Renal and urology conditions Flashcards
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1
Q
Acute Kidney Injury
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management
- Complications
- Prognosis
A
- Abrupt loss of kidney function resulting in retention of urea and other nitrogenous waste products and dysregulation of ECV and electrolytes -> can occur in pre-existing kidney conditions/healthy pts.
- KDIGO classification = increase in serum creatinine >26umol/L within 48h, increase in serum creatinine to 1.5x baseline within the preceding 7d, urine volume <0.5ml/kg/hr for 6h
- Risk factors = Age, CKD, comorbidities (HF), sepsis, hypovolaemia, use of nephrotoxic meds, emergency surgery and DM.
- Pre-renal = 90%, hypovolaemia, HF, cirrhosis, nephrotic syndrome, hypotension, renal hypoperfusion
- Intrinsic renal = glomerular (glomerulonephritis, haemolytic uraemic syndrome), tubular (acute tubular necrosis), interstitial (acute interstitial nephritis), vasculitides (wegner’s granulomatosis), eclampsia
- Post-renal (obstruction) = calculi, urethral stricture, prostatic hypertrophy/malignancy, bladder tumour
- 15% of adults admitted to hospital will develop AKI; most common in elderly
- Depends on underlying cause; oliguria/anuria (post-renal if abrupt), Nausea, vomiting, dehydration, confusion
- HTN, distended bladder, dehydration - postural hypotension, fluid overload (HF, cirrhosis, nephrotic syndrome) - raised JVP, pulm and peripheral oedema), pallor, rash, bruising
- Urinalysis = blood (nephritic), leucocyte esterase and nitrites (UTI), glucose, protein, urine osmolality; Bloods = FBC, blood film, U&Es, clotting, CRP, Immunology - sIg, ANA, complement, anti-GBM, antistreptolysin-O Ab, virology - hepatitis and HIV; US for postrenal cause and hydronephrosis; CXR pulm oedema, AXR renal stones
- Treat cause and monitor serum creatinine, Na, K, Ca, PO4, glucose, ID and treat infection;urgent relief of urinary tract obstruction; refer to nephrology if intrinsic renal disease suspected; Renal replacement therapy considered if hyperk refractory to medical management, pulm oedema refractory to medical mx, severe met acidaemia, uraemic complications. Mx 4 main components:
- Protect pt from hyperkalaemia
- Optomise fluid balance
- Stop nephrotoxic drugs
- Consider for dialysis
- Pulm oedema, acidaemia, uraemia, hyperkalaemia, bleeding
- Varies on cause and comorbidities; poor prognosis = age, multiple organ failure, oliguria, hypotension, CKD
2
Q
Benign prostatic hyperplasia
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management
- Complications
- Prognosis
A
- Slowly prgressive nodular hyperplasia of the periurethral zone of the prostate gland
- Unknown, link with hormonal changes; RF = reduced risk withsoya/veg based diets and -ve association with cirrhosis
- Common, 70% of men >70yrs have histological BPH, more common in west than east and in afro-caribbeans
- Obstructive and irrtative can be recalled using FUND HIPS
- Obstructive = hesitance, poor/intermittent stream, terminal dribbling, incomplete voiding
- Irritative/storage = frequency, urgency, urge incontinence, nocturia
- Acute retention = sudden inability to pass urine, severe pain
- Chronic retention = painless, frequency with small volumes passed, NOCTURIA
- DRE - prostate usually smoothly enlarged with palpable midline groove; acute retention = suprapubic pain, distended palpable bladder; chronic = large distended painless bladder (vol >1L), renal failure sx
- Urinalysis = for UTI and blood; Bloods = U&Es for renal and PSA; midstream urine (MC&S); Imaging = US of urinary tract (hydronephrosis), bladder pre and post voiding, trans-rectal USS for bladder size and vol; flexible cystoscopy
- Emergency = catheterisation; conservative = watchful waiting; medical = selective alpha blocker (tamsulosin, relax internal sphincter and prostate capsule) and 5-alpha-reductase inhibitors (finasteride, reduce prostate size); surgery (TURP and open prostatectomy)
- Recurrent UTI, actue/chronic urinary retention, urinary stasis, bladder diverticula, stone development, obstructive renal failure, post-obstructive diuresis, complication of TURP: retrograde ejaculation, haemorrhage, incontinence, TURP syndrome, urinary infection, erectile dysfunction, urethral stricture
- Mild syx usually well controlled medically; most pts get significant relief from surgery
3
Q
Chronic Kidney Disease
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Progressive loss of kidney function over a period of months/years, based on presence of kidney damage or decreased kidney function for 3months or more. Classification =
- Normal = eGFR > 90 ml/min per 1.73 m^2 with other evidence of CKD
- Mild impairment = eGFR 60-89 ml/min per 1.73 m2 and other evidence of CKD
- (a) Moderate impairment = eGFR 45-59 ml/min per 1.73m2
- (3b) Moderate impairment = eGFR 30-44 ml/min per 1.73m2
- (4) Severe impairment = eGFR 15-29 ml/min per 1.73m2
- (5) Established Renal Failure = eGFR <15 ml/min per 1.73m2 or on dialysis
- Age, DM, HTN, obesity, CVD, arteriopathic renal disease, nephropathies, FHx, neoplasia, myeloma, systemic disease, smoking, chronic use of NSAIDs
- Common, risk increases with age, often associated with other diseases
- Asyx, incidental finding, severe CKD: anorexia, N/V, fatigue, pruritus, peripheral oedema, muscle cramps, pulm oedema, sexual dysfunction is common
- Skin pigmentation, excoriation marks, pallor, HTN, peripheral oedema, peripheral vascular disease
- Assess renal function = urea (not good, varies with diet/hydration), creatinine (useful but limitations), isotopic GFR (expensive but gold standard); biochem = glucose, K (raised), check Na, HCO3, Ca, PO4; serology = Ab (ANA, c-ANCA, anti-GBM), hepatitis, HIV; Urinalysis = check for proteinuria/haematuria, check for 24hr urine collection, serum/urine protein electrophoresis; imaging = USS, CT/MRI, XR KUB; renal biopsy
4
Q
Epididymitis and orchitis
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management
- Complications
- Prognosis
A
- inflammation of the epididymis or testes
- Infective in origin, bacterial = <35yr chlamydia and gonococcus, if >35yr many coliforms (enterobacter, Klebsiella), RARE = TB, syphilis; Viral = mumps; fungal = candida if immunocompromised; RF = diabetes, rare: vasculitis
- Common, all age groups, 20-30yrs
- Painful, swollen and tender testis/epididymis (less acute onset than testicular torsion), penile discharge
- Swollen and tender epididymis/testis, scrotum may be oedematous, pyrexia, walking will be painful, eliciting a cremasteric reflex may be painful
- Urine = dipstick, early morning urine collections for MC&S; Bloods = FBC for WCC, high CRP, U&Es; imaging = increased blood flow on duplex examination
- Medical = ABx, surgical = exploration of testicles if testicular torsion can’t be excluded clinically, required if abscess develops
- Pain, abscess, fournier’s gangrene, mumps orchitis could cause testicular atrophy and fertility issues
- Good if treated but may take up to 2 months for the swelling to resolve
5
Q
Gomerulonephritis
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Immunologically mediated inflammation of the renal glomeruli
- Many types, some caused by Ag-Ab complex deposition in glomeruli, classification based on site of nephron pathology and its distribution ->
- Minimal change GN = light microscopy minimal change and electron microscopy loss of epithelial foot processes
- Membranous GN = thickening of glomerular basement membrane (GBM) from immune complex deposition, associated with goodpasture’s syndrome
- Membranoproliferative GN = thickening of GBM, mesangial cell prolif and interdeposition
- Focal segmental GN = glomerular scarring, associated with HIV
- Focal segmental proliferative GN = mesangial and endothelial cell prolif, focal = some glomeruli, segmental = parts of individual glomeruli
- Diffuse proliferative GN = same as FSPGN but all glomeruli
- IgA nephropathy = mesangial cell prolif, mesangial IgA and C3 deposits
- Crescentic GN = cresent formation by macrophages and epithelial cells filling up bowmans capsule
- Focal segmental necrotising GN = periph capillary loop necrosis, often evolving into crescentic GN
- 25% of chronic renal failure
- Haematuria, subcut oedema, polyuria/oliguria, hx of recent infection, syx of uraemia/renal failure
- HTN, proteinuria, haematuria (IgA nephropathy), renal failure, nephrotic syndrome (triad of proteinuria >3.5 g/24hrs, low serum albumin <24 g/L, oedema, hyperlipidaemia), nephritic syndrome (HTN, proteinuria, haematuria, low urine output)
- Bloods = FBC, U&Es and creatinine, LFTs, lipid profile, complement studies, Ab = ANA, anti-dsDNA, ANCA, anti-GBM ab, cryoglobulins; urine = microscopy, 24hr collection (creatinine clearance and protein); imaging = renal tract USS to exclude other pathology; renal biopsy = microscopy; investigations for associated conditions (HBV, HCV and HIV serology)
6
Q
Hydrocoele
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- The excessive collection of serous fluid within the tunica vaginalis
- Congenital, idiopathic, tumour, infection, trauma, underlying testicular torsion, testicular appendage; RF/association = indirect inguinal hernias in children, epididymo-orchitis, filariasis
- Very common in children in 1st year of life, common in older men
- Scrotal swelling, asyx, pts may complain of pain or urinary syx due to underlying cause
- Scrotal swelling, possible to get above swelling, transilluminates, difficult to separate the swelling from the testicle
- US exclude tumour; urine - dipstick and msu for infection; blood - markers of testicular tumour = alpha-fetoprotein, beta-HCG, lactate dehydrogenase
7
Q
Nephrotic syndrome
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Nephrotic syndrome characterised by triad of = proteinuria (>3g/24hr), hypoalbuminaemia (<30g/L), oedema, (hypercholesterolaemia is also a feature)
- Minimal change glomerulonephritis in children, all GN can cause nephrotic syndrome; other = DM, sickle cell disease, amyloidosis, malignancies, drugs, alport’s syndrome, HIV
- 90% due to minimal change glomerulonephritis in children; most common in adults is DM and membranous GN
- FHx of atopy/renal disease, swelling of face/abdo/limbs/genitalia (due to hypoalbuminaemia), syx of underlying cause, syx of complications
- Oedema = periorbital, peripheral, genital; ascites = fluid thrill, shifting dullness
- Bloods = FBC, U&Es, LFTs, ESR/CRP, glucose, lipid profile, Ig, complement; ID cause = SLE (ANA, anti-dsDNA ab), Infections (group A beta-haemolytic strep infection (ASO titre), HBV infection (serology), plasmodium malariae (blood film)), goodpasture’s syndrome (anti-glomerular basement ab), vasculitides (polyangitis with granulomatosis, microscopic polyarteritis); urine = urinalysis, MC&S, 24hr collection (calculate creatinine clearance and 24hr protein excretion); renal US = exclude other cause; renal biopsy; other imaging = doppler US, renal angiogram, CT/MRI
8
Q
Polycystic Kidney Disease
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Autosomal dominant inherited disorder characterised by development of multiple renal cysts that gradually expand and replace normal kidney substance, variably associated with extrarenal abnormalities
- 85% caused by mutations in PKD1 on chr16, 15% by mutations of PKD2 on chr4; prolif/hyperplastic abnormality of the tubular epithelium, cysts connected to tubules from which they arise and the fluid content is glomerular filtrate, cysts >2mm they detach from tubule and fluid content derived from secretion of the lining epithelium - with time cysts enlarge and cause progressive damage to adjacent functioning nephrons
- Most common inherited kidney disorder, responsible for 10% of end-stage renal failure
- present at 30-40yrs, 20% have no FHx, asyx, flank pain from cyst enlargement/bleeding/stone/blood clot migration/infection, haematuria, HTN; associated with berry aneurys,s and may present with subarachnoid haemorrhage
- Abdo distension, enlarged cystic kidneys, palpable liver, HTN, sx of chronic renal failure, sx of associated AAA or aortic valve disease
- US or CT showing multiple cysts bilat in enlarged kidneys with liver cysts maybe
9
Q
Renal atery stenosis
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Stenosis of renal artery
- Atherosclerosis (older pts), widespread aortic disease involving the renal artery ostia; fibromuscular dysplasia (younger - unknown aet., may be associated with collagen disorders, neurofibromatosis and takayasu arteritis, microaneurysms in mid and distal renal arteries; pathogenesis = renal hypoperfusion stimulates RAAS, so inc angII and aldosterone > inc BP > fibrosis, glomerulosclerosis and renal failure
- Prevalence unknown, ~1-5% of all HTN, fibromuscular dysplasia mainly in women with HTN <45yrs
- Hx of HTN in <50, HTN refractory to treatment, accelerated HTN and renal deterioration on ACEi, Hx of flash pulm oedema (ACEi BAD in RAS)
- HTN, sx of renal failure in advanced bilat disease, renal artery bruits
- Non-invasive = duplex US, US measurement of kidney size; CT angiogram/MR angiography = risk of contrast nephrotoxicity; Digital subtraction angiography = gold standard; renal scintigraphy = radioagent that is either excreted by glomerular filtration or by the tubules, addition of an ACEi causes delayed clearance by affected kidney
10
Q
Testicular Torsion
- Definition
- Explain aetiology/risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management
- Complications
- Prognosis
A
- Surgical emergency; 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; extravaginalis (neonates) = entire testis and tunica vaginalis twist in vertical axis on spermatic cord, due to incomplete fixation of the gubernaculum to the scrotal wall allowing free rotation. RF = imperfectly descended testes, high investment of tunica vaginalis
- most common cause of acute scrotal pain in 10-18yr olds
- Sudden onset severe hemiscrotal pain, abdo pain and N/V
- Swollen, erythematois scrotum on the affected side, swollen testicle will lie slightly higher than the unaffected one, testicle might lie horizontal, thickened cord, testicular appendix (visible necrotic lesion on transillumination), DDx = epididymo-orchitis, incarcenated inguinal hernia
- Doppler/Duplex imaging of testes; arterial inflow reduced in test torsion, increased in epididymo-orchitis
- Exploration of scrotum within 6hrs of onset of syx; after testicle twisted back into place, a bilat orchidopexy performed, involving suturing the testicle to scrotal tissue to prevent recurrence, if testicle is necrotic orchidectomy may be performed
- Testicular infarction/atrophy, infection, impaired, impaired fertility (anti-sperm ab)
- From onset, testicle may only survive 4-6hrs; surgical intervention (prompts), so most testicles salvaged
11
Q
Urinary tract calculi
- Definition
- Aetiology/Risk Factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management
- Complications
- Prognosis
A
- Crystal deposition within the urinary tract, ‘nephrolithiasis’ -> Types = calcium oxalate (most), struvite (quite common), Urate (5%), Cysteine (2%)
- Many are idiopathic, metabolic causes = hypercalciuria/uricaemia/cystinuria/oxaluria; infection = hyperuricaemia; drugs = indinavir; RF = low fluid intake and structural urinary tract abnormalities
- Common, 2-3% general popn, 3x more common in males, 20-50yrs affected; more common in developing is bladder stones, in industrialised is upper urinary tract
- Asyx, severe loin to groin pain, N/v, urinary urgency/freq/retention, haematuria
- Loin to lower abdo tenderness, no sx of peritonism, leaking AAA is DDx in older men, sx of symptomatic sepsis if obstruction and infection above the stone
- Bloods = FBC (high WCC), U&Es, calcium, urate, phosphate; urine = dipstick (haematuria common), MC&S; XR KUB; IV uroography, US, non-enhanced spiral CT, isotope radiography
- Acute presentation = analgesia, bed rest, fluid rep-placement, urine collection to try and retrieve stone that passed (obstructed and infected kidney is an emergency and treated asap to relieve obstruction; removal of calculi = urethoscopy (to remove stone or place a JJ stent), extracorporeal shock wave lithotripsy (break down stone for spontaneous passage, non-invasive), percutaneous nephrolithotomy (large stones, nephroscope inserted allowing disintegration and removal of stones); Treat cause; advice = increase oral fluid intake
- Stones = infection (pyelonephritis), septicaemia, urinary retention; uteroscopy = perforation, false passage; lithotripsy = pain and haematuria
- Good; infection could lead to irreversible scarring; recurrence of ~50% over 5yrs
12
Q
UTI
- Definition
- Aetiology/Risk Factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management
- Complications
- Prognosis
A
- Presence of a pure growth of >10^5 organisms per mL of fresh MSU; classification = lower UTI (urethritis, cystitis or prostatitis), upper UTI (pyelonephritis), uncomplicated UTI (normal renal tract and function), complicated UTI (abnormal renal/GU tract, voiding difficulty/obstruction, reduced renal function, impaired host defences, virulent organism
- Most caused by E coli, others inc = staph saprophyticus, proteus mirbilis, enterococci, in the immunocompromised = klebsiella, candida albicans, pseudomonas aeruginosa. RF = FEMALE, sexual intercourse, spermicide exposure, pregnancy, menopause, immunosuppression, catheterisation, urinary tract obstruction/malformation
- Very common, 1-3% of GP consultations, majority of women will have one in their lifetime, FEMALES>>>>>>males
- Cystitis = frequency, urgency, dysuria, haematuria, suprapubic pain; prostatitis = flu-like syx, low backache, few urinary syx, swollen/tender prostate on PR; acute pyelonephritis = high fever, rigors, vomiting, loin pain and tenderness, oliguria
- Fever, abdo/loin tenderness, foul-smelling urine, distended bladder, enlarged prostate
- Urine dipstick (+ve leucocyte esterase and nitirites), urine microscopy (presence of leucocytes = infection), urine culture (exclude dx/if pt failed to respond to empirical Abx), US (rule out obstruction), bloods (FBC, U&Es, CRP, Blood cultures
- For uncomplicated UTI = trimethoprim OR nitrofurantoin, treat for 3-6d (men may need longer course), alternatives = co-amoxiclav or cefalexin
- Ascending infection = pyelonephritis, perinephric and intrarenal abscess, hydronephrosis/pyonephrosis, AKI, sepsis; prostatitis is common in men with UTIs
- Good prognosis with appropriate treatment
13
Q
Varicocoele
- Definition
- Aetiology/Risk Factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Dilated veins of the pampiniform plexus
- More common on left (80-90%) due to angle of left testicular vein meeting left renal vein, lack of effective valves between LTV and LRV, increased reflux from compression of the renal vein and due to venous incompetence
- Unusual in boys under 10yrs old, incidence increases after puberty, 15% of general popn, associated with infertility
- Usually asyx, only 2-10% with syx, scrotum feels like ‘bag of worms’, scrotal heaviness, incidental finding on examination
- Pt standing on examination, side of scrotum with varicocoele will hang lower, swelling may reduce when lying down; valsava manouevre whilst standing will increase dilatation, cough impulse
- Sperm coung as part of fertility investigation; colour doppler scan
14
Q
Definition
Acute Kidney Injury
A
- Abrupt loss of kidney function resulting in retention of urea and other nitrogenous waste products and dysregulation of ECV and electrolytes -> can occur in pre-existing kidney conditions/healthy pts.
- KDIGO classification = increase in serum creatinine >26umol/L within 48h, increase in serum creatinine to 1.5x baseline within the preceding 7d, urine volume <0.5ml/kg/hr for 6h
15
Q
S+S
Acute kidney injury
A
- Depends on underlying cause;
- oliguria/anuria (post-renal if abrupt), Nausea, vomiting, dehydration, confusion
- HTN, distended bladder, dehydration - postural hypotension, fluid overload (HF, cirrhosis, nephrotic syndrome) - raised JVP, pulm and peripheral oedema), pallor, rash, bruising
16
Q
Investigations
Acute Kidney Injury
A
- Urinalysis = blood (nephritic), leucocyte esterase and nitrites (UTI), glucose, protein, urine osmolality;
- Bloods = FBC, blood film, U&Es, clotting, CRP, Immunology - sIg, ANA, complement, anti-GBM, antistreptolysin-O Ab, virology - hepatitis and HIV;
- US for postrenal cause and hydronephrosis;
- CXR pulm oedema,
- AXR renal stones
17
Q
Management
Acute Kidney Injury
A
- Treat cause and monitor serum creatinine, Na, K, Ca, PO4, glucose, ID and treat infection;urgent relief of urinary tract obstruction;
- refer to nephrology if intrinsic renal disease suspected;
- Renal replacement therapy considered if hyperk refractory to medical management, pulm oedema refractory to medical mx, severe met acidaemia, uraemic complications.
- Mx 4 main components:
- Protect pt from hyperkalaemia
- Optomise fluid balance
- Stop nephrotoxic drugs
- Consider for dialysis
18
Q
Definition
BPH
A
Slowly prgressive nodular hyperplasia of the periurethral zone of the prostate gland
19
Q
S+S
BPH
A
- Obstructive and irrtative can be recalled using FUND HIPS
- Obstructive = hesitance, poor/intermittent stream, terminal dribbling, incomplete voiding
- Irritative/storage = frequency, urgency, urge incontinence, nocturia
- Acute retention = sudden inability to pass urine, severe pain
- Chronic retention = painless, frequency with small volumes passed, NOCTURIA
- DRE - prostate usually smoothly enlarged with palpable midline groove;
- acute retention = suprapubic pain, distended palpable bladder;
- chronic = large distended painless bladder (vol >1L), renal failure sx
20
Q
Investigations
BPH
A
- Urinalysis = for UTI and blood;
- Bloods = U&Es for renal and PSA;
- midstream urine (MC&S);
- Imaging = US of urinary tract (hydronephrosis), bladder pre and post voiding, trans-rectal USS for bladder size and vol;
- flexible cystoscopy
21
Q
Management
BPH
A
- Emergency = catheterisation;
- conservative = watchful waiting;
- medical = selective alpha blocker (tamsulosin, relax internal sphincter and prostate capsule) and 5-alpha-reductase inhibitors (finasteride, reduce prostate size);
- surgery (TURP and open prostatectomy)
