Renal & Genitourinary Flashcards
What is the function of the urinary tract?
- To collect urine produced continuously by the kidneys
- to store collected urine safely
- to expel urine when socially acceptable
What is the location and blood supply of the kidneys?
- retroperitoneal organs
- lie between T11-L3
- blood supply from renal artery direct from aorta at L1 level
What is the location of the ureters?
- retroperitoneal organs
- run over psoas muscle, cross the iliac vessels at the pelvic brim and insert into trigone of the bladder
What prevents the reflux of urine?
By a valvular mechanism at the vesicoureteric junction
What are the 4 nerves that supply the bladder?
- Parasympathetic nerve = pelvic nerve
- Sympathetic nerve = hypogastric plexus
- Somatic nerve = pudendal nerve
- Afferent pelvic nerve
What occurs during the storage phase in the bladder?
- bladder fills continuously as urine is produced by the kidney and is passed through the ureters into the bladder
- as the volume in the bladder increases the pressure remains low due to ‘receptive’ relaxation and detrusor muscle compliance
What happens in the Filling phase in the bladder?
- at low volumes the afferent pelvic nerve send slow firing signals to the pons via the spinal cord
- SYMPATHETIC nerve (hypogastric plexus) stimulation maintains detrusor muscle RELAXATION
- Somatic (pudendal) nevre stimulation maintains urethral sphincter contraction
What happens during the Voiding Phase in the bladder?
(micturition reflex is an autonomic spinal reflex)
1. At higher volumes the afferent pelvic nerve sends FAST signals to the sacral micturition centre in the sacral spinal cord
2. PARASYMPATHETIC (Pee) pelvic nerve is stimulated = detrusor muscle CONTRACTS
3. Pudendal nerve is inhibited and the external sphincter relaxes
What allows bladder emptying to occur?
- coordinated detrusor contraction with external sphincter relaxation to expel urine from bladder
- positive feedback loop is generated until all urine is expelled
- detrusor relaxation and external sphincter contraction after complete emptying of bladder
Explain the Guarding Reflex in the bladder.
If voiding is inappropriate the Guarding Reflex occurs
- controlled by Onuf’s nucleus
- voluntary control of micturition can occur in anatomically and functionally normal adults
- sympathetic nerve relaxes detrusor
- pudendal nerve contracts external urethral sphincter
What does the cortex control in micturition?
Sensation of ‘full bladder’
initiation of voiding
What does the pontine micturition centre control in micturition?
completion of voiding
co-ordination
What are the spinal reflexes involved in micturition?
Reflex bladder contraction - sacral micturition centre
Guarding reflex - Onuf’s nucleus (in spinal cord)
Receptive relaxation - sympathetic pathway
What nerves control detrusor muscle relaxation and contraction?
Relaxation = sympathetic stimulation T11-L2
Contraction = parasympathetic stimulation S2-4 (para pee)
What nerves control external urethral sphincter relaxation and contraction?
Relaxation = pudendal inhibition S2-4
Contraction = pudendal stimulation S2-4
What are the Lower Urinary Tract symptoms relating to Storage ?
- frequency
- urgency
- nocturia (MC in men with enlarged prostates)
- incontinence
FUNI
What are the Lower urinary Tract symptoms relating to Voiding?
- Slow stream
- Splitting or
spraying - Intermittency
- Hesitancy
- Straining
- Terminal dribble (bladder not completely empty - enlarged prostate prevents bladder being completely emptied)
What are the Lower urinary Tract symptoms relating to Post-micturition?
- Post-micturition dribble
- Feeling of incomplete emptying
Define Overactive Bladder syndrome (OAB).
Urgency with frequency, with or without nocturia, when appearing in the absence of local pathology
What is the management for an Overactive Bladder?
- Behavioural therapy = caffeine, alcohol, bladder drill
- Anti-muscarinic agents = decreases parasympathetic activity
- B3 agnostics = increased sympathetic activity at B3 receptor in bladder
- Botox = blocks neuromuscular junction for Ach release
- Sacral neuromodulation = insertion of electrode to S3 nerve root to modulate afferent signals from bladder
- surgery = augmentation cystoplasty
What are the 4 types of incontinence?
- Stress = pregnant, lifting heavy objects, coughing, sneezing
- Urge = not making it to the toilet in time
- Neuropathic = MS, Parkinson’s
- Overflow = chronic urinary retention
What investigations would you do for incontinence?
- flowmetry
- bladder diary
- U&Es
- post void bladder scan
- urodynamic studies (measure pressures in bladder and abdomen to assess bladder function)
- prostate examination
What is the cause of stress incontinence in females?
- usually secondary to birth trauma
- denervation of pelvic floor and urethral sphincter
- weakening of fascial support of bladder and urethra - Neurogenic
- Congenital
What is the cause of stress incontinence in males?
- neurogenic
- iatrogenic (prostatectomy)
What is the management of stress urinary incontinence?
- pelvic floor physiotherapy
- Duloxetine = inhibtion of serotonin + noradrenaline
- surgery = sling, colposuspension, bulking agents and artificial sphincter
What are the two categories and causes of voiding problems that can occur?
- obstructive
- benign prostatic enlargement
- urethral sphincter
- prolapse/mass - Non-obstructive
- atonic bladder = detrusor under activity (doesn’t contract to push urine out)
What is the management for benign prostatic obstruction?
Without erectile dysfunction
1. alpha antagonist
2. 5alpha reductase inhibitor
3. TURP - transurethral resection of the prostate
With erectile dysfunction
1. PDE5 inhibitor (viagra)
2. Alpha antagonist
3. TURP/injections/implant
What are the consequence of spastic spinal cord injury on bladder function?
(supra-clonal lesion)
Lost:
- coordination
- completion of voiding
Features
- reflex bladder contractions
- detrusor sphincter dyssynergia (loss of muscle coordination)
- poorly sustained bladder contraction
What are the consequences of Flaccid Spinal Cord Injury on the bladder?
(conus lesion, decentralised bladder)
Lost
- reflex bladder contraction
- guarding reflex
- receptive relaxation
Features
- areflexic bladder (signals but no where to send them to)
- stress incontinence
- risk of poor compliance
What are the aims of management of neurogenic bladder?
- bladder safety
- continence/symptom control
- prevent autonomic dysreflexia
What is autonomic dysreflexia?
- a clinical emergency in individuals with spinal cord injury
- it is an uninhibited sympathetic nervous system response to a variety fo stimuli
- injury at T6 or above
What is the pathophysiology of autonomic dysreflexia?
- Stimulus (distended bowel or bladder) sends an afferent signal to the spinal cord
- signals unable to ascend past the spinal cord lesion
- may activate a massive sympathetic reflex causing widespread vasoconstriction of the blood vessels below the injury level
- resulting in hypertension
What is an unsafe bladder?
One that puts the kidneys at risk of damage
What are the risk factors for an unsafe bladder?
- raised bladder pressure
- vesicle-ureteric reflux
- chronic infection
What are the causes + consequences of raised bladder pressure?
Causes:
prolonged detrusor contraction
loss of compliance
Result:
problems with drainage of urine from the kidneys and ultimately hydronephrosis and renal failure
What are the 2 routes to manage bladder reflexes in spinal cord lesions?
- harness reflexes to empty bladder into incontinence device
- suppress reflexes converting bladder to flaccid type and then empty regularly
What is paraplegic bladder management?
- Suprapubic catheter or convene (bag that catches urine)
OR
- suppress reflexes or poorly compliant bladder converting bladder to safe type and then empty regularly using ISC (intermittent self-catheterisation)
What medications can be used to suppress reflex bladder contractions?
- anticholinergics
- mirabegron
- intravesical botulinum toxin
- posterior rhizotomy (spinal operation that reduces leg spasticity)
- cystoplasty (surgery to enlarge the bladder)
What are examples of conditions with flaccid and low spinal lesions?
Spina bifida
Sacral Fracture
Transverse Myelitis
Ischemic Injuries
Cauda Equina
What are examples of conditions that cause complete loss of distal cord function?
Flaccid paraplegia
Areflexic bladder
Stress Incontinence
Areflexic bowels
Loss of REFLEX erections
What are the 2 theories for recurrence of bladder cancer?
- Field effect = entire urothelial ‘field’ is exposed to a carcinogen and therefore many of the cells are equally susceptible to tumour formation.
- Implantation theory = tumour cells detach from one location in the bladder, float through the urine, then implant themselves at another location in the bladder.
What are the 5 GFR stages for chronic kidney disease?
1 = eGFR >90 not considered CKD unless evidence of renal damage (normal + high)
2 = eGFR 60-89 not considered CKD unless evidence of renal damage (mild reduction from normal)
3A = eGFR 45 -59 (mild to moderate reduction)
3B = eGFR 30-44 (moderate to severe)
4 = 15-29 (severe reduction)
5 = <15 dialysis or renal transplant required (end-stage kidney failure)
What evidence is required to show renal damage?
one or more of:
- albuminuria (ACR>3)
- urine sediment abnormalities
- electrolyte and other abnormalities due to renal dysfunction
- histological abnormalities on imaging
- structural abnormalities on imaging
- a history of kidney transplant
What are the key features of nephritic syndrome?
Haematuria
Hypertension
Oedema
What are the key features of nephrotic syndrome?
Proteinuria
Hypoalbuminaemia
Oedema
+/- hypertension
What conditions cause nephrotic syndrome?
Primary
- minimal changes disease
- focal segmental glomerulosclerorsis
- membranous nephropathy
- membranoproliferative glomerulonephritis
Secondary
- diabetes
- amyloidosis
- drugs
- infection
What conditions cause nephritic syndrome?
Rapidly progressive GN
IgA nephropathy
Alport’s syndrome
Post-streptococcal GN
Goodpastures
SLE
Systemic sclerosis
What conditions cause both nephritic and nephrotic syndrome?
Diffuse proliferative GN
Membranoproliferative GN
How do you differentiate between different scrotal lumps?
All testicular lumps = cancer until proven otherwise!
Acute, tender enlargement of testis = testicular torsion until proven otherwise!
- Cannot get above = inguinoscrotal hernia, hydrocele extending proximally
- Separate and cystic = epididymal cyst
- Separate and solid = epididymitis, varicocele
- Testicular and cystic = hydrocele
- Testicular and solid = tumour, haematocele, granuloma, orchitis, gumma (non cancerous growth)
What are the indication for LUTS surgery?
RUSHES
- Retention
- UTI’s
- Stones
- Haematuria
- Elevated creatinine due to bladder outflow obstruction
- Symptoms deterioration
What are the LUTS symptoms with storage?
Occur when bladder should be storing urine –> need to pee
FUNI
Frequency
Urgency
Nocturia
Incontinence
What are the LUTS symptoms with voiding?
Occur when bladder outlets obstructed –> hard to pee
SHID
poor Stream
Hesitancy
Incomplete emptying
Dribbling
What are renal stones also known as?
Nephrolithiasis
What are the risk factors for developing kidney stones?
Dehydration
Previous kidney stones
Stone forming foods
Metabolic
What are the most common types of kidney stones?
Calcium-based stones they account for 80%. Having a raised serum calcium and low urine output are key risk factors for calcium collecting into a stone
What are the two types of calcium stone?
Calcium oxalate (most common) results in a black or dark coloured stone.
Calcium phosphate- results in a dirty white colour stone
What are some other types of kidney stones?
Uric acid: red-brown in colour and not visible under an x-ray.
- Risk factors: food high in purines e.g. shellfish, anchovies, red meat or organ meat, as uric acid is a breakdown product of purine
Struvite- produced by bacteria therefore are associated with infection. Forms dirty white stones visible on X-ray.
Cystine – associated with cystinuria, an autosomal recessive disease form yellow or light pink coloured stones not visible on x-ray
What are the different types of stones you would get in the lower vs upper urinary tract?
Upper urinary tract
- renal stones
- ureteric stones
Lower urinary tract
- bladde stones
- prostatic stones
- urethral stones
Why do people get stones?
- Anatomical factors
Congenital (horseshoe, duplex, PUJO, spina bifida)
Acquired (obstruction, trauma, reflux) - Urinary factors
Metastable urine, promoters and inhibitors
Calcium, Oxalate, Urate, Cystine
Dehydration - Infection
What is nucleation theory?
suggest that stones form from crystals in supersaturated urine
What causes kidney stones?
When solutes in the urine precipitate out and crystalline. Urine is a combination of solvent and solutes
If solvent is low (dehydration) or there are high levels of solute (hypercalcaemia) then it is more likely a kidney stone will form.
What substances can prevent the formation of kidney stones?
Magnesium and citrates inhibit crystal growth
What causes struvite stones to form?
Bacteria release enzyme urase which causes ammonia to form. Ammonia makes urine more alkaline so favours the precipitation of phosphate, magnesium and ammonium.
These form jagged crystals called Staghorns
What are the characteristics of uric acid stones?
usually Lucent on KUB X-ray
What is the cause of the pain associated with kidney stones?
- The peristaltic action of the collecting duct against the stone.
- Pain is worse at the uteropelvic junction and down the ureter pain subsides once stone gets to the bladder
What are the signs of kidney stones?
Flank/ renal angle tenderness
Fever (if sepsis)
What are the symptoms of renal stones?
Acute severe flank pain: loin to groin pain that lasts minuets to hours
Fluctuating pain
Nausea and vomiting
Haematuria
reduced urine output
What are some first-line investigations for renal stones?
Urine dipstick can show blood
FBC check kidney function and calcium levels
1st: Non-contrast CT KUB (don’t want contrast to add to blockage)
USS - if pregnant or child
X-ray can show calcium based stones but not uric
What is hydronephrosis and hydroureter?
hydronephrosis = kidney becomes stretched + swollen from build up of urine inside them
hydroureter = abnormal dilation of ureter due to hydronephrosis
What is the gold standard test for renal/any type of stones?
Non contrast CT scan of kidney, ureters and bladder (CT KUB) .
Should be performed within 14 hours of admission
- can help work out other pathology
- but no info on function
May use ultrasound if radiation needs to be avoided (pregnant)
- sensitive in picking up hydronephrosis but not a stone
What is the best form of pain relief for renal stones?
NSAIDs are typically used. IM diclofenac is most commonly used. Opiates are typically used as not good
What is the conservative/medical treatment for renal stones?
- Watchful waiting is usually used in stones less than 5mm, as there is a 50-80% chance they will pass without any interventions.
- increase fluid intake so producing a lot of urine
- Tamsulosin is an alpha blocker that can be used to help passage of stones (not indicated for renal more for ureteric)
What are the surgical treatments for renal stones?
ESWL involves an external machine that generates shock waves and directs them at the stone under x-ray guidance. The shockwaves break the stone into smaller parts to make them easier to pass.
Ureteroscopy and laser lithotripsy:
A camera is inserted via the urethra, bladder and ureter, and the stone is identified. It is then broken up using targeted lasers, making the smaller parts easier to pass.
Percutaneous nephrolithotomy (PCNL):
(for larger stones)
PCNL is performed in theatres under a general anaesthetic. A nephoscopy (small camera on a stick) is inserted via a small incision at the patient’s back. The scope is inserted through the kidney to assess the ureter. Stones can be broken into smaller pieces and removed. A nephrostomy tube may be left in place after the procedure to help drain the kidney.
Nephrectomy = only done if kidney performs less than 10-15% of renal function
What is the treatment for bladder stones?
Endoscopic = and break down stones
Litholapaxy = tube through urethra and crush stone in bladder
open/laparoscopic surgery = ideal for larger stones
What is the advice for a patient suffering from recurrent renal stones?
Increase oral fluids
Reduce salt intake
Reduce oxalate/urate rich food intake
Avoid carbonated drinks
Add lemon juice to waters
WHat are the methods of kidney drainage?
(drain infection from kidney)
Nephrostomy = tube inserted into kidney
Ureteric stent = open up ureters
What medications can be used to reduce the risk of renal stone formation?
Potassium citrate in patients with calcium oxalate stones and raised urinary calcium
Thiazide diuretics (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium
What are the complications of renal stones?
- Obstruction and hydronephrosis: acute kidney injury and renal failure
- Urosepsis: an infected, obstructing stone is a urological emergency and requires urgent decompression
- pyonephrosis = combination of infection and obstruction (emergency)
What is the specific prevention for uric acid stones?
Only form in acid urine
Deacidification of urine to pH7-7.5 preventative
What is the specific prevention for cysteine stones?
Excessive overhydration
Urine alkalinisation
Cysteine binders (eg Captopril, Penicillamine)
+/- genetic counselling
What is acute kidney injury?
A sudden decline in renal function over a few days. It is diagnosed by measuring serum creatinine
What is the RIFLE criteria for classifying AKI?
RIF describes the three levels of renal dysfunction and two outcome measures (LE). These criteria are used to indicate the increasing degree of renal damage and have a predictive value for mortality.
R- Risk
I- Injury
F- failure
L-loss
E- end-stage renal disease
What is KDIGO?
Kidney Disease: Improving Global Outcomes it divides AKI into 3 stages
Stage 1: serum creatinine greater than 26.5 (150-200%) with urine output less than 0.5ml for 6-12 hours
Stage 2: serum creatinine 2-2.9 times (200-300%) the baseline and less than 0.5ml/kg for >12 hours
Stage 3: serum creatinine 3 times (>300%) the baseline and less than 0.3ml/kg of urine for greater than 12 hours
Loss: persistent ARF = complete loss of renal function >4 weeks
ESKD = end stage kidney disease >3 months
What are the NICE criteria for diagnosing an AKI?
Rise in creatinine of ≥ 25 micromol/L in 48 hours
Rise in creatinine of ≥ 50% in 7 days
Urine output of < 0.5ml/kg/hour for > 6 hours
What is the pre-renal cause of AKI?
- Hypoperfusion due to hypovolaemia. This causes ischaemia of the the renal parenchyma. Prolonged ischaemia can lead to intrinsic damage
- Heart failure
- Dehydration
- Hypotension
What are the intrinsic renal causes of an AKI?
- Vascular: can be due to atherosclerotic disease and dissections. Also can be caused by renal artery stenosis
- Glomerular: may be primary or secondary. Can lead to nephritic or nephrotic syndrome
- ** Tubulo-intestinal**: usually due to acute tubular necrosis or acute interstitial nephritis that can occur secondary to medications (e.g. NSAIDs, ACE inhibitors, PPI’s, penicillin’s) and infections.
What are the 3 diseases most linked to renal causes of an AKI?
A
Intrinsic disease in the kidney is leading to reduced filtration of blood. It may be due to:
Glomerulonephritis
Interstitial nephritis
Acute tubular necrosis
What is the post renal cause of an AKI?
Obstruction- due to urinary stones, malignancy or bladder neck obstruction e.g., benign prostate hyperplasia
What are the risk factors for developing an AKI?
Chronic kidney disease
Heart failure
Diabetes
Liver disease
Older age (above 65 years)
Cognitive impairment
Nephrotoxic medications such as NSAIDS and ACE inhibitors
Use of a contrast medium such as during CT scans
What are the signs and symptoms of pre-renal AKI?
Reduced capillary refill time
Reduced skin turgor
Thirst
Dizziness
Tachycardia
Hypotension
Reduced urine output
What are the signs and symptoms of a vascular AKI
Arterial hypertension and peripheral oedema
What are the signs and symptoms of nephrotic syndrome AKI?
Heavy proteinuria
Hypoalbuminemia
Oedema
What are the signs and symptoms of Nephritic syndrome AKI?
Haematuria
Proteinuria (a little)
Oliguria
Hypertension
What are the signs and symptoms of Tubulo-intestinal disease AKI?
Arthralgia (joint pain)
Rashes
Fever
What is the most useful investigation for investigating an AKI?
Urinalysis for protein, blood, leucocytes, nitrites and glucose.
- Leucocytes and nitrites suggest infection
- Protein and blood suggest acute nephritis (but can be positive in infection)
- Glucose suggests diabetes
What other investigations might you perform for an AKI?
Vasculitis screen (e.g. ANCA, ANA)
Hepatitis screen
Blood gas
LFT
What is the management for AKI?
Regular monitoring
Cease nephrotoxic drugs
IV fluids for hypovolaemia
Relieve obstruction
What is the major complication of an AKI and how would ypu treat it?
Hyperkalaemia as potassium is not being removed from the blood.
Treat first with calcium gluconate to protect the heart then use insulin and dextrose. Salbutamol can also be used to drive potassium into cells
What are some other complications of an AKI?
Fluid overload which can cause heart failure and oedema
Metabolic acidosis
Uraemia can lead to Encephalopathy or Pericarditis
What is the mnemonic for assessment and management of AKI?
RENAL DRS26
R- Record baseline creatinine
E- Exclude obstruction
N- Nephrotoxic drugs stopped
A- Asses fluid status
L- Losses+/-
D- Dipstick
R- review medications
S- Screen
26- Creatinine rise for AKI diagnosis of higher than 26
What is acute tubular necrosis?
- often the underlying reason of AKI
- often related to ischaemia (hypotension -> poorly defused
What is acute renal vein thrombosis?
formation of a clot in the vein that drains blood from the kidneys, ultimately leading to a reduction in the drainage of one or both kidneys and the possible migration of the clot to other parts of the body
What is chronic kidney disease?
A progressive deterioration in renal function over at least 3 months
What are the most common causes of CKD?
Diabetes (most common)
Hypertension (second most common)
What are some other causes of CKD?
Systemic disease e.g., Rheumatoid arthritis
Infections (HIV)
Medications, PPI, ACE inhibitor, NSAIDs, lithium
Toxins (in smoking)
Age-related decline
Glomerulonephritis
Polycystic kidney disease
How does hypertension cause CKD?
Walls of arteries thicken in order to withstand higher pressure resulting in a narrow lumen
This means less blood is delivered to the kidney resulting in ischaemic injury
This causes the infiltration of immune cells that secrete TGF-b1. This growth factor transforms mesangial cells back to more immature stem ell which diminishes their ability to filter the blood
How does diabetes cause CKD?
Excess glucose in the blood starts sticking to proteins (non-enzymatic glycation).
This particularly affects the efferent arteriole and causes it to get stiff and narrow. This creates an obstruction and makes it difficult for the blood to leave the glomerulus.
Over many years this process dimishes the nephrons ability to filter blood
What are the signs of CKD?
Hypertension
Fluid overload
Uraemic sallow: yellow or pale brown colour of skin
Uraemic frost: urea crystals can deposit in the skin
Pallor
Evidence of underlying cause
What are the symptoms of CKD?
Pruritis
Loss of appetite
Nausea
Oedema
Muscle cramps
What are the investigations for CKD?
- Estimated GFR: can be checked using U&E blood test. Two tests required 3 months apart
- Proteinuria: can be checked using a urine albumin:creatinine ratio. A result of greater than 3mg/mmol is significant
- Haematuria: can be checked using a **urine dipstick*
- Renal ultrasound
What can be used to stage CKD?
G score and A score
What is the G score?
G score is based of eGFR
G1: eGFR>90
G2: eGFR: 60-89
G3a: eGFR: 45-59
G3b: eGFR: 30-44
G4: eGFR: 15-29
G5: eGFR<15 known as end-stage renal failure
What is the A score?
Based off the albumin:creatinine ratio:
A1: <3
A2: 3-30
A3: >30
What score would indicate a patient does not have CKD?
A1 combined with G1 or G2
What is the management for CKD?
Slowing the progression of the disease
Optimise diabetic control
Optimise hypertensive control
Treat glomerulonephritis
Reducing the risk of complications
Exercise, maintain a healthy weight and stop smoking
Special dietary advice about phosphate, sodium, potassium and water intake
Offer atorvastatin 20mg for primary prevention of cardiovascular disease
What are the complications of CKD?
- Renal bone disease
- Anaemia
- Cardiovascular- hypertension, hypercholesterolemia, heart failure due to fluid overload and anaemia
How does CKD cause renal bone disease?
- There is high serum phosphate as there is reduced phosphate excretion. There is also a low amount of active vitamin D as it is activated in the kidneys
- Therefore there is secondary hyperparathyroidism as a result which leads to an increase in osteoclast activity
What are the 3 types of renal bone disease?
- Osteomalacia: occurs due to increased turnover of bones without calcium supply
- Osteosclerosis: osteoblasts respond to increase osteoclast activity and make new tissue but it is poorly mineralised due to the lack of calcium
- Osteoporosis
Osteomalacia (softening of bones)
Osteosclerosis (hardening of bones)
Osteoporosis (brittle bones)
What is the management of renal bone disease?
Supplements of active forms of Vit D. (alfacalcidol and calcitriol)
Low phosphate diet
Bisphosphonates can be used to treat osteoporosis
How does CKD cause anaemia
- Erythropoietin is used to stimulate the production of RBC. In CKD there is reduced secretion of erythropoietin.
- Anaemia caused by this can be treated by giving exogenous erythropoietin.
** Blood transfusions should be limited as they can sensitise the immune system (“allosensitisation”) so that transplanted organs are more likely to be rejected**
What are the 4 types of renal cancers?
- renal cell carcinoma
- transitional cells carcinoma
- squamous cell carcinoma
- Wilm’s tumour (neprhoblastoma)
What are the risk factors for Renal Cell carcinoma?
Smoking
obesity
renal failure
HTN
social deprivation
Von Hippel-lindau syndrome
tuberous sclerosis
hereditary papillary RCC
What is the presentation for RCC?
Classic triad = haematuria, loin pain, mass
metastatic disease
palpable renal mass
paraneoplastic syndrome - polycythaemia, hypercalcaemia, anemia, HTN, stauffer’s syndrome
What is a varicocele?
testicular vein occluded by tumour leading to varicocele
- more commonly on left
What are the investigations for RCC?
Ultrasound
CT
Staging CT chest = enhancing mass
MRI - if extending into vein
Metastatic disease - bone, brain
When do you consider a renal biopsy?
indeterminate mass
prior to ablation
metastatic disease - systemic therapy (need tissue proof)
not for cystic mass
What is the management for RCC?
partial (gold) or radical (MC) nephrectomy
radio frequency bastion or cryotherapy
embolisation (palliative)
immunotherapy
What are the 4 subtypes of renal cell carcinomas?
Clear cell
Papillary
chromophobe
collection duct
What are the risk factors for bladder cancer?
Smoking
aromatic hydrocarbons
dyes
rubber
industrial exposures - hairdressers, leather workers, chemical workers
drugs e.g. cyclophosphamide
What is the presentation for bladder cancer?
Haematuria - painless visible 85%
lower urinary tract symptoms
recurrent UTIs
What is the presentation and investigations for haematuria?
visible or non-visible (1in5 with visible have malignancy)
Ultrasound KUB +/- CT urogram
flexible cystoscopy
urine cytology
What are the causes of haematuria?
malignancy
stones
infection
prostate - cancer or benign prostatic enlargement
nephrological causes
no cause found
What is the management for bladder cancer?
muscle invasive (more serious) or non-muscle invasive
- transurethral resection of bladder
- intravesical therapy
-> Mitomycin = reduces recurrence
-> BCG - reduces progression and recurrence
- surgery (if invasive or large) = radical cystoprostatectomy, anterior extentoration in women
- radiotherapy
What are the types of bladder cancer surgery?
Males = remove bladder and prostate
Females = remove bladder, uterus, ovaries (anterior exentoration)
Diversion - ileal conduit
orthotopic neobladder
What are the types of bladder cancers?
- transitional cell carcinoma (MC)
- squamous cell carcinoma (chronic inflammation, dysplasia, schistosomiasis, stones)
- adenocarcinoma (rare, poor prognosis)
What are the risk factors for testicular cancer?
- cryptorchidism = testis doesn’t descend, abnormal
- family history
- HIV
- previous testicular cancer
- MC in caucasian males
What is important in a testicular cancer history?
- lump felt on self-examination
- duration of symptoms
- pain
- change in size of mass
- previous surgery on genitalia
- sexual history
- associated urinary symptoms
- trauma
What are the investigations for testicular cancer?
Examination = scrotal mass, enlarged lymph nodes
ultrasound
bloods = AFP, beta HCG, LDH
CXR if respiratory symptoms
staging CT chest abdomen pelvis
What is the treatment for testicular cancer?
- Radical inguinal orchidectomy (enter through inguinal canal instead of scrotum to reduce risk of seeding )
- Neoadjuvant treatments = chemo (MC) or radio therapy
- Retroperitoneal lymph node dissection
- sperm banking before chemo
What are the types of testicular cancer?
- germ cell = seminoma or non-seminoma
- leading
- sertoli
- lymphoma
What is pyelonephritis?
Upper urinary tract infection: acute inflammation of the renal pelvis (join between kidney and ureter) and parenchyma
What is the epidemiology of Acute pyelonephritis?
Affects females under 35
Unusual in men
Why are UTI’s more common in women?
The urethra is much shorter in women so it makes it easier for bacteria to reach the bladder and kidneys
What are the risk factors for Acute pyelonephritis?
Sexual intercourse
Catheter
Diabetes
Pregnancy
Renal stones
Describe the pathophysiology of Acute pyelonephritis?
- Most often caused by ascending infection. Bacteria will start by colonising the urethra and bladder and make their way up to the kidney
- Risk of lower UTI transferring to an upper UTI is increased by vesicoureteral reflux where urine is allowed to move back up the urinary tract due to a failure in the vesicoureteral orifice
What are the signs of Acute pyelonephritis?
Tender loin on examination
Pain on palpation of renal angle
Symptoms will often be present on both sides as both kidneys are affected