renal and urology Flashcards
define BPH
benign prostatic hyperplasia is an enlarged prostate compressing against the urethra increasing resistance => causing changes to the bladder => urinary frequency/urgency + reduced urine flow
pathophysiology of BPH
dihydrotestosterone binds to androgen receptor on prostate => increased stromal / epithelial cells => ENLARGED prostate
- increased urethral resistance
- increased detrusor pressure to maintain urine flow (can lead to reduced detrusor contractility/ instability)
causes of BPH
unknown but link to age-related hormonal changes (androgens)
presenting symptoms of BPH
Lower urinary tract symptoms
- Frequency
- Urgency
- Nocturia
- Dysuria (burning)
- Hesitancy
- Incomplete voiding
- Poor stream
- Smell/ odour
- incontinence
Haematuria
Examination findings of BPH
- enlarged prostate on digital rectal examination
- palpable distended bladder
- Ballotable kidneys
- Phimosis- narrow foreskin
- Meatal stenosis- narrowing of urethral opening
Investigations + findings for BPH
- urinalysis (midstream urine => MC&S test)
- blood test (check for prostate-specific antigen rule out prostate cancer, U&Es)
- Flow rate + PVR (post-void residual) high PVR= obstruction
- bladder diary (fluid intake/ outake)
Imaging
- USS KUB if impaired renal function, loin pain, hematuria, renal mass on examination
- transrectal ultrasound
- flexible cystoscopy
Management of BPH
- Mild symptoms => conservative (watchful waiting, lifestyle changes)
Medical (before surgery)
- selective alpha adrenergic antagonists (relax smooth muscle of internal urinary sphincter and prostate capsule)
- 5-alpha reductase inhibitors (less testosterone => dihydrotestosterone conversion- reduce prostate size)
Surgery
- transurethral resection of prostate
- transurethral incision of prostate
- open prostatectomy
When would you treat BPH with catheterisation?
acute urinary retention (EMERGENCY)
- sudden inability to pass urine + SEVERE PAIN
side effects of alpha adrenergic antagonists (e.g. tamulosin)
lowers bp => light headed
dry ejaculation
Complications of BPH
- recurrent UTIs
- acute/chronic urinary retention
- urinary stasis
- bladder diverticuli
- stones
- obstructibe renal failure
- post-obstructibe diuresis
prognosis for BPH
- mild symptoms usually controlled with medication
- most patients get relief from surgery
define testicular torsion
twisting of spermatic chord => venous outflow obstruction of testes => arterial occlusion => infarction
SURGICAL EMERGENCY
Types of testicular torsion
- intravaginal- spermatic chord twists within tunica vaginalis
- extravagina (neonates)- spermatic chord + tunica vaginalis twist
causes of testicular torsion
- testes haven’t descended properly
- high investment of tunica vaginalis
Differentials for testicular torsion
- epididymo-orchitis (older, gradual onset) => rule out with doppler sound
- incarcerated inguinal hernia
presenting symptoms of testicular torsion
- SUDDEN hemiscrotal pain (in one testes)
- difficulty walking
- nausea + vomiting
- abdominal pain (RLQ/LLQ)
examination findings of testicular torsion
- swollen, hot, tender testes
- one slightly higher/ horizontal
- thickened chord
- necrotic on transillumination
Investigations for testicular torsion
- Doppler imaging of testes (can see arterial inflow - reduced in testicular torsion)
*arterial inflow increased in epididymo-orchitis
BUT SHOULD NOT DELAY SURGERY
management of testicular torsion
- exploration of testes (<6hrs) and twists back into place
- bilateral orchidopexy - sutures testicles to scrotum to prevent further twisting
- If testes is necrotic => orchidectomy (remove testes)
complications of testicular torsion (3 Is)
- infarction
- infection
- infertility
- atrophy
define testicular cancer
malignancy of the testes
- seminomas 30-40 (mix of tumour cells and lymphocytes)- spreads via lymphatics => para-aortic nodes
- non-seminomatous germ-cell tumours (teratomas- spread to lungs via bloodstream) 20-30
- gonadal stromal tumours (rare)
Risk factors for testicular cancer
- mal/undescended testes (cryptochidism)
- ectopic testes
- atrophic testes
presenting symptoms of testicular cancer
- dragging/ heavy feeling in testes (disomfort)
- testes swelling
- firm irregular lump in testes
- back pain (para-aortic lymph node enlargement)
- lung metastasis (SOB, haemoptysis)
examination findings of testicular cancer
- painless, hard mass on testes
- secondary hydrocoele
- lymphadenopathy (para-aortic/ supraclavicular lymph nodes)
- gynaecomastia (tumour produces b-HCG)
investigations for testicular cancer
Bedside:
- urinalysis
- pregnancy test (could be +ve due to b-HCG from tumour)
Bloods:
- FBC
- LFTs
- U&Es
- tumour markers: b-HCG (choriocarcinomatous), alpha fetoprotein (teratomas), LDH (non-specific) placental alklaine phosphotase (seminatous component)
Imaging:
- US of testes
- CXR- check for lung metastasis
- Staging CT CAP
Management for testicular cancer
seminomas (early stage) => radical inguinal orchidectomy (remove spermatic chord + testes) + radiation => para-aortic lymph nodes
teratoma => radical inguinal orchidectomy + chemo
Monitor AFP + staging CT CAP
late stage => palliative chemo
Define UTI
urinary tract infection usualy >10^5 of organisms per ml
Classification of UTI
- lower UTI- urethraitis, cystitis (bladder), prostatitis (prostate)
- Upper UTI- pyelonephritis (kidneys)
- Uncomplicated UTI - normal renal tract + function
- Complicated UTI- abnormal renal tract + function (voiding, reduced renal function)
Risk factors for UTIs
- female (shorter urethra)
- sex
- pregnancy
- immunocompromised
- menopause
- Urinary tract obstruction/ malformation
- catheterisation
- exposure to spermacide
Pathogenic Causes of UTIs
- E.coli
- Staph. saprophyticus
- proteus mirabilius
- Enterococci
In immunocompromised
- klebsiella
- canadida albicans
- pseudomonas aeruginosa
Presenting symptoms of
- Cystitis (LUTI)
- Prostatis (LUTI)
- Pyelonephritis (UUTI)
- frequency, urgency, dysuria, haematuria, suprapubic pain
- flu-like, lower backache, swollen prostate, less urinary symptoms
- High fever, rigors, vomiting, loin pain, oligouria (AKI)
Examination findings of UTI
- fever
- foul smelling urine
- loin/ suprapubic pain
- enlarged prostate (prostatitis)
- enlarged bladder (cystitis)
Investigations for UTIs
Bedside:
- urine dipstick (FIRST LINE) => +ve leucocytes + nitrates
- Midstream urine test (MSU)=> MC&S (gold standard)
- Microscopy=> +ve leucocytes = infection
- Culture = >10^5 growth per ml
Bloods
- FBC
- U&Es- check renal function
- CRP
- blood culture (exclude urosepsis)
Imaging
- USS of kidneys ureter bladder
Management of UTIs
- empirical antibiotics (trimethoprim/ NITROFURANTOIN) for lower UTI
- 3-6 days in women (longer for men)
*Alternative: Co-amoxiclav, cefalexin
- Can give prophylaxis antibiotics for recurrent infections
- IV/PO co-amoxiclav (for uncomplicated non pregnant upper UTIs)
Complications of UTI
- pyelonephritis
- sepsis
- AKI
- renal abscess
- pyonephrosis
Define urinary tract calculi
crystals depositing in the urinary tract
- pelviureteric junction
- pelvic brim
- vesicoureteric junction
Types of ureteric stones
- calcium oxalate (most common)- hypercalceuria, IBD
- struviate- protos bacteria infection, staghorn stones
- uric acid- GOUT, leukaemia (high cell turnover)
- hydroxyapatite
- cysteine
- calcium phosphate - hyperparathyroidism (high Ca2+)
causes of urinary tract calculi
- idiopathic
- metabolic (hypercalceuria, hyperuraecemia, hyperoxaluria, renal tubular acidosis, hyperparathyroidism=>hypercalcemia)
- infection (hyperuraecemia, recurrent UTIs)
- drugs (Idinavir, diuretics, antacids, corticosteroids)
- abnormalities (hydronephrosis, narrow pelviureteric junction)
- foreign objects (catheters, stents)
Risk factors for urinary tract calculi
- diet high in oxalate (chocolate, nuts, rhubarb, strawberrries, spinach)
- low fluid intake
- high sodium diet/ low pottasium diet => promote stone formation
- seasonal (high Vit D)
- horseshoe kidney (congenital)
Presenting symptoms of urinary tract calculi
- can be asymptomatic
- SUDDEN SEVERE intermittent/colicky flank pain
- may radiate- loin=> groin pain (RENAL COLIC)
- Unable to lie still
- haematuria
- urinary frequency, urgerncy, retention
- nausea/ vomiting => as pain is severe
Examination findings of urinary tract calculi
- loin => groin tenderness
- no signs of peritonitis
Investigations for urinary tract calculi
Bedside
- Urine dipstick (first line)
- Pregnancy test
- Urine MC&S
Bloods
- U&Es - check renal function
- CRP
- FBC
- urate/ bone profile/ phosphate => hyperparathyroidism
- clotting
Imaging
- non-contrast CT KUB => look for stones, AAA, bowel pathology (gold standard)
- USS of KUB (in pregnant women)
Management of urinary tract calculi
Acutely
- analgesia (PR diclofenac/ IM or opioids)
- Bed rest
- IV fluids
- monitor urine to check if stone has come out
Remove stone
- <5mm from LUT most pass out in urine (hydration/analgesia)
- >5mm/ pain doesn’t reduce => medical expulsion with nifedipine/ alpha blockers (tamulosin)
- 48hrs later => urethroscopy, ESWL, keyhole surgery (percutaneous nephrolithotomy)
Treat cause
- Allopurinol (hyperuraecemia)
- Parathyroidectomy (hyperparathyroidism => hypercalcemia)
Lifestyle
- increase fluid intake
Obstruction +infection (EMERGENCY)=> decompress with nephrostomy
Describe Extra-corporeal shock-wave lithotripsy (ESWL)
electromagnetic shockwaves to break up stone into fragments so can pass in urine
Describe process of urethroscopy
- Insert scope up bladder => ureter to find stone
- Bag/ laser to break up stone
- If stone can’t be retrieved put a JJ stent to avoid urinary tract obstruction
Complications of urinary tract calculi
- INFECTION- Pyelonephritis
- Sepsis
- Urinary retention
Complications of invasive treatment for urinary tract stones
- urethroscopy=> perforation, fasle passage
- ESWL => pain, haematuria
define bladder cancer
malignancy of bladder cells (80% mucosa, 20% penetrate muscle)
- Transitional cell carcinomas (most common)
- Squamous cell carcinoma
Grade 1 = differentiated
Grade 2= intermediate
Grade 3= poorly differentiated
risk factors for bladder cancer
- smoking
- cyclophosphomide (chemo)
- chronic cystitis
- shistomiosis (chronic inflammation) => squamous cell carcinoma
- aromatic amines (rubber, dye)
- pelvic irradiation
presenting symptoms of bladder cancer
- PAINLESS macroscopic haematuria
- some urinary symptoms (frequency, urgency, nocturia)
- recurrent UTIs
investigations for bladder cancer
- urine dip
- MUS => MC&S
Imaging
- cytoscopy + biopsy (look at bladder + diagnostic)
- Ultrasound
- IV Urogram
- CT/MRI staging
Management of bladder cancer
Non-muscle invasive (early)
- low risk => TURBT (transurethral resection of bladder tumour during cystoscopy) + chemo
- medium risk => Chemo
- high risk => TURBT + BCG variant + cystectomy
Muscle invasive
- Cystectomy (remove bladder)
- Radiotherapy with a radiactive sensitiser
Side effects of radiotherapy
- cystitis
- diarrhoea
- hair loss
- tightening of vagina (painful sex)
- erectile dysfunction
- vomiting
Describe Transurethral resection of bladder tumour
- under general anaesthetic + insert cytoscope into bladder
- cut out tumour
- cauterise and close wound with mini-electric current
- urinary catheter
*
Describe nephrotic syndrome
damage to podocytes leading to
- proteinurea
- hypoalbuminanaemia
- oedema
- hypercholesterolemia
Causes of nephrotic syndrome
Primary
- minimal change glomerulonephritis (kids)
- membranous glomerulonephritis
Secondary
- diabetes mellitus => diabetic nephropathy
- SLE
- Sickle cell
- Drugs (NSAIDs)
- Alport syndrome
- HIV
- Hepaitis C/E
- malignancy
Presenting symptoms of nephrotic syndrome
- swelling of face, arms, legs, genitals
- family history of atopy, renal disease
- symptoms of causes (SLE => fatigue, joint pain, rashes)
Examination findings of nephrotic syndrome
- oedema (periorbital, peripheral, genital)
- ascites (shifting dullness, fluid thrill)
Investigations for nephrotic syndrome
Bedside
- urine dipstick (proteinurea)
- MUS => MC&S
Bloods
- FBC
- U&E
- LFT- low albumin
- glucose
- ESR/CRP
- lipid profile
Identify cause
- SLE autoantibodies (ANA, anti-dsDNA)
- Infections (HBV serology, malaria blood culture)
- Good pastures - anti-glomerular basement antibodies
Imaging
- renal ultrasound - exclude renal perforation
Renal biopsy
Management of nephrotic syndrome
Treat cause and complications
- anti-hypertensives
- angiotensin II receptor blocekers
- diuretics
- statins
- anti-coagulants
- corticosteroids (immunosuppressants)
Lifestyle
- less fat/cholesterol in diet
- low sodium
- reduce fluid intake
define epididymitis (epididymis) and orchitis (testes)
inflammation of epididymis and testes
- usually associated with each other
Causes of epididymo-orchitis
INFECTIVE origin
- <35- Chlamydia
- >35 - Kleibsella, enterobacter
- Viral = Mumps
- Fungal - canadidas (if immunocompromised)
IDIOPATHIC
Risk factors for epididymo-orchitis
- diabetes
- vasculitis
Presenting symptoms of epididymo-orchitis
- painful, swollen,tender testes
- difficulty waking
- acute onset (not as acute as torsion)
- penile discharge
- dysuria
- fevers/ sweating
-
Ask aboout Sexual history - (chlamydia)
*
Examination findings of epididymo-orchitis
- swollen, tender testes
- testes is erythematous/ oedematous
- painful eliciting cremasteric reflex
- painful walking
- pyrexia
Investigations for epididymo-orchitis
Bedside:
- urine dipstick - check for UTI
- early morning urine collection (MC&S)
Bloods
- FBC- raised WCC
- raised CRP
- U&Es
Other
- increased blood flow on Duplex scan
Management of epididymo-orchitis
ANALGESIA + ANTIBIOTICS (2-4 weeks)
- <35 (STI-related) = antibiotics (DOXYCYCLINE), gonnorrhoea (ceftriaxone)
- >35 (non-STI related) = antibiotics (CIPROFLOXACIN)
Surgical
- lapratomy exploratio of testes if torsion can’t be clinically excluded
- drainage if signs of abscess
Complications of epididymo-orchitis
- PAIN
- abscess
- fournieres gangrene
- mumps orchitis => testicular atrophy/ infertility
*
define inguinal hernia
protrusion of viscus through weakness in abdominal wall
features of an inguinal hernia
- can’t get above lump (from abdomen could be hydrocoele)
- superior/medial to pubic tubercle
- reducible
- cough impulse => hernia appears
- direct hernias reduce on pressing at mid-point of inguinal ring
define incarcaerated hernia
obstructed hernia gets stuck due to bowel obstruction narrowing hernial orifice so bowel can’t contents can’t pass through
features of incarcerated inguinal hernia
- hard
- irreducible
- can’t be ellicted by cough impulse
define strangulated inguinal hernia
blocked blood supply to bowel loops => ischaemia + infarction
features of strangulated hernia
- signs of peritonitis (rigid, rebound tenderness, guarding)
Treatment of incarcerated inguinal hernias
- oxygen, IV fluids, cannula, NGT, urinary catheter
what is acute kidney injury (AKI)
sudden minor/major loss of kidney function measured by increased serum creatinine/ low urine output
- usually due to less blood flow to kidneys (complication of another serious illness more common in elderly)
causes of AKI
- SEPSIS
pre-renal
- hypovolemia (bleeding, XS vomiting, diarrhoea, DEHYDRATION),
- low cardiac ouput (surgery/ cardiogenic shock)
intrinsic renal
- nephrotoxic drugs
- interstitial nephritis
post-renal
- renal stones
- prostate enlargment=> bladder outflow obstruction
presenting symptoms of AKI
- suddenly feeing sick / vomiting
- peeing less than usual
- dehydration
- confusion
- drowsiness
examination findings in AKI
- hypertension
- distended bladder (palpable)
- Capillary refill- reduced (dehydrated)
- raised JVP, oedema (fluid overload)
investigation findings in AKI
- urinalysis/ urine dipstick - proteinuria/ haemturia/ glucose (sign of renal disease)
- Bloods:
- FBC- low platelets,(haemolysis),
- LFT
- U&Es- HIGH SERUM CREATININE
- Immunology
- immunoglobulins (Multiple myeloma)
- ANA (SLE)
- complement (low in lupus)
- renal ultrasound (<24hrs) - small kidneys = Chronic kidney disease
X-ray => renal stones
Management for AKI
- IMMEDIATE => ABCDE approach + check for hyperkalemia
- monitor volume status => control to euvolemia
- stop Nephrotoxic drugs (NSAIDS/ ACE inhibitors/ aminoglycosides)
treat CAUSE
- pre-renal => fluids to correct volume depletion. ABs for sepsis
- post-renal => urinary catheter to drain bladder if theres blockage (check with CT)
- UNRESPONSIVE to other treatment=> renal replacement therapy (DIALYSIS)
Renal Replacement Therapy (RRT) considered if:
- Hyperkalaemia refractory to medical management
- Pulmonary oedema refractory to medical management
- Severe metabolic acidaemia
- Uraemic complications
prognosis of AKI
mortality depends on cause/ comorbidities/ early recognition (monitor with regular blood tests)
=> also develop CKD
poor prognosis: age, multiple organ failure, oligouria, hypotension, CKD
complications of AKI
- hyperkalemia
- pulmonary oedema
- acidaemia
- bleeding
define chronic kidney disease
- progressive loss of kidney function present for >3 months
- +/- kidney damage (GFR <60ml/min)
Diagnostic criteria: (serum creatinine)
- A rise in serum creatinine of 26 micromol/L or greater within 48 hours
- 50% increase in baseline within 7 days
- A fall in urine output to less than 0.5 mL/kg/hour for more than 6 hours
classification of CKD
based on eGFR
- Stage 1/normal : >90 + CKD if evidence of kidney damange (microalbuminuria, proteinuria, haematuria, structural abnormalities, biopsy showing glomerulonephritis)
- Stage 2/ mild impairment: 60-89: pathology on biospy/imaging, or if transplan
- Stage 3/moderate: 30-59
- Stage 4/ severe: 15-29
- Stage 5/ established renal failure: <15
risk factors for CKD
- diabetes (20%)
- hypertension/renovascular disease
- AGE
- glomerulonephritis (mainly IgA)
- systemic inflammation(SLE, vasculitis)
- Myelomas
- nephrotoxic drugs (ACE-i, gentamycin =>ototoxic, NSAIDs, bisphosphonates, contrast)
Others:
- obesity
- CVD
- Pyelonephritis
- family Hx
- Smoking, neoplasias
- Chronic NSAID use
symptoms of CKD
- usually asymptomatic
Severe CKD (<30 GFR):
- anorexia
- nausea + vomiting
- fatigue
- ptruitus
- peripheral oedema
- muscle cramps
- pulmonary oedema
examination findings of CKD
- usually non-specific signs
- can show underlying disease signs/ complications (anaemia)
Signs of CKD:
- skin pigmentation
- excoriation marks (scratch marks)
- pallor - anaemia
- uraemic tinge to skin (yellow-ish)
- purpura
- hypertension
- peripheral oedema/ pulmonary odema
- peripheral vascular disease
investigations for CKD
Bloods
- Hb
- U&Es - urea, creatinine, K+/Na+
- Ca2+ (low), phopshate (high)
- ESR
- glucose
Serology (identify cause/infection)
- antibodies- ANA (SLE), c-ANCA (granulomatosis with polyangiitis), anti-GBM (goodpasture’s)
- hepatitis serology
- HIV serology
Urine
- urinalysis (proteinuria/haematuria, albumin:creatinine ratio)
- MC&S
- 24hr urine collection
- serum/urine electrophoresis (multiple myeloma)
Imaging
- USS - renal structural abnormlaities
- X-ray KUB - stones
Biopsy
- consider renal biopsy in progresive disease, nephrotic syndrome, systemic disease, AKI wihtout recovery
- biopsy unlikely to change treatment if GFR stable and P:CR>150
management of CKD requires
- lifestyle changes
- reduce CVD risk - smoking, alcohol, salt
- control bp - <140/90 or <130/80 (if diabetic)
- avoid NSAIDs (ibuprofen), stay well hydrated when vomiting/diarrhoea
- medication - statins - reduce CVD risk
- Immunisations => flu/pneumococcal vaccines
appropriate referral to nephrology
- preparation for renal replacement therapy (dialysis/transplantation)
Monitoring:
- GFR and albuminuria annually
- high risk = 6 monthly
- very high risk = 3-4 monthly
- drop in eGFR >25% is significant
What factors could can increase serum creatinine other than an AKI?
- if they already have CKD
- on trimethoprim (increase serum creatinine but doesn’t affect glomerular filtration rate)
- recently completed pregnany (as serum creatinine lower during pregnancy)
consider referral to nephrology for CKD patients if
- stage G4/G5
- moderate proteinuria unless due to DM/already treated
- proteinuria with haematuria
- declining eGFR
- poorly controlled hypertension
- known/suspected rare/genetic cause of CKD
treatment to slow renal disease progression in CKD
- BP: target < 140/90 mmHg, 140/80 if DM or A:CR > 70
- RAAS: ACE inhibitor, ARB
- do not combine RAAS antagonists (risk of hyperkalaemia and hypotension) - glycaemic control
- lifestyle
treatment of renal complications of CKD
- anaemia - ESA, IV iron therapy
- acidosis - sodium bicarb, caution if hypertensive/fluid overload
- oedema - restrict fluids/sodium intake, loop diuretics, monitor fluid state/renal function
- bone mineral disorders - dietary restriction,phosphate binders, vit D supplements, paricalcitol
- restless legs/cramps - sleep hygiene, gabapentin/pregabalin/dopamine agonists
treatment of cardiovascular complications from CKD
- antiplatelets if at risk of atherosclerotic events
- atorvastatin for primary and secondary prevention of cardiovascular disease
- monitor GFR and potassium if on HF treatment
- low GFR may affected troponin and BNP
risk factors for decline of renal function in CKD
- increased BP
- DM
- metabolic disturbance
- volume depletion
- infection
- NSAIDs
- smoking
Complications of CKD
- CVD (due to hypertension, vascular stiffness, inflammation, oxidative stress, abnormal endothelial function)
define nephrotic syndrome and triad of features
- increased protein loss in urine usually due to damage to podocytes
Triad:
- proteinuria (>3.5g/24hrs)
- hypoalbuminanaemia (<25g/L)
- oedema (low albumin = lower serum oncotic pressure = fluid built up)
+ usually associated with hyperlipidemia
causes of nephrotic syndrome
children:
- minimal change glomerulonephritis (most common)
adults:
- diabetes mellitus
- membranous glomerulonephritis
- SLE
- Hepatits B/C
- Sickle cell
- Amyloidosis
- Malignancies
- HIV
- NSAIDs
- Alport syndrome (genetic conditon damages vessels in kidneys)
presenting symptoms of nephrotic syndrome
- FHx: atopy, renal disease
- PMHx: diabetes, SLE, viral infections
- swelling of face,abdomen, limbs, genetalia (hypoalbuminanaemia)
- symptoms of cause (SLE => joint pain, tiredness, skin rash)
- +/- vomiting
signs of nephrotic syndrome
- oedema- perioribital, peripheral, genital
- ascities- thrills, shifting dullness
- anaemia
- tachycardia
Investigations for nephrotic syndrome
Bloods:
- FBC
- U&Es
- LFTs (low albumin)
- ESR/CRP
- lipid profile (check for hyperlipidemia)
- glucose (check for diabetes)
- immunoglobulins
- complement
Urine
- urinalysis
- MC&S
- 24hour collection of urine
Identify cause
- ANA, anti-dsDNA antibodies (SLE)
- ASO tire (Group A- strep. infection)
- serology (HBV)
- anti-glomerular basement antibodies (goodpasture’s syndrome)
- ANCA (polyangitis with granulomatosis)
Imaging:
- Renal USS (exclude reflux nephropathy)
Renal biopsy
management of nephrotic syndrome
- Treat cause:
- soidum + fluid restrict
- oral/IV diuretics (loop)
- ACE inhibitors (reduces Na+ reabsorption)
Complications of nephrotic syndrome
- Infection (most common)- sepsis, pneumonia, peritonitis
- Clots
- hyperlipidemia => increased CVD
- AKI/CKD
define prostate cancer
- malignancy of prostate gland (usually adenocarcinomas)
causes/ risk factors of prostate cancer (ROAD AF)
- Raised testosterone
- Occupation (exposure to cadmium)
- Afro-carribeans
- Diet
- Age
- Fmily Hx
symptoms of prostate cancer
- usually asymptomatic
- Lower urinary tract obstruction - frequency, hesitancy, terminal dribbling, nocturia
- visible haematuria + erectile dysfuntion
- Metastatic spread
- systemic spread; FLAWS (malaise, weight loss, anorexia)
- bone pain
- spine compression
- paraneoplastic syndrome (hypercalcemia)
signs of prostate cancer
DRE
- hard nodular prostate
- loss of midline sulcus
investigations for prostate cancer
- Prostate specific antigen (first line but not specific)
- DRE
- Transrectal US guided biopsy (GOLD STANDARD)
- Isotope bone scan to check for metastasis
Management for prostate cancer
T1/T2
- conservative - active monitoring or watchful waiting
- SURGERY: radical prostatectomy
- radiotherapy
T3/T4 (locally advanced)
- hormone therapy
- radical prostatectomy
- radiotherapy
Metastatic disease: (reduce androgen levels)
- GnRH agonists (initial rise in LH => lower LH long term / antagonists
- bicalutamide (non-steroidal blocks androgen receptor)
- cyproterone acetate (steroidal anti-androgen)
- abiraterone
- bilateral orchidectimy
define erectile dysfunction
inability to get or maintain an erection
causes of erectile dysfunction
- vascular- CVD risk factors,
- neurogenic- MS, parkinson’s
- prostate cancer
- peyroniere’s disease - inflammation of penis => bending
- hormonal- hypogonadism, hypo/perthyroidism, cushing’s
- drugs- antihypertensives, antidepressants, antipsychotics
- psychological - depression/anxiety
Risk factors for erectile dysfunction (CVD)
- diabetes
- smoking
- poor diet- dyslipidemia
- low exercise
- obesity
- hypertension
- metabollic syndrome
Symptoms for organic/pscyhogenic erectile dysfunction
organic cause
- gradual onset of symptoms
- normal tumuscence (erection?)
- normal libido
- risk factors (drugs, high acohol + smoker)
psychogenic cause
- sudden onset of symptoms
- decreased libido
- good quality masturbation
- recent life/relationship problems
Examinations for erectile dysfunction
Basic obs:
- bp, HR, waist circumference, weight, BMI
Examine genetalia (for sudden onset)
- malignant lesions
- prostate enlargement/nodularity
- hypogonadism (small testes, changes in secondary sexual characteristics)
- penile deformity (Peyronie’s disease- penis inflammation => bending)
Check for gynacomastia
DRE (Hx of prostate cancer/ >50/ obstructive urinary symptoms)
- enlarged prostate
Investigations for erectile dysfunction
Bloods:
- HbA1c
- lipid profile
- total testosterone
- FSH, LH, prolactin
- PSA (if abnormal DRE/ >50+ risk factors for prostate cancer)
Management for erectile dysfunction
Conservative
- manage modifiable risk factors (smoking, alcohol, weight, increase exercise, manage CVD/diabetes/hypertension)
Medical- PDE-5 inhibitors (phosphodiesterase-5)
- viagra (sildenafil)
- cialis (tadalafil)
- vardenafil (Levitra)
- avanafil (Spedra)
Referral:
- urology- young men with persistant dysfunction, urinary symptoms
- endo- hypogonadism features (abnormal FSH,LH,prolactin or testsoterone)
- cardio- have CVD
How to Cardio-risk stratification patients with erectile dysfunction
Low risk
- asymtomatic, <3 risk factors for CAD
- controlled hypertension
- can do exercise at moderate intesitiy without symptoms
Intermediate risk
- >3 risk factors for CAD
- mild angina
- past MI
- LVD/CHF
- atherosclerotic disease
High risk
- unstable angina
- uncontrolled hypertension
- LVD/CHF
- recent MI without intervention
- HOCM
- moderate/severe valve disease
define urinary incontinence
= leakage of urine
most common in elderly females
Types
- stress- increased abdominal pressure (MOST COMMON)
- urge- increased urgency
- overflow- bladder doesn’t empty fully due to obstruction
- functional- physical/mental impairment can’t get to toilet in time
- mixed (stress + urge)
causes of urinary incontinence
stress
- pregnancy/childbirth
- exercise
- cough/sneezing
- elderly
- obesity
- hysterectomy - damage bladder/nerves
urgency
- infection
- cystitis
- neurological disease - MS, parkinson’s, stroke, spinal injury (CES)
- alcohol/caffeine
overflow:
- BPH/ prostate cancer
- obstruction (stones)
functional
- physical: arthritis- can’t unbutton
- mental: Parkinson’s/ dementia
OTHER:
- medication (ACE-inhibitors, duretics, antidepressants, sedatives, HRT)
investigations for urinary incontinence
- urinalysis (check for infection)
- blood glucose (check for diabetes)
- bladder diary
- post-voidal residual volume
Before surgery:
- cytoscopy
- pelvic MRI
management for urinary incontinence
Conservative
- lifestyle modification - reduce caffeine, control fluids, lose weight
- kegal exercises - strengthen pelvic floor muscles
- bladder training
- pads/ catheters
Medication
- STRESS (if unsuitable for surgery) => antidepressants -increase urethra tone
- URGE => antimuscurinics (oxybutynin)/ anticholinergics -
Surgery
Stress: increase urethra tone
- colposuspension - stitch neck of bladder higher up
- sling surgery - sling around bladder neck to stop leakage
- bulking agents - increase urethra tone
- artifical sphincter insertion
Urge: calm overactive bladder
- Botox - relax detrusor muscle
- Sacral nerve/posterior tibial nerve stimulator - less signals to urinate
- IF BPH => tamulosin (alpha-blocker -shrinks prostate)
complications of urinary incontinence
- contact dermatitis
- sores/ulcers => SECONDARY INFECTION
