Renal and GU investigations and treatments

Question 1

AKI

Answer 1

INVESTIGATIONS
1st - Urinalysis
Establish cause via urea:creatinine ratio (pre-renal, renal, post-renal) + diagnose with KDIGO classification (stage 1,2,3):
Reduced urine output - <0.5ml/kg/hr for at least 6 consecutive hours)
Serum creatinine - an increase >26 micromol/L within 48 hours or an increase >1.5 times baseline in 7 days

Urea:creatinine
>100:1 - Pre-renal (due to increased absorption of BUN due to reduced perfusion)
40:1 Post renal
<40:1 - Intra renal

U and E → K+, H+, urea, creatinine
FBC and CRP - check for infection

Ultrasound - to assess for obstruction (post-renal cause)
Biopsy - to confirm intra-renal cause

TREATMENT
Treat complications and underlying cause.
COMPLICATIONS
Hyperkalemia - Calcium gluconate
Fluid overload - diuretics
Hypovolemic patients - IV fluids

UNDERLYING CAUSE
Stop nephrotoxic medication e.g. gentamicin, NSAIDS

Last resort: Renal replacement therapy (haemodialysis) (depending on haemodynamic stability, severity of electrolyte imbalance)

In post-renal AKI - relieve obstruction (catheter)

Question 2

Nephrolithiasis

Answer 2

INVESTIGATIONS
First line - Urinalysis - haematuria,
Urine dipstick
Ultrasound KUB (but this is GS for children and pregnant women)

GS
(Suspected kidney stones) → within 24 hours perform Non-contrast CT scan (KUB) of the kidney, ureters and bladder - NCCT KUB
CONTRAINDICATED in children and pregnant women

X-ray may show calcium based stones but does not show uric acid stones.

TREATMENT
For stones <5mm
1st line - Watch and wait as they may be passed spontaneously

Symptomatic
Hydrate + give nsaid (DICLOFENAC) IM

If UTI confirmed –> Antibiotics e.g. Gentamycin

For larger stones
Surgical intervention
Extracorporeal shock wave lithotripsy (ESWL) - where shock waves are directed at the stones to break them into smaller pieces
Percutaneous nephrolithotomy (PCNL) - keyhole removal of stones - through the patient’s back.
Ureteroscopy

Question 3

CKD
- What complications to manage?

Answer 3

INVESTIGATIONS
1st line
Urine dipstick - proteinuria

FBC - Anaemia of chronic disease
Ultrasound - bilateral renal atrophy

GS
eGFR - <60

And eGFR function staging (G score 1-5)
G1 >90
G2 60-89
G3 30-59
G4 15-29
G5 <15

Serum creatinine - elevated

Diagnosis made when eGFR is sustained <60 over 3 months

TREATMENT
First line - really managing the complications
eGFR stage 1-4 →Ace inhibitors - Ramipril, (Angiotensin 2 receptor 2 blocker - telmisartan) + statins (to protect patients from cardioascular complications)

eGFR stage 5 → Dialysis

If End stage renal failure → Renal transplant

(For managing complications:
Anaemia → iron and erythropoietin
Renal osteodystrophy → vitamin D
Oedema → diuretics
Cardiovascular → ace inhibitors and statins

Question 4

BPH

Answer 4

INVESTIGATIONS
1st and GS
Digital rectal examination (to assess size, shape and characteristics of the prostate - SMOOTH AND ENLARGED, soft) - hard, irregular and enlarged could be prostate cancer

Urine dipstick - to assess for infection (leukocytes and nitrites)

Prostate specific antigen (PSA) test for prostate cancer
(may ask them to do a bladder diary)

TREATMENT
Lifestyle - decreasing caffeine (may need catheter acutely)

1st line - Alpha blockers (tamsulosin) - reduce muscle tone in bladder neck (but is CI in patients with postural hypotension)

2nd line - 5 alpha reductase inhibitor (finasteride) - blocks the synthesis of dihydrotestosterone from testosterone - which usually can lead to prostate growth
Can lead to sexual dysfunction

Last resort - Surgery (TURP) - Transurethral resection of the prostate (complication - retrograde ejaculation

Question 5

Pyelonephritis

Answer 5

INVESTIGATIONS
First line - Urine dipstick (positive for leukocytes and nitrites) - pyuria

FBC - increased WBC
(There would also be gas in the renal parenchyma)

GS - Midstream urine culture and sensitivity test

TREATMENT
1st line - Empirical antibiotics
Ciprofloxacin/co-amoxiclav, CEFALEXIN if pregnant

For pain management - Paracetamol (Analgesia)

Question 6

Cystitis

Answer 6

INVESTIGATIONS
First line - midstream urine dipstick

FBC - mostly normal WBC (only increased if WBC spread to upper urinary tract)

GS - Midstream urine culture and sensitivity test

TREATMENT
Antibiotics –> Trimethoprim or nitrofurantoin
(Amoxicillin if pregnant)

Question 7

Urethritis

Answer 7

INVESTIGATIONS

1st -
Nucleic acid amplification test (NAAT) → may detect N.gonorrhoeae or C.trachomatis

Urine dipstick + Urine culture and sensitivity test - to identify the pathogen in the case of a UTI

TREATMENT
Neisseria gonorrhoea - IM Ceftriaxone + azithromycin (if chlamydia not ruled out)

Chlamydia trachomatis - Azithromycin (doxycycline)

Question 8

Epididymo orchitis

Answer 8

INVESTIGATIONS
First line - Urine dipstick

GS - Urine Culture, microscopy and sensitivity test

Nucleic acid amplification test (NAAT) - for C.trachomatis and N.gonorrhoeae.

Treatment
Neisseria gonorrhoea - IM Ceftriaxone + azithromycin (if chlamydia not ruled out)

Chlamydia trachomatis - Azithromycin (doxycycline)

If its a UTI cause
Ciprofloxacin (wide spec)

Question 9

Nephrotic syndrome

Answer 9

• Pallor

INVESTIGATIONS
First line - urinalysis → proteinuria
For young patients (minimal change disease)
Biopsy + electron microscopy → podocyte effacement (and fusion)
No changes on light microscopy

In adults (focal segmental glomerulosclerosis)
Biopsy + light microscopy → Segmented sclerosis in <50% of the glomeruli (scarring of glomeruli - resulting in proteinuria)

In adults (membranous nephropathy)
Biopsy + light microscopy - thickened glomerular basement membrane
Biopsy + electron microscopy - Spike + dome appearance and subepithelial immune complex deposition (on thickened basement membrane)

TREATMENT
Steroids - Prednisolone

Minimal change - responds well
FSG and MN - responds less well

(Diuretics for oedema)
(Albumin infusion for severe hypoalbuminemia)

Question 10

IgA Nephropathy

Answer 10

INVESTIGATIONS
First line - Urine dipstick and urinalysis - haematuria and possible albuminemia

GS - Kidney biopsy with immunofluorescence microscopy - shows mesangial IgA deposition

TREATMENT
Non curative (30% progress to ESRF)
But supportive treatment for hypertension with ACE-I –> RAMIPRIL

Question 11

Post strep glomerulonephritis

Answer 11

INVESTIGATIONS
1st - urinalysis - haematuria, proteinuria

GS -
Kidney biopsy + light microscope (hypercellular glomeruli)
+ electron microscope+ immunofluorescence (hump shaped subepithelial immune complex deposits) –> shows starry sky appearance

Serology for S pyogenes (as self limiting)

TREATMENT
Usually self limiting
Supportive treatment for hypertension with Ace-inhibitor (ramipril)

Question 12

Good pasture’s syndrome

Answer 12

INVESTIGATIONS
First line - Anti GBM antibodies
GS - Renal biopsy which shows damage and immunoglobulin deposition. (Necrosis with epithelial cell crescents)

Treatment
Prednisolone + plasma exchange (to remove pathogenic antibody)

Question 13

Lupus nephritis

Answer 13

INVESTIGATIONS
Serology for ANA and anti double stranded DNA antibodies

Presents with WIRE LOOP glomerulonephritis - on biopsy

TREATMENT
Prednisolone, hydroxychloroquine

Methotrexate (immunosuppressant)

Question 14

Causes of rapidly progressing glomerulonephritis

Answer 14

Caused by: Wegener’s granulomatosis (C-ANCA positive), Microscopic polyangitis (P-ANCA positive + autoantibodies against myeloperoxidase90), Good pastures (Anti GBM antibodise)

INVESTIGATION
Biopsy would show inflammatory crescents in Bowman’s space.

Question 15

Renal cell carcinoma

Answer 15

INVESTIGATIONS
1st line - Ultrasound (abnormal renal mass/cyst)

GS - Contrast CT scan of chest/abdomen/pelvis

(Use robson staging or TNM staging)

TREATMENT
1st line - surgery –> Nephrectomy

Question 16

Bladder cancer

Answer 16

INVESTIGATIONS
(urinalysis to confirm for presence of haematuria)

GS - Flexible Cystoscopy - visualises bladder tumours
(with possible biopsy)

TREATMENT
1st line - Transurethral resection of bladder tumour
with [possible] intravesical chemotherapy (gemcitabine) - to reduce risk of recurrence

Medical - chemotherapy/radiotherapy

Question 17

Prostate cancer

Answer 17

INVESTIGATIONS
First line - Digital rectal examination
Serum PSA levels (elevated)
(Cancerous tumour feels hard, irregular, asymmetrical)

GS - GS - transrectal ultrasound + biopsy
Also grade tumour based on gleason score

TREATMENT
First line - Radical prostatectomy (for local cancer)

For metastatic cancer –>
1) Hormone therapy (to deprive androgens) with either
- Bilateral orchidectomy (Surgical removal of testes)
- Goserelin (GnRH agonist) - it desensitises GnRH receptors eventually so they produce less LH and FSH

2) Radiotherapy (External beam radiotherapy)

Question 18

Testicular cancer

Answer 18

INVESTIGATIONS
First line - Doppler ultrasound test → testicular mass (90% diagnostic)

Blood tests
Serum alpha feto-protein - elevated in teratoma, yolk sac tumour
Beta hcg - elevated in both seminoma an non seminoma

(Lactate dehydrogenase)

GS - biopsy and microscopy
Seminoma- fried egg (large central nuclei surrounded by clear cytoplasm)

(Staging CT scan to look for areas of spread and to stage the cancer)

TREATMENT
1st line
Radical (inguinal) orchidectomy (surgery to remove the affected testicle)
(offer sperm storage)

Adjuvant therapy (post surgery)
Chemotherapy
Radiation therapy

Question 18

Polycystic Kidney disease

Answer 18

INVESTIGATIONS

1st line - Renal ultrasound (enlarged kidneys with cysts)

Genetic testing - PKD1/2 mutation

TREATMENT
No curative treatment
1st - Lifestyle modification - smoking cessation, regular exercise

1st line drug treatment –> Tolvaptan for slowing down development of cysts and progression of renal failure

If patient is hypertensive - Ace inhibitors

If patient reaches end stage renal disease → Renal transplant first. (If cannot, dialysis)

Question 19

Varicocele

Symptoms also

Answer 19

SYMPTOMS
Painless scrotal mass described like a bag of worms
(More prominent on standing)

INVESTIGATIONS
Clinical diagnosis

In patients with a small scrotum/obese patients –> Doppler ultrasound can be used

TREATMENT
No treatment–> reassure patient

Surgery only required if varicocele is severe

Question 21

Epididymal cysts

RF

Pathophysiology
Symptoms
Investigations
Treatment

Answer 21

Cysts that occur at the head of the epididymis (Extratesticular cyst - above and behind testis)

Cyst - Abnormal sacs of fluid

SYMPTOMS
Scrotal mass is not transilluminated (because of fluid) - but the CYST itself is transuilluminated

(Soft round lump, typically at the top of the testicle)

INVESTIGATION
1st line + GS - Scrotal ultrasound

TREATMENT
Conservative treatment - no treatment needed, reassurance

If they cause pain, discomfort or infertility then consider surgical removal

Question 22

Hydrocele

RF

Pathophysiology
Symptoms
Investigations
Treatment

Answer 22

A collection of fluid within the tunica vaginalis

RF - Infants <6 months, infants whose testes descend late

PATHOLOGY
The tunica vaginalis is a sealed pouch of membrane surrounding the testes (and is part of the peritoneal membrane → during development of the fetus, it is separated from the peritoneal membrane and remains in the scrotum partially covering each testicle)

Can be idiopathic or can be secondary to:
Testicular torsion
Trauma
Epididymo Orchitis

SYMPTOMS
Scrotal mass that may enlarge with activity due to increased abdominal pressure –> fluid flows into scrotal sac

TRANSILLUMINATION (because of fluid)

INVESTIGATIONS
GS - Scrotal ultrasound

Serum HCG to exclude testicular cancer

TREATMENT
Mostly observation, only if hydrocele gets large and uncomfortable then surgical repair is definitive treatment

Question 23

Testicular torsion

RF

Pathophysiology
Symptoms
Investigations
Treatment

Answer 23

A urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply, time sensitive ischaemia, and necrosis of testicular tissue.

RF - <25 years, neonate, trauma, bell clapper deformity

PATHOLOGY
Causes:
– Bell clapper deformity - most common anatomical defect (testicle is freely mobile within the tunica vaginalis) - testes are lying horizontally instead of vertically

– Can be triggered by activity e.g. sport, trauma

SYMPTOMS
Rapid onset unilateral testicular pain
Abdominal pain
Nausea and vomiting
NO PAIN RELIEF WITH ELEVATING TESTES
Loss of cremasteric reflex

INVESTIGATIONS
1st
Ultrasound to check testicular blood flow

(if there is increased risk - do a surgical exploration rather than ultrasound)

TREATMENT
(Surgical exploration) then
Urgent surgery (within 6 hours) - Testicular detorsion

Question 24

Acute prostatitis

Answer 24

INVESTIGATIONS
1st - Urinalysis/urine dipstick - leukocytes

Urine microscopy, culture and sensitivity - for bacteria (mostly E.coli)

Digital rectal examination - Prostate is warm, boggy (wet and mushy to the touch)

TREATMENTS
Acute
Without sepsis
Oral antibiotics - Ciprofloxacin

Consider:
NSAIDS - Ibuprofen for pain relief

Chronic prostatitis - Alpha blockers (tamsulosin)