Renal and urology Flashcards
What cancer is aniline a RF for?
bladder cancer
What is the pathogen most common associated with haemolytic uraemic syndrome?
E. coli strain O157
what are the characteristic features of haemolytic uraemic syndrome?
microangiopathic haemolytic anaemia (MAHA)
acute renal failure (AKI)
thrombocytopenia
What are the symptoms of haemolytic uraemic syndrome?
profuse diarrhoea which turns bloody 1-3 days later
abdominal pain
reduced urine output
haematuria
nausea
fever
malaise
swelling/oedema
differentials for scrotal lumps
- Scrotal skin
- Sebaceous cyst
- Melanoma
- Intra-vaginal
- Hydrocele
- Epididymal cyst
- Epididymitis
- Hernia
- Torted hydatid
- Intra-testicular
- Orchitis
- Testicular abscess
- Testicular cancer
- Lymphoma
- Other
- Sarcoma of the cord
- Lipoma of the cord
causes of visible haematuria (UROLOGY)
- Bladder cancer
- Infection
- Simple UTI
- Schistosomiasis
- TB
- Urinary tract calculi
- Prostatic bleeding
- Trauma
- Upper tract transitional cell carcinoma
- Renal cancer
- Prostate cancer
- Radiation cystitis
causes of transient or spurious non-visible haematuria
- urinary tract infection
- menstruation
- vigorous exercise (this normally settles after around 3 days)
- sexual intercourse
causes of persistent non-visible haematuria
- cancer (bladder, renal, prostate)
- stones
- benign prostatic hyperplasia
- prostatitis
- urethritis e.g. Chlamydia
- renal causes: IgA nephropathy, thin basement membrane disease
how many stages of AKI are there?
3
describe stage 1 AKI
- Creatinine ↑ > 26 micromol/L within 48 hours OR
- Creatinine risk of 50-99% of baseline within 7 days (1.5-1.99 x baseline) OR
- Urine output < 0.5 ml/kg/hour for > 6 hours
describe stage 2 AKI
- 100-199% creatinine rise from baseline within 7 days (2-2.99 x baseline) OR
- Urine output < 0.5 ml/kg/hour for > 12 hours
describe AKI stage 3
- > 200% creatinine rise from baseline within 7 days (> 3 x baseline) OR
- Creatinine rise to > 354 micromol/L with acute rise of > 26 micromol/L within 48 hours or > 50% within 7 days OR
- Urine output < 0.3 ml/kg/hr for 24 hours or anuria for 12 hours
what are the indications for dialysis?
- Indications AEIOU
- Acidosis - severe metabolic acidosis with pH < 7.2
- Electrolyte imbalance - persistent hyperkalaemia > 7mM
- Intoxication - poisoning
- Oedema - refractory pulmonary oedema
- Uraemia - encephalopathy or pericarditis
where does BPH hyperplasia occur? histological features
hyperplasia in transitional zone
increase in stromal: epithelial ratio
Ix for BPH
- bedside
- DRE
- urinalysis
- bloods
- PSA + UE&s
- imaging
- bladder scan, USS KUB if concern of hydronephrosis
- specialist
- international prostate symptoms score (IPSS)
- urodynamic studies
management of BPH
-
Conservative
- Mild disease can watch-and-wait strategy
- Bladder training - less effective if LUTS + proven outlet obstruction
- reduce caffeine, ETOH, Tx constipation
-
Medical
-
Alpha adrenoceptor antagonist
- Alpha blocker e.g doxazosin, tamsulosin
- ↓ smooth muscle tone, quick effect
-
5-alpha reductase inhibitor
- e.g. finasteride
- If prostate > 30g or PSA >1.4 ng/ml + high risk of progression
- prevents dihydrotestosterone formation → ↓ prostate volume
- longer onset
-
Dual therapy
- Moderate-severe LUTs and prostate > 30g or PSA > 1.4ng/ml
-
Alpha adrenoceptor antagonist
-
Surgical
- Indicated - severe sx, refractory
- surgical resection to reduce prostate mass
what are the surgical options for BPH?
- TURP
- Transurethral incision of prostate (TUIP) if prostate < 30g but symptomatic
- REZUM - steam vapour to shrink prostate, 30-80g prostate, IPSS > 13
- HoLEP - holmium laser enucleates prostate, useful in very large prostates
- Urolift - staples back lateral lobes of prostate, useful in young as ↓ retrograde ejaculation
- Radical prostatectomy - prostate > 80g
types of bladder cancer + most common
- Transitional cell carcinoma (urothelial carcinoma, 90%)
- Adenocarcinoma
- Squamous cell carcinoma - associated with schistosomiasis
- Sarcoma
Ix for bladder cancer
-
Bedside
- Urinalysis + MC&S
-
Bloods
- FBC, U&Es, ALP
-
Imaging
- CT urogram
- multiparametric MRI - staging, indicated before TURBT
- USS KUB - usually 1st line if non-visible haematuria
-
Specialist or scoring
- Flexible cystoscopy - diagnostic
-
Transurethral resection of a bladder tumour (diagnostic or curative, must obtain detrusor biopsy)
- NICE - white-like guided TURBT with photodynamic diagnostics
2ww rules for bladder CA
- > 45 + unexplained visible haematuria w/o UTI
- > 45 + visible haematuria that persists/recurs after UTI treatment
- > 60 + unexplained non-visible haematuria and dysuria/↑ WCC
bladder cancer management
-
non muscle invasive
- low risk - TURBT single intravesible mitomycin C
- intermediate - TURBT + 6 course intravesical mitomycin
- high risk - intravesical chemo or radical cystectomy
- f/up with cytoscopy
-
muscle invasive
- neoadjuvant cisplatin chemo
- radical cystectomy or radial radiotherapy
-
locally advanced or metastatic
- cisplatin combination chemotherapy
- pembrolizumab (if PD-L1 +ve)
NICE definition of CKD
CKD should be diagnosed if any of the following met for more than 3 months(NICE):
- Markers of renal damage are present such as:
- Urinary ACR > 3mg/ml
- Urine sediment abnormalities
- Electrolyte or tubular disorders
- Abnormality on histology
- Structural abnormality on imaging
- History of transplant
- Persistent reduction in renal function with serum eGFR < 60
give the impairment of water balance seen in CKD and Sx + signs
Fluid overload, hypervolaemia
signs and symptoms
- Pleural effusions (SOB, cough)
- Pedal or sacral oedema
- Ascites
- Reduced urine output due to poor filtration
give the impairment of electrolyte homeostasis seen in CKD and Sx + signs
Hyperkalaemia
Cardiac dysrhythmias, palpitations
what is the excretion of waste impairment of function in CKD and presentation
uraemia
Pruritis, pericarditis, encephalopathy
what is the acid-base disturbance in CKD + PC
acidosis
N+V, tiredness
what is the endocrine disturbance in CKD and PC
-
Normocytic anaemia
- Tired, SOB, pallor, headaches, LOC, chest pain, weakness, HF
-
Hypocalcaemia
- Tetany, secondary hyperparathyroidism (Brown’s tumours, adynamic bone turnover), osteomalacia/osteoporosis
- Hypertension
complications of CKD
- ESRF, AKI (acute-on-chronic)
- HTN, dyslipidaemia (e.g. secondary to nephrotic syndrome), CVD risk ↑ (renal osteodystrophy
- anaemia
- bone pain/fragility #, renal osteodystrophy (osteoporosis, necrosis + pathological #)
- Peripheral neuropathy and myopathy incl. paraesthesia, sleep disturbance, restless leg syndrome
- Malnutrition (ESRF) - poor intake + hypoalbuminaemia
management of CKD conservative
- Diet - dietary advice and dietician input as required for potassium, phosphate, calorie + salt intake
- Psychological support
- Medication review
medical management of CKD
-
Blood pressure control - managing HTN
- ACR < 70mg/mmol target BP < 140/90 mmHg
- ACR > 70mg/mmol target BP < 130/80 mmHg
- 1st line
- ACR > 30mg/mmol → ACEi or ARB
- If DM ACEi/ARB if 3mg/mmol
- ACR < 30 mg/mmol → following NICE pathway for HTN
- ACR > 30mg/mmol → ACEi or ARB
-
Managing proteinuria
- ACEi/ARB if DM ACR > 3mg/mmol OR non-diabetic + non-HTN ACR > 70mg/mmol
- SGLT2 inhibitors offered to T2DM as dual therapy if ACR > 30mg/mmol + criteria eGFR met
-
Managing cardiovascular risk
- Statins - 20mg for prevention
- Optimise other health conditions
surgical management of CKD
renal transplant
management of CKD CoD - anaemia
- Treat concurrent hyperparathyroidism
- Optimise iron status
- oral iron if not on haemodialysis
- IV infusion if inadequate response in 3 months or on haemodialysis
- Erythropoietin stimulating agents
management of CKD CoD - hyperkalaemia
- Acute management as per hyperkalaemia guidance
-
Patiromer - potassium binder within GI tract
- Emergency acute life-threatening alongside standard care
- Stage 3b-5 with CKD or HF and persistent ↑ K+ confirmed as > 6, not taking RAAS inhibitors and not on dialysis
management of CKD CoD - hyperphosphataemia
- Dietary managing under dietician
- Phosphate binder if stage 4/5 not dialysis
- 1st line = calcium acetate, SE - ↑ Ca2+
- Parathyroidectomy is rarely required
most common pathogens for epidiymitis-orchitis
- < 35 → STI (chlamydia, gonorrhoea)
- > 35 → non-sexually transmitted e.g. gram negative bacteria (E.coli, pseudomonas)
management of epididymis-orchitis
Conservative
- Advise scrotal support
- Advise to abstain from sex is ?/confirmed STD till Tx complete
Medical
- NSAIDS - anti-inflammatory + analgesic
- Empirical anti-microbial therapy - 2-4 weeks
- < 35 years old - doxycycline 100mg/12 hour to cover chlamydia + treat partners
- Ceftriaxone 500mg/12h if suspected gonorrhoea
- > 35 → treat for gram-negative
- Re-assess after 3/7
Surgical - rare, if torsion can’t be excluded, abscess drain
features of nephrotic syndrome
Nephrotic syndrome
- Proteinuria (>3.5g/24h)
- low serum albumin (<24g/L)
- oedema
features of nephritic syndrome
HTN + proteinuria + haematuria
common causes of nephrotic syndrome
-
primary
- Membranous
- Minimal change
- FSGS
- Mesangiocapillary GN
-
secondary
- Diabetes
- SLE
- Amyloid
- Hepatitis B/C
common causes of nephritic syndrome
-
primary
- IgA nephropathy
- Mesangiocapillary GN
-
secondary
- Post streptococcal
- Vasculitis
- SLE
- Anti-GBM disease
- Cryoglobulinaemia
IgA nephropathy vs post-streptococcal glomerulonephritis
IgA nephropathy → days after URTI
post-strep → weeks after URTI
management of hydroce==
Congenital
- Reassure hydrocele likely to resolve by 2 years
- Refer if concern of underlying path., concurrent inguinal hernia, localised to spermatic cord, palpable abdominal mass
Adult
- Urgent USS if 20-40 years of age and testis cannot be palpated
- Conservative - watch and wait
-
Surgical
- Must exclude CA prior to Tx
- Aspiration - symptomatic relief, only frail + sx
- Lord’s repair - folding of tunica vaginalis, inguinal approach
-
Jaboulay’s repair - eversion of the sac
- Recommended for secondary non-communicating
- Scrotal approach
types of renal stone
-
calcium oxalate (MAJORITY, 85%)
- radio-opaque
- high Ca2+ in urine = RF
-
calcium phosphate (10%)
- radiopaque, RTA
- cysteine
-
uric acid (5-10%)
- radiolucent, associated with haemolysis/tissue breakdown
-
struvite
- Mg + ammonium + phosphate
- urease bacteria → chronic UTI
- staghorn
what is the type of stone that typically causes staghorn calculus?
struvite
Ix for renal calculi
-
Bedside
- Abdominal examination
- Urine dipstick - haematuria
-
Bloods
- Renal function and U&Es
- FBC + CRP + cultures - ?infection
- Serum calcium - assess if contributing cause
-
Imaging
-
Non contrast CT KUB - diagnostic imaging of choice
- Urgent, within 24 hours of presentation
-
Non contrast CT KUB - diagnostic imaging of choice
management of renal stones
Conservative
- Watchful waiting - stones < 5mm, no sx of obstruction
Medical
- Analgesia
- 1st line - NSAIDs, PR/IM diclofenac (75mg diclofenac IM)
- 2nd line - IV paracetamol
- Consider opioids
-
Alpha blockers - tamsulosin, alfuzosin
- Indications - distal stone < 10mm
Surgical
-
Percutaneous nephrolithotomy
- Indicated: stones > 2 cm, complex stones (staghorn, cysteine)
- Retrograde ureteral catheter, cystoscopy, stone collected
-
Ureteroscopy
- 1st line for _distal/middle ureteric stone_s, pregnant women
- Shock wave lithotropsy
-
Open stone surgery
- <1% o
- Indications: failed Tx, complex/staghorn calculi, morbid obesity, complex renal/ureteric anatomy
when to admit someone with renal stones?
- Shock or signs of systemic infection
- ↑ risk of AKI e.g. pre-existing CKD or solitary/transplanted kidney or bilateral stones suspected
- Dehydrated and not tolerating oral fluids
- Uncertainty of diagnosis
General management of nephrotic syndrome
General for adults 1. Sodium and fluid restriction 2. Diuretic treatment - furosemide 3. High dose steroids part of Tx for most. Good response in kids, less predictable in adults ACEi - can be used in less treatment-responsive adults
management of overactive bladder
-
conservative
- bladder training - 6/52
- fluid management
- pelvic floor exercises 8 TDS, 3/12
-
medical
- anticholinergics - oxybutynin, tolterodine
- mirabegron - beta-3 adrenergic agonist, 2nd or dual
-
surgical
- neurotoxin botulinum toxin A
- neuromodulation - perc. sacral or post. tibial nerve stimulation
- augmented cystoplasty
- urinary diversion (urostomy)
types of polycystic kidney disease
-
type 1 - AD, adult
- Ch16 (85%) - ESRF by 50s
- Ch4 (15%) - ESRF by 70s
- 1 in 1000
-
type 2 - AR, children
- rare
- Ch6, early presentation with renal + hepatic cysts
histological types of prostate cancer
- adenocarcinoma (most common, peripheral zone)
- TCC
- SCC
- small cell prostate cancer
RF for prostate cancer
- Non-modifiable = African ethnicity, FHx +ve, BRCA mutation, ↑ age
- Modifiable = Obesity, smoking, diet (high in animal fats and milk products)
2WW for prostate cancer
Indicated:
- DRE reveals hand, nodular prostate
- PSA > 3 nanogram/mL and ages 50-69
Ix for prostate cancer
-
Bedside
- Digital rectal examination
- Urine dipstick
-
Bloods
-
PSA:
- Normal 0-4
- 50-69 and if > 3nanogram/mL refer via 2WW
- bone profile (including calcium)
- FBC, U&Es, acid phosphatase, LFTs, U&Es
-
PSA:
-
Imaging
-
CT/MRI + isotope bone scan: staging
- Multiparametric MRI only if for radical treatment
-
CT/MRI + isotope bone scan: staging
-
Specialist or scoring
- Transrectal USS + needle biopsy: abnormal cells in 2 different samples → malignancy diagnosis
management of prostate cancer
-
low risk, Gleason < 7
- active surveillant
- radical prostatectomy
- radical radiotherapy
-
intermediate + local. 8+
- hormone therapy
- radical prostatectomy
- radiotherapy
- docetaxel chemotherapy
-
metastatic
- hormonal treatment
- GnRH agonist + 3/52 anti-androgen
- goserelin
- anti-androgen - flutamide, cyproterone acetate
what is the gleason score?
- prostate cancer
- histology is graded from 1-5 from 2 biopsies and added together
- < 6 is low, 7 - intermediate, > 8 is high risk
causes of renal artery stenosis
- atherosclerosis
- fibromuscular dysplasia (< 50)
- VTE
- compression by external mass
types of renal cell cancer
-
clear cell (70%, most common)
- epithelial renal tumour with clear cell sets in capillary network
- associated with VHL
-
papillary (15%)
- epithelial tumour of papillae + tubules
-
chromophobe RCC
- well circumscribed brown tumour
what is the histological type of RCC associated with long-term dialysis?
papillary
management of RCC
-
localised
- resection - partial if < 7cm, radial otherwise
- + chemotherapy + radiotherapy
-
advanced or metastatic
- radial nephrectomy + biological treatment
- interferon alpha, IL2
- radial nephrectomy + biological treatment
management of stress incontinence
-
conservative
- pelvic floor exercise 8 TDS, 3 months
- fluid intake
- reduce weight, optimise DM, Oestrogen if post-M
-
medical - 2nd line, non surg. candidate
- duloxetine
- desmopressin - nocturia specifically
-
surgical
- colposuspension
- autologous rectus fascial sling
- intramural bulking agents
- artificial urinary sphincter
types of testicular cancer
-
Germ cell tumour (95%)
-
Seminoma (50%)
- ↑ HCG + lactate, or normal
-
non-seminoma - AFP and beta-HCG usually raised
- Teratoma
- Embryonal carcinoma
- Yolk sac tumour
- Choriocarcinoma
- Mixed seminoma-teratoma
-
Seminoma (50%)
-
Non-germ cell tumour (5%)
- Sertoli
- Leydig
- Sarcoma
- Non-Hodgkin’s lymphoma
Ix for testicular cancer
-
Bedside
- Scrotal examination
-
Bloods
- Serum beta-HCG
- Serum alpha fetoprotein
- Serum lactate
- Basics - FBC, U&Es
-
Imaging
- Scrotal USS - visualisation of mass
- CT CAP - assessment for metastases
- CXR - assess for mets, cannonball
-
Specialist or scoring
- Sperm banking
*don’t biopsy as risk of seeding, automatic upgrade of stage
management of testicular cancer
-
Radical orchidectomy + lymph node dissection + prosthesis
- Inguinal orchidectomy (not scrotal)
-
+ chemotherapy
- Chemotherapy = mainstay
- Indicated: higher stage disease (metastatic), high risk
- Low risk - carboplatin regime
- High risk - BEP combination (bleomycin, etoposide, platinum - cisplatin), usually 3 cycles
- + radiotherapy - external beam radiation
summary of testicular cancer management
what is a varicocele?
Abnormal dilation of the internal spermatic veins and pampiniform plexus which drains into the testis.
what side is a varicocele more common?
More common on the left due to the angle at which the left testicular vein meets left renal vein means there are no effective valves and therefore ↑ reflux from compression of renal vein by SMA and aorta
Ix for varicocele?
-
Bedside
- Scrotal examination
-
Bloods
- Serum FSH and testosterone
-
Imaging
- Doppler USS - confirms diagnosis
-
Specialist or scoring
- Semen analysis - if presenting with concurrent fertility concerns, common cause of subfertility
- RCC screen if rapid onset/older/Sx CA
management of varicocele
-
Conservative
- If mild, aSx, normal semen analysis
- Observation
-
Referral to secondary care - if:
- Sudden onset > 40 years of age and remains tense on lying down - urgent
- Single right-sided varicocele - urgent
- Uncertainty about diagnosis
- Routinely causing pain or discomfort
- In adolescents consider
-
Surgical
- aim to ligate veins to prevent abnormal flow
- Open or laparoscopic repair - ligation of vessels affected
- Percutaneous embolisation
complications of TURP
T - TURP syndrome
U - urethral stricture/ UTI
R - retrograde ejaculation
P - perforation of the prostate
