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ΩΩ 2a Bateman - Systems Based > Renal and Urogenital System > Flashcards

Renal and Urogenital System Flashcards

1
Q

Where does each diuretic act in the nephron?

A
  1. Loop diuretics - Na-K-2Cl cotransporter in the thick ascending limb, diminsihing the osmotic gradient for water reabsorption
  2. Thiazide diuretics - Blocks NaCl transports in the DCT, stopping sodium and water reabsorption
  3. Potassium sparing diuretics - Blocks NaK channels in the Collecting duct
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2
Q

WHAT IS BPH?

A

Increase in epithelial (glandular)

and stromal (musculofibrous)

cell numbers in the periurethral area of the prostate

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3
Q

What is the incidence of BPH?

A

Older men affected

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4
Q

What are the symptoms of BPH?

A

Lower urinary tract symptoms (LUTS)

AND

Haematuria
Bladder stones
UTIs

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5
Q

What tests would you do for BPH?

A
  1. DRE
    • Enlarged prostate
  2. ‘Rule out’ cancer
    • PSA raised
    • Transrectal USS ± biopsy.
  3. Ultrasound (large residual volume, hydronephrosis)
    • Visulise kidneys
  4. MSU (midstream specimin of urine)
    • Bacteria
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6
Q

What are the management options for BPH?

A
  1. Drugs
    • 1st line - Alpha-blockers
    • Tamsulosin, alfuzosin
    • They Decrease smooth muscle tone (prostate and bladder).
    • 2nd line - 5alpha-reductase inhibitors
    • Finasteride
    • Decreases testosterone’s conversion to dihydrotestosterone
  2. Surgery
    • Transurethral resection of prostate
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7
Q

What are the side effects of alpha blockers?

A
  1. Dry mouth
  2. Weight gain
  3. Dizziness
  4. Hypotension
  5. Sexual dysfunction
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8
Q

What is a requirement of BPH but not BPE?

A

Androgens.

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9
Q

WHERE CAN YOU GET STONES?

A

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

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10
Q

What is the epidemology of urinary tract stones?

A

Common: lifetime incidence up to 15%

Peak age: 20–40yr

Male more than females

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11
Q

Why do patients get stones?

A

Anatomical factors
Congenital (horseshoe, duplex)
Acquired (obstruction, surgery)

Urinary factors
Metastable urine, promotors and inhibitors
Calcium, oxalate, urate, cystine
Dehydration

Infection

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12
Q

What symptoms can urinary tract stones cause?

A
  1. Asymptomatic
  2. Loin pain
  3. Renal colic
  4. UTI symtpoms
  5. Dysuria, stangury, urgency, frequency
  6. Recurrent UTIs
  7. Haematuria
    • Visible and non-visible (85%)
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13
Q

WHAT IS RENAL COLIC?

A

Pain resulting from upper urinary tract obstruction.

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14
Q

Where are the three main places where stones get stuck?

A
  1. Pelvic brim
  2. Pelvi-ureteric junction
  3. Vesico-ureteric junction
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15
Q

What are the symptoms of renal colic?

A
  1. Rapid, severe unilateral loin pain
  2. Unable to get comfortable - writhing
  3. Radiates to groin and ipsilateral testis/labia
  4. Associated nausea / vomiting
  5. Spasmodic / colicky, worse with fluid loading
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16
Q

How do you investigate a renal colic?

A

Imaging
CT-KUB

Urine dip

Urine microscopy

U&Es

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17
Q

How do you manage renal colic?

A
  1. Pain relief
    • Diclofenac or opioids; abxif infection suspected
  2. Stones <5mm diameter
    • 90%+ pass spontaneously
  3. Stones >5mm diameter:
    • Medical therapy (nifedipine or tamsulosin)
    • Extracorporeal shockwave lithotripsy
    • Percutaneous nephrolithotomy
  4. If obstruction + infection
    • Ureteric stent may be needed
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18
Q

WHAT IS PROSTATE CANCER?

A

Cancer of the prostate

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19
Q

What type of cancer is prostate cancer?

A

Adenocarcinoma

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20
Q

What are the risk factors of prostate cancer?

A
  1. +ve family history
  2. Increased testosterone
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21
Q

Where does prostate cancer occur in the prostate?

A

Occurs in peripheral zone of prostate

85% of tumours are multifocal

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22
Q

How does prostate cancer spread and where does it spread to?

A

Spreads locally through prostate capsule

Metastasises to
Lymph nodes
Bone (sclerotic)
Lung, liver and brain

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23
Q

What are the biomarkers for prostate cancer?

A

Tissue

Serum
Prostate-specific Antigen (PSA)
Prostate-specific membrane antigen (PSMA)

Urine
PCA3
Gene fusion products (TMPRSS2-ERG)

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24
Q

What does PSA do, what happens in BPH?

A

Serine protease responsible for liquefaction of semen

Small amount of retrograde leakage

Detected in small quantities in the blood

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25
Q

What does PSA show in prostate cancer?

A

PROSTATE SPECIFIC not CANCER SPECIFIC

Elevated in benign prostate enlargement, urinary tract infection, prostatitis

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26
Q

What are the symptoms of prostate cancer?

A

Asymptomatic or nocturia

Hesitancy

Poor stream

Terminal dribbling, or obstruction

Weight loss ± bone pain suggests mets

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27
Q

How can you diagnose prostate cancer?

A

DRE
Hard and irregular

Prostate specific antigen (PSA)
Increased

Prostate biopsy

Transrectal ultrasound scan (TRUSS)

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28
Q

What is the gleeson score? What is the T score?

A

Cancer grading of prostate

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

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29
Q

What is the treatment for prostate cancer?

A

Surgery - radical prostatectomy

Radiotherapy - external beam

Observation - watchful waiting

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30
Q

What is the treatment for metastatic prostate cancer?

A

Anti-androgen therapy

  1. Synthetic GnRH agonist or antagonists
    GnRH agonists: e.g. Goserelin (Zoladex)
    initially therapy is often covered with an anti-androgen to prevent a rise in testosterone
  2. Bicalutamide
    Non-steroidal anti-androgen
    Blocks the androgen receptor
  3. Chemotherapy
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31
Q

What condition are you more at risk of after radiotherapy for prostate cancer?

A

Colon, bladder, and rectal cancer

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32
Q

WHAT IS BLADDER CANCER?

A

Cancer of the bladder

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33
Q

What are the different types of bladder cancer?

A

Transitional cell carcinoma

Some are
Squamous cell carcinoma
Adenocarcinoma

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34
Q

What are some risk factors of developing bladder cancer?

A
  1. Paraplegia
  2. Smoking
  3. Occupational (rubber, cable, textile, printing)
  4. Drugs (phenacetin, aspirin, cyclophosphamide)
  5. Bladder stones
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35
Q

How can bladder cancer present?

A
  1. 85% painless VH (visible haematurtia)
  2. Irritative voiding / recurrent UTI’s (CIS)
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36
Q

How can you diagnose a bladder tumour?

A
  1. CT
    • Urogram is both diagnostic and provides staging
  2. Cytoscopy + Biopsy
    • Diagnostic
  3. Urine
    • Microscopy/cytology (cancers may cause sterile pyuria)
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37
Q

What are the different stages of bladder cacner?

A

Ta surface

T1 lamina propria, not hit the muscle

T2 hit the muscle

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38
Q

How can you treat bladder tumours?

A

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

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39
Q

WHAT IS RENAL CANCER?

A

Cancer of the kidney

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40
Q

What are the types of renal cancer?

A

95% renal cell carcinoma (RCC)
An adenocarcinoma

TCC (transitional cell carcinoma) <5%

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41
Q

What is the epidemology of renal cancer?

A

Sporadically
One tumour
Older men
Smokers

Inherited
E.g. Von Hippel-Lindau disease
Younger men and women
Both kidneys

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42
Q

What are the symptoms of renal cancer?

A
  1. Most found incidentally!
  2. Haematuria
  3. Flank pain
  4. Mass
  5. Weight loss
  6. Paraneoplastic syndromes
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43
Q

What substances do the paraneoplastic syndromes in renal cancer release?

A
  1. Erythropoetin - more red blood cells, polycythemia
  2. Renin - Increase blood pressure
  3. PTHrP
  4. ACTH - cortisol
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44
Q

What does a tumour of the left kidney cause that the right doesn’t?

A

Varicocles due to vein going into renal vein before IVC

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45
Q

How is renal cancer staged?

A

Using the TNM system.

T - Size, growth into nearby vein

N - Spread to lymph nodes

M - Degree of metastasis

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46
Q

How is renal cancer diagnosed?

A
  1. BP
    • Increased from renin secretion.
  2. Blood
    • FBC (polycythaemia from erythropoietin secretion);
    • ESR; U&E, ALP (bony mets?).
  3. Urine
    • RBCS
    • Haematuria
  4. Imaging
    • US; CT/MRI; IVU (filling defect ± calcification);
    • CXR (‘cannon ball’ metastases)
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47
Q

What is the treatment of renal cancer?

A
  1. Resection if localised
  2. Partial nephrectomy
  3. Radical nephrectomy
  4. Biological therapies if metastasized

Molecular targeted therapies
VEGF receptor
Sunitinib, bevacizumab and sorafenib

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48
Q

WHAT ARE EPIDIDYMAL CYSTS?

A

Masses that lie above and behind the testis

Lie on the epididymus

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49
Q

When do epididymal cysts develop?

A

Usually develop in adulthood

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50
Q

What is the causes of epididymal cysts?

A

Unknown

Theroies
Blockage
Trauma
Inflammation

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51
Q

What do epididymal cysts contain?

A

Clear or milky (spermatocele) fluid.

Dead sperm cells

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52
Q

What are the symptoms of epidiymal cysts?

A

Epididymal cysts are the most common cause of scrotal swellings seen in primary care.

Features

  1. Separate from the body of the testicle
  2. Found posterior to the testicle
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53
Q

What are the tests for epidiymal cysts?

A
  1. Usually discovered incidentally - physical exam
  2. They trans-illuminate
  3. Fluctuant - unstable
  4. Ultrasound
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54
Q

What is the treatment of epidiymal cysts?

A
  1. Usaully none
  2. Medications
    • NSAIDs
  3. Surgery
    • Spermatocoelectomy
  4. Aspiration and sclerotherapy
    • Draw fluid out and something put back in
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55
Q

WHAT IS A HYDROCELE?

A

Result of excessive fluid in tunica vaginalis (serous space surrounding testes)

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56
Q

What are the different types of hydrocoeles?

A

Primary
Associated with a patent processus vaginalis
Typically resolves during the 1st year of life

Secondary
Testis tumour/trauma/infection.

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57
Q

What are the symptoms for hydrocele?

A

Painless mass

Sometimes
Pain
Heaviness

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58
Q

What are the tests for hydrocele?

A

Painless smooth, non-tender, cystic sweeling

Ultrasound

Cannot palpate testis as located within the fluid collection

TRANSILLUMINATES

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59
Q

What are the managements for hydrocele?

A

Asymptomatic - Nothing

Symptomatic - Aspiration, resection

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60
Q

WHAT ARE VARICOCOELES?

A

Dilated veins of pampiniform plexus.

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61
Q

Which side of the testis of more affected by varicoceles?

A

Left side more commonly a effected.

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62
Q

Which is the cause of varicoceles?

A

Left side unknown

Right side venous obsturction from tumour

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63
Q

What are the symptoms of varicocele?

A
  1. Dull ache
  2. Bag of worms
  3. Heavy
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64
Q

What are the tests for varicoceles?

A
  1. Ultrasound with Doppler studies
  2. Physical exam
    • Valsalva monuver.
  3. Semen analysis
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65
Q

What are the treatments for varicoceles?

A

Conservative

Surgical treatment

Vascular ablation or embolization

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66
Q

WHAT IS EPIDIDYMITIS?

A

Inflammation of the epidiymis.

Acute epididymitis mostly occurs in young males.

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67
Q

What is the epidemology of epididmytis?

A

Acute epididymitis mostly occurs in young males.

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68
Q

What are the causes of epididymitis?

A

E. coli

Chlamydia

Gonorrhea

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69
Q

What is the pathology of epididymitis?

A

Organisms may get to Epididymis by retrograde spread from prostatic urethra & seminal vesicles or less commonly, through blood stream.

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70
Q

What are the symptoms of epididymitis?

A

Severe scrotal pain

Fever

Swollen scrotal area

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71
Q

What are the tests for epididymitis?

A
  1. Prehn’s sign - lift testicules to see if pain improves, it DOES in epididymitis
  2. Ultrasound - check for torsion
  3. Urethral swabs
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72
Q

What is the treatment of epididymitis?

A

Doxycycline

If gonorrhoea suspected add
Ceftriaxone

Scrotal elevation

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73
Q

WHAT IS TESTICULAR CANCER?

A

Cancer of the testis

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74
Q

What are the different types of testicular cancer?

A
  1. Seminomas (germ cell) – slow growing, classic appearance - betaHCG - cause gynocomastia
  2. Non-seminoma
  3. Sex cord (stromal)
  4. Mixed
  5. Lymphoma
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75
Q

What is the epidemology of testicular cancer?

A

The commonest malignancy in males aged 15–44

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76
Q

What are some risk factors for testicular tumours?

A

Cryptochidism - undecended testicle

Fhx - family history.

Previous testicular tumour.

Poorly understood.

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77
Q

What are the symptoms of testicular cancer?

A

80% painless lump in testis (hard/craggy, lies within testis, can be felt above).

Abdominal mass

HYDROCOELE

PAIN

METASTASES

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78
Q

What are some investigations for testicular tumour?

A

Scrotal US

Biopsy

Tumour markers

  1. AFP alpha feta protein (1/2 life 5 days) - also liver cancer, secreted by placenta
  2. B-hcg (24-48)
  3. LDH - lactacte dehydrogenase - shows turnover of cells
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79
Q

What operations do you do for testicular tumour?

A
  1. Early inguinal orchidectomy if malignant.

Types of tumour -

  1. SEMINOMAS are very radiosensitive.
  2. NON-SEMINOMAS (TERATOMAS) - cytotoxic chemotherapy.
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80
Q

WHAT IS ACUTE KIDNEY INJURY?

A

Rapid reduction in kidney function over hours to days

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81
Q

What are the risk factors for acute kidney injury?

A
  1. Age >75
  2. Chronic kidney disease
  3. Cardiac failure
  4. Peripheral vascular disease
  5. Chronic liver disease
  6. Diabetes
  7. Drugs (esp newly started)
  8. Sepsis
  9. Poor fluid intake/increased losses
  10. History of urinary symptoms
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82
Q

What are the pre-renal causes of AKI?

A

Renal hypoperfusion,

Hypotension
Renal artery stenosis ± ACE-i.

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83
Q

What are the Intrinsic renal causes of AKI?

A
  1. Glomerulonephritis
  2. Acute tubular necrosis (ATN)
  3. Acute interstitial nephritis (AIN), respectively
  4. Rhabdomyolysis
  5. Tumour lysis syndrome
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84
Q

What are the post renal causes of AKI?

A

Caused by urinary tract obstruction

Stones
Malignancy
Extrinsic compression

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85
Q

What are some nephrotoxic drugs?

A
  1. ACE inhibitors/ ARBs
    • Results in dilated efferent arterioles decreasing GFR
  2. NSAIDs
    • Inhibits cyclooxygenase which causes excess vasoconstriction of the afferent arteriole
  3. Metofrmin
  4. Diuretics
  5. Aminoglycosides (10-15% incidence of Acute Tubular Necrosis)
  6. Digoxin
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86
Q

What are the different stages of an AKI?

A
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87
Q

What is the presentation of AKI?

A
  1. Oliguria or anuria
  2. Nausea, vomiting
  3. Dehydration
  4. Confusion
  5. Hypertension
  6. Urinary retention (large painless bladder)
  7. Postural hypotension
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88
Q

How can you assess AKI?

A
  1. U&Es
  2. Urinalysis
  3. Imaging
    • Renal ultrasound
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89
Q

How do you diagnose acute kidney injury?

A

1 OUT OF 3

  1. Rise in creatine > 26 micromol/L in 48 hrs (above baseline).
  2. Rise in creatinine > 50% (best figure in last 6 months).
  3. Urine output < 0.5 ml/kg/hr for > 6 consecutive hours.
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90
Q

How can you treat AKI?

A
  1. Euvolaemia
  2. Stop nephrotoxic drugs
    NSAIDs
    Aminoglycosides
    ACE inhibitors
    Diuretics
    Sometimes - Metofrmin, Lithioum + Digoxin
  3. Treat underlying cause
  4. Manage complications
  5. Dialysis
    • IF ENCEPHALOPATHY PRESENT
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91
Q

What are some complications of AKI?

A
  1. Hyperkalaemia
  2. Pulmonary oedema
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92
Q

What are the implications for dialysis in a patient with an AKI?

A
  1. Severe metabolic acidosis
  2. Persistent hyperkalaemia
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93
Q

WHAT IS GLOMERULONEPHRITIS?

A

Inflammation in the glomerulus.

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94
Q

What is the basic difference between nephritic and nephrotic syndrome?

A

Nephrotic syndrome involves the loss of a lot of protein

Nephritic syndrome involves the loss of a lot of blood

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95
Q

What are the consequences of glomerulonephritis?

A

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

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96
Q

What is the spectrum of glomerulonephritis disease?

A
  1. Blood pressure
    • Normal to malignant hypertension
  2. Urine dipstick
    • Proteinuria mild –> nephrotic; haematuria mild –> macroscopic
  3. Renal function
    • Normal to severe impairment
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97
Q

What are the causes of glomerulonephritis?

A
  1. Nephrotic
    • Membranous
    • Minimal change
    • Diabetes
    • SLE (class V nephritis) Amyloid
    • Hepatitis B/C
  2. Nephritic
    • IgA nephropathy​
    • Post streptococcal
    • Vasculitis
    • SLE (other classes of nephritis)
    • Anti-GBM disease
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98
Q

WHAT IS NEPHRITIC SYNDROME?

A

Haematuria
+++ blood on urine dipstick (macro/microscopic)
Red cell casts (distinguishing feature)

Proteinuria
++ protein on urine dipstick

Hypertension

Low urine volume (<300ml/day)

99
Q

What are some causes of nephritic syndrome?

A
  1. Post-streptococcal glomerulonephritis
  2. IgA nephropathy
  3. Rapidly progressive glomerulonephritis (Goodpasture’s syndrome/vasculitis disorders)
100
Q

When does nephritic syndrome normally appear?

A

Often appears days-weeks after URTI

  1. IgA nephropathy – days after URTI
  2. Post-streptococcal glomerulonephritis – weeks after URTI
101
Q

What are the clinical features of nephritic syndrome?

A
  1. Haemoatruia
  2. Proteinuria
  3. Facial oedema
  4. Hypertension
  5. Oliguria
102
Q

What is the treatment for nephritic syndrome?

A
  1. Monitor fluid balance, weight, blood pressure and renal function
  2. Restrict sodium and potassium as appropriate
  3. Restrict fluids
  4. Treat hypertension
  5. Consider prophylactic penicillin
103
Q

WHAT IS IgA NEPHROPATHY?

A

IgA accumulates in nephron and causes inflammation

Classically presents as macroscopic haematuria in young people following an upper respiratory tract infection.

104
Q

What are the clinical features of IgA nephropathy?

A
  1. Commonly young male
  2. Macroscopic haematuria
105
Q

How can you diagnose IgA nephropathy?

A
  1. Biopsy
    • Focal proliferative glomerulonephritis with IgA
106
Q

What is the management of IgA nephropathy?

A
  1. Supportive care: BP control with RAAS inhibitors, Diet, Lower Cholesterol.
  2. Prednisolone (alternative-day regime)
  3. Phenytoin - causes reduced IgA levels
107
Q

WHAT IS NEPHROTIC SYNDROME?

A
  1. Proteinuria
  2. Hypoalbuminaemia
  3. Oedema
108
Q

What are the causes of nephrotic syndrome?

A

Primary
Minimal change disease
Membranous nephropathy
Focal segmental glomerulosclerosis

Secondary
Hepatitis
Diabetic nephropathy
Drug-related

109
Q

What are the test for nephrotic syndrome?

A

Urine dip (protein +++)

Bloods (show low albumin)

Biopsy (adults)

110
Q

What are the complications of nephrotic syndrome?

A
  1. Susceptibility to infection
    Loss of immunoglobulin in urine and also immunosuppressive treatments
  2. Thromboembolism
    Increase clotting factors and platelet abnormalities.
  3. Hyperlipidaemia
    Hepatic lipoprotein synthesis, response to low oncotic pressure
111
Q

What is the treatment of nephrotic syndrome?

A
  1. Steroids in children
  2. Diuretics for oedema
  3. ACE-i for proteinuria
  4. Treat underlying cause
112
Q

WHAT IS MEMBRANOUS GLOMERULONEPHRITIS?

A

Thickening of glomerular capillary wall.

IgG, complement deposit in sub epithelial surface causing leaky glomerulus

113
Q

What are the different types of membranous glomerularnephritis?

A

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.

114
Q

What are the causes of membranous glomerularnephritis?

A
  1. Idiopathic
    • Due to anti-phospholipase A2 antibodies
  2. Infections
    • Hepatitis B, malaria, syphilis
  3. Malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia
  4. Drugs
    • Gold, penicillamine, NSAIDs
  5. Autoimmune diseases
    • Systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid
115
Q

What are the clinical features of membranous glomerularnephritis?

A
  1. Proteinuria or nephrotic syndrome (80%)
  2. Hypertension (10-50%) seems to depend on the amount of renal damage
  3. Haematuria is rare
116
Q

What is the diagnosis for membranous glomerularnephritis?

A
  1. Renal biopsy
    • The basement membrane is thickened with subepithelial electron dense deposits.
    • Silver staining - this creates a ‘spike and dome’ appearance
117
Q

What is the treatment for membranous glomerularnephritis?

A
  1. All patients should receive an ACE inhibitor or an angiotensin II receptor blocker (ARB):
    • These have been shown to reduce proteinuria and improve prognosis
  2. Immunosuppression
    • Corticosteroids alone have not been shown to be effective. A combination of corticosteroid + another agent such as cyclophosphamide is often used
  3. Consider anticoagulation for high-risk patients
118
Q

WHAT IS MINIMAL CHANGE DISEASE?

A

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).

119
Q

What is the pathology of minimal change disease?

A
  1. T cells secrete inflammatory cytokines and damage foot processes on podocytes
  2. Charge is lost
  3. Albumin let through
  4. Ig not let through
120
Q

What is the presentation of minimal change disease?

A
  1. Normal apart from
  2. Nephrotic syndrome with selective proteinuria:
  3. [albumin] > [globulin]
  4. Minimal or absent haematuria (never macroscopic)
121
Q

What are the diagnosis options for minimal change disease?

A
  1. Biopsy: Normal under light microscopy (hence the name).
  2. Electron microscopy shows enhacement of the podocyte foot processes
122
Q

What is the treatment of minimal change disease?

A
  1. Majority of cases (80%) are steroid-responsive
  2. ​Cyclophosphamide is the next step for steroid-resistant cases
123
Q

WHAT IS CHRONIC KIDNEY DISEASE?

A

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

124
Q

What are the different stages of chronic kidney disease?

A

Only can call CKD if patient has symptoms and changes on urine dip

125
Q

After what GFR stage are symptoms seen?

A

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).

126
Q

What are some causes of chronic kidney disease?

A
  1. Glomerulonephritis - accounts for 25% of cases
  2. Multisystem disease:
    • Diabetes mellitus
    • Acute pyelonephritis / tubulointerstitial disease
    • Hypertension and vascular causes
127
Q

What are the symptoms of chronic kidney disease?

A
  1. Malaise
  2. Loss of appetite
  3. Insomnia
  4. Nocturia and polyuria due to inability to concentrate urine
  5. Anaemia
  6. Peripheral and pulmonary oedema
128
Q

What is the most useful sign of chronic kidney disease?

A

One of the most useful signs is bilaterally small kidneys on USS.

129
Q

What must happen for diagnosis of CKD?

A
  1. The renal failure must be demonstrated to be long-standing and not due to an acute and reversible renal insult
  2. The aetiology of the renal damage should be determined
  3. Any reversible factors should be identified and addressed
130
Q

What is the most important differences between AKI and CKD?

A
  1. Small kidneys on ultrasound for CKD
  2. Hypocalcaemia due to lack of vit D in CKD
131
Q

What is the treatment of CKD?

A
  1. Reduced dietary intake of phosphate is the first-line management
  2. IF ACR >70
    IF eGFR <60 on two occasions
    • Start ACE inhibitor and STATIN
  3. Phosphate binders
  4. Calcium binders e.g. calcium acetate
    • May cause hypercalcaemia
  5. Vitamin D:
    • Alfacalcidol
    • Calcitriol
  6. Parathyroidectomy may be needed in some cases
132
Q

What is acceptable once starting treatment for CKD?

Which levels can change and how much by?

A
  1. NICE suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, although any rise should prompt careful monitoring and exclusion of other causes (e.g. NSAIDs).
  2. A rise greater than this may indicate underlying renovascular disease.
133
Q

HOW IS ERECTILE FUNCTION CONTROLLED?

A

Erection is a neurovascular phenomenon under hormonal control

Arterial dilatation, smooth muscle relaxation, activation of the corporeal veno occlusive mechanism

134
Q

What is erectile dysfunction?

A

The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance

135
Q

What is the aeitology of erectile dysfunction?

A

Organic
Vasculogenic
Neurogenic
Hormonal
Anatomical
Drug induced

Psychogenic

136
Q

What are some common risk factors for erectile dysfunction?

A

In common with CVS disease
Lack of exercise
Obesity
Smoking
Hypercholesterolaemia
Metabolic syndrome

Diabetes x 3 risk of ED

137
Q

How can you diagnose ED?

A
  1. Indicators of psychological aetiology
  2. IIEF (International index for Erectile Function)
    Erectile function, orgasmic function, sexual desire, ejaculation, intercourse and overall satisfaction
  3. Physcial examination
138
Q

What are some indicators of psychological aetiology of ED?

A
  1. Sudden onset of ED
  2. Good nocturnal and early morning erections
  3. Situational ED
  4. Younger patient
139
Q

What is Peyronies disease?

A
140
Q

What labratory tests can you do for ED?

A
  1. Fasting glucose
  2. Lipid profile
  3. Morning testosterone
    • If low testosterone perform prolactin, FSH, LH
141
Q

What are the treatment options for ED?

A
  1. PDE-5 inhibitors (such as sildenafil, ‘Viagra’)
    • They should be prescribed (in the absence of contraindications) to all patients regardless of aetiology
  2. Vacuum erection devices are recommended as first-line treatment in those who can’t/won’t take a PDE-5 inhibitor.
142
Q

What are some curable causes of ED?

A
  1. 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
  2. Psychosexual counselling
    • Variable results
143
Q

What is each line of treatment for ED?

A

First Line
Phosphodiesterase (PDE5) inhibitors e.g. Sildenafil (Viagra)

Second Line
Apomorphine SL
Intracavernous injections
Intraurethral alprostadil
Vacuum devices

Third Line
Consider penile prosthesis implantation

144
Q

What are some common side effects from ED drugs?

A

Headache

Flushing

Dyspepsia

Nasal congestion

Dizziness

Visual disturbance

145
Q

HOW IS CHLAMYDIA TRACHOMATIS TRANSMITTED?

A

Adult
Urethra
Endocervical canal
Rectum
Pharynx
Conjunctiva

Neonate
Conjunctiva

Atypical pneumonia also in neonatal CT

146
Q

What are the symptoms for chlamydia?

A
  1. Asymptomatic in around 70% of women and 50% of men
  2. Women
    • Cervicitis (discharge, bleeding), dysuria
  3. Men
    • Urethral discharge, dysuria
147
Q

What is chlamydia diagnosis?

A
  1. Nucleic Acid Amplification Tests (NAAT)
    • High specificity and sensitivity
    • Sensitivity not 100%
    • Negative test ≠ not infected
  2. Female
    • Vulvovaginal swab
  3. Male
    • First void urine
148
Q

What is the chlamydia treatment?

A
  1. Doxycycline - 7 day course
  2. If pregnany then azithromycin, erythromycin or amoxicillin
149
Q

What are some chlamydia complications?

A
  1. Epididymitis
  2. Pelvic inflammatory disease
  3. Endometritis
  4. Increased incidence of ectopic pregnancies
  5. Infertility
  6. Reactive arthritis
  7. Perihepatitis (Fitz-Hugh-Curtis syndrome)
150
Q

HOW IS NEISSERIA GONORRHOEAE TRANSMITTED?

A

Adult
Urethra
Endocervical canal
Rectum
Pharynx
Conjunctiva

Neonate
Conjunctiva

Atypical pneumonia also in neonatal CT

151
Q

What are the symptoms for gonorrhoea?

A
  1. Males
    • Urethral discharge, dysuria
  2. Females
    • Cervicitis e.g. leading to vaginal discharge
  3. Rectal and pharyngeal infection is usually asymptomatic
152
Q

What is the Gonorrhoea diagnosis?

A
  1. Microscopic examination of Gram stained smears
    • ​​Genital secretions looking for gram negative diplococci within cytoplasm of polymorphs
    • Male urethra
    • Female endocervix
  2. Nucleic acid amplification tests (NAAT)
    • ​​Men - First pass utine
    • Women - vaginal or endocervical swab
  3. Culture on selective medium to confirm diagnosis
153
Q

What is the Gonorrhoea treatment?

A

Ceftriaxone IM

Partner notification

154
Q

WHAT IS SYPHILIS?

A

Syphilis is a sexually transmitted disease which is characterised by:

minor early illness

more serious late manifestations after a variable latent period

155
Q

How can syphilis be transmitted?

A

Safer sex – Men who have sex with men avoiding unprotected anal intercourse

BUT

Syphilis highly transmissible through oral sex

156
Q

What are the symptoms of syphilis?

A
  1. Primary
    • Chancre leision - mostly genital
    • Lymphadenopathy
  2. Secondary
    • Fever
    • Sore throat
    • Malaise
    • Skin rashes
  3. Tertiary
    • Gummata - granulomatous lesions
157
Q

How do you diagnose syphilis?

A
  1. Dark ground microscopy
    Detection of spirochaete in primary and secondary syphilis
  2. Serology
    ​- Treponema pallidum HaemAgglutination test (TPHA) - Always positive even after treatment
    ​- Venereal Disease Research Laboratory (VDRL Test) - Negative after treatment
158
Q

What is the treatment for syphilis?

A

Penicillin by injection is mainstay

Efficient follow up and partner notification essential

159
Q

WHAT IS THE DEFINITION OF A UTI?

A

The presence of a pure growth of >105 organisms per mL of fresh MSU

160
Q

What are some UTI syndromes?

A

Lower tract
Cystitis
Prostatitis
Epididymitis/orchitis
Urethritis

Upper tract
Pyelonephritis

161
Q

What is the classification of UTIs?

A

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

162
Q

What is pyuria?

A

Presence of leucocytes in the urine

Associated with infection

Sterile pyuria

163
Q

What is the most common pathogen for UTIs?

A

E.coli.

164
Q

What are the signs and symptoms of UTIs?

A

Loin/abdopain

Offensive-smelling urine

Haematuria

Fever

165
Q

How can you diagnose UTIs?

A
  1. MC&S of MSU [GOLD]
  2. Dipstick
  3. Bloods
166
Q

What can be investigated with Microscopy?

A
  1. White blood cells
  2. Red blood cells
  3. Casts
    • Give clues to renal pathology
    • Can be indicative of infection
    • Damage to kidney epithelium (glomerulonephritis)
  4. Bacteria
  5. Epithelial cells
167
Q

What are the first line antibiotics for UTIs?

A

Avoid broad spectrum antibiotics

Nitrofurantoin
Pregnancy - avoid near term
Renal function

Trimethoprim
Pregnancy - teratogenic in first trimester and should be avoided during pregnancy

168
Q

What are the risk factors for UTIs?

A
  1. Female
  2. Intercourse
  3. Pregnancy
  4. Menopause
  5. UT obstruction
  6. Malformations
  7. Immunosuppression
  8. Catheterization
169
Q

WHAT IS CYSTITIS?

A

Cystitis is inflammation of the bladder, usually caused by a bladder infection

170
Q

What are the symptoms of cystitis?

A
  1. Frequency
  2. Dysuria
  3. Urgency
  4. Haematuria
  5. Suprapubic pain.
171
Q

What are the investigations for cystitis?

A
  1. Urine dipstick
  2. Urine microscopy, culture and sensitivity
  3. Biopsy
172
Q

What is the treatment for cystitis?

A

Nitrofurantoin or Trimethoprim

Cefalexin if preggers

173
Q

WHAT IS PROSTATITIS?

A

Inflammation/swelling of the prostate gland

174
Q

What is the epidemology of prostatitis?

A

Affects 35-50% men

Common In men of all ages

175
Q

What is the pathogenesis of prostatitis?

A

Ascending infection from the urinary tract

Haematogenous spread

Gram negative organisms
E.coli, proteus, Klebsiella

176
Q

What are the symptoms of prostatitis?

A
  1. Pain
  2. Low back pain
  3. Few urinary symptoms
  4. Swollen or tender prostate
177
Q

What is the diagnosis of prostatitis?

A
  1. Urinalysis and MSU
  2. Bloods including cultures
  3. STI screen
  4. Urodynamic tests
  5. Imaging
  6. TRUSS +/- CT abdo and pelvis
178
Q

What is the treatment of prostatitis?

A

Trimethoprim OR

Nitrofurantoin

179
Q

WHAT IS URETHRITIS?

A

Inflammation of the urethra

180
Q

What is the cause of urethritis?

A

Gonococcal urethritis

“classic” form of infective urethritis

caused by Neisseria gonorrhoeae (1)

Non-gonococcal urethritis (NGU)

most often caused by either Chlamydia trachomatis or Mycoplasma genitalium

181
Q

What are the symptoms of urethritis?

A

Painful/difficult urination

182
Q

How is urethritis transmitted?

A
  1. Predominantly sexually transmitted
    • Gonococcal vs non gonococcal
    • Chlamydia trachomatis
    • Ureaplamsa urealyticum
    • T.vaginalis
    • M.genitalium
    • HSV
183
Q

How do you diagnose urethritis?

A

Microscopy of either urethral swab or first-void sample

Chlamydia trachomatis - nucleic acid amplification test (NAAT)

Gonorrhoea - urethral smear microscopy, NAAT and culture

184
Q

What is the treatment of urethritis?

A

Requires sexual health referral

Treatment (Abx depends on cause)
Ceftriaxone - Gonorrhoea
Azithromycin - One off dose
Doxycycline - 7 day course

185
Q

WHAT IS EPIDIDYMO-ORCHITIS?

A

Inflammatory process of the epididymis +/- testes

186
Q

How does epididymo-orchitis present?

A

Presents with acute onset of pain and swelling

187
Q

What is epididymo-orchitis caused by?

A

Sexually transmitted pathogens ascending from the urethra or non-sexually transmitted uropathogens spreading from the urinary tract.

188
Q

What does pathogenesis of epididymo-orchitis depend on?

A

Pathogenesis depends on age and lifestyle

–Age <35 – STI>UTI

–Age >35 – UTI>STI

Take a sexual history
Elderly predominantly catheter related

189
Q

What are the epididymo-orchitis aetiology?

A
190
Q

What is epididymo-orchitis signs and symptoms?

A

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

191
Q

What are the investigations for epidiymo-orchitis?

A
  1. Urethral swab: Gonorrhoeae
  2. First pass urine (FPU)/ urethral swab for nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis
  3. MSU: MC&S
192
Q

What is the treatment for epididmo-orchitis?

A

Analgesia

Antibiotics - if organism unknown
Ceftriaxone 500mg intramuscularly single dose
PLUS Doxycycline 100mg by mouth twice daily for 10-14 days

Sexual abstinence

Supportive underwear

Contact tracing

193
Q

What are the antibitotics for epididymo-orchitis?

A

Sexually transmitted

  1. IM Ceftriaxone
  2. AND Doxycycline Orally

For 14 days and refer to GUM

Non sexually transmitted

  1. Ofloxacin or Ciprofloxacin

For 14 days

194
Q

What is a disease you must rule out for epididymo-orchitis?

A

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

195
Q

WHAT IS TESTICULAR TORSION?

A

Testicular torsion happens when a spermatic cord becomes twisted, cutting off the flow of blood to the attached testicle.

196
Q

What are the symptoms of testicular torsion?

A

Sudden onset of pain in one testis, which makes walking uncomfortable. Pain in the abdomen, nausea, and vomiting are common.

197
Q

What are the signs of testicualr torsion?

A

Inflammation of one testis—it is very tender, hot, and swollen. The testis may lie high and transversely.

198
Q

What are the tests for testicular torsion?

A
  1. Tender testis retractecd upwards
  2. Cremasteric reflex is lost
  3. Elevation of the testis does not ease the pain (Prehn’s sign)
199
Q

What are the treatments for testicular torsion?

A
  1. Urgent surgical exploration
    • Untwist and fixation
    • Orchidectomy
    • Could return to scrotum
200
Q

WHAT IS PYELONEPHRITIS?

A

Infection of the renal parenchyma and soft tissues of renal pelvis /upper ureter

201
Q

What are the symptoms of pyelonephritis?

A

Classical triad

  1. Loin pain
  2. Fever
  3. Pyuria
202
Q

What is the most causative organism in pyelonephritis?

A

E. coli

203
Q

What are the investigations for pyelonephritis?

A

Mainly clinical

  1. Urinalysis
  2. Bloods including cultures
  3. X-ray - stone in upper tract
204
Q

What is the treatment for pyelonephritis?

A

Cefalexin - can give in pregnant women and children too

OR

Ciprofloxacin

205
Q

What are the pyelonephritis complications?

A

Sepsis

Renal abscess

Progression to chronic pyelonephritis

206
Q

WHAT IS POLYCYSTIC KIDNEY DISEASE?

A

Polycystic kidney disease (PKD) is an inherited kidney disorder. It causes fluid-filled cysts to form in the kidneys.

207
Q

What are the different types of polycystic kidney disease?

A

Dominant and recessive

208
Q

What are the dominant gene mutations in PKD?

A

85% have mutation in PKD1 – reach ESRF by 50s

15% have mutation in PKD2 – reach ESRF by 70s

Family screening important - MRI

209
Q

What do the PKDs do?

A

Polycystinsregulate tubular and vascular development in the kidneys but also in other organs.

210
Q

What are the signs of polycystic kidney disease?

A
  1. Excessive water and salt loss
  2. Nocturia
  3. Loin pain (due to renal haemorrhage, stones and UTIs)
  4. Hypertension
  5. Bilateral kidney enlargement
  6. Gross haematuria following trauma
  7. Renal colic due to clots
  8. UTI and pyelonephritis may be presenting features
  9. Renal stones are twice as common than in the general population
211
Q

What are the tests for PKDs?

A

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

212
Q

What are the treatment options for polycystic kidney disease?

A
  1. No cure
  2. Counselling and support for patients & family members
  3. Monitor for disease progression
  4. Treat hypertension, UTIs, stones, give analgesia
  5. Dialysis for end-stage renal failure
213
Q

What are the extra-renal manifesations of PKD?

A
  1. liver cysts (70% - the commonest extra-renal manifestation): may cause hepatomegaly
  2. berry aneurysms (8%): rupture can cause subarachnoid haemorrhage
  3. cardiovascular system: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
  4. cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary
214
Q

WHAT ARE THE CAUSES OF TRASIENT OR SPURIOIUS NON-VISIBLE HAEMATURIA?

A
  1. Urinary tract infection
  2. Menstruation
  3. Vigorous exercise (this normally settles after around 3 days)
  4. Sexual intercourse
215
Q

What are some causes of persistent non-visible haematruia?

A
  1. Cancer (bladder, renal, prostate)
  2. Stones
  3. Benign prostatic hyperplasia
  4. Prostatitis
  5. Urethritis e.g. Chlamydia
  6. Renal causes: IgA nephropathy, thin basement membrane disease
216
Q

What are some causes of red/orange urine?

A
  1. Foods: beetroot, rhubarb
  2. Drugs: rifampicin, doxorubicin
217
Q

What is used for testing haematuria?

A
  1. Urine dipstick is the test of choice for detecting haematuria
  2. Renal function, albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked
  3. Urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected
218
Q

What is the definition of non-visible haematuria?

A
  1. Persistent non-visible haematuria is often defined as blood being present in 2 out of 3 samples tested 2-3 weeks apart
219
Q

What are the criteria for 2 week wait referral to urology?

A
  1. Aged >= 45 years AND:
    • unexplained visible haematuria without urinary tract infection, or
    • visible haematuria that persists or recurs after successful treatment of urinary tract infection
  2. Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
220
Q

HOW SHOULD DIABETIC NEPHROPATHY BE INVESTIGATED?

A
  1. Albumin:cfeatinine ratio
  2. Early morning
221
Q

What should diabetic patients be started on with a ACR>3?

A

Ace inhibitor or angiotensin-II receptor antagonist

222
Q

WHAT IS ACUTE INTERMITTENT PORPHYRIA?

A
  1. Acute intermittent porphyria (AIP) is a rare autosomal dominant condition caused by a defect in porphobilinogen deaminase, an enzyme involved in the biosynthesis of haem.
  2. The results in the toxic accumulation of delta aminolaevulinic acid and porphobilinogen.
  3. It characteristically presents with abdominal and neuropsychiatric symptoms in 20-40-year-olds. AIP is more common in females (5:1)
223
Q

What are the features of acute intermittent porpyria?

A
  1. abdominal: abdominal pain, vomiting
  2. neurological: motor neuropathy
  3. psychiatric: e.g. depression
  4. hypertension and tachycardia common
224
Q

How do you dignose acute intermittent porphyria?

A

classically urine turns deep red on standing

raised urinary porphobilinogen (elevated between attacks and to a greater extent during acute attacks)

assay of red cells for porphobilinogen deaminase

raised serum levels of delta aminolaevulinic acid and porphobilinogen

225
Q

What is acute intermittent porphyria?

A
  1. Avoiding triggers
  2. Acute attacks
    • IV haematin/haem arginate
    • IV glucose should be used if haematin/haem arginate is not immediately available
226
Q

HOW DO YOU CALCULATE THE ANION GAP?

A

The anion gap is calculated by:

(sodium + potassium) - (bicarbonate + chloride)

A normal anion gap is 8-14 mmol/L

227
Q

What are the causes of a normal anion gap acidosis?

A
  1. gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
  2. renal tubular acidosis
  3. drugs: e.g. acetazolamide
  4. ammonium chloride injection
  5. Addison’s disease
228
Q

WHAT ARE THE FEATURES OF ACUTE GRAFT FAILURE?

A
  1. Acute graft failure (< 6 months)
    • usually due to mismatched HLA. Cell-mediated (cytotoxic T cells)
    • usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria
    • other causes include cytomegalovirus infection
    • may be reversible with steroids and immunosuppressants
229
Q

WHAT ARE THE FEATURES OF HYPERACUTE REJECTION?

A
  1. Hyperacute rejection (minutes to hours)
    • due to pre-existing antibodies against ABO or HLA antigens
    • an example of a type II hypersensitivity reaction
    • leads to widespread thrombosis of graft vessels → ischaemia and necrosis of the transplanted organ
    • no treatment is possible and the graft must be removed
230
Q

WHAT ARE HYALINE CASTS AND WHEN ARE THEY SEEN?

A
  1. consist of Tamm-Horsfall protein (secreted by distal convoluted tubule)
  2. seen in normal urine, after exercise, during fever or with loop diuretics
231
Q

WHAT IS ACUTE INTERSTITIAL NEPHRITIS?

A

Drug induced kdiney injury

  1. Caused by
    • Drugs: the most common cause, particularly antibiotics
    • Penicillin
    • Rifampicin
    • NSAIDs
    • Allopurinol
    • Furosemide
    • Systemic disease: SLE, sarcoidosis, and Sjögren’s syndrome
    • Infection: Hanta virus , staphylococci
232
Q

What are the features of acute interstitial nephritis?

A
  1. fever, rash, arthralgia
  2. eosinophilia
  3. mild renal impairment
  4. hypertension
233
Q

What are the investigations of acute interstitial nephritis?

A
  1. Sterile pyuria
  2. White cell casts
234
Q

WHAT IS THE MOST COMMON CAUSE OF PEITONITIS SECONDARY TO PERITONEAL DIALYSIS?

A

Staph epidermidis

235
Q

What is the best diuretic to treat asictes?

A

Spironolactone

236
Q

WHAT DOES RENAL ARTERY STENOSIS SHOW ON RENIN:ALDOSTERONE?

A

High in both

237
Q

WHAT IS RHABDOMYOLYSIS?

A

Rhabdomyolysis will typically feature in the exam as a patient who has had a fall or prolonged epileptic seizure and is found to have an acute kidney injury on admission.

238
Q

What are some causes of rhabdomyolysis?

A
  1. Long lie
  2. Excessive exercise
  3. Crush injuries
  4. Burns
239
Q

What are the investigations for rhabdomyolysis?

A
240
Q

By what mechanism does rhabdomyolysis cause AKI?

A

Acute tubular necrosis

241
Q

WHAT PRECAUTIONS SHOULD BE TAKEN AFTER A VASECTOMY?

A
  1. Doesn’t work immediately
  2. Additional contraception must be used until tests reveal azoospermia
  3. Semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)
242
Q

WHAT ARE THE CAUSES OF HYDRONEPHROSIS?

A
243
Q

What are the investigations for hydronephrosis?

A
  1. ultrasound - first-line: identifies presence of hydronephrosis and can assess the kidneys
  2. IVU- assess the position of the obstruction
  3. Antegrade or retrograde pyelography- allows treatment
  4. if suspect renal colic: CT scan (majority of stones are detected this way)
244
Q

What is the management of hydronephrosis?

A
  1. Remove the obstruction and drainage of urine
  2. Acute upper urinary tract obstruction: nephrostomy tube
  3. Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty

ΩΩ 2a Bateman - Systems Based (11 decks)

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