Renal & Genitourinary Flashcards

Question

What is the management of stress urinary incontinence?

Answer 1

- pelvic floor physiotherapy - Duloxetine = inhibtion of serotonin + noradrenaline - surgery = sling, colposuspension, bulking agents and artificial sphincter

Answer 2

1. obstructive - benign prostatic enlargement - urethral sphincter - prolapse/mass 2. Non-obstructive - atonic bladder = detrusor under activity (doesn't contract to push urine out)

Answer 3

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

Answer 4

(supra-clonal lesion) Lost: - coordination - completion of voiding Features - reflex bladder contractions - detrusor sphincter dyssynergia (loss of muscle coordination) - poorly sustained bladder contraction

Answer 5

(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

Answer 6

- bladder safety - continence/symptom control - prevent autonomic dysreflexia

Answer 7

- 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

Answer 8

1. Stimulus (distended bowel or bladder) sends an afferent signal to the spinal cord 2. signals unable to ascend past the spinal cord lesion 3. may activate a massive sympathetic reflex causing widespread vasoconstriction of the blood vessels below the injury level 4. resulting in hypertension

Answer 9

One that puts the kidneys at risk of damage

Answer 10

- raised bladder pressure - vesicle-ureteric reflux - chronic infection

Answer 11

Causes: prolonged detrusor contraction loss of compliance Result: problems with drainage of urine from the kidneys and ultimately hydronephrosis and renal failure

Answer 12

1. harness reflexes to empty bladder into incontinence device 2. suppress reflexes converting bladder to flaccid type and then empty regularly

Answer 13

1. Suprapubic catheter or convene (bag that catches urine) OR 2. suppress reflexes or poorly compliant bladder converting bladder to safe type and then empty regularly using ISC (intermittent self-catheterisation)

Answer 14

- anticholinergics - mirabegron - intravesical botulinum toxin - posterior rhizotomy (spinal operation that reduces leg spasticity) - cystoplasty (surgery to enlarge the bladder)

Answer 15

Spina bifida Sacral Fracture Transverse Myelitis Ischemic Injuries Cauda Equina

Answer 16

Flaccid paraplegia Areflexic bladder Stress Incontinence Areflexic bowels Loss of REFLEX erections

Answer 17

- 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.

Answer 18

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)

Answer 19

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

Answer 20

Haematuria Hypertension Oedema

Answer 21

Proteinuria Hypoalbuminaemia Oedema +/- hypertension

Answer 22

Primary - minimal changes disease - focal segmental glomerulosclerorsis - membranous nephropathy - membranoproliferative glomerulonephritis Secondary - diabetes - amyloidosis - drugs - infection

Answer 23

Rapidly progressive GN IgA nephropathy Alport's syndrome Post-streptococcal GN Goodpastures SLE Systemic sclerosis

Answer 24

Diffuse proliferative GN Membranoproliferative GN

Answer 25

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)

Answer 26

RUSHES - Retention - UTI’s - Stones - Haematuria - Elevated creatinine due to bladder outflow obstruction - Symptoms deterioration

Answer 27

Occur when bladder should be storing urine --> need to pee FUNI Frequency Urgency Nocturia Incontinence

Answer 28

Occur when bladder outlets obstructed --> hard to pee SHID poor Stream Hesitancy Incomplete emptying Dribbling

Answer 29

Nephrolithiasis

Answer 30

Dehydration Previous kidney stones Stone forming foods Metabolic

Answer 31

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

Answer 32

Calcium oxalate (most common) results in a black or dark coloured stone. Calcium phosphate- results in a dirty white colour stone

Answer 33

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

Answer 34

Upper urinary tract - renal stones - ureteric stones Lower urinary tract - bladde stones - prostatic stones - urethral stones

Answer 35

1. Anatomical factors Congenital (horseshoe, duplex, PUJO, spina bifida) Acquired (obstruction, trauma, reflux) 2. Urinary factors Metastable urine, promoters and inhibitors Calcium, Oxalate, Urate, Cystine Dehydration 3. Infection

Answer 36

suggest that stones form from crystals in supersaturated urine

Answer 37

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.

Answer 38

Magnesium and citrates inhibit crystal growth

Answer 39

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

Answer 40

usually Lucent on KUB X-ray

Answer 41

- 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

Answer 42

Flank/ renal angle tenderness Fever (if sepsis)

Answer 43

Acute severe flank pain: loin to groin pain that lasts minuets to hours Fluctuating pain Nausea and vomiting Haematuria reduced urine output

Answer 44

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

Answer 45

hydronephrosis = kidney becomes stretched + swollen from build up of urine inside them hydroureter = abnormal dilation of ureter due to hydronephrosis

Answer 46

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

Answer 47

NSAIDs are typically used. IM diclofenac is most commonly used. Opiates are typically used as not good

Answer 48

- 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)

Answer 49

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

Answer 50

Endoscopic = and break down stones Litholapaxy = tube through urethra and crush stone in bladder open/laparoscopic surgery = ideal for larger stones

Answer 51

Increase oral fluids Reduce salt intake Reduce oxalate/urate rich food intake Avoid carbonated drinks Add lemon juice to waters

Answer 52

(drain infection from kidney) Nephrostomy = tube inserted into kidney Ureteric stent = open up ureters

Answer 53

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

Answer 54

- 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)

Answer 55

Only form in acid urine Deacidification of urine to pH7-7.5 preventative

Answer 56

Excessive overhydration Urine alkalinisation Cysteine binders (eg Captopril, Penicillamine) +/- genetic counselling

Answer 57

A sudden decline in renal function over a few days. It is diagnosed by measuring serum creatinine

Answer 58

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

Answer 59

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

Answer 60

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

Answer 61

- Hypoperfusion due to hypovolaemia. This causes ischaemia of the the renal parenchyma. Prolonged ischaemia can lead to intrinsic damage - Heart failure - Dehydration - Hypotension

Answer 62

- 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.

Answer 63

A Intrinsic disease in the kidney is leading to reduced filtration of blood. It may be due to: Glomerulonephritis Interstitial nephritis Acute tubular necrosis

Answer 64

Obstruction- due to urinary stones, malignancy or bladder neck obstruction e.g., benign prostate hyperplasia

Answer 65

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

Answer 66

Reduced capillary refill time Reduced skin turgor Thirst Dizziness Tachycardia Hypotension Reduced urine output

Answer 67

Arterial hypertension and peripheral oedema

Answer 68

Heavy proteinuria Hypoalbuminemia Oedema

Answer 69

Haematuria Proteinuria (a little) Oliguria Hypertension

Answer 70

Arthralgia (joint pain) Rashes Fever

Answer 71

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

Answer 72

Vasculitis screen (e.g. ANCA, ANA) Hepatitis screen Blood gas LFT

Answer 73

Regular monitoring Cease nephrotoxic drugs IV fluids for hypovolaemia Relieve obstruction

Answer 74

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

Answer 75

Fluid overload which can cause heart failure and oedema Metabolic acidosis Uraemia can lead to Encephalopathy or Pericarditis

Answer 76

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

Answer 77

- often the underlying reason of AKI - often related to ischaemia (hypotension -> poorly defused

Answer 78

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

Answer 79

A progressive deterioration in renal function over at least 3 months

Answer 80

Diabetes (most common) Hypertension (second most common)

Answer 81

Systemic disease e.g., Rheumatoid arthritis Infections (HIV) Medications, PPI, ACE inhibitor, NSAIDs, lithium Toxins (in smoking) Age-related decline Glomerulonephritis Polycystic kidney disease

Answer 82

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

Answer 83

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

Answer 84

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

Answer 85

Pruritis Loss of appetite Nausea Oedema Muscle cramps

Answer 86

- 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

Answer 87

G score and A score

Answer 88

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

Answer 89

Based off the albumin:creatinine ratio: A1: <3 A2: 3-30 A3: >30

Answer 90

A1 combined with G1 or G2

Answer 91

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

Answer 92

- Renal bone disease - Anaemia - Cardiovascular- hypertension, hypercholesterolemia, heart failure due to fluid overload and anaemia

Answer 93

- 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

Answer 94

1. Osteomalacia: occurs due to increased turnover of bones without calcium supply 2. Osteosclerosis: osteoblasts respond to increase osteoclast activity and make new tissue but it is poorly mineralised due to the lack of calcium 3. Osteoporosis Osteomalacia (softening of bones) Osteosclerosis (hardening of bones) Osteoporosis (brittle bones)

Answer 95

Supplements of active forms of Vit D. (alfacalcidol and calcitriol) Low phosphate diet Bisphosphonates can be used to treat osteoporosis

Answer 96

- 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**

Answer 97

1. renal cell carcinoma 2. transitional cells carcinoma 3. squamous cell carcinoma 4. Wilm's tumour (neprhoblastoma)

Answer 98

Smoking obesity renal failure HTN social deprivation Von Hippel-lindau syndrome tuberous sclerosis hereditary papillary RCC

Answer 99

Classic triad = haematuria, loin pain, mass metastatic disease palpable renal mass paraneoplastic syndrome - polycythaemia, hypercalcaemia, anemia, HTN, stauffer's syndrome

Answer 100

testicular vein occluded by tumour leading to varicocele - more commonly on left

Answer 101

Ultrasound CT Staging CT chest = enhancing mass MRI - if extending into vein Metastatic disease - bone, brain

Answer 102

indeterminate mass prior to ablation metastatic disease - systemic therapy (need tissue proof) not for cystic mass

Answer 103

partial (gold) or radical (MC) nephrectomy radio frequency bastion or cryotherapy embolisation (palliative) immunotherapy

Answer 104

Clear cell Papillary chromophobe collection duct

Answer 105

Smoking aromatic hydrocarbons dyes rubber industrial exposures - hairdressers, leather workers, chemical workers drugs e.g. cyclophosphamide

Answer 106

Haematuria - painless visible 85% lower urinary tract symptoms recurrent UTIs

Answer 107

visible or non-visible (1in5 with visible have malignancy) Ultrasound KUB +/- CT urogram flexible cystoscopy urine cytology

Answer 108

malignancy stones infection prostate - cancer or benign prostatic enlargement nephrological causes no cause found

Answer 109

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

Answer 110

Males = remove bladder and prostate Females = remove bladder, uterus, ovaries (anterior exentoration) Diversion - ileal conduit orthotopic neobladder

Answer 111

1. transitional cell carcinoma (MC) 2. squamous cell carcinoma (chronic inflammation, dysplasia, schistosomiasis, stones) 3. adenocarcinoma (rare, poor prognosis)

Answer 112

- cryptorchidism = testis doesn't descend, abnormal - family history - HIV - previous testicular cancer - MC in caucasian males

Answer 113

- lump felt on self-examination - duration of symptoms - pain - change in size of mass - previous surgery on genitalia - sexual history - associated urinary symptoms - trauma

Answer 114

Examination = scrotal mass, enlarged lymph nodes ultrasound bloods = AFP, beta HCG, LDH CXR if respiratory symptoms staging CT chest abdomen pelvis

Answer 115

- 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

Answer 116

- germ cell = seminoma or non-seminoma - leading - sertoli - lymphoma

Answer 117

Upper urinary tract infection: acute inflammation of the renal pelvis (join between kidney and ureter) and parenchyma

Answer 118

Affects females under 35 Unusual in men

Answer 119

The urethra is much shorter in women so it makes it easier for bacteria to reach the bladder and kidneys

Answer 120

Sexual intercourse Catheter Diabetes Pregnancy Renal stones

Answer 121

- 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

Answer 122

Tender loin on examination Pain on palpation of renal angle Symptoms will often be present on both sides as both kidneys are affected

Answer 123

Fever Loin to groin pain Dysuria (painful to piss) and urinary frequency Haematuria Cloudy foul smelling urine

Answer 124

Fever Loin/back pain Nausea/vomiting Renal angle tenderness

Answer 125

Urine Dipstick: Nitrites as gram negative bacteria such as E.coli and Klebsiella breakdown nitrates into nitrites Leukocyte esterase on urine dipstick indicates an infection Nitrites are better indication. But leukocyte esterase plus haematuria indicates infection

Answer 126

Mid-stream urine MCS- white blood cell in the urine

Answer 127

Broad spectrum antibiotics (e.g. co-amoxiclav) until culture and sensitivities are available Hydration

Answer 128

Renal abscess Recurrent infections Chronic pyelonephritis- which can leads to the scaring of renal tissue which can lead to AKI and CKD Papillary necrosis

Answer 129

A lower UTI that involves the bladder

Answer 130

Post-menopause the absence of oestrogen increases the risk Sexual intercourse Diabetes Poor bladder emptying- allows the bacteria to adhere and colonise the bladder

Answer 131

- An inflamed bladder is usually the result of a bacterial infection, but also can result from fungal infections, chemical irritants, foreign bodies like kidney stones, as well as trauma. - Lower UTIs are almost always caused by an ascending infection, where bacteria typically moves from the rectal area to the urethra and then migrate up the urethra and into the bladder. - On rare occasions, a descending infection can happen as well where bacteria starts in the blood or lymph and then goes to the kidney and makes its way down to the bladder and urethra.

Answer 132

Suprapubic tenderness

Answer 133

Dysuria Frequency Urgency Nocturia changes in appearance Suprapubic discomfort

Answer 134

Mid-stream urine microscopy, culture and sensitivity (MC&S): - The most specific and sensitive test; bacteria, WBCs, +/- RBCs expected

Answer 135

Treatment may be delayed if symptoms are mild 1. First line would be 3 days of nitrofurantoin avoided in patients with CKD or trimethoprim 2. Second line Antibiotic course for 3 days -pivmacillinam or fosfomycin single-dose sachet

Answer 136

1. First line: Antibiotic course for 7 days - nitrofurantoin avoid in third trimester. Trimethoprim is avoided in first trimester as it increases the risk of neural tube defects 2. Second line: Antibiotic course for 7 days - amoxicillin or cefalexin

Answer 137

Pre-term delivery Low-birthweight

Answer 138

A severe infection involving the prostate that may cause significant systemic upset

Answer 139

E.coli most common STI’s Catheter Disseminated infections- secondary to S.aureus due to metastatic spread

Answer 140

Tender, hot swollen prostate (on digital rectal exam) Palpable bladder Tachycardia Pyrexia

Answer 141

Dysuria Frequency and retention Straining Back pain Fever Perineal, rectal or pelvic pain

Answer 142

Digital rectal exam Urine dipstick MSU, semen and blood culture

Answer 143

First line- Oral ciprofloxacinor ofloxacin Second line- Oral levofloxacin or co-trimoxazole

Answer 144

Acute urinary retention Epididymitis Chronic prostatitis Prostatic abscess

Answer 145

The four glass (or two glass) test: pre- and post- prostatic massage. Voided bladder 1 (VB1):first 10ml of urine passed, represents urethra. Voided bladder 2 (VB2):second 10ml of urine passed, represents bladder. Expressed prostatic secretions (EPS):first 10ml of urine passed, represents urethra. Voided bladder 3 (VB3):first 10ml of urine passed, after EPS. The two glass test, just involving EPS and VB3 is commonly used. I:Acute bacterial prostatitis (ABP) II:Chronic bacterial prostatitis (CBP) III:Chronic pelvic pain syndrome(CPPS) IIIA:Inflammatory CPPS (leucocytes in semen/EPS/VB3) IIIB:Non-inflammatory CPPS (no leucocytesin semen/EPS/VB3) IV:Asymptomatic inflammatory prostatitis (histological prostatitis)

Answer 146

Urethral inflammation due to infectious or non-infectious causes. It is primarily a sexually acquired disease!

Answer 147

Gonococcal and non-gonococcal

Answer 148

Neisseria gonorrhea

Answer 149

Chlamydia trachomatis (most common accounts for up to 50%) Mycoplasma genitalium

Answer 150

Trichomonas vaginalis Yeasts Herpes simplex virus Adenovirus Other bacteria such as streptococci, mycobacteria, or anaerobes.

Answer 151

Trauma Irritation Urinary calculi/stone

Answer 152

Male to male sex Unprotected sex multiple sexual partners

Answer 153

Urethral discharge Urethral irritation/itching Dysuria Penile discomfort Skin lesions

Answer 154

Nucleic acid amplification test Microscopy of gram-stained smears of genital secretions Culture of urethral discharge Urine dipstick to rule out UTI

Answer 155

Oral azithromycin or oral doxycycline If pregnant give erythromycin

Answer 156

IM ceftriaxone with oral azithromycin Also partner notification and contact tracing

Answer 157

Reactive arthritis Gonococcal conjunctivitis Periurethral abscess Urethral stricture or fistula Epididymitis Prostatitis Penile lymphangitis

Answer 158

First line- Oral ciprofloxacin or ofloxacin Second line- Oral levofloxacin or co-trimoxazole

Answer 159

Acute urinary retention Epididymitis Chronic prostatitis Prostatic abscess

Answer 160

Inflammation of the epididymis (epididymitis) and inflammation of the testicle (orchitis)

Answer 161

STIs e.g., Chlamydia trachomatis, Neisseria Gonorrhoea and mycoplasma genitalium

Answer 162

E.coli and proteus sp. Can also be caused by TB and viral infections such as mumps

Answer 163

Tenderness and palpable swelling Prehn’s sign positive: pain is relieved with lifting the testicle, negative in testicular torsion Cremasteric reflex preserved- unlike testicular torsion

Answer 164

Unilateral tender, red, and swollen testicle (Pain develops over a few days) Lower urinary tract symptoms e.g. dysuria Urethral discharge: may and or may not be present

Answer 165

Urinalysis Nucleic acid amplification test (NAAT) Swab of urethral secretions

Answer 166

Fluoroquinolone e.g., ofloxacin or ciprofloxacin

Answer 167

Musculoskeletal: reactive arthritis Infective: disseminated infection secondary to gonorrhoea

Answer 168

Nephritic syndrome or acute nephritic syndrome refers to a group of symptoms, not a diagnosis. They fit a clinical picture of having inflammation of their kidney and it does not represent a specific diagnosis or give the underlying cause. -

Answer 169

Haematuria Oliguria Proteinuria Fluid retention

Answer 170

Peripheral oedema Proteinuria Hypoalbuminemia = Serum albumin less than 25g/L Hypercholesterolemia

Answer 171

Defined by the presence of dominant or co-dominant mesangial IgA immune deposits, often accompanied by C3 and IgG. Also called Berger’s disease

Answer 172

80% diagnosed between 16 and 35 and more common in Asian population

Answer 173

- Occurs when abnormal IgA antibodies are produced by the body usually after a respiratory or GI tract infection - This causes the body to recognise them as foreign producing IgG antibodies to target them. This immune complexes travel in the blood stream and get trapped in the kidneys

Answer 174

- They are deposited in the mesangium (tissue surrounding the Bowman’s capsule). - This activates the complement pathway leading to the release of cytokines and macrophages which damage the glomerulus

Answer 175

Haematuria Oedema due to proteinuria Cervical lymphadenopathy suggests recent URTI as trigger Hypertension

Answer 176

Pink, red or “coke” tinged urine (haematuria) Foamy urine (proteinuria) Sore throat: suggests an URTI as a recent trigger Loose stools and abdominal discomfort: suggests gastroenteritis as a recent trigge

Answer 177

U&Es and urine dipstick C3 and C4- C4 will be normal where as C3 might be low (MC complements)

Answer 178

Renal biopsy On light microscopy: see mesangial proliferation. On immunofluorescence: IgA immune complexes in the mesangium On electron microscopy: immune complexes are seen in the mesangium.

Answer 179

IgA vasculitis (/Henoch-Schonlein purpura): the difference is IgA nephropathy only affects the kidneys, while IgA vasculitis can cause nephritic or nephrotic syndrome, and also presents with colicky abdominal pain, bloody stool, arthritis, and palpable skin lesions.

Answer 180

Non-curative (30% progress to ESRF) ACE inhibitor for BP Corticosteroids Statins Omega-3 fatty acids

Answer 181

Hypertension: due to damage to the glomerulus and its filtering function Acute kidney injury Chronic kidney disease (CKD) Rapidly progressive glomerulonephritis (RPGN)

Answer 182

Post-streptococcal glomerulonephritis (PSGN) is usually an immunologically-mediated delayed consequence of pharyngitis or skin infections caused by streptococcus pyogenes Most frequently seen in children

Answer 183

Some strep A strains carry the M-protein virulence factor which initiates a type III hypersensitivity reaction. IgG and IgM antibodies form immune complexes These immune complexes get deposited on the basement membrane of the glomerulus which initiates an inflammatory response

Answer 184

Haematuria Recent strep infection

Answer 185

Bloods: low levels of C3 and CH50 Positive streptozyme test confirms recent group A streptococcal infection

Answer 186

Kidney biopsy: isn’t always necessary, but can provide specific clues On light microscopy: the glomeruli are enlarged and hypercellular. On immunofluorescence: IgG, IgM and C3 deposits along the glomerular basement membrane and the mesangium, which create a “starry sky” appearance. On electron microscopy: subepithelial deposits which appear as “humps”.

Answer 187

Furosemide Antibiotics

Answer 188

PSGN usually resolves on its own in children. In adults, it can sometimes lead to renal failure. Age affects prognosis!

Answer 189

Diffuse proliferative glomerulonephritis is the most common form of lupus nephritis.

Answer 190

- Middle-aged: peak age of onset is between 15 and 45 years old - Female gender:12 times more common in females - African and Afro-Caribbean: more common and more severe in these patients

Answer 191

- Lupus is an autoimmune condition that affects multiple organs. It is a type III hypersensitivity reaction where immune complexes are deposited in various parts of the body - Most common site of deposition is in the subendothelial space of the glomerular basement membrane

Answer 192

Haematuria Proteinuria Hypertension Oedema Lethargy Musculoskeletal pain and butterfly rash

Answer 193

Urinalysis: haematuria and proteinuria U&Es: reduced eGFR as renal failure progresses Renal USS: exclude structural pathology

Answer 194

Renal biopsy On light microscopy: immune complexes create an overall thickening of the capillary wall, which gives a “wire loop” appearance. On immunofluorescence: granular immune complexes. On electron microscopy: sub-endothelial immune complexes

Answer 195

Lifestyle stop smoking and exercise more Pharmacological: Corticosteroids Immunosuppressants e.g., azathioprine mercaptopurine and cyclophosphamide DMARD = Hydroxychloroquine (reduce inflammation)

Answer 196

Goodpasture’s disease, also known as anti-glomerular basement membrane antibody (anti-GBM) disease, - is an important cause of pulmonary-renal syndrome (Goodpasture’s syndrome). - Pulmonary-renal syndrome consists of glomerulonephritis and pulmonary haemorrhage.

Answer 197

- It is caused by antibodies to the alpha-3 chain of type IV collagen (makes the basement membrane if you can remember phase 1) . - Alpha-3 subtype only affects basement membrane of a few tissues particularly Alveoli and the glomeruli

Answer 198

HLA-DRB1 or DR4

Answer 199

Reduced urine output Haemoptysis (pulmonary haemorrhage) Oedema

Answer 200

- Renal function tests - GOLD STANDARD- renal biopsy - anti-glomerular basement membrane (anti-GBM) antibody titre - ANCA test (50% of patients will have these antibodies as well)

Answer 201

Oral corticosteroid Plasmapheresis to remove the anti-GBM antibodies Cyclophosphamide

Answer 202

It occurs when the basement membrane in the glomerulus becomes highly permeable to protein allowing them to leak from the blood into the urine.

Answer 203

Class I - simple cyst - benign Class II - minimally complex - single thin septation, thin Ca++ - non-malignant Class IIF - minimally complex - needing follow up - as hyperdense on CT <3cm diameter - US or CT followup Class III - indeterminate - thick or multiple septations, mural nodule, hyperdense on CT - partial nephrectomy Class IV - clearly malignant - solid mass with cystic spaces - surgery = partial or total nephrectomy

Answer 204

Acute Nephritic Syndrome Nephrotic syndrome Asymptomatic urinary abnormalities Chronic Kidney Disease – ie progressive decline in kidney function with abnormal dipstick

Answer 205

Persistent inability to attain and maintain an erection

Answer 206

10% men aged 40-70 years old

Answer 207

Neurogenic = failure to initiate Arteriogenic = failure to fill venogenic = failure to store

Answer 208

arteries dilation corpus callosum = engorgement (fill with blood) corpus spongiosum = erect smooth muscle relaxation sinusoid expands -> blocks venous outflow

Answer 209

Parasympathetic = erectile S2-4 (pelvic nerve) Sympathetic = T11- L2 (hypogastric) (Point and Shoot) Join = pelvic plexus signals relayed via cavernosa nerve (parasympathetic) - innervates penis somatic sensory = dorsal nerve somatic motor = pudendal nerve

Answer 210

IMPOTENCE Inflammatory = prostatitis Mechanical = peyron's disease (scarring around tunica albugnea) P Occlusive vascular factors = smoking, diabetes Trauma Extra factors = increasing age, chronic renal failure Neurogenic = MS, Parkinson's, spina bifida Chemical = anti-arrythmics, anti-hypertensives, antidepressants Endocrine = hyper/hypothyroidism

Answer 211

Cv diabetes depression obesity alcohol medications history of pelvic surgery neurological disease endocrine (hyper/hypothyroidism)

Answer 212

- examination - international index of erectile dysfunction (grade how severe their symptoms are) - urinalysis - fasting blood glucose - fasting lipids - total testosterone - morning testosterone - PSA - DRE - digital rectal exam

Answer 213

Treat underlying causes Psychosexual consuelling PDE-5 inhibitors (aka. viagra = improve smooth muscle relaxation I corpus cavernosa) Intraurethral suppository (if viagra hasn't worked) Vacuum assisted device = increases blood flow Penile implant = semi-rigid, inflatable penile prosthesis, surgical implant into corpora (mainly for spinal injuries)

Answer 214

use before sexual intercourse localised within the penis compared to viagra being systemic like viagra causes relaxation of smooth muscle

Answer 215

Deranged lipid profile (high levels) - as the liver increases synthesis in response to low levels of albumin High blood pressure Hyper-coagulability- due to loss of protein C and S in the urine

Answer 216

Frothy urine Oedema Pallor

Answer 217

The most common cause in children causing over 90% of cases in children under 10. In minimal change disease, nephrotic syndrome occurs in isolation, without any clear underlying condition or pathology

Answer 218

If you spot a 2 – 5 year old child with oedema, proteinuria and low albumin, you may be asked about the underling cause. The answer is likely to be nephrotic syndrome.

Answer 219

It is the most common cause of nephrotic syndrome in individuals of African or Hispanic descent

Answer 220

HIV Heroin abuse Infection Interferon treatment

Answer 221

On light microscopy, there’s sclerosis and hyalinosis among the glomeruli. FSG is segmental - only a part of the glomeruli is affected - and focal - only some of the glomeruli are affected.

Answer 222

Primary FGS has an inconstant response to corticosteroids and some individuals may progress to CKD

Answer 223

Can be primary Or secondary to - SLE, - drugs e.g. NSAIDs, gold and penicillamine, - infections- particularly hep B, hep C or syphillis - solid tumours e.g. colorectal carcinoma

Answer 224

- Damage is caused by immune complexes. They are called subepithelial deposits because they build up between podocytes and glomerular basement membrane. - One major antigen that’s been identified is the phospholipase A2 receptor or PLA2R - In the serum of individuals with membranous nephropathy - you can find IgG antibodies against PLA2R.

Answer 225

Diffuse capillary and basement membrane thickening caused by immune complex deposition

Answer 226

Three types of MPGN: they all cause proliferation of mesangial and endothelial cells in the glomerulus. Membranoproliferative glomerulonephritis is a type of glomerulonephritis caused by deposits in the kidney glomerular mesangium and basement membrane thickening, activating complement and damaging the glomeruli.

Answer 227

Most common subtype accounts for 90% of cases associated with SLE, hepatitis CLL and lymphoma - Deposits in the subendothelial space

Answer 228

Due to persistent activation of the alternative pathway. Low levels of circulating C3 Associated with factor H deficiency and lipodystrophy Deposits in the basement membrane

Answer 229

- Type III MPGN: poorly understood - Characterised by subendothelial and subepithelial deposits - Associated withhepatitis BandC

Answer 230

Age 75% of people are 8-16 Infections CLL Acquired partial lipodystrophy (ADP): APL is a very rare condition characterised by the loss of fat and is particularly associated with type II MPGN

Answer 231

It starts one of two ways: Way 1: through hypersensitivity reaction to Hep A or Hep B antigens. These complexes get deposited in the glomerulus and activate the classical complement pathway. Way 2: There is inappropriate activation of the alternative pathway due to over activity of C3 convertase which can be caused by a special IgG antibody called nephritic factor Either way there are deposits that end up in the subendothelial space which causes inflammation leading to the thickening of the basement membrane and proliferation of the mesangial cells

Answer 232

It is caused by nephritic factors which stabilise C3 convertase leading to complement deposits in the basement membrane as opposed to the subendothelial space Leads to inflammation of the basement membrane and low levels of circulating C3. Will show tram track appearance on light microscopy

Answer 233

Oedema Oliguria Haematuria Hypertension foamy urine ** Pink urine**

Answer 234

U&Es Urine dipstick: C3 and C4 levels: all types of MPGN are associated with C3 hypocomplementaemia Type 1 MPGN: activates classical component pathway → possible C4 depletion Type 2 MPGN: normal C4 C4 levels can be used to distinguish between type 1 and type 2

Answer 235

Renal biopsy Type 1 subendothelial and mesangial immune deposits resulting in tram-track appearance Type 2- Intramembranous dense deposits

Answer 236

Oral cyclophosphamide: offered for all patients with presumed idiopathic MPGN accompanied by nephrotic syndromeanddeclining kidney function Oral mycophenolate mofetil (MMF) and oral corticosteroids: consider in addition to oral cyclophosphamide

Answer 237

Increase in the size of the prostate without malignancy. This causes bladder outlet obstruction and lower urinary tract symptoms

Answer 238

Men from 51-60 there is a prevalence of 50% above 80 prevalence is 80%

Answer 239

Increasing age Family history Ethnicity more common in black people Diabetes Obesity due to increasing circulation of oestrogen

Answer 240

1. Basal and luminal cells rely on stimulation from androgens for survival. - Such as testosterone (produced by testicles) and dihydrotestosterone (produced by prostate). - DHT is produced by 5α-reductase which converts testosterone into the more potent dihydrotestosterone. 2. As age increases levels of testosterone drop but levels of DHT increase as there is an increase in 5a-reductase activity 3. This will form hyperplastic nodules to form

Answer 241

the median and lateral lobes are usually enlarged. (transitional zone)

Answer 242

1. Hyperplastic nodules will form in the inner portions of the gland typically around the urethra 2. These nodules will compress the urethra making it more difficult to pass urine. 3. This will mean the smooth muscles of the bladder will have to work harder leading to bladder hypertrophy 4. The stagnation of the urine in the bladder also promotes bacterial growth leading to UTIs

Answer 243

Digital rectal exam will find smooth, enlarged and non-tender prostate Lower abdominal tenderness and palpable bladder: Indicates acute urinary retention Perform bladder scan Requires urgent catheterisation

Answer 244

Digital rectal exam = smooth, enlarged and non-tender prostate Lower abdominal tenderness and palpable bladder: Indicates acute urinary retention Perform bladder scan Requires urgent catheterisation

Answer 245

Voiding: weak stream and incomplete emptying Storage: urgency and incontinence Oliguria: if complete obstruction Lower abdominal pain and inability to urinate Indicates acute urinary retention

Answer 246

Prostate-specific antigen (PSA): predicts prostate volume, may suggest cancer if significantly raised but BPH can also raise it International Prostate Symptom Score (I-PSS): a 7-symptom questionnaire with an additional bother score to predict progression and outcome

Answer 247

α-1 antagonists: Tamsulosin it is considered first-line. It inhibits the action of noradrenaline and relaxes the smooth muscle. Can cause Postural hypotension, dizziness, dry mouth and depression 5-α reductase inhibitors e.g. finasteride. This will work to reduce the prostate size but can take up to 6 months to work. Can cause: reduced libido, erectile dysfunction, and gynaecomastia

Answer 248

Prostate<30g - Transurethral incision of the prostate (TUIP): one or two cuts in the small grooves of the bladder neck to open the urinary channel and allow urine to pass through more easily. Prostate 30-80g Transurethral resection of the prostate (TURP): accessing the prostate through the urethra and “shaving” off prostate tissue from inside using diathermy (heat) Prostate >80g Transurethral electrovaporisation of the prostate (TUVP): prostate tissue is removed using a laser Open prostatectomy via abdominal or perineal incision

Answer 249

Raise - older - Benign prostatic hyperplasia - Prostatitis - recent ejaculation - prostate cancer lower - obesity - drugs

Answer 250

- a blood test to check antigen levels - 2 tests with a 2 week referral between them Can't ejaculate 48 hrs before can't have recent UTI Or a recent PR exam

Answer 251

life-threatening triad of fluid overload, dilutional hyponatraemia and neurotoxicity due to systemic absorption of irrigation fluids during TURP procedure

Answer 252

Prostate adenocarcinoma

Answer 253

1. Transitional cell carcinoma 2. Small cell prostate cancer arising form neuroendocrine cells

Answer 254

Being tall Obesity and high fat diet Use of steroids Cadmium exposure found in cigarettes, batteries and those in welding industry BRCA1 and BRCA

Answer 255

They commonly arise in the PERIPHERAL zone of the prostate. This is often a result of a mutation in the luminal cells causing an uncontrollably dividing tumour Early on the cancer relies heavily on androgens to survive but can find a way later on in disease to divide without it.

Answer 256

Hyperproliferation of epithelial and stromal cells in INNER transitional zone of prostate

Answer 257

-Spreads to the bones of the vertebrae and pelvis resulting in hip and in back pain

Answer 258

Asymmetrical, hard and nodular prostate with the loss of the median sulcus Urinary retention

Answer 259

Frequency Dribbling Haematuria or haematospermia Dysuria Bone pain (suggests metastatic disease)

Answer 260

Multiparametric MRI is first-linefor suspected localised cancer. Reported on using Likert score: Prostate-specific antigen (PSA) Often increased in patients with prostate cancer Also raised with increasing age and BPH PSA testing is unreliable, with a high rate of false positives (75%) and false negatives (15%).

Answer 261

1- very low suspicion 2- low suspicion 3- Equivocal 4- probable cancer 5- Definite cancer Prostate biopsy offered to those with scores of 3 or greater

Answer 262

Transrectal ultrasound-guided biopsy (TRUS) Transperineal biopsy Prostate biopsy carries a risk of false-negative results if the biopsy misses the cancerous area. Multiple needles are used to take samples from different areas of the prostate. The MRI scan results can guide the biopsy to decide the best target for the needles.

Answer 263

The Gleason grading system is based on the histology from the prostate biopsies. It is specific to prostate cancer and helps to determine what treatment is most appropriate It is made up of two numbers from the two most prevalent areas of the biopsy and they are graded 1-5. 1 Being well differentiated (good) and 5 being poorly differentiated. A Gleason score of: 6 is considered low risk 7 is intermediate risk (3 + 4 is lower risk than 4 + 3) 8 or above is deemed to be high risk

Answer 264

Active surveillance or observation

Answer 265

External beam radiotherapy directed at the prostate Brachytherapy Hormone therapy Surgery

Answer 266

Involves the implanting of radioactive seeds into the the prostate delivering continuous targeted radiotherapy. The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis). Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.

Answer 267

it aims to reduce the levels of testosterone that can stimulate the tumour to grow Drugs include - androgen-receptor blockers-bicalutamide - GnRH agonists- such as goserelin (Zoladex) or leuprorelin (Prostap) - ** Bilateral orchidectomy**- removal of the testicles

Answer 268

- prostatectomy - TURP - cystoplasty - urinary diversion

Answer 269

Early-stage disease has a fantastic prognosis, with an overall 5-year survival rate of approximately 100% for localised prostate cancer. Metastatic disease is associated with a 5-year survival rate of approximately 30%.

Answer 270

Germ cell tumours

Answer 271

Non-germ cell (sex-cord stromal) Lymphomas

Answer 272

Most common malignancy in young males Testicular cancer is the 18th most common cancer in males in the UK Often presents between 15 and 35 years old

Answer 273

Caucasian Infertility Cryptorchidism Intersex (discrepancy between internal + external genitalia) Mumps In-utero exposure to pesticides

Answer 274

Seminoma: the most common and best prognosis Non-seminoma - Teratoma: composed of tissue from different germinal layers e.g. teeth, common in children. Can contain all types of tissues! (most common form of non-seminoma) - Yolk-sac tumour: common in children and aggressive. Made from germ cells that differentiate into yolk sac tissue - Choriocarcinoma: rare but most aggressive. Made out of germ cells that differentiate into syncytiotrophoblasts and cytotrophoblasts (cells that help form placenta) - Embryonal carcinoma: aggressive and metastasises early. Made from germ cells that turn into embryonic pluripotent stem cells

Answer 275

Painless lump that will be: Arising from the testicle Hard irregular No transillumination with torch

Answer 276

Sometimes there can be a sharp or dull testicular pain that can be present in the abdomen as well Symptoms related to raised β-hCG Hyperthyroidism occurs as the alpha subunit of β-hCG mimics TSH Gynaecomastia Loss of libido Erectile dysfunction Testicle atrophy

Answer 277

Ultrasound testicular doppler diagnostic in over 90% of cases

Answer 278

Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas) Beta-hCG – may be raised in both teratomas and seminomas (20%) Lactate dehydrogenase (LDH) is a very non-specific tumour marker

Answer 279

May be used as a form of immunotherapy,. Giving BCG vaccine (TB) into the bladder is thought to stimulate the immune system to attack the tumour

Answer 280

Polycystic kidney disease is a genetic condition where the kidneys develop multiple fluid-filled cysts. Kidney function is significantly impaired. There are a number of associated findings outside the kidneys such as hepatic cysts and cerebral aneurysms.

Answer 281

Autosomal dominant Autosomal recessive

Answer 282

PKD-1 on chromosome 16* which accounts of 85% of cases and is associated with a more severe phenotype PKD-2 on chromosome 4

Answer 283

Polycystin proteins are not coded for correctly which allow for calcium influx into to cells to inhibit cell proliferation . Consequently cells proliferate abnormally and start to express proteins that cause water to be transported into the cyst.

Answer 284

- Leads to the enlargement of certain nephrons which starve healthy nephrons of oxygen. - This results in the activation of RAAS which causes fluid retention and hypertension - Over time when enough nephrons are affected it will result in renal failure

Answer 285

Cerebral aneurysms Hepatic, splenic, pancreatic, ovarian and prostatic cysts Cardiac valve disease (mitral regurgitation) Colonic diverticula Aortic root dilatation

Answer 286

Bilateral flank masses Hypertension

Answer 287

Abdominal flank or back pain Haematuria Dysuria Renal colic – Constitutional features of chronic kidney disease fatigue, weakness, reduced energy Polyuria, polydipsia, nocturia: excess urine due to poor concentrating ability of kidneys (i.e. not responding to anti-diuretic hormone)

Answer 288

Ultrasound: principle investigations, especially in screening Renal MRI/CT: high sensitivity and good for assessing progression (e.g. kidney size). Useful if concern regarding renal cell carcinoma (RCC)

Answer 289

Known family history - < 30 years: ≥3 cysts (unilateral or bilateral) - 30-39 years: ≥3 cysts (unilateral or bilateral) - 40-59 years: ≥2 cysts in each kidney

Answer 290

Blood pressure control Regular follow up Maintain adequate hydration Avoid NSAIDs and anticoagulants Avoid contact sport to prevent cyst rupture

Answer 291

Vasopressin receptor antagonists (Tolvaptan) can slow the development of the cysts

Answer 292

A gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others. Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility.

Answer 293

Aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner

Answer 294

Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding (intermenstrual or postcoital) Painful sex (dyspareunia) Painful urination (dysuria)

Answer 295

Urethral discharge or discomfort Painful urination (dysuria) Epididymo-orchitis Reactive arthritis

Answer 296

100mg of doxycycline twice a day for 7 days

Answer 297

Chlamydial Conjunctivitis

Answer 298

A gram-negative diplococcus bacteria. It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It spreads via contact with mucous secretions from infected areas.

Answer 299

Odourless purulent discharge, possibly green or yellow Dysuria Pelvic Testicular swelling and pain

Answer 300

90% of men and 50% of women are symptomatic.

Answer 301

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

Answer 302

Caused by bacteria called Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection.

Answer 303

Primary syphilis involves a painless ulcer called a chancre at the original site of infection (usually on the genitals). Secondary syphilis involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage. Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Tertiary syphilis can occur many years after the initial infection and affect many organs of the body, particularly with the development of gammas and cardiovascular and neurological complications. Neurosyphilis occurs if the infection involves the central nervous system, presenting with neurological symptom

Answer 304

Primary syphilis can present with: A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks. Local lymphadenopathy Secondary syphilis typically starts after the chancre has healed, with symptoms of: Maculopapular rash Condylomata lata (grey wart-like lesions around the genitals and anus) Low-grade fever Lymphadenopathy Alopecia (localised hair loss) Oral lesions

Answer 305

Headache Altered behaviour Dementia Tabes dorsalis (demyelination affecting the spinal cord posterior columns) Ocular syphilis (affecting the eyes) Paralysis Sensory impairment

Answer 306

A single deep intramuscular dose of benzathine benzylpenicillin (penicillin)

Answer 307

Dilated testicular veins within the pampiniform plexus. Around 90% of them occur on the left side

Answer 308

Occurs most commonly in adolescent boys may affects up to 15% Seen in around 40% of men with infertility

Answer 309

They form when there is increased pressure in the testicular veins that drain the pampiniform plexus. This may be caused by incompetent valves leading to venous reflux. The majority occur on the left side as the testicular vein drains into the renal vein at a shard angle first before IVC.

Answer 310

They can be a sign of renal cancer. The majority occur on the left side so if there is a tumour compressing venous return this could be a cause

Answer 311

Palpable veins Scrotum hanging lower

Answer 312

Painless swelling Some patients experience dragging sensation

Answer 313

testicular examination: demonstrates dilated veins (bag of worms) Examination is conducted both standing and lying. The size of each testicle should be evaluated. Doppler USS may be used in cases of diagnostic uncertainty and to confirm diagnosis. Fertility assessments may be completed. Semen analysis can be sent alongside FSH and testosterone levels

Answer 314

Does not drain when lying down It appears suddenly and is painful Solitary ride-sided

Answer 315

Sub-clinical:No clinical abnormality, only detected by Doppler ultrasound. Grade I (small):Only clinically palpable with Valsalva manoeuvre. Grade II (moderate):Palpable without Valsalva manoeuvre. Grade III (large):Varicocele is visible through the scrotal skin, easily palpable.

Answer 316

It is the twisting of the spermatic cord with rotation of the testicle

Answer 317

Young age Bell clapper deformity (what a great name this is for a deformity of the testicle). It’s when the testicle is high riding and it’s horizontal Cryptorchidism Trauma

Answer 318

Abnormal lie Prehn’s negative pain is not relieved on lifting the ipsilateral testicle Absent cremasteric reflex

Answer 319

Awful debilitating pain Pain can be intermittent and be brought on by exercise Nausea and vomiting

Answer 320

Imaging should not be considered if testicular torsion is suspected as it will delay surgery! Think of how much pain the poor man must be in don’t wait give him blood back to his testicle Surgical exploration: should be performed immediately if there is high clinical suspicion as it allows definitive diagnosis and management. Should be performed within 6 hours to prevent irreversible damage (90% salvageable at 6 hours and 10% salvageable at ≥24 hours)

Answer 321

Bilateral orchiopexy if the testicle is viable. This involves untwisting the testicle and fixing it to scrotal sac. Contralateral one should be fixed as well\ Ipsilateral orchiectomy and contralateral orchiopexy if the testicle is not viable : removal of the affected testis and fixation of the contralateral testis to the scrotal sac to prevent contralateral torsion

Answer 322

Infertility/ subfertility: torsion for 10-12 hours results in ischaemia and irreversible damage. Orchiectomy results in decreased spermatogenesis Pubertal delay: may occur, particularly if bilateral orchiectomy is performed; hormone replacement may be required

Answer 323

Within 4-6 hours of symptoms, the testis can be saved in the majority of cases A delay of 10-12 hours or more results in irreversible ischaemia and necrosis The testis is salvageable<10% ofcases at≥24 hours

Answer 324

Hydrocele refers to a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis (membrane covering the testes).

Answer 325

- a blood test to check antigen levels - 2 tests with a 2 week referral between them Can't ejaculate 48 hrs before can't have recent UTI Or a recent PR exam

Answer 326

Membranoproliferative = deposits in both basement membrane and mesangium Membranous = only basement membrane

Answer 327

Clear cell carcinoma = proximal renal tubular epithelium

Answer 328

Risk factor for clear cell carcinoma

Answer 329

High levels of anticoagulants – the filtration barrier is broken which causes the loss of proteins (including albumin), this lowers the oncotic pressure in blood. - To compensate the liver increases its activity. - As a result of this there is an increase in the amount of anticoagulants produced. - Anticoagulants must be given.

Answer 330

Thiazide Early - distal tubule, inhibition of Na+ and Cl- cotransport Loop Diuretic - Loop of Henle, inhibition of the Na+/K+/Cl- cotransporter K+ sparring diuretic - Late distal tubule and collecting duct, inhibition of Na+ reabsorption and K+ secretion. Aldosterone sensitive channels in principal cells. Osmotic diuretic - Proximal tubule, loop of Henle, collecting duct, inhibition of water and Na+ reabsorption Carbonic anhydrase inhibitors - Proximal tubules, inhibition of bicarbonate reabsorption

Answer 331

ACE inhibitors = ramipril to control hypertension

Answer 332

Postural hypotension Hyponatraemia Hypokalaemia Gout

Answer 333

Hyponatraemia Hyperkalaemia

Answer 334

Hyponatraemia Hypokalaemia Gout

Answer 335

Circulatory volume depletion leads to hypoperfusion of the kidneys Examples: NSAIDs (non steroidal anti-inflammatory drugs) ACE inhibitors Diuretics

Answer 336

Direct toxicity to, or hypersensitivity reactions involving the glomerular or interstitial tissues Examples: Many types of antibiotics Diuretics NSAIDs ACE inhibitors

Answer 337

Anticholinergics may cause retention Sulphonamides (a type of antimicrobial) and methotrexate may cause crystalluria.

Answer 338

Granulomatosis with polyangiitis = - Nasopharynx (chronic pain, bloody mucus, saddle nose, sinusitis, Otitis media), - lung (dyspnoea, bloody cough), - kidneys (restricts blood flow, decreased urine, increased BP) Microscopic polyangiitis = only kidney and lungs affected Eosinophilic granulomatosis with polyangiitis = mistaken for allergy or asthma

Answer 339

DAMN mnemonic Diuretics ACE/ARB Metformin NSAIDs