Renal and GU investigations and treatments Flashcards
AKI
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)
Nephrolithiasis
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
CKD
- What complications to manage?
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
BPH
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
Pyelonephritis
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)
Cystitis
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)
Urethritis
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)
Epididymo orchitis
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)
Nephrotic syndrome
- 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)
IgA Nephropathy
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
Post strep glomerulonephritis
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)
Good pasture’s syndrome
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)
Lupus nephritis
INVESTIGATIONS
Serology for ANA and anti double stranded DNA antibodies
Presents with WIRE LOOP glomerulonephritis - on biopsy
TREATMENT
Prednisolone, hydroxychloroquine
Methotrexate (immunosuppressant)
Causes of rapidly progressing glomerulonephritis
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.
Renal cell carcinoma
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
Bladder cancer
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
Prostate cancer
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)
Testicular cancer
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
Polycystic Kidney disease
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)
Varicocele
Symptoms also
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
Epididymal cysts
RF
Pathophysiology
Symptoms
Investigations
Treatment
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
Hydrocele
RF
Pathophysiology
Symptoms
Investigations
Treatment
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
Testicular torsion
RF
Pathophysiology
Symptoms
Investigations
Treatment
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
Acute prostatitis
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)
