Renal and Urogenital System Flashcards
1
Q
What is the function of the urinary tract?
A
To collect urine produced continuously by the kidneys
To store collected urine safely
To expel urine when socially acceptable.
2
Q
What kind of organs are the kidneys?
A
Retroperitoneal.
3
Q
Where are the kidneys located?
A
T11-L3.
4
Q
Where is the blood supply to the kidneys from?
A
Blood supply from renal artery direct from aorta at L1 level
5
Q
How many nephrons does each kidney contain and how much urine is produced each day?
A
Each kidney contains around 1 million nephrons and produces 1-1.5L of urine per day.
6
Q
Where do the ureters run?
A
Run over psoas muscle, cross the iliac vessels at the pelvic brim and insert into trigone of bladder.
7
Q
How is reflux of urine prevented?
A
valvular mechanism at the vesicoureteric junction.
8
Q
What does the Bladder, Sphincter and Urethra look like?
A
9
Q
What is the nervous control of the bladder and spincters?
A
Parasympathetic Nerve (pelvic nerve) S2-S4
Acetylcholine neurotransmitter
Involuntary control
Sympathetic Nerves (hypogastric plexus) T11 – L2
Noradrenaline neurotransmitter
Involuntary control
Somatic Nerve (pudendal nerve) S2-S4
“Onuf’s nucleus”
Acetylcholine neurotransmitter
Afferent pelvic nerve
Sensory nerve
Signals from detrusor muscle
10
Q
What is each of these doing in neural control?
Cortex
Pontine Micturition Centre
Sacral Mictruition Centre
Onuf’s Nucleus
A
Cortex: voluntary control
Pontine Micturition Centre/Periaqueductal Grey: Co-ordination of voiding
Sacral Micturition Centre: Micturition reflex
Onuf’s Nucleus: Guarding reflex
11
Q
What are the different phases of micturition?
A
Storage.
Guarding Reflex.
Micturition Reflex.
12
Q
What happens in the storage phase of mictruition?
A
Bladder fills continuously as urine is produced by kidney and is passed through the ureters into the bladder
Normal adult bladder capacity 400-500ml with first sensation at 100-200ml
As the volume in the bladder increases the pressure remains low due to “receptive relaxation” and detrusor muscle compliance
13
Q
What happens during the filling phase of mictruition?
A
At lower volumes the afferent pelvic nerve sends slow firing signals to the pons via the spinal cord.
Sympathetic nerve (hypogastric plexus) stimulation maintains detrusor muscle relaxation.
Somatic (Pudendal) nerve stimulation maintains urethral contraction.
14
Q
What happens during the voiding phase?
A
Micturition reflex is an autonomic spinal reflex
Higher volumes stimulate the afferent pelvic nerve to send fast signals to the sacral micturition centre in the sacral spinal cord
Pelvic parasympathetic nerve is stimulated and the detrusor muscle contracts
Pudendal nerve is inhibited and the external sphincter relaxes
15
Q
What happens during bladder emptying and what is needed?
A
Coordinated detrusor contraction with external sphincter relaxation to expel urine from bladder
A positive feedback loop is generated until all urine is expelled
Detrusor relaxation and external sphincter contraction after complete emptying of bladder
16
Q
What happens during the guarding reflex?
A
Afferent signals from the pelvic nerve are received by the PMC/PAG and transmitted to higher cortical centres
If voiding is inappropriate the guarding reflex occurs
Sympathetic (hypogastric) nerve stimulation results in detrusor relaxation
Pudendal nerve stimulation results in contraction of the external urethral sphincter
17
Q
What does the urinary tract have to do?
A
Convert a continuous process of excretion (urine production) to an intermittent process of elimination.
Store urine insensibly.
18
Q
What do the detrusor muslce and distal spincter have to do in mictruition?
A
Detrusor muscle
Relaxes during storage (compliant)
Contracts during voiding
Distal sphincter mechanism
Contracts during storage
Relaxes during voiding
19
Q
What are some lower urinary tract symptoms?
A
Storage symptoms
Frequency
Nocturia
Urgency
Urgency incontinence.
Voiding symptoms
Hesitancy
Straining
Poor/intermittent stream
Incomplete emptying
Post mictruition dribbling
20
Q
What are these definitions?
BPH?
BPE?
BOO?
LUTS?
A
Benign prostatic hyperplasia.
Benign prostatic enlargement
Bladder outflow obstruction
Lower urinary tract symptoms
21
Q
WHAT IS BPH?
A
Increase in epithelial (glandular)
and stromal (musculofibrous)
cell numbers in the periurethral area of the prostate
22
Q
What is the incidence of BPH?
A
Older men affected
23
Q
What are the symptoms of BPH?
A
Lower urinary tract symptoms (LUTS)
AND
Haematuria
Bladder stones
UTIs
24
Q
What tests would you do for BPH?
A
DRE
Enlarged prostate
‘Rule out’ cancer
PSA raised
Transrectal USS ± biopsy.
Ultrasound (large residual volume, hydronephrosis)
Visulise kidneys
MSU (midstream specimin of urine)
Bacteria
25
What are the management options for BPH?
Lifestyle
Drugs
Surgery
26
What are the lifestyle management options for BPH?
**_Lifestyle_**
Avoid caffeine, alcohol (to decrease urgency/nocturia).
Relax when voiding.
Void twice in a row to aid emptying.
Control urgency by practising distraction methods (eg breathing exercises).
27
What are the drug management options for BPH?
**_Drugs_**
**_1st line Alpha-blockers_**
Tamsulosin
They Decrease smooth muscle tone (prostate and bladder).
**_2nd line 5alpha-reductase inhibitors_**
Finasteride
Decreases testosterone’s conversion to dihydrotestosterone
28
What are the surgery management options for BPH?
**_Surgery_**
Transurethral resection of prostate
Transurethral incision of the prostate
Transurethral laser-induced prostatectomy (TULIP)
Retropubic prostatectomy is an open operation
29
What are the side effects of alpha blockers?
Dry mouth
Weight gain
Dizziness
Hypotension
Sexual dysfunction
30
What is a requirement of BPH but not BPE?
Androgens.
31
WHERE CAN YOU GET STONES?
Anywehere from collecting duct to external urethral meatus (EUM).
**_Upper urinary tract_**
Renal Stones
Ureteric Stones
**_Lower urinary tract_**
Bladder stones
Prostatic stones
Urethral stones
32
What is the epidemology of stones?
Common: lifetime incidence up to 15%
Peak age: 20–40yr
Male more than females
33
Why do patients get stones?
Anatomical factors
Urinary factors
Infection
34
Why do patients get stones anatomical factors?
**_Anatomical factors_**
Congenital (horseshoe, duplex)
Acquired (obstruction, surgery)
35
Why do patients get stones urinary factors?
**_Urinary factors_**
Metastable urine, promotors and inhibitors
Calcium, oxalate, urate, cystine
Dehydration
36
How are stones formed?
Nucleation theory suggest that stones form from crystals in supersaturated urine.
Solubility point and formation point play factors
37
What are stones made of?
80% calcium - oxalate, phosphate.
10% uric acid.
5-10% struvite - infection stones.
1% cystine - congenital.
38
How can stones be prevented?
Overhydration.
Low salt
Normal dietary intake
Healthy protein intake
Reduce BMI
Active lifestyle
39
How can you prevent uric acid stones?
Only form in acid urine
Deacidification of urine to ph7-7.5 preventative
40
How do you prevent cystine stones?
Excessive overhydration
Urine alkalinisation
Cysteine binders
+/- genetic counselling
41
What symptoms can urinary tract stones cause?
Asymptomatic
Loin pain
Renal colic
UTI symtpoms
Dysuria, stangury, urgency, frequency
Recurrent UTIs
Haematuria
Visible and non-visible (85%)
42
WHAT IS RENAL COLIC?
Pain resulting from upper urinary tract obstruction.
43
Where are the three main places where stones get stuck?
Pelvi-ureteric junction
Pelvic brim
Vesico-ureteric junction
44
What are the symptoms of renal colic?
Severe unilateral loin pain
Rapid onset
Unable to get comfortable - writhing
Radiates to groin and ipsilateral testis/labia
Associated nausea / vomiting
Spasmodic / colicky, worse with fluid loading
45
How do you investigate a renal colic?
Blood and urine tests
Imaging
46
How do you investigate a renal colic blood and urine?
**_Bloods_**
Calcium, Phosphate, Uric acid
**_Urine_**
Urinalysis, MSU if positive
24hr urine for stone substances
47
How do you investigate a renal colic imaging?
**_Imaging_**
**_Kidney, ureters and bladder (KUB) XR_**
70%
**_Spiral non contrast CT_**
Look for stones 99%
48
What are the differential diagnosis of renal colic?
Ruptured AAA
Diverticulitis, appendicitis
Pyelonephritis
Testicular torsion
Musculoskeletal
Ectopic pregnancy, ovarian (cyst) torsion
49
How do you manage renal colic?
**_Pain relief_**
Diclofenac or opioids; abxif infection suspected
**_Stones \<5mm diameter_**
90%+ pass spontaneously
**_Stones \>5mm diameter_**:
Medical therapy (nifedipine or tamsulosin)
Extracorporeal shockwave lithotripsy
Percutaneous nephrolithotomy
**_If obstruction + infection_**
Ureteric stent may be needed
**_Prevention_**
Drink plenty
50
Why does infection matter?
Pyonephrosis
Can lose renal function in 24hrs
Systemic sepsis leading to septic shock
IV antibiotics.
Drainage
51
How can kidney stones be dangerous?
Smaller ones can migrate into ureter
Larger stones occlude calyces and/or PUJ
Can acutely obstruct – renal or ureteric colic
Chronic renal damage (esp. if infection stone)
52
WHAT ARE THE GENERAL SYMPTOMS OF CANCER?
**_Systemic or Constitutional_**
Non-specific
Specific
Paraneoplastic syndromes
* *_Local_**
e. g. Haematuria in Bladder Cancer
53
What are the constitutional non-specific symptoms of cancer?
**_Non-specific_**
Weight Loss
Anorexia
Fever
Anaemia (normocytic)
54
What are the specific constitutional symptoms of cancer?
**_Hypercalcaemia_**
Anorexia
Thirst
Confusion
Collapse
**_Marrow replacement_**
Purpura
Anaemia
Immune suppression
55
WHAT IS PROSTATE CANCER?
Cancer of the prostate
56
What is the epidemology of prostate cancer?
Most commonly diagnosed cancer in men
A disease of the industrialised West.
Old age
57
What type of cancer is prostate cancer?
Adenocarcinoma
58
What are the risk factors of prostate cancer?
+ve family history
Increased testosterone
59
Where does prostate cancer occur in the prostate?
Occurs in peripheral zone of prostate
85% of tumours are multifocal
60
How does prostate cancer spread and where does it spread to?
Spreads locally through prostate capsule
**_Metastasises to_**
Lymph nodes
Bone (sclerotic)
Lung, liver and brain
61
What are the biomarkers for prostate cancer?
**_Tissue_**
**_Serum_**
Prostate-specific Antigen (PSA)
Prostate-specific membrane antigen (PSMA)
**_Urine_**
PCA3
Gene fusion products (TMPRSS2-ERG)
62
What is PSA?
Prostate specific antigen
63
What does PSA do, what happens in BPH?
Serine protease responsible for liquefaction of semen
Small amount of retrograde leakage
Detected in small quantities in the blood
64
What does PSA show in prostate cancer?
PROSTATE SPECIFIC not CANCER SPECIFIC
Elevated in benign prostate enlargement, urinary tract infection, prostatitis
65
What are the symptoms of prostate cancer?
Asymptomatic or nocturia
Hesitancy
Poor stream
Terminal dribbling, or obstruction
**_Weight loss ± bone pain suggests mets_**
66
How can you diagnose prostate cancer?
**_DRE_**
Hard and irregular
**_Prostate specific antigen (PSA)_**
Increased
**_Prostate biopsy_**
**_Transrectal ultrasound scan (TRUSS)_**
67
What is the gleeson score? What is the T score?
Most common grade + highest grade
Grades 1 - 5
**_T staging_**
T1 Non palpable
T2 Palpable + confined to prostate
T3 Palpable + through capsule
T4 Palpable + invade other structures
68
What is the treatment for localised prostate cancer?
**_Surgery_** - radical prostatectomy
**_Radiotherapy_** - external beam
**_Observation_** - watchful waiting
69
What is the treatment for locally advanced prostate cancer?
Surgery
Radiotherapy and neoadjuvant hormone therapy.
70
What is the treatment for metastatic prostate cancer?
**_Hormone therapy_**
**_LHRH analogues_**
Goserelin
**_LH antagonists_**
Degarelix
**_Peripheral androgen receptor antagonists_**
71
What is the differential diagnosis of renal, bladder and testis cancer?
Infection: UTI, pyelonephritis, TB.
Malignancy: anywhere in tract
Stones: bladder, kidneym ureteric
Trauma: penetrating Vs Blunt
Nephrological: diabetes, nephropathy
72
What are the side effects of hormone replacement?
Osteoporosis
Gynaecomastia
Sexual dysfunction
73
WHAT IS BLADDER CANCER?
Cancer of the bladder
74
What are the different types of bladder cancer?
Transitional cell carcinoma
**_Some are_**
Squamous cell carcinoma
Adenocarcinoma
Rare: sarcoma, lymphoma, melanoma and secondaries
CIS: poorly differentiated, but confined epithelium, 50% become MI.
75
What are some risk factors of developing bladder cancer?
Paraplegia
Smoking
Occupational (rubber, cable, textile, printing)
Drugs (phenacetin, aspirin, cyclophosphamide)
Bladder stones
76
How can bladder cancer present?
85% painless VH (visible haematurtia)
Irritative voiding / recurrent UTI's (CIS)
77
How can you diagnose a bladder tumour?
**_CT_**
Urogram is both diagnostic and provides staging
**_Cytoscopy_**
Diagnostic
**_Biopsy_**
**_Urine_**
Microscopy/cytology (cancers may cause sterile pyuria).
MRI or lymphangiography may show involved pelvic nodes.
78
What are the different stages of bladder cacner?
Ta surface
T1 lamina propria, not hit the muscle
T2 hit the muscle
79
How can you treat bladder tumours?
**_T1_**
Surveillance
Transurethral resection of bladder tumour (TURBT) Transurethral cystoscopy + diathermy
+/- maintenance chemo
**_T2-3_**
Radical cystectomy
Chemo (either post-op or neoadjuvant)
Preserve bladder function – orthotopic bladder reconstruction or urostomy
**_T4_**
Palliative chemo/radio
80
WHAT IS RENAL CANCER?
Cancer of the kidney
81
What are the types of renal cancer?
95% renal cell carcinoma (RCC)
An adenocarcinoma
TCC (transitional cell carcinoma) \<5%
82
What is the cause of renal cancer?
Short arm chromosome 3
VHL tumour suppressor gene mutation
IGF-1 has free rein
83
What is the pathology of renal cancer?
Form from epithelial cell in proximal convulted tubule
Polygonal epithelial cells
Clear cytoplasm with carbohydrates and lipids
IGF-1 causes
Dysregulated cell growth
Hypoxia causing more angiogensis
84
What is the epidemology of renal cancer?
**_Sporadically_**
One tumour
Older men
Smokers
**_Inherited_**
E.g. Von Hippel-Lindau disease
Younger men and women
Both kidneys
85
What are the symptoms of renal cancer?
Most found incidentally!
Haematuria
Flank pain
Mass
Weight loss
Paraneoplastic syndromes
86
What are the paraneoplastic syndromes renal cancer?
Erythropoetin - more red blood cells, polycythemia
Renin - Increase blood pressure
PTHrP
ACTH - cortisol
87
What does a tumour of the left kidney cause that the right doesn't?
Varicocles due to vein going into renal vein before IVC
88
How is renal cancer staged?
Using the TNM system.
T - Size, growth into nearby vein
N - Spread to lymph nodes
M - Degree of metastasis
89
How is renal cancer diagnosed?
**_BP_**
Increased from renin secretion.
**_Blood_**
FBC (polycythaemia from erythropoietin secretion);
ESR; U&E, ALP (bony mets?).
**_Urine_**
RBCS
Haematuria
**_Imaging_**
US; CT/MRI; IVU (filling defect ± calcification); CXR (‘cannon ball’ metastases).
90
What is the treatment of renal cancer?
Resection if localised
Biological therapies if metastasized
**_Immunomodulation_**
Chemokines
Antibodies
**_Molecular targeted therapies_**
VEGF receptor
Sunitinib, bevacizumab and sorafenib
91
WHAT ARE EPIDIDYMAL CYSTS?
Masses that lie above and behind the testis
Lie on the epididymus
92
When do epididymal cysts develop?
Usually develop in adulthood
93
What is the causes of epididymal cysts?
Unknown
**_Theroies_**
Blockage
Trauma
Inflammation
94
What do epididymal cysts contain?
Clear or milky (spermatocele) fluid.
Dead sperm cells
95
What are the symptoms of epidiymal cysts?
Usually none
**_Can cause_**
Pain
Discomfort
Heaviness
96
What are the tests for epidiymal cysts?
Usually discoered incidentally - physical exam
Trans-illumination - if light passes through shows fluid
Ultrasound
97
What is the treatment of epidiymal cysts?
Usaully none
**_Medications_**
NSAIDs
**_Surgery_**
Spermatocoelectomy
**_Aspiration and sclerotherapy_**
Draw fluid out and something put back in
98
WHAT IS A HYDROCELE?
Result of excessive fluid in tunica vaginalis (serous space surrounding testes)
99
What are the different types of hydrocoeles?
Primary or secondary
100
What is the primary type of hydrocele?
Associated with a patent processus vaginalis
Typically resolves during the 1st year of life
101
What is the secondary type of hydrocoele?
Testis tumour/trauma/infection.
102
Which hydrocoele is more common?
Primary hydroceles are more common, larger, and usually in younger men.
103
What is the difference between communicating and non-communicating hydroceles?
Communicating is peritoneal fluid collection
104
What are the symptoms for hydrocele?
Painless mass
**_Sometimes_**
Pain
Heaviness
105
What are the tests for hydrocele?
Physical exam
Painless smooth mass
Ultrasound
106
What are the managements for hydrocele?
Asymptomatic - Nothing
Symptomatic - Aspiration, resection
107
WHAT ARE VARICOELES?
Dilated veins of pampiniform plexus.
108
Which side of the testis of more affected by varicoceles?
Left side more commonly a effected.
109
Which is the cause of varicoceles?
Left side unknown
Right side venous obsturction from tumour
110
What are the symptoms of varcoceles?
Dull ache.
Bag of worms
Heavy
111
What are the tests for varicoceles?
Physical exam
Valsalva monuver.
Semen analysis
Ultrasound
112
What are the treatments for varicoceles?
Surgical treatment
Vascular ablation or embolization
113
WHAT IS EPIDIDYMITIS?
Inflammation of the epidiymis.
Acute epididymitis mostly occurs in young males.
114
What is the epidemology of epididmytis?
Acute epididymitis mostly occurs in young males.
115
What are the causes of epididymitis?
E. coli
Chlamydia
Gonorrhea
116
What is the pathology of epididymitis?
Organisms may get to Epididymis by retrograde spread from prostatic urethra & seminal vesicles or less commonly, through blood stream.
117
What are the symptoms of epididymitis?
Severe scrotal pain
Fever
Swollen scrotal area
118
What are the tests for epididymitis?
Prehn's sign - lift testicules to see if pain improves
Ultrasound - check for torsion
Urethral swabs
119
What is the treatment of epididymitis?
Doxycycline
If gonorrhoea suspected add
Ceftriaxone
Scrotal elevation
120
Why do you remove the testicle out through the groin?
Damage testicle, release tumour cells into skin.
121
WHAT IS TESTICULAR CANCER?
Cancer of the testis
122
What are the different types of testicular cancer?
Seminomas (germ cell) – slow growing, classic appearance
Non-seminoma
Sex cord (stromal)
Mixed
Lymphoma
123
What is the epidemology of testicular cancer?
The commonest malignancy in males aged 15–44
124
What is the staging of testicular cancer?
Stage 1 - Confined to testicle
Stage 2 - Spread but below diaphragm
Stage 3 - Above diaphragm or in solid organs.
Stage 4 - In lungs
125
What are some risk factors for testicular tumours?
Cryptochidism - undecended testicle.
Fhx - family history.
Previous testicular tumour.
Poorly understood.
126
What is the differential diagnosis for testicular cancer?
Inguinal hernias.
Epididymitis
Infection.
Torsion.
Catheters, UTI.
Hydrocele.
127
What are the symptoms of testicular cancer?
80% painless lump in testis (hard/craggy, lies within testis, can be felt above).
Abdominal mass
HYDROCOELE
PAIN
METASTASES
128
What are some investigations for testicular tumour?
**_Scrotal US_**
**_Biopsy_**
**_Tumour markers_**
AFP alpha feta protein (1/2 life 5 days) - also liver cancer, secreted by placenta
B-hcg (24-48)
LDH - lactacte dehydrogenase - shows turnover of cells.
**_CXR if respiratory sym_****_ptoms_**
**_Staging CT_**
129
What operations do you do for testicular tumour?
Early inguinal orchidectomy if malignant.
Types of tumour -
SEMINOMAS are very radiosensitive.
NON-SEMINOMAS (TERATOMAS) - cytotoxic chemotherapy.
bleomycin + etoposide + cisplatin.
130
WHAT ARE THE FUNCTIONS OF THE KIDNEY?
Homeostasis
Filtration and reabsorption
Blood pressure
Potassium.
Vitamin D and bone disease
Erythropoeitin.
131
What happens with homeostasis?
Filtration - Blood minus cells and large negatively charged molecules.
Reasborption and secretion.
132
What is there a net excretion of?
Sodium.
Phosphate.
Potassium.
Acid.
Uraemic toxins.
133
What is the glomerular filtration rate? What percentage of cardiac output does it take?
120ml/min = 170L/day.
20% of cardiac output.
134
What happens when you progressively worse CKD?
Anaemia.
Bone disease.
135
At what eGFR is dialysis end stage disease needed?
7-10.
136
How do you calculate eGFR?
Predict creatinine generation from age, gender, race.
Require steady state.
Extremes of muscle mass may be misleading.
137
What can make serum creatinine look worse?
Creatinine is secreted as well as filtered:
Creatinine clearnace \> GFR
More porminant at low GFR
Inhibitors of this secretion will make serum Cr rise and function look worse
Inhibitors of secretion: trimethoprim.
138
How can you measure how leaky the glomerulus is?
Look at the levels of Albumin.
\>30mg Normal.
30-300mg Microalbuminuria
\>300mg macro albuminuria
\>1g Heavy' glomerular pathology likely
\>3g Nephrotic range
139
How can you work out how much Albumin a person produces in one day?
Get the proportion of creatinine and use this in Albumin.
140
What happens at the proximal tubule?
70% filtered sodium.
Phosphate.
Glucose
Amino acids.
141
What happens with acute tunular necrosis?
Proximal tubules don't get an adequte blood supply and subsequently die.
142
What is Fanconi syndome?
Proximal tubular insult.
Glycosuria
Acidosis with failure of urine acid secretion
Phosphate wasting; rickets/osteomalacia
Aminoaciduria.
Various causes: Cystinosis, tenofovir, paraprotein disease.,
143
How do the kidneys control blood pressure?
Volume
Vascocontriction.
144
How is volume control done?
All about sodium.
70% in proximal tubule
25% loop of Henle
5% distal tubule
2% collecting duct.
145
What happens at the loop of Henle? What is the disease assocaited with this?
Concentration gradient,
Dilute at top of loop
Concentrated at bottom of loop
Used at collecting ducts, passive transport of water.
Diabetes insipidus.
146
When do you get extra water retention? How can you treat this?
Kidney failure
Heart failure
Liver failure
Loop diuretics.
Thiazides (distal tubule)
Aldosterone antagnosit (collecitng duct) - Spiraloactone - pottasium sparing diuretic.
Aquaporins - vasopressin antagnoist.
147
What happens at the juxtaglomerular apparatus?
Macula densor cells next to the afferent arterioles.
Sense amount of sodium in the distal convoluted tuble.
More blood = more filtered, more delivered to distal tubule.
Drop in delivery secretes renin and then opens up afferent arteriole.
148
What is the renin-angiotensin pathway?
Angiotensinogen + Renin-\>
Angiotensin + ACE -\>
Anginotensin 2-\>
Vasoconstriciton (increase blood pressure) and Aldosterone (affects reabsorption of sodium).
149
What happens in renal artery stenosis?
Kidneys are getting less blood,
Renin gets reduced.
Retain more sodium.
More vasoconstriction.
Blood pressure goes higher until adequete flow.
150
What do NSAIDs do to the kidneys?
Lower the amount of prostaglandin, prostaglandin preferentially dilates the afferent arteriole and therefore gets constricted.
Angiotensin 2 preferentially constricts the efferent arteriole, block this and it will dilate.
Therefore little blood flow in + more coming out = no filtration.
151
What can Albumin do to the kidneys if it is filtered?
Damages the kidneys on the way through.
152
What can treat proteinuric CKD?
ACE inhibitors and ARB.
A small drop in eGFR is okay.
153
Where is potassium control done?
K freely filtered and mostly absorbed in proximal tubule/loop of Henle.
Distal secretion determines renal excretion.
154
What is potassium control governed by?
Distal delivery of Na.
Aldosterone. (help pumps working)
Distal tubule - sodium reabsorption and potassium secretion. 1 for 1.
155
How is buffereing of acute changes controlled?
Insulin and catecholamines drive cellular potassium uptake.
156
Why do ACE inhibtors, aldosterone inhibitors give hyperkalemia?
Block aldosterone, end up with low sodium and high potassium and high hydrogen.
157
How is vitamin D activated?
7-dehydrocholesterol to cholecalciferol (vitamin D3) using UV light.
Cholecalciferol to 25-hydroxyvitamin D.
25 to 1-25 in kidney
calcitriol = active vitamin D.
158
What does calcitriol do?
Increases calcium and phosphate absorption from the gut.
Suppresses parathyroid hormone.
Deficiency causes secondary hyperparathyroidism.
PTH has effects on bone health.
159
What does renal anaemia do?
Erythropoetin deficiency in advanced kdiney disease leads to reduced haemopoesis and anaemia.
Exacerbated by functiuonal iron deficiency in renal disease.
Seldom seen until eGFR below 30.
160
WHAT IS ACUTE KIDNEY INJURY?
Rapid reduction in kidney function over hours to days
161
How do you diagnose acute kidney injury?
Rise in creatine \> 26 micromol/L in 48 hrs (above baseline).
Rise in creatinine \> 50% (best figure in last 6 months).
Urine output \< 0.5 ml/kg/hr for \> 6 consecutive hours.
162
How many of the diagnosis do you need to diagnose a AKI?
1 out of the 3.
163
What are the risk factors for acute kidney injury?
Age \>75
Chronic kidney disease
Cardiac failure
Peripheral vascular disease
Chronic liver disease
Diabetes
Drugs (esp newly started)
Sepsis
Poor fluid intake/increased losses
History of urinary symptoms
164
What are the most common causes of AKI?
Commonest are ischaemia, sepsis and nephrotoxins, although prostatic disease causes up to 25% in some studies and has the best prognosis.
165
What are the pre-renal causes of AKI?
Renal hypoperfusion,
Hypotension
Renal artery stenosis ± ACE-i.
166
What are the Intrinsic renal causes of AKI?
Acute tubular necrosis
Autoimmune
Glomerulonephritis
Vasculitis
167
What are the post renal causes of AKI?
Caused by urinary tract obstruction
Stones
Malignancy
Extrinsic compression
168
What are some nephrotoxic drugs?
**_ACE inhibitors/ ARBs_**
Results in dilated efferent arterioles decreasing GFR
**_NSAIDs_**
Inhibits cyclooxygenase which causes excess vasoconstriction of the afferent arteriole
**_Aminoglycosides (10-15% incidence of Acute Tubular Necrosis)_**
169
What is the presentation of AKI?
Depends on underlying cause and severity
Oliguria or anuria
Nausea, vomiting
Dehydration
Confusion
Hypertension
Urinary retention (large painless bladder)
Postural hypotension
170
How can you assess AKI?
Full examination
**_Renal_**
Creatinine
U+E
Glucose
Urine dipstick
Renal USS
**_Liver enzymes_**
Clotting
Autoantibodies (anti-GBM, ANCA)
171
How can you treat AKI?
Euvolaemia
Stop nephrotoxic drugs
Treat underlying cause
Manage complications
172
What is a complication of AKI?
Hyperkalaemia
173
What would you see on a hyperkalemic ECG?
Peaked T waves.
Small or indiscernible P waves.
174
How can you manage hyperkalaemia?
Insulin and Dextrose ( insulin drive potasssium into cell)
Dextrose compensate for sugar
Calcium gluconate. (to protect heart)
IV fluid.
Salbutamol.
Calcium resonium.
175
What do you do before referral?
* Proper history and examination
* Blood tests & Imaging
* IV fluid
* Urine dip sticks
* Review of drugs
* Fluid balance ( intake /output )
* Current volume status
176
When do you refer to a Nephrologist?
* Treat the urgent causes first !
* Hyperkalaemia or fluid overload unresponsive to medical treatment
* Urea \> 40mmol/L +/- signs of uraemia
* No obvious cause
* Creatinine \> 300 or rising \> 50micromol/L per day
177
When will you start dialysis?
* Refractory pulmonary oedema
* Persistent hyperkalaemia
* Severe metabolic acidosis
* Uraemic encephalopathy or pericarditis
* Drug overdose – BLAST ( Barbiturate, Lithium, Alcohol-ethylene glycol, Salicylate, Theophylline)
178
WHAT IS GLOMERULONEPHRITIS?
Inflammation in the glomerulus.
179
What is the basic difference between nephritic and nephrotic syndrome?
Nephrotic syndrome involves the loss of a lot of protein
Nephritic syndrome involves the loss of a lot of blood
180
What are the consequences of glomerulonephritis?
Damage to the glomerulus restricts blood flow, leading to compensatory increased BP
Damage to the filtration mechanism allows protein and blood to enter the urine
Loss of the usual filtration capacity leads to acute kidney injury
181
What is the spectrum of glomerulonephritis disease?
1 Blood pressure: normal to malignant hypertension
2 Urine dipstick: proteinuria mildnephrotic; haematuria mildmacroscopic
3 Renal function: normal to severe impairment
182
What are the causes of glomerulonephritis?
**_Syndrome_** Common primary causes Common secondary causes
**_Nephrotic_**
Membranous
Minimal change
FSGS
Mesangiocapillary GN
Diabetes
SLE (class V nephritis) Amyloid
Hepatitis B/C
**_Nephritic_**
IgA nephropathy
Mesangiocapillary GN
Post streptococcal
Vasculitis
SLE (other classes of nephritis)
Anti-GBM disease
Cryoglobulinaemia
183
WHAT IS NEPHRITIC SYNDROME?
**_Haematuria_**
+++ blood on urine dipstick (macro/microscopic)
Red cell casts (distinguishing feature)
**_Proteinuria_**
++ protein on urine dipstick
**_Hypertension_**
**_Low urine volume (\<300ml/day)_**
184
What happens to the podocytes in nephritic syndrome?
Podocytes develop large pores so blood and protein can escape through into urine
185
What are some causes of nephritic syndrome?
Post-streptococcal glomerulonephritis
IgA nephropathy
Rapidly progressive glomerulonephritis (Goodpasture’s syndrome/vasculitis disorders)
186
When does nephritic syndrome normally appear?
**_Often appears days-weeks after URTI_**
IgA nephropathy – days after URTI
Post-streptococcal glomerulonephritis – weeks after URTI
187
What is the treatment for nephritic syndrome?
Treat underlying cause
188
WHAT IS IgA NEPHROPATHY?
IgA accumulates in nephron and causes inflammation
189
What are the clinical features of IgA nephropathy?
Haematuria
190
How can you diagnose IgA nephropathy?
Biopsy.
191
What is the management of IgA nephropathy?
Supportive care: BP control with RAAS inhibitors, Diet, Lower Cholesterol.
Immunosuppression
192
WHAT IS NEPHROTIC SYNDROME?
Proteinuria
Hypoalbuminaemia
Oedema
193
What are the causes of nephrotic syndrome?
**_Primary_**
Minimal change disease
Membranous nephropathy
Focal segmental glomerulosclerosis
**_Secondary_**
Hepatitis
Diabetic nephropathy
Drug-related
194
What is the pathophysiology of nephrotic disease?
Injury to the podocyte
195
What are the test for nephrotic syndrome?
Urine dip (protein +++)
Bloods (show low albumin)
Biopsy (adults)
196
What are the complications of nephrotic syndrome?
**_Susceptibility to infection_**
Loss of immunoglobulin in urine and also immunosuppressive treatments
**_Thromboembolism_**
Increase clotting factors and platelet abnormalities.
**_Hyperlipidaemia_**
Hepatic lipoprotein synthesis, response to low oncotic pressure
197
What is the treatment of nephrotic syndrome?
Steroids in children
Diuretics for oedema
ACE-i for proteinuria
Treat underlying cause
198
WHAT IS MEMBRANOUS GN?
Thickening of glomerular capillary wall.
IgG, complement deposit in sub epithelial surface causing leaky glomerulus.
199
What are the different types of membranous GN?
Primary MN:
PLA2R antigen is the target antigen in 70-80% cases of primary MN.
Secondary MN:
Associated with autoimmune conditions, virsues, drugs and tumours.
200
What are the clinical features of MN?
Nephrotic syndrome, benign urinary sediment.
201
What is the diagnosis for MN?
Serum PLA2R Ab
Renal biopsy.
202
What is the treatment for MN?
Supportive treatment- control of oedema, hypertension, hyperlipidemia and proteinuria.
RAS blockade, anti coagulation( only retrospective reviews)
Immunosuppression( steroids/ cyclophosphamide/ CNI)
203
WHAT IS MINIMAL CHANGE DISEASE?
Commonest cause of nephrotic syndrome in children
In adults it can be idiopathic or in association with drugs (NSAIDS) or paraneoplastic (usually Hodgkin’s lymphoma).
204
What is the pathology of minimal change disease?
T cells secrete inflammatory cytokines and damage foot processes on podocytes
Charge is lost
Albumin let through
Ig not let through
205
What is the presentation of minimal change disease?
Nephrotic syndrome, benign urine sediment.
206
What are the diagnosis options for minimal change disease?
Biopsy: Normal under light microscopy (hence the name).
Electron microscopy shows enhacement of the podocyte foot processes.
207
What is the treatment of minimal change disease?
Steroids
Relapsing- remitting course treated with:
Cyclophosphamide or ciclosporin/tacrolimus
208
WHAT IS CHRONIC KIDNEY DISEASE?
Impaired renal function for \>3 months based on abnormal structure or function, or GFR \<60mL/min/1.73m2 for \>3 months with or without evidence of kidney damage
209
What are the different stages of chronic kidney disease?
Stage GFR (mL/min) Notes
1 \>90 Normal or GFR with other evidence of renal damage\*
2 60–89 Slight GFR with other evidence of renal damage\*
3A 45–59
3B 30–44 Moderate GFR with or without evidence of other renal damage\*
4 15–29 Severe GFR with or without evidence of renal damage\*
5 \<15 Established renal failure
210
After what stages are symptoms seen?
Symptoms usually only occur once stage 4 is reached (GFR \<30).
End-stage renal failure (ESRF) is defined as GFR \<15 mL/min/1.73m2 or need for renal replacement therapy (RRT—dialysis or transplant).
211
What are some causes of chronic kidney disease?
**_Congential/inherited_**
Polycystic kidney disease,
**_Renal artery stenosis_**
**_Hypertension_**
Accelerated hypertension
**_Glomerular diseases_**
IgA nephropathy, Wegener’s granulomatosis, amyloidosis,
**_Interstitial diseases_**
Reflux nephropathy, tuberculosis, schistosomiasis, multiple myeloma
**_Systemic inflammatory disease_**
SLE, vasculitis
**_Diabetes mellitus_**.
**_Unknown_**
212
What is the most useful sign of chronic kidney disease?
One of the most useful signs is bilaterally small kidneys on USS.
213
What are the symptoms of chronic kidney disease?
Malaise, loss of appetite, insomnia, nocturiaand polyuria due to inability to concentrate urine, itching due to high levels of urea, N/V/D, symptoms of anaemia, peripheral and pulmonary oedema, bruising, bone pain due to metabolic bone disease.
In more advanced disease
CNS symptoms such as mental slowing, seizures, or myoclonus.
Eventually there may also be oliguria, which tends to occur in ARF and in the very late stages of CRF.
214
HOW IS ERECTILE FUNCTION CONTROLLED?
Erection is a neurovascular phenomenon under hormonal control
Arterial dilatation, smooth muscle relaxation, activation of the corporeal veno occlusive mechanism
215
What is erectile dysfunction?
The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
216
What is the aeitology of erectile dysfunction?
**_Organic_**
Vasculogenic
Neurogenic
Hormonal
Anatomical
Drug induced
**_Psychogenic_**
217
What are some common risk factors for erectile dysfunction?
In common with CVS disease
Lack of exercise
Obesity
Smoking
Hypercholesterolaemia
Metabolic syndrome
Diabetes x 3 risk of ED
218
What diseases are associated with erectile dysfunction?
Diabetes mellitus
Cardiovascular disease
MI, hypertension
Liver disease and alcohol
Renal failure
Trauma
Pelvic fracture
Iatrogenic
Prostatectomy
219
How can you diagnose ED?
Indicators of psychological aetiology
IIEF (International index for Erectile Function)
Erectile function, orgasmic function, sexual desire, ejaculation, intercourse and overall satisfaction
Physcial examination
220
What are some indicators of psychological aetiology?
Sudden onset of ED
Good nocturnal and early morning erections
Situational ED
Younger patient
221
What are you looking for on a physical examination for erectile dysfunction?
BP and heart rate
Hepatosplenomegaly
Genitalia
Peyronie’s disease
Prostatic enlargement or cancer
Hypogonadism
Small testes, secondary sexual characteristics
222
What is Peyronies disease?
223
What labratory tests can you do?
**Fasting glucose**
**Lipid profile**
**Morning testosterone**
If low testosterone perform prolactin, FSH, LH
Rarely done:
**Nocturnal penile tumescence and rigidity
Intracavernosal injection test
Duplex USS of penile arteries
Arteriography**
224
What are the treatment options for ED?
**Goal is to treat underlying condition**
ie treat reversible factors
Identify and treat reversible causes of ED
Lifestyle and risk factor modification
Patient and partner involvement in education and counselling
225
What are some curable causes of ED?
**_Hormonal causes_**
**Testosterone deficiency**
Primary testicular failure
Pituitary/hypothalamic failure
**Testosterone replacement**
Contraindicated if history of prostate cancer
Check DRE and PSA beforehand
Monitor for hepatic or prostatic disease
**_Psychosexual counselling_**
Variable results
226
What is each line of treatment for ED?
**_First Line_**
Phosphodiesterase (PDE5) inhibitors
**_Second Line_**
Apomorphine SL
Intracavernous injections
Intraurethral alprostadil
Vacuum devices
**_Third Line_**
Consider penile prosthesis implantation
227
What do PDE5 inhibitors do?
PDE5 inhibitors result in increased arterial blood flow, vasodilatation, and erection
Action on Nitric oxide
3 PDE5 inhibitors have been approved. Not initiators of erections – require sexual stimulation
228
What are some examples of ED drugs?
Sildenafil (Viagra)
Effective 30-60 mins after administration
Reduced efficiency after fatty meal
Tadalafil (Cialis)
Vardenafil
229
What are some common side effects from ED drugs?
Headache
Flushing
Dyspepsia
Nasal congestion
Dizziness
Visual disturbance
230
What is Sublingual Apomorphine?
Centrally acting dopamine agonist
Sublingual 2 or 3mg
Not contraindicated with nitrates
Lower efficiency than PDE5 inhibitors
Limited in mild to moderate ED
231
HOW ARE CHLAMYDIA TRACHOMATIS AND NEISSERIA GONORRHOEAE TRANSMITTED?
**_Adult_**
Urethra
Endocervical canal
Rectum
Pharynx
Conjunctiva
**_Neonate_**
Conjunctiva
Atypical pneumonia also in neonatal CT
232
What are the symptoms for GC and CT for a male?
Dysuria and urethral discharge
233
How long is incubation, how many are asymptomatic in males and what is the transmission from feamle to male?
Incubation
GC 2-5 days CT 7-21 days
Asymptomatic
GC 10% CT at least 50%
Transmission female to male
GC 20 – 60-80% CT 70%
234
What are the complications of CT for a male?
Epididymo-orchitis; reactive arthritis
235
What are the symptoms for GC and CT for a female?
Non-specific symptoms – discharge, menstrual irregularity, dysuria
236
How long is incubation, how many are asymptomatic in females and what is the transmission from male to female?
•Asymptomatic
–GC 50% CT over 70%
•Incubation
–GC up to 10 days CT ill-defined
•Transmission male to female
GC 50-90% CT 70%
237
What are some GC and CT female complications?
**_Pelvic inflammatory disease_**
Tubal factor infertility
Ectopic pregnancy
Chronic pelvic pain
**_Neonatal transmission_**
Ophthalmia neonatorum
Atypical pneumonia with CT
Fitz Hugh Curtis syndrome – peri-hepatitis
238
What is used for chlamydia diagnosis?
**_Nucleic Acid Amplification Tests (NAAT)_**
High specificity and sensitivity
Sensitivity not 100%
negative test ≠ not infected
**_Female_**
Self collected vaginal swab
endocervical swab
first void urine – lower sensitivity. Sometimes used in community based asymptomatic screening
**_Male_**
first void urine
239
What is involved with community screening for chlamydia?
Community based studies show prevalence of about 10% in asymptomatic \<25 year olds
Asymptomatic carriage of Chlamydia for a number of years is well described
Diagnosis of Chlamydia in an asymptomatic person does not necessarily imply recent partner change
Community screening aims to reduce complications by reducing the prevalence of asymptomatic infection
240
What is the chlamydia treatment?
Partner management
**_Azithromycin_** or **_Doxycycline_**
**_Erythromycin_** or Azithromycin in pregnancy
Antibiotic resistance not a clinically important problem
241
What is the Gonorrhoea diagnosis?
**_Near patient test_**
Microscopy of gram stained smears of genital secretions looking for gram negative diplococci within cytoplasm of polymorphs
Male urethra
Female endocervix
Rectum
**_Culture on selective medium to confirm diagnosis_**
**_Sensitivity testing_**
**_NAAT_**
242
What is the Gonorrhoea treatment?
Partner notification!
Continuous surveillance of antibiotic sensitivity
Single dose treatment preferred
Aim to cure at least 95% of people at first visit
**_Ceftriaxone_** IMI with **_Azithromycin_** orally
243
What is the importance of partner notification?
Prevent re-infection of index patient
Prevent complications in asymptomatic contacts
244
What are the different infectious syphilis?
Treponema pallidum subspecies pallidum
Early infectious syphilis (within 2 years of infection)
Primary, Secondary and Early Latent
```
Late syphilis (over 2 years since infection)
Late latent, CNS, CVS, gummatous
```
245
How can syphilis be transmitted?
Safer sex – Men who have sex with men avoiding unprotected anal intercourse
BUT
Syphilis highly transmissible through oral sex
246
What are the symptoms of syphilis?
Primary chancre - 95% genital skin, also nipples, mouth
Incubation ‘9-90 days’ - usually 21-35 days
Dusky macule - papule- indurated clean based non-tender ulcer. 50% solitary
Regional nodes 1-2/52 after chancre
Untreated - heals without scarring 4-8/52
247
How do you diagnose syphilis?
Early moist lesions – may be able to identify motile spirochetes on wet mount using dark ground microscopy
Mainstay of diagnosis is serology
**_Genital ulcer_**
Serology usually positive if ulcer present for 2 or more weeks. If serology negative, repeat at 6 and 12 weeks to exclude diagnosis
Rash or other features of suspected secondary syphilis, serology can confidently confirm or refute the diagnosis
248
What are the serology tests for syphilis?
Screening EIA
Confirmatory tests for samples which screen positive
Treponema pallidum particle agglutination test (TPPA)
Non- treponemal test to assess disease activity
VDRL or RPR
Titratable – negative, positive in neat serum, 1:2 dilution, 1:4. 1:8. 1:16., 1:32, 1:64 etc
249
What is the treatment for syphilis?
Penicillin by injection is mainstay
Efficient follow up and partner notification essential
250
WHAT IS THE DEFINITION OF A UTI?
The presence of a pure growth of \>105 organisms per mL of fresh MSU
251
What are some UTI syndromes?
**_Lower tract_**
Cystitis
Prostatitis
Epididymitis/orchitis
Urethritis
**_Upper tract_**
Pyelonephritis
252
What is the classification of UTIs?
**_Asymptomatic bacteriuria_**
**_Uncomplicated_**
Normal renal tract + function
**_Complicated_**
Abnormal renal/GU tract, voiding difficulty/obstruction, decreased renal function, impaired host defences, virulent organism
**_Recurrent_**
Further infection with a new organism
**_Relapse_**
Further infection with the same organism
253
What is pyuria?
Presence of leucocytes in the urine
Associated with infection
Sterile pyuria
254
Where does uncomplicated and complicated UTIs take place?
**_Uncomplicated_**
Non pregnant women
**_Complicated_**
Pregnant
Men
Catheterised
Children
Recurrent/persistent infection
Immuncompromised
Noscomial infection
Structural abnormality
Urosepsis
Associated urinary tract disease
255
What is the most common pathogen for UTIs?
E.coli.
256
Why might a UTI occur?
UTIs may occur either because of the pathogenicity of the organism, the susceptibility of the host or a combination of both factors.
257
How can you diagnose UTIs?
MC&S of MSU [GOLD]
Dipstick
Bloods
258
What can be investigated with Microscopy?
White blood cells
Red blood cells
**_Casts_**
Give clues to renal pathology
Can be indicative of infection
Damage to kidney epithelium (glomerulonephritis)
Bacteria
Epithelial cells
259
What are the signs and symptoms of UTIs?
Loin/abdopain
Offensive-smelling urine
Haematuria
Fever
260
What is the Investigation of recurrent/complicted UTI?
MSU
Examination including DRE/PV
Post void bladder scan
USS scan of renal tract/pelvis
+/- Xray/KUB/NCCT KUB to rule out stones +/- CT
+/- Flexible cystoscopy
261
What are the first line antibiotics for UTIs?
Avoid broad spectrum antibiotics
**_Nitrofurantoin_**
Pregnancy
Renal function
**_Trimethoprim_**
Pregnancy
262
What are the risk factors for UTIs?
Female
Intercourse
Pregnancy
Menopause
UT obstruction
Malformations
Immunosuppression
Catheterization
263
WHAT IS CYSTITIS?
Cystitis is inflammation of the bladder, usually caused by a bladder infection
264
What are the symptoms of cystitis?
Frequency
Dysuria
Urgency
Haematuria
Suprapubic pain.
265
What are the investigations for cystitis?
Urine analysis
Cystoscopy
Biopsy
266
What is the treatment for cystitis?
Nitrofurantoin or Trimethoprim
Cefalexin if preggers
267
WHAT IS PROSTATITIS?
Inflammation/swelling of the prostate gland
268
What is the epidemology of prostatitis?
Affects 35-50% men
Common In men of all ages
269
What is the pathogenesis of prostatitis?
Ascending infection from the urinary tract
Haematogenous spread
Gram negative organisms
E.coli, proteus, Klebsiella
270
What are the symptoms of prostatitis?
Pain
Low back pain
Few urinary symptoms
Swollen or tender prostate
271
What is the diagnosis of prostatitis?
Urinalysis and MSU
Bloods including cultures
STI screen
Urodynamic tests
Imaging
TRUSS +/- CT abdo and pelvis
272
What is the treatment of prostatitis?
Trimethoprim OR
Nitrofurantoin
273
WHAT IS URETHRITIS?
Inflammation of the urethra
274
What are the symptoms of urethritis?
Painful/difficult urination
275
How is urethritis transmitted?
Predominantly sexually transmitted
Gonococcal vs non gonococcal
Chlamydia trachomatis
Ureaplamsa urealyticum
T.vaginalis
M.genitalium
HSV
276
What is the treatment of urethritis?
Requires sexual health referral
Treatment (Abx depends on cause)
Ceftriaxone
Azithromycin
Oflaxacin
Doxycycline
277
WHAT IS EPIDIDYMO-ORCHITIS?
Inflammatory process of the epididymis +/- testes
278
How does epididymo-orchitis present?
Presents with acute onset of pain and swelling
279
What is epididymo-orchitis caused by?
Sexually transmitted pathogens ascending from the urethra or non-sexually transmitted uropathogens spreading from the urinary tract.
280
What does pathogenesis of epididymo-orchitis depend on?
Pathogenesis depends on age and lifestyle
–Age \<35 – STI\>UTI
–Age \>35 – UTI\>STI
Take a sexual history
Elderly predominantly catheter related
281
What are the epididymo-orchitis aetiology?
282
What is epididymo-orchitis signs and symptoms?
Symptoms
Acute onset –usually unilateral scrotal pain +/- swelling
Urethritis symptoms
UTI Symptoms
Signs
Unilateral swelling and tenderness of epididymis +/- testes, urethral discharge, hydrocoele, erythema +/- oedema of scrotum, pyrexia
283
What are the investigations for epidiymo-orchitis?
Samples
Urethral smear
Dipstick/MSU
Laboratory investigation
Urethral swab: Gonorrhoeae
First pass urine (FPU)/ urethral swab for nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis
MSU: MC&S
CRP &ESR
284
What is the treatment for epididmo-orchitis?
Analgesia
Antibiotics
Sexual abstinence
Supportive underwear
Contact tracing
285
What are the antibitotics for epididymo-orchitis?
Sexually transmitted
Ceftriaxone and Doxycycline OR
Ofloxacin
14 days
Refer to GUM
Non sexually transmitted
Ofloxacin or Ciprofloxacin
14 days
286
What is a disease you must rule out for epididymo-orchitis?
MUST RULE OUT TORSION
Any doubt = surgical scrotal exploration
Surgical emergency
Features suggestive of torsion
Short duration of pain
Associated nausea/abdo pain
Previous short duration orchalgia
287
WHAT IS TESTICULAR TORSION?
Testicular torsion happens when a spermatic cord becomes twisted, cutting off the flow of blood to the attached testicle.
288
What are the symptoms of testicular torsion?
Sudden onset of pain in one testis, which makes walking uncomfortable. Pain in the abdomen, nausea, and vomiting are common.
289
What are the signs of testicualr torsion?
Inflammation of one testis—it is very tender, hot, and swollen. The testis may lie high and transversely.
290
What are the differential diagnosis of testicular torsion?
Epididymo-orchitis
Tumour
Hydrocele
291
What are the tests for testicular torsion?
Doppler USS may demonstrate lack of blood flow to testis, as may isotope scanning.
292
What are the treatments for testicular torsion?
Orchidectomy
Could return to scrotum
293
WHAT IS PYELONEPHRITIS?
Infection of the renal parenchyma and soft tissues of renal pelvis /upper ureter
294
What is the epidemology of pyelonephritis?
Predominantly affects
women \<35
295
What are the symptoms of pyelonephritis?
Classical triad
Loin pain
Fever
Pyuria
296
What are the pyelonephritis routes of infection?
Ascending
Urethra colonised with bacteria. Massage of the urethra during intercourse can force bacteria into the female bladder
Haematogenous
S.aureus/Candida
Lymphatic spread
Rare
297
What are the investigations for pyelonephritis?
Abdominal examination
Tender loin
Renal angle tenderness
PV: rule out tubal/ovarian/appendix pathology
Bloods including cultures
U/S scan
Rule out obstruction in upper tract
MSU
298
What is the treatment for pyelonephritis?
Ciprofloxacin or co-amoxiclav
Surgery if needed
299
What are the pyelonephritis complications?
Sepsis
Renal abscess
Progression to chronic pyelonephritis
300
WHAT IS POLYCYSTIC KIDNEY DISEASE?
Polycystic kidney disease (PKD) is an inherited kidney disorder. It causes fluid-filled cysts to form in the kidneys.
301
What are the different types of polycystic kidney disease?
Dominant and recessive
302
What is are the dominant gene mutations?
85% have mutation in PKD1 – reach ESRF by 50s
15% have mutation in PKD2 – reach ESRF by 70s
Family screening important - MRI
303
What are the recessive gene mutations?
Rarer
Variable signs, may present in infancy with multiple renal cysts and congenital hepatic fibrosis
No specific treatment
304
What do the PKDs do?
Polycystinsregulate tubular and vascular development in the kidneys but also in other organs.
305
What are the signs of polycystic kidney disease?
Excessive water and salt loss
Nocturia
Loin pain (due to renal haemorrhage, stones and UTIs)
Hypertension
Bilateral kidney enlargement
Gross haematuria following trauma
Renal colic due to clots
UTI and pyelonephritis may be presenting features
Renal stones are twice as common than in the general population
306
What are the tests for PKDs?
Ultrasound diagnostic criteria
At least two unilateral or bilateral renal cysts at age \<30 years
At least two cysts in each kidney between the ages of 30-59 years
At least four cysts in each kidney at age \>60 years
The diagnosis is supported by hepatic or pancreatic cysts
307
What are the treatment options for polycystic kidney disease?
No cure
Counselling and support for patients & family members
Monitor for disease progression
Treat hypertension, UTIs, stones, give analgesia
Dialysis for end-stage renal failure
