Renal and Urology 🫘🍆 Flashcards
F
1
Q
What is epididymo-orchitis?
A
Inflammation of the epididymis and testes on one side, presenting with acute scrotal pain
2
Q
What are the causes of epididymo-orchitis?
A
STI - chlamydia and gonorrhoea
UTI - E. coli
Mumps
TB
3
Q
What is the presentation of epididymo-orchitis?
A
Testicular pain
Dragging or heavy sensation
Swelling of testicle and epididymis
Tenderness on palpation
Urethral discharge (STI)
Systemic symptoms - fever
Prehn’s positive - lifting testicle relieves pain
Cremasteric reflex is intact
4
Q
What are the differentials of epididymo-orchitis?
A
Testicular torsion
Inguinal hernia
Testicular cancer
5
Q
What investigations can be carried out to help establish a diagnosis of epididymo-orchitis?
A
Urinalysis and urine culture
NAAT testing - chlamydia and gonorrhoea
Charcoal swab
Saliva swab - mumps
Scrotal ultrasound - rule out testicular torsion
6
Q
What is the management of epididymo-orchitis?
A
Analgesia
Scrotal elevation
If STI cause:
- 1g IM ceftriaxone and 100mg doxycycline BD for 10-14 days
If UTI cause:
- Ofloxacin for 14 days or levofloxacin for 10 days
7
Q
What are the complications of epididymo-orchitis?
A
Chronic pain
Chronic epididymitis
Testicular atrophy
Sub-fertility or infertility
Scrotal abscess
8
Q
What are the types of renal stones?
A
Calcium oxalate
Calcium phosphate
Uric acid
Struvite- associated with infection
Cystine - associated with cystinuria (autosomal recessive condition)
9
Q
What are the most common kind of renal stones?
A
Calcium stones - calcium oxalate and calcium phosphate
10
Q
What is the presentation of renal stones?
A
Renal colic
Haematuria
Nausea and vomiting
Reduced urine output
Symptoms of sepsis if infection is present
11
Q
What investigations are performed in investigation of renal stones?
A
Urine dipstick - haematuria
U&E
FBC - signs of infection
Abdominal X-ray - can show calcium based stones
Non-contrast CT-KUB - initial investigation of choice
12
Q
What is the management of renal stones?
A
NSAIDs for analgesia
Antiemetics
Antibiotics if infection present
Tamsulosin
Surgical intervention - for stones larger than 10mm, stones that do not pass spontaneously, or where there is complete obstruction, or infection
13
Q
What types of surgery are available for renal stones?
A
ESWL - extracorporeal shock wave lithotripsy
Ureteroscopy and laser lithotripsy
PCNL - percutaneous nephrolithotomy
Open surgery
14
Q
What analgesia is preferred in renal colic?
A
IM Diclofenac
15
Q
What is the second line analgesia for renal colic?
A
IV paracetamol (if diclofenac insufficient or NSAIDs contraindicated)
16
Q
What is the management of stones under 5mm?
A
Watchful waiting
17
Q
What is the management of 5-10mm renal stones?
A
Shockwave lithotripsy
18
Q
What is the management of 10-20mm renal stones?
A
Shockwave lithotripsy or ureterosopy
- Uretoscopy if stone is ureteric
19
Q
What is the management of renal stones >20mm?
A
Percutaneous nephrolithotomy
20
Q
What medications can be used to prevent calcium stone formation?
A
Potassium citrate
Thiazide diuretics
21
Q
What can be given in ureteric renal stones?
A
Alpha blockers - can help relax the ureters to allow the stone to pass
22
Q
Which type of renal stones are radiolucent?
A
Uric acid
23
Q
What are the types of urinary incontinence?
A
Stress incontinence
Urge incontinence
Overflow incontinence
Functional incontinence
Mixed incontinence
24
Q
What is stress incontinence?
A
Incontinence when intra-abdominal pressure is raised
25
What is urgency incontinence?
The sudden and involuntary loss of urine associated with the urge to urinate
26
What is overflow incontinence?
The leakage of small amounts of urine without warning
27
Why does overflow incontinence occur?
When the pressure of the bladder overcomes the pressure of the outlet structures - usually due to underactivity of the detrusor muscle, or extra pressure on the urinary outlet structures
28
What can put extra pressure on the urinary outlet structures?
BPH
Constipation
29
What is functional incontinence?
The patient has the urge to pass urine, but is unable to access the necessary facilities
30
What are the causes of functional incontinence?
Sedating medications
Alcohol
Dementia
31
What are the risk factors for stress incontinence?
Childbirth
Hysterectomy
32
What can trigger stress incontinence?
Laughing
Coughing
Physical activity
Sneezing
33
What are the risk factors for urge incontinence?
Recent or recurrent UTI
High BMI
Smoking
Caffeine
34
What investigations are helpful in diagnosing urinary incontinence?
Questionnaires
Bladder diary
Cystometry - measures bladder pressure whilst voiding
Cystogram - radiological image with contrast
Urine dip
MSU
35
What lifestyle advice can improve stress incontinence?
Pelvic floor exercises
Avoiding alcohol and caffeine
Avoiding excessive fluid intake
36
What is the surgical management of stress incontinence?
Incontinence pessaries - supports the base of the bladder
Urethral bulking agents - injections into the area around the urethra to improve the sphincter's ability to close
Mid urethral sling procedure (gold standard)
37
What is the medical management of urge incontinence/ overactive bladder?
Anticholinergic medications
- Oxybutynin
- Tolterodine
- Festerodine
38
What is the surgical management of urge incontinence?
Botox injections (to paralyse the detrusor)
Sacral neuromodulation
39
Give 4 reversible causes of urinary incontinence.
UTI
Type 2 diabetes
Diuretics
Delirium
40
What medication can be used for urge incontinence in elderly people at risk of confusion?
Mirabegron
41
What type of cancer is renal cell carcinoma?
Adenocarcinoma
42
Where does RCC most commonly arise from?
Epithelium of the proximal convoluted tubule
43
What are the subtypes of renal cell carcinoma?
Clear cell (80%)
Papillary (15%)
Chromophobe (5%)
44
What are the risk factors for renal cell carcinoma?
Increasing age
Male
Black ethnicity
Smoking
Obesity
Hypertension
Haemodialysis
Von HIppel-Lindau disease
45
What are the clinical features of renal cell carcinoma?
50% of patients are asymptomatic
Classic triad:
- Haematuria
- Flank pain
- Abdominal mass
Weight loss
Fatigue
Fever
Flank mass
Left-sided varicocele
Hypertension
46
Why might RCC cause left-sided varicocele?
Left testicular vein drains into the left renal vein - a left RCC can invade the renal vein causing backpressure and varicocele formation
- The right testicular vein drains directly into the IVC
47
Who should be referred for a two week wait?
Any patient aged over 45 with unexplained visible haematuria
48
What stage of RCC are patients typically at on presentation?
Stage 4 (metastatic)
49
What are the primary investigations for RCC?
FBC - anaemia of chronic disease
U&Es - renal dysfunction
LFTs and coagulation
Bone profile - elevated calcium is poor prognostic marker
LDH
Abdominal ultrasound
50
What is the definitive test for diagnosis of RCC?
CT abdo/pelvis with contrast
51
What is the management of localised RCC?
Partial nephrectomy (T1)
Radical nephrectomy (T2-T4) - may include lymph node dissection and adrenalectomy
52
What is the management of metastatic RCC?
Molecular therapy (sunitinib and pazopanic)
Radiotherapy
Cytoreductive surgery
53
What is the staging of RCC?
T1 - tumour <7cm and confined to kidney
T2 - tumour >7cm and confined to kidney
T3 - tumour extends into major veins and perinpehric tissues, but not ipsilateral adrenal or renal fascia
T4 - tumour invades beyond renal fascica (Gerota's fascia)
54
What are the complications of RCC?
Metastasis - adrenal, liver, bone, lung, brain
Paraneoplastic - EPO, PTH, ACTH
Stauffer syndrome
55
What paraneoplastic syndromes is RCC associated with?
Polycythemia - excess EPO
Hypercalcaemia - secretion of hormoe that mimics PTH
Hypertension - increased renin, polycythaemia and physical compression
Stauffer's syndrome - abnormal LFTs without liver mets
56
What are cannonball metastases?
Metastases to the lungs that appear as clearly-defined circular opacities on CXR
57
What is nephrotic syndrome?
Where the basement membrane of the glomerulus becomes highly permeable to protein - allowing proteins to leak from the blood into the urine
58
What are the common causes of nephrotic syndrome in adults?
Focal segmental glomerulosclerosis
Membranous nephropathy
Membranoproliferative glomerulonephritis
Diabetes
Amyloidosis
59
What is the triad of nephrotic syndrome?
Proteinuria > 3g/24 hours
Hypoalbuminaemia < 30g/L
Oedema
60
What is the clinical presentation of nephrotic syndrome?
Frothy urine
Facial and peripheral oedema
Recurrent infections
Predisposition to VTE
61
What are the primary investigations for nephrotic syndrome?
Urinalysis
24 hour urine protein collection
Urine albumin-creatinine ratio - raised
U&Es
LFTs - hypoalbuminaemia
Lipid profile
Renal ultrasound - exclude structural pathology
62
What is the management of nephrotic syndrome?
Lifestyle modification
- Low salt, protein and fat
- Improve cardiovascular risk factors
Diuretics
ACE inhibitor - used to reduce proteinuria
63
What is the management of focal segmental glomerulosclerosis?
First line - prednisolone
Second line - ciclosporin
64
What is the treatment of membranous nephropathy?
Corticosteroids (prednisolone) combines with an immunosuppressant
- Cyclophosphamide is the first line immunosuppressant
65
What are the complications of nephrotic syndrome?
Hypercholesterolaemia
VTE risk
Infection
Progression to CKD
66
What VTE prophylaxis is given to patients with nephrotic syndrome?
LMWH - enoxaparin, dalteparin etc.
67
What is AKI?
A rapid drop in kidney function diagnosed by measuring serum creatinine
68
What are the criteria for diagnosis of an AKI?
A rise in creatinine of 26 micromol/L or greater within 48 hours
A 50% or greater rise in serum creatinine in 7 days
A fall in urine output to less than 0.5ml/kg/hour for more than 6 hours
69
What extra criteria can be used to diagnose AKI in children?
Fall in eGFR of more than 25%
70
What are the risk factors for AKI?
Older age
Sepsis
CKD
Heart failure
Diabetes
Liver disease
Cognitive impairment - reduced fluid intake
Medications
Radiocontrast agents
71
What medications commonly cause AKI?
NSAIDs
Gentamicin
Diuretics
ACE inhibitors
ARBs
72
What are the pre-renal causes of AKI?
Dehydration
Shock
- Haemorrhagic shock
- Cardiogenic shock
- Septic shock
- Anaphlactic shock
Heart failure
Drugs
73
What are the renal causes of AKI?
Acute tubular necrosis
Glomerulonephritis
Acute interstitial nephritis
Haemolytic uraemic syndrome
Rhabdomyolysis
74
What are the post-renal causes of AKI?
Kidney stones
Tumours
Ureteral or urethral stricture
BPH
Neurogenic bladder
75
What is the most common intrinsic cause of AKI?
Acute tubular necrosis
76
What is acute tubular necrosis?
The damage and death of epithelial cells of the renal tubules (due to hypoperfusion or nephrotoxins)
77
What investigations are performed in suspected AKI?
Serum creatinine
Urinalysis
Ultrasound of urinary tract (to determine post-renal cause)
ABG
Bloods - FBC, U&E, LFTs, glucose, CK, CRP
ECG - hyperkalaemia
CXR - pulmonary oedema
78
What is a stage 1 AKI?
Rise of >26micromol or more within 48 hours
Rise in creatinine of more than 50% in 7 days
Urine output less than 0.5ml/kg/hour for more than 6 hours
79
What is a stage 2 AKI?
More than 100% rise in creatinine in 7 days
Urine output less than 0.5ml/kg/hour for more than 12 hours
80
What is a stage 3 AKI?
More than 200% rise in creatinine in 7 days
Urine output less than 0.3ml/kg/hour for 24 hours
Anuria for 12 hours
81
What is the management of AKI?
IV fluids
Withhold medications that may worsen the condition
Withhold/adjust medications that may accumulate with reduced renal function
Relieve obstruction in post-renal AKI
Dialysis
82
What are the complications of AKI?
Fluid overload
Heart failure
Pulmonary oedema
Hyperkalaemia
Metabolic acidosis
Uraemia
83
What are the clinical features of AKI?
Reduced urine output
Confusion or drowsiness
Swollen legs
Suprapubic pain
Haematuria
Dry mucous membranes
Reduced BP
Palpable bladder
84
What are the indications for renal replacement?
Acidosis - refractory
Electrolyte imbalance - refractory
Ingestion of toxins
Oedema/overload
Uraemia - refractory
85
What is pyelonephritis?
Inflammation of the renal pelvis and parenchyma as a result of bacterial infection
86
What is the most common cause of pyelonephritis?
E. coli
87
What are the other causes of pyelonephritis?
Klebsiella pneumoniae
Enterococcus
Pseudomonas aeruginosa
Staphylococcus saprophyticus
Candida albicans
88
What are the risk factors for pyelonephritis?
Female sex
Structural urological abnormalities
Vesico-ureteric reflux
Diabetes
89
What are the indicators of complicated pyelonephritis?
Pregnancy
Uncontrolled diabetes
Kidney transplants
Urinary anatomical abnormalities
Acute or chronic kidney failure
Immunocompromised patients
Hospital-acquired bacterial infections
90
What are the clinical features of pyelonephritis?
Flank pain
Myalgia
Rigors
Dysuria
Haematuria
Confusion
91
What signs are found on examination in pyelonephritis?
Renal angle tenderness
Suprapubic tenderness
Fever
Tachycardia
Hypotension
Altered mental status
92
What are the first line investigations for pyelonephritis?
Urinalysis
Urine MC&S
FBC
CRP
U&Es
93
What other investigations may be considered in pyelonephritis?
US KUB - assess structural abnormalities
CT KUB - if renal colic is suspected
94
What is the management of pyelonephritis?
First line
- Oral Cefalexin for 7-10 days
- Oral Ciprofloxacin for 7 days
Second line - for severe disease
- IV gentamicin
- IV ciprofloxacin
95
What is the most common type of prostate cancer?
Adenocarcinoma
96
Where is the most common site of prostate cancer?
Peripheral zone of the prostate
97
What genes are associated with prostate cancer?
BRCA1 and BRCA2
98
What are the risk factors for prostate cancer?
Increasing age
Family history
Black African or Carribean origin
Tall stature
Anabolic steroids
Obesity
99
What are the symptoms of prostate cancer?
LUTS
- Frequency
- Hesitancy
- Terminal dribbling
- Nocturia
Haematuria
Dysuria
Bone pain (in metastatic disease)
Weight loss
Erectile dysfunction
100
What are the clinical signs of prostate cancer?
Urinary retention
Asymmetrical, hard prostate
Palpable lymphadenopathy (metastatic disease)
101
What are the common causes of raised PSA?
Prostate cancer
BPH
Prostatitis
UTI
Vigorous exercise
Recent ejaculation
102
What is the main drawback of PSA testing?
High rate of false positive and false negative
103
What findings on prostate exam are suggestive of prostate cancer?
Hard, asymmetrical, craggy or irregular prostate
Loss of the central sulcus
104
What investigations are used in the diagnosis of prostate cancer?
PSA
Bone profile (raised ALP and hypercalcaemia - bone mets)
LFTs
U&Es
Multiparametric MRI
Prostate biopsy
105
What is the first-line investigation for suspected localised prostate cancer?
Multiparametric MRI
106
What is the gold standard investigation of prostate cancer?
Prostate biopsy - Transrectal ultrasound guided biopsy or transperineal biopsy
107
What is the Linkert scale?
The Linkert scale is the probability from multiparametric MRI that the patient has prostate cancer
1 - very low suspicion
2 - low suspicion
3 - equivocal
4 - probable cancer
5 - definite cancer
108
Where does advanced prostate cancer most commonly spread to?
Lymph nodes
Bone
109
What is the Gleason score?
Gleason score is used to grade prostate cancer - the two most common type of cells are graded from 1-5 and added together to give a score out of 10
- low grade - <6
- intermediate grade - 7
- high grade - 8-10
110
What is the TNM staging for prostate cancer?
TX - unable to assess size
T1 - to small to be felt on examination or seen on scans
T2 - contained within the prostate
T3 - extends out of the prostate
T4 - spread to nearby organs
NX - unable to assess nodes
N0 - no nodal spread
N1 - spread to lymph nodes
M0 - no metastasis
M1 - metastasis
111
What are the management options for low-intermediate risk prostate cancer?
Active surveillance
Radical prostatectomy
Radical radiotherapy or brachytherapy (+/- anti-androgen therapy)
112
What are the management options for high risk localised cancer?
Radical prostatectomy
Radical radiotherapy with anti-androgen therapy
Radical radiotherapy with brachytherapy
Docetaxel chemotherapy with anti-androgen therapy
113
What is the most common organism causing UTIs?
E. coli
114
What other organisms can cause UTI?
Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
Candida
Pseudomonas aeruginosa
115
What are the risk factors for UTI?
Female
Post-menopause
Sex
History of UTI in childhood
Urinary incontinence
Atrophic vaginitis
Cystocele
116
What are the clinical features of UTI?
Dysuria
Frequency
Urgency
Incontinence
Haematuria
Cloudy or foul smelling urine
Confusion
Suprapubic tenderness
117
What are the initial investigations for UTI?
Urine dipstick
- Positive for nitrites, leukocytes and RBCs
Urine microscopy, culture and sensitivity
118
When should MC&S be requested for UTI?
Request in all women with positive dipstick findings
Request in all women >65 years, cathetrised, pregnant or with visible/non-visible haematuria regardless of dipstick findings
119
What are the first choice antibiotics for UTI?
Nitrofurantoin (avoid in patients with GFR<45)
Trimethoprim
120
What are the alternative antibiotics used in UTI?
Pivmecillinam
Amoxicillin
Cefalexin
121
How long are antibiotics given for UTI?
3 days - simple UTI in women
5-10 days - immunosuppressed women, abnormal anatomy or impaired kidney function
7 days - men, pregnant women, or catheter related UTIs
122
Which antibiotics are suitable for UTI in pregnancy?
Nitrofurantoin (avoid in third trimester)
Cefalexin
Amoxicillin (only after sensitivities are known)
123
What is the treatment of asymptomatic bacteriuria in long term catheterised patients?
No treatment required
124
What is the treatment of symptomatic bacteriuria in long term catheterised patients?
7 days of antibiotics
Remove or change catheter if it has been in place for longer than 7 days
125
What is testicular torsion?
A urological emergency where the spermatic cord is twisted, which can result in ischaemia and necrosis
126
What is the presentation of testicular torsion?
Sudden onset of severe, unilateral pain
Pain may be referred to lower abdomen
Nausea and vomiting
127
What are the examination findings in testicular torsion?
Loss of cremasteric reflex
Firm, swollen testicle
Elevated testicle
Abnormal testicular lie
128
What is a Bell-Clapper deformity?
Fixation between the testicle and tunica vaginalis is absent
There is increased risk of the testicle rotating within the tunica vaginalis, causing testicular torsion
129
What is the management of testicular torsion?
Urgent surgical exploration
Nil by mouth (preparation for surgery)
Analgesia
Orchioplexy
Orchidectomy
130
What investigation can be used to confirm testicular torsion?
Scrotal ultrasound
131
What will be seen on scrotal ultrasound in testicular torsion?
Whirlpool sign
132
What is polycystic kidney disease?
A genetic condition where healthy kidney tissue is replaced with many fluid-filled cysts
133
What genes are affected in polycystic autosomal dominant PKD?
PKD1 gene on chromosome 16
PKD2 gene on chromosome 4
134
What are the extra renal manifestations of PKD?
Cerebral aneurysms - berry aneurysm
Hepatic, splenic, pancreatic, ovarian and prostatic cysts
Mitral regurgitation
Colonic diverticula
135
What are the complications of PKD?
Chronic loin/flank pain
Hypertension
Gross haematuria if cyst ruptures
Recurrent UTIs
Renal stones
End stage renal failure
136
What investigations are used in the diagnosis of PKD?
Ultrasound
Genetic testing
137
What is the management of PKD?
Antihypertensives - ACE inhibitors
Analgesia
Antibiotics for infections
Drainage of symptomatic cysts
Dialysis for end stage renal failure
Renal transplant
138
What is a hydrocele?
A collection of fluid within the tunica vaginalis that surrounds the testes
139
What is the tunica vaginalis?
A sealed pouch of membrane that surrounds the testes
140
What are the examination findings of a hydrocele?
Testicle palpable within the hydrocele
Soft, fluctuant
Irreducible
Lump has no bowel sounds (unlike a hernia)
Transilluminated by shining a torch through the skin
Swelling is confined to the scrotum
141
What is a communicating hydrocele?
A communicating hydrocele is seen in newborns - caused by a patency of the processus vaginalis, allowing peritoneal fluid to drain down into the scrotum
142
What is a non-communicating hydrocele?
Caused by excessive fluid production within the tunica vaginalis
143
What is the management of hydrocele?
Infants
- Surgery if they do not resolve spontaneously by 1-2 years
Conservative approach
144
What investigation is usually performed for a suspected hydrocele?
Ultrasound - to exclude other causes of a scrotal lump
145
What is a varicocele?
Where the veins in the pampiniform plexus become swollen (the venous network draining the testes and epidydimis)
146
Which side are varicoceles more common on?
Left side
147
Why are varicoceles more common on the left side?
The right testicular vein drains directly into the IVC, whereas the left testicular vein drains into the left renal vein
148
What is the presentation of a varicocele?
Throbbing/dull pain
Pain worse on standing
Dragging sensation
Sub-fertility or infertility
149
What are the findings of a varicocele on examination?
Scrotal mass that feels like a bag of worms
More prominent on standing
Disappears when lying down
Asymmetry in testicular size
150
What investigations can be used in the diagnosis of a varicocele?
Ultrasound with doppler imaging - diagnostic
Semen analysis
Hormonal tests - FSH and testosterone
151
What is the management of varicocele?
Most cases can be managed conservatively
Some cases may need surgery or endovascular embolisation
152
What is the most common type of bladder cancer?
Transitional cell carcinoma
153
What are the less common types of bladder cancer?
Squamous cell carcinoma
Adenocarcinoma
154
What is squamous cell carcinoma of the bladder associated with?
Schistosomiasis
155
What are the risk factors for bladder cancer?
Smoking
Increased age
Exposure to aniline dyes
Rubber manufacture
Schistosomiasis
Cyclophosphamide
156
What is the 2 week wait criteria for bladder cancer?
Over 45 with unexplained visible haematuria (without a UTI or persisting after a UTI)
Over 60 with microscopic haematuria, plus dysuria or raised white cells on full blood count
157
What is the presentation of bladder cancer?
Painless haematuria
Can cause dysuria
Frequency
Weight loss
Palpable suprapubic mass (advanced cases)
Anaemia
158
What investigation is diagnostic of bladder cancer?
Flexible cystoscopy
159
What investigations are useful in the diagnosis of bladder cancer?
Urinalysis
FBC
U&Es
Bone profile (bone metastasis)
CTAP - assess spread
CT urogram
Pelvic MRI - for staging
160
What is the management of superficial/ non-muscle invasive bladder cancer?
Trans-urethral resection of bladder tumour
- Involves removing the tumour through a cystoscopy procedure
Intravesical chemotherapy is given alongside TURBT
161
What is the management of muscle invasive bladder cancer?
Radical cystectomy with neoadjuvant chemotherapy
Radical radiotherapy with neoadjuvant chemotherapy
162
What cells do most testicular tumours arise from?
Germ cells
163
How can germ cell testicular tumours be divided?
Seminomas
Non-seminoas (mostly teratomas)
164
What non-germ cell testicular tumours exist?
Leydig cell tumour
Sertoli cell tumour
165
What are the risk factors for testicular cancer?
Young males
Caucasian
Family history
Infertility
Undescended testes
166
What is the appearance of a testicular lump in testicular cancer?
Painless
Arising from testicle
Hard
Irregular
Not fluctuant
No transillumination
167
What is the initial investigation for diagnosis of testicular cancer?
Scrotal ultrasound
168
What tumour markers may be raised in testicular cancer?
Alpha-fetoprotein - teratomas
Beta-hCG - teratomas and seminomas
LDH - non-specific tumour marker
169
What investigation is used to stage testicular cancer?
CT chest, abdo, pelvis
170
What is the Royal Marsden staging system for testicular cancer?
Stage 1 - isolated to testicle
Stage 2 - spread to retroperitoneal lymph nodes
Stage 3 - spread to lymph nodes above the diaphragm
Stage 4 - metastasised to other organs
171
Where does testicular cancer commonly metastasise to?
Lymphatics
Lungs
Liver
Brain
172
What is the management of testicular cancer?
Radical orchidectomy (a prothesis can be inserted)
Chemotherapy
Radiotherapy
Sperm banking
173
What are the long term side effects of testicular cancer treatment?
Infertility
Hypogonadism
Peripheral neuropathy
Hearing loss
Increased risk of cancer in the future
174
What is BPH?
BPH is the hyperplasia of the stromal and epithelial cells of the prostate
175
What are the LUTS that occur with prostate pathology?
Hesitancy
Weak flow
Urgency
Frequency
Intermittency
Straining to pass urine
Terminal dribbling
Incomplete emptying
Nocturia
176
What is the pathophysiology of BPH?
An increased in the activity of the enzyme, 5-alpha reductase, causes an increase in dihydrotestosterone and oestrogen.
DHT acts on androgen receptors in the prostate to cause hyperplasia
177
Where in the prostate does hyperplasia occur?
Hyperplasia typically occurs in the transition zone, which causes compression of the prostatic urethra
178
What are the differentials of BPH?
Prostate cancer
UTI
Neurogenic bladder dysfunction
Urethral stricture
179
What makes up the initial assessment of a man presenting with LUTS?
DRE - prostate examination
Abdominal examination
Urinary frequency volume chart
Urine dipstick
PSA for prostate cancer
180
What are the common causes of a raised PSA?
Prostate cancer
BPH
Prostatitis
UTI
Vigorous exercise
Recent ejaculation
181
What does a normal prostate feel like?
Smooth
Symmetrical
Slightly soft
Maintained central sulcus
182
What is the international prostate symptom score?
A 7-symptom questionnaire that predicts progression and outcome of BPH
183
How is the severity of LUTS classified?
By IPSS score:
- Mild - score 0-7
- Moderate - score 8-19
- Severe - score 20-35
184
What lifestyle modifications can improve symptoms of BPH?
Fluid restriction
Avoidance of caffeine and alcohol
Timed voiding
185
What is the first line pharmacological management of BPH?
Alpha antagonists - tamsulosin
186
What are the side effects of alpha blockers?
Postural hypotension
Dizziness
Dry mouth
Depression
187
What is the second line pharmacological management of BPH?
5-alpha reductase inhibitors e.g finasteride
188
What are the side effects of finasteride?
reduced libido
Erectile dysfunction
Gynaecomastia
Reduced ejaculate volume
189
What are the indications for surgery in BPH?
RUSHES
- Recurrent or refractory urinary retention
- U - recurrent UTIs
- S - bladder stones
- Haematuria refractory to medical therapy
- Elevated creatinine due to bladder outflow obstruction
- Symptom deterioration despite maximal medical therapy
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What are the surgical intervention for BPH?
Prostate < 30g - transurethral incision of the prostate
Prostate 30-80g - transurethral resection of the prostate
Prostate >80g - open prostatectomy
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What are the complications of TURP?
Bleeding
Infection
Urinary incontinence
Erectile dysfunction
Retrograde ejaculation
Urethral strictures
Failure to resolve symptoms
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What is prostatitis?
Inflammatory and/or infectious condition involving the prostate gland
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What is the most common cause of prostatitis?
Bacterial infection
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What is the classification of prostatitis?
Acute bacterial prostatitis
Chronic bacterial prostatitis
Chronic non-bacterial prostatitis/ chronic pelvic pain syndrome
Asymptomatic inflammatory prostatitis
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What are the risk factors for prostatitis?
UTIs
Epididymitis
Catheter use
Previous urethral surgery
Presence of prostate stones
HIV
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What is the presentation of acute bacterial prostatitis?
Fever
Myalgia
Nausea
Fatigue
Sepsis
+ similar symptoms to chronic prostatitis
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What are the symptoms of chronic prostatitis?
Pelvic pain
LUTS
Sexual dysfunction
Pain with bowel movements
Tender and enlarged prostate
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What are the differentials of prostatitis?
UTI
Epididymitis
BPH
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What investigations are useful in the diagnosis of prostatitis?
DRE
Urinalysis
Urine MC&S
PSA
Screening for STIs
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What is the management of acute bacterial prostatitis?
Hospital admission
Sepsis screen
Oral antibiotics for 2-4 weeks - ciprofloxacin, ofloxacin or trimethoprim
Analgesia
Laxatives for pain during bowel movements
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What is the management of chronic prostatitis?
Alpha-blockers
Analgesia
Antibiotics if <6 months of symptoms - trimethoprim or doxycycline for 4-6 weeks
Laxatives for pain during bowel movements
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What are the causes of CKD?
Diabetes
Hypertension
Medications
Glomerulonephritis
Polycystic kidney disease
Renal involvement secondary to multisystem disease
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What is the classification of CKD?
G stages
G1 - eGFR over 90 with evidence of kidney damage
G2 - 60-89 - with evidence of kidney damage
G3a - 45-59
G3b - 30-44
G4 - 15-29
G5 - under 15
A stage - based on albumin:creatinine ratio
A1 - under 3mg/mmol
A2 - 3-30 mg/mmol
A3 - above 30 mg/mmol
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What is the presentation of CKD?
Most patients asymptomatic
Fatigue
Pallor
Foamy urine
Nausea
Loss of apetite
Pruritis
Oedema
Hypertension
Peripheral neuropathy
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What investigations are performed in CKD?
Urine dipstick
MC&S if haematuria
Early morning albumin: creatinine ratio
U&Es
FBC
LFTs
Bone profile
HbA1c
Lipid profile
Clotting screen
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When is a renal biopsy indicated for diagnosis of CKD?
If cause of renal impairment is unclear
Rapid progression of CKD
When glomerulonephritis is suspected
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What are the complications of CKD?
Anaemia
Renal bone disease
Cardiovascular diease
Peripheral neuropathy
End-stage kidney disease
Dialysis-related complications
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What lifestyle advice should be provided to those with CKD?
Smoking cessation
Moderating alcohol intake
Maintaining a healthy weight with regular exercise
Maintaining a health diet
Avoid over the counter nephrotoxics
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What is the medical management of CKD?
Treat the underlying cause of CKD
Review medications and reduce/stop nephrotoxic drugs
Treat hypertension with up to 4 hypertensives
Optimise diabetic control
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When should patients be referred to a renal specialist?
eGFR < 30
Urine ACR more than 70
Accelerated progression
5 year risk of requiring dialysis over 5%
Uncontrolled hypertension despite four or more antihypertensives
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What is the target blood pressure for those with CKD?
140/90 for most patients with CKD
130/80 in patients with an ACR of more than 70
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What medications can help slow the progression of CKD?
ACE inhibitors
SGLT-2 inhibitors (specifically dapagliflozin)
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Which CKD patients are ACE inhibitors offered to?
Diabetics with a urine ACR of above 3
Hypertension plus a urine ACR of above 30
All patients with an ACR of above 70
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How does CKD cause bone disorders?
Reduced phosphate excretion lead to high serum phosphate
Kidneys metabolise vitamin D - without vitamin D, calcium is unable to be absorbed, leading to low serum calcium
Low serum calcium causes PTH secretion, resulting in secondary hyperparathyroidism
PTH stimulates osteoclast activity, increasing calcium absorption from the bone - can result in osteomalacia and osteosclerosis
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What is the classical finding on XR of renal bone disease?
Rugger jersey spine - sclerosis of both ends of each vertebral body, and osteomalacia in the centra of the vertebral body
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What is the management of renal bone disease?
Low phosphate diet
Phosphate binders
Active forms of vitamin D
Ensuring adequate calcium intake
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What type of anaemia is typically seen in CKD?
Normocytic and normochromic
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When is an ACE inhibitor offered to CKD patients?
When ACR (albumin:creatinine ratio) is above 30 (if a patient has hypertension)
When ACR is above 70 with no hypertension
Diabetics with a ACR of over 3
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How much can creatinine and eGFR change when starting an ACE inhibitor?
Creatinine - 30%
eGFR - 25%
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What are the causes and contributing factors to erectile dysfunction?
Vascular disease
Autonomic neuropathy
Medications
Psychogenic - anxiety, depression
Endocrine causes - prolactinoma, hypogonadism
Pelvic surgery
Anatomical abnormalities
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What is the clinical presentation of erectile dysfunction?
Reduced sexual desire
Difficulty in ejaculation
Anxiety or depression related to sexual performance
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What are the signs that suggest an organic cause?
Lacking erections
Slow-onset
Normal libido
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What are the signs that suggest a psychogenic cause?
Situational
High levels of stress
Still having early morning erections
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What investigations are performed in the diagnosis of erectile dysfunction?
Detailed sexual and psychological history
FBC
U&E
TFTs
Lipid profile
Testosterone
Prolactin
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What is the management of erectile dysfunction?
Psychosexual therapy
Oral phosphodiesterase inhibitors - sildenafil
Vacuum erection devices
Intra-cavernosal injections to increase blood flow
Penile prostheses for cases resistant to other treatments
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What are the contraindications for sildenafil?
Individuals taking nitrates
Hypertension/hypotension
Arrhythmias
Unstable angina
Stroke
MI
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What are the cautions for sildenafil use?
Patients with angina
Peptic ulcers
Liver or kidney impairment
Peyronie's disease
Complex antihypertensive regimes
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What is interstitial cystitis?
A chronic condition causing inflammation in the bladder, resulting in LUTS and suprapubic pain
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What is the presentation of interstitial cystitis?
Suprapubic pain
Pain worse with full bladder and relieved with empty bladder
Frequency of urination
Urgency of urination
Symptoms may be worse during menstruation
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What investigations are used in the diagnosis of interstitial cystitis?
Urinalysis
Swabs for STIs
Cystoscopy
Prostate examination in men
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What are the findings on cystoscopy in patients with interstitial cystitis?
Hunner lesions
Granulations
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What are hunner lesions?
Red, inflamed patches of the bladder mucosa associated with small blood vessels
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What are granulations in interstitial cystitis?
Tiny haemorrhages of the bladder wall
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What is the first line management of interstitial cystitis?
Supportive management:
- Avoiding alcohol, caffeine and tomatoes
- Stopping smoking
- Pelvic floor exercises
- Bladder retraining
- CBT
- TENS
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What medications may be helpful in interstitial cystitis?
Analgesia
Antihistamines
Anticholingerics - solifenacin or oxybutynin
Mirabegron
Cimetidine
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What intravesical medication can be given for interstitial cystitis?
Lidocaine
Pentosan polysulfate sodium
Hyaluronic acid
Chondroitin sulfate
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What surgical procedures can be performed in the management of interstitial cystitis?
Cauterisation of hunner lesions
Botulinium toxin injections
Neuromodulation with implanted electrical nerve stimulator
Augmentation of the bladder
Cystectoym
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What is the aetiology of ADPKD?
PKD genes cause mutations in polycystin 1 and 2, which leads to cyst formation
239
Where are the PKD genes located?
PKD1 is located on chromosome 16
PKD2 is located on chromosome 4
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What is the presentation of ADPKD?
Flank pain
Haematuria
Fever and systemic illness
Polyuria
Nocturia
CKD
241
What examination findings are common in ADPKD?
Bilateral large masses in the flanks
Hepatomegaly (liver cysts)
Hypertension
242
What are the differentials of ADPKD?
Simple renal cysts
Acquired cystic kidney disease
ARPKD
Tuberous sclerosis
Von-hippel lindau disease
243
What investigation is diagnostic of ADPKD?
USS kidneys
244
What other investigations are used in the diagnosis of ADPKD?
Urine dip
FBC - polycythemia
U&Es, LFTs
CT/MRI - more sensitive than USS
245
What advice should be given to patients with ADPKD?
Advice to avoid contact sport
Smoking cessation
Healthy diet and regular exercise
Avoid nephrotoxic drugs and oestrogens
246
What is the medical management of ADPKD?
Antihypertensives
- ACE inhibitor or ARB
Tolvaptan - slows cyst growth
Analgesia
247
What are the surgical management options for ADPKD?
Drainage or renal cysts
Nephrectomy
Renal transplant
248
What are the complications of ADPKD?
Cyst haemorrhage
Cyst infection
Recurrent UTI
Liver cysts
Intracranial aneurysms
Chronic pain
End stage renal disease
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What is minimal change disease?
The most common cause of nephrotic syndrome in children
250
What are the causes of minimal change disease?
Idiopathic - most common
Drugs - NSAIDs, rifampicin
Hodgkin's lymphoma
Infectious mononucleosis
251
What are the features of minimal change disease?
Nephrotic syndrome
- Oedema
- Proteinuria
- Hypoalbuminaemia
No hypotension
252
What investigations are used in the diagnosis of minimal change disease?
Renal biopsy
Urinalysis
253
What is seen on a renal biopsy in minimal change disease?
Normal glomeruli
Fusion of podocytes and effacement of foot processes
254
What is the management of minimal change disease?
Oral corticosteroids
255
What is seen on urinalysis in minimal change disease?
Small molecular weight proteins and hyaline casts
256
What is the second line management of minimal change disease?
Cyclophosphamide
257
What is IgA nephropathy?
Macroscopic haematuria in young people, following an URTI
258
What is the pathophysiology of IgA nephropathy?
Deposition of IgA immune complexes in the kidneys
259
What is the presentation of IgA nephropathy?
Presents a few days after URTI
Macroscopic haematuria
Typically seen in young males
260
What is the management of IgA nephropathy?
If isolated haemturia, no proteinuria and normal eGFR:
- No treatment needed
Persistent proteinuria
- ACE inhibitors
Failing GFR
- Immunosuppression with corticosteroids
261
What investigations can be used to diagnose IgA nephropathy?
Blood - high IgA titres
Renal biopsy - mesangial deposits of IgA complexes
262
What is acute tubular necrosis?
Necrosis of the tubular epithelial cells affects the functioning of the kidney
263
What are the causes of acute tubular necrosis?
Ischaemia (shock, sepsis)
Nephrotoxins
264
What is the presentation of acute tubular necrosis?
Typical features of AKI + muddy brown casts in the urine
265
What is the management of acute tubular necrosis?
Treat AKI
Tubular epithelial cells regenerate in 1-3 weeks
266
What drugs cause acute interstitial nephritis?
Penicillins
Rifampicin
NSAIDs
Allopurinol
Furosemide
267
What is the presentation of acute interstitial nephritis?
Fever
Rash
Arthralgia
Eosiophilia
268
What is seen on urinalysis in acute interstitial nephritis?
Sterile pyuria
White cell casts
269
What is the pathophsyiology of goodpasture's?
Anti-glomerular basement membrane antibodies target type 4 collagen in the glomerular basement membrane
270
What antibodies are seen in goodpasture's?
ANti glomerular basement membrane antibodies
271
What other organ system does goodpasture's affect?
Lungs - anti GBM membranes affect basement membranes in the lungs
272
What is the management of goodpasture's?
Plasma exchange
Steroids
Cyclophosphamide
273
What is the most common cause of glomerulonephritis?
IgA nephropathy
274
What is the most common presentation of lupus nephritis?
Diffuse proliferative glomerulonephritis
275
What antibodies are seen in the blood for diffuse proliferative nephritis?
Anti ds-DNA
ANA
276
What is alport syndrome?
Defects in type 4 collagen of the basement membrane - caused by inherited X-linked syndrome
277
What is the presentation of alport syndrome?
Sensorineural hearing loss
Eye problems - retinitis pigmentosa
Nephritic syndrome
278
What are the features of nephritic syndrome?
Haematuria
Oliguria
Proteinuria
Fluid retention/oedema
279
What are the features of goodpasture's syndrome?
Pulmonary haemorrhage
Rapidly progressive glomerulonephritis
280
What is the investigation of choice for goodpasture's syndrome?
Renal biopsy - liner IgG deposits seen along the basement membrane
