ureteric junction)
- Pelvic brim - ureters cross over iliac vessels
- VUJ (vesico-ureteric junction - where ureter enters bladder)
9
Q
What is an acute kidney injury (AKI)?
A
Abrupt decline in kidney function (hrs-days)
Characterised by:
↑ serum creatinine + urea
↓ urine output
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)
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)
11
Q
What are the 3 broad categories of AKI?
A
PRE-RENAL = hypoperfusion
RENAL = nephron + parenchyma damage
POST-RENAL = obstructive uropathy
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)
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)
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
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)”
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”
15
Q
What are the top 3 causes of AKI?
A
- Sepsis
- Cariogenic shock
- Major surgery
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
17
Q
How does hyperkalaemia present on an ECG?
A
Tall tented T waves
P wave flattening
Wide QRS
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…)
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
20
What is CKD?
eGFR <60ml /min /1.73m2 for 3+ months
21
What is eGFR? And what is the ‘normal’ value?
Estimated glomerular filtration rate
120ml /min /1.73m2
22
What 4 parameters are used to classify CKD?
CAGE
1. Creatinine
2. Age
3. Gender
4. Ethnicity
23
Which drug is contraindicated when eGFR is low? Who is this likely to affect?
Metformin contraindicated, eGFR <30
This is a T2DM drug
24
How are the stages of CKD defined?
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"
25
What are the best clinical readings to quantify CKD?
eGFR
ACR (albumin:creatinine ratio) - more sensitive than just PCR (protein:creatinine ratio)
26
What are the risk factors for CKD? And which are most common?
DM + Hypertension (these are most common)
Glomerulonephritis
PKD
Nephrotoxic drugs (NSAIDs)
27
What is the pathophysiology of CKD?
~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
28
What are the symptoms and signs of CKD?
Early on asymptomatic (lots of nephrons = reserve supply!)
Sx due to substance accumulation + renal damage (diabetic nephropathy)
29
What are the potential complication of CKD?
- ANAEMIA (↓EPO)
- OSTEODYSTROPHY (↓VIT D ACTIVATION_
- NEUROPATHY + ENCEPHALOPATHY
- CVD (most mortality complication!)
- Haematuria / Proteinuria
- Brown tumour (bone tumour 2˚ to CKD)
30
How should you investigate suspected CKD?
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)
31
How do you treat CKD?
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)
32
How do you treat a patient in ESRF (end stage renal failure)? And which stage of CKD is this?
RRT (dialysis) —> ultimately renal transplant (cure!)
Stage 5 based of GFR
33
What are the differences between AKI and CKD?
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)
34
How are UTIs divided?
Location:
UPPER (KIDNEY) —> PYELONEPHRITIS
LOWER (BLADDER ONWARD) —> CYSTITIS, PROSTATITIS, URETHRITIS, EPEIDYDYMO-ORCHITIS
35
What are the main causative organisms of UTIs? And which is most common?
KEEPS
- Klebsiella
- Enterobacter
- E. coli = most common (80% = UPEC, uropathogenic E. coli)
- Proteus
- Staph. saprophyticus
36
Who is most likely to present with a UTI?
FEMALES - shorter urethra ∴ closer to anus and easier for bacteria to colonised
37
How should you investigate a suspected UTI?
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
38
What is pyelonephritis?
Infection of renal parenchyma + upper ureter, ascending transurethral spread
Usually UPEC (uropathogenic E. coli)
39
What are the risk factors for pyelonephritis?
Urine stasis (stones)
Renal structural abnormalities
Catheters
40
Who is most likely to present with pyelonephritis?
Female <35
41
What are the symptoms and signs of pyelonephritis?
NICE Triad: LOIN PAIN + FEVER + N&V
Pyuria (pus in urine)
WBC in urine
41
How should you investigate suspected pyelonephritis?
1st line = URINE DIPSTICK
Gold standard = MC+S (microscopy, culture + sensitivity)
Ix for stones if suspected
42
How do you treat pyelonephritis?
Analgesia, paracetamol
Antibiotics - ciprofloxacin or co-amoxiclav (cefalexin if pregnant)
43
What is cystitis?
UPEC infection of bladder (uropathogenic E. coli)
44
Who is most likely to present with cystitis?
Females
45
What are the risk factors for cystitis?
Urine stasis, bladder lining damage, catheters
46
What are the symptoms and signs of cystitis?
Suprapubic tenderness + discomfort
↑ frequency + urgency
Visible haematuria
(Confusion in elderly?)
47
How should you investigate suspected cystitis?
1st line = urine dipstick
Gold standard = MC+S (microscopy, culture + sensitivity)
48
How do you treat cystitis?
Antibiotics - trimethoprim or nitrofurantoin (amoxicillin if pregnant)
49
What is urethritis? And how are you most likely to you get it?
Urethral inflammation +/- infection
Most commonly = SEXUALLY ACQUIRED CONDITION
50
What are the main causes of urethritis?
INFECTIVE
- non-gonococcal (Chlamydia trachomatis) - most common
- gonococcal (Neisseria gonorrhoea)
NON-INFECTIVE
- trauma
51
What type of bacterium is Chlamydia trachomatis?
Obligate intracellular (requires a host cell to replicate)
Gram -ve aerobe
Bacillus
52
What type of bacterium is Neisseria gonorrhoea?
Gram -ve diplococcus
53
What are the risk factors for urethritis?
MSM
Unprotected sex
54
What are the symptoms and signs of urethritis?
DYSURIA (pain weeing) +/- URETHRAL DISCHARGE (blood/pus), urethral pain
55
How should you investigate suspected urethritis?
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)"
56
How do you treat urethritis?
Neisseria gonorrhoea = IM ceftriaxone + azithromycin
Chlamydia trachomatis = azithromycin (or doxycycline)
57
What are the symptoms and signs of reactive arthritis?
TRIAD:
Can’t see (CONJUNCTIVITIS)
Can’t wee (URETHRITIS)
Can’t climb a tree (ARTHRITIS)
58
What is epididymo-orchitis?
Inflammation of epididymus, extending to testes
59
What are the main causes of epididymo-orchitis? And who is most likely to present with each?
1. Urethritis (STI) - more in <35 yo MALE
2. Cystitis (‘KEEPS’) extension - more in >35 yo MALE
(Elderly MALE = due to catheter)
60
What are the symptoms and signs of epididymo-orchitis?
Unilateral scrotal pain + swelling
PAIN RELIEVED W/ ELEVATING TESTIS (+ve PREHN’S SIGN)
Cremaster reflex intact
61
How should you investigate suspected epididymo-orchitis?
NAAT (nucleic acid amplification test)
Urine dipstick
MC+S (microscopy, culture + sensitivity)
62
How do you treat epididymo-orchitis?
ANTIBIOTICS
Depend on STI (NG / CT) or UTI
- Neisseria gonorrhoea - IM ceftriaxone + azithromycin
- Chlamydia trachomatis = azithromycin (or doxycycline)
63
What are the symptoms and signs of prostatitis?
Perianal pain when orgasming
64
What is the aetiology of nephritic syndrome? What are they all examples of? And which is most common?
- 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)
65
Who is most likely to present with IgA nephropathy?
Asian populations
Associated w/ HIV
66
What are the symptoms and signs of IgA nephropathy?
Visible haematuria (Ribena / Coke)
67
When are you most likely to present with IgA nephropathy?
1-2 DAYS after tonsillitis VIRAL INFECTION (or gastroenteritis viral infection)
68
How should you investigate suspected IgA nephropathy?
Immunofluorescence microscopy shows IgA complex deposition (ONLY IN KIDNEY)
69
How do you treat IgA nephropathy?
Non curative, 30% progress to ESRF
1st line = BP control (ACE-i)
69
What are the symptoms and signs of post strep glomerulonephritis?
Visible haematuria (Ribena / Coke)
70
When are you most likely to present with post strep glomerulonephritis?
2 WEEKS after pharyngitis from GROUP α, β HAEMOLYTIC STREP (S. pyogenes)
71
How should you investigate suspected post strep glomerulonephritis?
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
How do you treat post strep glomerulonephritis?
Usually self limiting
Can progress to RPGN (rapidly progressing glomerulonephritis)
72
How does SLE cause nephritic syndrome?
Lupus nephritis 2˚ to SLE (ANA deposition in endothelium) (antinuclear antibody)
73
What is an ANA?
Antinuclear antibody
Antibodies that target ‘normal’ nuclear proteins
Can indicate autoimmune disease
74
How should you investigate suspected nephritic syndrome caused by SLE?
ANA +ve
Anti dsDNA +ve (anti-double stranded DNA antibodies - v specific SLE marker)
75
How do you treat nephritic syndrome caused by SLE?
Steroids, hydroychloroquine + immunosuppressants (cyclophosphamide)
76
What is a DMARD? And give an example?
Disease-modifying anti-rheumatic drug
Blocks the effects of chemicals released when your immune system attacks your body
- hydroxychloroquine
- methotrexate"
77
What is Goodpasture’s syndrome?
Pulmonary + alveolar haemorrhage AND glomerulonephritis due to autoantibodies (anti-GBM) (anti-glomerular basement membrane)
78
How do you treat Goodpasture’s syndrome?
Steroids + plasma exchange
79
What causes haemolytic uraemic syndrome?
5 days post infection against SHIGA TOXIN (E. coli, Shigella)
80
What are the symptoms and signs of haemolytic uraemic syndrome?
Triad:
Haemolytic anaemia
AKI (glomerulonephritis) ∴ uraemia
Thrombocytopenia
81
How do you treat nephritic syndrome caused by haemolytic uraemic syndrome?
Mostly self limiting
But as medical emergency - SUPPORTIVE FLUIDS + antibiotics
82
What is rapidly progressing glomerulonephritis (RPGN)?
Subtype of GN that progresses to ESFR v fast - weeks to months
83
How should you investigate suspected rapidly progressing glomerulonephritis (RPGN)?
INFLAMMATORY CRESCENTS IN BOWMAN’S SPACE
84
What are the causes of rapidly progressing glomerulonephritis (RPGN)?
Wegener’s granulomatosis (GPA)
MPA (pANCA +ve)
Goodpasture’s (c-ANCA +ve)
85
What is the aetiology of nephrotic syndrome? And which is most common?
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
What are the symptoms and signs of nephrotic syndrome?
Proteinuria (FROTHY APPLE JUICE)
Hypoalbumineruia
Oedema (puffy face)
Hyperlipidemia
Weight gain
87
How should you investigate suspected 1˚ nephrotic syndrome?
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
What is podocyte effacement?
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
How do you treat nephrotic syndrome?
Steroids for 12 weeks, w/ variable response
- minimal change = responds v well
- FSG + MN = responds less well
90
Who is most likely to present with minimal change disease?
Children (e.g. 7yo)
91
Who is most likely to present with focal segmental glomerulosclerosis?
Adults
92
What are the key differences between nephrotic and nephritic syndrome?
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
Which conditions can present as both nephrotic ad nephritic?
Diffuse proliferative glomerulonephritis
Membrano-proliferative glomerulonephritis
94
What is benign prostate hyperplasia?
Non malignant prostate hyperplasia
Normal w/ ageing
95
What are the risk factors for benign prostate hyperplasia? And which extreme measure is protective?
↑ age (+ Afro-Caribbean ethnicity = ↑ testosterone)
Castration is PROTECTIVE
96
What is the pathophysiology of benign prostate hyperplasia?
INNER TRANSITIONAL ZONE of prostate (muscular, gland) proliferate + narrows urethra
97
What are the symptoms and signs of benign prostate hyperplasia?
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
How should you investigate suspected benign prostatic hyperplasia?
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
How do you treat benign prostate hyperplasia?
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
What is the most common complication of TURP surgery (transurethral resection of prostate)?
Retrograde ejaculation
101
What is renal cell carcinoma?
PCT epithelium carcinoma (proximal convoluted tubule)
102
What are the risk factors for renal cell carcinoma?
SMOKING
Haemodyalysis (15% chance)
Hereditary
VON HIPPEL-LINDAU SYNDROME
103
What are the symptoms and signs of renal cell carcinoma?
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
How should you investigate suspected renal cell carcinoma?
1st line = USS
Gold standard = CT chest / abdo / pelvis (MORE SNESITIVE)
105
How do you treat renal cell carcinoma?
Nephrectomy (full / partial if bilateral)
IF METASTASISED = IFN-α or biologics (eg. Sunitinib)
105
How do you stage renal cell carcinoma?
ROBSON STAGING
1-4
106
Who is most likely to present with renal cell carcinoma?
>40 yo
107
What is the most common type of renal cancer?
Renal cell carcinoma
108
What is Von Hippel-Lindau syndrome? And what are the symptoms and signs?
Autosomal dominant
Loss of tumour suppressor gene
BILATERAL RCC (50%)
- renal + pancreas cysts
- cerebellum cancers
109
What is a Wilms’ tumour?
Renal mesenchymal stem cell tumour
SEEN IN CHILDREN <3 yo
Rare
AKA nephroblastoma
110
What is bladder cancer?
Transitional cell carcinoma (TCC) of bladder
111
What are the risk factors for bladder cancer?
Occupational exposure to dyes / paints / rubber
- Painter
- Hairdressers
- Mechanic working w/ tyres
Smoking
Chemo + radiotherapy
Age (mean age @presentation = 73)
Male
112
What are the symptoms and signs of bladder cancer?
PAINLESS HAEMATURIA (macro/microscopic)
113
How should you investigate suspected bladder cancer?
Gold standard = FLEXIBLE CYSTOSCOPY
Biopsy
114
How do you treat bladder cancer?
Conservative = support eg. specialist nurse
Medical = chemo / radio
Surgery = TURBT (transurethral resection of bladder tumour) or cystectomy (last resort)
115
What is the most common subtype of transitional cell carcinoma?
Bladder cancer - transitional (urothelium) lines renal pelvis —> bladder
116
If a patient has schistosomiasis what type of carcinoma is more likely than TCC?
SQUAMOUS CELL CARCINOMA
117
What is prostate cancer?
Adenocarcinoma (malignant tumour formed from glandular structures in epithelial tissue)
Outer zone of peripheral prostate neoplastic, malignant proliferation
118
What is the most common type of male malignancy?
Prostate cancer
119
What are the risk factors for prostate cancer?
Genetic - BRC12, HOXB13
↑ age
fHx
Afro-caribbean ethnicity
120
What are the symptoms and signs of prostate cancer?
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
How should you investigate suspected prostate cancer?
DRE (digital rectal exam - hard irregular) + PSA in community
Gold standard (DIAGNOSTIC) = Transrectal USS (+ biopsy)
122
How do you grade prostate cancer?
GLEASON SCORE
Higher = worse prognosis (based on BIOPSY)
123
How do you treat prostate cancer?
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
What type of cancer is most sensitive to hormone therapy?
Prostate cancer
125
What are the side effects of hormone therapy?
Erectile dysfunction
Libido loss
126
What are the main types of testicular cancer? And which is most common?
GERM CELL (90+ %)
- seminoma teratoma
NON GERM CELL (<10%)
- sertoli leydig sarcoma
127
What is the most common cancer in young men (20-45 yo)?
Testicular cancer
128
What are the risk factors for testicular cancer?
Cryptorchidism (undescended testes)
Infertility
fHx
129
What are the symptoms and signs of testicular cancer?
PAINLESS LUMP IN TESTICLE which does NOT transilluminate (often self-found)
May show lung metastasis signs eg. cough (CONSIDER CXR!)
130
How should you investigate suspected testicular cancer?
Urgent (Doppler) USS testes (90% diagnostic!)
Tumour markers AFT (raised in TERATOMA), βhCG (raised in seminomas) (+ LDH —> raised non specifically in tumours)
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How do you treat testicular cancer?
ALWAYS 1st line = Urgent radical orchidectomy (+ offer sperm storage)
Adjuvant chemo or radio
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What is an obstructive uropathy?
Blockage of urine flow, can affect one (OBSTRUCTIVE NEPHROPATHY) or both kidneys depend on level of obstruction
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What most commonly causes obstructive uropathy?
BPH and stones - OBSTRUCTIONS!
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What is the pathophysiology of obstructive uropathy?
Obstruction —> retention + ↑ KUB pressure —> refluxing / backlogged urine in renal pelvis (HYDRONEPHROSIS - dilated renal pelvis, which is more infection prone)
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What are the symptoms and signs of obstructive uropathy?
Obstruction!
May be asymptomatic if only 1 kidney affected!
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How do you treat obstructive uropathy?
1. Relieve kidney pressure —> catheterise urethra, ureteral stent
2. Treat BPH or stones (+ infection!)
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What is polycystic kidney disease?
Cyst formation throughout renal parenchyma
Bilateral enlargement + damage
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What is the aetiology of polycystic kidney disease? What are the 2 main types? And which is most common?
FAMILIAL INHERITED
1. AUTO DOM (most common) - mutated PKD1 (85%) or PKD2 (15%)
2. AUTO REC - a disease of infancy or prebirth w/ ↑ mortality
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Who is most likely to present with autosomal dominant polycystic kidney disease?
Males
20-30 yo
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What is are the complications of autosomal recessive polycystic kidney disease? And give an example?
Many congenital abnormalities
Potter’s sequence
- flattened nose
- clubbed feet"
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What is the pathophysiology of polycystic kidney disease?
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"
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What are the symptoms and signs of polycystic kidney disease?
BILATERAL FLANK / BACK OR ABDO PAIN (+/- hypertension and haematuria
EXTRA-RENAL CYSTS - particularly in circle of Willis (Berry aneurysm if ruptured —> SUBARACHNOID HAEMORRHAGE)
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How should you investigate suspected polycystic kidney disease?
Kidney USS - enlarged bilateral kidneys w/ multiple cysts
Also, genetic testing + fHx of PKD
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How do you treat polycystic kidney disease?
Non curative
Manage Sx
hypertension —> ACE-i
ESRF (end-stage renal failure)—> RRT, transplant
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If you find a scrotal mass, what should you assume until proven otherwise?
Cancer
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What is an epididymal cyst?
Extratesticular cyst (above + behind testis) that WILL TRANSILLUMINATE
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How should you investigate a suspected epididymal cyst?
USS scrotum
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What is a hydrocele?
Fluid collection in tunica vaginalis
Cyst that testicle sits within that WILL TRANSILLUMINATE
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How should you investigate a suspected hydrocele?
USS scrotum
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What is a varicocele?
Distended pampiniform plexus due to ↑ left renal vein pressure causing reflux
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What are the symptoms and signs of a varicocele?
BAG OF WORMS (on LHS mostly)
Typically painless, rarely painful (when larger ∴ more severe)
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How should you investigate a suspected varicocele?
Clinical
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What is the main complication of a varicocele?
Infertility
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What is testicular torsion?
Spermatic cord twists on itself
Occlusion of testicular artery
Causes ischaemia —> gangrene of testis if not dealt w/
SURGICAL EMERGENCY
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What are the risk factors for testicular torsion?
Bell clapper deformity ("horizontal lie" of testes)
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What are the symptoms and signs of testicular torsion?
SEVERE uni-testicular pain (HURTS TO WALK)
Abdo pain
N+V
Cremasteric reflex lost
NO PAIN RELIEF W/ ELEVATING TESTIS (-ve PREHN SIGN)
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What is the cremasteric reflex?
Stroke inner thigh
Ipsilateral testicle should elevate (retract upwards)
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How should you investigate suspected testicular torsion?
1st = SURGICAL EXPLORATION IF THERE IS ↑ RISK!
(USS to check testicular blood flow)
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How do you treat testicular torsion?
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"
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Who is most likely to present with incontinence?
Females
(Stress - post pregnancy trauma)
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What are the 3 main types of incontinence?
STRESS (sphincter weakness) - wee leaks w/ intraabdo pressure rise
URGE (detrusor muscle overactivity)
Spastic paralysis (neurological UMN lesion) - overactive reflexes + hypertonia of detrusor
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How do you treat incontinence?
Surgery
Anticholinergic drugs
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Who is most likely to present with retention?
Males
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What is retention? And what is another name for it?
Inability to pass urine even when bladder full (500+ ml)
“Overflow incontinence”
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What causes retention?
Obstruction
- stones
- BPH
- neurological flaccid paralysis (hypotonia of detrusor, as LMN)
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How do you treat retention?
Catheterise
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What are the main storage LUT symptoms? And when do they occur?
Occur when bladder should be storing urine ∴ NEED TO WEE
FUNI:
- FREQUENCY
- URGENCY
- NOCTURIA
- INCONTINENCE"
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What are the main voiding LUT symptoms? And when do they occur?
Occur when bladder outlet’s obstructed ∴ HARD TO WEE
SHID:
- STREAM IS POOR
- HESITANCY
- INCOMPLETE EMPTYING
- DRIBBLING
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What are the red flag LUT symptoms?
Haematuria
Dysuria
