RENAL AND UROGENITAL Flashcards
BPH
Describe the treatment for BPH
1st line = Alpha-1-antagonists (A-blockers) e.g. tamulosin
- relaxes smooth muscle in bladder neck & prostate
2nd line = 5-alpha-reductase inhibitors e.g. finasteride
- blocks conversion of testosterone to dihydrotestosterone -> decreases prostate size
TURP = gold standard
BPH
What are the indications in someone with BPH to do a TURP?
RUSHES
- Retention
- UTI’s
- Stones (in bladder)
- Haematuria (refractory to medical therapy)
- Elevated creatinine
- Symptom deterioration (despite maximal medical therapy)
TESTICULAR CANCER
what are the risk factors for testicular cancer?
- Cryptorchidism (undescended testes)
- Family history
- previous testicular cancer
- HIV
- age 20-45
- Caucasian
- infant hernia
- intersex conditions e.g. kleinfelters syndrome
- mumps orchitis
TESTICULAR CANCER
what are the clinical features of testicular cancer?
SYMPTOMS
- painless testicular lump
- hyperthyroidism
- gynaecomastia
- bone pain (indicates metastasis)
- breathlessness (indicates lung metastasis)
SIGNS
- firm, non-tender testicular mass (does not transluminate, hydrocele may be present)
- supraclavicular lymphadenopathy
HYDROCELE
Name 3 causes of secondary hydrocele
- Testicular tumours
- Infection
- Testicular torsion
- TB
- trauma - is rarer and present in older boys and men
CKD
How is CKD diagnosed?
- eGFR < 60mL/min/1.73m2,
or: - eGFR < 90mL/min/1.73m2 + signs of renal damage,
or: - Albuminuria > 30mg/24hrs (Albumin:Creatinine > 3mg/mmol)
DIURETICS
On which part of the nephron do thiazides act?
The distal tubule Act on NCC channels
DIURETICS
On which part of the nephron do aldosterone antagonists act on?
Collecting ducts
AKI
What is the diagnostic criteria for AKI?
1/3 = diagnostic
- Rise in creatinine >26 mmol/L in 48 hours
- Rise in creatinine >1.5 x in last 7 days
- Urine output fall to < 0.5 ml/kg/h for more than 6 hours
UTI
What is the first line treatment for an uncomplicated UTI?
NON-PREGNANT FEMALE
- 1st line = NITROFURANTOIN (if eGFR>45) or TRIMETHOPRIM for 3 days
- 2nd line = NITROFURANTOIN (if not used 1st line + eGFR>45) or PIVIMECILLINAM or FOSFOMYCIN for 3 days
PREGNANT FEMALE
- 1st line = NITROFURANTOIN (if eGFR>45 + avoid near term) for 7 days
- 2nd line = AMOXICILLIN (only if culture-sensitive) or CEFALEXIN for 7 days
CATHETERISED FEMALE
- 1st line = NITROFURANTOIN or TRIMETHOPRIM for 7 days
MALE
- 1st line = TRIMETHOPRIM or NITROFURANTOIN for 7 days
- 2nd line = AMOXICILLIN (only if culture sensitive) or CEFALEXIN for 7 days
CYSTITIS
What is the treatment for cystitis?
1st line = Trimethoprim or nitrofurantoin (avoid trimethoprim in pregnancy -> teratogenic)
2nd line = ciprofloxacin or Co-amoxiclav
PROSTATITIS
How would you treat prostatitis?
1st line
- fluoroquinolone antibiotic (CIPROFLOXACIN), alternatives are trimethoprim + ofloxacin
- acute = 2-4 weeks
- chronic = 12 weeks
other treatment
- alpha blockers (TAMSULOSIN)
- NSAIDs
- stool softeners
URETHRITIS
what is the treatment for urethritis?
oral doxycycline for 7 days of single dose of azithromycin
PYELONEPHRITIS
Describe the treatment for pyelonephritis
MILD DISEASE - ORAL ANTIBIOTICS
- oral cefalexin - 500mg BD or TDS for 7-10 days
- oral ciprofloxacin - 500mg BD for 7 days
SEVERE DISEASE - IV ANTIBIOTICS
- IV gentamicin (dosage based of body weight + renal function)
- IV ciprofloxacin 400mg TDS
ADJUNCT THERAPY
- hydration = oral or IV
- analgesia = PR DICLOFENAC
HYDROCELE
what is communicating hydrocele?
processus vaginalis fails to close, allowing peritoneal fluid to communicate with the scrotal portion
POLYCYSTIC KIDNEY
what are the causes of autosomal dominant polycystic kidney disease?
- mutations in PKD1 gene on chromosome 16 = 85%
- mutations in PKD2 gene on chromosome 4
CKD
what is stage 1 CKD?
eGFR > 90ml/min
CKD
what is stage 2 CKD?
eGFR 60-89ml/min
CKD
what is stage 3a CKD?
eGFR 45-59ml/min
CKD
what is stage 4 CKD?
eGFR 29-15ml/min
CKD
what is stage 5 CKD?
eGFR < 15ml/min
GOODPASTURES
what is the management for goodpasture’s disease?
plasma exchange
steroids
cyclophosphamide (for immune suppression)
RENAL PHYSIOLOGY
which part of the loop of henle is permeable to water?
descending limb
RENAL PHYSIOLOGY
what is the innervation of the external urinary sphincter?
pudendal nerve S2-S4
RENAL PHYSIOLOGY
what is the innervation of internal urinary sphincter?
pelvic splanchnic nerve S2-S4
RENAL PHYSIOLOGY
what is the innervation of the bladder?
sympathetic = sympathetic chain T11-L2 parasympathetic = pelvic splanchnic S2-S4
CKD
what is stage 3b CKD?
eGFR 30-44ml/min
DIALYSIS
what is the most common causative organism of peritonitis secondary to peritoneal dialysis?
staphylococcus epidermidis
s.aureus is another common cause
DIALYSIS
what is the management of peritonitis secondary to peritoneal dialysis?
vancomycin + ceftazidime added to dialysis fluid
OR
vancomycin added to dialysis fluid + oral ciprofloxacin
EPIDIDYMO-ORCHITIS
what is the management?
ANTIBIOTICS
- STI related = ceftriaxone 500mg-1g IM single dose + doxycycine 100mg BD for 10-14 days
- UTI related = oflaxacin 200mg BD for 14 days or levofoxacin 500mg OD for 10 days
SUPPORTIVE CARE
- analgesia (paracetamol + NSAIDS)
- safety net
- referral
BLADDER CANCER
what are the 2WW referral criteria?
> 45 + unexplained visible haematuria without UTI
45 + visible haematuria that persists/recurs after successful treatment of UTI
60 + unexplained microscopic haematuria + dysuria or raised WCC
AKI
what are the different stages of AKI?
STAGE 1
- Cr rise to 1.5-1.9 x baseline
- Cr rise by 26umol/L
- fall in urine to <0.5ml/kg/hr for >6hrs
STAGE 2
- Cr rise to 2.0-2.9 x baseline
- fall in urine output to 0.5ml/kg/hr for >12 hrs
STAGE 3
- Cr rise to >3.0 x baseline
- Cr rise to >353.6umol/L
- fall in urine to <0.3ml/kg/hr for >24hrs
- in patients <18yr, fall in eGFR to <35ml/min/1.73m2
RENAL CELL CARCINOMA
what are the endocrine associations?
EPO = polycythaemia
PTH hormone-related peptide (PTHrP) = hypercalcaemia
ACTH = cushings syndrome
renin
URINARY STONES
what are the risk factors?
- dehydration
- previous kidney stones
- stone-forming foods (chocolate, rhubarb, spinach, tea, most nuts)
- genetic
- crohns disease
- hypercalcaemia
- hyperparathyroidism
- kidney related disease (polycystic kidney)
- drugs (loop diuretics, acetazolamide, protease inhibitors)
- gout
NEPHRITIC SYNDROME
what are the findings for IgA nephropathy?
Blood = high IgA titres, normal complement
Biopsy = mesangial deposits of IgA complexes
NEPHRITIC SYNDROME
what are the features of alport’s syndrome?
comprises of triad of ophthalmological issues, auditory issues and nephritic syndrome
x-linked dominant inheritance
NEPHRITIC SYNDROME
what are the findings for Alport’s syndrome?
- renal biopsy = gold standard (basket-weave appearance under electron microscope)
- genetic testing = mutation in alpha chain of type IV collagen
NEPHRITIC SYNDROME
what are the findings for lupus nephritis?
- loop wire appearance
NEPHROTIC SYNDROME
what is the classic triad for nephrotic syndrome?
- proteinuria (>3.5g/day)
- hypoalbuminaemia (<30g/L) - leads to severe oedema
- hyperlipidaemia
NEPHROTIC SYNDROME
what are the causes?
- minimal change disease (most common in children)
- focal segmental glomerulosclerosis
- membranous nephropathy
- membranoproliferative GN
- diabetes
- amyloidosis
NEPHROTIC SYNDROME
what are the findings for minimal change disease?
- light microscopy = normal glomeruli
- electron microscopy = effacement of foot processes
NEPHROTIC SYNDROME
what are the findings for focal segmental glomerulonephritis?
- light microscopy = focal + segmental glomerular sclerosis
- electron microscopy = effacement of foot processes
NEPHROTIC SYNDROME
what are the findings in membranous nephropathy?
- light microsopy = thick glomerular basement membrane
- electron microscopy = subepithelial immune complex deposition (spike + dome pattern)
NEPHROTIC SYNDROME
what are the findings for amyloidosis?
- apple-green birefringence under polarise microscopy with congo red stain
RENAL TUBULAR ACIDOSIS
what is the blood results for renal tubular acidosis?
hyperchloraemic metabolic acidosis with normal anion gap
RENAL TUBULAR ACIDOSIS
what is type I RTA?
- defective H+ secretion in distal tubule
- causes hypokalaemia
RENAL TUBULAR ACIDOSIS
what are the causes of type I RTA?
- idiopathic
- RA
- SLE
- Sjogren’s
- amphotericin B toxicity
- analgesic nephropathy
RENAL TUBULAR ACIDOSIS
what are the complications of type I RTA?
nephrocalcinosis
renal stones
RENAL TUBULAR ACIDOSIS
what is type II RTA?
- decreased HCO3- reabsorption in proximal tubule
- causes hypokalaemia
RENAL TUBULAR ACIDOSIS
what are the causes of type II RTA?
- idiopathic
- fanconi syndrome
- wilson’s disease
- cystinosis
- outdated tetracyclines
- carbonic anhydrase inhibitors (acetazolamide, topiramate)
RENAL TUBULAR ACIDOSIS
what is type IV RTA?
- reduction in aldosterone leads in turn to reduction in proximal tubular ammonium excretion
RENAL TUBULAR ACIDOSIS
what are the causes of type IV RTA?
- hyperaldosteronism
- diabetes
RENAL TUBULAR ACIDOSIS
what is the management?
- stop causative medications
- treat electrolyte imbalance
- Type 1 + 2 = bicarbonate (or potassium citrate)
- type 4 = lifelong mineralocorticoid + glucocorticoid replacement
ACUTE INTERSTITIAL NEPHRITIS
what are the investigations?
URINE
- microscopy = pyuria + white cell casts
- culture = negative (sterile pyuria)
BLOODS
- FBC = eosinophilia
- U&Es
- autoimmune screen
IMAGING
- renal USS
ACUTE INTERSTITIAL NEPHRITIS
what is the management?
CONSERVATIVE
- stop any causative medications
- supportive fluid management
- refer to specialist renal services
MEDICAL
- if autoimmune = steroids
- fluid overload = furosemide
ACUTE TUBULAR NECROSIS/INJURY
what are the investigations?
URINE
- dipstick = may be false positive for blood
- microscopy = muddy brown granular casts and renal tubular epithelial cells
- osmolality = low
- urinary sodium = high
BLOODs
- blood gas
- U&Es
- urea:creatinine ratio
- FBC
IMAGING
- ECG
- USS KUB
ACUTE TUBULAR NECROSIS/INJURY
what is the management?
CONSERVATIVE
- identify + treat cause
- avoid nephrotoxic meds
- fluid balance monitoring
MEDICAL
- IV fluids
- blood if haemorrhage
URINARY STONES
what is the management of renal stones?
- < 5mm + asymptomatic = watchful wait
- 5-10mm = shockwave lithotripsy
- 10-20mm = shockwave lithotripsy or ureteroscopy
- > 20mm = percutaneous nephrolithotomy
URINARY STONES
what is the management of uretic stones?
- <10mm = shockwave lithotripsy (+/- alpha blockers)
- 10-20mm = ureteroscopy
CKD
how would you manage proteinuria in CKD?
- ACEi
- SGLT-2
CKD
what change in eGFR and creatinine is acceptable when starting ACEi?
- decrease in eGFR up to 25%
- rise in creatinine up to 30%
CKD
what level of albumin-creatinine ratio (ACR) would you begin treatment for proteinuria?
if ACR > 30mg/mol + HTN
if ACR>70mg/mol even without HTN
NEPHRITIC SYNDROME
what is the management of IgA nephropathy?
no proteinuria = no treatment required
proteinuria 0.5-1g/day = ACEi
failure to respond to treatment = corticosteroids
AKI
what are the indications for renal replacement therapy?
AEIOU
- acidosis (refractory)
- electrolyte imbalance (refractory)
- ingestion of toxins
- oedema/overload
- uraemia (refractory)
LUTS
what screening tool is used to evaluate LUTS + give a symptom score?
International Prostate Symptom Score
PROSTATE CANCER
which zone of the prostate is primarily affected?
peripheral zone
PROSTATE CANCER
what is the 1st line investigation?
multiparametric MRI
PROSTATE CANCER
how is the Gleason score calculated?
- two most common tumour patterns across all samples are graded based on differentiation
- the sum of the two grades is the Gleason score
POLYCYSTIC KIDNEY
what is the most common inheritance pattern?
autosomal dominant
POLYCYSTIC KIDNEYS
what is the role of tolvaptan in the treatment of this condition?
- reduce the growth rate of the cysts
