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Y3 Content > Renal and Urology > Flashcards

Renal and Urology Flashcards

1
Q

Define BPH.

A

Slowly progressive nodular hyperplasia of the periurethral (transitional) zone of the prostate gland.

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2
Q

What are the risk factors for BPH?

A

o Low soya/vegetable based diet

o No cirrhosis

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3
Q

What are the presenting symptoms of BPH?

A

Obstructive and Irritative symptoms = FUND HIPS

  • Frequency
  • Urgency
  • Nocturia
  • Dysuria
  • Hesistancy
  • Incomplete voiding/Incontinence
  • Poor stream
  • Smell/odour

o Acute retention = Sudden inability to pass urine, Severe pain

o Chronic retention = Painless, Increased fequency of small volumes, Nocturia

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4
Q

What are the clinical signs of BPH on examination?

A

o DRE = the prostate is usually smoothly enlarged with a palpable midline groove

o Signs of Acute Retention = Suprapubic pain with a distended, palpable bladder

o Signs of Chronic Retention = A large distended painless bladder (volume > 1 L), Signs of renal failure

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5
Q

What are the appropriate investigations for BPH?

A

o Urinalysis = Check for UTI signs and blood

o Bloods = U&Es (check for impaired renal function), PSA

o Midstream Urine = MC&S

o Imaging = USS of urinary tract (check for hydronephrosis), Bladder scanning to measure pre- and postvoiding volumes, Transrectal Ultrasound Scan (TRUS) (allows assessment of bladder size and volume), Flexible Cystoscopy

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6
Q

What is the management plan for BPH?

A

o In Emergency/Acute Urinary Retention = Catheterisation

o Conservative (if mild) = Watchful waiting

o Medical = Selective a-blockers (e.g. tamsulosin - relax the smooth muscle of the internal urinary sphincter and prostate capsule), 5a-reductase inhibitors (e.g. finasteride - inhibits the conversion of testosterone to dihydrotestosterone, which can reduce prostate size by around 20%)

o Surgery = TURP, Open prostatectomy

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7
Q

What are the possible complications of BPH?

A

o Recurrent UTI

o Acute or chronic urinary retention

o Urinary stasis

o Bladder diverticula

o Stone development

o Obstructive renal failure

o Post-obstructive diuresis

o TURP complications

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8
Q

What are the stages of CKD?

A

o Stage 1 = Normal - eGFR > 90 ml/min per 1.73m2 with other evidence of CKD (microalbuminuria, proteinuria, haematuria, structural abnormalities, biopsy showing glomerulonephritis)

o Stage 2 = Mild Impairment - eGFR 60-89 ml/min per 1.73m2 with other evidence of CKD

o Stage 3a = Moderate Impairment - eGFR 45-59 ml/min per 1.73m2

o Stage 3b = Moderate Impairment - eGFR 30-44 ml/min per 1.73m2

Stage 4 = Severe Impairment - eGFR 15-29 ml/min per 1.73m2

o Stage 5 = Established Renal Failure = eGFR < 15 ml/min per 1.73m2 or on dialysis

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9
Q

What are the risk factors for CKD?

A

o Age

o DM

o Hypertension

o Obesity

o CVD

o Others = arteriopathic renal disease, nephropathies, family history, neoplasia, myeloma, systemic disease (e.g. SLE), smoking, chronic use of NSAIDs

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10
Q

What are the presenting symptoms of CKD?

A

o Often asympatomatic - routine blood/urine finding

o Severe symptoms = Anorexia, Nausea and vomiting, Fatigue, Pruritus, Peripheral oedema, Muscle cramps, Pulmonary oedema

  • Sometimes there is sexual dysfunction
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11
Q

What are the clinical signs of CKD on examination?

A

o Physical examination rarely reveals many clues

o May show signs of underlying disease (e.g. SLE)

o May show complications of CKD (e.g. anaemia)

o Signs of CKD = Skin pigmentation, Excoriation marks, Pallor, Hypertension, Peripheral oedema, Peripheral vascular disease

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12
Q

What are the appropriate investigations for CKD?

A

o Assessment of Renal Function = Urea (not ideal because it varies massively), Creatinine (useful but has limitations - renal function can fall with minimal change), Isotopic GFR = Gold standard but expensive

o Biochemistry = Glucose (check for undiagnosed diabetes and diabetic control), Potassium (raised), Check sodium, bicarbonate, calcium, phosphate

o Serology = Antibodies (ANA - SLE, c-ANCA - granulomatosis with polyangiitis (Wegener’s), Anti-GBM - Goodpasture’s syndrome), Hepatitis serology, HIV serology

o Urinalysis = Check for proteinuria/haematuria, 24 hr urine collection, Serum or urine protein electrophoresis - check for multiple myeloma

o Imaging = Ultrasound (Check for structural abnormalities), CT/MRI, X-Ray KUB - check for stones)

o Renal Biopsy

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13
Q

Define epididymitis and orchitis.

A

Inflammation of the epididymis or testes.

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14
Q

What are the causes and risk factors for epidiymitis and orchitis?

A

o Causes

  • Bacterial = < 35 yrs - Chlamydia and Gonococcus, > 35 yrs - mainly coliforms (e.g. Enterobacter, Klebsiella), rare - TB, syphilis
  • Viral = Mumps
  • Fungal = Candida if immunocompromised
  • 1/3 are idiopathic

o Risk Factors = Diabetes, Rare: vasculitis (e.g. Henoch-Schonlein purpura)

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15
Q

What are the presenting symptoms of epididymitis and orchitis?

A

o Painful, swollen and tender testis or epididymis

o Penile discharge

o Important to ask about sexual history

  • Less acute onset than testicular torsion
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16
Q

What are the clinical signs of epididymitis and orchitis examination?

A

o Swollen and tender epididymis or testis

o Scrotum may be erythematous and oedematous

o Pyrexia

o Walking will be painful

o Eliciting a cremasteric reflex may be painful

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17
Q

What are the appropriate investigations for epididymitis and orchitis?

A

o Urine = Dipstick, Early morning urine collections for MC&S

o Bloods = FBC (high WCC), High CRP, U&Es

o Imaging = Increased blood flow on duplex examination

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18
Q

What is the management plan for epididymitis and orchitis?

A

o Medical = Antibiotics

o Surgical = Exploration if testicular torsion cannt be excluded, drainage of an abscess

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19
Q

What are the possible complications of epididymitis and orchitis?

A

o Pain

o Abscess

o Fournier’s gangrene - if left untreated and the infection spreads

o Mumps orchitis - testicular atrophy and fertility issues

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20
Q

Define glomerulonephritis.

A

An immunologically mediated inflammation of the renal glomeruli.

  • A large group of disorders that include Goodpastures syndrome
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21
Q

What are the risk factors for glomerulonephritis?

A

o Antigens to which the antibodies are produced are unknown but may be associated with:

  • Bacteria (e.g. Streptococcus viridans, Staphylococci)
  • Viruses (e.g. HBV, HCB, measles, mumps, EBV)
  • Protozoal (e.g. Plasmodium malariae, schistosomiasis)
  • Inflammatory/Systemic diseases (e.g. SLE, vasculitis, cryoglobulinaemia)
  • Drugs (e.g. gold, penicillinamine)
  • Tumour
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22
Q

What are the presenting symptoms of glomerulonephritis?

A

o Haematuria

o Subcutaneous oedema

o Polyuria or oliguria

o History of recent infection

o Symptoms of uraemia or renal failure (acute and chronic)

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23
Q

What are the signs of glomerulonephritis on examination?

A

o Hypertension

o Proteinuria

o Haematuria (especially in IgA nephropathy)

o Renal failure

o Nephrotic syndrome = Triad of Proteinuria > 3.5g/24 hrs, Low serum albumin < 24g/L and Oedema

  • Proteins move into the urine

o Nephritic syndrome = Triad of Haematuria, Hypertension and Proteinuria (can also cause a low urine output due to decreased renal function)

  • Pores in the podocytes are large enough to allow protein AND red blood cells to pass into the urine
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24
Q

What are the appropriate investigations for glomerulonephritis?

A

o Bloods = FBC, U&Es, Creatinine, LFTs (check albumin), Lipid profile, Complement studies

o Serology - Antibodies = ANA, Anti-dsDNA, ANCA, Anti-GBM antibody, Cryoglobulins

o Urine = Microscopy (check for red cell casts), 24 hr collection - creatinine clearance and protein

o Imaging = Renal tract ultrasound to exclude other pathology (e.g. obstruction)

o Renal Biopsy

o Investigations for associated conditions (e.g. HBV, HCV and HIV serology)

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25
Q

Define hydrocoele.

A

Excessive collection of serous fluid within the tunica vaginalis.

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26
Q

What are the causes/risk factors for hydrocoele?

A

o Congenital

o Idiopathic

o Tumour

o Infection

o Trauma

o Underlying testicular torsion

o Testicular appendage

o Associations = Indirect inguinal hernias in children, Epididymo-orchitis, Filariasis (belongs to the helminthiases group of disease)

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27
Q

What are the presenting symptoms of hydrocoele?

A

o Scrotal swelling

o Often asymptomatic

o Patients may complain of pain or urinary symptoms due to the underlying cause

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28
Q

What are the clinical signs of hydrocoeles on examination?

A

o Scrotal swelling which is possible to get above the swelling

o Transilluminates

o Difficult to separate the swelling from the testicle

29
Q

What are the appropriate investigations for hydrocoeles?

A

o Ultrasound to exclude tumour

o Urine = dipstick and MSU for infection

o Blood - Markers of testicular tumours = a-fetoprotein, b-HCG, Lactate dehydrogenase

30
Q

Define nephrotic syndrome.

A

Nephrotic syndrome is characterised by a triad of:

o Proteinuria (> 3g/24 hr)

o Hypoalbuminaemia (< 30g/L)

o Oedema

- Hypercholesterolaemia is also a common feature

31
Q

What are the causes and risk factors for nephrotic syndrome?

A

o Most commonly caused by minimal change glomerulonephritis in children - all forms of glomerulonephritis can cause nephrotic syndrome

o Risk factors = DM, Sickle cell disease, Amyloidosis, Malignancies (lung and GI adenocarcinomas), Drugs (e.g. NSAIDs), Alport’s syndrome, HIV

32
Q

What are the presenting symptoms of nephrotic syndrome?

A

o Family history of atopy (in those with minimal change glomerulonephritis) or renal disease

o Swelling of face, abdomen, limbs, genitalia (due to hypoalbuminaemia)

o Symptoms of the underlying cause (e.g. SLE)

o Symptoms of complications

33
Q

What are the clinical signs of nephrotic syndrome on examination?

A

o Oedema - periorbital, peripheral, genital

o Ascites - fluid thrill, shifting dullness

34
Q

What are the appropriate investigations for nephrotic syndrome?

A

o Bloods = FBC, U&E, LFTs (low albumin), ESR/CRP, Glucose, Lipid profile (check for secondary hyperlipidaemia), Immunoglobulins, Complement

o Tests to identify the cause = SLE (ANA, anti-dsDNA antibodies), Infections, Goodpasture’s Syndrome (anti-glomerular basement antibodies), Vasculitides (polyangiitis with granulomatosis, microscopic polyarteritis (check ANCA))

o Urine = Urinalysis (check protein and blood), MC&S, 24 hr collection (calculate creatinine clearance and 24 hr protein excretion)

o Renal Ultrasound = Exclude other causes (e.g. reflux nephropathy)

o Renal Biopsy

Other imaging = Doppler ultrasound, renal angiogram, CT or MRI (if renal vein thrombosis suspected)

35
Q

Define polycystic kidney disease.

A

Autosomal dominant inherited disorder characterised by the development of multiple renal cysts that gradually expand and replace normal kidney substance, variably associated with extrarenal (liver and cardiovascular) abnormalities.

36
Q

What are the presenting symptoms of polycystic kidney disease?

A

o Present at 30-40 yrs - can be an incidential finding

o 20% have no family history

o Flank Pain - may result from cyst enlargement/bleeding, stone, blood clot migration, infection

o Haematuria

o Hypertension

o Associated with berry aneurysms and may present with subarachnoid haemorrhage

37
Q

What are the clinical signs of polycystic kidney disease on examinations?

A

o Abdominal distension

o Enlarged cystic kidneys

o Palpable liver

o Hypertension

o Signs of chronic renal failure (at late stage)

o Signs of associated AAA or aortic valve disease

38
Q

What are the appropriate investigations for polycystic kidney disease?

A

o US or CT - Will show multiple cysts bilaterally in enlarged kidneys

  • Liver cysts may also be seen
39
Q

Define renal artery stenosis.

A

Stenosis of the renal artery.

40
Q

What are the risk factors for renal artery stenosis?

A

o Atherosclerosis (older patients) - widespread aortic disease involving the renal artery ostia

o Fibromuscular Dysplasia (younger patients) - may be associated with collagen disorders, neurofibromatosis and Takayasu’s arteritis

  • Can cause micro-aneurysms in the mid and distal renal arteries (resembling a string of beads on angiography)
41
Q

What are the presenting symptoms of renal artery stenosis?

A

o History of hypertension in < 50 yrs

o Hypertension refractory to treatment

o Accelerated hypertension and renal deterioration on starting ACE inhibitors - ACE inhibitors are contraindicated in patients with bilateral renal artery stenosis

o History of flash pulmonary oedema

42
Q

What are the clinical signs of renal artery stenosis on examination?

A

o Hypertension due to excessive RAS activation due to kidney hypoperfusion

o Signs of renal failure in advanced bilateral disease

o Renal artery bruits

43
Q

What are the appropriate investigations for renal artery stenosis?

A

o Non-Invasive = Duplex ultrasound, Ultrasound measurement of kidney size

o CT Angiogram or MR Angiography but has a risk of contrast nephrotoxicity

o Digital Subtraction Angiography = Gold standard

o Renal Scintigraphy - uses radio-agent that is either excreted by glomerular filtration or by the tubules -> addition of an ACE inhibitor causes delayed clearance by the affected kidney but may not be useful in bilateral renal artery stenosis

44
Q

Define testicular torsion.

A

Twisting or torsion of the spermatic cord results, initially, in venous outflow obstruction from the testicle, progressing to arterial occlusion and testicular infarction if not corrected.

    • Intravaginal (most common) = spermatic cord twists within the tunica vaginalis*
    • Extravaginal (usually in neonates) = entire testis and tunica vaginalis twist in a vertical axis on the spermatic cord due to incomplete fixation of the gubernaculum to the scrotal wall allowing free rotation*
45
Q

What are the riks factors for testicular torsion?

A

o Imperfectly descended testes

o High investment of the tunica vaginalis

46
Q

What are the presenting symptoms of testicular torsion?

A

o Sudden-onset severe hemiscrotal pain

o Abdominal pain

o Nausea and vomiting

47
Q

What are the clinical signs of testicular torsion on examination?

A

o Swollen, erythematous scrotum on the affected side

o Swollen testicle will lie slightly higher than the unaffected one

o Testicle might lie horizontal

o Thickened cord

o Testicular Appendix = Visible necrotic lesion on transillumination

48
Q

What are the appropriate investigations for testicular torsion?

A

o Doppler/Duplex Imaging of the Testes but DON’T delay surgery

  • Arterial inflow = reduced in testicular torsion but increased in epididymo-orchitis
49
Q

What is the management plan for testicular torsion?

A

o Exploration of the scrotum within 6 hrs of onset of symptoms

  • Testicle is twisted back into place and a bilateral orchidopexy is performed (suturing the testicle to the scrotal tissue to prevent recurrence)

o If the testicle is necrotic = orchidectomy may be performed

50
Q

What are the possible complications of testicular torsion?

A

o Testicular infarction

o Testicular atrophy

o Infection

o Impaired fertility (due to production of anti-sperm antibodies)

51
Q

Define urinary tract calculi.

A

Crystal deposition within the urinary tract. Also known as nephrolithiasis.

o Types of Stone:

  • Calcium oxalate - Most common
  • Struvite - Quite common
  • Urate - 5%
  • Cysteine - 2%
52
Q

What are the causes and risk factors for urinary tract calculi?

A

o Many cases are idiopathic

o Metabolic Causes = Hypercalciuria, Hyperuricaemia, Hypercystinuria, Hyperoxaluria

o Infection = Hyperuricaemia

o Drugs = Indinavir

o Risk Factors = Low fluid intake, Structural urinary tract abnormalities (e.g. horseshoe kidney), Being male

53
Q

What are the presenting symptoms of urinary tract calculi?

A

o Often asymptomatic

o Severe loin to groin pain

o Nausea and vomiting

o Urinary urgency, frequency or retention

o Haematuria

54
Q

What are the clinical signs of urinary tract calculi on examination?

A

o Loin to lower abdominal tenderness

o No signs of peritonism

o Signs of systemic sepsis if there is an obstruction and infection above the stone

  • Leaking AAA is the main differential to consider in older men - MUST BE EXCLUDED
55
Q

What are the appropriate investigations for urinary tract calculi?

A

o Bloods = FBC (high WCC if infection), U&Es (check renal function), Calcium, Urate, Phosphate

o Urine = Dipstick (haematuria is common), MC&S

o X-Ray KUB = 80% of kidney stones are radio-opaque

o Intravenous Urography (IVU) = Allows visualisation of the kidneys and ureters

o Ultrasound = May show hydronephrosis, hydroureter and kidney stones

o Non-enhanced Spiral CT = Can also be used to image stones

o Isotope Radiography = Used to assess kidney function

56
Q

What is the management plan for urinary tract calculi?

A

o Acute = Analgesia, Bed rest, Fluid replacement, Urine collection to try and retrieve any stone that has passed

  • Most stones < 5 mm will pass spontaneously but an obstructed, infected kidney is an EMERGENCY and should be treated as soon as possible to relieve the obstruction (e.g. by placing a percutaneous nephrostomy)

o Removal of Calculi = Urethroscopy, Extracorporeal Shock-Wave Lithotripsy (ESWL) (non-invasive), Percutaneous Nephrolithotomy (PCNL)

o Treat the Cause = Depends on the cause - e.g. parathyroidectomy if hypercalcaemia due to hyperparathyroidism, allopurinol if hyperuricaemia

o Advice = Increase oral fluid intake

57
Q

What are the possible complications of urinary tract calculi?

A

o Of Stones = Infection (pyelonephritis), Septicaemia, Urinary retention

o Of Ureteroscopy = Perforation, False passage

o Of Lithotripsy = Pain, Haematuria

58
Q

Define UTI.

A

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

o Lower UTI = urethra (urethritis), bladder (cystitis) or prostate (prostatitis)

o Upper UTI = renal pelvis (pyelonephritis)

59
Q

What are the causes and risk factors for UTIs?

A

o Most UTIs = Escherichia coli

o Other causative organisms = Staphylococcus saprophyticus, Proteus mirabilis, Enterococci

o Immunocompromised individuals = Klebsiella, Candida albicans, Pseudomonas aeruginosa

o Risk Factors = Female, Sexual intercourse, Exposure to spermicide, Pregnancy, Menopause, Immunosuppression, Catheterisation, Urinary tract obstruction, Urinary tract malformation

60
Q

What are the presenting symptoms of UTI?

A

o Cystitis = Frequency, Urgency, Dysuria, Haematuria, Suprapubic pain

o Prostatitis = Flu-like symptoms, Low backache, Few urinary symptoms, Swollen or tender prostate on PR

o Acute Pyelonephritis = High fever, Rigors, Vomiting, Loin pain and tenderness, Oliguria (if AKI)

61
Q

What are the clinical signs of UTI on examination?

A

o Fever

o Abdominal or loin tenderness

o Foul-smelling urine

o Distended bladder (occasionally)

o Enlarged prostate (if prostatitis)

62
Q

What are the appropriate investigations for UTIs?

A

o Urine Dipstick = Positive leucocyte esterase and nitrites

o Urine Microscopy = Presence of leucocytes indicates infection

o Urine Culture = Exclude UTI or if the patient failed to respond to empirical antibiotics

o Ultrasound = Rule out obstruction

o Bloods = FBC, U&Es (check renal function), CRP, Blood cultures if systemically unwell and risk of urosepsis

63
Q

What is the management plan for UTIs?

A

o Empirical treatment of uncomplicated UTI = Trimethoprin or Nitrofurantoin for 3-6 days -> men with UTI may need a longer course of antibiotics

  • Alternative Treatments = Co-amoxiclav or Cefalexin

o Prophylactic antibiotics may be used in certain circumstances (e.g. recurrent cystitis associated with sexual intercourse)

64
Q

What are are the possible complications of UTIs?

A

o Ascending infection can lead to:

  • Pyelonephritis
  • Perinephric and intrarenal abscess
  • Hydronephrosis or pyonephrosis
  • AKI
  • Sepsis
65
Q

Define varicocoele.

A

Dilated veins of the pampiniform plexus forming a scrotal mass.

66
Q

What are the risk factors for varicocoele?

A

o Venous incompetence - e.g. varicose veins

67
Q

What are the presenting symptoms of varicocoele?

A

o Usually asymptomatic (2-10% have symptoms) - can be found due to investigation into inferility or examination

o Scrotum feels like a bag of worms

o Scrotal heaviness

o Usually on the left - angle at which the left testicular vein meets the left renal vein, lack of effective valves between the left testicular vein and left renal vein and increased reflux from compression of the renal vein (between the superior mesenteric artery and the aorta)

68
Q

What are the clinical signs of varicocoele on examination?

A

o Patient must be standing for examination

o Side of the scrotum with the varicocoele will hang lower

o Swelling may reduce when lying down

o Valsalva manouevre whilst standing will increase dilatation

o Cough impulse to discount a hernia

69
Q

What are the appropriate investigations for varicocoele?

A

o Sperm count

o Colour Doppler scan

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