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Year 3 > renal and urology > Flashcards

renal and urology Flashcards

1
Q

define BPH

A

benign prostatic hyperplasia is an enlarged prostate compressing against the urethra increasing resistance => causing changes to the bladder => urinary frequency/urgency + reduced urine flow

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2
Q

pathophysiology of BPH

A

dihydrotestosterone binds to androgen receptor on prostate => increased stromal / epithelial cells => ENLARGED prostate

  1. increased urethral resistance
  2. increased detrusor pressure to maintain urine flow (can lead to reduced detrusor contractility/ instability)
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3
Q

causes of BPH

A

unknown but link to age-related hormonal changes (androgens)

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4
Q

presenting symptoms of BPH

A

Lower urinary tract symptoms

  • Frequency
  • Urgency
  • Nocturia
  • Dysuria (burning)
  • Hesitancy
  • Incomplete voiding
  • Poor stream
  • Smell/ odour
  • incontinence
    Haematuria
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5
Q

Examination findings of BPH

A
  • enlarged prostate on digital rectal examination
  • palpable distended bladder
  • Ballotable kidneys
  • Phimosis- narrow foreskin
  • Meatal stenosis- narrowing of urethral opening
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6
Q

Investigations + findings for BPH

A
  • 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
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7
Q

Management of BPH

A
  • 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
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8
Q

When would you treat BPH with catheterisation?

A

acute urinary retention (EMERGENCY)
- sudden inability to pass urine + SEVERE PAIN

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9
Q

side effects of alpha adrenergic antagonists (e.g. tamulosin)

A

lowers bp => light headed
dry ejaculation

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10
Q

Complications of BPH

A
  • recurrent UTIs
  • acute/chronic urinary retention
  • urinary stasis
  • bladder diverticuli
  • stones
  • obstructibe renal failure
  • post-obstructibe diuresis
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11
Q

prognosis for BPH

A
  • mild symptoms usually controlled with medication
  • most patients get relief from surgery
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12
Q

define testicular torsion

A

twisting of spermatic chord => venous outflow obstruction of testes => arterial occlusion => infarction
SURGICAL EMERGENCY

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13
Q

Types of testicular torsion

A
  • intravaginal- spermatic chord twists within tunica vaginalis
  • extravagina (neonates)- spermatic chord + tunica vaginalis twist
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14
Q

causes of testicular torsion

A
  • testes haven’t descended properly
  • high investment of tunica vaginalis
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15
Q

Differentials for testicular torsion

A
  • epididymo-orchitis (older, gradual onset) => rule out with doppler sound
  • incarcerated inguinal hernia
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16
Q

presenting symptoms of testicular torsion

A
  • SUDDEN hemiscrotal pain (in one testes)
  • difficulty walking
  • nausea + vomiting
  • abdominal pain (RLQ/LLQ)
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17
Q

examination findings of testicular torsion

A
  • swollen, hot, tender testes
  • one slightly higher/ horizontal
  • thickened chord
  • necrotic on transillumination
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18
Q

Investigations for testicular torsion

A
  • Doppler imaging of testes (can see arterial inflow - reduced in testicular torsion)
    *arterial inflow increased in epididymo-orchitis
    BUT SHOULD NOT DELAY SURGERY
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19
Q

management of testicular torsion

A
  1. exploration of testes (<6hrs) and twists back into place
  2. bilateral orchidopexy - sutures testicles to scrotum to prevent further twisting
  3. If testes is necrotic => orchidectomy (remove testes)
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20
Q

complications of testicular torsion (3 Is)

A
  • infarction
  • infection
  • infertility
  • atrophy
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21
Q

define testicular cancer

A

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)
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22
Q

Risk factors for testicular cancer

A
  • mal/undescended testes (cryptochidism)
  • ectopic testes
  • atrophic testes
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23
Q

presenting symptoms of testicular cancer

A
  • dragging/ heavy feeling in testes (disomfort)
  • testes swelling
  • firm irregular lump in testes
  • back pain (para-aortic lymph node enlargement)
  • lung metastasis (SOB, haemoptysis)
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24
Q

examination findings of testicular cancer

A
  • painless, hard mass on testes
  • secondary hydrocoele
  • lymphadenopathy (para-aortic/ supraclavicular lymph nodes)
  • gynaecomastia (tumour produces b-HCG)
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25
Q

investigations for testicular cancer

A

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
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26
Q

Management for testicular cancer

A

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

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27
Q

Define UTI

A

urinary tract infection usualy >10^5 of organisms per ml

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28
Q

Classification of UTI

A
  • 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)
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29
Q

Risk factors for UTIs

A
  • female (shorter urethra)
  • sex
  • pregnancy
  • immunocompromised
  • menopause
  • Urinary tract obstruction/ malformation
  • catheterisation
  • exposure to spermacide
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30
Q

Pathogenic Causes of UTIs

A
  • E.coli
  • Staph. saprophyticus
  • proteus mirabilius
  • Enterococci

In immunocompromised

  • klebsiella
  • canadida albicans
  • pseudomonas aeruginosa
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31
Q

Presenting symptoms of

  1. Cystitis (LUTI)
  2. Prostatis (LUTI)
  3. Pyelonephritis (UUTI)
A
  1. frequency, urgency, dysuria, haematuria, suprapubic pain
  2. flu-like, lower backache, swollen prostate, less urinary symptoms
  3. High fever, rigors, vomiting, loin pain, oligouria (AKI)
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32
Q

Examination findings of UTI

A
  • fever
  • foul smelling urine
  • loin/ suprapubic pain
  • enlarged prostate (prostatitis)
  • enlarged bladder (cystitis)
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33
Q

Investigations for UTIs

A

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
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34
Q

Management of UTIs

A
  • 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)
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35
Q

Complications of UTI

A
  • pyelonephritis
  • sepsis
  • AKI
  • renal abscess
  • pyonephrosis
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36
Q

Define urinary tract calculi

A

crystals depositing in the urinary tract

  • pelviureteric junction
  • pelvic brim
  • vesicoureteric junction
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37
Q

Types of ureteric stones

A
  • 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+)
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38
Q

causes of urinary tract calculi

A
  • 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)
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39
Q

Risk factors for urinary tract calculi

A
  • 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)
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40
Q

Presenting symptoms of urinary tract calculi

A
  • 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
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41
Q

Examination findings of urinary tract calculi

A
  • loin => groin tenderness
    • no signs of peritonitis
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42
Q

Investigations for urinary tract calculi

A

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)
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43
Q

Management of urinary tract calculi

A

Acutely

  • analgesia (PR diclofenac/ IM or opioids)
  • Bed rest
  • IV fluids
  • monitor urine to check if stone has come out

Remove stone

  1. <5mm from LUT most pass out in urine (hydration/analgesia)
  2. >5mm/ pain doesn’t reduce => medical expulsion with nifedipine/ alpha blockers (tamulosin)
  3. 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

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44
Q

Describe Extra-corporeal shock-wave lithotripsy (ESWL)

A

electromagnetic shockwaves to break up stone into fragments so can pass in urine

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45
Q

Describe process of urethroscopy

A
  • 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
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46
Q

Complications of urinary tract calculi

A
  • INFECTION- Pyelonephritis
  • Sepsis
  • Urinary retention
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47
Q

Complications of invasive treatment for urinary tract stones

A
  • urethroscopy=> perforation, fasle passage
  • ESWL => pain, haematuria
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48
Q

define bladder cancer

A

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

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49
Q

risk factors for bladder cancer

A
  • smoking
  • cyclophosphomide (chemo)
  • chronic cystitis
  • shistomiosis (chronic inflammation) => squamous cell carcinoma
  • aromatic amines (rubber, dye)
  • pelvic irradiation
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50
Q

presenting symptoms of bladder cancer

A
  • PAINLESS macroscopic haematuria
  • some urinary symptoms (frequency, urgency, nocturia)
  • recurrent UTIs
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51
Q

investigations for bladder cancer

A
  • urine dip
  • MUS => MC&S

Imaging

  • cytoscopy + biopsy (look at bladder + diagnostic)
  • Ultrasound
  • IV Urogram
  • CT/MRI staging
52
Q

Management of bladder cancer

A

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
53
Q

Side effects of radiotherapy

A
  • cystitis
  • diarrhoea
  • hair loss
  • tightening of vagina (painful sex)
  • erectile dysfunction
  • vomiting
54
Q

Describe Transurethral resection of bladder tumour

A
  • under general anaesthetic + insert cytoscope into bladder
  • cut out tumour
  • cauterise and close wound with mini-electric current
  • urinary catheter
    *
55
Q

Describe nephrotic syndrome

A

damage to podocytes leading to

  • proteinurea
  • hypoalbuminanaemia
  • oedema
  • hypercholesterolemia
56
Q

Causes of nephrotic syndrome

A

Primary

  • minimal change glomerulonephritis (kids)
  • membranous glomerulonephritis

Secondary

  • diabetes mellitus => diabetic nephropathy
  • SLE
  • Sickle cell
  • Drugs (NSAIDs)
  • Alport syndrome
  • HIV
  • Hepaitis C/E
  • malignancy
57
Q

Presenting symptoms of nephrotic syndrome

A
  • swelling of face, arms, legs, genitals
  • family history of atopy, renal disease
  • symptoms of causes (SLE => fatigue, joint pain, rashes)
58
Q

Examination findings of nephrotic syndrome

A
  • oedema (periorbital, peripheral, genital)
  • ascites (shifting dullness, fluid thrill)
59
Q

Investigations for nephrotic syndrome

A

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

60
Q

Management of nephrotic syndrome

A

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
61
Q

define epididymitis (epididymis) and orchitis (testes)

A

inflammation of epididymis and testes

  • usually associated with each other
62
Q

Causes of epididymo-orchitis

A

INFECTIVE origin

  • <35- Chlamydia
  • >35 - Kleibsella, enterobacter
  • Viral = Mumps
  • Fungal - canadidas (if immunocompromised)

IDIOPATHIC

63
Q

Risk factors for epididymo-orchitis

A
  • diabetes
  • vasculitis
64
Q

Presenting symptoms of epididymo-orchitis

A
  • painful, swollen,tender testes
  • difficulty waking
  • acute onset (not as acute as torsion)
  • penile discharge
  • dysuria
  • fevers/ sweating
  • Ask aboout Sexual history - (chlamydia)
    *
65
Q

Examination findings of epididymo-orchitis

A
  • swollen, tender testes
  • testes is erythematous/ oedematous
  • painful eliciting cremasteric reflex
  • painful walking
  • pyrexia
66
Q

Investigations for epididymo-orchitis

A

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
67
Q

Management of epididymo-orchitis

A

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
68
Q

Complications of epididymo-orchitis

A
  • PAIN
  • abscess
  • fournieres gangrene
  • mumps orchitis => testicular atrophy/ infertility
    *
69
Q

define inguinal hernia

A

protrusion of viscus through weakness in abdominal wall

70
Q

features of an inguinal hernia

A
  • 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
71
Q

define incarcaerated hernia

A

obstructed hernia gets stuck due to bowel obstruction narrowing hernial orifice so bowel can’t contents can’t pass through

72
Q

features of incarcerated inguinal hernia

A
  • hard
  • irreducible
  • can’t be ellicted by cough impulse
73
Q

define strangulated inguinal hernia

A

blocked blood supply to bowel loops => ischaemia + infarction

74
Q

features of strangulated hernia

A
  • signs of peritonitis (rigid, rebound tenderness, guarding)
75
Q

Treatment of incarcerated inguinal hernias

A
  • oxygen, IV fluids, cannula, NGT, urinary catheter
76
Q

what is acute kidney injury (AKI)

A

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)
77
Q

causes of AKI

A
  • 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
78
Q

presenting symptoms of AKI

A
  • suddenly feeing sick / vomiting
  • peeing less than usual
  • dehydration
  • confusion
  • drowsiness
79
Q

examination findings in AKI

A
  • hypertension
  • distended bladder (palpable)
  • Capillary refill- reduced (dehydrated)
  • raised JVP, oedema (fluid overload)
80
Q

investigation findings in AKI

A
  1. urinalysis/ urine dipstick - proteinuria/ haemturia/ glucose (sign of renal disease)
  2. Bloods:
  • FBC- low platelets,(haemolysis),
  • LFT
  • U&Es- HIGH SERUM CREATININE
  • Immunology
  • immunoglobulins (Multiple myeloma)
  • ANA (SLE)
  • complement (low in lupus)
  1. renal ultrasound (<24hrs) - small kidneys = Chronic kidney disease
    X-ray => renal stones
81
Q

Management for AKI

A
  1. IMMEDIATE => ABCDE approach + check for hyperkalemia
  2. monitor volume status => control to euvolemia
  3. stop Nephrotoxic drugs (NSAIDS/ ACE inhibitors/ aminoglycosides)

treat CAUSE

  1. pre-renal => fluids to correct volume depletion. ABs for sepsis
  2. post-renal => urinary catheter to drain bladder if theres blockage (check with CT)
  3. 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
82
Q

prognosis of AKI

A

mortality depends on cause/ comorbidities/ early recognition (monitor with regular blood tests)
=> also develop CKD

poor prognosis: age, multiple organ failure, oligouria, hypotension, CKD

83
Q

complications of AKI

A
  • hyperkalemia
  • pulmonary oedema
  • acidaemia
  • bleeding
84
Q

define chronic kidney disease

A
  • 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
85
Q

classification of CKD

A

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
86
Q

risk factors for CKD

A
  • 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
87
Q

symptoms of CKD

A
  • usually asymptomatic

Severe CKD (<30 GFR):

  • anorexia
  • nausea + vomiting
  • fatigue
  • ptruitus
  • peripheral oedema
  • muscle cramps
  • pulmonary oedema
88
Q

examination findings of CKD

A
  • 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
89
Q

investigations for CKD

A

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
90
Q

management of CKD requires

A
  1. lifestyle changes
  2. reduce CVD risk - smoking, alcohol, salt
  3. control bp - <140/90 or <130/80 (if diabetic)
  4. avoid NSAIDs (ibuprofen), stay well hydrated when vomiting/diarrhoea
  5. medication - statins - reduce CVD risk
  6. 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
91
Q

What factors could can increase serum creatinine other than an AKI?

A
  • 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)
92
Q

consider referral to nephrology for CKD patients if

A
  • 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
93
Q

treatment to slow renal disease progression in CKD

A
  1. BP: target < 140/90 mmHg, 140/80 if DM or A:CR > 70
  2. RAAS: ACE inhibitor, ARB
    - do not combine RAAS antagonists (risk of hyperkalaemia and hypotension)
  3. glycaemic control
  4. lifestyle
94
Q

treatment of renal complications of CKD

A
  1. anaemia - ESA, IV iron therapy
  2. acidosis - sodium bicarb, caution if hypertensive/fluid overload
  3. oedema - restrict fluids/sodium intake, loop diuretics, monitor fluid state/renal function
  4. bone mineral disorders - dietary restriction,phosphate binders, vit D supplements, paricalcitol
  5. restless legs/cramps - sleep hygiene, gabapentin/pregabalin/dopamine agonists
95
Q

treatment of cardiovascular complications from CKD

A
  • 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
96
Q

risk factors for decline of renal function in CKD

A
  • increased BP
  • DM
  • metabolic disturbance
  • volume depletion
  • infection
  • NSAIDs
  • smoking
97
Q

Complications of CKD

A
  • CVD (due to hypertension, vascular stiffness, inflammation, oxidative stress, abnormal endothelial function)
98
Q

define nephrotic syndrome and triad of features

A
  • 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

99
Q

causes of nephrotic syndrome

A

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)
100
Q

presenting symptoms of nephrotic syndrome

A
  • 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
101
Q

signs of nephrotic syndrome

A
  • oedema- perioribital, peripheral, genital
  • ascities- thrills, shifting dullness
  • anaemia
  • tachycardia
102
Q

Investigations for nephrotic syndrome

A

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

103
Q

management of nephrotic syndrome

A
  1. Treat cause:
  • soidum + fluid restrict
  • oral/IV diuretics (loop)
  • ACE inhibitors (reduces Na+ reabsorption)
104
Q

Complications of nephrotic syndrome

A
  • Infection (most common)- sepsis, pneumonia, peritonitis
  • Clots
  • hyperlipidemia => increased CVD
  • AKI/CKD
105
Q

define prostate cancer

A
  • malignancy of prostate gland (usually adenocarcinomas)
106
Q

causes/ risk factors of prostate cancer (ROAD AF)

A
  • Raised testosterone
  • Occupation (exposure to cadmium)
  • Afro-carribeans
  • Diet
  • Age
  • Fmily Hx
107
Q

symptoms of prostate cancer

A
  • usually asymptomatic
  • Lower urinary tract obstruction - frequency, hesitancy, terminal dribbling, nocturia
  • visible haematuria + erectile dysfuntion
  • Metastatic spread
  1. systemic spread; FLAWS (malaise, weight loss, anorexia)
  2. bone pain
  3. spine compression
  4. paraneoplastic syndrome (hypercalcemia)
108
Q

signs of prostate cancer

A

DRE

  • hard nodular prostate
  • loss of midline sulcus
109
Q

investigations for prostate cancer

A
  1. Prostate specific antigen (first line but not specific)
  2. DRE
  3. Transrectal US guided biopsy (GOLD STANDARD)
  4. Isotope bone scan to check for metastasis
110
Q

Management for prostate cancer

A

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
111
Q

define erectile dysfunction

A

inability to get or maintain an erection

112
Q

causes of erectile dysfunction

A
  • 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
113
Q

Risk factors for erectile dysfunction (CVD)

A
  • diabetes
  • smoking
  • poor diet- dyslipidemia
  • low exercise
  • obesity
  • hypertension
  • metabollic syndrome
114
Q

Symptoms for organic/pscyhogenic erectile dysfunction

A

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
115
Q

Examinations for erectile dysfunction

A

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
116
Q

Investigations for erectile dysfunction

A

Bloods:

  • HbA1c
  • lipid profile
  • total testosterone
  • FSH, LH, prolactin
  • PSA (if abnormal DRE/ >50+ risk factors for prostate cancer)
117
Q

Management for erectile dysfunction

A

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
118
Q

How to Cardio-risk stratification patients with erectile dysfunction

A

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
119
Q

define urinary incontinence

A

= 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)
120
Q

causes of urinary incontinence

A

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)
121
Q

investigations for urinary incontinence

A
  • urinalysis (check for infection)
  • blood glucose (check for diabetes)
  • bladder diary
  • post-voidal residual volume

Before surgery:

  • cytoscopy
  • pelvic MRI
122
Q

management for urinary incontinence

A

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)
123
Q

complications of urinary incontinence

A
  • contact dermatitis
  • sores/ulcers => SECONDARY INFECTION
124
Q
A
125
Q
A

Year 3 (27 decks)

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