Renal and urology Flashcards
Urinary tract infections
NOT bacteriuria, and can also get sterile pyuria
- 4x more in women, in men more likely complicated
RFs
- bacterial innoculation - sex, incontinence, constipation
- binding of uropathogenic bacteria - spermicide use, low oestrogen
- reduced urine flow - DEHYDRATION, obstruction
- increased bacterial growth - diabetes, immunosuppression, catheter, renal tract malformation, pregnancy
UTI just based on signs:
- cystitis = frequency, dysuria, urgency, polyuria, suprapubic pain, haematuria
- pyelonephritis = + fever, rigor, vomiting, loin pain/tenderness, costovertebral tenderness, sepsis
- prostatitis = pain in perineum / scrotum / rectum / penis etc, + fever, malaise, urinary symptoms
Management of UTI
Causes
- 80% uncomplicated cases are from e coli, or strep faecalis (anaerobes and gram-ves from bowel / vagina), or enterobacteriacae eg proteus, pseudomonas or klebsiella
- in complicated, get the same + others
Ix
- urine dipstick NOT in >65yrs, pregnancy or catheterised (need MC+S)
- MSU culture
- bloods (if systemically unwell)
- imaging (USS + urology referral in men with upper UTI / failure to respond to treatment / recurrent UTI / unusual organism / persistent haematuria)
Mx (not for asymptomatic bacteriuria)
- Trimethoprim (folic acid analogue to kill bacterial cell walls NOT for 1st trimester pregnancy) or Nitrofurantoin (DNA disruptor, NOT for 3rd trimester pregnancy or if eGFR<30 but more useful when resistance likely)
- Co-amoxiclav (B lactam + B lactamase inhibitor)
- Ciprofloxacin (only in hospital not community as C diff risk)
Obstructive uropathy
= urinary tract obstruction
- acute upper tract - loin-groin pain ± infection with loin tenderness or enlarged kidney
- acute lower tract - acute urinary retention (severe suprapubic pain and confusion)
- chronic upper tract - flank pain, renal failure, infection, polyuria
- chronic lower tract - frequency, hesitancy, poor stream, terminal dribbling, overflow incontinence, chronic retention
- – so first get voiding symptoms due to blockage, this irritates the bladder so then get secondary detrusor overactivity, then may get backflow pressure reducing renal blood flow, atrophy of renal tubules, irreversible fibrosis
Causes
- BPH (bilateral)
- urethral stricture, due to perineal trauma or surgery
- phimosis / paraphimosis
- renal stones (unilateral)
- bladder or prostate cancer
Investigations and management of obstructive uropathy
Ix
- dipstick (infection + blood)
- renal USS (hydronephrosis + stones)
- U+Es (AKI / CKD), FBC
- CT pyelogram (to visualise stones or tract abnormalities)
Mx
- analgesia, hydration
- lithotripsy, abx
- surgery: percutaneous nephrolithotomy, nephrostomy, ureteric stent
Benign prostatic hyperplasia
Voiding symptoms 1st (terminal dribbling, hesitancy, poor stream, straining)
Then irritative symptoms (nocturia, frequency, urgency) as bladder has to work harder
Ix
- PR exam, examine external genitalia, abdo exam (?retention)
- urinalysis (UTI)
- PSA
- international prostate symptoms score /35
- flow test
- USS for post-void residual
Mx
- conservative (caffeine and drinking advice) if IPSS 0-7
- Tamsulosin (blocks alpha adrenergic receptors in prostate smooth muscle, good for younger patients as drops BP)
- Finasteride (reduces testosterone metabolism, SE of reduced libido so better for older)
- surgery - TURP (leaves with retrograde ejaculation)
Renal cell carcinoma
- mean age onset 55, 2x more in men, common in haemodialysis patients, smoking, HTN (direct tubule damage)
- 50% asymptomatic, incidental finding
- haematirua, loin pain, abdominal mass, anorexia, malaise, weight loss, pyrexia
Ix
- urinalysis (haematuria)
- creatinine (raise)
- abdo USS (renal mass)
- CTAP
Mx
- surgical resection if non-metastatic
- targeted small molecule therapy if metastatic (-inib)
Transitional cell carcinoma = urothelial carcinoma
Most arise in bladder, or can be ureter or renal pelvis
- RFs - SMOKING, aromatic amines, schistosomiasis, pelvic radiation
- haematuria (80%)
+ frequency, urgency, dysuria, obstruction
Ix
- urinalysis
- urine cytology (for cancer cells)
- cytoscopy + biopsy
- CT urogram to stage
- MRI for pelvic nodes
Mx
- TURBT diathermy + chemo intravesically if
Prostate cancer
Gleason scoring of 2-10 (2 areas graded 1-5)
- fhx, age, black ethnicity
Presentation
- LUTS
- metastatic symptoms - bone pain, pathological fractures, spinal cord compression, + post renal AKI, bilateral hydronephrosis
- weight loss
Ix
- PR (irregular, hard prostate)
- PSA (rise, but more useful as monitoring)
- MRI prostate
- transrectal USS and prostate biopsy (to grade and give Gleason)
Management of prostate cancer
Watchful waiting
- if older (>80) and Gleason <6
- 6mo follow up to monitor symptoms and PSA
Radical treatment
- if younger (~55) and Gleason >7
- staging MRI and bone scan, then if localised get surgery or radiotherapy (patient choice re SEs)
Hormone therapy
- mostly, if mets or in between above categories
- GnRH analogue (zoladex / prostop), get initial tumour flare for first 2 weeks, then shrinks (so give anti-androgen bicalutamide initially)
- non-curative, effective for ~2-3 years usually
Palliative care
- once exhausted all hormone options
Testicular cancer
- most common malignancy in young men, curable when caught early
RFs - cryptorchidism, fhx
Germ cell tumours, mostly seminomas
- see painless lump ± haemospermia, hydrocele, pain, dyspnoea (lung mets), abdo mass (lymph), hormonal effects
Ix
- USS accurate diagnostic
+ CT, excision biopsy, alpha FP and beta HCG tumour markers
Mx
- radical orchidectomy + radiotherapy (very effective for seminomas)
- post-op chemo needed for non-seminomatous
Scrotal swellings with pain
Epididymitis
- red, swollen scrotum
- lifting scrotum eases pain (Prehn’s sign positive)
- infectious (STI, UTI) or not
- take first catch urine, give abx and NSAIDs
Orchitis
- also get headache, fever, parotid swelling (usually caused by mumps virus)
Testicular trauma
- blunt force from sport, RTA, fights
Testicular torsion
- usually spontaneous, testicle around spermatic cord
- sudden onset pain in testis + in abdo, nausea, vomiting
- tender hot testis lying high and transversely (Prehn’s negative)
- need surgery ASAP <6hrs
Incacerated scrotal hernia
Scrotal swellings without pain
Hydrocele
- fluid in tunica vaginalis
- primary, or secondary to tumour/trauma/infection
- transillumination positive, anechoic on USS
- may need aspiration
Spermatocele
- cyst of epididymis, usually small with positive transillumination
Varicocele
- ‘bag of worms’ varicose veins in paminiform plexus, causes higher temps and threatens infertility
- exacerbated by valsalva
- backflow seen on doppler USS
- may be caused by RCC
Haematocele
- blood in tunica vaginalis after trauma, may need drainage
Epididymal cyst
- above and behind testis, well circumscribed serous fluid
Scrotal hernia
Chronic kidney disease classification
> 3mo duration
CKD 1 - eGFR>90, + evidence of kidney damage (proteinuria / haematuria / pathology on biopsy etc)
CKD 2 - eGFR 60-90, as above
CKD 3 - 30-60
CKD 4 - 15-30
End stage renal failure (5) - <15
Can also be classified according to albumin:creatinine ratio or albuminuria
– remember to correct eGFR for ethnicity and drugs
Presentation / causes / investigations / management of CKD
Presentation
- peripheral oedema (fluid retention + protein loss)
- nausea
- fatigue
- anorexia
Causes - diabetes mostly - glomerulonephritis - HTN / renovascular disease \+ polycystic, obstruction, nephrotic syndrome
Ix
- bloods - U+Es, FBC, glucose, (low) calcium, (high) phosphate and PTH
- ANA / ANCA / antiphospholipids if ?intrinsic cause
- urinalysis
- renal USS (kidneys may be small in CKD, asymmetrical in renovascular disease)
- biopsy
Mx
- anti-HTN (ACEi, ARB, CaCB)
- statin
- EPO-stimulating agent if anaemic
- active vit D + calcium if secondary hyperPTH
- dialysis / transplant if severe (uraemia or metabolic acidosis)
Nephrolithiasis
= calculi / kidney stones
- renal colic (loin - groin pain) ± nausea and vomiting, can’t sit still
- haematuria, proteinuria
- or asymptomatic
- or obstructed kidney / ureter
- or infection
Calcium oxalate 75%
Struvite / triple phosphate (staghorn, from proteus)
Urate
Hydroxyapatite
Ix
- urinalysis
- bloods - U+Es, FBC, calcium, phosphate, bicarbonate, urate
- stone analysis
Mx
- hydration and analgesia
- nifedipine or tamsulosin to medically expulse
- extracorporeal shockwave lithotripsy
- uretoscopy
- percutaneous nephrostomy rarely
Renal vascular disease
Renal vein thrombosis and renal atheroembolism, but main focus on …
Renal artery stenosis
- onset HTN <55
- accelerated or refractory HTN
- unexplained kidney dysfunction
- abdominal bruits
- coronary artery disease associated - lipids, smoking, diabetes
Usually due to atherosclerosis (also fibromuscular dysplasia)
Ix
- U+Es (low eGFR, hypokalaemia)
- aldosterone:renin ratio (if normal, not primary aldosteronism)
Mx
- anti-HTN (ACEi, ARB, thiazide, B blocker, CaCB)
- statin
- antiplatelet
- renal artery stenting
Urinary incontinence
Stress - involuntary leakage on exertion
Urge - usually from detrusor overactivity or neurological disorder
Mixed
Overflow - overdistended bladder
Ix
- supine stress test (valsalva and check leakage)
- urinalysis
- post-void residual by USS
- urodynamic testing
RFs
- age
- vaginal delivery in pregnancy, especially instrumental
- obesity
- care home resident
- neurological pathology (MS, dementia, stroke)
- constipation
- caffeine / diuretics
Mx
- stress - pelvic floor exercises, weight loss, sling procedure
- urge - bladder training, anticholinergic medication, botulinum toxin
Acute kidney injury
= rise in creatinine 1.5x baseline within 7 days
or = urine output <0.5ml/kg/hr for >6 consecutive hours
(or stage 2 is 2-2.9x baseline / urine >12hrs, stage 3 is >3x baseline / urine >24hrs or anuria >12)
Causes
- pre-renal - shock, sepsis, haemorrhage, D+V, renal vasoconstriction (NSAIDs, ACEi)
- renal - glomerular, infection, infiltration, vasculitis
- post-renal - stone, malignancy
RFs
- age
- male
- DM, CVS disease, existing CKD, malignancy, complex surgery
Ix and Mx
- VBG (hyperK+, lactate, pH)
- fluid challenge (if improves, pre-renal)
- urinalysis
- bloods
- catheterise
- renal USS always
